• • • 
 
 
 
DISEASES 
 
 OF THE 
 
 NOSE, THROAT AND EAR 
 
 MEDICAL AND SURGICAL 
 
 BY 
 
 WILLIAM LINCOLN BALLENGEK, M.D. 
 
 PROFESSOR OF OTOLOGY, RHINO LOGY, AND LARYNGOLOGY, COLLEGE OF PHYSICIANS AND SURGEON! 
 
 DEPARTMENT OF MEDICINE, UNIVERSITY OF ILLINOIS; FELLOW OF THE AMERICAN 
 
 LARYNGOLOGICAL ASSOCIATION; FELLOW OF THE AMERICAN LARYNGOLOGICAL 
 
 RHINOLOGICAL, AND OTOLOGICAL ASSOCIATION; FELLOW OF AMERICAN 
 
 ACADEMY OF OPHTHALMOLOGY AND OTOLARYNGOLOGY, ETC. 
 
 SECOND EDITION, REVISED AND ENLARGED 
 
 ILLUSTRATED WITH 491 ENGRAVINGS AND 17 PLATES 
 
 LEA & FEBIGER 
 
 PHILADELPHIA AND NEW YORK 
 1909 
 
/ 
 
 Entered according to Act of Congress, in the year 1909 by 
 
 LEA & FEBIGER, 
 in the Office of the Librarian of Congress. All rights reserved. 
 
 CL A 2 51 4g 3 
 
PREFACE TO SECOND EDITION. 
 
 The exhaustion of the first edition within a year has given the author 
 an unexpected opportunity. He has sedulously endeavored to remove 
 the imperfections unavoidable in an issue from the original manuscript, 
 and to make such improvements as are naturally suggested by having 
 the whole book before the eye in printed form. Each line has been 
 scrutinized to insure clearness, every page carefully corrected and 
 many rewritten, and in several chapters new material has been added — 
 the whole book, in short, being brought abreast of its subjects to date of 
 issue. Among other changes may be mentioned the redescription of the 
 operation for submucous resection, with several new engravings. The 
 chapter on the surgery of the nasal accessory sinuses has been greatly 
 enlarged, several new operations being described and fully illustrated. 
 The same is true of the chapter on the surgery of the tonsils. The 
 functional tests of the labyrinth and their clinical application, as elabo- 
 rated by Barany, Neumann, and others, are fully described and illus- 
 trated. This addition places the section on the Ear on a new and higher 
 plane. The otologist of today cannot render full service to his patients 
 without the application of these tests and their clinical deductions, 
 hence the author has endeavored to make them plain both by carefully 
 describing them and illustrating the technique. Several pages would 
 be required to enumerate the changes and improvements in this edition, 
 and those above mentioned must stand as examples. 
 
 The general purpose of the work is unchanged. It was designed as 
 a text-book for students, as a guide for the general practitioner, and 
 as a reference for specialists. Its contents are very comprehensive, as 
 they include the medical and surgical treatment of the diseases in the 
 entire region of the nose, throat, and ear, specialties naturally belonging- 
 together. A feature that has been favorably received is the elaborate 
 illustration throughout the work. Thus the successive steps of nearly 
 every accepted operation are shown, so that the reader can master 
 them at leisure. The engravings are mostly from original drawings. 
 In this revision there are one hundred and twenty-five new figures, 
 showing the latest surgical procedures and diagnostic measures. Many 
 
iv PREFACE 
 
 of the pen drawings in the first edition have been replaced with more 
 effective brush work. It may not be amiss to characterize the volume 
 as a combined text-book and atlas covering its three subjects. 
 
 The author desires to thank Dr. J. R. Fletcher for his valuable aid 
 in preparing the section on the Functional Tests of the Labyrinth and 
 their Clinical Applications, and Dr. W. Golden Mortimer for assistance 
 in the proofreading and in the preparation of the Index. 
 
 As the publishers gave the author absolute liberty to make such 
 changes in the text and illustrations as he might deem for the advantage 
 of the work, the type has been wholly reset. 
 
 W. L. B. 
 Chicago, 1909. 
 
CONTENTS. 
 
 PAET I. 
 THE NOSE AND ACCESSORY SINUSES. 
 
 CHAPTER I. 
 
 THE CLINICAL ANATOMY AND PHYSIOLOGY OF THE NOSE AND 
 
 ACCESSORY SINUSES 17 
 
 CHAPTER II. 
 
 THE NOSE, THROAT, AND EAR IN RELATION TO GENERAL 
 
 MEDICINE 27 
 
 CHAPTER III. 
 THE OFFICE EQUIPMENT 37 
 
 CHAPTER IV. 
 
 THE ETIOLOGY OF DEFORMITIES AND DEVIATIONS OF THE 
 
 SEPTUM NASI 58 
 
 CHAPTER V. 
 
 THE CHOICE OF SEPTUM OPERATIONS. THE SURGICAL COR- 
 RECTION OF OBSTRUCTIVE LESIONS OF THE SEPTUM 68 
 
 CHAPTER VI. 
 
 THE ETIOLOGY OF INFLAMMATORY DISEASES OF THE NOSE 
 
 AND ACCESSORY SINUSES Ill 
 
 CHAPTER VII. 
 
 THE METHODS FOR PROMOTING THE REACTION OF INFLAM- 
 MATION 123 
 
 CHAPTER VIII. 
 THE INFLAMMATORY DISEASES OF THE NOSE ...... 130 
 
 CHAPTER IX. 
 THE INDIVIDUAL SINUSES .161 
 
vi CONTENTS 
 
 CHAPTER X. 
 GENERAL CONSIDERATIONS IN REFERENCE TO THE SINUSES 176 
 
 CHAPTER XI. 
 THE SURGERY OF THE ACCESSORY SINUSES 197 
 
 CHAPTER XII. 
 
 NASAL NEUROSES. NASAL HYDRORRHEA. CEREBROSPINAL 
 
 RHINORRHEA . . . 242 
 
 CHAPTER XIII 
 NEOPLASMS OF THE NOSE 258 
 
 CHAPTER XIV. 
 
 EPISTAXIS (NASAL HEMORRHAGE). RHINOSCLEROMA. FURUN- 
 
 CULOSIS. SCREW-WORMS 272 
 
 CHAPTER XV. 
 THE SURGICAL CORRECTION OF EXTERNAL NASAL DEFORMITIES 279 
 
 CHAPTER XVI. 
 CHRONIC GRANULOMATA OF THE NOSE, THROAT, AND EAR . 291 
 
 PAET II. 
 THE PHARYNX AND FAUCES. 
 
 CHAPTER XVII. 
 DISEASES OF THE EPIPHARYNX AND BASE OF THE TONGUE . 317 
 
 CHAPTER XVIII. 
 INFLAMMATORY DISEASES OF THE MESOPHARYNX AND FAUCES 338 
 
 CHAPTER XIX. 
 THE FUNCTIONAL NEUROSES OF THE PHARYNX ... . . . 350 
 
 CHAPTER XX. 
 NEOPLASMS OF THE PHARYNX 354 
 
CONTENTS vii 
 
 CHAPTER XXI. 
 DISEASES OF THE FAUCES AND TONSILS 365 
 
 CHAPTER XXII. 
 THE INFLAMMATORY DISEASES OF THE TONSILS 381 
 
 CHAPTER XXIII. 
 THE SURGERY OF THE TONSILS 398 
 
 CHAPTER XXIV. 
 NEOPLASMS OF THE TONSILS 419 
 
 PART III. 
 DISEASES OF THE LARYNX. 
 
 CHAPTER XXV. 
 INFLAMMATORY DISEASES OF THE LARYNX AND EPIGLOTTIS 425 
 
 CHAPTER XXVI. 
 
 PACHYDERMIA LARYNGIS. MALFORMATIONS AND DEFORMI- 
 TIES. PROLAPSE OF THE VENTRICLES. STENOSIS. 
 SUBGLOTTIC STENOSIS 478 
 
 CHAPTER XXVII. 
 NEUROSES OF THE LARYNX 486 
 
 CHAPTER XXVIII. 
 THE SINGING VOICE 503 
 
 CHAPTER XXIX. 
 DEFECTS OF SPEECH 514 
 
 CHAPTER XXX. 
 NEOPLASMS OF THE LARYNX 522 
 
 CHAPTER XXXI. 
 
 FOREIGN BODIES IN THE LARYNX, TRACHEA, BRONCHI, AND 
 
 ESOPHAGUS 554 
 
viii CONTENTS 
 
 PAKT IV. 
 
 THE EAR. 
 
 CHAPTER XXXII. 
 THE CLINICAL ANATOMY AND PHYSIOLOGY OF THE EAR . . 575 
 
 CHAPTER XXXIII. 
 THE FUNCTIONAL TESTS OF THE EAR 590 
 
 CHAPTER XXXIV. 
 THE GENERAL ETIOLOGY OF DEFECTIVE HEARING .... 619 
 
 CHAPTER XXXV. 
 
 FOREIGN BODIES IN THE EAR. CERUMINOUS PLUGS IN THE 
 
 MEATUS 625 
 
 CHAPTER XXXVI. 
 MALFORMATIONS AND NEOPLASMS OF THE AURICLE .... 635 
 
 CHAPTER XXXVII. 
 DISEASES OF THE AURICLE AND EXTERNAL MEATUS ... 645 
 
 CHAPTER XXXVIII. 
 MALFORMATIONS AND DISEASES OF THE MEMBRANA TYMPANI 660 
 
 CHAPTER XXXIX. 
 DISEASES OF THE EUSTACHL4N TUBES ". " 674 
 
 CHAPTER XL. 
 THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION . 683 
 
 CHAPTER XLI. 
 INFLAMMATORY DISEASES OF THE TYMPANUM 694 
 
 CHAPTER XLII. 
 HYPEROSTOSIS OF THE BONY CAPSULE OF THE LABYRINTH f 725 
 
CONTENTS ix 
 
 CHAPTER XLIII. 
 
 ACUTE AND CHRONIC SUPPURATIVE OTITIS MEDIA. CHOLES- 
 TEATOMA 730 
 
 CHAPTER XLTV. 
 
 THE SEQUELAE OF SUPPURATIVE OTITIS MEDIA,. MASTOIDITIS, 
 AND CHOLESTEATOMA. SUPPURATION OF THE LABY- 
 RINTH 753 
 
 CHAPTER XLV. 
 
 PRINCIPLES OF TREATMENT AND GENERAL CONSIDERATIONS 
 
 IN SUPPURATIVE OTITIS MEDIA 762 
 
 CHAPTER XLVL 
 THE GENERAL PATHOLOGY OF OTITIS MEDIA AND MASTOIDITIS 769 
 
 CHAPTER XLVII. 
 
 INTRACRANIAL AND JUGULAR PYOGENIC DISEASES OF OTITIC 
 
 ORIGIN 774 
 
 CHAPTER XLVIIL 
 THE SURGERY OF THE TEMPORAL BONE 789 
 
 CHAPTER XLIX. 
 FACIAL PARALYSIS 857 
 
 CHAPTER L. 
 
 DISEASES OF THE PERCEPTION APPARATUS. AUDITORY NERVE 
 
 APPARATUS 864 
 
 CHAPTER LI. 
 DEAF-MUTISM 892 
 
DISEASES OF NOSE, THROAT, AND EAR, 
 
 PART I. 
 THE NOSE AND ACCESSORY SINUSES, 
 
 CHAPTER I. 
 
 THE CLINICAL ANATOMY AND PHYSIOLOGY OF THE NOSE 
 AND ACCESSORY SINUSES. 
 
 THE NOSE. 
 
 The Nasal Chambers. — The nose is divided, by the nasal septum, 
 into two chambers, the right and the left. The nasal chambers are for 
 respiratory, olfactory, phonatory, and gustatory purposes. The inspira- 
 tory current passes upward from the vestibules to the middle and superior 
 meatuses, and is thence deflected downward and backward by the 
 middle turbinals and the roof of the nose to the choanal, into the epi- 
 pharynx. The expiratory current is deflected from the vault of the 
 epipharynx into the choanal, and thence forward through the middle and 
 inferior meatuses to the vestibules of the nose (Fig. 2). 
 
 The practical clinical application of the foregoing facts lies in the 
 different effects of stenosis in the inferior and in the superior portions 
 of the nasal chambers. An obstructive deformity of the lower portion 
 of the septum may interfere somewhat with the expiratory current, as 
 it blocks the inferior meatus while the middle and superior meatuses 
 are free, and the expiratory current, therefore, passes through the nasal 
 chamber upon the obstructed side with but little or no impediment. 
 The obstruction in the lower portion of the nasal chamber does not 
 materially interfere with the inspiratory current, as its course is normally 
 higher in the nasal passage. There are exceptions, however, to this rule. 
 If, for example, the deformity of the septum extends well forward into 
 the vestibule of the nose it will materially interfere with the inspiratory 
 current, as it blocks the entrance to the nose. (See Chapter IV.) 
 
 The Septum. — This subject is fully discussed in connection with the 
 deformities and malformations of the septum. (See Chapter IV.) 
 
 The Turbinated Bodies. — The turbinated bodies, three in number, 
 are located upon the outer wall of the nasal chambers, and are known 
 as the inferior, middle, and superior turbinated bodies (Fig. 2), of which 
 2 
 
18 THE NOSE AND ACCESSORY SINUSES 
 
 only the inferior and middle are of clinical importance. These are 
 characterized by the presence of venous plexuses in the submucous tissue 
 of the membrane, known as " swell bodies/' or the erectile tissue of the 
 nose. The erectile tissue is chiefly distributed along the inferior border of 
 the inferior turbinal, and on the posterior ends of the inferior and middle 
 turbinals. Its function is supposed to be that of warming the inspired 
 air and of regulating the amount of serous secretion. Either process is 
 of vital importance to the lower respiratory tract. The lower respira- 
 tory tract does not secrete enough moisture for physiological purposes 
 (protective), nor is it capable of warming the inspired air sufficiently 
 to bring it to the body temperature without injury to its mucous mem- 
 brane. It is important that the heating and humidifying apparatus of 
 the nose should be in good physiological condition. When, therefore, the 
 vasomotor nerves which regulate the erectile tissue are disturbed in their 
 function, the preparation of the inspired air for the lower air tract is 
 imperfectly performed. The lower air tract is exposed to the irritating 
 influence of the inspired air, and irritation of the lining mucosa and of 
 the endothelial cells which line the air vessels of the lungs may result in 
 bronchitis, while the transfusion of the gases, oxygen and carbon dioxide, 
 may be disturbed in the air vesicles. The processes of tissue metabolism 
 or the chemistry of nutrition are perverted. 
 
 In addition to the foregoing conditions resulting from the disturbed 
 functions of the "swell bodies," the patient may experience either a 
 sense of "stuffiness" of the nose or of a foreign body, or the reverse, an 
 unduly open nose. If, for example, there is an anterior or vestibular 
 obstruction from any cause, the negative pressure thus brought about 
 causes an engorgement of the "swell bodies," with the resultant dis- 
 agreeable symptoms already described. This condition is known as 
 rhinitis with turgescence. If, on the contrary, the patient is anemic, the 
 swell bodies may become collapsed and the nasal chambers unduly 
 patulous. This condition is known as rhinitis with collapse of the erectile 
 tissue. The turbinated bodies are of clinical interest, for the further 
 reason that they divide the nasal chambers into three partial chambers 
 or meatuses. The inferior meatus is the space between the floor of the 
 nose and the inferior turbinal. The middle meatus is the space between 
 the inferior and middle turbinals. The superior meatus is the space 
 above the middle turbinal. The meatuses are of great clinical interest 
 on account of the accessory nasal sinuses opening into them. 
 
 The Meatuses. — The inferior meatus is of clinical importance, as the 
 nasal orifice of the tear duct opens in its anterior portion (Fig. 167), and 
 because it is a part of the expiratory air tract. 
 
 The Middle Meatus. — The middle meatus is of great clinical impor- 
 tance because the frontal, anterior ethmoidal, and the maxillary sinuses 
 open into it. The frontal and the anterior ethmoidal cells drain into the 
 infundibulum in 50 per cent, of the cases. The bulla ethmoidalis and 
 the cells in the middle turbinal (Fig. 142) do not drain into the infundib- 
 ulum, but open directly into the middle meatus. The bulla is often 
 quite large and bulges so much toward the septum that it encroaches 
 
THE NOSE 19 
 
 upon the infundibulum and entirely obstructs it. It thereby interferes 
 with the drainage of the frontal, maxillary, and the anterior ethmoidal 
 cells. The cells opening into the middle meatus are referred to for 
 convenience as Series I. 
 
 When pus is present in the middle meatus it is significant of empyema 
 of one or more of the cells comprising Series I, namely, the frontal 
 sinus, the anterior ethmoidal, and the maxillary sinuses (antrum of 
 Highmore). 
 
 The Superior Meatus. — The superior meatus is of clinical interest 
 because the posterior ethmoidal and the sphenoidal cells (Series II) 
 open into it. This meatus cannot be directly inspected on account of 
 its hidden position above the middle turbinal. It may, however, be 
 examined with a probe. When pus flows into it from the posterior 
 ethmoidal and sphenoidal sinuses, and the olfactory fissure is not com- 
 pletely closed, it may be seen lying between the septum and the middle 
 turbinal (the olfactory fissure). 
 
 The superior meatus is of still further clinical interest because the 
 terminal filaments of the olfactory nerve are distributed there. (See 
 Olfactory Nerves.) 
 
 The Sinuses Residual Organs. — The nasal accessory sinuses in man 
 are the remains of the olfactory organ, hence they have a low recupera- 
 tive power after operations. I have repeatedly observed the slow 
 and sometimes incomplete repair after operations, even after the most 
 thorough exenteration, especially of the ethmoidal cells. I attribute 
 this to the fact that the structures in man have ceased to perform the 
 function they were originally designed to do. Through long ages of 
 retrogression the tissues have lost some of their vitality and do not regene- 
 rate with the same degree of vigor as those structures which still perform 
 their functions. 
 
 The Nerve Supply of the Nose. — The Sensory Nerves.— The sensory 
 nerves of the nasal septum, the X. ethmoidalis anterioris and the N. 
 nasopalatine, send their filaments to the anterior and posterior por- 
 tions of the septum respectively. The N. ethmoidalis anterioris passes 
 through the anterior portion of the cribriform plate (Fig. 1), thence for- 
 ward and downward to the vestibule. The X. nasopalatine extends 
 forward and downward on the septum to the canalis incisivus, anas- 
 tomoses with that of the other side, and ends in the mucous membrane, 
 of the hard palate. 
 
 The sensory nerve supply of the outer walls of the nose is derived from 
 the X T . ethmoidalis anterioris and from branches of the ganglion spheno- 
 palatinum. The X T . ethmoidalis anterioris supplies the anterior portion 
 of the lateral walls in front of the turbinated bodies, and the turbinated 
 bodies are supplied by branches of the sphenopalatine ganglion (Fig. 2). 
 The hard and soft palates are also supplied from this ganglion. These 
 anatomical facts may be utilized in injecting cocaine for anesthetic 
 purposes (Killian) and in injecting alcohol in the treatment of hyper- 
 esthetic rhinitis (O. J. Stein). 
 
 Vasomotor branches are also supplied to the vessels of the mucous 
 
20 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 membrane and erectile tissue of the turbinated bodies from the ganglion 
 sphenopalatinum, and are under the control of the vasomotor centers of 
 the medulla; there is probably a connection with the nuclei of the vagus 
 through association fibers (Watson Williams). 
 
 Fig. 1 
 
 Nerve supply of the septum nasi, a, N. ethmoidalis anterioris; b, N. olfactorii; 
 c, N. nasopalatinus; d, canalis incisivus. (After Spalteholz.) 
 
 Fig. 2 
 
 Nerves of the lateral wall of the nose, a, ganglion sphenopalatinum; b, rami nasales posteriores 
 superiores laterales; c, rami nasales posteriores inferiores laterales; d, Nn. palatini; e, Nn. olfactorii; 
 f, rami nasales interni, N. ethmoidalis anteriores. (After Spalteholz.) 
 
 The distribution of the accessory nerves over the septum and the outer 
 walls of the nose, and especially the branches from the sphenopalatine 
 ganglion over the turbinate, at once suggests the reason for the sensitive- 
 ness of these areas when the mucous membrane is inflamed, or is so 
 
THE NOSE 21 
 
 swollen that it impinges against the septum. It also suggests the reflex- 
 phenomena, as asthma, often observed when there is inflammation 
 or other disease of these regions. The association fibers, referred to 
 above, connecting the sphenopalatine ganglion with the vagus establish a 
 physiological relationship between the upper and the lower respiratory 
 tracts, hence the asthma of nasal origin. I have repeatedly seen cases 
 in which the asthma promptly disappeared after the removal of nasal 
 polypi, or after an exenteration of the ethmoidal labyrinth for sinuitis. 
 The irritation of the terminal filaments of the turbinal branches from 
 the sphenopalatine ganglion was thus removed, and the reflex stimulus 
 through the ganglion to the vagus and thence to the bronchial muscles 
 ceased to be given off; hence, the bronchial spasm (asthma) was cured. 
 
 The vascular engorgement present in chronic rhinitis with turgescence 
 is due to a paresis of the vasomotor constrictor muscles supplied by the 
 branches of the sphenopalatine ganglion. 
 
 The Olfactory Nerve. — The olfactory nerve descends through the lamina 
 cribrosa (cribriform plate) from the under surface of the olfactory bulb 
 and is distributed in the mucous membrane covering the upper portion 
 of the superior turbinal and a corresponding portion of the septum 
 (Figs. 1, 2, and 5). Formerly it was thought that the distribution of 
 the olfactory nerve in man covered a much more extensive area, the 
 upper and median surfaces of the middle turbinal and a corresponding 
 area of the septum being included in the alleged area of distribution. In 
 many of the lower animals the nerve has a wider distribution; the sinuses 
 communicate more freely with the nasal chambers and arc utilized for 
 the spread of the terminal olfactory nerve filaments. In man they are 
 the remains of the organ of smell, and only communicate with the nasal 
 cavities through small ostei or cell openings, as they are no longer needed 
 for olfaction. 
 
 To return to the olfactory nerve. It is obvious that if the middle 
 turbinal and the septum are in apposition, the inspired air does not 
 reach the olfactory region, and anosmia or loss of smell results. It 
 follows that if the obstruction to the olfactory fissure is overcome, either 
 by the removal of the middle turbinal or by the correction of the devia- 
 tion of the septum, air is admitted to the olfactory region and the sense 
 of smell is restored, provided the nerve has not undergone degeneration. 
 
 Inasmuch as the distribution of the olfactory nerve is limited to the 
 superior turbinal and the corresponding portion of the septum, the 
 middle turbinal and the ethmoidal cells may be removed in their entirety 
 without interfering with its distribution. In such operations the superior 
 turbinal should be left intact in so far as it is compatible with a com- 
 plete exenteration of the ethmoidal cells. 
 
 The Blood Supply of the Nose.— The middle meningeal artery 
 gives off the sphenopalatine branch, which, when it reaches the posterior 
 portion of the lateral wall of the nose, subdivides into the lateral pos- 
 terior nasal arteries. These are distributed over the middle and inferior 
 turbinals and the middle and inferior meatuses. The superior tur- 
 binal and the anterior portion of the outer wall of the nasal chamber 
 
22 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 are supplied by the posterior ethmoidal and the anterior ethmoidal 
 arteries respectively (Fig. 3). 
 
 Fig. 3 
 
 The arterial supply of the lateral wall of the nose, a, A. meningea anterior; 6, A. ethmoidalis 
 anterior; c, A. ethmoidalis posterior; d, Aa. nasales posteriores laterales; e, A. sphenopalatina; 
 /, Aa. palatinae major et minores. 
 
 Fig. 4 
 
 The arterial supply of the septum nasi, a, A. ethmoidalis anterior; b, A. ethmoidalis posterior; 
 c, A. nasales posteriores septi; d, anastomosis with the A. palatina major. (After Spalteholz.) 
 
 As the posterior lateral nasal arteries are of considerable size, it is to 
 be expected that the removal of either the middle or inferior turbinated 
 
THE PHYSIOLOGY OF THE NOSE 
 
 23 
 
 bodies may be attended by considerable hemorrhage. As a matter of 
 fact, the removal of the middle turbinal is usually followed by more or 
 less bleeding for twenty-four hours. There is a free anastomosis be- 
 tween the lateral nasal arteries and the anterior ethmoidal artery; hence, 
 after the removal of the turbinated body bleeding may come from both 
 sources though but one artery is injured. 
 
 The septum is supplied by the A. nasales posteriores septi, a branch 
 of the A. sphenopalatina, through the foramen sphenopalatinum. It 
 has three main branches : one supplies the posterior, another the inferior, 
 and the other the middle and posterior portions of the septum. 
 
 The A. ethmoidalis anterior and the A. ethmoidalis posterior are 
 distributed to the anterior and the superior portions of the septum 
 (Fig. 4). Severe hemorrhage occasionally attends or follows an operation 
 upon the septum, especially when the operative field includes the middle 
 branch of the A. nasales posteriores septi. 
 
 Fig. 5 
 
 THE PHYSIOLOGY OF THE NOSE. 
 
 The functions of the nose are olfactory, phonatory, respiratory, 
 gustatory, and the ventilation of the nasal accessory sinuses. The 
 gustatory function in man is prob- 
 ably of least importance, the olfac- 
 tory of secondary importance, the 
 phonatory of tertiary importance, 
 while the respiratory and ventilat- 
 ing functions are of the greatest 
 importance. 
 
 The Sense of Smell.— The 
 olfactory nerve, or organ of 
 smell, is located in the upper 
 portion of the nasal chambers, 
 The olfactory nerve (Fig. 5) is 
 distributed over the attic of the 
 nose as far downward as the 
 upper margin of the middle tur- 
 binated body and on the septum 
 over a corresponding area. A 
 knowledge of the area of dis- 
 tribution of this nerve is of prac- 
 tical importance in the diagnosis, 
 prognosis, and treatment of cer- 
 tain diseases of the nose. If there 
 is anosmia, or loss of the sense of 
 smell, the question arises as to 
 whether the impairment is due to a degenerative change in the nerve 
 itself, or to an obstruction to the entrance of the odoriferous particles 
 or emanations to the terminal cells of the olfactory nerve. 
 
 Showing the area of distribution of the olfac- 
 tory terminal nerve cells in the human nose. The 
 triangular flap is the septum turned upward; the 
 area of distribution is limited to the region of the 
 superior turbinal, and a corresponding area of the 
 septum, the middle turbinal receiving few or no 
 olfactory cells. 
 
24 THE NOSE AND ACCESSORY SINUSES 
 
 The lesions may, however, be intracranial, in which case there may be 
 no evidence of either an obstructive lesion or of degenerative changes 
 in the attic of the nose. 
 
 The loss of the sense of smell, while not comparable to the loss of the 
 nasal respiratory function, is, nevertheless, attended by considerable 
 inconvenience. The pleasure experienced by the recognition of certain 
 odors is longed for by those affected by anosmia. More than this, they 
 have lost one of the senses whereby they are protected from harm by 
 certain substances, as ammonia, etc. By its aid we are warned of the 
 near approach to decaying matter, or other foul-smelling and unsanitary 
 substances. In the lower animals the sense of smell is of much greater 
 utility in seeking food and in detecting the approach of hunters and 
 animals intent upon their destruction. 
 
 Phonation. — The function of the nose in speaking and singing is so 
 important that Jeane de Reske has said that the more he studies the 
 voice the more he is convinced that it is a question of the nose. I have 
 often noted that popular public speakers had well-developed nasal 
 resonance, while speakers lacking resonance had difficulty in holding the 
 attention of their audiences. While the initial tone is produced by the 
 vibrations of the vocal cords, the voice is decidedly unpleasant and 
 unmusical if it is not rich in overtones from the resonance chambers of 
 the nose, throat, and chest. (See The Singing Voice.) The nasal cham- 
 bers and accessory cavities are of prime importance in voice production, 
 and any obstruction from swelling of the mucous membrane, deflection, 
 or other lesion of the septum so materially alters the quality of the voice 
 as to make it disagreeable and inartistic. 
 
 Nasal Respiration. — As before stated, the respiratory function of 
 the nose is the most important. The nasal chambers are more than 
 mere tubes through which air is drawn into the lungs; they produce 
 certain changes in the air which prepare it so that the normal trans- 
 fusion of oxygen and carbon dioxide may take place through the walls 
 of the air vesicles. The respiratory functions of the nose are three- 
 fold, namely: (a) to temper, (6) humidify, and (c) filter the inspired 
 air. 
 
 Experiments have demonstrated that no matter what the temperature 
 of the air may be before it is inhaled, it is raised or lowered, as the case 
 may be, to near the body temperature. The delicate structures of the 
 deeper respiratory tract are thereby protected against the great varia- 
 tions and extremes of temperature. 
 
 It has also been shown that the air in passing through the nasal cham- 
 bers receives moisture from the nasal mucous membrane. The mucosa 
 of the lower respiratory tract and the epithelial walls of the air vesicles 
 of the lungs are thus protected from the varying humidity of the atmo- 
 sphere. In passing through the nose the air is raised (usually) in tem- 
 perature, thus expanding it and increasing its capacity to absorb moisture. 
 The " swell bodies," or erectile tissue of the nose, and the serum-secreting 
 glands of the nasal mucosa give off moisture, which is rapidly taken up 
 by the expanded air and carried to the lower respiratory tract, where 
 
THE PHYSIOLOGY OF THE NOSE 25 
 
 the serum-secreting organs are much less developed. It has been esti- 
 mated that approximately one pint of serum is thus transferred from 
 the nasal cavities to the lower respiratory tract in twenty-four hours. 
 
 The part of the nasal structures which secrete most of the serum 
 is generally supposed to be the ''swell bodies" or erectile tissue, located 
 chiefly along the free border of the inferior turbinated bodies, and on 
 the posterior ends of the middle and inferior turbinated bodies. The 
 latter portions sometimes become enlarged and form the so-called 
 mulberry hypertrophies. It is probable that the mucous glands also 
 secrete some of the serum. The "swell bodies" are under the control 
 of the vasomotor nervous system, which, under normal conditions, 
 regulates the supply of moisture to meet the demands. If the air is dry 
 the swell bodies enlarge and become just active enough to fully saturate 
 the expanded air in the nose; whereas if the atmosphere is humid 
 they are less active. When an obstructive lesion, or catarrhal inflamma- 
 tion, is present, the "swell bodies" and glands do not respond normally 
 to the atmospheric conditions, hence the air is not properly humidified 
 in its passage through the nose. The treatment of these conditions 
 should be, therefore, so directed as to restore the "swell bodies" and 
 glands to their normal activity. In order to do this, it may be necessary 
 to give stability to the vasomotor nervous system by judicious bathing, 
 outdoor exercise, etc. In addition, local massage of the mucous mem 
 brane and other treatment may be necessary. Surgical interference 
 should always be accomplished with respect to the location of the "swell 
 bodies," care being exercised to avoid their destruction, except in those 
 cases in which they have undergone considerable hypertrophy. The 
 surgery of the middle turbinated body may be practised with much 
 greater freedom, because it does not have so much to do with the respira- 
 tory functions of the nose. The inferior turbinated body, however, 
 should be treated surgically only when its secretory function is largely 
 destroyed, or when it is so enlarged by hypertrophic or hyperplastic 
 changes that it obstructs nasal respiration. 
 
 That the nose is a filter is evident upon inspection of the secretions 
 and the vibrissas of the vestibule, as they are loaded with dirt. The 
 vibrissa? guarding the atrium of the nostrils act as a coarse filter, the 
 larger particles lodging on them, the smaller ones entering the nasal 
 cavities, where they are caught upon the irregular surface of the moist 
 mucous membrane. The lower air tract is thus protected from the 
 irritation which would otherwise result. F. C. Cobb, under the direction 
 of Frederick Coolidge, of Harvard University, has shown by a long 
 series of experiments that the secretions posterior to the vestibules of the 
 nose are sterile, thus demonstrating the great physiological importance 
 of the vibrissa* and the sterilizing quality' of the nasal secretions. 
 
 The Gustatory Function of the Nose. — The real gustatory or 
 taste sense (sweet, sour, acid, bitter, and salt) is supplied by the dis- 
 tribution of the glossopharyngeal and the fifth nerves to the fauces and 
 the base of the tongue, whereas the delicate flavors which give so much 
 pleasure to the consumption of foods and drinks are appreciated through 
 
26 THE NOSE AND ACCESSORY SINUSES 
 
 the olfactory nerve. If the nostrils are closed and the eyes covered it 
 is almost impossible to distinguish between coffee and water of the 
 same temperature, as the aromatic flavor cannot be appreciated by the 
 nose when closed. 
 
 Ventilation of the Sinuses. — I have assumed a fifth function of the nose 
 — the ventilation of the accessory sinuses — which has not heretofore 
 been described under the physiology of the nose. It is obvious to anyone 
 who has had an abundant opportunity of observing inflammation of the 
 sinuses, that ventilation is a prime requisite for the maintenance of the 
 mucous membrane of these cavities in a healthy condition. Any inter- 
 ference with the ventilation of these cavities lowers the resistance of the 
 mucous membrane and the diminished amount of oxygen allows the 
 secretion to undergo rapid decomposition. 
 
 Summary: The functions of the nose are fivefold, namely: 
 
 1. Olfactory, located in the attic of the nose. 
 
 2. Phonatory, enriching the voice by overtones. 
 
 3. Respiratory. 
 
 (a) The air is warmed or tempered to or nearly to the body tempera- 
 ture in passing through the nose, thereby preventing shock and irritation 
 to the mucosa and air vesicles of the lower respiratory tract. 
 
 (b) The air is expanded by the warmth of the nasal chambers, and 
 its capacity to absorb the moisture thrown off by the "swell bodies" and 
 mucous glands is increased. The mucosa and air vesicles are thus 
 moistened, or, at least, their moisture is not absorbed (the air being 
 already saturated in its passage through the nose), and irritation is 
 prevented. The nose keeps the inspired air in a state of saturation. 
 
 (c) The air is filtered in its passage through the nose by the vibrissa? 
 and the moist mucous membrane. The irritation to the mucosa and 
 air vesicles which would otherwise occur is thus prevented. 
 
 4. The gustatory (olfactory) sense complements the sense of taste. 
 
 5. The ventilation of the accessory sinuses maintains the normal 
 resistance of the mucous membrane and prevents the rapid decompo- 
 sition of the secretions. 
 
CHAPTER II. 
 
 THE NOSE, THROAT, AND EAR IN RELATION TO GENERAL 
 
 MEDICINE. 
 
 The writings of William Meyer, of Copenhagen, William Daly, of 
 Pittsburg, and E. P. Friedreich, of Leipsic, have given a breadth to 
 rhinology, laryngology, and otology which they did not have in the days 
 when practice along these lines was regarded as a "specialty." With 
 this broader view they are now regarded as the pursuit of the practice 
 of general medicine and surgery, with special reference to the diagnosis 
 and treatment of diseases in general, and those of the nose, throat, and 
 ear in particular. 
 
 A proper comprehension of the relation of the nose, throat, and ear 
 to general medicine and surgery will be facilitated by a brief analysis 
 of the interdependence and coordination of the various organs and 
 parts of the body. 
 
 ELEMENTARY FACTS. 
 
 (a) The Breathway. — The upper respiratory tract is the channel in 
 which the air is prepared for the interchange of gases which takes place 
 in the air vesicles of the lungs. The nose is especially concerned in the 
 process of humidifying, warming, and filtering the inspired air, and it 
 is obvious that any disease or obstruction that interferes with these physio- 
 logical processes will affect the transfusion of gases through the capillaries 
 of the walls of the air vesicles. The absorption of oxygen by, and the 
 elimination of carbon dioxide from, the blood will not occur in normal 
 ratio. The blood will be deficient in oxygen and surcharged with 
 carbon dioxide. As oxygen is essential to the processes of assimilation 
 and nutrition, its lessened quantity in the blood gives rise to certain dis- 
 turbed conditions of the digestive, the assimilative, and the nutritive 
 functions. The presence of an excess of carbon dioxide also adds to these 
 disturbances. It is well known that the excessive accumulation of 
 carbon dioxide in the blood acts as a poison to the leukocytes, thus inter- 
 fering with their functional activity. A normal amount of carbon dioxide 
 in the blood favors the assimilative, nutritive, and leukocytic processes, 
 and it is only after a greatly increased amount of it is present that there 
 are marked disturbances. It not only interferes with the activity of the 
 leukocytes, but also with other cellular structures of the body as well. 
 The combined effect, therefore, of an increased amount of carbon dioxide 
 and a diminished quantity of oxygen in the blood is to produce general 
 anemia, indigestion, malassimilation and nutrition, and infectious 
 processes. 
 
28 THE NOSE AND ACCESSORY SINUSES 
 
 The xanthin group of toxins, including indican, are thrown into the 
 circulation and give rise to certain nervous phenomena, as restlessness, 
 peevishness, headache, mental depression, aprosexia, and a general feel- 
 ing of malaise. 
 
 The digestive disturbances are still further increased by the ingestion 
 of the infected secretions from the epipharynx and the tonsils. Putre- 
 factive as well as pathogenic bacteria are swallowed with the secretions 
 from the nose and throat, and give rise to what is commonly known as 
 chronic dyspepsia or indigestion. It is probable that the putrefactive 
 germs are more potent in this connection than the streptococci and the 
 staphylococci. The conditions of the nose and throat which most com- 
 monly give rise to this kind of discharge are nasal stenosis, atrophic 
 rhinitis, chronic rhinitis, sinuitis, epipharyngeal catarrh, and chronic 
 follicular tonsillitis. 
 
 There are certain conditions of the stomach and of the intestinal 
 tract which affect the mucous membrane of the upper respiratory tract. 
 If, for example, there is chronic indigestion, there is also malassimilation 
 and faulty metabolism. The imperfect products of indigestion are in- 
 completely oxidized and are thrown into the circulation, where they irri- 
 tate the mucous membrane of the nose, as well as the vasomotor nerves, 
 thus causing local congestion and overnutrition. The secretions of 
 the glands of the mucous membrane of the upper respiratory tract are 
 also thereby modified, thus predisposing to, or at least intensifying, the 
 catarrhal disease present. In the same way hyperacidity and subacidity 
 of the stomach may indirectly irritate the mucosa of the nose and throat. 
 One of the most potent influences exerted by the products of indigestion 
 is through the reflex nervous system, pharyngitis, hypersensitiveness, 
 sneezing, etc., being the direct expression of this condition. 
 
 In atony of the stomach there is a putrefactive formation of gases, 
 which act reflexly and through the circulatory system on the mucous 
 membrane of the upper respiratory tract and cause phenomena quite 
 similar to those just mentioned. Another condition which is quite 
 similar in many respects to the foregoing is that which occurs in gout or 
 lithemia. In connection with this disease the larynx and the pharynx 
 are particularly affected. In the pharynx there may be itching behind 
 the pillars of the fauces, associated with a similar irritation in the external 
 meatus of the ear. Some observers regard these signs as characteristic 
 of gout. 
 
 When such symptoms appear, the administration of calomel and the 
 bicarbonate of soda, followed in twelve hours by a saline purge, will 
 give marked relief. After this, teaspoonful doses of the phosphate of 
 soda should be given two or three times daily for a few weeks. 
 
 Vomiting and eructation of gases from the stomach exert an irritating 
 effect upon the mucous membrane of the pharynx, the epipharynx, 
 and the nose. The irritation is due to biochemical as well as mechanical 
 causes. Catarrhal inflammation in the epipharynx is thus perpetuated, 
 and may finally extend to the Eustachian tube and the middle ear, and 
 cause tinnitus and deafness. 
 
ELEMENTARY FACTS 29 
 
 (6) Intimate Relation between Organs. — All the organs of the body 
 are more or less intimately connected by the vascular, the lymphatic, 
 and nervous systems, hence disturbances in one more or less affect 
 the others. The bloodvessels and the lymph channels carry toxic and 
 infective material to all the organs of the body, including the nose, 
 throat, and ear, and thus influence the functional and the pathological 
 processes in these organs. While the data considered under this subject 
 somewhat overlap those considered under (a), it is well, nevertheless, 
 to emphasize certain features more prominently in this connection. 
 
 Anemia is a condition of the blood due to various causes, and often 
 gives rise to collapse of the erectile tissue of the nose. This is usually 
 spoken of as "rhinitis with collapse of the turbinated bodies." (See 
 Rhinitis with Collapse of the "Swell Bodies," page 153.) 
 
 On the other hand, another condition of the nasal mucous membrane 
 which may cause anemia instead of being a result of it, as related in the 
 preceding paragraph, is atrophic rhinitis. It is characterized by anemia, 
 which is probably due to the absorption of toxic material from the nose, 
 and to the loss of the respiratory functions of the nose. 
 
 If the lymphatic vessels are charged with infective material, which is 
 finally transferred to the bloodvessels and tissues of the entire body, a 
 state of general toxemia is induced, the nose, throat, and ear participating 
 in the disturbed processes. On the other hand, one of the commonest 
 clinical pictures is that wherein the lymphatic glands are enlarged by 
 suppurative disease of the ear, nose, and throat. This subject is dis- 
 cussed more fully in the chapter on the Clinical Anatomy of the Tonsils. 
 I wish, however, to emphasize the influence of suppurative diseases 
 of the ear upon the lymphatic glands of the neck. As the ear is more 
 intimately connected with the lymphatic glands of the posterior triangle 
 of the neck, it is to the glands in this region that we should look for 
 enlargement in inflammatory disease of this organ. 
 
 The close approximation of the mucous membrane of the nose and 
 ear to the contents of the cranial cavity may also give rise to serious 
 consequences by the conveyance of infective material thereto. Brain 
 abscess, meningitis, septic thrombophlebitis, etc., may be thus caused, 
 although the usual channel of invasion is through a necrotic area in 
 the floor of the cranial cavity. 
 
 The nervous system, when disturbed in its function, necessarily influ- 
 ences the upper respiratory tract, as well as other parts of the body. 
 We may thus have vasomotor rhinitis and asthma, as well as certain 
 functional disturbances of the ear and the larynx as a result of a disturb- 
 ance of the general nervous system. 
 
 Hysteria probably comes under this heading, and while it is not 
 demonstrable histologically, it may have a histological basis. Hysteria 
 of the nose, throat, and ear, as in other parts of the body, is characterized 
 by a disturbance of those functions which are more particularly under 
 the control of the mind, the involuntary functions not being affected. In 
 the larynx, for instance, the normal respiratory movements are not dis- 
 turbed, as they are involuntary; whereas the movements of the larynx 
 
30 THE NOSE AND ACCESSORY SINUSES 
 
 which are concerned in the production of speech, being under the con- 
 trol of the mind, are voluntary, and are affected. 
 
 Hay fever, laryngeal cough, sneezing, bronchial asthma, anesthesia 
 and hyperesthesia of the mucous membranes of the ear, nose, and throat 
 are reflex phenomena, which may result from the irritation of the nervous 
 system by the toxic material in the circulation. 
 
 Another very important disease generally regarded as due to infection 
 of the blood is rheumatic fever, or acute articular rheumatism. The 
 gateway of infection is often through the tonsils, or some portion 
 of Waldeyer's ring. The throat symptoms of this disease are a red- 
 dened pharynx, with a defined or circumscribed inflammation of the 
 larynx, redness and swelling in the arytenoid region, and sometimes 
 fixation of the arytenoid cartilages. Pain and difficulty in phonation 
 and deglutition may also be present in rheumatic fever. The physician 
 should not only look upon the tonsils as the portals of infection, but he 
 should look to the pharynx and larynx for some symptoms of the 
 rheumatism. Acute rheumatic fever also gives rise to certain symptoms 
 which are not commonly recognized. For example, it may cause nose- 
 bleed in children, and in some cases is undoubtedly the cause of chorea. 
 
 Malaria is another disease affecting the blood which gives rise to 
 certain symptoms in the ear, nose, and throat. Mastoid pain, and, 
 indeed, mastoid suppuration, has been observed in which the malarial 
 element was prominent. In view of some recent observations, it may 
 be questioned, however, whether these cases were distinctly malarial 
 in their origin. We now know that there are certain septic conditions 
 which give rise to symptoms so nearly like those due to the plasmodium 
 of malaria that it may be questioned whether these cases were truly 
 malarial, or whether they were septic. It is known, however, that the 
 malarial poison may cause nasal hydrorrhea and vasomotor rhinitis. 
 
 The bloodvessels and lymphvessels are channels of communication 
 between the throat and the appendix. In certain cases of appendicitis 
 it has been shown that streptococcus infection was present both in the 
 throat and in the appendix. Another possible source of communication 
 in these cases is through the alimentary tract. 
 
 (c) The Digestive Tract. — The digestive tract, which prepares the 
 food for tissue building, is affected by the putrefactive and the patho- 
 genic microorganisms from the nose, throat, and ear. The primary 
 treatment should be addressed to the relief of the diseased conditions of 
 the upper respiratory tract, rather than to the stomach and the intestines. 
 The presence of dyspepsia, or other functional disturbances of the 
 stomach and the intestines, should lead to the examination of the nose 
 and throat, with special reference to the discharges from them, which 
 may be swallowed by the patient. On the other hand, if there is an irri- 
 table state of the nasal, pharyngeal, and laryngeal mucous membranes, 
 which is not explained by any local source of irritation, careful attention 
 should be given to the condition of the stomach and the intestines, or to 
 the organs of digestion and assimilation in general, with a view to deter- 
 mining whether they are properly performing their functions. If they 
 
ELEMENTARY FACTS 31 
 
 are not, the nutritive properties of the food are thrown into the circu- 
 lation imperfectly or insufficiently prepared for their purposes. The 
 irritation thus carried to the nasal mucous membrane and to the nerves 
 supplying it may be the chief cause of the local disturbances. It is obvious 
 that under these circumstances the treatment should be addressed to 
 the correction of the disorders of the digestive tract, rather than to the 
 nose, throat, and ear. 
 
 (d) Excretory Organs. — The function of the excretory organs is to 
 throw off the refuse material formed during the processes of nutrition. 
 The refuse consists not only of the material not needed for the nutrition 
 of the body, but also of the toxic material and the half-way products 
 of oxygenation already referred to. Hence, any impairment of the 
 functions of these organs results in an excess of toxic material in the 
 blood and the lymphatic vessels, thereby causing congestion, irritation, 
 hypertrophy, hyperplasia, or altered secretions in the upper respiratory 
 tract. This feature of the subject is intimately associated with those in 
 the preceding paragraphs. 
 
 The skin and the kidneys are the chief excretory organs of the body. 
 We will dismiss the skin with a brief reference to the fact that eczema, 
 lupus, etc., affecting other portions of the body, may also involve the 
 external nose and external ear. Or, the pathogenic processes may begin 
 with the skin of the nose or the external ear, and extend to other parts 
 of the body. We will also incidentally state that erysipelas of the 
 nose may involve the nasal mucous membrane, and that erysipelas of 
 the skin over the mastoid process may extend to the middle ear and 
 the mastoid cells, or even to the cranial cavity through the lymphatics 
 and the bloodvessels of this region. 
 
 The kidneys, however, are the excretory organs which chiefly interest 
 us in this connection. They may be diseased by prolonged infection in 
 remote parts of the body, as in the nasal sinuses or the alveolar processes — 
 pyorrhea alveolaris. Bright's disease may manifest its earliest symp- 
 toms in the mucous membrane of the throat. The throat symptom 
 complained of is dryness. This same symptom may also be present in 
 diabetes. Diabetes is mentioned here not because it is a disease of 
 the kidneys, but because its chief symptom is to be found in the examina- 
 tion of the excretions from the kidneys. 
 
 When a patient complains of persistent dryness of the pharynx his 
 urine should be tested for albumin, casts, and sugar. In some cases 
 albumin will not be found at first, but after a few years its presence may 
 be detected. 
 
 Edema of the glottis, causing laryngeal stenosis, is often due to uremia 
 developing as a result of Bright's disease. In the milder forms of uremia 
 bronchial asthma and hemorrhage of the upper air passages are some- 
 times found to be the chief expression of the disease. In the more pro- 
 nounced uremic conditions there may be aphasia from edema of the 
 brain. 
 
 (e) Proximity of Organs. — The close proximity of the organs of the 
 head favors a correlated pathological activity. The eye is near the 
 
32 THE NOSE AND ACCESSORY SINUSES 
 
 nose and has immediate communication with it through the tear duct, 
 as well as through the lymphatics, the bloodvessels, and the nervous 
 system; hence, disease in one often gives rise to certain symptoms in the 
 other. Experiments with certain colored solutions dropped into the eye 
 have shown the coloring matter within a very short time in the nasal 
 mucous membrane. The instillation of bacteria yields the same results. 
 Clinically, it is not uncommon to observe an inflammatory condition in 
 the eye simultaneously with or following a similar process in the nose. 
 I have often had cases referred to me by ophthalmologists who were 
 unable to prescribe satisfactory glasses until after I had corrected the 
 nasal condition, usually involving the middle turbinated body or the 
 ethmoid cells. The proximity of the nose to the ear, as well as the physio- 
 logical communication between them via the Eustachian tube, gives 
 rise to a very intimate relation between these organs. 
 
 It is well known that inflammation of the epipharynx sometimes extends 
 through the Eustachian tube, by continuity of tissue, to the middle ear. 
 This condition may develop until there is suppurative otitis media, 
 mastoiditis, and even intracranial complications. Adenoids are also 
 a fruitful source of mischief to the ear and the mastoid process. They 
 may mechanically obstruct the Eustachian tube, or the epipharyngitis 
 which almost invariably accompanies them may cause the ear disease. 
 The removal of adenoids in children is often followed by immediate 
 relief of deafness and of suppurative inflammation of the middle ear. 
 
 While the stomach is not so closely related to the ear as the epipharynx, 
 nevertheless it has a close pathological and anatomical connection 
 through the esophagus. In vomiting, foreign matter may be forced into 
 the Eustachian tube and the middle ear, and may cause otitis media 
 and its attending complications. From this same organ eructations 
 of gas may also cause irritation in the epipharynx and the Eustachian 
 tubes. 
 
 The nasal discharges, especially when there is empyema of the acces- 
 sory sinuses of the nose, usually pass backward into the epipharynx 
 and cause irritation and inflammation in this region. They also pass 
 to the larynx and cause more or less trouble there. Stenosis of the nose 
 interferes with the functions of that organ, and thus allows the air to 
 pass into the epipharynx, the larynx, and the bronchial tubes insufficiently 
 warmed, insufficiently moistened, and imperfectly filtered. Irritation 
 of the mucosa of the lower respiratory tract is thus caused and gives 
 rise to catarrhal inflammation. 
 
 The ear- is separated from the cranial cavity by a partition of bone 
 which in places is not more than one-sixteenth to one-eighth of an inch 
 in thickness. Chronic suppuration within the middle ear and the mas- 
 toid cavity often results in necrosis of this thin plate of bone, thus opening 
 a channel of communication between the middle ear and the cranial 
 cavity. The sequels or complications of mastoiditis, such as meningitis, 
 brain abscess, septic thrombophlebitis, etc., may thus result from ear 
 disease. 
 
 The nose is but slightly separated from the cranial cavity, and through 
 
ELEMENTARY FACTS 33 
 
 the ophthalmic veins may cause thrombophlebitis of the cavernous 
 sinus, which is usually fatal. 
 
 (/) Infections. — Systemic infections from the upper respiratory 
 tract have already been more or less considered in this chapter as well 
 as in the one on the Tonsils as Portals of Infection; hence, the subject 
 will not be elaborated here. 
 
 (g) The Central Nervous System. — It is obvious, inasmuch as the 
 central nervous system supplies the innervation of the nose, throat, and 
 ear, that in disease of the central nervous system the parts which it 
 supplies must be affected. In other words, in certain diseases of the 
 central nervous system some of its characteristic symptoms may be 
 found in the upper respiratory tract. 
 
 In tabes dorsalis there may be certain motor laryngeal disturbances, 
 which may be either bilateral or unilateral. There may be ataxic move- 
 ments of the vocal cords. Laryngeal crises, as spasmodic cough, may 
 be present. 
 
 Ear symptoms in tabes are rare. The cochlear and vestibular nerve 
 endings may, however, be congested. In this event there will be dimin- 
 ished or entire absence of bone conduction and hearing for the higher 
 tones. Dizziness, nausea, and nystagmus may also be present in excep- 
 tional cases. 
 
 In multiple sclerosis a tremulous voice, which is easily fatigued, and 
 is deep and hoarse in character, may be present. Muscular palsy of the 
 laryngeal muscles is rare. The ear symptoms in this disease are tinnitus, 
 and loss of hearing by bone conduction through the sclerotic degeneration 
 of the nuclei. 
 
 The symptoms found in paralysis agitans are about the same as those 
 found in multiple sclerosis. 
 
 (h) The Lymphatic System. — There are certain constitutional 
 symptoms due to infections through the lymphatic system which should 
 be especially singled out, although they have already been referred to 
 in Section (a) of this chapter. 
 
 We now recognize that a fever, characteristic of childhood, which has 
 heretofore been regarded as one of the ill-defined malarial infections, 
 is due to an infection through the adenoid growths in the epipharynx. 
 The fever usually runs an irregular course of about ten days, and is 
 characterized by an afternoon temperature of 100° to 104°, with rest- 
 lessness, peevishness, sharp pains through the ears at night, anemia, 
 general debility, loss of appetite, coated tongue with indentations from 
 the teeth, constipation, and cervical adenitis. Mouth breathing is 
 not essential as a factor in causing the infection. A small amount of 
 lymphatic tissue in the epipharynx is a sufficient portal for the entrance 
 of the bacteria. The presence of this type of fever is almost always 
 an indication for the removal of the adenoids. If the child is known to 
 be tuberculous, some consideration may be given to the matter before 
 removing them, for if the removal is imperfectly done, it may give rise to 
 a recrudescence of the tuberculous infection, which may extend to the 
 lungs and lead to a fatal issue. 
 
34 THE NOSE AND ACCESSORY SINUSES 
 
 Another disease which may express itself through certain patho- 
 logical changes in the ear, nose, and throat is syphilis. The nose may 
 be the primary seat of the lesion, the infection taking place in the removal 
 of crusts from the septum with the finger. The tonsils are occasionally 
 the seat of the primary lesion or chancre through the use of infected 
 instruments in the throat. The author has seen cases in which both 
 tonsils were the seat of chancre as a result of the instruments used in 
 lancing a peritonsillar abscess. 
 
 In one case there was the characteristic initial lesion in the left tonsil, 
 with the cervical bubo on the same side, which was followed a few days 
 later by the characteristic skin eruption. The source of the infection 
 in this case was the dirty instruments used in lancing a peritonsillar 
 abscess. I first saw the case six weeks after the tonsils were lanced. 
 The patient had been complaining of sore throat for two or three weeks. 
 The tonsils and the bubo were still very much in evidence and the erup- 
 tion on the skin had just begun to show. In the course of another week 
 the corona veneris developed. The copper-colored eruption on the 
 face showed more plainly at a distance of twelve or fifteen feet than it 
 did when viewed near by. 
 
 Secondary syphilis may manifest itself by mucous patches in the 
 buccal cavity, by hyperemia of the larynx, hoarseness, and syphilitic 
 coryza, with scanty, thick secretion from the nose. Syphilitic coryza 
 is not always recognized by the family physician, it being regarded as a 
 simple obstinate cold in the head. The scanty thick discharge, with 
 stenosis of the nose, should, however, excite suspicion of the true nature 
 of the disease. 
 
 I once saw a case in which there was a marked arrest of development 
 of the bones of the face because, when in childhood the syphilitic coryza 
 developed, the family physician regarded it as an ordinary cold. He 
 treated the patient for the same without success, and was finally surprised 
 to find the nasal bones and the septum giving way. The soft palate and 
 the pharynx later became involved and rapidly melted away under the 
 blighting influence of the Spirocheta pallida. The patient is now thirty- 
 six years old, and has the most pronounced "frog" face I have ever 
 seen. Adhesive bands bind the soft palate to the pharyngeal wall, 
 making it difficult for him to speak distinctly, though he is now suc- 
 cessfully engaged in business. 
 
 The tertiary manifestations of syphilis are syphilitic pharyngitis and 
 laryngitis, with a raucous voice. Syphilitic lesions of the tonsils, pre- 
 senting a dirty grayish necrotic surface resembling diphtheria, are occa- 
 sionally observed. Syphilitic gummata are not excessively destructive 
 in character. Syphilitic papillomata of the tonsils and the soft palate 
 are elsewhere described. 
 
 Recent investigations have discredited the oft-repeated statement that 
 the skin and the mucous membranes of the animal organism are insur- 
 mountable barriers to microorganisms so long as the epithelial coat is 
 intact. Bono and Frisco report that the researches undertaken at the 
 Institute of Hygiene at Palermo have established the fact that germs 
 
ELEMENTARY FACTS 35 
 
 deposited on the intact skin or mucosa are found soon afterward in the 
 lymphatic ganglia of the respective regions. If the germs are so numerous 
 or so virulent as to overcome the resistance offered by the lymphatic 
 ganglia, general infection follows. If not, there is merely a local 
 reaction on the part of the ganglia, which become tumefied and undergo 
 various modifications in their structure proportional to the number of 
 germs which reach them. 
 
 Diseases of the Eye Due to Nasal Lesions. — To establish the 
 relationship between the nasal mucous membrane and the eye, micro- 
 organisms were placed on the nasal mucous membrane, both with and 
 without obliteration of the nasolacrymal canal. The result of the 
 experiments showed the penetration of the germs into the vitreous and 
 the aqueous humors of the eye on the same side. (Bono and Frisco.) 
 
 "None of the animals exhibited any signs of general infection. One 
 or two colonies, at most, could be derived from the blood in the heart, 
 the liver, the spleen, and the lymphatic ganglia of the neck, and occasion- 
 ally from the anterior auricular, the submaxillary, the deep jugular, 
 and the carotid lymphatic ganglia. This fact, considered in connection 
 with the presence of large numbers of germs in the aqueous and the 
 vitreous humor, and the absence of general infection, warrants the con- 
 clusion that the bacteria penetrated directly into the eye from the nasal 
 and the conjunctival mucous membranes, and that they also arrived 
 secondarily in the eye through the blood, but reduced in numbers and 
 virulence. Part of the germs were retained by the ganglia connected 
 with the anterior lymphatic vessels of the eyeball and its appendages. 
 In further experiments with instillations of India ink it was possible to 
 trace the exact route followed by the particles from the conjunctival 
 lymphatics along Sehlemm's canal into the anterior chamber and thence 
 into the vitreous. From the lymphatics of the nasal, mucosa the particles 
 passed into the ethmoid cells and the lamina papyracea, thence into 
 Tenon's capsule, and on into the eyeball. The practical results of these 
 researches are particularly important in the pathology of the eye." 
 
 F. Mendel, after observing many cases, comes to the conclusion that 
 the nasal infection and inflammation is transferred to the eye by the direct 
 connection or continuance of the epithelium of the nasal mucous mem- 
 brane to the conjunctiva, as well as by the intimate vascular association. 
 
 The ophthalmic artery gives off the anterior ethmoidal, w T hich supplies 
 the nose and the lacrymal canal. The venous supply of the nasal mucous 
 membrane, by means of the lacrymal plexus, is in direct communication 
 with the ophthalmic vein. 
 
 Heber Nelson Hoople, in a paper read before the American Laryn- 
 gological, Rhinological, and Otological Association, in 1901, advances 
 the theory that faulty pressure within the nose can cause asthenopia 
 of both the ciliary and external ocular muscles. That is, mechanical 
 pressure in a limited area of the nose, called by Mackenzie the reflex 
 area, can cause muscular asthenopia. By muscular asthenopia he 
 means the impairment of the efficiency of the ocular muscles in the 
 performance of their ordinary functions. 
 
36 THE NOSE AND ACCESSORY SINUSES 
 
 The pressure to which Hoople refers is confined chiefly to the middle 
 turbinal, especially in great enlargement of the middle turbinated body. 
 
 A concomitant symptom usually occurring in conjunction with the 
 asthenopia is a browache or headache referred to the frontal region or 
 to the occiput in rarer instances. 
 
 He cites a number of cases in his own practice and in that of others 
 in which the asthenopia disappeared as soon as the nasal pressure was 
 overcome. The asthenopic cases referred to belong to the so-called 
 normal type rather than to the excessive type. 
 
 He concludes that a moderate amount of pressure or mechanical irri- 
 tation of the middle turbinated body against the adjacent septum will 
 temporarily impair the function of the ciliary muscle; to a lesser or more 
 variable degree it will also impair that of the external ocular muscles. 
 If mechanical irritation (from congestion or swelling of the soft tissues) 
 can impair the functions of these muscles, how much more would a con- 
 tinuous pressure from a septal spur or other deviation of the septum 
 digging into the middle turbinal keep up this impairment? 
 
 The reason for the association of headache with asthenopia is that they 
 have a common cause — pressure upon the sensorimotor branches of the 
 trigeminus. So far as the sensory part is affected, a radiated or a reflex 
 headache is produced; so far as the sympathetic fibers are affected a 
 vasomotor reflex is produced. This is equally true where there are 
 inflammatory conditions, as ethmoiditis. It matters little whether the 
 pressure is from within the ethmoid cells and turbinal or from without 
 these structures. The important point is that the same branches of 
 these nerves are pressed upon, and, therefore, the same kind of dis- 
 turbances should be expected to follow. 
 
 The asthenopic disturbance is probably due to irritation of the sym- 
 pathetic fibers in this particular class of cases. That it is such in all 
 cases is also probable. It could be inferred from other facts, e. g., when 
 treatment addressed to the uterus, the bladder, or the stomach has given 
 relief to the asthenopic symptoms. 
 
 In the light of the foregoing views expressed by Hoople, asthenopia or 
 disturbed function of the ciliary and external ocular muscles is usually 
 due to intranasal pressure and irritation in the middle turbinal and 
 ethmoidal regions, rather than to toxemia from infection of the sinuses. 
 The speedy relief of the asthenopia following the divulsion or the removal 
 of the offending middle turbinal seems to prove this view rather than the 
 view referring the disturbance to toxemia. 
 
 In the cases referred to by Hoople the headaches were of the ocular 
 rather than the sinus type, as they were induced, or aggravated, by the 
 use of the eyes, and were relieved upon retiring for the night. Sinus 
 headache is not always aggravated by using the eyes, and is often most 
 pronounced upon awakening. 
 
CHAPTEE III. 
 
 THE OFFICE EQUIPMENT. 
 
 In the equipment of an office the chief point to be considered is facility 
 in treating patients. The treatment and consultation rooms should 
 be equipped for work rather than for entertainment. Everything for 
 facility and thoroughness; nothing for show. "Bluff" is a confession 
 of unfitness. Thorough knowledge and frankness of statement will 
 inspire confidence and give an impression of mastery as no amount 
 of " bluffing" will do. 
 
 The essential furnishings of the consultation room and treatment 
 room should consist of the following : 
 
 (a) Treatment and operating chair. (6) A revolving stool for the 
 surgeon, (c) A treatment table or cabinet, (d) A fountain cuspidor, (e) 
 A linen cupboard, (f) A writing desk, (g) A sterilizer. (/*) A revolving- 
 desk chair, (i) Two small chairs. (;) An adjustable bracket for the 
 examination lamp, (k) A selection of instruments and apparatus for 
 examinations, treatments, and operations. 
 
 The Treatment and Operating Chair. — This should be a revolving 
 chair, as suggested by Dr. Robert Levy, as it is desirable to turn the 
 patient from side to side in treating his ears, and for other reasons as well. 
 The bottom should be on a central screw pin, so that it can be adjusted 
 to different heights for children and adults. The back should be so 
 constructed that it can be lowered to a horizontal position in case of 
 faintness and when it is desirable to operate with the patient in a prone 
 position. An adjustable head-rest should be attached to the back of 
 the chair (Figs. 6 and 7.) An ordinary chair may, of course be used, 
 but in the case of faintness, etc., the work is greatly facilitated and the 
 comfort of the patient assured if the chair is of the adjustable type 
 described. 
 
 The Treatment Table or Cabinet. — If an assistant is employed it is 
 preferable to have the instruments in a separate cabinet in an adjoining 
 sterilizing room or corner. The treatment cabinet may then consist of 
 a metal enamelled frame with a plate-glass top, or it may be a double- 
 decked table, with top and shelves about one foot apart. These tops 
 afford ample room for the distribution of bottles containing remedies 
 for topical applications and for the instruments of examination and 
 operation. 
 
 The treatment table or cabinet (Fig. 8) is an important piece of 
 furniture. Its selection should depend largely upon whether the sur- 
 geon has an assistant to wait upon him. If he has, the cabinet need not 
 be constructed to contain all his instruments, as the assistant will bring 
 
38 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 the ones which are necessary for each case. If he does not have an 
 assistant, it is convenient to have the instruments in the cabinet within 
 his reach. 
 
 The Hot-water Basin. — A most excellent addition to the table is a 
 basin, set in the centre of the upper glass top, with running hot water for 
 the purpose of rinsing instruments during the course of treatments. If 
 preferred, the hot-water basin may be attached to a special wall bracket 
 (Fig. 9), as it is only intended as a convenience. It is also useful in 
 
 Fig. 6 
 
 Fig. 7 
 
 Operating chairs. 
 
 cleansing and warming the laryngeal mirror during throat examinations. 
 No matter how sterile the tongue depressor may be when first used, its 
 introduction into the mouth the second or third time without cleansing 
 is, to say the least, disgusting to the patient. 
 
 A basin of running hot water is, therefore, an invaluable, and I might 
 add an indispensable, adjunct to the office equipment. It is not, however, 
 indispensable in so far as the safety of the patient is concerned, as only 
 his own secretions come in contact with the instrument used. If the 
 fundamental principles of common cleanliness are to be recognized it is a 
 
THE OFFICE EQUIPMENT 
 
 39 
 
 valuable and necessary office fixture. It is not a question of whether 
 it pays, but rather one of common decency, and that always pays. 
 
 Fig. 8 
 
 Pynchon's medicine and instrument cabinet. 
 Fig. 9 Fig. 10 
 
 Clark's hot-water basin. 
 
 Clark's fountain cuspidor. 
 
 A bowl of antiseptic solution is not a substitute for running hot water 
 unless the bowl is refilled for each rinsing. The solution would otherwise 
 
40 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 soon become thick with secretions and detritus, and the introduction of 
 an instrument into it for rinsing purposes would be even more digusting 
 than no rinsing at all. 
 
 The Examination Lamp. — The examination lamp may be a kerosene, 
 gas, or an electric lamp; the latter is preferable, because it gives off less 
 heat and requires less attention. The lamp may or may not have a hood 
 
 with a focussing lens, as the surgeon may 
 Fig. 11 elect. Personally, I prefer an electric lamp 
 
 of 50 candle-power (Fig. 11). This should 
 have a ground-glass surface, except a circular 
 area on one side, where the glass should be 
 clear. 
 
 It affords plenty of light, is simple, throws 
 out little heat, and is inexpensive. 
 
 A wall bracket to support the lamp is an 
 important item, inasmuch as it is constantly 
 used. It should, therefore, be well con- 
 structed and accommodate itself to the vary- 
 ing conditions under which it is used. That 
 is, it should be so constructed that the lamp 
 can be raised and lowered and turned from 
 side to side with the least trouble to the 
 operator. It should be so well made that 
 it will never get out of order, a state or con- 
 . M dition into which many wall-lamp brackets 
 
 A 50 candle-power electric lamp «/ f 
 
 with a rotating socket. are likely to fall. I hat shown in big. 12 
 
 Fig. 12 
 
 Wall-lamp bracket. 
 
 has proved quite satisfactory in nearly every respect. A Kierstein 
 head lamp (Fig. 13) is preferred by some operators. 
 
 Compressed-air Apparatus. — The compressed-air apparatus may 
 be one of three types : (a) A hand bulb; (6) a tank pumped by hand or by 
 some automatic device, as a water pump ; or (c) a system of compressed 
 
THE OFFICE EQUIPMENT 
 
 41 
 
 air supplied throughout the building by means of pipes from a central 
 compressed-air tank. The latter is preferable when it can be obtained, 
 as it requires no attention whatever. A compressed-air tank in the 
 office automatically supplied by means of a hydraulic pump is the 
 next most preferable arrangement. A hand pump is inconvenient 
 and necessitates considerable labor. The hand bulb is suitable when 
 eight pounds or less of pressure is required. 
 
 An Accessory Regulating Air Tank. — An accessory regulating air 
 tank is a very convenient and valuable addition to the compressed-air 
 system, as it enables the surgeon to use the amount of pressure required 
 for various purposes. The nasal mucous membrane, for example, will 
 not tolerate a higher pressure than ten pounds with the De Vilbiss spray 
 tube, whereas the pharynx will tolerate from twenty to forty pounds' 
 pressure. A nebulizer requires a higher pressure than the spray tube, 
 and in inflation of the Eustachian tube and middle ear the pressure 
 
 Fig. 13 
 
 Kierstein lamp and head bracket. 
 
 required varies from eight to twenty pounds, according to the degree 
 of obstruction present. Hence, a regulating air tank is a convenient 
 if not a necessary apparatus. The tank should be connected with the 
 main reservoir and the compressed air turned on until the gauge indi- 
 cates the required pressure, say ten pounds. If at another time in the 
 treatment but two pounds' pressure is needed the escape valve may be 
 opened until the gauge indicates two pounds. There are many other 
 ways in which such a regulating air tank may be used to advantage. 
 The gauge regulators on the market are not nearly so satisfactory as the 
 Pynchon and Hubbard regulating tanks, and are not recommended. 
 
 Massage Apparatus. — Ear Drum. — Pneumomassage or the massage 
 of the ear drum by the alternate rarefaction and condensation of the air 
 in the external auditory meatus is accomplished by means of a hand 
 pump, as first devised by Delstanche, of Brussels (Fig. 14), or it may be 
 operated by an electric motor, as first devised by Chevalier Jackson, of 
 
42 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Pittsburg, and later, in 1893, improved by Pynchon (Fig. 15). The 
 pneumomassage of the ear drum is recommended in deafness and ear 
 
 Fig. 14 
 
 Delstanche's rarefactor and artificial leech. 
 Fig. 15 
 
 The Victor electrocautery with Pynchon' s pneumomassage pump. 
 
 noises of catarrhal origin, though its value has been greatly exaggerated. 
 Delstanche was of such high repute that he was awarded the Lenval prize 
 
THE OFFICE EQUIPMENT 43 
 
 for having designed the best instrument for relief of deafness, hence 
 the procedure was adopted by aurists all over the world. Subsequent 
 experience with it and its modifications has not justified the high expecta- 
 tions with which it was received. Pneumomassage has a place in aural 
 practice, however, as by it the mucous membrane is brought into a 
 more active and resistant state, and the labyrinth is also stimulated 
 to greater functional activity by it. In a limited number of cases the 
 ossicles of the ear are rendered more mobile and transmit sound better 
 after its application. Tinnitus is also occasionally relieved by it. Such 
 cases require rare skill and knowledge to determine what is best to do 
 for them. Routine inflation and pneumomassage are almost without 
 result except in a few cases. Accurate diagnosis is of first importance; 
 then the treatment should be very carefully and intelligently prescribed. 
 Few cases of deafness and tinnitus are relieved by pneumomassage. 
 
 Then, too, the massage apparatus should be regulated to suit each 
 case. The length of the piston stroke, the frequency of the vibrations, 
 and the length of time the massage should be used are questions to be 
 settled according to the peculiarities of each case and the experience 
 and judgment of the surgeon. Massage per se is of no value as a thera- 
 peutic agent. It is only when it is used with " brains" that it becomes 
 of value. Surgeons who are uninformed and inexperienced are often 
 tempted to furnish their offices with formidable-looking mechanical 
 devices, with the belief that they are thus preparing themselves to ade- 
 quately cope with disease. If they are intelligent observers, they soon 
 learn that the "man behind the gun" is the first requisite for the 
 attainment of success. 
 
 I have, however, found the hand apparatus of Delstanche of the great- 
 est value as a diagnostic agent. With it the ear drum may be observed 
 under compression and rarefaction, and points of adhesions and of 
 atrophy are clearly demonstrated. When the air is rarefied in the meatus, 
 the points of adhesion being fixed, the remainder of the membrane bulges 
 outward, leaving no doubt as to the condition of the middle ear. If 
 there is an atrophic area in the ear drum it bulges like a blister beyond 
 the other parts of the membrane. If the otoscopic portion of the 
 apparatus is provided with a magnifying lens the texture of the ear 
 drum may be clearly demonstrated. 
 
 Aside from the diagnostic value of the Delstanche apparatus, its greatest 
 usefulness is in the treatment of the exudative forms of middle-ear 
 catarrh. It is in the protracted course of these cases that the adhesive 
 processes form. The viscid exudate agglutinates the ear drum to the inner 
 tympanic wall, becomes organized, and thus permanently fixes it to the 
 inner wall of the middle-ear cavity. The timely and intelligent use of 
 the Delstanche rarefactor, or other pneumomassage apparatus, may 
 prevent permanent adhesions. The apparatus should in the beginning 
 be used daily with a slow, long stroke of the piston. After the inflam- 
 matory process has abated and the exudate is less viscid and less 
 profuse the treatment may be gradually reduced in frequency and 
 finally abandoned. The length of the stroke (force of the suction) 
 
44 THE NOSE AND ACCESSORY SINUSES 
 
 should be gradually diminished, as a too long-continued stretching of 
 the membrana tympani will render it abnormally lax from pressure 
 (suction) atrophy. 
 
 Another device for the massage of the ear drum consists of a glass 
 tube partially filled with metallic mercury (Fig. 16). The open end of 
 the tube is shaped to fit the external meatus, and when not in use is 
 closed with a rubber cork. Its application is simple, the uncorked end 
 being placed firmly in the external meatus, and the patient instructed to 
 move the head from side to side, allowing the mercury to drop against the 
 ear drum. This procedure is repeated several times at each daily seance. 
 According to Dr. Joseph C. Beck, its originator, the rationale of its use 
 consists in the impact of the mercury against the malleus and ear drum, 
 the force being transmitted to the entire ossicular chain and to the laby- 
 rinth. This stimulates the functional activity of these structures and 
 improves the condition present. Dr. Beck has found its chief useful- 
 ness in the relief of the tinnitus rather than the deafness, a fact which 
 to my mind is significant. That is, the mechanical shocks thus applied 
 to the membrana tympani and transmitted to the labyrinth affect the 
 circulation of the labyrinth, improve the nutrition and increase the local 
 leukocytosis. Dr. Beck has also noted that the improvement was usually 
 transient, lasting only a few days or weeks after discontinuing the treat- 
 ment. 
 
 Fig. 16 
 
 aiiiliiii; 
 
 Beck's mercury massage. 
 
 The Electrocautery. — So much has been said within recent years 
 about the use, or rather the uselessness, of the electrocautery (Fig. 15) 
 that I feel impelled to defend it. It is still a very useful apparatus, 
 and an office is incomplete without it. It is true that it has been too 
 frequently, indiscriminately, and unintelligently used, but it still fills 
 a place of great usefulness in the armamentarium of the specialist. 
 Its usefulness in turgescent rhinitis has been greatly abridged by the 
 improved methods of operating upon the nasal septum (notably the sub- 
 mucous resection), but even in this condition it still affords a means of 
 temporarily overcoming the excessive swelling of the inferior turbinated 
 bodies. It also affords a valuable means of treating chronic granular 
 pharyngitis with lymphoid enlargements along the lateral and posterior 
 walls of the pharynx. Still other uses could be described, but as they 
 are mentioned in connection with the respective diseases, the two cita- 
 tions are sufficient to show that the electrocautery apparatus is not an 
 obsolete instrument. 
 
 Spray Tubes. — The spray tubes and the medicated fluids used in 
 them have also come under the ban as therapeutic agents. There was 
 a time when the rhinologist and laryngologist was called the "spray 
 specialist/' more derisively a "squirt-gun doctor/' Whatever grounds 
 
THE OFFICE EQUIPMENT 
 
 45 
 
 there may have been for these characterizations it is certain that they do 
 not apply to the specialist of the present time. Nearly all special sur- 
 geons now recognize the futility of attempting to cure diseases of the 
 nose and throat by means of medicated water and oil. The etiology of 
 the catarrhal and suppurative inflammations of the nose and throat is 
 better understood, and the ideas concerning their treatment have under- 
 gone corresponding changes. It is being more and more recognized that 
 mucous-lined cavities are subject to catarrhal and infective inflammation 
 somewhat in proportion to the degree of obstruction to their drainage 
 and ventilation. This one factor is probably the most significant etiolog- 
 ical factor emphasized in recent years. Goodale and Jonathan Wright 
 emphasize it in reference to the crypts of the tonsil. Heath has recently 
 emphasized the same truth in reference to the mastoid antrum and the 
 middle ear. (See M e at o mastoid Operation; also the Clinical Anatomy 
 of the Nose, and the Inflammatory Diseases of the Xose and Accessory 
 Sinuses.) 
 
 Fig. 17 
 
 De Vilbiss' atomizer and nebulizer. 
 
 In view of this more modern conception of the etiology of the inflam- 
 matory diseases of the ear, nose, and throat, surgical procedures have 
 largely replaced the topical and caustic applications once in popular 
 favor. The spray tube or atomizer occupies a less conspicuous place 
 than it did a few years ago (Fig. 17). An array of fifty or a hundred 
 spray bottles, each with a different medicated or perfumed solution, 
 is no longer a necessary part of an office outfit; indeed, such an array 
 of spray formulae is in some ways a confession of an antique, if not alto- 
 gether obsolete, conception of medical practice. Spray tubes are, never- 
 theless, necessary adjuncts to the office outfit, as they should be used 
 to cleanse the nasal and throat cavities before operating and treating 
 acute and chronic inflammations. 
 
 George F. Hawley's spray tube (Fig. 18) is the best cleanser, as it 
 throws out a coarse spray in every direction and softens and dislodges 
 
46 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 the tenacious and dried secretions. The straight tip may be inserted 
 into the sphenoidal sinus after the middle turbinate has been removed, 
 and the secretions thoroughly washed out. The apparatus as a whole 
 is an excellent substitute for other methods of irrigating the nose. The 
 straight tip may be bent to conform to the requirements for reaching 
 the frontonasal duct and maxillary sinus. Postnasal and laryngeal 
 tips make it a universal instrument for irrigating the upper respiratory 
 passages on account of the improved methods of topical and surgical 
 treatment now in vogue. 
 
 Fig. 18 
 
 Hawley's spray tubs. 
 
 The Mechanical Vibrator. — Some years ago the mechanical vibrator 
 was mentioned as acting favorably upon tinnitus and deafness, but its 
 more general use by English and American otologists has demonstrated 
 its comparative uselessness for these purposes. At that time it 
 was stated that when applied over the spinal column it seemed to act 
 favorably upon the ear. I have tried it faithfully for this purpose, with 
 no appreciable effect. Its chief field of usefulness is in reducing the 
 swelling and sensitiveness of the glands of the neck and the headache 
 accompanying the various sinus affections. But even these conditions 
 are better and more pleasantly ameliorated by the leukodescent lamp. 
 The vibratory or mechanical massage increases the lymphatic flow, 
 improves the nutrition, and increases local leukocytosis. Hence, it 
 relieves pain and tenderness, and reduces the activity of an inflammatory 
 process, provided it can be applied to the parts. In this respect it acts 
 upon the principle of Bier's constriction and negative pressure treatment, 
 and the leukodescent-light treatment; that is, it increases the local leuko- 
 cytosis, improves the local nutrition, and thus diminishes the infectious 
 process. 
 
 Negative Pressure Apparatus. — This apparatus consists of a device 
 whereby the air pressure is reduced in the upper air passages, notably 
 the nose and accessory sinuses (Fig. 19). The negative air pressure 
 within the nose and accessory sinuses facilitates the discharge of the 
 
THE OFFICE EQUIPMENT 
 
 47 
 
 secretions and purulent accumulations, increases the local nutrition and 
 leukocytosis, and acts favorably upon the inflammatory process. Its chief 
 field of usefulness seems to be in the treatment of the subacute inflamma- 
 tions of the sinuses, though it exerts a favorable influence upon chronic 
 sinuitis. 
 
 The Leukodescent Lamp. — The leukodescent lamp is a single in- 
 candescent globe of 500 candle-power (Fig. 20), around which is placed a 
 reflector eighteen inches in diameter. The reflector focuses the rays of 
 light, thus increasing their penetrating power. The therapeutic properties 
 of the leukodescent light is in the heat and chemical rays. The leuko- 
 descent light is rich in blue-violet rays, in addition to the light and heat 
 rays. The blue-violet are very active chemical rays and increase the 
 tissue metabolism and the leukocytosis, thus providing for the destruction 
 of the pathogenic bacteria. 
 
 Fig. 19 
 
 Fir,. 20 
 
 Pynchon's modification of Dabney's vacuum aspirator. The leukodescent therapeutic lamp. 
 
 Clinically, I have found the leukodescent light of value in infectious 
 and inflammatory processes. For instance, I have seen cases of chronic 
 maxillary empyema with granulations cease discharging under its influ- 
 ence. The pain, tenderness, and swelling likewise disappeared. In 
 no case, however, have I seen a cure by this mode of treatment. In 
 acute sinuitis I have seen marked and rapid improvement follow its 
 use. Infection of the mastoid wound rapidly improves under its use 
 three times daily. Cervical adenitis usually responds readily to the 
 rays. Pain of almost any origin is relieved and in many cases stopped 
 by it. The pain of sarcoma is almost invariably checked. It seems 
 to exert a slight control over an oozing postoperative hemorrhage. Its 
 
48 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 power to increase tissue metabolism and local leukocytosis reduces 
 the bacterial activity. The latter is probably due more to the increased 
 leukocytosis than to the bactericidal property of the rays. While they are 
 bactericidal when applied continuously for ten minutes at a distance 
 of thirteen inches in the laboratory, they are probably not bactericidal 
 at eighteen inches for a few moments at short intervals in their clinical 
 application. The rays are too hot to be tolerated constantly at close 
 range, hence the effects produced in laboratory experiments cannot be 
 duplicated in actual practice. 
 
 Lamps of less candle-power are correspondingly poor in the blue- 
 violet rays, the 50 candle-power lamp having scarcely a trace of them. 
 It has been shown that ten 50 candle-power lamps grouped have iden- 
 tically the same quality of rays as a single 50 candle-power lamp, and 
 that the rays are in no way similar to those given off by a 500 candle- 
 power lamp. A single 500 candle-power lamp should be chosen, as 
 a lamp of less capacity is not sufficiently rich in the chemical rays to 
 produce the best results. 
 
 Fig. 21 
 
 Pynchon's sterilizer and instrument dryer. 
 
 A Sterilizer for Instruments and Gauze. — An office outfit is not com- 
 plete without a sterilizer of some kind. All instruments should be boiled 
 in a 2 per cent, solution of sodse biboras for at least twenty minutes 
 before they are used, for either examinations, treatments, or surgical 
 operations. The instruments may be boiled in a porcelain-lined bucket 
 or pan, or in a specially designed sterilizer, as shown in Fig. 21. The 
 apparatus shown in the illustration is provided with a drying chamber 
 in addition to the boiling tray, and is recommended on this account. 
 Instruments are often damaged or altogether ruined because they are not 
 dried after being sterilized. With this sterilizer they may be boiled 
 and dried after an operation. 
 
 Topical Applications. — Topical remedies which should have place 
 upon the treatment table are numerous, though individual preference 
 may greatly modify their number and character. I shall only refer to 
 those which have proved satisfactory in my practice. 
 
 Nitrate of Silver. — The following solutions of the nitrate of silver should 
 be kept on the treatment table in blue-glass bottles, or in a cabinet within 
 convenient reach of the surgeon or his assistant. 
 
THE OFFICE EQUIPMENT 49 
 
 1^. — Argenti nitratis gr. x 
 
 Aquae des 5J — M. 
 
 This is approximately a 2 per cent, solution of the silver salt, and is 
 useful when a mild but positive astringent action is required, as in 
 simple subacute catarrhal inflammation of the upper respiratory tract. 
 It may be applied with a spray tube, the essential parts of which are made 
 of hard rubber and aluminum, or of glass. Other metals are acted 
 upon by the silver salt, and are not suitable for the silver solutions on 
 this account. The silver solution may also be applied with a cotton- 
 wound applicator. A camePs-hair brush is not recommended, on ac- 
 count of the difficulty of keeping it sterile. 
 
 1$. — Argenti nitratis gr. xx 
 
 Aquae des 3J — M. 
 
 This solution is approximately 4 per cent, in strength, and may be 
 used as No. 1 when a more positive astringent and antiseptic action is 
 required. 
 
 1$. — Argenti nitratis gr. xl 
 
 Aquae des 5J — M. 
 
 This solution is approximately 8 per cent, in strength, and is useful 
 in the more chronic catarrhal inflammations of the upper respiratory 
 tract. Solutions of greater strength than this are rarely indicated in 
 chronic inflammations of the mucous membrane except when a caustic 
 action is required. Greater strengths are apt to cause irritation and an 
 aggravation of the local chronic inflammation. 
 
 In the very acute inflammations a much higher percentage of silver 
 may be used. 
 
 1$. — Argenti nitratis 5j 
 
 Aqua? des q. s. ad 3J — M. 
 
 This is a V2h percent, solution, and is a valuable local remedy in acute 
 lacunar inflammation of the tonsils. The more acute the attack and 
 the more edematous the tissue the stronger the silver solution should be. 
 
 1$. — Argenti nitratis 3 i J 
 
 Aqua? des q. s. ad 5j — M. 
 
 This is a 25 per cent, solution, and is useful as a local application in 
 acute infectious inflammations of the fauces. It is especially useful in 
 acute lacunar tonsillitis, one application in the primary stage often being 
 sufficient to abort the inflammatory process. 
 
 1$. — Argenti nitratis gr. ccccxxxij 
 
 Aquae des q. s. ad 5j 
 
 This is a 90 per cent, solution, and is useful in acute lacunar tonsillitis 
 in the most virulent and acute stage. It should only be applied when 
 the inflammation is very recent and aggravated in type. The tissues 
 should be succulent and highly inflamed. In such a case it is a specific 
 remedy. I have never seen a case corresponding to the above descrip- 
 •i 
 
50 THE NOSE AND ACCESSORY SINUSES 
 
 tion in which the second application of the remedy was necessary. Its 
 use in this strength is not painful, but, on the contrary, relief immedi- 
 ately follows. 
 
 If this strength of solution were applied to a subacute inflammation 
 the chemical trauma would probably aggravate the existing inflammatory 
 process rather than relieve it. A solution of silver salt of this strength 
 coagulates the mucous secretions and blanches the surface of the inflamed 
 mucous membrane. It is also a powerful germicide. The inflammatory 
 infiltration of the tissue is checked and the vitality of the infective bac- 
 teria is greatly impaired. 
 
 Caution should be observed in using silver nitrate. The salt in any 
 strength has a marked irritating effect on the intrinsic muscles of the 
 larynx. To avoid this accident the cotton-wound applicator should be 
 freed of the excess of the solution by squeezing it with a liberal wad of 
 cotton. When this is done the inflamed area should be lightly brushed 
 with it. 
 
 The following rules are valuable: (a) The milder the inflammation 
 the milder the solution, (b) The more intense the inflammation the 
 stronger the solution. 
 
 Guaiacol Solutions. — Solutions of guaiacol in olive oil are useful 
 local remedies in acute inflammation of the fauces and pharynx. 
 
 The strengths recommended are 10, 25, and 50 per cent, of guaiacol 
 in pure olive oil. The more severe the inflammation the stronger the 
 solution required. 
 
 While guaiacol is not as efficient a remedy in acute tonsillitis as the 
 stronger solution of silver, it is nevertheless very positive in its action, 
 many cases requiring but a few applications to check the inflammatory 
 process. It produces a pungent, hot sensation which lasts for about 
 thirty seconds. 
 
 Compound Tincture of Benzoin. — The compound tincture of benzoin 
 is a valuable local remedy in the throat when a mild but positive astrin- 
 gent and antiseptic remedy is indicated. It may be used in chronic 
 granular pharyngitis during the mild exacerbations of the disease with 
 good effect. 
 
 Its chief value is as an adjunct in dressing the nasal accessory cavities. 
 The gauze should be moistened in the solution, the excess removed by 
 squeezing, and packed in the nasal cavity. It prevents decomposition 
 and stimulates healthy granulations. A plain gauze dressing in the 
 nasal chambers, if allowed to remain more than twenty-four hours, 
 often takes on a very offensive odor. If the gauze is moistened with 
 the compound tincture of benzoin, it may remain in the nose seventy- 
 two hours without acquiring an offensive odor. 
 
 A foul-smelling chronic otorrhea may be rendered sweet by mopping 
 the cavity dry and applying a dressing of gauze moistened with the 
 compound tincture of benzoin. 
 
 Subnitrate of Bismuth Powder.— This powder may be used with 
 gauze dressings as a substitute for the compound tincture of benzoin. 
 It also prevents decomposition, though not over so extended a period. 
 
THE OFFICE EQUIPMENT 51 
 
 It may also be insufflated (Fig. 22) into the nose after an intranasal 
 operation, where it forms a coating which acts as a mechanical and a 
 chemical protection to the underlying tissue. 
 
 Fig. 
 
 SECTION SHOWING POWDER SCOOP. 
 
 Powder insufflator. 
 
 Ichthyol Solutions. — Ichthyol in aqueous and glycerin solutions may 
 be used as a topical application in the nasal chambers where there is 
 a foul or ozenic secretion. The nose should be packed with cotton or 
 gauze saturated with the solution. Personally, I prefer to use a cork- 
 screw applicator wound with cotton and dipped in the ichthyol solution. 
 This is then introduced into the nasal cavity and the applicator removed 
 with a reverse screw motion, leaving the ichthyol pad in the nose. This 
 should be left in place for from ten to thirty minutes, according to the 
 degree of infection and tumefaction of the tissue. If the secretions are 
 profuse and dried in the nasal cavities, the aqueous solution should be 
 used; if there is a state of sepsis and local tumefaction of the tissues, the 
 glycerin solution should be used on account of its hygroscopic action. 
 
 Iodine Solutions. — Iodine in a glycerin menstruum is a valuable 
 remedy in chronic granular pharyngitis, and in those cases of middle- 
 ear catarrh associated with granular pharyngitis or atrophic rhinitis. 
 
 The following formula? may be used in such cases: 
 
 1$.— Tr. iodini Hlxlviij 
 
 Glycerini q. s. ad 3J — M. 
 
 1$. — Iodoformi gr. j 
 
 Potas. iodidi gr. x-xx 
 
 Morphia sulphatis gr. j 
 
 Glycerini 5J — M. 
 
 1$. — Iodini gr. v-xx 
 
 Potas. iodidi gr. x-xxx 
 
 01. gaultherise T\[v 
 
 Glycerini 5j — M. 
 
 fy— Tr. iodidi, 
 
 Tr. ferri chl., 
 
 Glycerini fia q. s. 3J — M. 
 
 The fourth formula is very astringent, and is used to promote even 
 healing by granulation after tonsillectomy in adults. It is also of great 
 value in the subacute type of granular pharyngitis. 
 
 Carbolic Acid. — Carbolic acid may be used in any strength from 10 
 to 95 per cent, aqueous or glycerin solution. 
 
 1$. — Carbolic acid gr. xx 
 
 Glycerin 3j — M. 
 
52 THE NOSE AND ACCESSORY SINUSES 
 
 This is approximately a 4 per cent, solution, and may be used in sub- 
 acute dry dermatitis of the external auditory meatus and in subacute 
 otitis media. 
 
 ]$. — Carbolic acid 3J 
 
 Glycerin q. s. ad 3j — M. 
 
 This is a 12 per cent, solution, and may be used in acute otitis media. 
 It should be dropped into the meatus two or three times daily and a 
 cotton plug introduced to prevent its escape (A. H. Andrews). It is 
 claimed that if dropped into the meatus in the initial stage of acute 
 suppurative otitis media it aborts the further progress of the inflammation 
 in nearly every instance. On the other hand it is claimed that its frequent 
 Use causes a fibrosis and thickening of the ear drum, and thus causes 
 permanent diminution of hearing. It may be said, however, that its 
 frequent use is not often required to abort an attack of acute otitis media. 
 
 1^. — Carbolic acid gr. ccclvj 
 
 Aquae des ■ . TT|xxiv — M. 
 
 This is a 95 per cent, solution of carbolic acid, and may be used when 
 a superficial caustic effect is desired, as in infective granulomata of the 
 middle ear and mastoid, either before or after operation. I have occa- 
 sionally used it in cases of old, foul-smelling otorrhea to diminish the 
 odor and to stimulate healthy granulation. (See Chemical Caustics.) 
 
 Alcohol. — Alcohol is also a valuable remedy for topical applications. 
 I know of no better ingredient for a gargle than alcohol. It is astrin- 
 gent and antiseptic, and, when properly diluted, is grateful to an inflamed 
 surface. 
 
 ~R/,. — Alcohol, 
 
 Cinnamon water aa gij 
 
 Formaldehyde ffjij 
 
 Glycerin 3v 
 
 Aquae des q. s. ad 5viij — M. 
 
 The above formula is a good gargle in acute tonsillar and pharyngeal 
 inflammations and in the soreness following the removal of the tonsils. 
 In very young children it may be used in a more diluted form. 
 
 In chronic otorrhea alcohol may be used in the following dilutions 
 and mixtures: 
 
 1$. — Alcohol 1 part 
 
 Aquae des . 2 parts — M. 
 
 1$. — Alcohol ' 1 part 
 
 Aquae des 1 part — M. 
 
 1^. — Alcohol 2 parts 
 
 Aquse des .1 part — M. 
 
 ]$. — Alcohol 3 parts 
 
 Aquae des 1 part — M. 
 
 1$. — Alcohol 95 per cent. 
 
THE OFFICE EQUIPMENT 53 
 
 The alcohol dilutions given above are used principally in the treat- 
 ment of chronic suppurative otitis media. 
 
 They constitute the so-called "alcohol treatment" of this disease: 
 The meatus is first filled with the weakest solution, then mopped out, 
 and each solution applied in series until the patient tolerates the 95 per 
 cent, solution. If the strongest solution is applied at once it causes 
 considerable pain and irritation, whereas if the strength is gradually 
 increased unpleasant results are avoided. 
 
 Alcohol is a positive astringent and antiseptic remedy of considerable 
 value. 
 
 1$. — Alcohol (95 per cent.) 3j 
 
 Boric acid gr. xx — M. 
 
 ]$. — Alcohol (95 per cent.) 5J 
 
 Iodoform gr. v — M. 
 
 The addition of boric acid and iodoform is supposed to give the local 
 antiseptic effect of these drugs. If an excess of either drug is added, 
 and the solution is agitated just before the instillation of the solution, 
 a precipitate of the partially suspended drug is deposited on the diseased 
 mucous membrane. 
 
 These solutions should be used after having applied the weaker alco- 
 holic solutions. 
 
 Ointments. — Various drugs may be prepared with an oily menstruum, 
 preferably lanolin, as it has greater affinity for the mucous membrane 
 than vaselin. Pure olive oil may also be used as a menstruum. The 
 following mixtures are recommended: 
 
 1$. — Zinc oxide gr. xlviij 
 
 Lanolin 3J — M. 
 
 ]$. — Zinc oxide gr. xlvij 
 
 Morph. sulph gr. j 
 
 Atropine gr. T ^ 
 
 Lanolin q. s. ad 3i — M. 
 
 The first formula is soothing to an inflamed surface, and may be 
 applied in those cases in which there is an irritating mucous or sero- 
 mucous discharge in catarrhal sinuitis. It is also of use in the massage 
 of the nasal mucous membrane in rhinitis with collapse, and in tumes- 
 cence of the "swell bodies." For this purpose a delicate silver applicator 
 should be wound with a small wisp of cotton and dipped into the oint- 
 ment. The nasal mucous membrane should then be gently massaged 
 with the ointment, the probe being lightly held between the thumb and 
 forefinger. The wrist movement, or the combined wrist and forefinger 
 movement, should be used in performing the massage. The applicator 
 should be held so lightly that if the cotton-wound applicator should 
 strike a turbinated body or other obstruction the probe will slip through 
 the fingers and do no damage. 
 
 The sensitiveness of the mucous membrane may be quickly removed 
 by the above procedure. 
 
 The second mixture is of value when the nasal mucous membrane 
 
54 THE NOSE AND ACCESSORY SINUSES 
 
 is sensitive and when there is an acute exacerbation of the inflammation. 
 The morphine and atropine relieve the sensitiveness and reduce the con- 
 gestion. 
 
 1$. — Ichthyol gr. xlviii 
 
 Lanolin §j — M. 
 
 The ichthyol ointment may be used in those cases where the secretions 
 are dined in the nasal cavities to stimulate the glandular functions. It 
 may be applied by massage, as described above. 
 
 Chemical Caustics. — Chemical caustics are largely replaced by the 
 electrocautery, though there are instances in which the chemical caustics 
 are preferable. The following are recommended: 
 
 Carbolic Acid (95 per cent.). — Where a superficial and diffused cauteri- 
 zation is desired, as in an unhealthy granulating surface, carbolic acid 
 is an ideal caustic agent. It does not penetrate deeply, nor does it pro- 
 duce pain. It is also of value in cases of old suppuration of the ear, in 
 which there is a foul odor and exuberant granulations. The ear should 
 first be thoroughly freed from secretions with a cotton-wound probe, and 
 the carbolic acid applied afterward. After one minute has elapsed 
 alcohol should be dropped into the meatus to check the action of the 
 carbolic acid and to prevent its action upon the skin of the meatus and 
 auricle during its removal. The carbolic acid should be dropped into the 
 middle ear with a medicine dropper, care being exercised to avoid con- 
 tact with the cutaneous surface. 
 
 Carbolic acid may also be used in the pharynx when a diffused 
 superficial caustic action is desired, as in a mild case of granular pharyn- 
 gitis, though in these cases it is usually preferable to puncture the fol- 
 licles or nodules scattered over the pharyngeal wall with the galvano- 
 cautery. 
 
 Chromic Acid. — Chromic acid has long been a favorite chemical caustic 
 in the nose, throat, and ear, though it has been largely replaced by the 
 galvanocautery. A few crystals are engaged upon the end of a probe 
 and held over an alcohol or gas blaze to drive off the water of crystal- 
 lization, but not long enough to reduce them to an ash or cinder. The 
 bead of acid thus formed is drawn across the area to be cauterized, 
 where it rapidly abstracts the water from the tissue and thus destroys or. 
 cauterizes its superficial layers. 
 
 It may be used in turgescent rhinitis, follicular pharyngitis (granular 
 pharyngitis), and in any other condition requiring cauterization. It is 
 not as deep in its penetration as is usually desired in either of these con- 
 ditions, hence it is not as reliable as the galvanocautery. 
 
 In order to increase its efficiency, Norval H. Pierce and Max A. Gold- 
 stein have devised instruments for its subcutaneous use. The submucous 
 method has not, however, appealed strongly to the profession, as the 
 galvanocautery is easily and efficiently applied with equally good or 
 even better results. 
 
 It should be remembered that chromic acid is quite irritating to the 
 
THE OFFICE EQUIPMENT 55 
 
 kidneys, and may cause albuminuria. Its extensive use is, therefore, 
 contraindicated in cases already thus affected. 
 
 Technique. — (a) Local cocaine anesthesia, (b) Puncture the mucous 
 membrane at the anterior end of the free border of the inferior turbinated 
 body, (c) Introduce a probe or other elevator through the puncture 
 and tunnel the substance of the mucous membrane, keeping near the 
 periosteum, (d) Introduce the Goldstein concealed probe containing 
 the bead of chromic acid into the depth of the tunnel, (e) Uncover 
 the bead of chromic acid and withdraw it through the tunnel. This 
 cauterizes the wall of the tunnel within the mucous membrane. If 
 sloughing does not occur the result is very good (Fig. 96). 
 
 Trichloracetic Acid. — This is a valuable chemical caustic agent and 
 is generally used in a 20 per cent, solution. It has been employed chiefly 
 in tuberculosis of the larynx, in conjunction with curettage, and in 
 hypertrophied and diseased tonsils, after splitting the walls of the crypts. 
 
 In laryngeal tuberculosis after the intralaryngeal removal of all the 
 tuberculous tissue available by this route the operated area is swabbed 
 with a 20 per cent, solution of trichloracetic acid, to destroy any remain- 
 ing tuberculous tissue and to seal up the lymphatic openings to prevent 
 the spread of the tuberculous process. 
 
 Kaufmann has recommended the free and deep incision of the crypt 
 walls of the tonsils, especially of those crypts opening into the supra- 
 tonsillar fossa, and applying a 20 per cent, solution of trichloracetic 
 acid to the incised surfaces. More than one sitting is usually required 
 for this purpose. The object of this procedure is to destroy the diseased 
 epithelial lining of the crypts and to cause cicatricial contraction of the 
 substance of the tonsil. In this way the tonsil is reduced in size and its 
 non-resistant cryptic epithelium is destroyed. 
 
 The acid applications are very painful for a prolonged period of time. 
 This, together with the fact that repeated applications are often necessary, 
 renders the procedure an undesirable one. The complete removal of 
 the tonsil by dissection is a more certain and desirable procedure, as 
 both tonsils may be removed at one sitting. 
 
 Nitrate of Mercury. — A 10 per cent, solution of the nitrate of mercury 
 may be used to cauterize deep sloughing syphilitic ulcers of the nose and 
 throat, as it excites healthy granulation, and thereby checks the slough- 
 ing and syphilitic ozena. 
 
 Antiseptic and Detergent Solutions. — The cleansing of the nose and 
 throat with detergent sprays and washes is not as popular a procedure 
 now as formerly. Experience has shown that such applications exert 
 little curative action on catarrhal and other diseases. They do, however, 
 promote temporary increase in the hyperemia and leukocytosis. Such 
 solutions also stimulate the constrictor muscle fibers of the "swell bodies" 
 of the turbinals, and thus temporarily reduce the turgescence. The 
 antiseptic action is probably but slight and of little value. The three 
 useful effects of the antiseptic and alkaline nasal washes are therefore 
 as follows: (a) Detergent or cleansing effects, (b) Muscular contrac- 
 tion of the interlacing fibers of the "swell bodies." (c) Slight promotion 
 
56 THE NOSE AND ACCESSORY SINUSES 
 
 of the reaction of inflammation. The detergent and stimulating solutions 
 recommended are as follows : (1) Seller's solution. (2) Dobel-Pynchon 
 solution. 
 
 (2) I£. — Powd. sod. bibor (Squibb), 
 
 Powd. sod. bicarb (Merck) aa §ij 
 
 Thymoline Oss 
 
 Glycerin (C. P.) Oiss 
 
 First mix and triturate the two salts and place them in a one-gallon 
 bottle, adding one-half the quantity of glycerin; then let it stand twenty- 
 four hours uncorked, with frequent agitations. Next add the remainder 
 of the glycerin and continue the agitations for another twenty-four 
 hours, with the bottle uncorked as before. Lastly, add the thymoline 
 and let the solution stand twenty-four hours. One ounce of this mixture 
 should be added to one pint of water, when it is ready for use. 
 
 The solutions may be used with an atomizer, a nasal douche, or a 
 syringe. They may also be used as gargles, although the distinctly 
 alkaline taste is usually disagreeable to the patient. 
 
 Oily Solutions for Use with a Nebulizer. — Aromatic and antiseptic 
 drugs may be added to an oily menstruum and thrown into the respiratory 
 tract with a nebulizing device. The action of such mixtures is as an 
 emollient or protective agent, and as a stimulant to the mucous glands. 
 They also cause contraction of the circular muscle fibers of the arterioles, 
 and thereby reduce the congestion. The effects are transient, and afford 
 relief without exerting a marked curative effect. 
 
 The following formulae are recommended : 
 
 1. Chlorotone inhalant. 
 
 1$. — Chlorotone gr. xv 
 
 Camphor gr. xxx 
 
 Menthol gr. xxx 
 
 Oil cinnamon V([v 
 
 Oil petrolatum 3ij — M. 
 
 2. Acetozone inhalant. 
 
 1$. — Chlorotone Hlvij 
 
 Acetozone TT|xv 
 
 Oil petrolatum q. s. ad §ij — M. 
 
 The spray bottles and nebulizing bottles devised by De Vilbiss (Fig. 
 17) have proved more satisfactory than any others, as their construction 
 is simple and they rarely need repairing or other attention. 
 
 Hawley's spray tube is also a useful device for washing the nasal cavi- 
 ties, and is often preferable to the spray tube, as it does not injure the 
 epithelium of the nasal mucous membrane. 
 
 The air pressure allowable for spraying the various mucous surfaces 
 with De Vilbiss' spray apparatus is as follows: (a) The nasal mucous 
 membrane, 4 to 10 pounds. (6) The epipharynx (nasopharynx), 8 to 
 20 pounds, (c) The mesopharynx (oropharynx), 10 to 30 pounds. 
 (d) The hypopharynx, and larynx, 10 to 30 pounds. The air pressure 
 needed for De Vilbiss' nebulizing bottles, 10 to 40 pounds. 
 
THE OFFICE EQUIPMENT 57 
 
 The Pynchon and Hubbard regulating tanks, elsewhere mentioned, 
 are of great value in conjunction with the spray and nebulizing tubes. 
 Hubbard's regulating tank is especially recommended, as it has a filter- 
 ing device for cleansing the air. It also has an arrangement for heating 
 the air. 
 
 Solutions which Produce Ischemia.— Solutions which produce local 
 blanching of the mucous membrane are chiefly derived from the supra- 
 renal glands of sheep. They produce a powerful contraction of the 
 circular muscle fibers of the arteries, which lasts for several minutes. 
 They are on this account of diagnostic and therapeutic value. They 
 also reduce the amount of primary hemorrhage in operations. 
 
 The following formulae are recommended : 
 
 1$. — Adrenalin chloride 1 to 1000 
 
 1$. — Adrenalin chloride 1 to 2000 
 
 1$. — Adrenalin chloride 1 to 4000 
 
 It is rarely necessary to use the first formula except when there is a 
 great deal of secretion and blood to dilute the solution. If applied to a 
 clean mucous membrane the second and third formulae are of sufficient 
 strength to contract the vessels. Local ischemia is produced for diag- 
 nostic purposes in the various forms of rhinitis and in reducing the 
 engorgement of the tissues to admit a view of the nasal chambers. 
 Adrenalin is also used to check local oozing of blood after operations. 
 
CHAPTER IV. 
 
 THE ETIOLOGY OF DEFORMITIES AND DEVIATIONS OF THE 
 
 SEPTUM NASI. 
 
 According to Freeman, Trendelenburg was the first to describe the 
 high-arched palate with deformity of the septum nasi, though he did not 
 consider it due to lack of development of the maxillary bones. Loewy 
 was of the same opinion, though he regarded the Gothic arch as of 
 rachitic origin. Zuckerkandl does not accept the rachitic origin, as he 
 believes that the lower jaw and not the upper exhibits the rachitic 
 influence. However this may be, Freeman reminds us that it is 
 common to find the Gothic arch associated with deviated septa. He 
 shows that in 302 cases of high-arched palate, 290, or 96 per cent., were 
 associated with deviated septa. 
 
 In studying the Mutter collection, Freeman found many straight septa 
 associated with Gothic palates, thus demonstrating that a high arch is 
 not necessarily a cause of septal deviation. Indeed, he believes that 
 the faulty development of the superior maxillse is a fruitful source of 
 deviated septa, especially in dolichocephalic heads. The skulls were 
 those of non-Europeans, in whom, as Zuckerkandl has pointed out, the 
 deformities of the septum are much more infrequent than in Europeans. 
 Mosher has recently called attention to the low position of the floor of 
 the antrum of Highmore in skulls with the Gothic palate. 
 
 As the Gothic arch is naturally present in infants, it is easy to under- 
 stand that anything which interferes with the development of the skull 
 will prevent development of the hard palate and its consequent descent. 
 Indeed, in such cases the later development of the alveolar processes 
 and the eruption of the teeth will cause the arch to become more 
 peaked. As the arch remains high, the septum in its further develop- 
 ment must bend to make room for its growth. Welcker, in support of 
 this view, has shown that those cases in which one maxillary bone 
 descends, the other remaining high-arched, convexity of the septum is 
 toward the descended maxilla. 
 
 According to Eugene S. Talbot, Morgagni believed that deviated 
 septa were due to excessive development of the vomer, while Jarvis 
 reported four cases in one family suggesting an hereditary influence. 
 Talbot believes that direct hereditary influence is rare, though there 
 may be a family development of the facial skeleton, as shown by 
 Sachus' and Welcker's investigations. 
 
 According to Bosworth, the deformities of the septum are usually 
 traumatic in origin. He points out that an injury to the nose need not 
 be attended by an immediate and obvious deformity, but it may set up 
 
DEFORMITIES AND DEVIATIONS OF THE SEPTUM NASI 59 
 
 a low-grade inflammation, which in a number of years finally results in 
 an obstructive malformation of the septum. This is undoubtedly a 
 frequent cause of septal deviations, especially of the anterior cartilaginous 
 portion, which is exposed to traumatic influences. That it is a frequent 
 cause of deformity of the bony portions (perpendicular plate and the 
 vomer) is extremely doubtful, as they are protected from blows by the 
 nasal and superior maxillary bones. 
 
 Talbot holds that deviations of the septum are due to the unequal 
 development of the adjacent bones, more especially the turbinated 
 bodies. Their development in turn depends upon the growth of the 
 facial bones, which are modified as the facial angle increases and 
 prognathism is lost. The turbinated body being displaced or enlarged 
 toward the septum, the septum is crowded to the opposite side. The 
 septum is not necessarily pushed over by direct contact of the turbin- 
 ated bone, as the respiratory currents of air may cause it to deflect 
 during the prepuberty period, when the vomer and perpendicular plate 
 are soft and cartilaginous. Talbot believes that the underlying cause of 
 septal deformities is a neurosis and degeneracy, in which conditions 
 there may be an imballance of development of the various bones of the 
 face, total collapse of the outer walls of the nose, associated with an 
 arrest of the development of the bones of the face, jaws, dental arch, 
 chest, and shoulders. 
 
 Summary. — 1. Morgagni thought they were due to excessive develop- 
 ment of the vomer; the vomer crowding upward against the descending 
 perpendicular plate of the ethmoid caused septal deflection to one side, 
 in order to allow of continued development. 
 
 2. Trendelenburg and Freeman think the chief cause of the deflection 
 is in the persistent high or Gothic arch of the hard palate. The vomer 
 and the perpendicular plate of the ethmoid are thereby crowded and 
 deflected in order to find room for further complete development. 
 
 3. Jarvis believes the chief cause is heredity, and quotes observations 
 in support of this theory. 
 
 4. Schaus and Weleker advance the hypothesis of a faulty develop- 
 ment of the facial bones, including those of the nose. 
 
 5. Bosworth argues that traumatism is the chief cause of deflections. 
 
 6. Talbot takes the theory of Schaus and Weleker and carries it still 
 farther, and says that malformations of the septum are due to neuroses 
 or stigmata of degeneracy, which result in irregular development of the 
 facial bones. He believes that pigeon chest, adenoids, and deformed 
 nasal septa are all due to the same neurotic influences, which arrest 
 development in some parts while in others there is an increase in the 
 development. 
 
 It is difficult to arrive at a final conclusion concerning these theories, 
 as data of almost any kind can be found by one who diligently searches 
 for it. It is easy to say there is excessive development of the vomer, and 
 to report so many thousands of observations on skulls in which this 
 theory is substantiated. Trendelenburg and Freeman have satisfied 
 themselves that the Gothic arch is the cause. They say the high arch of 
 
60 THE NOSE AND ACCESSORY SINUSES 
 
 childhood does not descend as it should, and that the space for the 
 vomer and the ethmoid plate is thereby encroached upon and deflection 
 results. Talbot and others have studied the so-called high arch and find 
 that it rarely exists, also that in some instances there is lack of lateral 
 development of the superior maxillse, which gives rise to the Gothic arch, 
 or what appears to be an abnormally high arch. Actual measurements 
 show them to be no higher than normal. Then, too, Talbot claims that 
 many hard palates which are lower than the average are attended by sep- 
 tal deformities. He does not deny that traumatism does in some instances 
 account for septal deformities, but he does deny that it is the chief cause 
 of deviations. He believes that consanguineous marriages predispose to 
 the neuroses and that facial deformities result therefrom. He holds 
 that the facial bones are transitory and more subject to developmental 
 influence than most parts of the skeleton, hence are either arrested or 
 overdeveloped in those tainted with the stigmata of degeneracy. 
 
 Dr. Talbot's views present the most rational explanation of this much 
 mooted question that has yet been offered. He does not name the over- 
 development of a particular bone nor does he claim the failure of the 
 palatine arch (roof of the mouth) to descend as being the cause of devia- 
 tions of the septum. If these conditions are present he claims they 
 are incidental signs of a neurosis or degeneracy. The factor which causes 
 excessive development of the vomer or of a Gothic or narrow (not high) 
 arched palate causes the deformed septum also. 
 
 In conclusion, I will epitomize the etiology of deformities of the nasal 
 septum as follows, in the order of their importance : 
 
 (a) Neuroses or stigmata of degeneracy which causes either an arrest 
 or an excessive development of the bones of the face, including the nose; 
 one of the expressions of the neurosis being deformed septa (Talbot). 
 
 The theories of Trendelenburg, Freeman, Morgagni, Jarvis, Schaus, 
 and Welcker are swallowed up in that of Talbot. The individual theories 
 they advance imperfectly convey the true explanation, while Talbot's 
 comprehends them all and strikes at the root of the matter. 
 
 (b) Bosworth's traumatic hypothesis is true as to a certain number of 
 cases. That it explains a majority or even a large percentage of them 
 is doubtful. 
 
 The phraseology used by Talbot may be objectionable, inasmuch as 
 it assumes that there are "stigmata of degeneracy" present in all cases 
 not due to traumatism. It would be better perhaps, to say that deflections 
 of the septum are usually due to an incoordination in the development 
 of the bones of the face, including those of the nose. 
 
 A CLINICAL CLASSIFICATION OF DEVIATIONS OF THE 
 SEPTUM NASI. 
 
 Malformation and deviation of the nasal septum may be either develop- 
 mental or traumatic in origin. When developmental, any or all portions 
 of the septum may be involved, whereas if it is of traumatic origin the 
 anterior or cartilaginous portion only is affected, except in rare cases. 
 
A CLASSIFICATION OF DEVIATIONS OF THE SEPTUM NASI 61 
 
 The point of chief clinical interest, however, is in the type and location 
 of the deformity rather than in its origin. Even the type and location 
 of the deviation have to a considerable degree lost their clinical signifi- 
 cance in so far as treatment is concerned, since the perfection of the 
 submucous resection of the septum has been accomplished, and so 
 many types of septal malformations are found to be amenable to it. 
 
 Cartilaginous Deviations. — When the deformity is limited to the 
 cartilaginous portion of the septum it is one of three types, viz. : 
 
 (a) A deflection of the anterior portion generally known as the 
 columnar cartilage (Fig. 23). The antero-inferior border of the cartilage 
 is turned outward into the vestibule of the nose and obstructs the respira- 
 tory passage. This type of deviation is not as serious in its consequences 
 as those that obstruct the nasal chamber in 
 the region of the middle turbinated body, as Fig. 23 
 
 it only interferes with the ventilation of the 
 nasal chamber and accessory sinuses, the 
 drainage being unimpaired, except in so far 
 as it depends upon the mechanical aid of 
 the air current in propelling the secretions 
 to the epipharynx. 
 
 (6) An angular deviation in an antero- 
 posterior direction is serious in proportion 
 to its proximity to the middle turbinal. If 
 it is limited to the region of the vestibule 
 or the inferior turbinate it is of less clinical 
 importance, though its removal is still indi- 
 cated. If it obstructs both the middle and the 
 inferior meatuses its removal is of greatest Deviation of the anterior portion 
 
 ., . . P .., , ° ,, ,, of the septal cartilage, which mav 
 
 importance, as it interferes with both the be removed through Hajek's incision 
 drainage and ventilation of the nasal chamber by sharp dissection. 
 and the accessory sinuses of the nose. 
 
 (c) A perpendicular deviation of the cartilage only interferes with 
 the ventilation, without blocking the drainage of the secretions, except 
 anteriorly, which is inconsiderable. 
 
 Osseous Deviations. — For clinical purposes osseous deviations of 
 the septum may be divided into three types: 
 
 (a) A bony ridge or crest along the upper border of the crista nasalis 
 and the vomer. The direction of this deformity is backward and upward, 
 usually beginning anteriorly about one-half inch from the border of the 
 inferior portion of the nasal opening, near the floor of the nose. A 
 ridge in this location does not necessarily obstruct the normal inspira- 
 tory tract (middle and superior meatuses), nor does it greatly interfere 
 with the drainage of the secretions. It does, however, encroach upon 
 the inferior turbinated body, and thus causes irritation of this important 
 physiological organ and produces a sense of stuffiness of the nose. It 
 interferes also to some extent with the posterior drainage of the secretions. 
 It also projects to some extent into the respiratory pathway and forms 
 a favorable place for the desiccation of the secretions. Crusts are, there- 
 
62 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Fig. 24 
 
 fore, generally found upon the anterior extremity of the ridge, and in 
 blowing the nose become detached, tear the epithelium, and give rise 
 to epistaxis. While the ridge may not cause nasal obstruction, it should 
 be removed on account of the mechanical irritation of the inferior tur- 
 binal and the resulting turgescent and hypertrophic rhinitis. 
 
 (b) The perpendicular plate of the ethmoid bone is often convex or 
 cup-shaped and impinges upon the middle turbinate upon the side of 
 convexity. This is, perhaps, one of the most serious obstructive lesions 
 of the septum, as it obstructs both the drainage and the ventilation of the 
 superior meatus, and of the frontal, ethmoidal, and sphenoidal cells. 
 Sufficient importance has not been given this type of deviation, hence 
 I wish to lay special emphasis upon it. It is this type of deviation, more 
 than any other, that gives rise to conditions which result in catarrhal 
 
 and suppurative inflammation of the 
 accessory sinuses. In the first place 
 the secretions are retained, undergo 
 decomposition, and impair the vital- 
 ity of the mucous membrane. In- 
 fection and inflammatory reaction 
 naturally follow. The ostei of the 
 sinuses become closed from swelling 
 of the mucosa, and this still further 
 interferes with the drainage. Further- 
 more, the ventilation of the superior 
 meatus and of the obstructed sinuses 
 is partially or completely lost, and 
 the decomposition of the secretions 
 is thereby encouraged. The oxygen 
 of the air within the obstructed sin- 
 uses is absorbed and rarefaction 
 results. 
 
 The blood of the lining mucous 
 membrane is attracted to the parts by 
 the negative pressure thus created, 
 and catarrhal inflammation is promoted. If, in the course of events, 
 active pus-producing microbes, such as the streptococci, staphylococci, 
 diplococcus pneumonia?, etc., find lodgement there, a suppurative in- 
 flammation of the sinuses results. 
 
 It is obvious that this type of deviation is of the greatest importance 
 andlthat the indications for its removal are urgent. 
 
 (c) The combined deviation, including the ridge along the crest of 
 the vomer and the convexity of the perpendicular plate of the ethmoid 
 bone (Fig. 24), is a very common type of septal deformity, and often 
 calls for correction at the hands of a surgeon. The indications for 
 operative interference are given under (a) and (b) of Osseous Deviations, 
 and need not be further discussed here. The indications are obviously 
 more urgent than in either the simple ridge or the convex perpendicular 
 plate of the ethmoid, as the ill effects of both deviations are to be reckoned 
 
 A compound deviation of the septum. The 
 upper deviation is of the greater clinical im- 
 portance, as it blocks the ventilation and drain- 
 age of the sinuses. 
 
SEQUELS OF OBSTRUCTIVE LESIONS OF THE SEPTUM 63 
 
 with. It should be noted that the convexity of the perpendicular plate of 
 the ethmoid is usually on the side opposite to the ridge along the crest 
 of the vomer, though it may be on the same side. It should also be 
 noted that the cartilaginous portion of the septum is deviated with the 
 perpendicular plate of the ethmoid, and should, of course, be included 
 in the operative field. 
 
 (d) There are still other deformities of the osseous septum, as the 
 so-called spurs on the anterior portion, which in reality are composed of 
 the crista nasalis and cartilage in combination, though they may be true 
 osteomata. 
 
 THE COMPLICATIONS AND SEQUELS OF OBSTRUCTIVE LESIONS 
 
 OF THE SEPTUM. 
 
 A review of the preceding paragraphs naturally leads to the conclusion 
 that many of the catarrhal and suppurative inflammations of the nasal 
 and accessory sinuses are often due either directly or indirectly to obstruc- 
 tive malformations of the septum. 
 
 The whole truth is not expressed in the above statement; nevertheless, 
 the deduction is fundamental and should form the working basis in a 
 large majority of cases. The etiology of the inflammatory diseases of 
 the nose and accessory sinuses is given in Chapter VI. 
 
 The following morbid conditions within the nose and accessory sinuses 
 are either directly or indirectly caused, or their course is often largely 
 influenced, by a preexisting deviation of the septum: 
 
 1. Acute rhinitis or coryza. 
 
 2. Chronic turgescent rhinitis. 
 
 3. Chronic hypertrophic rhinitis. 
 
 4. Chronic hyperplastic rhinitis. 
 
 5. Acute sinuitis, catarrhal and suppurative. 
 
 6. Chronic sinuitis, catarrhal and suppurative. 
 
 7. Polypoid degeneration of the mucosa of the nose and sinuses. 
 
 8. Atrophic rhinitis. 
 
 It is apparent, therefore, that deviations of the nasal septum should be 
 a primary rather than a secondary subject in a systematic text-book on 
 diseases of the nose. They are, therefore, herein discussed before taking 
 up the consideration of the inflammatory diseases which are so largely 
 dependent upon them. 
 
 Indications. — The indications for the correction, or the removal, of 
 obstructive deviations of the septum are based upon the following con- 
 siderations : 
 
 1. If the deviation of the septum does not interfere with (a) the func- 
 tional activity of the "swell bodies" of the inferior turbinates, (6) the 
 ventilation of the middle and superior meatuses and the accessory sinuses, 
 and (c) the drainage of the same areas it should not be subjected to 
 surgical treatment. In other words, deviations of the septum should 
 never be corrected simply because they are departures from the median 
 
64 THE NOSE AND ACCESSORY SINUSES 
 
 line of the nose, but only when they obstruct ventilation and drainage, 
 or interfere with the function of the "swell bodies." 
 
 2. The positive indications for the correction of deviated septa are 
 present when the septum (a) interferes with the normal functional activity 
 of the "swell bodies," or (6) prevents the normal ventilation and (c) drain- 
 age of the nasal chambers and accessory sinuses. 
 
 If, for instance, a ridge along the crest of the vomer is so prominent 
 as to touch the inferior turbinate, or if it extends forward into the vestibule 
 far enough to partially obstruct the inspiratory current of air, and thereby 
 produces rarefaction of the air posterior to the obstruction, it should be 
 removed. The same is true in reference to anterior angular deflections 
 of the cartilaginous septum. 
 
 If the deviation is higher up, in the region of the middle turbinate, and 
 interferes with the ventilation of the superior meatus and the accessory 
 sinuses draining into it, it should be corrected. 
 
 If a septum is tested by the foregoing standards, with a negative 
 result, it should not be subjected to surgical correction, no matter how 
 great the deviation or deviations may be. 
 
 If, on the contrary, a septum is tested by the foregoing standards, 
 with a positive result, it should be corrected by some surgical procedure. 
 
 THE SYMPTOMS OF DEVIATIONS OF THE SEPTUM. 
 
 The Subjective Symptoms of Obstructive Deviations. — The subjec- 
 tive symptoms of nasal obstructions are (a) a sense of fulness, either in the 
 lower or upper portion of the nasal chambers, according to the location 
 of the deviation. If, for instance, the deviation impinges upon the "swell 
 body" of the inferior turbinate there is a sense of stuffiness or fulness in 
 the lower portion of the nose; whereas if it is in the region of the middle 
 turbinate there is a sense of stuffiness or pressure through the bridge of 
 the nose between the eyes. 
 
 (6) If the obstruction in the region of the middle turbinate is great 
 enough, or has given rise to a catarrhal inflammation in the anterior 
 ethmoidal cells, there may be pain, upon pressure, at the inner angle 
 of the orbit under the floor of the frontal sinuses. When pain is elicited 
 upon pressure in this region, it is very significant of anterior ethmoidal 
 inflammation, and possibly of the frontal sinus as well. 
 
 (c) Frontal headache is frequently present in high deviations, and is 
 most severe in the morning upon awakening. If of ocular origin it 
 subsides at night and recurs during the day while using the eyes. 
 
 (d) Dizziness or vertigo is sometimes a direct expression of inflamma- 
 tion or irritation in the ethmoidal and the frontal sinuses. The dizziness 
 is often exaggerated, or is produced by stooping forward or suddenly 
 rising from the stooping posture, and is present when the eyes are closed. 
 Dizziness or vertigo of ocular origin is often relieved when the eyes are 
 closed, as the irritation from the light is thereby eliminated. Dizziness 
 of nasal origin is aggravated by jarring the body. 
 
THE SYMPTOMS OF DEVIATIONS OF THE SEPTUM 65 
 
 Fig. 25 
 
 &&& 
 
 3 
 
 b 
 
 D 
 
 A. Types of non-obstructive septa, a, deviated from the median line; 6, normal, straight 
 septum in the median line; c, deviation of the lower portion of the septum, with a concavity in 
 the left nasal chamber, but with compensatory hypertrophy of the left inferior turbinated body. 
 
 B. Types of obstructive septa, a, ridge pressing against the inferior turbinate; b, ridge pressing 
 against the left inferior turbinate and a convexity higher up on the right side obstructing the olfac- 
 tory fissure on that side; c, a split septum causing double obstructive convexity of the septum. 
 
 C. a, an S-shaped septum causing obstruction in the inferior portion of the nasal chamber on 
 the right side and the superior portion of the chamber on the left side; b, a high, angular devia- 
 tion of the septum causing obstruction of the olfactory fissure of the left side. 
 
 D. a, marked deviation of the septum along the crest, the vomer wedged firmly against the 
 left inferior turbinate; b, abscess or hematoma of the septum obstructing both nasal chambers. 
 
 5 
 
66 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 (e) Asthma of reflex nasal origin is sometimes due to intranasal 
 pressure and irritation in the middle turbinate and ethmoidal regions. 
 This is particularly true when polypi are present. 
 
 (/) The nasal secretions are changed in character and quantity. If a 
 chronic catarrhal inflammation of the lower portion of the nasal mucous 
 membrane is present the secretions are heavier than normal, and 
 expulsion is only accomplished by blowing the nose. If the obstruction 
 is in the middle turbinal and ethmoidal regions and a simple inflammation 
 is present in the ethmoidal cells the secretion is sometimes watery in 
 consistency, though it may be mucoid and quite acrid in character. 
 Associated signs of this type of secretion are the reddened and irritated 
 appearance of the mucosa and a fissure or eczematous eruption of the 
 margins of the nostrils and the upper lip. 
 
 A traumatic deformity of the external nose and of the septum. The straight dotted line indicates 
 the median line of the nose while the curved one indicates the deviation of the septum. 
 
 (g) Postnasal or epipharyngeal "dropping" is usually present. The 
 olfactory fissure may be obstructed, and, as the closure prevents drain- 
 age through the fissure, the secretions flow backward over the middle 
 turbinal into the epipharynx. 
 
 (K) Intermittent stenosis is usually present in those cases in which 
 there is an anterior deviation which does not completely block the nasal 
 passage. The obstruction interferes with the intake of air, and the 
 descent of the diaphragm acts as the piston valve of a syringe and pro- 
 duces rarefaction of the air in the nasal chamber posterior to the obstruc- 
 tion. This in turn develops turgescence of the erectile tissue and a 
 temporary stenosis. 
 
 (i) Alternating stenosis is another sign of an obstructive lesion in the 
 lower portion of the nasal chambers and is due to the same causes given 
 in the preceding paragraph. The associated disease is usually turges- 
 cent rhinitis. 
 
THE SYMPTOMS OF DEVIATIONS OF THE SEPTUM 67 
 
 The Objective Symptoms of Obstructive Deviations.— (a) The 
 appearance of the septum and its relation to the various aspects of the 
 outer walls of the nose constitute the most important objective symptom. 
 For example, if the septum is characterized by a ridge on the left side 
 opposite the inferior turbinate and by a convexity in the region of the 
 middle turbinate on the right side, an examination shows the deviations 
 and the impingement of the same against the inferior turbinate on the 
 left side and the middle turbinate on the right side (Fig. 25, B, b). Each 
 case should be carefully examined with reference to the equal distribu- 
 tion of space in the respiratory tract of the nose and with reference to 
 its adequacy for physiological purposes. The various types of deviation, 
 of course, present different pictures upon examination, each having its 
 peculiar clinical significance in proportion to the degree of obstruction 
 caused by it, and in particular to its proximity to the middle turbinated 
 body. 
 
 (b) The presence of pus and dried secretions in the olfactory fissure 
 between the deviation of the septum and the middle turbinate is sugges- 
 tive of the causative relationship of the deviation to the diseased posterior 
 ethmoidal sinuses, from which the secretions in all probability flow. 
 
 (c) Hemorrhage or epistaxis is often a sign of a deviated septum, more 
 particularly in its lower and anterior portions. A prominent crest pro- 
 jecting into the breathwav is subjected to an undue exposure to the air 
 current and the secretions become dried and adherent to it. When the 
 crust is detached, either by blowing or picking the nose, the epithelium 
 is torn from the mucous membrane and hemorrhage results. 
 
 (d) External deformity of the nose is often indicative of a correspond- 
 ing deviation of the septum (Fig. 26). 
 
CHAPTEK V. 
 
 THE CHOICE OF SEPTUM OPERATIONS. THE SURGICAL CORREC- 
 TION OF OBSTRUCTIVE LESIONS OF THE SEPTUM. 
 
 There is no one method of correcting obstructive deviations or mal- 
 formations of the septum nasi. The submucous resection of the septum 
 is the most nearly universally applicable, though there are some devia- 
 tions in which it can be used with great difficulty, whereas another 
 method of surgical procedure may be easily and successfully used. Under 
 such conditions poor judgment would be shown in selecting the sub- 
 mucous operation. In choosing a surgical procedure a method should 
 be adopted that will remove the obstructive lesion of the septum with the 
 most simple technique and the least risk to the integrity of the nasal 
 septum. The object of the operation should be to establish free drainage 
 and ventilation of the nasal chambers and of the accessory nasal sinuses 
 (see Etiology of the Inflammatory Diseases of the Nose and Accessory 
 Sinuses), rather than to exploit one method of operating over another. 
 It will be my endeavor, therefore, to give some general rules to guide 
 the surgeon in the proper selection of an operation for the correction or 
 removal of obstructive lesions of the nasal septum. 
 
 Cartilaginous Deviations. — When the deviation is limited to the 
 septal cartilage other operations than the submucous resection may often 
 be chosen to correct it ; indeed, they may often be chosen in preference to 
 the submucous resection. An extreme angular deviation of the septal 
 cartilage (Fig. 38) is rather difficult to correct by the submucous method, 
 and is easily corrected by the Sluder operation (Fig. 37, 38 and 39). 
 The Sluder operation is practically limited to extreme angular devia- 
 tions of the cartilaginous septum, as stated by its author. 
 
 A cup-shaped deviation may be corrected by the Asch, the Gleason, 
 the Watson, the Price-Brown, or the submucous resection operation. The 
 simpler of these procedures are the Watson, the Gleason, and the Price- 
 Brown operations, and of these the Watson is, perhaps, the more simple. 
 The choice of operation will largely depend upon the location of the cup- 
 shaped deviation and the thickness of the cartilage surrounding it. If, 
 for example, the cartilage anterior to the deviation is extremely thin, or 
 has become fibrous from antecedent chondritis, the triangular flap of 
 the Watson operation will not engage against the opposing incised 
 cartilage. If, on the other hand, the cartilage anterior to the cup is of 
 the usual thickness and texture the Watson operation may be used with 
 excellent effect. The cup deviation may also be corrected by the Gleason 
 operation if the cartilage below the cup is firm and of the usual thickness. 
 The H-incision of Price-Brown is also well adapted to this type of devia- 
 tion. The perpendicular incision should be made, one anterior and 
 
THE CHOICE OF SEPTUM OPERATIONS 69 
 
 the other posterior to the cup, and the intersecting horizontal incision 
 through the centre of the cup. 
 
 Compound or S-shaped deviations or compound angular deviations 
 of the septal cartilage are peculiarly well adapted to the Kyle operation, 
 provided the convexities are thickened. The redundancy of cartilage 
 may be removed with the V-shaped file saws at the crest of each convex 
 surface, thus permitting the septum to be forced to an upright position 
 in the median line. This type of deviation is also easily corrected by the 
 submucous operation by the author's method with the swivel knife, 
 and is perhaps more fully and surely thus corrected. In this type of 
 deviation there is usually little difficulty in elevating the mucoperichon- 
 drium, after which the cartilage is readily encircled with the swivel knife 
 and removed en masse with dressing forceps. 
 
 Simple angular (anteroposterior) deviations and L-shaped angular 
 deviations of the septal cartilage are usually very successfully corrected 
 by the Watson operation (Figs. 35 and 36), though they are equally well 
 adapted to the submucous resection operation with the swivel knife. 
 
 The deviated portion of the cartilaginous septum may be readily 
 removed by submucous resection in practically all types of deviations 
 except the extreme angular type, and even this may be thus removed. 
 It is often preferable, however, to use one of the other methods of operat- 
 ing, as they are simpler and almost, if not quite, as satisfactory in their 
 results. When, however, the obstructive deviation also involves the 
 bony portion of the septum, it is often expedient to adopt a method 
 of operating that will be equally applicable to both the cartilaginous and 
 bony deviations. Obstructive deviations usually involve both the carti- 
 laginous and osseous framework of the septum, hence the indications given 
 above are not unqualifiedly applicable, except in deviations limited to the 
 cartilaginous portion of the septum. One of the chief objections to the 
 operations other than the submucous resection is the necessity of wearing 
 a dressing or splint in the nose for two or more weeks. This alone 
 should often influence the surgeon to elect the submucous operation. 
 
 Osseous Deviations. — As osseous deviations of the septum are nearly 
 always associated with one or the other of the types of cartilaginous devia- 
 tions already referred to, a method of operating should be adopted that 
 will successfully remove both the cartilaginous and the bony deviations. 
 The operation most universally applicable is the submucous resection. 
 There are, however, important exceptions to this rule, notably a simple 
 spur or ridge, unattended by other deviations of the septum in which the 
 obstructive lesions may be removed by Bosworth's method with a saw. 
 When the deviation consists of a deflection of the vomer to one side, it 
 may be corrected by grasping it with the Asch septum forceps and 
 freely fracturing it at the floor of the nose and introducing a nasal splint 
 for a few days to hold it in its new position. Another important exception 
 is a deviation limited to the perpendicular plate of the ethmoid, which 
 may be successfully reduced with Roe's forceps. 
 
 1. A simple spur or ridge may be successfully removed with a saw 
 or spokeshave, with less risk to the integrity of the septum than it can 
 
70 THE NOSE AND ACCESSORY SINUSES 
 
 by submucous resection. If, however, the spur or ridge is accom- 
 panied by a deviation of the cartilage or the perpendicular plate of the 
 ethmoid, it may be necessary to adopt some other method of procedure. 
 
 2. Spurs or Ridges Associated with a Cartilaginous Deviation. — 
 These types of compound deviation may be effectively corrected by first 
 removing the ridge with a saw or spokeshave, and subsequently correcting 
 the cartilaginous deflection by one of the methods described under carti- 
 laginous deviations; or both may be removed at one time by the sub- 
 mucous resection operation. 
 
 3. Spurs and Ridges Associated with an Obstructive Deviation of 
 the Perpendicular Plate of the Ethmoid. — These types of compound 
 osseous deviations may also be corrected by two operations, or by a single 
 operation. The ridge or spur may be removed with a saw or spokeshave 
 at one time and the deviation of the perpendicular plate of the ethmoid 
 corrected at a subsequent time with Roe's crushing forceps. The sub- 
 mucous resection operation is usually preferable, as the operation is com- 
 pleted at one sitting, and the results obtained are usually much better 
 than by the two operations. 
 
 4. A Simple Deviation Limited to the Perpendicular Plate of the 
 Ethmoid. — Two operative procedures are applicable to this type of 
 deviation, one the Roe operation and the other the submucous resection 
 operation. 
 
 As generally practised, the submucous resection operation sacrifices 
 more or less of the cartilage whether it is deviated or not. This is done 
 to expose the bony parts to operative interference. I have, in a few cases, 
 in which the deviation was limited to the perpendicular plate of the 
 ethmoid, made the incision just anterior to the union of the cartilage and 
 perpendicular plate of the ethmoid, elevating the mucoperiosteum over 
 the ethmoid plate on the side of the incision, then extending the incision 
 through the cartilage and elevating the mucoperiosteum on the oppo- 
 site side of the plate, as is done when the Killian incision is made. 
 
 Principles. — The principles which should guide the operator in select- 
 ing an operation other than the submucous resection are the following: 
 
 (a) Never choose an operation which requires the prolonged (more 
 than four days) use of an intranasal splint or tampon. The operations 
 requiring the prolonged use of a nasal splint or tampon are the Rach 
 and the Kyle operations, as the flaps are not self-supporting; that is, the 
 principle of a bevelled edge, or extensive overlapping flaps with union 
 by adhesions, cannot be utilized in these operations. 
 
 (6) Operations utilizing bevelled-edged flaps do not require prolonged 
 use of splints or tampons; hence, such operations may be chosen in 
 selected cartilaginous deviations. The operations utilizing bevelled- 
 edged flaps are the Watson, the Gleason, and the Price-Brown 
 operations. 
 
 (c) Operations utilizing overlapping flaps with subsequent adhesion 
 along the overlapping surfaces may be chosen in extreme angular 
 deviation of the cartilaginous portion of the septum. The Sluder 
 operation is such an operation. 
 
OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 71 
 
 (d) Operations in which the bony portion of the septum may be 
 fractured or comminuted and reset in any desired position may be per- 
 formed in selected cases, in which only the bony portion of the septum 
 is deviated. Roe's crushing operation may be selected when only the 
 perpendicular plate of the ethmoid bone is deviated. The author's 
 method of fracturing the vomer may be chosen when only the vomer is 
 deviated. These operations do not require the prolonged use of intra- 
 nasal splints, as bony tissue remains in position without support. 
 
 When the foregoing principles cannot be applied, the submucous 
 operation should be used. 
 
 THE SURGICAL CORRECTION OF OBSTRUCTIVE LESIONS OF 
 THE NASAL SEPTUM. 
 
 Having first determined that the deviation is an obstructive one (see 
 indications) the surgeon should next elect the procedure that will afford 
 the greatest amount of correction with the least shock and inconvenience 
 to the patient. The type of deviation will have much to do with the 
 choice of the operative procedure. No hard-and-fast rules can be laid 
 down as to the choice of operation, each case being somewhat different 
 from all others. 
 
 The following operative methods will, however, with slight variations 
 in technique meet nearly all the indications for the surgical correction 
 of the various types of septal deviations. 
 
 1. Soft Hypertrophies of the Septum. — Soft hypertrophies of the 
 mucous membrane of the septum occur at two points, namely: (a) At 
 the anterior portion just opposite to or below the inferior margin of 
 the middle turbinated body, and (6) at the posterior end of the vomer. 
 In the first instance the enlargement closes the anterior end of the olfac- 
 tory fissure and interferes with the proper ventilation of the superior 
 meatus and the sinuses draining into it. Its reduction is best accom- 
 plished as follows : 
 
 First, induce local anesthesia with a 5 to 10 per cent, solution of cocaine 
 applied to the parts with a thin pledget of cotton. 
 
 Second, make one or two linear incisions through the hypertrophied 
 tissue with the actual cautery at a bright cherry red heat (Fig. 27). 
 
 This procedure may be repeated two weeks later if the first application 
 was insufficient to reduce the mass. 
 
 In posterior hypertrophy of the septum the same procedure may be 
 followed, having first reduced the engorgement of the turbinated bodies 
 with a spray of 1 to 2000 solution of adrenalin. 
 
 2. Bos worth's Operation. — When the septum is normally placed, 
 with the exception of a spur or ridge, the obstructive lesion may be 
 removed with a nasal saw (Fig. 28). If the deviation is a pronounced 
 one, it may be preferable to resort to the submucous resection operation, 
 as all other deflections can be removed by it at one time. 
 
72 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 The technique of the saw operation is as follows : 
 
 (a) Induce local anesthesia over the spur or ridge by the application 
 of pledgets of cotton saturated with a 5 per cent, solution of cocaine. 
 After ten minutes remove the cotton, as anesthesia is usually complete 
 in this time. 
 
 Fig. 27 
 
 The reduction of an anterior hypertrophy of the mucous membrane of the septum in the region 
 of the anterior end of the middle turbinate, a, linear cauterization; b, cautery electrode making 
 a second linear incision. 
 
 Fig. 28 
 
 'Win ii liWMii ~Tniniiwnn >y J!^ 
 
 »^iii 
 
 Bosworth's saw. 
 
 Fig. 29 
 
 Fig. 30 
 
 a, ridge or deformity of the septum; b, the 
 inferior turbinate encroached upon by the de- 
 viation; c, line of incision to be followed in 
 removing the ridge with a saw. 
 
 Showing the method of applying the 
 to remove ridges from the septum. 
 
 (b) Introduce the nasal saw beneath the ridge or spur with its cutting 
 edge turned inward and upward, as though it were the intention to saw 
 obliquely through the septum (Figs. 29 and 30). 
 
 (c) After the saw is engaged in the bony tissue direct it upward (Fig. 
 30), parallel with the surface of the septum, until the ridge or spur is 
 completely severed from it. 
 
OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 
 
 73 
 
 It is not necessary to make a preliminary incision along the crest of 
 the ridge or spur for the purpose of elevating the mucoperiosteum, as 
 experience has shown that healing takes place quite as quickly and satis- 
 factorily when the mucoperiosteum is removed with the bone. Healing 
 takes place by granulation and the periosteum is extended by the same 
 process of repair over the sawn surface. In a number of cases thus 
 operated on, and subsequently operated upon by the submucous method, 
 I have had little difficulty in elevating the mucoperiosteum over the old 
 field of operation. 
 
 Fig. 31 
 
 Pischel's collodion dressing, a, a thin pledget of cotton placed over the wound after the removal 
 of a septal ridge with a saw; b, the collodion being applied to the cotton with a pipette. 
 
 The postoperative dressings should be omitted altogether unless the 
 method described by Dr. Pischel is adopted. He first secures absolute 
 dryness of the wound, and then applies a thin pledget of cotton over the 
 surface and saturates it with an ethereal solution of collodion by means 
 of a pipette, and allows it to dry in place (Fig. 31). The wound is thus 
 hermetically sealed with the collodion film, which protects it from, the 
 nasal secretions. The collodion dressing should be left in position until 
 it is voluntarily thrown off, which usually occurs in three or four days. 
 Subsequent dressings are not required. 
 
 3. The Removal of Spurs and Ridges with the Spokeshave. — The 
 spokeshave may be used instead of the saw, though it is attended by 
 more risk to the integrity of the septum and shock to the patient. 
 
 The technique is as follows: 
 
 (a) Local anesthesia. 
 
74 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 (b) Make an elliptical incision around the base of the spur or ridge so 
 as to prevent tearing of the mucous membrane with the spokeshave 
 (Fig. 33). 
 
 (c) Introduce the spokeshave (Fig. 32) into the nostril until its blade 
 engages the posterior end of the ridge, and then pull it forward with 
 considerable force, again and again if necessary, until it splinters the 
 ridge from the septum (Fig. 34). The elliptical incision previously made 
 saves the mucous membrane from mutilation. 
 
 (d) The dressing may be omitted or the collodion dressing may be 
 used. 
 
 Fig. 32 
 
 Chaleway's spokeshave. 
 
 Caution. — So much force is usually required to engage the spokeshave 
 that there is danger of fracturing the cribriform plate and causing 
 meningitis. 
 
 Another accident which should be taken into consideration is perfora- 
 tion of the septum. It is not possible to exercise full control over the 
 course of the spokeshave, as it does not cut through the tissue (bony) but 
 acts as a wedge. I have sometimes resorted to a procedure which in 
 a measure controls the direction of the splintering, as follows: 
 
 Fig. 33 
 
 Incisions above and below the ridge. 
 
 Removal of ridge with the spokeshave. 
 
 After making the elliptical incision, grooves are made with a saw at the 
 base of the ridge on its upper and lower aspects. The grooves guide 
 the spokeshave as it comes forward through the bone and thus prevents 
 cutting too deeply into the tissue. The grooves weaken the attachment 
 of the ridge and render its removal possible with less force. 
 
 The Watson Operation. — The Watson operation consists in making 
 one or more incisions through the septum and then pushing the projecting 
 
OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 
 
 75 
 
 or deviated bevelled portion toward the concave side, the bevelled edges 
 formed by the incision retaining the septal flap in its new position. 
 
 Technique. — (a) Local anesthesia. 
 
 (6) Make the incision or incisions with a short-bladed bistoury. 
 
 Fig. 35 
 
 Fig. 36 
 
 The Watson operation for correcting a simple 
 angular deviation of the cartilaginous septum. 
 
 The Watson operation for a combined 
 horizontal and perpendicular bowing of 
 the nasal septum. 
 
 Fig. 37 
 
 (c) Introduce the index finger or a broad, blunt instrument into the 
 nose on the side of the septal convexity and force the deviated flap to 
 the opposite side. If the single incision is made (Fig. 35), force the angu- 
 lar flap to the opposite side along the entire line of incision. If the double 
 incision (Fig. 36) is made, first force 
 the anterior triangular flap (a) to the 
 concave side and then force the pos- 
 terior triangular flap (b) to the concave 
 side. The bevelled edges formed in 
 
 making the incision help to hold the 
 flaps in the new position. 
 
 (a) Additional support should be 
 given to the flaps by a tampon on 
 the side of the convexity or by a sep- 
 tum tube splint for a period of three 
 or four days. 
 
 Sluder's Operation. — Dr. Green- 
 field Sluder has used a modification 
 of the Watson operation, with excel- 
 lent results, and he especially recom- 
 mends it in children with extreme angular cartilaginous deflections. 
 
 Technique. — (a) Cocaine anesthesia. 
 
 (b) Make three parallel incisions through the entire thickness of the 
 septum parallel with the crest (Figs. 37 and 38). The middle incision 
 should extend the whole length of the crest. The other incisions are 
 
 Sluder' 
 
 eptum operation. 1, 2 and 3, the 
 lines of incision. 
 
76 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 made at the apices of the less acute angles 1 and 2. Two strips of cartilage 
 are thus formed, their only attachments being at the anterior and posterior 
 extremities. 
 
 (c) Either the upper or lower strip is then forced to the concave side 
 with the index finger or a blunt instrument. 
 
 (d) The other strip is likewise displaced to the concave side, thus 
 causing them to overlap, as shown in Fig. 39. 
 
 (e) A Mayer nasal tube is then introduced on the side of convexity 
 to hold the strips in position while union takes place, a period of three 
 or four days. 
 
 Fig. 38 
 
 Fig. 39 
 
 Sectional view of the nose before the Sluder 
 operation, 1, 2, 3, the lines of incision shown 
 in Fig. 37; 4, the median line of the nose. 
 
 Sectional view of the nose after the 
 Sluder operation. 1, 2, 3, the lines of 
 incision as shown in Fig. 37. The bands 
 of cartilage overlap and should be held 
 in position with a nasal tube. 
 
 If the opposed surfaces are curetted before coaptation, union will 
 take place more rapidly. Dr. Sluder reports 24 cases, 5 in adults and 
 19 in children, without perforation of the septum, all of which were cases 
 of extreme deflections. 
 
 4. The Gleason Operation. — The election of this operation may be 
 made when the septum is bowed or cup-shaped, and without a heavy 
 ridge along the crest of the vomer. It consists essentially of a U-shaped 
 incision extending either entirely through the septum and both its mucous 
 coverings, or only through the mucous membrane of one side and the 
 bone and cartilage. The incision may be made with a saw (Fig. 40) 
 or with a knife. 
 
 The Technique. — (a) Local anesthesia is induced with a 5 to 10 per 
 cent, solution of cocaine applied to the mucous membrane on both sides 
 of the septum. 
 
OBSTRUCTIVE LESIOXS OF THE NASAL SEPTUM 
 
 77 
 
 (6) The nasal saw is applied on the convex side of the septum at its 
 inferior portion, and the incision is carried through the septum in an 
 upward direction, the ends of the saw remaining upon the side of 
 convexity while its middle portion passes through to the concave or 
 opposite side. A U-shaped incision is thus made with a bevelled tongue- 
 flap suspended between the limbs of the U (Figs. 40 and 41). 
 
 Fig. 40 
 
 Fig. 41 
 
 The Gleason operation. A tongue-flap of the deviated 
 portion of the septum. 
 
 Gleason's tongue-flap pushed through 
 the window. 
 
 Fig. 42 
 
 On account of the low position of the nasal orifice the anterior limb 
 of the incision is usually too short. This is obviated by removing the 
 saw and reinserting it through the anterior limb alone and continuing the 
 incision upward, or it may be extended with a knife, as the framework 
 of the septum is cartilaginous in this region. 
 
 If it is not desired to extend the incision through the 
 mucous membrane on the concave side the saw should 
 be directed upward parallel with the septal surface on the 
 concave side just beneath the mucous membrane. This 
 is not at all difficult, as the mucoperichondrium and peri- 
 osteum usually separate very readily from the cartilage and 
 bone. Or the membrane may first be elevated on the con- 
 cave side by the injection of normal salt solution beneath 
 the mucoperichondrium and periosteum, thus lifting it 
 away from the cartilage and bone. 
 
 (c) Having made the U-shaped incision, the tongue-flap 
 should be forced from the convex side through to the con- 
 cave side with the finger inserted into the nostril. The 
 bevelled edges of the flap and those of the fixed portion of 
 the septum engage so as to hold it in its new position on the concave 
 side (Fig. 42). The tongue-flap has a tendency to spring back into its 
 former position, owing to the elasticity of the cartilaginous and bony 
 tissue contained in it, hence it is necessary to overcome its resiliency 
 by forcing it as far to the concave side as possible, the flap being thus 
 fractured at its upper extremity. 
 
 By the foregoing procedure the convex portion of the septum is dis- 
 
 view 
 
 a, sectional 
 of the 
 septum after 
 the Gleason 
 operation. 
 
78 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 placed toward the side of the greatest nasal space, and the obstructed 
 side is opened for freer drainage and ventilation. 
 
 The Gleason tongue-flap may also be used when the deviation 
 embraces both cartilage and bony tissues, as shown in Fig. 43, which 
 illustrates a case operated by me with entire success. There was a 
 prominent ridge on the left side of the septum corresponding with the 
 crests of the crestanasalis and the vomer. The quadrilateral cartilage 
 was also deviated to the left. The septum was perforated at the 
 junction of the cartilage, perpendicular plate and vomer (dark spot). A 
 nasal saw was inserted through this opening and the perpendicular 
 plate and membranes cut upward. The vomer was then sawn to the 
 floor of the nose. The saw was then directed anteriorly and the vomer 
 
 Fig. 43 
 
 Fig. 44 
 
 The Gleason operation, including the quad- 
 rilateral cartilage, the perpendicular plate of 
 the ethmoid, and the vomer. The incisions a, 
 b, c, are made with a nasal saw, and incision d 
 with a knife. The saw is introduced at the junc- 
 tion of the vomer and perpendicular plate, as 
 indicated by the swelling of the line a, b. 
 
 The Roe operation. 
 
 severed at the floor. (The heavy line shows the area of the incision 
 made with the saw, the light line that made with a knife.) A small 
 bistoury was used to make the anterior limb of the U-shaped incision. 
 The saw and knife should be inserted from the side which will permit 
 the bevelled edges to hold the flap in position when pushed through the 
 opening. As a large portion of the thickened crest is cartilaginous, it 
 will atrophy after being pushed through the window to the opposite 
 side. If this fact is not borne in mind, it may appear to the operator 
 that the opposite nostril will be occluded, and the patient be left in as 
 bad a condition as before the operation. 
 
 Dressings. — It may be necessary to insert a nasal tube (Fig. 49) on 
 the side of convexity for a day or two to insure the fixation of the tongue- 
 flap in its new position. Dressings are not otherwise needed. 
 
OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 79 
 
 5. The Roe Operation. — The Roe operation may be used to correct 
 deviations of the perpendicular plate of the ethmoid bone, and it may 
 also be used to correct the bowing of the septum in the region of the 
 middle turbinal, where there is also a ridge on the lower portion of the 
 septum, though it is not applicable for the correction of an obstruction 
 due to a heavy ridge. Roe has devised special forceps, with a male and 
 a female blade (Fig. 44), for this operation. 
 
 Technique. — (a) Local anesthesia upon both sides of the septum, 
 indeed of the whole nasal mucous membrane, is necessary; or the opera- 
 tion may be done under general anesthesia. 
 
 (6) The Roe forceps should be introduced, the male blade into the 
 side of convexity and the female blade into the opposite side. By closing 
 the forceps blades the convex portion of the septum is forced toward the 
 opposite side through the opening of the female blade. The entire area 
 of obstruction may be thus fractured and forced toward the concave 
 side. 
 
 (c) The fractured portion of the septum should be held in its new 
 position, with nasal splints, or with strips of bismuth gauze, for a few 
 days, or until it becomes fixed in its new position. This operation is 
 especially adapted to deviations of the perpendicular plate, which, being 
 composed of bony tissue, remains in position after being fractured. 
 
 6. The Asch-Mayer Operation. — This operation consists of a crucial 
 incision through the cartilaginous portion of the septum, the four tri- 
 angular flaps thus created being pushed toward the side of concavity and 
 held in their new position with a Mayer nasal tube (Fig. 49). The opera- 
 tion may be used in curved or cup-shaped deviations of the cartilaginous 
 septum. In other words, the Gleason, Watson, Sluder, Roe, and Asch- 
 Mayer operations are suitable for much the same type of deviated septa. 
 I have often included the deviated portion of the perpendicular plate of 
 the ethmoid in the field of operation with good results, and see no objec- 
 tion to it, though the operation as originally devised by Dr. Asch was 
 limited to the cartilaginous portion of the septum. 
 
 Technique. — (a) The operation may be performed under local anes- 
 thesia, though it is generally preferable to do it under general anesthesia, 
 as the shock and pain are otherwise considerable. 
 
 (b) After cleansing the nasal chambers and the face, the straight Asch 
 scissors (button-hole) (Figs. 45, 46 and 47) should be introduced into the 
 nostrils, the narrower blade into the side of convexity and the wider into 
 the opposite, from three-eighths to one-half of an inch above the floor 
 of the nose, and the septum cut through. The Asch angular scissors 
 (Fig. 46) is then introduced and the perpendicular incision made, 
 bisecting the middle of the horizontal one. Four triangular flaps are 
 thus made (Fig. 48). 
 
 (c) The septum should next be seized with forceps (Fig. 47) and 
 fractured by rotating it from side to side. It has been my practice to 
 include the perpendicular plate of the ethmoidal bone in the grasp of the 
 septum forceps, as it is nearly always deviated with the cartilaginous 
 portion. I have also included the remnants of the ridge left after the 
 
80 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 sawing operation, thus fracturing it (the vomer) from its attachment to 
 the maxilla. 
 
 Fig. 45 
 
 Asch's straight scissors. 
 Fig. 46 
 
 Asch'o curved scissors. 
 Fig. 47 
 
 Asch's septum forceps. 
 
 Fig. 48 
 
 The Asch operation. The crucial incision 
 is made through the deviated portion of the 
 quadrilateral cartilage of the septum, thus 
 forming four non-bevelled triangular flaps. 
 The flaps are then pushed forcibly to the 
 convex side of the septum and fractured at 
 their bases, as shown by the dotted lines. 
 This is done to overcome the resiliency of 
 the cartilage. 
 
 (d) The index finger is then inserted 
 into the nostril on the side of septal 
 convexity and the four triangular 
 flaps pushed as far as possible to the 
 opposite side (Fig. 48), care being 
 exercised to fracture the flaps at their 
 uncut bases. If this is not done the 
 resiliency of the cartilage gradually 
 brings them back to their original 
 position. 
 
 (e) Severe hemorrhage usually oc- 
 curs, but it may be quickly checked 
 by the introduction of the Mayer 
 nasal tubes. The tubes are primarily 
 used, however, for the purpose of 
 holding the incised and fractured sep- 
 tum toward the concave side (Fig. 
 49). The tube selected for the con- 
 vex side should be large enough to 
 force the septum beyond the point 
 
OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 81 
 
 it is desired to fix it, as it will swing back a little toward its old position 
 in spite of all precautions. A smaller tube should be introduced into the 
 opposite nostril to exert counterpressure against the septum to check the 
 hemorrhage. 
 
 Fig. 49 
 
 Mayer's nasal tube splints. 
 
 After-treatment. — Both tubes should be left in position for two or 
 three days and then removed. A tube one size smaller should then be 
 introduced into the side of convexity but none into the opposite side. 
 The tubes should be worn for about six weeks, being removed and 
 cleansed every alternate day during this period. Experience has shown 
 that the septum gradually swings back to its former position if the tube 
 is not worn for about this length of time. 
 
 Objections.— (a) Perforation of the septum sometimes follows the 
 operation, (b) The shock attending the operation is often great, (c) 
 The inflammatory reaction is sometimes severe, (d) The presence of 
 the tube in the nose for six weeks is a source of considerable annoyance. 
 (e) The hemorrhage is occasionally severe and difficult to control. 
 
 7. The Kyle Operation. — The Kyle operation may be used in simple 
 and compound curvatures of the septum in which there is a redundancy 
 of tissue along the lines of convexity. It consists in making V-shaped 
 grooves in the septum along the lines of greatest convexity, the object 
 being to remove tissue where it is redundant, so that the septum may be 
 made straight without overlapping along the lines of incision. 
 
 Technique. — (a) Local anesthesia of both sides of the septum should 
 be induced. 
 
 (b) A linear incision with a small bistoury should be made along the 
 lines of convexity. 
 
 Fig. .50 
 
 =^.w^f//^.*ra?>s 
 
 Fetterolf s file saw. 
 
 (c) The Fetterolf V-shaped file saw (Fig. 50) should be used along 
 the lines of incision until the thickness of the cartilage and bone are 
 penetrated (Fig. 51). 
 
 (d) The incised septum should then be forced into the median line 
 by the introduction of Kyle's malleable tubes into either nasal chamber 
 (Figs. 52 and 53). The tube being malleable may be spread with 
 forceps introduced into its lumen until the septum is adjusted in the 
 median line. 
 
 6 
 
82 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 (e) The after-treatment consists in removing and reintroducing the 
 tubes until all tendency of the tissues to return to their former position 
 is overcome. 
 
 Fig. 51 
 
 Fig. 52 
 
 Kyle's operation. Side view of septum 
 after groove is made. 
 
 a, sectional view of the Septum after the 
 V-shaped incision; b, Kyle's malleable 
 tube holding the septum in position. 
 
 Fig. 53 
 
 Kyle's malleable tubes. 
 
 Fig. 54 
 
 Fig. 55 
 
 The Price-Brown operation. Two parallel 
 incisions are made, one on either side of 
 the long axis of the deviation. An inter- 
 secting incision is then made across the 
 long axis of the deviation. All incisions are 
 made with bevelled edges, so that when the 
 two quadrilateral flaps are pushed to the 
 concave side they will engage in the opening 
 as in the Watson and the Gleason operations. 
 
 The removal of the bony ridge of the sep- 
 tum, the preliminary step in Moure's operation 
 for the correction of deviations of the septum. 
 
OBSTRUCTIVE LESIONS OF THE NASAL SEPTUM 
 
 83 
 
 The Price-Brown Operation. — This operation consists of two parallel 
 incisions united by an intersecting incision as shown in Fig. 54. The 
 two rectangular flaps thus formed are pushed through to the side of 
 the concavity and held in position for a few days with a nasal 
 splint or dressing upon the side of the convexity. The operation is 
 extremely simple, and is especially applicable to cup-shaped deviations 
 of the cartilaginous portion of the septum. This operation is also 
 applicable to simple perpendicular or horizontal angular deviations of 
 the cartilaginous septum, the intersecting incision being made across 
 the crest of the angular deviation, as shown in Fig. 54. The incision 
 should be so made that the bevelled edges hold the flap in their new 
 position as in the Watson operation. 
 
 Fig. 56 
 
 Cross-section of the nose, illustrating certain 
 details of Moure's septum operation 1, the 
 ridge severed with the spokeshave; 2, the in- 
 cision with the spokeshave; 3, the septum; 4, 
 the inferior turbinate crowded upon by the 
 ridge of the septum; 5, the middle turbinate 
 also crowded upon by the deviated septum. 
 
 The incisions of the septum in Moure's oper- 
 ation. 1, the incision along the floor of the nose 
 below the septal ridge; 2, the thickened septal 
 ridge; 3, the upper incision through the septum 
 being made with Moure's scissors. 
 
 Moure's Operation. — Moure's method of straightening the septum is 
 especially applicable to those cases in which there is a concavity on one 
 side of the septum and a marked thickening or ridge of bone upon the 
 opposite side (Fig. 56). This type of deviation is also well suited for 
 the submucous operation. 
 
 Technique. — (a) Cocaine anesthesia. 
 
 (b) Remove the ridge with a spokeshave or saw as indicated by 2 in 
 Fig. 56. The removal of this ridge of bone materially relieves the pres- 
 sure upon the middle (5) and inferior turbinated bodies (4). The septum 
 mav still crowd too much to the convex side, hence Moure advises the 
 
84 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 following procedure to force the remaining portion of the septum (3) to 
 the opposite side : 
 
 (c) Having removed the ridge, two incisions are made as shown in Fig. 
 57. One is made below the ridge (Fig. 58), and the other above and in 
 front of it, parallel with the ridge of the nose. The incisions are made 
 with specially devised scissors resembling those of Asch. 
 
 (d) A malleable metal splint is then inserted on the side of convexity 
 and spread with forceps until the septum is sufficiently forced to the 
 opposite side, as shown in Fig. 59. The two incisions permit the septum 
 to be forced to the opposite side, where it should be held with the 
 malleable splint until it becomes fixed in its new position. 
 
 Fig. 58 
 
 Fig. 59 
 
 V\Jl/r 
 
 Making the incisions through the septum 
 with Moure's scissors. 1, Moure's scissors; 2, 
 the septum. 
 
 Moure's malleable splint in operation. 
 1, the septum displaced to the right side 
 of the nose; 2, the incision made with 
 Moure's septum scissors; 3, the outer wall of 
 the nasal splint resting against the inferior 
 turbinated body; Z r , the inner wall of 
 Moure's nasal splint crowding the septum 
 to the right side of the nose. 
 
 After-treatment. — The splint should be removed in three or four days, 
 cleansed, and reinserted and moulded to the parts. This procedure 
 should be repeated every two or three days for one week, or until firm 
 union takes place. Should excessive granulations form they should be 
 reduced with fused chromic acid crystals. The open skeleton tube used 
 by Moure permits free respiration and nasal irrigation while it is in 
 position. 
 
THE SUBMUCOUS RESECTION OF THE SEPTUM 85 
 
 THE SUBMUCOUS RESECTION OF THE SEPTUM. 
 
 1. Position of the Patient. — -The patient may be placed in either 
 the sitting or the reclining posture. Most operators will probably prefer 
 the sitting posture in an ordinary office chair (Figs. 6 and 7), though the 
 reclining posture may become necessary if the patient faints either from 
 psychical or cocaine depression. I have found, when the patient is thus 
 overcome, that the reclining position gives immediate relief, and allows 
 the operator to proceed with but slight loss of time. The back of the 
 chair should be tipped almost to the horizontal position, and the head 
 of the patient supported by a head-rest or by an assistant. When the 
 patient is thus reclining the operator should sit by his right side, facing 
 the patient. If the operator prefers to stand the patient may be placed 
 upon an operating table. 
 
 2. Anesthesia. — Cocaine anesthesia is preferable, though a general 
 anesthetic may be administered. The method of applying the cocaine 
 is important. Freer has called attention to this fact, and, in general, I 
 follow his suggestion in reference to it. Pulverized cocaine is used 
 instead of a solution. A delicate silver cotton-wound applicator is 
 moistened in adrenalin solution, the excess squeezed from it, and then 
 dipped into the powdered cocaine. The loose granules are then gently 
 knocked off, and the mucous membrane of the entire septum on both 
 sides is thoroughly massaged or rubbed with it. The membranes should 
 be massaged for about three minutes. After an interval of five minutes 
 they should be massaged again with a fresh preparation. Three appli- 
 cations usually induce complete anesthesia, though in rare instances 
 numerous applications are required. 
 
 The advantages of this method of applying cocaine over the use of 
 solutions are the speed with which anesthesia is induced and the com- 
 parative infrequencv of cocaine toxemia. By this method little or no 
 cocaine is swallowed, whereas when a solution is used a considerable 
 amount may be swallowed and produce toxic symptoms. 
 
 When Hajek's incision is made at the anterior end of the columnar 
 cartilage (Fig. 60) Schleich's solution should be injected beneath the 
 membrane, as the application of cocaine will not produce anesthesia. 
 Furthermore, the membrane is very adherent in this region (vestibular 
 portion of the septum) and is elevated with difficulty. The subcutaneous 
 injection of the solution partially elevates the membrane and renders 
 the completion of the elevation comparatively easy. 
 
 3. The Incision. — The choice of the location of the incision should 
 depend upon the character and location of the septal deviation. If it 
 extends into the vestibule of the nose, Hajek's incision should be made at 
 the extreme anterior margin of the cartilage of the septum, as shown in 
 Fig. 60, a. As the membrane of the vestibular portion of the septum is 
 firmly attached to the fibrocartilage beneath it, this incision should only 
 be made when the deflection is far enough forward to render it necessary 
 to remove the anterior portion of the deflected cartilage. 
 
86 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 When the deviation does not extend forward into the vestibule Killian' s 
 incision (Fig. 60, b) should be made at the junction of the vestibular 
 membrane with the mucous membrane of the septum, as the muco- 
 perichondrium elevates with comparative ease posterior to this point. 
 
 The Killian incision is usually preferable and should be made with 
 a sharp-pointed knife upon the left side of the septum. All other writers 
 have recommended that it be made upon the side of the convexity of 
 the septum, as they believe this allows greater freedom of access in 
 elevating the membrane over the region of convexity. I believe this to 
 be ill advised, as most operators are more dextrous with their right 
 
 Fig. 60 
 
 Fig. 61 
 
 Incisions for the sub- The elevation of the mucoperichondrium upon the side of the 
 
 mucous resection of the primary incision in the mucous membrane. The elevation is 
 
 septum. a, the Hajek begun with a sharp or semisharp elevator and is completed with 
 
 incision; b, the Killian the blunt elevator, 
 incision. 
 
 hands. Furthermore, it is unnecessary, as the tip of the nose is flexible 
 and may be turned to one side out of the way. Hence, I recommend that 
 the incision be made upon the left side of the septum except for left- 
 handed or ambidextrous surgeons. 
 
 The tip of the index finger of the left hand should be introduced into 
 the right nasal chamber to exert counterpressure while the incision is 
 being made. The incision should only extend through the mucous 
 membrane and perichondrium. If it is carried deeper it interferes 
 with the elevation of these tissues. 
 
 4. The Elevation of the Mucoperichondrium and Periosteum. — 
 This step of the operation is often the beginning of either success or failure 
 
THE SUBMUCOUS RESECTION OF THE SEPTUM 87 
 
 in the operation. If the elevation is properly done over the entire area 
 of the deviation on both sides of the septum, the subsequent steps are 
 comparatively easy to carry out. If, however, the elevation is not properly 
 executed and extended over the entire field of the deviation, it may 
 interfere with the remaining steps of the operation to such an extent as 
 to defeat its purpose. Many of the younger rhinologists have told me 
 of the difficulties they have encountered, and almost without exception 
 they have failed to elevate over a large enough field. In the average 
 case in which the cartilage, perpendicular plate of the ethmoid, and the 
 vomer are involved in the deviation, the membrane should be elevated 
 over almost the entire area of both sides of the septum. If, however, 
 only the cartilage of the septum is affected, the elevation should be 
 extended about one-half inch beyond the junction of the cartilage and 
 the perpendicular plate, and down to the floor of the nose. Always 
 elevate at least one-half inch beyond the area of the tissue to be removed, 
 as otherwise the membrane may be injured in the process of removing 
 the deviated portion of the framework of the septum. 
 
 The technique elevation of the mucoperichondrium may be accom- 
 plished in various ways. Some operators, notably Freer, prefer small, 
 thin, sharp elevators with which the mucoperichondrium and periosteum 
 are dissected from the framework of the septum. Curved elevators are 
 also used to work around curved portions of the septum. Personally, 
 I prefer heavy, broad and dull elevators, and I have never found it neces- 
 sary to use curved elevators to get around a curved or an angular devia- 
 tion. A study of the following descriptive technique will show how 
 the heavy blunt elevators may be successfully used to encompass curved 
 and angular deviations of the cartilage and the perpendicular plate of 
 the ethmoid. The chief reason for using the blunt heavy elevators is 
 the greater speed and the lessened liability of tearing the membrane 
 in the process of elevation. 
 
 To start the elevation a sharp or semisharp elevator should be used 
 (Fig. 80), care being exercised to get beneath the perichondrium. If the 
 elevator penetrates between the mucous membrane and perichondrium, 
 the surface of the cartilage will present a velvety red appearance as the 
 perichondrium is still covering it. If, however, the elevator penetrates 
 beneath the perichondrium the exposed cartilage presents a glistening 
 white surface. Great patience is often required to start the elevation 
 properly; this being done, the remaining elevation is comparatively 
 easy. The point of least resistance is usually at the upper portion of 
 the Killian incision, whereas at the lower portion the perichondrium is 
 often so adherent as to require a knife to separate it from the cartilage. 
 
 Having succeeded in starting the elevation (Fig. 61) abandon the sharp 
 elevator and insert the blunt one (Fig. 80) into the small pocket already 
 made. Direct the elevator parallel with the ridge of the nose, as this 
 is the direction of least resistance (Fig. 62). Having introduced the 
 elevator almost to the cribriform plate the elevation should be continued 
 backward and downward with the whole length of the shank of the 
 elevator within the pocket of the membrane The mistake is usually 
 
88 THE NOSE AND ACCESSORY SINUSES 
 
 made of attempting to elevate with the tip of the elevater, whereas it 
 should be done with the shank. With the former it is easy to tear the 
 mucoperichondrium, while with the latter the elevation may be rapidly 
 accomplished with but little danger of tearing it. The principle 
 involved is obvious, namely, a small tip will perforate more readily 
 than a long shank. As a matter of fact, the mucoperichondrium and 
 periosteum elevate readily under moderate tension with a broad dull 
 instrument, whereas if a small sharp elevator is used extreme care must 
 be constantly exerted to avoid making a perforation. 
 
 After introducing the heavy blunt elevator as high as the cribriform 
 plate (Fig. 62), exert pressure downward and backward with a twisting 
 motion, and, as a rule, the membrane will strip down to the crest of the 
 vomer in a few seconds, or at most in a minute or two. Five minutes 
 or more may be required to start the elevation, whereas to complete it 
 will require but a comparatively short time. 
 
 The question naturally arises, How can the elevation be accomplished 
 with the shank of the elevator when the cartilaginous or perpendicular 
 plate portion of the septum is convex? The operator should remember 
 that these portions of the septum are thin and flexible. Being so, they 
 may be forced with the elevator to the median line and thus temporarily 
 rendered straight. While held in this straightened position the shank of 
 the instrument is passed downward and backward elevating the mem- 
 brane as it proceeds. I have rarely observed a septum in more than 400 
 submucous operations that did not yield to this method of procedure. 
 It may also be asked, How can the elevation be accomplished with the 
 tip of the straight, blunt elevator when there is a perpendicular deviation 
 of the cartilage f 
 
 The procedure is very simple. The tip of the nose is flexible, and the 
 instrument should be held parallel with the anterior portion of the 
 cartilage until it reaches the crest of the perpendicular deviation. The 
 instrument should then be shifted until it is parallel with the cartilage 
 posterior to the crest. The flexibility of the tip of the nose makes this 
 possible, hence a curved elevator is not necessary for the purpose; or 
 the crest may be forced to the concave side, thus rendering it straight 
 and the elevation continued. My contention in favor of the use of blunt 
 elevators (after the elevation is started) is based upon the conviction 
 that the average operator will do less damage and will operate with 
 greater speed than he will with small sharp elevators, or with small 
 blunt ones. Otherwise, I have no objection to Freer's elevators, with 
 which he, with infinite pains, accomplishes good results. 
 
 According to Neumann (J. R. Fletcher), the development of the peri- 
 osteum of the septum nasi throws interesting light upon the technique 
 of the submucous resection of the septum. He has found upon histological 
 examinations of sections of the septum that the periosteum is not uniformly 
 reflected over the bony portion of the septum. That only where 
 bone unites with bone, as where the perpendicular plate of the ethmoid 
 unites with the vomer, is the periosteum continuously spread over the 
 septum; and that where the vomer unites with the cartilage of the septum, 
 
THE SUBMUCOUS RESECTION OF THE SEPTUM 
 
 89 
 
 the periosteum is not continuous with the perichondrium of the cartilage. 
 In the latter region the periosteum arises from the floor of the nose and 
 
 Fig. 62 
 
 The Ha jek elevator introduced beneath the 
 mucoperichondrium along the line of least resist- 
 ance. When thus introduced the elevation 
 should be made with the whole shank of the 
 instrument in a downward and backward direc- 
 tion to the crest of the vomer. The periosteum 
 along the crest of the vomer should then be in- 
 cised, as shown in Figs. 63, 64, 65, and 66. 
 
 Fig. 63 
 
 Section through the nasal septum, a, quad- 
 rilateral cartilage; b, vomer; c, c, agglutina- 
 tion of the perichondrium to the periosteum; 
 d, d, periosteum reflected over the crest of 
 the vomer (it is not continuous within the 
 perichondrium); e, e, mucoperichondrium. 
 
 Elevation of the membranes of the cartilage 
 and vomer, a, quadrilateral cartilage; b, 
 vomer; c, c, perichondrium; d, d, periosteum of 
 vomer with two incisions (/, /) at the crest ; e, 
 mucous membrane; f , f, two incisions through 
 the periosteum along the crest of the vomer, 
 to facilitate the elevation of the membranes 
 anterior to the junction of the perpendicular 
 plate of the ethmoid with the vomer. 
 
 a, cartilage; b, Vomer; c, c, perichondrium; 
 d, d, periosteum of the vomer; e, e, mucous 
 membrane; f, two incisions through the peri- 
 osteum along the crest of the vomer. On the 
 concave side the periosteum over the vomer is 
 elevated. 
 
 passes upward over the lateral surface of the vomer to its crest, over 
 which it is reflected, and then passes downward over the opposite 
 lateral wall of the vomer to the floor of the nose. He also claims that 
 
90 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Fig. 
 
 the perichondrium is reflected over the periosteum in this region and 
 that it is closely adherent to it (Figs. 63 and 64). 
 
 This arrangement of the periosteum and perichondrium explains 
 the well-recognized difficulty experienced in elevating the periosteum 
 below the crest of the anterior portion of the vomer when the elevation 
 is begun above it. I have long recognized this difficulty and attributed 
 it to fibrous prolongations from the periosteum to the vomer, which, 
 according to Carter, were due to the presence of the tuberculum or 
 gland in this region. It appears, however, from the investigations of 
 Neumann that this is not the true explanation. 
 
 The elevation should be begun along the ridge of the nose, as shown 
 in Fig. 62, and carried down to the upper border of the vomer with the 
 
 whole length of the elevator. The 
 elevator should then be removed and 
 a short-bladed scalpel introduced and 
 an incision made with it along the 
 crest anterior to the perpendicular 
 plate of the ethmoid (Figs. 64, 65, 
 and 66). The elevator should then be 
 reintroduced and the elevation (on the 
 side of concavity of the septum) con- 
 tinued to the floor of the nose. Pos- 
 terior to the cartilage the elevation is 
 easily made to the floor of the nose as 
 the periosteum is continuous from 
 the roof to the floor of the nose. 
 
 I have often noted the liability of 
 the mucoperiosteum to tear at the 
 junction of the vomer with the carti- 
 lage. Neumann's findings, namely, 
 the close adherence of the mucoperi- 
 chondrium to the underlying periosteum and the reflection of the peri- 
 osteum over the crest, adequately explain it. This knowledge, and the 
 periosteal incisions I have recommended, greatly facilitates the eleva- 
 tion and reduces the liability of perforations. 
 
 5. The Incision through the Cartilage. — The incision through the 
 cartilage (after Killian's incision) may be made with' a small short-bladed 
 sharp knife, though it may be done with the tip of a curette or other 
 semisharp instrument. Some operators prefer the latter method, believ- 
 ing there is less danger of perforating the opposite mucous membrane. 
 If a knife is used the tip of the finger should be placed in the opposite 
 nostril to exert counterpressure while the incision is being made (Fig. 68). 
 The cartilage should be incised very cautiously, almost cell by cell, with 
 very delicate pressure, until the tip of the instrument is felt through the 
 thickness of the opposing mucoperichondrium. Under no circumstance 
 should the opposite mucoperichondrium be incised, as this would cause 
 a permanent perforation of the septum unless the incision were 
 immediately closed with sutures. I wish to emphasize the fact that 
 
 Showing the line of incision (a, a) through 
 the periosteum along the crest of the 
 vomer to facilitate the elevation of the 
 membranes. A similar incision should be 
 made on the opposite side of the crest. 
 
THE SUBMUCOUS RESECTION OF THE SEPTUM 
 
 91 
 
 if both mucous membranes are perforated, at points exactly opposite, 
 a permanent perforation will follow unless one is sutured by Yankauer's 
 
 The mucoperichondrium being elevated, the cartilage is incised, care being exercised to avoid 
 perforating the mucoperichondrium upon the opposite side of the septum. 
 
 Fig. 68 
 
 The cartilage being incised, the mucoperichondrium of the opposite side of the septum is being 
 elevated. The elevation is begun with a sharp or semisharp elevator, and is completed with a 
 blunt elevator. 
 
92 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Fig. 69 
 
 Showing the Foster sep- 
 tum speculum in position 
 after the membranes are ele- 
 vated. 
 
 method. If the perforations are not opposite a permanent perforation 
 will not result, though the process of repair will be prolonged. 
 
 If the incision through the cartilage is made 
 with a curette or other semisharp instrument, 
 the finger should be placed in the opposite nostril 
 to exert counterpressure while the instrument is 
 being ground through the cartilage. The tip of 
 the finger enables the operator to detect when 
 the entire thickness of the cartilage is penetrated. 
 The cartilage should be incised in a line corre- 
 sponding with the Killian incision. If, however, 
 the Hajek incision is made the cartilage is not 
 incised, as the incision is anterior to its forward 
 extension. When this incision is made the muco- 
 cutaneous membrane is dissected from both 
 sides of the fibrocartilage of the septum with a 
 small, sharp knife. 
 
 6. The Elevation of the Opposite Muco- 
 perichondrium and Periosteum. — When the 
 cartilage is completely incised, the semisharp 
 elevator (Fig. 68), with its flat surface in appo- 
 sition with the cartilage, is inserted into the carti- 
 laginous incision. The sharp edge of the tip of 
 the elevator should be moved up and down between the edge of the 
 cartilage and the adherent mucoperichondrium, especially at the upper 
 limit of the incision, as the membrane is less adherent at this point (Fig. 
 68). Having started the elevation the blunt elevator should be intro- 
 duced and passed upward parallel with the ridge of the nose (direction 
 of least resistance) until its tip is near the cribriform plate of the ethmoid 
 bone. The elevation should then be continued downward and backward, 
 with the shank of the instrument as previously described, and extending 
 over an area considerably larger than the area of cartilage and bone 
 to be removed. Never attempt to elevate below the crest of the vomer 
 when it forms a dense bony ridge, as to do so would only result in an 
 extensive laceration of the membrane. (See Removal of the Vomer.) 
 
 7. The Removal of the Cartilaginous Portion of the Septum. — In 
 nearly all cases this is most easily accomplished with my swivel knife 
 (Figs. 71 and 78), though it may be done with Killian's double-edged 
 spokeshave, a biting forceps, or angular knives. The advantage of the 
 swivel knife is the ease, precision, and rapidity with which it encircles 
 the cartilage, and the further fact that it removes it in one piece, thus 
 allowing the operator to study the specimen as a whole. 
 
 Before using the swivel knife the mucoperichondria should be distended 
 with a septum speculum (Figs. 69 and 86) to lift them from the cartilage 
 and to provide room for the swivel knife. This exposes the cartilage to 
 full view. The swivel knife may be applied to the cartilage at either 
 the upper or lower portion of the incision. If to the upper portion, the 
 incision will be made upward, backward, downward, and finally forward, 
 
THE SUBMUCOUS RESECTION OF THE SEPTUM 
 
 93 
 
 along the floor of the nose, thus completely encircling the portion of the 
 cartilage to be removed (Fig. 70). If applied at the lower portion of the 
 incision, the cut will extend backward, along the crest of the vomer to the 
 junction of the vomer and perpendicular plate of the ethmoid, thence 
 
 Fig. 70 
 
 The removal of the quadrilateral cartilage of the septum with the author's swivel knife. The 
 membrane is shown removed to expose the knife to view. In the actual operation the mem- 
 brane is not removed. 
 
 The author's swivel knife in position at the lower portion of the incision of the cartilage. 
 
 upward and forward, along the antero-inferior margin of the perpen- 
 dicular plate, and then downward, parallel with the ridge of the nose to 
 the upper limit of the primary incision of the cartilage, thus encircling 
 the portion of the cartilage to be removed (Fig. 71). If the incision is 
 
94 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 begun at the lower limit of the primary incision it may be necessary 
 first to make a slight cut with a knife or scissors, as the cartilage is 
 often fibrous at this point. 
 
 Fig. 72 
 
 The cartilage having been excised submucously with the swivel knife, is removed from the 
 mucoperichondrial pouch with dressing forceps. 
 
 Fig. 73 
 
 Showing the mucoperichondrial pouch after the removal of the cartilage. The bony crest of 
 the vomer is shown in the bottom of the pouch, while deep in the pouch is shown the perpen- 
 dicular plate of the ethmoid extending upward from the crest of the vomer. This should be removed 
 with the Ballenger-Foster forceps, as shown in Fig. 74. 
 
 The swivel knife is easily controlled and is an instrument of great 
 precision. The swivel blade follows the direction toward which the 
 tips of the prong are directed. 
 
 The resistance of the tissues controls 
 
THE SUBMUCOUS RESECTION OF THE SEPTUM 
 
 95 
 
 the position of the swivel blade so that it always follows the prong-tips. 
 This instrument was suggested by Killian's fixed double-edged septum 
 cartilage spokeshave, though the swivel blade is an entirely new prin- 
 ciple in surgical instruments. While the general appearance of the 
 instruments are much alike, the swivel principle in my knife makes 
 it quite different. They are alike only in the fact that the handle and 
 prongs are similar. 
 
 Having encircled the cartilage it is removed en masse, with dressing 
 forceps, as shown in Fig. 72. Fig. 73 shows the perpendicular plate 
 in the depth of the mucoperichondrial pouch after the cartilage is 
 removed. 
 
 Fig. 
 
 The removal of the perpendicular plate of the ethmoid bone with the Foster-Ballenger forceps. 
 a, the area of cartilage previously removed with the swivel knife; b, the area of bone removed with 
 ». single bite of the forceps. 
 
 8. The Removal of the Perpendicular Plate of the Ethmoid. — This 
 is accomplished with the Foster-Ballenger bone forceps (Fig. 79). They 
 remove a comparatively large piece at each bite, and two or three bites 
 remove all that is necessary. The bites may be made without removing 
 the forceps from the mucoperichondrial pouch (Figs. 74 and 79), a point 
 of considerable importance, as each introduction of an instrument into 
 the perichondrial pouch increases the chance of injuring the membranes. 
 The perpendicular plate may also be removed by seizing it w T ith heavy 
 dressing forceps and twisting it from its attachments, though this is a 
 crude and dangerous method, as it may fracture the cribriform plate. 
 
 9. The Removal of the Vomer. — Various methods are in vogue for 
 the removal of the deviated vomer, which often forms the so-called 
 ridge of the septum. It is obviously almost impossible to elevate the 
 mucoperiosteum beneath the crest of the ridge (vomer), as its anterior 
 portion is near the floor of the nose, and to attempt to pass the elevator 
 over the margin of the crest would almost certainly tear the tense mucous 
 membrane along this line. Fortunately it is not necessary to elevate 
 
96 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 below the crest, as the deviated or thickened bone can be removed 
 without previously elevating the membrane beneath the crest. 
 
 Fig. 75 
 
 The removal of the thickened crest of the vomer with the author's V-shaped gouge 
 
 Fig. 76 
 
 The author's method of removing the ridge of bone in the submucous resection of the septum. 
 a, the septum forceps grasping the ridge, the blades being external to the mucous membranes. 
 The forceps is rotated on its longitudinal axis, as in the Asch operation, thus fracturing the vomer 
 from its lower attachment; b, the area of cartilage and perpendicular plate of the ethmoid pre- 
 viously removed; the mucous membrane is shown removed, though this is not actually done in 
 the operation. 
 
 An old and approved method of removing the vomer is with Hajek's 
 gouge or some modification of it (Figs. 75, 81 and 82). The V-shaped end 
 
THE SUBMUCOUS RESECTION OF THE SEPTUM 
 
 97 
 
 of the gouge is engaged at the anterior end of the ridge of bone and driven 
 
 with a mallet into its substance for a short distance, and then the handle 
 
 of the gouge is depressed, and thus partially splinters the bone from its 
 
 attachment. The gouge is then driven farther into the ridge until it is 
 
 finally removed in its entirety. As 
 
 the vomer is loosened it separates FlG - 77 
 
 from the mucoperiosteum without 
 
 tearing it, provided, of course, the 
 
 gouge is always directed parallel 
 
 w 7 ith the anteroposterior direction 
 
 of the crest of the vomer. 
 
 Another method of removing the 
 deviated vomer is with a specially 
 devised bone-cutting forceps. Of 
 these, L. M. Hurd's is probably the 
 best (Fig. 84). It is powerful, has 
 downward cutting blades, and with 
 it the bone may be bitten away with 
 considerable ease. 
 
 R. H. Brown has devised a 
 guarded drill, to be used w 7 ith an 
 electric motor for the submucous 
 removal of the deviated vomer. 
 
 Personally, I prefer to first frac- 
 ture the vomer from the premax- 
 illary bone at the floor of the nose, 
 and then to remove it with heavy 
 
 dressing forceps, introduced into the mucoperiosteal pouch. During 
 the process of fracture the mucoperiosteum separates from beneath 
 the crest of the vomer and thus allows the long ridge of bone to be 
 removed from the pouch (Fig. 77). In young adults and children 
 my method is not applicable, as the vomer is not yet fully ossified. In 
 adults it is a speedy and an almost painless procedure, and results in 
 
 The removal of the vomer after it is fractured 
 is shown in Fig. 76. 
 
 Fig. 78 
 
 The author's swivel cartilage knife. 
 
 but little or no shock, as the cartilage and perpendicular plate of the 
 septum have been previously removed. There is, therefore, no solid 
 tissue above to communicate the shock to the cranial contents (Fig. 76). 
 
 The technique of the procedure is as follows: 
 
 Introduce the blades of the Asch septum forceps into the nasal cham- 
 bers outside of the mucoperichondria, and grasp the deviated vomer 
 firmly, twisting the forceps in its longitudinal axis and fracturing the 
 7 
 
98 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 vomer from its attachment at the floor of the nose The blades of the 
 Asch forceps should be placed a little above the floor of the nose, as they 
 may otherwise tear the mucous membrane at the junction of the vomer 
 with the floor of the nose. The fracture should be thorough, in order 
 to permit the detachment of the fragments from the floor of the nose. 
 
 Fig. 7 
 
 Foster-Ballenger perpendicular plate bone forceps. 
 Fig. 
 
 Hajek-Ballenger mucoperichondria elevators. 
 Fig. 81 
 
 liiiiiiiiiiiiiiiin'iiiiiii'iiM 
 
 II! 11 """" 1 " "'""M! 
 
 ll!I!!!!!!»NIlll|l||!imi!!!!| 
 
 The author's mucosa knife. 
 
 Fig. 82 
 
 S^^Ul^« 
 
 Hajek's septum gouge. 
 
 Fig. 83 
 
 -IIIIMIIIIIllllllllillllllllll 
 F.AiHARD^S CO, CHICAGO 
 The author's septum gouge. 
 
 M 1 1 M M 1 1 f i M 1 1 1 1 M 1 1 1 1 1 1 Tl I ill IH;lil'lllllHlt:iliri9l 
 
 Remove the Asch forceps and introduce the tips of heavy dressing 
 forceps into the mucoperichondrial pouch, grasp the vomer, and with a 
 tugging, teasing motion lift it from its fractured base. The mucoperi- 
 osteum remaining attached below the crest will readily separate and 
 allow the bone to be removed (Fig. 77). 
 
THE SUBMUCOUS RESECTION OF THE SEPTUM 
 
 99 
 
 10. Inspection of the Field Operated Upon. — After the completion 
 of the various steps of the operation, the field operated upon should be 
 subjected to the closest scrutiny. If a portion of the deviated cartilage 
 or bone is left in place it may be found, when healing is complete, that 
 it will still cause obstruction of the nasal chambers. Every vestige of the 
 deviated framework of the septum should be removed (Dundas Grant). 
 Bone-cutting forceps of one type or another are usually used for this 
 purpose in the cartilaginous and perpendicular plate portions of the 
 
 Fig. 84 
 
 Fig. 85 
 
 Hurd's bone septum forceps. 
 Fig. SG 
 
 Allen's nasal speculum. 
 Fig. 87 
 
 F.A.HARDY SCO 
 CHICAGO. 
 
 Ballenger-Foster septum speculum. 
 
 Simpson's nasal sponge splint. 
 
 septum, though the gouge may be more useful for cutting along the floor 
 of the nose. I have found it a very helpful practice to insert a finger an 
 inch or two into the nasal chambers, as it enables me to detect the presence 
 of bony prominences which might otherwise have escaped my notice. 
 
 1 1 . The Dressing". — A dressing should be placed in the nasal chambers 
 for two purposes, namely: (a) coaptation of the membranes, and (6) 
 prevention of the formation of a blood clot in the mucoperichondrial 
 pouch. 
 
 The dressing most frequently used is composed of compressed cotton 
 
100 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 or Berney's sponge tents (Fig. 87). They have been placed on the market 
 under the name of the Simpson-Berney nasal splints. The mucoperi- 
 chondria are first clamped together with the septum speculum, then one 
 or two of the splints are introduced into each nasal chamber. The 
 patient's head is then inclined backward and a few drops of distilled 
 water, or of the peroxide of hydrogen, are instilled into the ends of the 
 splints (Fig. 88). This causes them to swell and compress the mem- 
 branes together. 
 
 12. The After-treatment.— The nasal dressing should be removed 
 in from twenty-four to forty-eight hours after the operation. The use 
 of bismuth paste on the splints has a chemotactic effect (reaction of 
 
 inflammation) upon the mucous 
 FlG - 88 membranes (Emile Beck) and thus 
 
 reduces the chance of infection. 
 The splints interfere with the ven- 
 tilation and drainage of the nose, 
 and are therefore usually removed 
 at the expiration of twenty-four to 
 forty-eight hours. Subsequently 
 the nasal chambers are irrigated 
 with a mild solution of the per- 
 manganate of potash three or four 
 times daily. The temperature of 
 the solution should be about 104° 
 F., or as hot as the patient will 
 tolerate. If crusts form over the 
 incision the patient should be pro- 
 vided with a tube of sterile vaseline 
 and instructed to squeeze some of 
 it into the vestibules of the nose, 
 twice a day, and to compress the 
 alee of the nose and thus smear it 
 over the mucous membranes. Heal- 
 ing should be completed in from 
 three to ten days, unless one of the 
 membranes has been lacerated, in 
 which event it may be somewhat 
 prolonged. 
 Accidents. — This operation is peculiarly liable to certain accidental 
 complications, some of which are inherent in the difficult technique, 
 while others are the results of the inexperience or temperamental weak- 
 nesses of the operator. 
 
 Incision through Both Mucous Membranes. — The novice is likely to 
 extend the incision through both mucous membranes, as the cartilage 
 is easily incised and the most delicate manipulation of the knife is 
 necessary in making the incision through it. Before the operator realizes 
 it the incision has extended through the mucous membrane upon the 
 opposite side. To avoid this accident the cartilage should be incised, 
 
 The Simpson sponge-tent dressing in posi- 
 tion at the close of the submucous operation. 
 The left side shows the tents dry, the right moist 
 and swollen. The Foster speculum holds the 
 membranes in apposition while the tents are 
 being introduced. 
 
THE SUBMUCOUS RESECTION OF THE SEPTUM 101 
 
 as it were, cell by cell, until the point of the knife is perceived by the 
 tip of the index finger, inserted in the opposite nostril. Should both 
 mucous membranes be incised along the line of the Killian incision it 
 will be necessary to close one of the incisions with Yankauer's needles 
 and methods of suture. The sutures should be removed at the expira- 
 tion of the third day. 
 
 Tears through Both Mucous Membranes. — Sometimes during the 
 process of elevating them, the mucous membranes are lacerated at points 
 exactly opposite. Should this accident occur an endeavor should be 
 made to close one of the apertures by Yankauer's method of suturing. 
 This procedure is more difficult than suturing the anterior incision, 
 because it is located more deeply in the nasal chambers. 
 
 Destruction of the Mucous Membrane upon One Side of the Septum. — 
 This accident may occur during the elevation of the membrane or during 
 the removal of the cartilaginous and bony portions of the septum with 
 cutting forceps. This is especially true if the elevation of the muco- 
 periosteum has not been extended over a sufficiently large area. 
 It may also occur while the cutting forceps are in use, the mucous 
 membrane being accidentally engaged in the forceps. This can be 
 avoided by exercising great care through observation before closing the 
 forceps. 
 
 Sinking in of the Ridge of the Nose. — This accident has been reported 
 only a few times and need not be feared except under a few conditions. 
 When it occurs it is due to one of three conditions: (a) the removal of 
 the cartilage too near the ridge of the nose, (6) chondritis following 
 or preceding the operation, and (c) traumatism. 
 
 (a) A cartilaginous ridge at least one-fourth of an inch in depth 
 should be left to support the external nose. A greater width is desirable 
 especially if the deviation is traumatic in origin, as in this case chon- 
 dritis may have weakened the cartilage. 
 
 (6) Chondritis or inflammation of the cartilage following the operation 
 may soften the cartilage of the ridge of the nose and cause it to drop 
 or sink in and thus produce external deformity. The nose should be 
 carefully observed for several days after the operation for inflamma- 
 tory symptoms, and if they occur strenuous efforts should be made to 
 combat them. Perhaps the best procedure is to employ heat over the 
 nose. The application of hot fomentations every fifteen minutes is the 
 best mode of procedure. In addition to this the nasal chambers should 
 be irrigated with normal salt solution (one teaspoonful of table salt to 
 each quart of water) every three hours. The head should be inclined 
 well forward, almost between the knees, and the mouth kept open 
 during the irrigations. These precautions prevent the patient swallow- 
 ing and carrying the solution to the tympanic cavities, in which case it 
 might produce otitis media or mastoiditis. 
 
 When the ridge of the nose sinks in after submucous resection of the 
 septum, it is sometimes possible to correct the deformity by the sub- 
 cutaneous injection of cold paraffin. 
 
 (c) A blow upon the nose after the submucous resection operation 
 
102 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Fig. 89 
 
 might cause a sinking-in of the ridge below the nasal bones. I have 
 never known of such an accident, though I presume it will occur in a 
 few cases in due course of time, as the cartilaginous support of the 
 nose is weakened by the submucous operation. 
 
 The Freer or Open Method. — According to O. T. Freer, this pro- 
 cedure is especially adapted to cases in which unusual difficulties neces- 
 sitate an operative field as open as possible for inspection, as those in 
 which the mucous coverings are very adherent, or in which the operation 
 is performed in the small nostrils of children, for deviations with extreme 
 angles or for extensive deep-seated deflections. The open operative field 
 is obtained by means of Freer's reversed L mucous membrane incision 
 (Fig. 89), consisting of a vertical limb, made well back in the nose, 
 joined by a horizontal one conducted forward from it along the base of 
 the septum, in most cases to the front of the nasal vestibule. These 
 incisions outline a flap which is dissected upward and backward with a 
 suitable blade from its basal line until the vertical incision is reached 
 
 (Fig. 88) . The flap is then uplifted 
 by means of the dulled elevator and 
 held forward out of the way by 
 means of a retractor, by means of 
 which the nose is held open by an 
 assistant, these retractors taking the 
 place of a speculum. A large field of 
 cartilage is thus uncovered in front 
 so that the first incision through it 
 can be made in plain view. It out- 
 lines a tongue-shaped flap of cartilage 
 with its base backward; and which, 
 when uplifted from the mucous cov- 
 erings of the concave side of the de- 
 viation, gives a broad entrance into 
 the concavity of the deflection, mak- 
 ing all of its recesses readily accessible to sight as the denudation progresses, 
 so that sharp dissection can be safely accomplished without risk of per- 
 foration. After the posterior portion of the mucous coverings have then 
 been uplifted on the side of the convexity of the deviation, the cartilage, 
 now entirely denuded, is excised with a little keen, hoe-shaped blade 
 and by sharp elevators. The remains of the cartilage are then detached 
 posteriorly from their usual attachments to the side of the vomer by 
 means of long elevators; and the bony resection is begun by an incision 
 upon the upper border of the ridge (often hidden) and anterior border 
 of the vomer, splitting the periosteal envelope of these structures. The 
 periosteum is then pushed off from their convex and concave sides by 
 means of suitable chisel-edged raspatories and blades and the entire bony 
 deviation bared by them and by the elevators. It is then cut away by 
 the Freer reinforced punch forceps, including the ridge of the nasal floor, 
 and as much of the vomer and perpendicular plate as is needed. The 
 chisel should only be used in cases in which the ridge is unusually broad. 
 
 a, a, Freer's incision. 
 
THE SUBMUCOUS RESECTION OF THE SEPTUM 103 
 
 Freer operates with the patient in a semirecumbent position on a 
 dental chair, which can be raised and lowered. He employes the Kir- 
 stein head lamp, and stands beside the patient. 
 
 He has devised a special instrumentarium for the operation. It 
 includes a number of keen-edged blades for dissection, which he uses 
 
 
 Fig. 90 
 
 
 
 
 HH '■■ 
 
 
 
 
 |^ 
 
 ftBWffi' 'ifflto&mfciP 
 
 
 »*2L^i 
 
 
 
 sSEtJ^Jfci^i^"- 
 
 ^^£3rei*i!fiSl& 
 
 ^U'tA:' 
 
 
 jyK^w^^v 
 
 HK^^^^e^ 
 
 
 v ^3B5« 
 
 
 
 Kg^~~ \ ■■ rx ^m 
 
 
 
 
 
 SrSf*' "° 
 
 j^TjiP^J7*tfy^hjk«^ 
 
 
 
 
 
 ?^^^^^^ 
 
 
 
 
 
 
 
 
 
 agggj6i»^/igS 
 
 
 
 SiwSS^ 
 
 ^sgjjjlB 
 
 Section of septum two and one-halt years after a submucous resection of bene and cartilage 
 shows no regeneration of either bone or cartilage, but is replaced by a dense fibrous tissue. Age. 
 forty-seven years. (Specimen kindly loaned by Dr. J. C. Beck.) 
 
 Fig, 91 
 
 Same as Fig. 90, with higher power. 
 
104 THE NOSE AND ACCESSORY SINUSES 
 
 whenever, in his opinion, the coverings of the deviation cannot be 
 uplifted readily with dull-edged instruments. 
 
 After the operation, the nostril of the side on which the incisions 
 have been made, should be packed with narrow strips of lint saturated 
 with bismuth subnitrate and soaked in oil vaseline ; the strips should be 
 introduced in layers, in order to avoid injurious bunching and also to 
 hold the flaps in place. 
 
 Hematoma of the septum does not occur when coaptation of the 
 mucoperiosteal membranes has resulted from the use of suitable dress- 
 ings in either method of operating, and perforations are rare if the 
 technique is carefully carried out, even in extensive bony resections. 
 
 Remarks. — Some writers have stated that the swivel knife is objection- 
 able because it is likely to tear the mucous membrane. Such a statement 
 can mean but one of two things, namely: (a) that the operator is extremely 
 awkward, or (6) that he fails to elevate the membrane sufficiently. Any 
 operator with but a moderate experience with the submucous resection of 
 the septum knows that it is almost impossible to tear the mucous mem- 
 brane with the swivel knife if the mucoperichondrium is previously 
 elevated over the entire operative field. 
 
 One writer makes the claim that the swivel knife is not an exact instru- 
 ment — is not under the exact control of the operator. This is a mistaken 
 idea, and is not based upon personal experience, but is a theoretical 
 deduction. As a matter of fact, it is one of the most exact and easily 
 controlled instruments used in this operation. It cuts cartilage with 
 but slight resistance, and may be directed with the greatest precision, 
 so as to encircle the amount of cartilage it is necessary to remove. 
 
 Authors differ as to the reformation of the cartilage of the septum 
 after its removal. According to J. C. Beck (Figs. 90 and 91), no cartilage 
 cells were found in the tissue after a lapse of two and one-half years. 
 The removed cartilage was replaced by dense fibrous tissue. Freer, on the 
 other hand, claims that the cartilage reforms, especially in the younger 
 subjects. 
 
 PERFORATION OF THE SEPTUM. 
 
 Etiology. — -The causes of perforation of the septum may be divided 
 into (a) congenital, (6) chronic granuloma, (c) traumatic, (d) acute 
 infection, and (e) atrophic or perforating ulcer. 
 
 (a) Congenital perforation is extremely rare, Zuckerkandl having 
 reported a few cases. 
 
 (6) Chronic granulomata — as syphilis, tubercle, and lupus — have 
 caused a considerable percentage of the cases, some authors attributing 
 as high as 50 to 60 per cent, to syphilis alone. In my experience the 
 percentage due to syphilis is much less than this ; syphilis is not, however, 
 as common in this as in some other countries. Syphilitic perforations 
 almost always include the bony portion of the septum, whereas, tubercle 
 and lupus are limited to the cartilaginous portion. The tuberculous 
 and lupous origin of the perforating ulcer may be determined by finding 
 
PERFORATION OF THE SEPTUM 105 
 
 the tubercle bacilli, or tuberculous histological changes in the tissues. 
 A slow but reliable method of demonstrating the tuberculous process 
 is to inject a guinea pig with some of the tissue from the ulcer. Six weeks 
 later hold a postmortem on the pig and note the presence or absence of 
 a tuberculous process. 
 
 (c) Traumatic perforations may include any portion of the septum, 
 as they are usually due to surgical procedures, though they may be due 
 to accidental violence and to picking the nose with the finger nail. 
 
 (d) Acute infectious diseases, as diphtheria, scarlet fever, typhoid 
 fever, phlegmonous abscess, etc., may result in perforations. 
 
 (e) Atrophic or perforating ulcer of the septum is probably the most 
 common type of perforation. Several conditions contribute to the 
 etiology of this type of perforating ulcer. An anterior spur or deviation 
 of the cartilaginous portion of the septum is usually present, and on 
 account of its projection into the field of the inspiratory current of air, 
 it is subjected to constant mechanical irritation and to the desiccation 
 of the secretions which constantly accumulate upon it. The ciliated 
 columnar epithelium undergoes retrograde changes to a less specialized 
 type of epithelium (pavement epithelium). The dust and other foreign 
 substances in the air also irritate the epithelium and mucous membrane. 
 
 The crusts thus formed in this area become adherent, and are forcibly 
 blown or picked off with the finger nail, the epithelium coming away 
 with them. Hemorrhagic deposits in the mucous membrane occur, and 
 epitaxis is of frequent occurrence. The retrograde process continues 
 until the entire thickness of the septum is destroyed. Infection plays 
 a part in the foregoing process. 
 
 Symptoms. — The symptoms of perforation of the septum vary with 
 the size, cause, and location of the perforation. A small anterior per- 
 foration sometimes gives rise to a musical, whistling sound, whereas a 
 large one does not. If the perforation is associated with a prominent 
 bony spur, there may be a sense of stuffiness in the nose. Crusts, if of 
 large size, may give rise to the feeling of a foreign body in the nose, and, if 
 forcibly blown or picked off, may cause nasal hemorrhage. Repeated 
 epistaxis should arouse suspicion of a perforating ulcer. Syphilitic 
 ulceration is usually accompanied by an offensive necrotic odor. Many 
 cases will progress to complete perforation without the patient's knowl- 
 edge of the fact. 
 
 Treatment. — If seen in the ulcerative stage, before perforation, the 
 progress of the local retrograde changes may be checked by appropriate 
 local cleansing and antiseptic washes and ointments, or, if due to syphilis, 
 by the administration of the proper remedies for this disease. When 
 the perforation is complete, little can be done except in a surgical way. 
 Large perforations are not, however, amenable to surgical closure. 
 Small ones may often be closed by proper plastic surgical procedures. 
 
 Goldstein's Plastic Flap Operation. — Dr. M. A. Goldstein has suggested 
 and successfully used the following operation. A plastic flap of mucous 
 membrane is turned into the opening and inserted and sutured between 
 the elevated membranes of the two sides of the septum. 
 
106 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Technique. — (a) Cocaine anesthesia. 
 
 (6) The rim or edge of the perforationis freshened by paring off 
 the epithelium and mucous membrane. 
 
 (c) The mucoperichondrium is 
 FlG - 92 then elevated for a distance of one- 
 half inch around the edge of the 
 perforation. 
 
 (d) A ring of cartilage is then 
 resected for one-eighth to one-fourth 
 inch from the edge of the perfora- 
 tion, the author's single-tined 
 swivel knife being used for the 
 purpose (Fig. 92). 
 
 (e) A mucous membrane flap, the 
 area of which is considerably larger 
 than the perforation, is then dis- 
 sected from the most convenient 
 surface of the septum and turned 
 into the perforation and tucked 
 
 between the elevated membranes around the perforation. I have de- 
 vised a trailing swivel knife (Fig. 93) for outlining this flap. The 
 method of using it is shown in Fig. 94. 
 
 The edge of the cartilage around the perfora- 
 tion (c) being removed with the author's single 
 tined swivel knife in Goldstein's plastic sep- 
 tum operation. 
 
 Fig. 93 
 
 The author's mucosa swivel knife. 
 
 (/) When the pedicled flap is in position (Fig. 95) three or four 
 Yankauer stitches hold it in position. One surface is covered by 
 epithelium, while the other is left to heal by granulation from the edges 
 of the closed perforation. 
 
 Hazletine's Plastic Operation. — This operation is also only suited to 
 small perforations. It is more simple than the pedicled flap operation, 
 and appears to be a more satisfactory procedure. 
 
 Technique. — (a) Cocaine anesthesia. 
 
 (b) Freshen the edges of the perforation and elevate the mucoperi- 
 chondrium, as in the submucous resection operation. 
 
 (c) Make a long curved incision (Fig. 96, b, b) through the mucoperi- 
 chondrium one-fourth to one-half inch anterior to the perforation, and 
 elevate the ribbon-flap thus made. 
 
 (d) Make a long curved incision (e, e) through the mucoperichondrium 
 of the opposite side of the septum, one-fourth to one-half inch posterior 
 to the perforation and elevate the flap. 
 
PERFORATION OF THE SEPTUM 
 
 107 
 
 (c) Suture the anterior flap to the freshened posterior edge of the mu- 
 cous membrane of the perforation (Fig. 99), and the posterior flap on 
 the opposite side of the septum to the freshened anterior edge of the 
 membrane of the perforation, as shown in Fig. 98. The areas a and a 
 heal bv granulation. 
 
 Fig. 94 
 
 Fig. 95 
 
 Showing the method of outlining the flap with 
 the author's swivel mucosa knife for the closure 
 of a perforation of the septum. 
 
 f, the plastic flap sutured in the perfora- 
 tion; c, the pedicle of the plastic flap; b, the 
 denuded area from which the plastic flap is 
 removed heals by granulation; d, the edge 
 of the plasitc flap between the mucoperi- 
 chondria of the septum. 
 
 Fig. 9G 
 
 Fig. 97 
 
 Schema of Hazletine's plastic operation 
 for the closure of perforations of the septum. 
 b, b, incision in front of the perforation; e, e, 
 the incision posterior to the perforation on 
 the opposite side of the septum; c, c, the 
 freshened edges of the perforation. 
 
 Detail of Fig. 96, showing the opposite 
 side of the septum, the flap formerly cov- 
 ering area a is sutured to the posterior 
 margin of the perforation. 
 
108 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 (J) Remove the sutures in twenty-four to thirty-six hours. By this 
 procedure the perforation is covered by two mucous membranes, and, 
 the lines of suture not being opposite, closure of the perforation follows. 
 
 Yankauer's Intranasal Suture. — Sydney Yankauer has devised instru- 
 ments for intranasal suturing which may be applied in repairing rents 
 in the mucous membrane of the septum following the submucous 
 resection operation, in closing the mucous membrane wound of the 
 
 Fig. 98 
 
 Detail of Fig. 96. a, the denuded cartilage after the plastic flap (d, d) is sutured. 
 
 Fig. 99 
 
 Yankauer's intranasal suture. A, A, A, the suture thread, being drawn forward with the hook. 
 The needle is then reversed and withdrawn from the nose, rethreaded, and another stitch taken in 
 the torn mucous membrane. 
 
 inferior turbinate after resecting the hypertrophied membrane and 
 bone, and in the plastic operations upon the septum for the closure of 
 chronic perforations. The technique is as follows: 
 
 The Introduction of the Suture. — Catgut suture eighteen inches in 
 length should be used. It should be placed in sterilized water in 
 carbolic solution for a few moments to soften it. The suture may be 
 passed through either flap, preferably through the more movable one. 
 It should then be passed through the other flap after first coapting the 
 
PERFORATION OF THE SEPTUM 
 
 109 
 
 two flaps. If necessary, the crotch forceps may be used to facilitate the 
 penetration of the flaps with the needle. 
 
 Grasping the Thread. — The eye of the needle should project only 
 one-eighth of an inch through the membranes. One of the threads 
 should then be seized with the hook, which may be rotated with the 
 pilot wheel at the end of the instrument until it is in position to seize 
 the thread. 
 
 Withdrawing the Needle. — When the thread is in the grasp of the 
 hook, the needle should be removed from the flaps by rotating it back- 
 
 Fig. 100 
 
 Fig. 101 
 
 The slip-knot. 
 
 Yankauer's intranasal suture method of conveying the 
 knot into position in the nasal chamber. 
 
 ward until it is free from the membranes. It should then be withdrawn 
 from the nose. The hook should in the meantime be kept close to the 
 needle puncture to prevent the thread from tearing out. 
 
 Withdrawing the Hook. — The hook is then withdrawn from the nose 
 with the loop of thread. One side of the loop is then drawn from the 
 nose ready for making the slip-knot. 
 
 Making the Slip-knot.— First see that both ends of the thread are 
 outside of the nose, and that they are not entangled. To make the 
 slip-knot, have one end include half of the thread (nine inches) outside 
 
HO THE NOSE AND ACCESSORY SINUSES 
 
 of the nose, the other end being correspondingly shorter. Then make 
 a simple overhand knot near the middle of the long ends, and pass the 
 shorter end through the bight of the knot, as shown in Fig. 100. 
 Tighten the slip-knot until it binds the through thread. Two threads 
 now come through the knot, one the knot end, the other the slip end. 
 
 Closing the Slip-knot. — The slip-knot being drawn tight over the 
 thread, it is brought near the nostril. The knot end of the thread is 
 passed through the ring of the suture closer until the ring is near the 
 knot. The end of the thread is then held with the thumb against the 
 handle of the instrument, as shown in Fig. 101. The left hand holds 
 the slip end, and the ring suture closer is advanced into the nose and 
 the knot closed where the suture passes through the mucous membrane. 
 The ring passes beyond the point where the suture passes through the 
 membranes, and thus makes as firm a knot as may be desired. 
 
 The remaining portion of the wound may be closed by making a 
 continuous suture with the longer end of the thread, only using the 
 slip-knot for the last stitch to fix it in place. If preferred for any 
 reason, each stitch may be made separately as above described, cutting 
 off the ends as in external suturing. 
 
 The sutures should be removed in from two to three days. 
 
 The Safety Knots. — In order to prevent the slip-knot from becoming 
 loose, it is advisable to make a true surgical knot, consisting of two 
 overhand knots, above the slip-knot. 
 
CHAPTER VI. 
 
 THE ETIOLOGY OF INFLAMMATORY DISEASES OF THE NOSE 
 AND ACCESSORY SINUSES. 
 
 INFLAMMATION. 
 
 Acute Inflammation. — Acute inflammation is a threefold reaction 
 excited by the presence of certain noxa, or irritant material, in the tissues. 
 The noxa or irritant is usually a pathogenic microorganism and its 
 toxin, or it may be of chemical or traumatic origin. When of chemical 
 or traumatic origin the irritant primarily consists of the dead or broken- 
 down cells of the tissues. 
 
 Dead or broken-down cells, when present in the tissues in excess, be- 
 come foreign bodies, and, as such, a reaction of the living cells is excited 
 for the purpose of eliminating them from the body. Furthermore, the 
 dead cells in the process of disintegration give off a ferment or chemical 
 substance which also excites a reaction, the purpose of which is to free 
 the tissues of its presence. The reaction thus far excited is directly 
 traceable to the presence of dead and disintegrating tissue cells. Or- 
 dinarily, after a short time, a secondary irritant gains entrance to the 
 injured tissues and becomes the more important factor in the reactionary 
 process. That is, pathogenic bacteria infect the impaired tissues so 
 that in nearly every acute inflammatory process, whether it is due to 
 primary infection or to chemical or mechanical trauma, pathogenic 
 microorganisms must be regarded as the paramount exciting or noxious 
 agent causing the reaction of inflammation. 
 
 The reaction of inflammation is, therefore, an increased physiological 
 activity of the living tissues of the body for the purpose of disposing of a 
 noxious or irritant substance or organism that has invaded them in 
 excess of the normal quantities. 
 
 The reaction of acute inflammation is a threefold process, namely: 
 
 1. Increased hyperemia. 
 
 2. Increased nutrition (increased resistance). 
 
 3. Increased leukocytosis. 
 
 1. Increased hyperemia is a constant and important reaction, as 
 through it the cells are provided with the extra nutrition they need under 
 conditions of stress. The increased blood supply also stimulates and 
 facilitates the increased migration of leukocytes, and it flushes the 
 poisoned area and dilutes the noxious substance, and thus reduces the 
 intensity of the irritation. The hyperemia is nearly always passive in 
 type. 
 
 2. Increased nutrition of the cells is promoted by the hyperemia 
 
112 THE NOSE AND ACCESSORY SINUSES 
 
 for obvious reasons. They are under stress because of the presence of 
 noxious substances, and need extra nutritional facilities. Their vital 
 force, or resistance, is not equal to the emergency placed upon them, 
 and upon their resistance depends the issue of the warfare. Their means 
 of defence may be characterized as twofold, namely: (a) their ability 
 to envelop and digest microorganisms, and (6) their ability to produce 
 and emit a biochemical substance or ferment, the purpose of which is 
 to weaken or destroy their foe. This all requires increased nutrition 
 (blood), which begets increased powers of resistance. If the nutrition 
 is not adequate for these purposes, the microorganisms and their toxin, or 
 biochemical irritant, may cause destructive and what we are accustomed 
 to call pathological changes in the tissues. 
 
 3. Increased leukocytosis is also an important reaction of inflamma- 
 tion. While the function and modes of activity of the leukocytes is not 
 fully understood, it has been fairly well demonstrated that the poly- 
 morphonuclear leukocytes envelop and destroy bacteria, while the 
 lymphocytes envelop and destroy broken-down cells. Other cells, as the 
 fibroblasts, also participate in these functions under certain conditions. 
 
 Quality of Reaction. — Parenthetically, I wish to add one additional 
 statement concerning the adequacy of the reaction of inflammation. 
 According to Adami the reaction of inflammation may be of three types : 
 
 1. Adequate reaction. 
 
 2. Inadequate reaction. 
 
 3. Excessive reaction. 
 
 The reaction is usually inadequate; that is, the increased hyperemia, 
 cell nutrition, and migration of leukocytes is insufficient to dispose of 
 the pathogenic microorganisms before they have caused considerable 
 damage to the tissues. It follows, therefore, that in the treatment of 
 inflammatory diseases the reaction of inflammation should be promoted 
 rather than diminished. By so aiding the defensive and offensive 
 activities of the tissues, the bacteria, their toxins, and the broken-down 
 tissue cells may be speedly removed and a cure effected. 
 
 Inflammation Affecting Mucous Surfaces. — According to Adami, the 
 main distinguishing feature of the mucous surface is the presence of a 
 layer of mucous cells of a glandular type, capable, when stimulated, 
 of forming and discharging relatively large amounts of mucin. The 
 hyperemia, the exudation of serum, the migration of leukocytes, occur 
 in the submucous layer just as in the subserous layers. The changes 
 in the reaction are due solely to the interposition of this layer of mucous 
 cells. There is, in the first place, a more definite basement substance 
 interposing a certain amount of resistance to surface exudation. The 
 layer of mucous cells is more complicated, and although the fully devel- 
 oped cells may be discharged, they are apt to remain relatively undif- 
 ferentiated "mother cells" at the base; or otherwise the same intensity 
 of irritation does not lead to as extensive a denudation. And, thirdly, 
 by the combined action, it may be, of the irritant and of the hyperemia, 
 the fully formed mucous cells are stimulated to produce increased 
 amounts of mucin, so that an inflammation of moderate grade is char- 
 
INFLAMMATION 113 
 
 acterized by an abundant amount of mucinous discharge rather than of 
 fibrinous deposit. 
 
 Adami speaks of such a moderate case, with exudation of serum 
 containing abundant mucin, cast-off mucous cells, and relatively few 
 leukocytes, as a ''catarrhal inflammation;" if sufficient leukocytes are 
 extruded the character is altered to that of a "mucopurulent inflamma- 
 tion ;" if more severe, with complete destruction of the mucous membrane 
 proper, then, as in serous surfaces, there is the same tendency for the 
 leukocytic exudation to favor a deposit of fibrin upon the surface, and 
 then we obtain a "membranous inflammation." 
 
 He says that despite the fact familiar to all that diphtheria is a disease 
 set up by a specific bacillus, and the equally well-known fact that a like 
 membranous inflammation may be induced by several forms of microbes, 
 we still commonly speak of such a membrane as being diphtheritic. It 
 would be better to confine this term purely to cases in which we know that 
 the bacillus diphtheria is the causative factor; failing this, we may accept 
 the term diphtheritic as covering all such membranous inflammation, 
 and employ the term diphtherial for such cases as are of pure diphtherial 
 origin . 
 
 If there is a more severe destruction of the superficial cells, ulceration 
 may occur. When pyogenic organisms are present, there is a dissolution 
 and breaking down of any fibrin that is formed and a consequent absence 
 of a membrane. In such cases there is a distinct tendency for the process 
 to extend in the submucosa beneath the still intact mucous membrane, 
 the part becoming infiltrated with pus, forming what is known as phleg- 
 monous inflammation. 
 
 Chronic Inflammation. — The reaction of chronic inflammation con- 
 sists of the following phenomena: 
 
 (a) Slightly increased hyperemia. 
 
 (6) Slightly increased cell nutrition. 
 
 (c) Slightly increased migration of leukocytes. 
 
 It is needless to add that the reaction is inadequate to remove the noxa 
 or irritants, which, according to pathologists, are usually bacteria of low 
 virulence. 
 
 A product of chronic inflammation that is always present is the pro- 
 liferation of fixed cells, usually of the least differentiated type, namely, 
 connective-tissue cells. 
 
 Etiology. — Having thus briefly defined inflammation, we are prepared 
 to discuss its causes. 
 
 The causes of inflammatory diseases of the nose and accessory sinuses 
 are divided into two groups, namely: 
 
 1. Exciting causes. 
 
 2. Predisposing causes. 
 
 1. Exciting Causes. — The exciting causes are bacteria and chemical 
 and traumatic destruction of tissue cells. This phase of the subject 
 has already been discussed under Inflammation, and will not be dwelt 
 upon in this connection further than to say that pathogenic bacteria 
 cannot irritate the tissues of the body so long as the resistance of the cells 
 8 
 
114 , THE NOSE AND ACCESSORY SINUSES 
 
 is normal ; that is, so long as they are healthy. There may be an exception 
 to this rule when the germs are exceptionally virulent, though this is 
 rare. Virulent pathogenic bacteria are constantly present in the upper 
 respiratory tract, though they are harmless until the resistance of the 
 cells is lowered by some intracorporeal or extracorporeal influence. 
 
 2. Predisposing Causes. — There are many predisposing causes of 
 inflammatory diseases of the nose, some of which are best explained by 
 grouping them around a well-recognized physiopathological law, namely : 
 When the drainage and ventilation of a mucous membrane-lined cavity is 
 impaired or blocked, the conditions are favorable for the growth of patho- 
 genic bacteria. 
 
 If this is true, each case of inflammatory disease of the nose and acces- 
 sory sinuses should be examined to ascertain if the drainage and ventila- 
 tion of these spaces are impaired or blocked. If they are, the obvious 
 therapeutic duty is to remove the obstruction by such remedial measures 
 as will best accomplish the purpose. These measures may be either 
 medicinal, hygienic, or surgical. 
 
 If, on the contrary, no obstructive lesion is found, other causes for the 
 lowered resistance of the tissue should be sought for. If the inflamma- 
 tion is a primary acute one, and the lowered resistance is due to shock 
 from exposure, it may be useless to attempt to remove the cause, as it 
 is transient. The immediate duty in such a case is to promote the 
 reaction of inflammation and thus check the inflammatory process. As 
 Adami so aptly says, the way to cure inflammation is to increase it. 
 
 In order to approach logically the consideration of the causes of the 
 lowered resistance of the mucous membrane of the nose and accessory 
 sinuses they should be divided into two groups, namely: 
 
 (a) Extranasal. 
 
 (b) Intranasal. 
 
 Extranasal Predisposing Causes. — Age seems to exert some influence 
 upon the resistance of the nasal mucous membrane. Young children 
 and young adults are more frequently subject to inflammatory diseases 
 of the nose and accessory sinuses than those of more advanced years 
 This is, no doubt, due in part to indiscretion, as the improper habits, 
 and protection of the body from the inclemencies of the weather. Persons 
 of more mature years have more mature minds and better judgment, 
 and do not expose themselves needlessly, as in youth and childhood. 
 Then, too, the tissues acquire a resistance, or immunity to the noxious 
 irritations. 
 
 Sex, perhaps, exerts some influence on the occurrence of inflammatory 
 processes. Males are more exposed and more reckless than females, 
 hence they are more often affected by inflammatory diseases. They are 
 more pugilistic, and often have broken noses and consequent nasal 
 obstruction. 
 
 Climate undoubtedly influences the occurrence of inflammatory 
 processes. In regions where there is much cold, wet weather with sudden 
 changes of temperature and of hygroscopic conditions of the atmosphere, 
 it is more difficult to protect the body, particularly the feet, from the 
 
INFLAMMATION 115 
 
 shock incident to such exposures. The shock thus sustained by the 
 vasomotor nervous system leads to a lowered resistance of the mucous 
 membranes, especially of the nose and accessory sinuses, hence the 
 growth of bacteria in these regions is favored. 
 
 Exposure, especially unusual or unequal exposure of the body to damp, 
 cold, or other atmospheric and metallurgic conditions, weakens the 
 resistance of the tissues. The exposure of the feet to damp and cold is 
 a most fruitful source of rhinitis and inflammations elsewhere in the 
 body. Draughts striking a single portion of the body are detrimental 
 to the resistance of the tissues much more than when the whole body is 
 thus exposed. Within certain limitations the exposure of the wmole 
 body often has a tonic effect, as all the animal mechanisms of the body 
 are equally and simultaneously stimulated. When partial exposure is 
 experienced, only a portion of the mechanism is stimulated, and an 
 imbalance of the functional processes results; that is, there is confusion 
 and havoc in the cellular activities, the nasal expression of which is 
 often some form of inflammation. 
 
 The clothing is an important factor in maintaining or lowering the 
 resistance of the mucous membrane of the upper respiratory tract. 
 Too much is as productive of evil as too little clothing. If too much is 
 worn, the skin is rendered sensitive to slight exposure, and if too little, 
 the body is subjected to continual stress, and exhaustion of the vital 
 forces results. Either condition prepares the soil for the growth of 
 pathogenic bacteria in the respiratory passages. Perhaps the most 
 vulnerable part of the body is the feet, through the soles of w T hich course 
 large bloodvessels. Cold or wet feet is a common cause of acute rhinitis 
 and sinuitis. 
 
 The proper selection of underwear is a much mooted question. Wool 
 is advocated by some, while linen or linen mesh is strenuously recom- 
 mended by others. At the present time, most persons buy cotton for 
 summer and cotton and w r oolen mixtures for winter wear; not because 
 they believe they are the best, but because they are cheaper. My ideas 
 on the subject are as follows: 
 
 Linen absorbs moisture better than either cotton or wool, and is, 
 therefore, better for summer wear. Wool is warmer than either cotton 
 or cotton and wool, and is better for winter wear. Those who perspire 
 easily in winter should wear linen next to the skin. If this does not 
 retain enough body heat, light wool should be worn over the linen 
 underwear. Cotton or cotton and woolen mixtures are perhaps never 
 preferable to wool and linen, and woolen underwear during the winter 
 months. 
 
 The outer garments should be of medium weight for the winter months, 
 the overgarments being depended upon for extra protection for outdoor 
 wear. If the indoor clothing is too heavy, the skin becomes tender and 
 subjects the wearer to shock upon undue exposure when out of doors. 
 The underclothing and outer garments should, therefore, be selected 
 for their absorptive and heat-retaining properties. Hard-and-fast rules 
 cannot be laid down with reference to the clothing, as every individual 
 
116 THE NOSE AND ACCESSORY SINUSES 
 
 is a law unto himself. The aim should be to so regulate the clothing as to 
 avoid either extreme, as to do otherwise subjects the system to shock, 
 and thus lowers the cellular resistance and prepares the soil for the growth 
 of microorganisms, and inflammation. 
 
 The digestive tract is regarded by Woakes and Stucky as contributory 
 to inflammatory processes of the upper respiratory tract. In this they are 
 correct. If the processes of digestion and nutrition are imperfectly per- 
 formed, noxious material enters the vascular lymphatic circulation and 
 thus places unusual stress upon all the fixed and migratory cells of the 
 body. Lowered resistance, therefore, naturally follows. 
 
 Certain constitutional diseases likewise produce a lowered resistance of 
 the tissues, including the mucous membrane of the nose, accessory sinuses, 
 and ears. Diabetes, syphilis, and all diseases due to faulty metabolism 
 especially affect the tissues of the respiratory tract, and predispose them 
 to infection and inflammation. 
 
 Heredity probably has no direct influence in the predisposition to 
 infectious and inflammatory diseases of the nose. Indirectly it may have 
 such an influence. That is, certain anatomical conformations of the 
 nasal chambers may be transmitted from parents to the child and thus 
 establish a predisposition to infection and inflammation. 
 
 Adenoids may interfere with the drainage and ventilation of the nose 
 and accessory sinuses, or inflammation focalized in them may lower the 
 resistance of the mucous membrane of the nasal and accessory sinuses, 
 and thus predispose to infection and inflammation. These and other 
 extranasal influences may prepare the soil for the growth of pathogenic 
 bacteria in the nose and accessory sinuses and result in empyema 
 of the sinuses without obstructive lesions in the nose. Whatever the 
 cause of the lowered resistance of the mucous membrane, the result 
 is the same. 
 
 I do not wish to be understood as saying that infection and inflamma- 
 tion always follow a lowered resistance of the nasal mucous membrane. 
 I only claim that a lowered resistance predisposes to such a process. The 
 virulence of the microorganisms and other conditions enter in the 
 equation. 
 
 Intranasal Predisposing Causes. — I wish to repeat the physiopathological 
 law which largely explains the occurrence of infection and inflammation 
 of the nose and accessory sinuses, namely: Cavities lined with mucous 
 membrane are predisposed to inflammation when their drainage and 
 ventilation are obstructed. 
 
 We know that when such obstructions have been present and are 
 removed, either by local applications or by surgical interference, relief 
 often promptly follows. 
 
 Let us direct our attention, therefore, to some of the obstructive 
 lesions of the nose which predispose the mucous membrane to infection 
 and inflammation. 
 
 Obstruction of the Lower Portion of the Nose. — I desire to first call 
 attention to a fact that has long impressed me as very important, namely, 
 that obstructions in the lower portion of the nasal cavity have a different 
 
INFLAMMATION 117 
 
 clinical significance than those located higher in the nasal passages* 
 I also wish to call attention to the clinical significance of anterior obstruc- 
 tions as contrasted with obstructions otherwise located. 
 
 Obstruction of the inferior portion of the nasal passage causes an 
 approximation or an impingement of the inferior turbinal against the 
 septum at certain points. The pressure may be either intermittent 
 or constant. The question of greatest importance is, How does such 
 an obstruction affect the drainage and ventilation of the nose and 
 sinuses? As most of the mucous membrane of the nose and sinuses is 
 located above the inferior turbinal, it is obvious that ventilation is but 
 little affected by such an obstruction. The pathway of the inspiratory 
 current is largely limited to the middle and superior meatuses of the nose, 
 and, inasmuch as an obstruction located infer iorly does not materially 
 occlude the inspiratory tract, there is comparatively little disturbance 
 of function. Furthermore, the drainage of the secretions is not materially 
 blocked. The usual obstructive lesion in this region is a spur or ridge 
 on the septum. The ridge is rarely equally prominent along its entire 
 length. On the contrary, it presents one or two prominent spines or 
 knuckles which approximate or impinge against the inferior turbinated 
 body, thus leaving wide gaps through which the secretions may drain 
 to the floor of the nose without marked impediment. 
 
 The practical deduction to be drawn from these facts is, that an 
 obstruction in the lower portion of the nose does not markedly reduce 
 the resistance of the mucous membrane, especially in the upper portion 
 of the nasal chambers and in the accessory sinuses. It does, however, 
 have some influence in this direction, and in a degree predisposes to 
 infection and inflammation. The crests of the spines or knuckles 
 may accumulate secretions, which become desiccated in the form of 
 moist or dry crusts. The tissue cells beneath the crusts are injured 
 and their resistance lowered, and to this extent there is a predisposition 
 to infection and inflammation. Furthermore, the impingement of the 
 spur or ridge against the outer wall of the nose causes traumatic injury 
 and results in some degree of lowered resistance, which may lead to 
 bacterial infection and inflammation. 
 
 Obstructive lesions in the lower portion of the nose, therefore, may 
 cause a turgescence of the mucous membrane, which is richly supplied 
 with erectile tissue (the "swell bodies"), which after a more or less pro- 
 longed period may result in hypertrophy. In the early or turgescent 
 stage the condition is called turgescent rhinitis; in the later stage it is 
 called hypertrophic rhinitis. If, however, repeated infection occurs, the 
 irritation is of a different type and causes hyperplastic changes. 
 
 Unfortunately, however, a deviation of the lower portion of the septum 
 is usually accompanied by a deviation of the upper portion in the region 
 of the middle turbinal. When this is the case the type of inflammation 
 is radically different from that present in an uncomplicated lower 
 deviation. That is, a deviation in the region of the middle turbinate 
 often obstructs the drainage and ventilation of the superior meatus and 
 of all, or nearly all, of the nasal accessor v sinuses. The secretions are 
 
118 THE NOSE AND ACCESSORY SINUSES 
 
 retained, undergo decomposition, liberate a ferment, and irritate the 
 mucous membrane. In brief, the inflammation is attended by the pro- 
 liferation of the least differentiated of the fixed cells, or connective-tissue 
 cells. In other words, hyperplasia of the mucous membrane occurs. 
 This is known as hyperplastic rhinitis. The irritation in the middle 
 turbinal region may extend by continuity of tissue to the inferior turbinate 
 and cause hyperplasia of this structure as well. Hence, hyperplastic 
 rhinitis often involves both turbinated bodies. In simple deviations, 
 however, limited to the lower portion of the nasal chambers, the inflamma- 
 tion is usually of the hypertrophic type. 
 
 Obstruction of the Anterior Portion of the Nose. — Deviation of the 
 anterior portion of the septum from traumatism is a common cause of 
 obstruction of the anterior portion of the nasal chamber. The relation- 
 ship it bears to inflammatory processes of the nose and accessory sinuses is 
 interesting and instructive. An anterior deviation does not interfere with 
 the drainage of the secretions except in so far as it may interfere with 
 the mechanical force of the respiratory currents of air. The mechanical 
 force of the inspired air is especially manifested in the region of the infun- 
 dibulum and posterior ethmoidal cells where the inspiratory current 
 sweeps over the hiatus semilunaris and the ostei of the posterior ethmoidal 
 cells and causes slight rarefaction of the air within the sinuses drained 
 by these openings. The mechanical impact facilitates the flow of 
 secretions from the ostei and hiatus semilunaris, and thus prevents 
 desiccation and stoppage of these openings. To this extent obstructive 
 anterior deviations of the septum interfere with drainage. 
 
 The ventilation upon the obstructed side is, however, very materially 
 affected. The slight interference with the flow of the secretions caused by 
 the absence of the mechanical impact of air results in a moderate reten- 
 tion of secretions. Decomposition of the secretions may therefore take 
 place and 'cause a lowered resistance of the mucous membrane, and thus 
 establish a predisposition to infection and inflammation. 
 
 When the ridge or spur in the lower portion of the nose extends well 
 forward into the vestibule, it also interferes with the ventilation and 
 drainage, as described in the preceding paragraph. 
 
 When either type of anterior obstructive deviation is present, another 
 and more important etiological factor must be taken into consideration, 
 namely, the rarefaction of air posterior to the obstruction. Air being 
 unable to enter the nostrils rapidly enough during the descent of the 
 diaphragm is rarefied, or a state of negative air pressure is established. 
 This, according to Bier's theory, should prevent serious inflammatory 
 processes, as the negative air pressure thus produced promotes the reac- 
 tion of inflammation and should prevent serious inflammatory disease. 
 Doubtless the negative pressure thus automatically produced does exert 
 a favorable influence upon the inflammatory process excited by the lack 
 of ventilation and the slight retention of the secretions. Thus, strange 
 as it may seem, the anterior obstructive lesion predisposes to infection 
 and inflammation, and at the same time tends to cure it. 
 
 Clinically, I have often noted the comparatively slight inflammatory 
 
INFLAMMATION 119 
 
 disease of the nasal mucous membrane which is present in cases of 
 simple anterior deviations. 
 
 The chief departure from the normal is a turgescence or an hypertrophy 
 of the inferior turbinates. Little pathological change is present in the 
 middle turbinate region unless there is an associated obstruction in 
 that location. The negative air pressure easily accounts for the turges- 
 cence of the erectile tissue of the inferior turbinates. After a prolonged 
 duration of the turgescence, whether intermittent, alternating, or con- 
 stant, hypertrophy occurs as a result of the increased nutrition. 
 
 Obstruction in the Middle Turbinal Region. — Obstruction in this por- 
 tion of the nasal chambers is productive of more serious inflammatory 
 disease of the nose and accessory sinuses than obstruction in any other 
 portion of the nose. The reason is obvious when we recall the fact that 
 the ostei of the posterior ethmoidal and sphenoidal sinuses drain into the 
 superior meatus above the middle turbinate, while the frontal, anterior 
 ethmoidal, and maxillary sinuses drain into the middle meatus beneath 
 the middle turbinate. 
 
 If the septum is deviated so as to pross against or approximate near 
 to the middle turbinate, the olfactory fissure is blocked and the drainage 
 of the posterior ethmoidal, and possibly of the sphenoidal cells, is inter- 
 fered with. 
 
 Clinically, I have noted the presence of two types of deviations of the 
 septum that close, or nearly close, the olfactory fissure. One is a bowing 
 of the perpendicular plate of the ethmoid bone and quadrilateral cartilage, 
 and the other is a thickening of the septum in the region of the middle 
 turbinated body. The bowed septum is thin and easily corrected by the 
 submucous resection of the septum, whereas the thickened septum often 
 involves only the mucous membrane and is more difficult to correct. 
 
 In some subjects there are large ethmoidal cells in the middle 
 turbinate which may either close a part or all of the olfactory fissure or 
 they may encroach upon the hiatus semilunaris beneath it. In the first 
 instance the drainage and ventilation of the superior meatus of the nose, 
 and in the second instance the drainage and ventilation of the frontal, 
 anterior ethmoidal, and maxillary sinuses are impaired. 
 
 A large bulla ethmoidals projecting median ward and downward may 
 obstruct the hiatus semilunaris, and thus obstruct the drainage and 
 ventilation of the cells draining into the infundibulum, namely, the 
 frontal, anterior ethmoidal, and maxillary sinuses. 
 
 Likewise, the occasional presence of cells in the inner wall of the 
 infundibulum, or uncinate process of the ethmoid bone, may block 
 the infundibulum and cause serious inflammatory disease of the frontal 
 and anterior ethmoidal cells and the maxillary antrum ("vicious circle"). 
 
 In about 50 per cent, of the cases the frontonasal canal does not com- 
 municate with the infundibulum, but opens directly into the middle 
 meatus more anteriorly (Logan Turner). In these subjects an enlarged 
 projecting bulla ethmoidalis and cells in the uncinate process would not 
 block the drainage and ventilation of the cells draining through the 
 frontonasal canal, namely, the frontal and anterior ethmoidal cells. 
 
120 . THE NOSE AND ACCESSORY SINUSES 
 
 The ostium of the antrum, however, may be obstructed, as it always 
 opens into the infundibulum. 
 
 The Results of High Obstructions in the Nose. — When the olfactory 
 fissure is obstructed by either septal or turbinal deformity, the drainage 
 of the secretions and the ventilation of the posterior ethmoidal and 
 sphenoidal sinuses are impaired. The secretions are retained and 
 undergo retrograde changes. The mucous membrane bathed in the 
 secretions is injured and its functional activity and resistance are lowered. 
 The biochemical substances liberated in the process of decomposition 
 constantly irritate the mucous membrane, especially of the middle 
 turbinated body. Acute infection occasionally occurs. During the 
 intervals between the acute inflammatory processes a mild staphylococcal 
 or other infectious inflammation persists. Under these conditions there 
 is a proliferation of fixed cells in the tissues, usually the least differentiated 
 or connective-tissue cells. 
 
 The result is known as hyperplastic rhinitis, which chiefly involves 
 the middle turbinated body, though it often extends to the inferior tur- 
 binal as well. 
 
 Obstruction of the Olfactory Fissure. — The partial or complete closure 
 of the olfactory fissure and the consequent retention of the secretions of 
 the superior meatus, and the ethmoidal and sphenoidal sinuses draining 
 into it, cause hyperplastic changes in the mucous membrane, not alone 
 of the middle turbinate, but of the superior meatus and of the ethmoidal 
 and sphenoidal sinuses opening into it. The conditions thus produced 
 favor infection and inflammation. The inflammatory process may be 
 either catarrhal, purulent, fibrinous, or phlegmonous in type, and in each 
 instance the active causes are pathogenic microorganisms. 
 
 The sinuitis thus excited may continue for years without engaging 
 the attention of either the patient or physician. Headache and slight 
 dizziness, aggravated upon stooping, may be the only symptoms com- 
 plained of, except, possibly, recurrent attacks of acute coryza. Or the 
 sinuitis may be distinctly and frankly purulent, with copious discharge 
 into the epipharynx, and possibly to some extent through the olfactory 
 fissure into the middle meatus. 
 
 Atrophic rhinitis with ozena in adults is, in my opinion, often a result 
 of suppurative sinuitis. Space does not permit of a full discussion of 
 this phase of the subject. Personally, I have repeatedly overcome the 
 ozenic secretion by treating the case as though it were a suppurative 
 sinuitis. I have made skiagraphs of several cases of atrophic rhinitis 
 with ozena, and without exception they have shown the existence of 
 sinus disease. This does not, of course, determine which was primary, 
 the atrophic rhinitis or the sinuitis. My opinion is largely based upon 
 the results following the treatment for the sinuitis. 
 
 Obstruction Due to the Bulla Ethmoidalis, the Middle Turbinate, and 
 Uncinate Cells. — As previously stated, a large bulla ethmoidalis may 
 occlude the infundibulum and thus block the drainage and ventilation 
 of the maxillary sinus, the frontal and anterior ethmoidal cells. This, 
 as heretofore explained, causes the retention of the secretions and 
 
IN FLAM MA TION \ 2 1 
 
 lowered resistance of the tissue, thus establishing a predisposition to 
 infection and inflammation. (See "Vicious Circle" of the Nose.) 
 
 Cells in the middle turbinated body and uncinate process may likewise 
 block the infundibulum and cause similar results. The exception has 
 been referred to wherein the frontonasal canal opens directly into the 
 middle meatus anterior to the infundibulum. 
 
 It appears, therefore, that there are several factors entering into the 
 causation of inflammatory diseases of the nose and accessory sinuses. 
 The exciting causes are nearly always pathogenic microorganisms, while 
 the predisposing causes are numerous extranasal influences which are 
 often combined with obstructive lesions in the nose. The latter should 
 always be studied with reference to whether they interfere with the 
 drainage and ventilation of the nose and accessory sinuses. If only extra- 
 nasal causes of lowered resistance are found, the treatment should be 
 addressed to their removal; and if in addition to the extranasal influences 
 obstructive lesions are found, they should be corrected by probing or by 
 surgical interference. 
 
 Conclusions. — 1. Acute inflammation is usually a threefold reaction 
 excited by pathogenic bacteria and their toxins, namely: 
 
 (a) Increased hyperemia. 
 
 (b) Increased nutrition of the tissues. 
 
 (c) Increased migration of leukocytes. 
 
 The reaction of acute inflammation is the response of Nature's forces 
 for the purpose of destroying the bacteria and their toxins. 
 
 2. The reaction of inflammation is usually incapable of removing 
 quickly the infective bacteria and their toxins, hence the inflammation 
 continues for several days, or it may be indefinitely prolonged. 
 
 3. Chronic inflammation consists of the same reactions in much less 
 decree, and is still further characterized by the proliferation of fixed 
 cells into the tissues, notably connective-tissue cells. 
 
 4. The exciting causes of inflammation are pathogenic microorganisms. 
 
 5. Pathogenic bacteria do not per se cause inflammation. There 
 must be a lowered resistance of the tissues before they will rapidly 
 multiply and produce inflammation. 
 
 6. Anything that lowers the vitality or resistance of the mucous mem- 
 brane of the nose and accessory sinuses predisposes it to infection and 
 inflammation. 
 
 7. The extranasal influences that lower the vitality of the mucous 
 membrane are sex, climate, exposure, improper clothing, digestive 
 disorders, constitutional diseases and dyscrasias, hereditary anatomical 
 peculiarities of the framework of the nose, adenoids, etc. 
 
 8. The intranasal predisposing causes of inflammation of the mucous 
 membrane of the nose and accessory sinuses are, perhaps, best explained 
 by the well-recognized law: Obstruction of the drainage and ventilation 
 of mucous membrane-lined cavities predispose them to infection and inflam- 
 mation. The character of the inflammation and the final result are 
 partially determined by the location of the obstruction in reference to the 
 various structures of the nose and to the accessorv sinuses. 
 
122 THE NOSE AND ACCESSORY SINUSES 
 
 9. Anterior and inferior obstructions more often than any others cause 
 turgescent and hypertrophic rhinitis, as they do not materially interfere 
 with the drainage of the secretions, and therefore cause little or no 
 irritation. 
 
 10. Obstruction higher in the nose, in the region of the middle turbinate 
 and the inf undibulum, causes the retention of the secretions and interferes 
 with the ventilation of the superior meatus and the accessory sinuses, 
 thus lowering the resistance of the tissues and establishing a marked 
 predisposition to infection and inflammation of the nasal and accessory 
 sinuses. The inflammation may be catarrhal or suppurative, and acute 
 or chronic in type. 
 
 11. The long-continued mild irritation excited by obstructive lesions 
 in the middle turbinal region often results in hyperplastic rhinitis, which 
 may be limited to the middle turbinate, though it may extend to the 
 inferior turbinate. 
 
 12. Inflammation also extends to adjacent parts by the continuity of 
 tissue, hence it may extend from one part of the nasal mucous mem- 
 brane to another, or it may extend from the nasal mucous membrane to 
 the sinuses, the Eustachian tube and cavum tympani. 
 
CHAPTER VII. 
 
 THE METHODS FOR PROMOTING THE REACTION OF 
 INFLAMMATION. 
 
 Ix the preceding chapter I have shown that acute inflammation 
 is a series of reactions excited by the presence of bacteria, their toxins, 
 and the cellular debris. The object of the reactions is to rid the tissues 
 of these substances. Experience has shown that in acute inflammation 
 the reaction is not sufficient to do this as quickly as should be to prevent 
 damage to the tissues. That is, necrosis, cellular deposits, and adhesive 
 processes are likely to occur before the reaction frees the cellular 
 structures of the irritants. It is rational therapy, therefore, to promote 
 the inflammatory reaction rather than to repress it. As a concrete 
 example, I will cite acute coryza, or " cold in the head/' This is a reaction 
 due to certain bacteria and their toxins. It is understood, of course, 
 that certain predisposing causes have prepared the soil for the growth 
 of the bacteria. Ordinarily, the reaction (increased hyperemia and 
 leukocytosis) is inadequate to throw off quickly the bacteria and their 
 toxins. The question naturally arises, How promote or increase the 
 reaction? Do not make the common mistake of assuming that the 
 inflammatory reaction is already excessive. It may be, but it is usually 
 inadequate. Those who assume the reaction to be excessive often apply 
 adrenalin locally to reduce the reaction. This reduces the hyperemia, 
 cell nutrition, and leukocytosis, whereas they should be increased. 
 It does, however, establish better drainage, and to this extent acts 
 favorably. 
 
 The same law applies to nearly all acute inflammations of the upper 
 respiratory tract, including the ear. It is the purpose of this section to 
 discuss the various procedures whereby the reaction of inflammation is 
 promoted or increased, and to outline the indications and the methods 
 for their therapeutic application. 
 
 Counterirritation. — Counterirritation has long been used to counter- 
 act inflammatory processes, the prevalent idea being that it diverted the 
 blood to the surface and away from the seat of inflammation. We 
 know now that while its use was rational, the explanation of its good 
 effects was irrational. Counterirritation applied over the inflamed 
 area not only increases the superficial hyperemia, but it increases it in 
 the deeper tissues as w^ell. It also increases the leukocytosis and cell 
 nutrition. Thus, instead of diminishing the inflammation, it promotes 
 the inflammatory reaction. 
 
 Counterirritation has but little place in otolaryngological practice, for 
 two reasons: (1) because the blistering and scarring which occasionally 
 
124 THE NOSE AND ACCESSORY SINUSES 
 
 result from it are objectionable for cosmetic reasons, and should surgical 
 interference become necessary the skin is in bad condition, and (2) 
 because more efficacious methods may be employed. 
 
 Poulticing. — This is also an old method of treating inflammation. 
 The moist poultice of bread and milk, or other ingredients, is usually 
 applied hot, the whole being covered with cloths or oiled silk to retain 
 the heat and moisture. While poulticing promotes inflammatory 
 reaction, it has fallen into disuse, because better procedures have taken 
 its place. It obviously has little place about the head. 
 
 Scarification and Wet Cupping; Artificial Leeching. — Scarifiers 
 were once a part of every family physician's outfit, whereas they are now 
 rarely seen. Scarification was usually combined with cupping, and 
 was designated "wet cupping." With a comb-like knife or with a 
 series of concealed blades liberated by pressing a spring, the super- 
 ficial layers of the skin were many times incised, and a cup in which 
 a few drops of alcohol or a piece of paper was burned was quickly 
 applied over the incised surface, and the negative air pressure Created by 
 the heat in the cup caused free oozing of blood. The idea prevailed 
 that this diminished the excessive inflammatory reaction, whereas, as a 
 matter of fact, it increased it. That is, it increased the hyperemia 
 and leukocytosis, established adequate reaction, and hastened the elim- 
 ination of the bacteria, toxins, and cellular detritus. 
 
 Wet cupping was formerly much practised in cases of acute mastoiditis, 
 and doubtless with beneficial results. I have often used it in such cases, 
 and recommend it as a valuable mode of treatment in the early stages. 
 
 Leeching. — This is an old therapeutic measure of great value in 
 promoting inflammatory reaction. I have seen children with broncho- 
 pneumonia quickly pass from a state of stupefaction, with a pulse of 
 200 per minute, to one of complete consciousness, with quiet respiration 
 and a pulse of 100 per minute after the application of a few leeches to 
 the chest. Likewise, I have seen the pain and tenderness in acute 
 mastoiditis subside under leeching. With the improved technique of 
 mastoid surgery, and with the accumulated observations of aural sur- 
 geons to the effect that, while many of the cases of acute mastoiditis 
 subsided, but few were cured, leeching and kindred measures have 
 been gradually abandoned. The keynote to the present-day mastoid 
 therapy is the total eradication of the diseased process at the earliest 
 possible moment by surgical intervention. Doubtless the pendulum 
 has swung too far to the surgical side. An increased knowledge of the 
 pathology of inflammation and of the processes of repair will enable 
 the surgeon to differentiate more closely between the operative and non- 
 operative cases. 
 
 From three to six leeches may be applied over the mastoid process and 
 in front of the tragus in the very early stages of acute mastoiditis with 
 decidedly beneficial effect. This is good treatment while watching the 
 development of a case, and in some cases it promotes the inflammatory 
 reaction (increased hyperemia and leukocytosis) to such a degree as to 
 lead to a speedy recovery. It is doubtful if leeching is efficacious after 
 
PROMOTING THE REACTION OF INFLAMMATION 125 
 
 the disease has continued several days. Even then, however, it will 
 affect the inflammatory process favorably. The case must then be treated 
 surgically (removal of adenoids in children, and possibly the exenteration 
 of the ethmoidal sinuses in adults, or a mastoid operation) or allowed 
 to assume a latent or chronic form. 
 
 Irrigation or Lavage. — This mode of treatment has long been applied 
 to inflamed mucous-lined cavities and accessory sinuses of the nose. 
 The prevalent idea as to its mode of action is that the solution used 
 mechanically removes the inflammatory secretions, and thus lessens 
 the noxa or local irritant, all of which is doubtless true. It also increases 
 the local hyperemia and migration of leukocytes, i. e., promotes the 
 inflammatory reaction. Its action, however, is usually slight and 
 transient, and inadequate for the purpose. The inflammatory process 
 passes into the chronic type with tissue deposit, thus causing permanent 
 changes detrimental to the physiological integrity of the structures. 
 There are circumstances, however, under which lavage must be used in 
 the treatment of sinuitis. If for any reason operation is refused or is not 
 advisable, lavage may be practised through the ostia or through artificial 
 openings into the sinuses. In acute cases the reaction thus established 
 quickly overcomes the noxa, and healing speedily results. In chronic 
 cases the reaction thus promoted is inadequate, and, indeed, in the nature 
 of things, is not calculated to arrest the noxious process. Chronic 
 inflammation consists of hyperemia, slight exudation, slight migration 
 of leukocytes, and great tissue proliferation. The last-named process is 
 probably not to be checked by any direct means we can employ. 
 
 From the foregoing it is plainly good treatment to employ such solu- 
 tions by irrigation as will increase the hyperemia, the migration of 
 leukocytes, and the nutrition of the chronically inflamed mucous mem- 
 brane. To these ends normal salt, boric acid, mild iodine, and other 
 solutions may be employed. It is to be expected, therefore, that while 
 lavage will not remove the tissue proliferation, it will promote the 
 inflammatory reaction, increase the nutrition, and remove the infective 
 noxa still remaining. It also removes the irritating toxic secretions and 
 thus relieves the tissues of another source of vicious irritation. 
 
 Massage. — Under this term are included three methods of treat- 
 ment, namely: (a) Manual massage, (b) mechanical massage, and (c) 
 alternate rarefaction and condensation of air in a cavity, the so-called 
 pneumomassage as devised by Delstanche and as modified in the various 
 mechanically driven machines so commonly used in America. 
 
 The effect of massage upon inflamed tissue is to increase the hyperemia 
 and nutrition, and the diapedesis of leukocytes. The inflammatory 
 reaction is thereby promoted and the tissues measurably relieved of the 
 irritant noxa. 
 
 (a) Massage of the larynx in acute laryngitis and for the relief of 
 singers' nodules has been used with decided benefit. It may be applied 
 by hand manipulations or by a vibratory massage machine. The motion 
 and physical force thus applied to the exterior of the larynx increases the 
 hyperemia, nutrition and leukocytosis of the parts, and thus aids in the 
 removal of bacterial infection. 
 
126 THE NOSE AND ACCESSORY SINUSES 
 
 (b) Mechanical or vibratory massage is of special value in acute 
 adenitis of the cervical glands, and its application quickly reduces the 
 swelling and tenderness. It is not good treatment, however, to limit 
 the attention to this mode of procedure, for to do so is to ignore the 
 primary source of the glandular disease, namely, the tonsils, adenoids, 
 and pharyngeal glands. The massage is only an adjunct treatment. 
 
 (c) Pneumomassage by means of hand or mechanically driven devices 
 has been used extensively and almost empirically for the relief of deaf- 
 ness and tinnitus, with but little result. The same procedure applied 
 in cases of acute otitis media with an exudative secretion would promote 
 the absorption of the exudate and prevent adhesive processes. That 
 it has been used for this purpose I am unprepared to say. It is 
 reasonable, however, to suppose that the movements thus imparted to 
 the membrana tympani and the ossicular chain would increase the 
 hyperemia, the cell nutrition, and the migration of the leukocytes in the 
 inflamed mucous membrane, and thus hasten the reparative process. 
 
 Leukodescent Light.— During the past few years radiant energy in 
 the form of light from a 500 candle-power incandescent globe has been 
 used in the treatment of inflammatory processes. The beneficial effects 
 are, perhaps, best explained by saying that this treatment promotes 
 inflammatory reaction (hyperemia, cell nutrition, and diapedesis of 
 leukocytes) and thus hastens the removal of the bacteria and other 
 noxious material. I have made use of the light for about four years, 
 and have found it one of the most useful, if not the most useful, mechani- 
 cal agency for promoting reaction in inflammatory diseases of the upper 
 respiratory tract. Acute coryza is sometimes cured under its influence. 
 I have repeatedly seen chronic suppurative sinuitis become painless and 
 cease to discharge purulent secretions into the nose when this form of 
 treatment has been used. I have never cured such a case by its use, 
 for the purulent discharge has commenced again in a few days or weeks 
 after ceasing to apply the treatment. Whether its prolonged use would 
 have effected a cure I am not prepared to state. The rays of light relieve 
 pain, tenderness, and swelling in an astonishingly short time, and 
 superficial infections sometimes disappear rapidly. This is not surprising 
 in view of our knowledge of radiant energy from the Finsen light, the 
 Rontgen ray, and the high-frequency electrical currents. The 500 candle- 
 power lamp is known to possess high chemical and penetrating properties. 
 In addition to this the heat rays are, of themselves, of great usefulness in 
 promoting inflammatory reactions. The combination of the chemical 
 and the heat rays is ideal for the treatment of inflammatory diseases, as 
 the reaction is more profound than that which results from either the 
 heat or the chemical rays alone. The range of application of the 500 
 candle-power lamp is as wide as inflammation itself. It will not cure all 
 cases, but if the reaction is inadequate it will be of benefit in so far as it 
 promotes adequate reaction. If the reaction is excessive its use is 
 contraindicated, and cold applications should be made. If the reaction 
 is adequate, as in cases of incised wounds which heal naturally, its use is 
 contraindicated. It should be remembered that the inflammatory 
 
PROMOTING THE REACTION OF INFLAMMATION 127 
 
 reaction usually reaches its maximum of efficiency at the end of about 
 twenty-four hours, and that to get the maximum results by any of the 
 treatments referred to in this section they should be applied within the 
 first twenty-four hours, before tissue proliferation begins. Tissue 
 proliferation of a permanent type begins at about the fifth day of acute 
 inflammation, and becomes more and more established as time goes on. 
 
 The failure of the leukodescent light to cure chronic inflammations 
 is explained by the well-known fact that tissue proliferation is a 
 manifestation of chronic inflammation, and that chronic inflammation 
 is not readily checked by any direct mechanical means at our command, 
 except by the most thorough exenteration of all the diseased tissue and 
 the establishment of free drainage and ventilation. 
 
 Bier's Treatment. — Bier's treatment has attracted a great deal of 
 attention within the last few years. It is based upon the promotion of 
 hyperemia in the treatment of acute suppurative, tuberculous, and other 
 conditions. He promotes both active and passive hyperemia; active 
 by the use of hot air, and passive by constriction of the parts and by 
 negative air pressure in cavities. He finds active hyperemia of more 
 value in chronic cases, where proliferative tissue is to be absorbed. He 
 also finds it useful in acute cases, but not so useful as passive hyperemia 
 induced by compression so applied as to obstruct temporarily the efferent 
 veins of a part, without arresting the entry of blood through the afferent 
 arteries. He also applies suction by cupping over small inflamed areas, 
 and by large glass chambers into which the affected part, as the hand or 
 foot, may be introduced and the surrounding air rarefied. 
 
 Sondermann has devised an apparatus especially adapted for pro- 
 ducing negative air pressure in the air cavities of the head. Brawley, 
 Dabney, and Pynchon have also devised apparatuses for this purpose. 
 
 Bier's treatment is applicable to those cases of acute inflammation in 
 which the inflammatory reaction is inadequate to cope with the irritant 
 noxa causing the inflammation. The treatment should not be applied 
 so as to produce excessive reaction (white edema) of the tissues. It 
 should never cause pain. It must not produce paresthesia or false 
 sensation. In the nasal chambers it should not be prolonged for more 
 than one-half to one hour at a time. The mode of treatment requires 
 great caution in its use, as much harm can be done with it. If white 
 edema is induced, the bacteria spread through the tissues and the 
 process becomes more generalized. Heat is then indicated. 
 
 Inflammation is not yet fully understood, and until it is cases cannot 
 be individualized for treatment. Wright's demonstration of antitro- 
 phins, precipitins, lysins, and opsonins in the blood, and that the opsonins 
 are of greater importance than the leukocytes, as the latter are dependent 
 upon the former for their efficiency, has disturbed existing ideas to 
 such an extent that there is a "shuffling of dry bones" in the scientific 
 world. It appears that the leukocytes cannot digest or neutralize the 
 bacteria until the latter have been acted upon, weakened, or rendered vul- 
 nerable by the opsonins. These researches show that Bier's method 
 of inducing hyperemia does not simply flush out the inflamed area, but 
 
128 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 that the supply of leukocytes and antitropins causes a rapid removal of 
 the dead bacteria from the field of action through the energized leukocytes 
 (Adami). It appears therefore that the opsonic index is of even greater 
 importance than the leukocytic index. Should the leukocytosis be 
 marked and the opsonins scanty, the bactericidal and scavengerial 
 properties of the leukocytes would be greatly impaired, and the reaction, 
 while apparently adequate according to the older standard, would be 
 inadequate according to the newer standard of the opsonins. However 
 this may be, further observations are necessary before the older standard 
 is abandoned for clinical purposes. 
 
 Technique. — In acute inflammatory diseases of the nose and accessory 
 sinuses negative air pressure produced by the Sondermann, the Brawley, 
 or the Dabney-Pynchon devices may be obtained as follows: 
 
 Fig. 102 
 
 Showing the soft palate closed during suction through the nose. 
 
 (a) Introduce the nasal tip or tips into the anterior naris, turn on 
 the exhaust power (hand bulb, water, or compressed air, according to the 
 apparatus used), and instruct the patient to swallow. This brings the 
 soft palate in contact with the posterior wall of the pharynx and closes 
 the communication between the epipharynx and the mesopharynx. 
 The air in the nose and accessory sinuses and the Eustachian tubes is 
 rarefied, and hyperemia of the mucous membrane results. After a 
 little practice the patient is able to maintain the state of negative pressure 
 for several minutes at a time (Fig. 102). 
 
 (6) The negative pressure should be alternated every three to five 
 minutes with periods of rest, the whole period of treatment extending 
 over fifteen to forty-five minutes. 
 
 (c) If the treatment is attended by pain, bleeding, or white edematous 
 swelling, the negative pressure is too great and should be reduced. Heat 
 in the form of hot air is indicated to counteract the white edematous 
 swelling should it occur. 
 
 (d) The nose-piece should be patterned after the Seigel otoscope, so 
 that the mucous membrane may be inspected during the course of applica- 
 
PROMOTING THE REACTION OF INFLAMMATION 129 
 
 fcion of the negative air pressure, and if the membrane becomes pale and 
 edematous, or bleeds, the treatment should be abandoned for twenty-four 
 hours; that is, paralysis instead of dilatation of the vessels has occurred, 
 and the nutrition of the cell structures and the local leukocytosis have 
 been still further diminished. The method of treatment, therefore, 
 requires the greatest care and intelligent application to be beneficial. 
 Its careless and indiscriminate use can only produce harmful effects. 
 The greatest objection to the mode of treatment is the ease of application 
 and readiness with which great harm can be done with it. 
 
 Indications. — It should be used: (a) In the first five days of acute 
 rhinitis, (b) In the first five days of acute sinuitis. (c) In the first five 
 days of acute inflammation of the pharyngeal tonsil, (d) In acute tubal 
 catarrh, (e) In chronic purulent inflammation of the sinuses. In all 
 cases the negative air pressure should be very moderate, as otherwise it 
 will produce edema and white swelling and "add fuel to the flames." 
 Its greatest efficiency will be found in acute inflammation. In chronic 
 inflammation, either catarrhal or suppurative, heat in the form of hot air 
 is a more rational mode of treatment, as it produces an active hvperemia 
 and increases the cell nutrition. The negative pressure produces a passive 
 hyperemia and leukocytic migration, processes much needed to promote 
 speedy resolution of the inflammatory process. 
 
 (e) When purulent secretions are present they are drawn into the 
 bottle reservoir of the apparatus. In these cases the negative air pressure 
 not only promotes the inflammatory reaction, but it removes the irritating 
 secretions as well. 
 
 (/) The treatment should be repeated every day or every other day. 
 
CHAPTER VIII. 
 
 THE INFLAMMATORY DISEASES OF THE NOSE. 
 
 ACUTE RHINITIS COMPLICATING SPECIFIC FEVERS AND 
 CONSTITUTIONAL DYSCRASIAS. 
 
 The initial stage of the various exanthematous or specific fevers is 
 characterized by an attack of acute rhinitis. Certain constitutional 
 dyscrasias also give rise to it. The infectious or exanthematous fevers 
 commonly characterized by an attack of acute rhinitis are smallpox, 
 typhoid fever, acute articular rheumatism, epidemic influenza (la grippe), 
 erysipelas, measles, and diphtheria. 
 
 The symptoms of all the foregoing types of specific acute rhinitis are 
 about the same, except in diphtheria, in which case a pseudomembrane 
 may be present. The usual manifestations found in coryza with con- 
 junctivitis and photophobia are present. An examination of the mucous 
 membrane of the nose and fauces sometimes shows an eruption quite 
 similar to that found on the skin. 
 
 The treatment should consist in the use of mild alkaline solutions with 
 an atomizer or a nasal douche. The objection to the douche is the 
 possibility of carrying the infection to the middle ear should the patient 
 happen to swallow while the fluid is in the nose. The nose should be 
 irrigated three or four times daily. 
 
 The constitutional dyscrasias which cause acute rhinitis are acute 
 articular rheumatism, diabetes mellitus, and scorbutus. In diabetic 
 rhinitis the symptoms when present rise and fall with the percentage of 
 sugar in the urine. Scorbutic rhinitis is associated with infantile scurvy, 
 and is characterized by an excoriation about the nasal orifice. 
 
 The treatment should be addressed to the relief of the local nasal 
 symptoms and to the improvement of the constitutional dyscrasias. 
 
 ACUTE RHINITIS. 
 
 Synonyms. — Acute coryza; cold in the head. 
 
 Definition. — Acute rhinitis is an acute inflammation of the mucous 
 membrane of the nose and accessory sinuses, characterized by chilly 
 sensations, lassitude, nasal discharge, and a swelling of the mucous 
 membrane of the nose. The patient also complains of a stuffiness of the 
 nose and of sneezing. 
 
 Etiology. — The chief predisposing cause of acute rhinitis in adults is 
 an obstructive lesion of the nasal septum, which predisposes to the local 
 
ACUTE RHINITIS 131 
 
 growth of the pathogenic bacteria and the development of their toxins, 
 hence the inflammatory reaction in the form of an acute rhinitis. The 
 ridge or other deviation of the septum impinges upon, or is closely 
 approximated to, the inferior nasal concha (inferior turbinated body), 
 thus interfering with drainage and ventilation of the nose and accessory 
 sinuses. When the anterior portion of the septum is thus deformed it 
 obstructs the breathway, and each descent of the diaphragm acts like the 
 piston valve of a syringe and rarefies the air in the nasal chamber posterior 
 to the obstruction. The negative pressure thus created causes the blood 
 to fill the vascular tissue of the "swell bodies" on the inferior and middle 
 turbinals, hence the stuffiness of the nostrils. Furthermore, the me- 
 chanical irritation caused by the pressure of the ridge or other deviation 
 against the turbinals still further aggravates the irritation and swelling 
 of the mucous membrane. The secretions are thereby increased in 
 quantity and changed in character. 
 
 Inquiry usually elicits the statement that the patient (if an adult) 
 has been inclined to chronic rhinitis; indeed, a complete examination 
 often shows the patient to have been subject to acute exacerbations of a 
 chronic rhinitis, and that a septal deformity is present. Septal deformity 
 is not, however, always present, hence each case should be studied 
 for its peculiar etiological factors, so that the treatment for the ultimate 
 cure and prevention of the acute exacerbations may be intelligently 
 directed. 
 
 Another very common cause of acute rhinitis is a disturbance in 
 the vasomotor nervous system. There is a paralysis of the vasocon- 
 strictor muscle fibers of the capillaries, or an irritant in the blood which 
 affects the dilator fibers. 
 
 The paresis and irritation may be due to the presence of uric acid and 
 its kindred products or to other acquired dyscrasia. The lack of balance 
 of the vasomotor nervous system may also be due to the inadequate 
 ventilation of the living and sleeping rooms, offices, etc., or to the wearing 
 of improper clothing. The removal from the country to the city is often 
 followed by frequent attacks of acute rhinitis on account of the changed 
 conditions of living. In the countrv the houses are less tightiv con- 
 structed and but partially heated, whereas in the city the houses are more 
 tightly constructed and either overheated or, as is often the case, are 
 underheated in all rooms. In either case the conditions are less healthful 
 in the city dwelling because fresh oxygen is a negligible quantity on 
 account of the poor ventilation. Then, too, residents of the country spend 
 much of the day in the open air, whereas those in the city spend much of 
 the time in crowded and illy ventilated offices and shops. It is obvious, 
 therefore, that rhinitis due to poor ventilation should be treated by 
 changing the mode of living to one which keeps the patient in the open 
 air or in a well-ventilated residence and business building. 
 
 The causative relationship of clothing to acute rhinitis is unquestioned, 
 though it is difficult to describe the exact mode of clothing that predis- 
 poses to rhinitis. It may be said, however, that clothing which promotes 
 perspiration is pernicious. There is normally some evaporation of 
 
132 THE NOSE AND ACCESSORY SINUSES 
 
 moisture from the body, hence the underwear should be of such material 
 as to absorb it readily. The function of underwear is twofold, namely : 
 (a) to retain the body heat between it and the skin; (b) to absorb the 
 excess of perspiration. If, therefore, the clothing is of such density 
 that it causes undue perspiration, and of such material that it does not 
 absorb it, the conditions are favorable for the development of acute 
 rhinitis, even though the septum is normal. Wool retains the body heat, 
 but is a poor absorbent. Cotton is neither a good heat retainer nor an 
 absorbent. Linen is a fair heat retainer and a good absorbent. In some 
 cases wool retains too much heat and induces profuse perspiration. A 
 garment of wool and cotton, or wool and linen, or of thin linen under a 
 light woollen garment, seems to be suitable to the proper protection of 
 the body. Linen mesh in some cases is insufficient protection during 
 the winter months for some people, whereas it is worn with the greatest 
 comfort and satisfaction by others throughout the year. It should be 
 determined in each case whether the rhinitis is due, in part, at least, to 
 excessive protection and perspiration, or to deficient absorption of the 
 perspiration. Then, too, the question extends to the external garments 
 worn both indoors and outdoors. For the sake of convenience the outer 
 garments should be lessened or added to as the exposure to the tempera- 
 ture and weather demands, while the undergarments should be of 
 moderate weight and capable of absorbing the visible and invisible 
 perspiration. 
 
 A preexisting chronic rhinitis is a common factor in the causation of 
 acute rhinitis, especially in adults, whereas infants and young children 
 are more susceptible, and often have colds in the head without a pre- 
 existing chronic rhinitis. 
 
 As stated in Chapter VI, inflammation is almost always of bacterial 
 origin, the condition necessary for the growth of the bacteria being a 
 lowered vitality of the cells of the tissues. I also stated that mucous 
 membrane-lined cavities with blocked drainage and ventilation were 
 especially subject to infection and inflammation. Trauma, chemical 
 injury, and shock also lower the cell vitality and prepare the soil for 
 infection and inflammation. Exposure to cold and draughts are com- 
 mon sources of shock that result in acute coryza or inflammation of the 
 nasal mucous membrane; hence, obstructive lesions of the nasal septum 
 are not always present in patients subject to acute coryza. Certain 
 constitutional diseases, as diabetes, rheumatism, etc., reduce the vitality 
 of the mucous membrane of the nose and accessory sinuses, and are, 
 therefore, predisposing causes of this disease. All conditions, local 
 and general, which lower the resistance of the mucous membrane of 
 the nose act as predisposing causes to infection and inflammation of 
 the nasal mucous membrane. I wish to emphasize again the fact that 
 in many instances the chief predisposing cause of acute coryza (acute 
 infectious inflammation of the nasal mucous membrane) is an obstruc- 
 tive lesion of the septum. The influence of exposure to cold, draughts, 
 foul air, poor ventilation of houses, offices, etc., have heretofore been 
 given undue prominence, to the neglect of nasal stenosis (partial and 
 
ACUTE RHINITIS 133 
 
 complete), which so often bears an important relation to this disease. It 
 follows that chronic rhinitis is often present in persons subject to recurrent 
 attacks of coryza, a condition which still further lowers the vitality of 
 the membrane and predisposes to the growth of bacteria and the 
 development of their toxins, which excite the inflammatory reaction 
 known as coryza, acute rhinitis, and "cold in the head." 
 
 In emphasizing these facts I do not wish to obscure or belittle the 
 other factors that reduce the vitality of the tissues and which predispose 
 to the acute inflammatory disease. I only wish to give a true perspective 
 to the underlying causes of acute coryza, so that in the treatment a more 
 rational basis of procedure may be adopted. 
 
 Acute rhinitis undoubtedly has an infectious origin, and the foregoing 
 etiological factors predispose to the infection. Nasal polypi and other 
 morbid processes within the nasal chambers also predispose to rhinitis. 
 
 Pathology. — The vasomotor constrictor muscle fibers of the capillaries 
 are paralyzed and the dilator fibers irritated, and, as a consequence, there 
 is a passive hyperemia of the venous capillaries and lymph vessels, 
 and the nose becomes "stuffed." There is also an increased migration 
 of leukocytes and a transudation of lymph and serum. The production 
 of mucous is temporarily checked, but later is increased. The epithe- 
 lium is exfoliated and admixed with the other inflammatory products 
 and secretions. 
 
 During the first stage the secretions are greatly reduced in quantity or 
 are entirely absent. In the second stage the secretions are at first serous, 
 and later become thick and viscid from the excessive degeneration of 
 the goblet and glandular epithelial cells. In the third stage the secretions 
 are mucopurulent or purulent in character. 
 
 The duration and course of the inflammatory process varies. The 
 course of the average case is completed in from eight to ten days, though 
 under appropriate treatment it may be greatly shortened. 
 
 Symptoms.— The symptoms are, for clinical purposes, divided into 
 three groups, as follows : 
 
 First Stage, or Onset. — The patient experiences a sense of dryness or 
 prickling in the nose, with itching at the inner canthi of the eyes. Chilly 
 sensations and a feeling of malaise are complained of. Examination 
 shows the mucosa to be red and hyperemic, but not fully turgescent. 
 The mucous membrane is abnormally dry and free from secretions. 
 Headache is usually present, and there is a sense of fulness between 
 the eyes. This stage lasts but a few hours. The temperature ranges 
 from 100° to 103°. 
 
 Second Stage. — This stage is characterized by a profuse serous discharge 
 and turgescence of the mucous membrane. In some cases the headache 
 and the sense of fulness between the eyes are diminished, whereas 
 in others they are increased, depending upon the patency or closure 
 of the ostei of the accessory sinuses. In those cases in which there is a 
 marked deviation of the nasal septum in the region of the middle turbinate 
 the obstruction to drainage on one side may be great and the pain and 
 sense of fulness correspondingly increased on that side. 
 
134 THE NOSE AND ACCESSORY SINUSES 
 
 Third Stage. — This stage is characterized by a mucopurulent or puru- 
 lent discharge and by a marked decrease in the temperature. The 
 headache and the sense of fulness between the eyes may be diminished 
 to a dull heavy feeling across the forehead and between the eyes. If 
 the nasal accessory sinuses are also markedly involved in the inflam- 
 matory process, the frontal headache and the sense of pressure are 
 correspondingly pronounced. If the sinuses are not involved these 
 symptoms may be entirely absent. Dizziness and vertigo also may be 
 present if the sinuses are involved. 
 
 The use of the eyes in reading, sewing, or at the theatre often pro- 
 duces headache or other evidence of ocular irritation when the sinuses 
 are involved in acute rhinitis. 
 
 Prognosis. — The natural duration of acute rhinitis is from eight to ten 
 days. When the sinuses are extensively involved the duration is extended 
 to two weeks, or even longer, unless the attack is aborted by appropriate 
 treatment. Some writers claim that there is no curative treatment of 
 acute rhinitis. I believe this to be an erroneous view, and hold that 
 nearly all cases may be cured if taken sufficiently early and rational 
 treatment is used. 
 
 Treatment. — The treatment of acute rhinitis should be undertaken 
 with a knowledge of the nature of inflammation and the chief predis- 
 posing and active etiological factors in mind. These are (a) obstructive 
 lesions ; (b) lowered tonicity of the cellular structures of the nasal mucous 
 membrane, and (c) the infectious microorganisms. 
 
 (a) If there is an obstructive lesion in the nose it should be located 
 by rhinoscopic examination. When found, and demonstrated to be 
 spongy or erectile tissue, local applications of cocaine, adrenalin, and 
 antipyrine should be made to this region to reduce the swelling and to 
 establish the patency of the nasal chambers. By so doing drainage and 
 ventilation are reestablished, points of immense value in promoting the 
 reaction against bacteria and toxins which cause the disease. It is not 
 advisable to attempt to remove by surgical means the obstructive lesion 
 during the acute symptoms, though such a procedure may well be under- 
 taken after they have subsided. The retention of the secretions and the 
 lack of ventilation, together with the mechanical irritation from pressure, 
 aggravate the existing irritation and tend to perpetuate the reaction of 
 inflammation and prolong the disease. The reaction is often inadequate 
 to throw off the bacteria and their toxins, hence measures should be used 
 that will promote the reaction of inflammation, which is Nature's effort 
 to cure the disease. 
 
 The question naturally arises, How may the reaction of inflam- 
 mation be promoted ? That is, what measures may be adopted that 
 will aid in combating the bacteria and their toxins ? As stated in the 
 section on Inflammation, acute inflammation consists in three reac- 
 tions, namely: (a) increased hyperemia, (b) increased cell nutrition, and 
 (c) increased migration of leukocytes. The purpose of these reactions 
 is (1) to increase the vitality of the attacked tissues, (2) to remove the 
 bacteria and toxins, and (3) to remove the dead and broken-down cells. 
 
ACUTE RHINITIS 135 
 
 The increased hyperemia furnishes extra food for the cells which have 
 been attacked and weakened, while the increased migration of leukocytes 
 provides for the destruction and removal of the invading bacteria and the 
 dead and broken-down cells. Adami has shown that in acute inflamma- 
 tion the inflammatory reaction is usually inadequate for these purposes, 
 although it has generally been thought to be excessive. He advises, 
 therefore, that acute inflammations be treated by such methods as 
 will promote the reaction of inflammation, rather than check it. Formerly 
 remedies which acted favorably upon acute inflammations were said 
 to lessen the inflammatory reaction, whereas a more correct and scientific 
 statement is, that the remedies promoted the inflammatory reaction 
 (Nature's effort to rid the tissues of bacteria and their toxins) and 
 thereby hastened the cure of the disease. It is with this understanding 
 that I advise the use of such remedial measures as will promote the 
 reaction of inflammation. 
 
 The empirical use of drugs has long been practised, and must doubtless 
 continue to be practised until their action is better understood. We 
 know enough about a few of them to criticise their use in acute coryza. 
 Adrenalin has been much used in this disease because it was thought 
 that the progress of the disease would be affected favorably by reducing 
 the inflammatory reaction. I believe that its use for this purpose is 
 contra-indicated except as a temporary measure to establish drainage 
 and ventilation, because the inflammatory reaction is an effort to 
 remove certain noxa or irritants from the tissues, and should not, 
 therefore, be checked by the local use of adrenalin or any other 
 substance. The physician should recognize the activities known as 
 inflammation as forces directed against a noxious foe, and should aid 
 or promote them rather than thwart or check them. The chief difficulty 
 in arriving at a correct understanding of inflammation is that the results 
 of inflammation are confused with the process itself. When I advise 
 the promotion of inflammatory reaction, I do not mean that it should be 
 made worse, that cell proliferation should be increased, that the pain and 
 soreness should be increased, that adhesive processes should be encour- 
 aged, etc. These are the results of inflammation, and are not essential 
 features of the reaction. What I mean by promoting the reaction of 
 inflammation is to use such treatment as will increase the hyperemia, 
 the cell nutrition, and the migration of leukocytes. By so doing the 
 irritant noxa is removed, and the cell proliferation, pain, and adhesive 
 processes are quickly relieved or altogether prevented. 
 
 While the methods of treatment to be given are somewhat hypothetical 
 and in some instances purely empirical, they have been rather extensively 
 tried and have proved to be of more or less value in promoting the 
 inflammatory reaction of acute coryza; that is, they have hastened the 
 destruction of the bacteria and noxa which cause the disease. 
 
 (6) The tonicity of the vasomotor nervous system should be main- 
 tained by the administration of strychnine and arsenious acid in the usual 
 tonic doses. Furthermore, the patient should have plenty of fresh air 
 in his room if it can be arranged without exposing him to a draught. 
 
136 THE NOSE AND ACCESSORY SINUSES 
 
 The administration of aconite or belladonna may be resorted to for the 
 immediate effect upon the turgescence and the secretions, especially in 
 the second stage. An alcohol rub over the entire body also acts as a 
 tonic to the vasomotor nervous system and increases the hyperemia of 
 the arterioles and capillaries, and thereby increases the nutrition of the 
 mucous membrane. 
 
 (c) While it has not been shown that the disease is due to a specific 
 microorganism, it is evident that bacteria are the exciting cause. An 
 endeavor should be made, therefore, to establish conditions favorable 
 for their destruction and elimination. This should be done by establish- 
 ing and maintaining drainage and ventilation and promoting the reaction 
 of inflammation. The use of antiseptics has no effect in destroying 
 the bacteria, though they do promote reaction of inflammation. Surgi- 
 cal experience has shown that free drainage is of prime importance in the 
 treatment of infected cavities, as, for instance, in septic peritonitis com- 
 plicating a ruptured appendix. Irrigation of the abdominal cavity has 
 been abandoned and simple drainage substituted, with the most brilliant 
 results. The same principle applied to acute infectious inflammations 
 of the nasal and accessory sinuses brings equally good results. Hence, 
 the mode of treatment described in paragraph (a) will, in most instances, 
 meet the indications. If it does not, the obstructive lesions of the septum 
 (or other lesion) should be removed by surgical means at the earliest 
 possible time, so as to prevent such a complication during subsequent 
 attacks of acute rhinitis. 
 
 In addition to the foregoing measures the use of the leukodescent 
 lamp over the nose and eyes is recommended, to promote the reaction of 
 inflammation. The light from this lamp is rich in blue violet rays, in 
 addition to the heat rays, and they exert a powerful and immediate 
 salutary effect upon the inflammatory process; that is, they greatly 
 increase the hyperemia and the leukocytosis, and thus dispose of the 
 bacteria, their toxin, and the dead cells of the tissues. Having done this, 
 the reaction often rapidly subsides and a cure results. 
 
 A treatment with the lamp should cover a period of from twenty to 
 thirty minutes. It should be placed at a distance of about eighteen to 
 twenty inches from the face. The light is more effective if applied over 
 the closed eyes, as the tissues are soft and easily penetrated by the rays, 
 and because the veins of the accessory sinuses empty into the ophthalmic 
 vein. Hence, any increased flow through the ophthalmic vein promotes 
 the flow from the veins of the sinuses and the nose. As acute rhinitis 
 is essentially an acute sinuitis, the reaction affecting the sinuses effects a 
 speedy relief or a cure. 
 
 The above mode of treatment is based upon rational principles, 
 which, for the sake of emphasis, are recapitulated here : 
 
 (a) The establishment of ventilation and free drainage of the nasal 
 accessory chambers. 
 
 (6) The establishment of the tonicity of the vasomotor nervous system. 
 
 (c) The promotion of the elimination of the bacteria by the drainage 
 and ventilation of the nasal and accessory sinuses. 
 
CHRONIC RHINITIS WITH TURGESCENCE 137 
 
 (d) The promotion of the reaction of inflammation by the leuko- 
 descent light. 
 
 Other Methods of Treatment. — 1. The administration of full doses of 
 quinine and a hot lemonade at bedtime will, in some instances, during 
 the first stage, abort acute rhinitis by increasing the hyperemia and 
 leukocytosis. If given during the second or third stages they are ineffec- 
 tive. This method is not as efficacious as the one given above, but is 
 worth trying. 
 
 2. Ten grains of Dover's powder and a hot mustard foot bath at bed- 
 time promote the reaction of inflammation to a considerable degree, and 
 if given during the first stage may abort the disease. During the escond 
 and third stages it is more difficult to promote the reaction of inflamma- 
 tion, hence this mode is not sufficiently effective in these stages to be of 
 much value. 
 
 3. The administration of rhinitis or coryza tablets, containing quinine, 
 belladonna, and morphine, during the first stage will often abort acute 
 rhinitis. One tablet should be given every twenty minutes until dryness 
 of the nose is produced. 
 
 4. Aconite administered hourly in the first stage in 1 minim doses 
 until dryness of the throat or tingling of the fingers is produced will 
 sometimes abort the disease. During the second and third stages the 
 remedy is of little use. 
 
 Cathartics should always be given early in the disease. 
 
 CHRONIC RHINITIS WITH TURGESCENCE. 
 
 Synonyms. — Alternating stenosis; simple chronic rhinitis. 
 
 Definition. — Chronic rhinitis with turgescence is characterized by 
 fugitive swelling or turgescence of the "swell bodies" of the inferior tur- 
 binated bodies, and the patient complains of attacks of nasal obstruction 
 and a thick mucous discharge. 
 
 Etiology. — The causes of rhinitis are given under the etiology of 
 acute rhinitis, and will not be repeated in detail. It should be stated, 
 however, that in most cases there is a deviation of the septum in its lower 
 and middle portion. The deviation may also be an anterior one near the 
 vestibule of the nose in the cartilaginous portion of the septum, thereby 
 producing anterior nasal stenosis. With each descent of the diaphragm 
 the air is rarefied posterior to the obstruction, and a negative pressure in 
 the nasal chambers results. The blood in the mucous membrane lining 
 the nasal chambers is thus drawn to the venous plexuses (swell bodies) 
 of the turbinates, and turgescence or engorgement results. 
 
 In the section on the Deviations of the Septum I have shown that 
 obstructive lesions in the region of the inferior turbinal act in such a 
 way as to produce engorgement of the tissues without much irritation. 
 Hence, the effect at first is simply one of turgescence, which in the course 
 of years of increased nutrition results in hypertrophy or hypertrophic 
 rhinitis. If, in addition to the local turgescence, there is an associated 
 
138 THE NOSE AND ACCESSORY SINUSES 
 
 obstruction in the region of the middle turbinal, the retention and 
 decomposition of the secretions in the superior meatus and the posterior 
 ethmoidal cells cause a prolonged low-grade irritation which may result 
 in a hyperplasia of the mucous membrane, not only of the middle turbinal, 
 but of the inferior as well. As an obstructive lesion of the septum in 
 the middle turbinal region often co-exists with the obstructive ridge or 
 spur in the inferior turbinal region, hyperplasia or hyperplastic rhinitis 
 affecting the inferior and middle turbinate is often present. When, 
 however, the upper obstruction is absent, the rhinitis is usually of the 
 turgescent or hypertrophic type. 
 
 Pathology. — In the early stage there is a distention of the venous or 
 cavernous tissue of the conchse (turbinates). If the inflammatory process 
 continues a true hypertrophy of the tissues takes place on account of the 
 increased nutrition from the large blood supply. 
 
 Symptoms. — The symptoms are chiefly caused by transient stenosis 
 of the breathway of the nose. In addition, the secretions are heavier; 
 that is, the mucoid element is increased, while the serous element may 
 be decreased in quantity. The patient believes there is an actual increase, 
 whereas, as a matter of fact, there is probably a decrease in the amount 
 of secretion. The apparent increase is due to the greater consistency of 
 the secretion, which renders it less absorbable by the ingoing current 
 of air. In a normal nose the secretions are comparatively thin or serous, 
 and are largely absorbed for physiological purposes and carried to the 
 lower respiratory tract. 
 
 The transient stenosis is either intermittent or alternating; that is, 
 both sides may be stenosed for a period and then open, or the stenosis 
 shifts from one side to the other. These symptoms are quite character- 
 istic of turgescent rhinitis. 
 
 The objective signs of turgescent rhinitis are chiefly found in the 
 evidences of engorgement of the "swell bodies" of the inferior turbinates. 
 Upon inspection by anterior rhinoscopy, the outline of the inferior 
 turbinate is smooth and boggy-like, whereas, in true hypertrophic rhinitis 
 it is firm and unyielding. The application of cocaine or adrenalin causes 
 shrinkage of the mucous membrane which covers the inferior turbinate, 
 whereas in hypertrophic rhinitis there is little or no shrinkage. 
 
 The secretions are mucoid in character, and when the "swell bodies" 
 are contracted strings of mucous extend from the septum to the inferior 
 turbinate. 
 
 A spur or ridge is usually present upon the lower portion of the septum, 
 causing obstruction in some degree in the region of the inferior turbinate. 
 The cartilaginous portion of the septum may also be deflected, thereby 
 causing anterior nasal stenosis and a consequent rarefaction of the air 
 within the nasal chambers with each inspiratory current. 
 
 Epistaxis is also occasionally complained of. The ridge or crest of the 
 septum' projects into the inspiratory tract, and is thereby subjected to 
 excessive evaporation of the secretions accumulated upon it. The dried 
 crusts are blown or picked off, tearing the underlying epithelium and the 
 capillary vessels; hence the epistaxis. 
 
CHRONIC RHINITIS WITH TURGESCENCE 
 
 139 
 
 Cough when present is due to an associated bronchitis or laryngitis. 
 
 Posterior rhinoscopy reveals an enlargement of the "swell bodies" 
 upon the posterior ends of the middle and inferior turbinated bodies. 
 The enlargement has often been likened to a mulberry. It is nodular 
 in outline and of a grayish-blue color. 
 
 Prognosis. — If allowed to run its course, true hypertrophy and a 
 lessened functional activity of the tissues occurs. Under appropriate 
 treatment the disease is curable. 
 
 Treatment. — The treatment should be twofold in character: (a) the 
 removal of the predisposing causes, and (b) the control of the immediate 
 symptoms. 
 
 (a) The removal of the predisposing causes is usually accomplished 
 by the correction of the deviated septum. (See Treatment of Deviations 
 of the Septum.) When this is done the negative air pressure in the nasal 
 
 Fig. 103 
 
 Method of moistening a thin pledget of cotton with cocaine or adrenalin solution. 
 in an inverted bottle; 6, the pledget of cotton. 
 
 a, the solution 
 
 chambers disappears and the blood ceases to be drawn to the mucous 
 membrane, and the tendency to intermittent and alternating stenosis 
 is greatly reduced. The choice of operation should be determined 
 according to the type and location of the deviation of the septum. 
 
 (b) The palliative treatment should be addressed to the immediate 
 control of the distressing symptoms, namely, the stenosis and the heavy 
 secretions. The transient stenosis may be controlled by the use of the 
 electric or chemical cautery or by incising the turgescent "swell bodies." 
 
 Electrocauterization. — The technique of electrocauterization is as 
 follows : 
 
 (a) Induce cocaine anesthesia by the application of a 4 per cent, solu- 
 tion of cocaine on a thin pledget of cotton to the swollen free border 
 of the inferior turbinate for a period of ten minutes (Figs. 103 and 104). 
 
140 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 (b) Turn on the electric current until the. point of the cautery electrode 
 is of a bright cherry-red color. 
 
 Fig. 104 
 
 Method of applying the pledget of cotton to the inferior turbinated body, a, the pledget of 
 cotton after being moistened with the cocaine or adrenalin solution is engaged upon the tip of a 
 delicate silver probe; b, the pledget of cotton being ' 'pasted" or spread upon the inferior turbinated 
 body. 
 
 (c) Introduce the electrode into the nasal chamber cold and place it 
 on the free border of the inferior turbinate (Fig. 105). Then move it 
 backward and forward, while still cold, until sure of its correct position. 
 Maintain the to-and-fro motion and press the contact spring of the 
 
 Fig 105 
 
 Lateral view, showing the cautery electrode in position for cauterizing the inferior turbinated body. 
 
 cautery handle for one or two seconds, when the contact should be 
 broken. The to-and-fro motion should be continued until the electrode 
 is cold, that is for two or three seconds after the spring contact is broken, 
 and then it should be removed from the nose. 
 
CHRONIC RHINITIS WITH TURGESCENCE 
 
 141 
 
 If these instructions are followed the procedure is painless and does 
 not tear the eschar from the turbinal. If the to-and-fro motion is not 
 maintained before, during, and after the electrode is heated, the eschar 
 will be torn off and the cautery effect lost. 
 
 The eschar must be left in place. If bleeding follows the removal of 
 the electrode, the eschar is lost and the cauterization rendered useless. 
 
 The cauterization should be linear, and should be about one inch in 
 length. The whole length of the inferior turbinate may be cauterized 
 in three sittings (Fig. 106), never in one, as too great a reaction and 
 sloughing may follow. 
 
 The sittings should be from five to seven days apart. A week after 
 the first cauterization the opposite side may be treated in like manner. 
 At the end of another week the middle portion of the inferior turbinate 
 first cauterized may be thus treated. And so continue to cauterize the 
 turbinates alternately, at weekly intervals, until the whole length of both 
 turbinates has been cauterized. 
 
 The after-treatment of a cauter- 
 ized turbinate should consist in an 
 immediate spray of an alkaline 
 solution — Dobel's or Seiler's solu- 
 tion. An oily aromatic nebula 
 should follow this. Prescribe 
 Seiler's solution for daily use by 
 the patient. The wash should 
 be used with a glass nasal 
 rather than an atomizer, 
 force of the spray might injure 
 the cauterized surface. 
 
 Should infection occur, gently 
 pack the nose with small cotton 
 pledgets saturated with a 10 per 
 cent, aqueous solution of Merck's 
 ichthyol. Remove the pledget in 
 about fifteen minutes and insuf- 
 flate bismuth powder into the 
 
 nose. The clothing of the patient should be regulated according to the 
 indications. Heavy-soled shoes should be prescribed. 
 
 Submucous Cauterization. — N. H. Pierce first introduced the submucous 
 cauterization of the inferior turbinated body for the reduction of turges- 
 cent and hypertrophic rhinitis. The mucous membrane was punctured 
 near the anterior end of the free border of the turbinate and a tunnel 
 made with a blunt probe beneath the turgescent membrane. A fused 
 bead of chromic acid was then introduced into the artificial tunnel or 
 channel. M. A. Goldstein improved the instruments for this procedure, 
 as shown in Fig. 105. By Goldstein's method the bead of chromic acid 
 is concealed in the cannula while being introduced, the fused bead of 
 acid then being thrust from the end of the cannula and withdrawn 
 through the channel in the submucous tissue. 
 
 douche 
 
 as the 
 
 Showing the lines for linear cauterization in 
 turgescent rhinitis. A, B, and C, representing 
 respectively the first, second, and third cauteriza- 
 tions, which should be made one week apart. 
 
142 THE NOSE AND ACCESSORY SINUSES 
 
 Sloughing sometimes follows this method of cauterization. Chromic 
 acid is very irritating to the kidneys and may cause nephritis. It should 
 never be used in a patient already subject to nephritis, for obvious 
 reasons. 
 
 Fig. 107 
 
 Goldstein's chromic acid applicator for submucous cauterization. 
 
 HYPERTROPHIC RHINITIS. 
 
 Synonyms. — True hypertrophic rhinitis; obstructive rhinitis ; hyper- 
 trophic nasal catarrh ; hypertrophic ozena ; hypertrophy of the turbinated, 
 bodies ; hyperplastic rhinitis. 
 
 Definition. — Chronic hypertrophic rhinitis is characterized by a 
 partial stenosis of the nasal chambers, due to an hypertrophy of the 
 mucous membrane of the inferior turbinated body. 
 
 Etiology. — The causes of hypertrophic rhinitis are essentially those 
 given under turgescent rhinitis. When there is an anterior devia- 
 tion of the septum there is a negative air pressure within the nasal 
 chambers with each inspiratory effort. The hyperemia resulting there- 
 from leads to an overnutrition of the mucous membrane, especially 
 of the "swell bodies." The contact of the deviated septum with 
 the mucosa of the inferior turbinal irritates it and thus still further 
 excites the hypertrophic process. The altered secretions add to the 
 irritation, and still further increase the hypertrophy of the mucous 
 membrane. 
 
 In cases which are complicated by a high deviation of the septum, and 
 in which there is a complicating sinuitis (catarrhal or suppurative), the 
 tissue changes are somewhat modified. Instead of an hypertrophy, 
 the irritating discharge from the sinuses often causes a hyperplasia of 
 the mucous membrane. There may be present, therefore, both an hyper- 
 trophy and a hyperplasia of the tissue. Either the hypertrophy or the 
 hyperplasia may predominate. The so-called hypertrophic rhinitis 
 may, therefore, be divided into two groups: (a) the hypertrophic 
 variety, and (b) the combined hypertrophic and hyperplastic variety. 
 This subdivision is still further justified by the clinical fact that the 
 
HYPERTROPHIC RHINITIS 143 
 
 symptomatology and treatment of the two conditions are often quite 
 different. The hypertrophic variety presents symptoms which are due 
 chiefly to the anterior and the inferior obstruction of the nose, whereas 
 the combined variety presents symptoms due to obstruction in the 
 middle turbinal region as well as to the obstruction in the anterior and 
 inferior portions of the nasal chambers. 
 
 The causes of uncomplicated hypertrophic rhinitis are, therefore, 
 those conditions which give rise to a chronic hyperemia of the mucosa 
 and to a passive engorgement of the "swell bodies." These conditions 
 are the anterior and inferior obstructive deviations of the nasal septum 
 and the climatic and hygienic conditions which affect the vasomotor 
 nervous system. 
 
 Pathology.— The morbid anatomy of hypertrophic rhinitis consists 
 in an increased blood supply and an increase of tissue from nutritional 
 rather than from irritative and inflammatory causes. The part most 
 frequently hypertrophied is the mucous membrane containing the 
 "swell bodies," as there is naturally a greater flow of blood through 
 these vascular bodies. 
 
 Symptoms. — The symptoms are chiefly those of more or less nasal 
 stenosis. The secretion is usually heavier than normal, and pasty in 
 consistency, although it may be comparatively thin and watery, especially 
 during an acute exacerbation. 
 
 The nasal stenosis may be limited to one side, the side of greater septal 
 convexity. The inferior turbinate on the side of the concavity is often 
 greatly hypertrophied, a so-called compensatory hypertrophy, although, 
 as a matter of fact, it may be due to a negative air pressure within the 
 nasal chamber on that side. The anterior opening of the nose on that 
 side, while normal in size, is, on account of the diminished size of the 
 opposite chamber, inadequate to admit air rapidly enough for phy- 
 siological purposes; hence, engorgement and subsequent hypertrophy 
 results. It follows that both nasal passages are often more or less con- 
 stantly blocked in the region of the inferior turbinate. The patient com- 
 plains of stuffiness, or sense of a foreign body in the nose, and makes 
 frequent but ineffectual attempts to remove it by blowing the nose. 
 
 Upon anterior rhinoscopic examination the inferior turbinal is observed 
 to be enlarged and to have an irregular nodular surface. Probe pressure 
 does not cause pitting, as in turgescent rhinitis, but elicits a sense of 
 resistance and of thick fleshy tissue. The application of cocaine or 
 adrenalin is not followed by marked contraction of the tissue. 
 
 Epistaxis from the dislodgement of an adherent crust upon the crest 
 of the deflection occasionally occurs. 
 
 Prognosis. — If allowed to run its natural course, hypertrophic rhini- 
 tis tends to become worse rather than better. Indeed, in the course 
 of time the secretions may become so heavy and so adhesive in quality 
 as to be removed with great difficulty. In such subjects irritation results 
 and a hyperplasia of the tissue follows. If this is allowed to progress 
 the vascular and glandular tissues become enmeshed in the contractile 
 hyperplastic tissue, and atrophy of the mucous membrane begins. 
 
144 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Fig. 108 
 
 If, on the contrary, appropriate treatment is instituted sufficiently 
 early, the prognosis is fairly good. 
 
 Treatment. — The treatment consists mainly in overcoming the 
 stenosis and removing a part or all of the hypertrophic tissue. Sprays 
 and douches of alkaline antiseptic solutions do little more than tem- 
 porarily increase the reaction of inflammation and relieve the symptoms 
 by the removal of the altered secretions. The nasal stenosis is overcome 
 by the surgical correction of the septal deformity and the removal of the 
 excessively hypertrophied turbinal tissue (Fig. 108). (See Obstructive 
 Deviations of the Septum and the Methods of Correcting Deviations 
 of the Septum.) Be assured that in most instances hypertrophic rhinitis 
 is a surgical rather than a medical disease. Be assured, also, that 
 hypertrophic rhinitis cannot be cured by sprays and other local medicinal 
 applications, although they may temporarily relieve some of the 
 symptoms. 
 
 The actual cautery has been recommended for the reduction of the 
 hypertrophied mucous membrane. I can only condemn it as inade- 
 quate for this purpose. If it is used freely enough to accomplish 
 
 anything, it produces excessive scar 
 tissue, a result to be carefully 
 avoided. 
 
 Surgical Treatment. — If the hy- 
 pertrophy is great enough to ob- 
 struct the nasal passages, it should 
 be removed surgically with scissors, 
 saw, or spokeshave. 
 
 The Scissors. — The scissors are 
 generally used for the removal of the 
 hypertrophied portion of the free 
 border of the inferior turbinated 
 body. The technique is as follows : 
 
 (a) Induce local anesthesia by the application of a 5 per cent, solution 
 of cocaine by means of a thin pledget of cotton, which should be placed 
 over the hypertrophied area for ten minutes. 
 
 (b) With nasal scissors (Fig. 109) cut off the necessary portion of the 
 hypertrophied membrane. 
 
 (c) Use no dressing except an antiseptic dusting powder. An exception 
 may be made, however, in favor of Pischel's collodion dressing if perfect 
 dryness of the parts can be secured. 
 
 (d) If severe hemorrhage occurs, it becomes necessary to pack the 
 nose in order to check it. This may be done by introducing a postnasal 
 tampon with Bellocq's cannula (Fig. 110), or with a rubber urethral 
 catheter. A long strip of gauze should then be packed against it through 
 the anterior nares. When such a tampon is used it should be moistened 
 with the compound tincture of benzoin or impregnated with bismuth 
 powder to prevent decomposition of the secretions. When either of 
 these precautions is taken the tampon may be left in place for three or 
 four days without putrefaction. 
 
 Hypertrophy of the mucous membrane of 
 the inferior turbinated body, a, anterior at- 
 tachment; p, posterior attachment. Removed 
 by the author with his turbinotome. (Dr. 
 Henrietta Gould's case.) 
 
HYPERTROPHIC RHINITIS 
 
 145 
 
 The Saw. — The saw may be used instead of the scissors when it 
 is necessary to remove a portion of the inferior turbinated bone with 
 the hypertrophied membrane (Holmes, Vail). 
 
 Technique. — (a) Induce local anesthesia with cocaine. 
 
 (b) Introduce a slender nasal saw beneath the inferior turbinated 
 body and saw in an inward and upward direction through it. If it is 
 
 Fig. 109 
 
 Beckmann's serrated scissors. 
 Fig. 110 
 
 Fig. Ill 
 
 Bellocq's postnasal tampon cannula. 
 
 impossible to insert the saw beneath the turbinated body it may be 
 introduced above it and the incision carried downward and outward 
 through the tissue. 
 
 (c) Either use no dressing or use the Pischel collodion dressing when 
 conditions are favorable, that is, when all hemorrhage ceases. 
 
 The Spokeshave. — The spoke- 
 shave may be used if it can be en- 
 gaged posteriorly in such a position 
 as to enable the operator to control 
 its direction in cutting forward. 
 This operation is rarely justifiable, 
 as too much of the turbinate is re- 
 moved by it. 
 
 The Technique. — (a) Induce local 
 cocaine anesthesia. 
 
 (6) Make a linear incision along 
 the mediosuperior surface of the 
 inferior turbinate just at the upper 
 margin of the hypertrophied tissue 
 (Fig. 111). The incision is for the 
 purpose of preventing laceration of 
 10 
 
 Showing the incision preliminary to the re- 
 moval of the inferior turbinated body with 
 the spokeshave or swivel knife. 
 
146 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 the mucous membrane as the spokeshave is drawn through it. Healing 
 is promoted by making a clean cut. 
 
 c 
 
 __^iiinf>--" 
 
 Fig. 112 
 
 5i 
 
 ^—UH.j.a. ^ 
 
 Spokeshave. 
 Fig. 113 
 
 I 
 
 (iiiiiiiiiiimiiiiiiiim in' 
 
 Miiii!i|||i|||i!ll|||||ll|||!l|< 
 
 ,,,«riinpfli|l|lllll|lll 
 
 'iillllllllll 
 
 null 
 
 a 
 
 :::' ^ """i'iii'ipw^^ 
 
 F.A.HARDY ZCQ CHICAGO. 
 
 The author's swivel turbinotome. 
 Fig. 114 
 
 The removal of the anterior two-thirds of the inferior turbinate with the author's wide 
 swivel knife (Fig. 113). 
 
 Fig. 115 
 
 Showing the removal of the inferior turbinate with the author's large swivel knife. 
 
HYPERPLASTIC RHINITIS 147 
 
 (c) Introduce the spokeshave (Fig. 112) at the posterior extremity 
 of the turbinate if there is a mulberry hypertrophy there, or along the 
 free border of it if only that portion is involved. Engage the turbinated 
 body and pull forward in such a direction as to include only the hyper- 
 trophic tissue. The spokeshave should not be used unless it is desired 
 to remove some bone as well as soft tissue. 
 
 (d) Follow the same method of after-treatment given in the previous 
 operations. 
 
 The Swivel Knife. — The author's large swivel knife (Fig. 113) may 
 be used with even greater advantage than the spokeshave, as it can be 
 made to engage or leave the tissue at any desired point along the free 
 border of the turbinate. The knife used for this purpose is especially 
 designed with a view to its width and strength. Otherwise it is similar 
 to the one used in the submucous resection of the nasal septum. 
 
 The Technique. — (a) Induce local cocaine anesthesia. 
 
 (b) Insert the swivel knife as though it were a spokeshave and force 
 the blade into the turbinate posterior to the hypertrophied tissue (Figs. 114 
 and 115). When it is sufficiently engaged in the tissue pull it forward, 
 as in the spokeshave operation, and disengage it by directing it downward 
 toward the floor of the nose when the anterior limit of the hypertrophy 
 has been reached. The preliminary incision of the membrane is un- 
 necessary, as the cutting edge of the blade is concave and prevents 
 laceration of the mucosa. Bone, as well as soft tissue, may be removed 
 with it. 
 
 (c) The after-treatment should be the same as in the other operations. 
 
 HYPERPLASTIC RHINITIS. 
 
 Synonyms. — The same as given under hypertrophic rhinitis, as the 
 two conditions are often confused. 
 
 Definition. — Hyperplastic rhinitis is characterized by an increase 
 in the thickness of the mucous membrane as a result of prolonged 
 mild irritation by the secretions from the sinuses. It differs from hyper- 
 trophic rhinitis in its causation and in its morbid anatomy. In hyper- 
 trophy there is an increase in the size of the cells from overnutrition, 
 whereas in hyperplasia there is an increase in the number of cells, and 
 especially of the connective-tissue cells, from the slight but prolonged 
 irritation. 
 
 Etiology. — The chief causes are pressure, or the close approxima- 
 tion of the septum to the middle turbinate, the resultant retention of 
 the secretions, and the inflammation of the obstructed sinuses. The 
 septum does not, in all cases, impinge upon the middle turbinate, and is 
 not, therefore, a constant etiological factor in producing the hyperplasia. 
 The sinuses may be diseased independently of the septal deviation, and 
 may thus be the primary cause of the hyperplasia. In either event 
 the irritation resulting from the secretions constantly flowing over the 
 mucous membrane of the middle and inferior turbinates causes the morbid 
 changes in these structures. The secretion is not necessarily purulent, 
 
148 THE NOSE AND ACCESSORY SINUSES 
 
 but, on the contrary, is often serous or mucous in character; that is, 
 the inflammation in the sinuses may not be suppurative, but may be 
 catarrhal in character. 
 
 Symptoms. — The symptoms of hyperplastic rhinitis are often com- 
 plex, as the disease is often associated with a catarrhal or a suppurative 
 inflammation of the ethmoidal, sphenoidal, and possibly the frontal 
 sinuses. 
 
 The symptoms arising from the hyperplasia are those of nasal obstruc- 
 tion, especially in the region of the middle turbinate; that is, there is 
 more or less nasal obstruction and a sense of stuffiness or of pressure 
 in this portion of the nose. The handkerchief is frequently used in 
 efforts to dislodge the secretions and to overcome the sense of stuffiness. 
 While the secretions may be thus removed, the stuffy feeling often' 
 remains, as it is due to the contact of the turbinate with the septum. 
 
 The secretions may be serous, mucopurulent, or purulent, depending 
 largely upon the complicating disease of the sinuses. 
 
 Anterior rhinoscopy shows the inferior turbinate to be enlarged, paler 
 than normal, or it may be red and boggy, and somewhat nodular in 
 outline. If the septum is deviated, and it usually is, a ridge corre- 
 sponding to the crista nasalis and the crest of the vomer may be present 
 on one side, while there is a bowing of the septum toward the opposite 
 side in the region of the middle turbinate. The septum is also often 
 thickened in its upper portion on both sides, thereby obstructing both 
 olfactory fissures. 
 
 If an empyema of the ethmoidal cells (cellulae ethmoidales) is present, 
 pus may be seen in the olfactory fissure as well as in the lower portion 
 of the nose. If there is catarrhal ethmoiditis the anterior end of the 
 middle turbinate may be red and boggy in texture. Patients with this 
 type of ethmoidal inflammation sometimes complain of soreness or of 
 fissures at the margins of the vestibules. 
 
 The subjective symptoms are due to obstructive lesions and to the 
 disease in the accessory sinuses of the nose. 
 
 The obstruction in the upper part of the nose gives rise to a sense of 
 stuffiness and of pressure across the bridge of the nose. These symptoms 
 are rather constant, as the tissue enlargement is permanent. 
 
 The obstructive lesion in the upper portion of the nose gives rise to 
 the additional symptoms of headache and vertigo peculiar to inflamma- 
 tion of the sinuses; that is, there is headache in the frontal region limited 
 to, or more pronounced on, one side, and to a feeling of soreness or 
 tenderness of the eyeball upon ocular movements. The stooping posture 
 increases the headache and temporary vertigo is often thereby produced. 
 The headache is also sometimes in the temporal, vertexial, and occipital 
 regions, especially if the posterior ethmoidal and sphenoidal sinuses are 
 involved. 
 
 The symptoms given in the above paragraph are due to the sinuitis, 
 and are not always present in hyperplastic rhinitis. 
 
 Prognosis. — The prognosis of hyperplastic rhinitis is not as favorable 
 as that of hypertrophic rhinitis. The etiology is more complex and 
 
HYPERPLASTIC RHINITIS 
 
 149 
 
 the disease more serious, and it necessitates more extensive surgical 
 procedures for its eradication. If the disease processes are allowed to 
 run their natural course, they may result in an atrophy of the mucous 
 membrane, especially of the middle and inferior turbinated bodies. 
 
 If the treatment is instituted sufficiently early, the atrophic process 
 may be checked and the stenosis and disease of the sinus eradicated. 
 
 Treatment. — The treatment of hyperplastic rhinitis should have 
 two chief objects, namely: (a) The removal of the obstructive lesion, 
 whether it be a deviation of the septum or an hypertrophy of the middle 
 
 Fig. 116 
 
 The removal of the anterior end of the middle turbinated body with Casselberry's scissors. 
 
 Fig. 117 
 
 Krause's nasal snare. 
 
 or inferior nasal concha (middle or inferior turbinate); and (6) the cure 
 of the sinuitis, if present, whether it be in the ethmoidal and sphenoidal, 
 or the frontal and maxillary sinuses. 
 
 Hyperplasia of the inferior nasal concha (inferior turbinate) may be 
 removed by any one of the operative procedures described under 
 hypertrophic rhinitis and ethmoidal sinuitis. 
 
 An hyperplastic middle nasal concha (middle turbinate) may be 
 removed with the scissors and snare, the author's turbinate knife (Fig. 
 113), or with the swivel knife. 
 
150 THE NOSE AND ACCESSORY SINUSES 
 
 The Author's Turbinotome. — With the author's turbinal knife (Fig. 121) 
 all or any portion of the middle turbinate may be removed under cocaine 
 anesthesia. The technique for the removal of the anterior portion is 
 as follows : 
 
 (a) Introduce the knife through the olfactory fissure as far posteriorly 
 as it is desired to begin the incision. 
 
 (6) Turn the cutting edge of the blade outward and forward and 
 force it into the turbinate as far as it will go. 
 
 (c) Then cut forward to the anterior attachment of the turbinated 
 body as shown in Fig. 121. 
 
 (d) Remove the severed portion with dressing forceps. 
 The Scissors and Snare. — The technique is as follows: 
 
 (a) Induce local anesthesia with a 10 per cent, solution of cocaine. 
 A weaker solution is often inadequate in hyperplastic tissue. 
 
 Fig. 118 
 
 Holmes' middle turbinal scissors. 
 
 (b) Grasp the anterior attachment of the middle nasal concha (middle 
 turbinate) with the scissors and make an incision about one inch in length, 
 thus severing the attachment of the anterior one-third or one-half of the 
 middle turbinated body (Fig. 116). 
 
 (c) Introduce a cold wire loop over the detached portion of the turbinate 
 and cut it off at the posterior limit of the incision, or sever the detached 
 portion of the turbinate with Griinwald's forceps. Still more tissue may 
 be removed if necessary. 
 
 Holmes' Scissors. — With Holmes' scissors (Fig. 118) the snare is not 
 necessary, as the blades are so curved that the cut made with them 
 extends backward and downward until it emerges from the tissue (Figs. 
 119 and 120). 
 
 The Swivel Knife. — The technique of the removal of the middle tur- 
 binate with the swivel knife differs from that employed with a larger 
 instrument in the removal of the inferior turbinate. 
 
 The technique is as follows: (a) Induce local anesthesia with a 
 10 per cent, solution of cocaine applied on a thin pledget of cotton over 
 the whole of the middle turbinate. It may be neccessary to apply a 20 to 
 
HYPERPLASTIC RHINITIS 
 
 151 
 
 30 per cent, solution, or even powdered cocaine with a delicate cotton- 
 wound applicator to the less accessible areas. 
 
 (b) Introduce the small swivel knife and engage the anterior attach- 
 ment of the middle turbinate (Figs. 121 and 122), so that one prong tip 
 is above and the other below the attachment. 
 
 Fig. 119 
 
 The removal of the anterior half of the middle turbinated body with Holmes' scissors. 
 
 Fig. 120 
 
 The anterior half of the middle turbinate removed with Holmes' scissors, exposing the 
 
 bulla ethmoidalis. 
 
 (c) Carry the swivel blade backward with short strokes until the whole 
 or a part of the middle turbinate is severed from its attachment. The 
 severed middle turbinate does not pass between the prongs of the instru- 
 ment, but is pushed downward beneath them. If only a portion of the 
 middle turbinate is to be removed, the swivel blade is directed downward 
 through the turbinate at the desired point, or, failing in this, the swivel 
 knife is removed and the loop of a snare is engaged over the detached 
 fragment and the removal completed. 
 
152 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Remarks. — The swivel knife is not universally suited for turbinectomy 
 or turbinotomy, although in many cases it is an ideal instrument for 
 these purposes. In each case the instruments and mode of operation 
 should be selected with reference to the conditions present rather than 
 to follow blindly any described method of operating. 
 
 Fig. 121 
 
 The removal of the anterior portion of the middle turbinated body with the author's 
 
 turbinal knife. 
 
 Fig. 122 
 
 The author's narrow swivel knife placed at the anterior attachment of the middle turbinate 
 preparatory to removing it. 
 
 (d) The postoperative treatment should consist of the insufflation of 
 bismuth powder, and, in the case of severe persistent hemorrhage, the 
 nose should be packed with bismuth, or compound tincture of benzoin 
 gauze. 
 
 Hemorrhage. — The middle turbinate is supplied with blood by the 
 anterior and posterior ethmoidal arteries (A. ethmoidalis anterior et 
 
CHRONIC RHINITIS WITH COLLAPSE OF ERECTILE TISSUE 153 
 
 posterior) (Fig. 4), and hemorrhage of considerable severity may occur 
 either at the time of operation or at a later period. As a matter of fact, 
 an oozing of blood continues in many cases for twenty-four hours. 
 
 The danger of septicemia and of meningitis is increased by nasal 
 tampons, hence it is not advisable to pack the nose except in extreme 
 necessity. Several cases of meningitis have occurred as a result of 
 nasal tampons introduced after middle turbinectomy. The packing 
 should be done with caution, and the gauze should be moistened with 
 
 Ftg. 123 
 
 The removal of the middle turbinate with the author's narrow swivel knife. 
 
 the compound tincture of benzoin and squeezed until the excess of fluid 
 is removed. If the operation is performed in a hospital it is rarely 
 necessary to pack the nose as the patient remains quiet and severe 
 hemorrhage rarely occurs. If it does occur the house surgeon should 
 be instructed to introduce the tampon. 
 
 The chief causes of complications and sequelae after nasal operations 
 are, namely : (a) the failure to sterilize the nasal chambers; (b) the use of 
 nasal tampons; (c) ragged contused wounds; and (d) blowing the nose, 
 thus forcing infectious material into the sore, sinuses, and cranial cavity. 
 
 CHRONIC RHINITIS WITH COLLAPSE OF THE ERECTILE TISSUE. 
 
 Definition. — This is not a true inflammatory disease, but is usually 
 classed as such. It is a local manifestation of a general anemia; it 
 is characterized by the collapse of the erectile tissue of the nose, and 
 resembles atrophy in this region. 
 
 Etiology. — Its chief cause is general anemia. Atrophic rhinitis is 
 also characterized by anemia that is secondary to the conditions causing 
 the atrophy. In simple collapse of the "swell bodies" the anemia is 
 primary and the collapse secondary. It is most often found in women, 
 as they are more subject to anemia. It is occasionally found in gouty 
 individuals. 
 
154 THE NOSE AND ACCESSORY SINUSES 
 
 Symptoms. — The chief symptoms are dryness of the upper respira- 
 tory tract and patency of the nose. Upon anterior rhinoscopic examina- 
 tion the inferior turbinates appear quite small, on account of the collapse 
 of the " swell bodies." Upon probe pressure the mucous membrane is 
 found to be thin and tightly drawn over the underlying bone. The great 
 space in the nasal chambers and the small size of the inferior turbinates 
 at once suggest an atrophic condition, though true atrophy is absent; 
 crusts and ozena are absent, nor is there a history of their previous 
 presence. An examination of the blood shows anemia to be present. 
 The sense of smell is unimpaired and ulceration of the mucosa and 
 caries of the bone are absent. The condition is always bilateral, as it 
 is due to constitutional rather than local causes. 
 
 Treatment. — The treatment should be directed to the anemia. It 
 is necessary, therefore, to ascertain the type of the anemia by blood 
 examinations and to carry out the treatment accordingly. I wish to 
 suggest that an examination of the rectum will sometimes reveal ulcera- 
 tions or other pathological processes that may be the cause of the anemia 
 and the resultant collapse of the erectile tissue. 
 
 ATROPHIC RHINITIS. 
 
 Synonyms. — Chronic dry rhinitis; simple mucous rhinitis; mucopuru- 
 lent rhinitis ; ozena. 
 
 Definition. — Atrophic rhinitis is characterized by a sclerotic change 
 in the mucous membrane and occasionally of the underlying bone and 
 by the presence of crusts and an offensive nasal breath. The conditions 
 giving rise to these phenomena are varied and often complex. 
 
 Etiology. — The three causes of this condition are as follows: 
 
 (a) A simple atrophic process which is not dependent upon other 
 local diseases of the mucous membrane. Meissner holds that atrophic 
 ozena (see below) is due to a primitive or broad, shallow nose, and to a 
 congenital development of pavement epithelium instead of the columnar 
 or mucus-producing variety. 
 
 (b) Pressure necrosis due to excessive distention of the bloodvessels. 
 This is a cyanotic congestion due to a heart lesion, and the general venous 
 circulatory system participates in the sluggish venous flow. The mucosa 
 covering the vessels is kept constantly stretched, and pressure atrophy 
 results, as in red atrophy of the liver (D. Braden Kyle). 
 
 (c) Sclerotic atrophy due to a preexisting inflammation of the sinuses 
 during which there is an excessive proliferation of connective-tissue cells. 
 These after a time become fibrous tissue and gradually cut off the blood 
 supply and choke out the glandular and vascular structures of the 
 membrane. The nutrition of the mucous membrane is diminished, and 
 functional activity is diminished or destroyed. 
 
 These and various other theories are thought to be the cause, or causes, 
 of atrophic rhinitis. None of them is definitely proved, although the 
 one (c) advocated recently by Grunwald, and by Vieussens, Reininger, 
 
ATROPHIC RHINITIS 155 
 
 and Guns at the end of the seventeenth century, has rapidly gained 
 ground in popular opinion. Those who hold to this theory believe that 
 all or nearly all cases of atrophic rhinitis are due to suppuration of the 
 accessory sinuses of the nose, more especially the ethmoidal and sphe- 
 noidal. My own experience is in accord with this view. I have seen 
 many cases cured or greatly relieved by attention to the accessory sinuses. 
 The ozena is invariably influenced favorably. In conjunction with Dr. 
 Joseph C. Beck I have had skiagraphs of the sinuses made in cases of 
 atrophic rhinitis, and without exception the sinuses appear cloudy, as 
 they do in sinuitis, i. e., their outline is poorly defined and the area of 
 the cavities is opaque. This shows that in atrophic rhinitis the sinuses 
 are often diseased, though it does not prove the disease of the sinus to be 
 primary. 
 
 (a) Simple Atrophic Rhinitis. — -Simple atrophy may take place in the 
 nasal mucous membrane as well as in mucous membranes elsewhere in 
 the body. 
 
 Etiology. — The etiology is not clear, but it is probable that the disease 
 is due to the presence of some irritant in the blood, as in syphilis, tuber- 
 culosis, scrofula, etc. At any rate, the trophic nervous system is in- 
 volved and nutrition modified. 
 
 Treatment. — The treatment should be addressed to the constitutional 
 dyscrasia, upon the disappearance of which the atrophic and ozenic 
 processes improve or disappear. 
 
 (6) Atrophic Rhinitis Due to Pressure (Cyanotic Engorgement). — 
 Etiology. — (a) There may be some lesion of the heart, kidneys, liver, 
 or lungs which causes a damming back of the venous blood upon the 
 nasal mucous membrane, as well as elsewhere in the body, (b) The 
 organs thus affected do not eliminate the waste products as rapidly 
 as they should, and these are retained in the blood, where they act as 
 irritants, and excite a slight inflammatory reaction. These two factors 
 account for the phenomena known as pressure atrophy as it occurs 
 in the nasal mucosa. 
 
 Symptoms. — Although there is true atrophy, the membrane is con- 
 gested to such a degree that there is nasal stenosis. The mucosa of the 
 nose is swollen, purplish red in color, and inflamed. The ozenic odor 
 may be slight. There is an exudation from the engorged vessels, but it is 
 not a true mucous secretion. The skin of the nose may be red. There 
 is a sense of fulness across the bridge of the nose, and frontal headache 
 is commonly present. The conjunctiva may be infected, and this is 
 attended by an overflow of tears. 
 
 D. Braden Kyle refers to a case due to organic mitral lesion. I have 
 seen a case of this character in which the whole mucosa of the upper 
 respiratory tract was cyanotic; the tonsils were enlarged and markedly 
 blue from cyanotic congestion. 
 
 Prognosis. — This depends upon the curability of the lesions giving rise 
 to the cyanotic congestion. In the cases referred to the patient had a 
 valvular heart lesion. 
 
 It is obvious that the treatment in such cases must be palliative only, 
 
156 THE NOSE AND ACCESSORY SINUSES 
 
 (c) Atrophic Rhinitis Due to Suppurative Sinuitis. — Etiology. — All the 
 causes given under the various types of catarrhal rhinitis may act as causes 
 of this type of disease. The inflammation attending them is followed by 
 a deposit of connective-tissue cells, which, after they become organized, 
 cut off the blood supply and choke down the glandular tissue. The 
 functional activity is gradually lost and the true mucous elements of the 
 membrane finally disappear. The secretions become thick and in- 
 spissated. They dry upon the surface of the membrane, where, through 
 biochemical changes, they develop the ozenic odor. Various theories 
 have been advanced in explanation of the cause of the odor. 
 
 The following are suggestive but not conclusive : 
 
 (a) Simple decomposition of the mucopus. 
 
 (b) Degenerative changes in which certain fatty acids are liberated, 
 giving rise to the odor. 
 
 (c) The presence of certain bacteria, as the Bacillus fetidus. 
 
 Ozena a Symptom. — Ozena is not a disease, but a sign of certain 
 diseased conditions. It is a "stench," and it is in this sense that the 
 term is used. The fetid odor is associated with an inspissated secre- 
 tion, which forms greenish crusts over the whole of the nasal mucous 
 membrane. Other peculiar conditions may be associated with it, 
 especially in those cases in which there is marked atrophy of the mucosa. 
 For example, the nose may be broad and flat, the tip somewhat elevated, 
 and the blood anemic. The anemia is secondary and not primary as 
 in chronic rhinitis with collapse of the erectile tissue. The absorption 
 of septic material and the loss of the respiratory functions of the nose 
 are probably the chief causes of the anemia. It is a well-recognized fact 
 that in mouth breathers from the presence of postnasal adenoids there 
 is anemia, which is quickly cured after the removal of the adenoids. 
 
 The mucous membrane becomes atrophied in the later stages, and 
 after a longer period the secretion and foul odor spontaneously cease 
 and leave a comparatively clean but sclerotic membrane. The ozenic 
 odor stops spontaneously after a number of years, hence it is a self- 
 limited symptom. The mucous membrane, however, is left very much 
 damaged. Its histological character and physiological function are 
 changed or entirely lost. 
 
 The sclerosis and ozena in this type of atrophic rhinitis is in all prob- 
 ability due to a chronic sinuitis, or to other focalized suppurative pro- 
 cesses, as has been shown by Griinwald in his work on Nasal Suppuration. 
 In other words, the atrophy is not primary, but is secondary to a suppu- 
 rative inflammation of the sinuses. Indeed, nearly all cases of atrophic 
 rhinitis probably fall under this category. This subdivision of atrophic 
 rhinitis is, therefore, from a clinical standpoint of the greatest importance. 
 
 The rationale of the atrophic process is generally as follows : 
 
 The secretions from the sinuses, more particularly the frontal, eth- 
 moidal, and sphenoidal, flows downward over the nasal membrane, 
 where it becomes dried into crusts. It undergoes decomposition and 
 irritates the underlying mucosa. There is, in addition, a mechanical 
 irritation from the shrinkage and contact of the crusts with the mucous 
 
ATROPHIC RHINITIS 157 
 
 membrane. The biochemical and mechanical irritation thus produced 
 cause a proliferation of connective-tissue cells, which, when fully organ- 
 ized, contract and choke the normal tissues of the mucous membrane. 
 Shrinkage and atrophy progress until the mucous membrane is replaced 
 by a sclerotic tissue, devoid of mucous glands and columnar ciliated epi- 
 thelium, pavement epithelium replacing the columnar type. 
 
 During the progress of the atrophic process the ozena is a symptom, 
 but after the true mucous membrane is destroyed the mucous secretion 
 and ozena disappear. Crust formation and ozena are self -limited pheno- 
 mena, many years being required, however, to rid the patient of them. 
 
 Symptoms. — The symptoms vary with the state of advancement 
 and activity of the process. The clinical picture presents the features 
 shown in the comparative table given below. This is adapted from 
 MacDonald's work on Diseases of the Nose. 
 
 Comparative Table of the Symptoms of Atrophic Rhinitis and 
 Rhinitis with Collapse 
 
 Chronic Rhinitis with Collapse of the Erectile Atrophic Rhinitis with Sclerosis and Mucous 
 
 Tissue. Secretion. Ozena. 
 
 1. Chiefly in anemic women. The anemia is 1. Chiefly in women and children: all subjects 
 
 primary. become anemic. 
 
 2. No peculiarity of physiognomy. 2. Small, sunken wide nose with wide nasal 
 
 fossa?. 
 
 3. Mucous membrane anemic. 3. Mucous membrane anemic. 
 
 4. Collapse of erectile tissue; no tendency to 4. Collapse of the erectile tissue with tendency 
 
 atrophy. to atrophy. 
 
 5. No ulceration. 5. Sometimes there is ulceration, and necrotic 
 
 bone if the disease is of sinus origin. 
 
 6. Always bilateral, as it is of constitutional 6. Usually bilateral: may be unilateral. 
 
 origin. 
 
 7. Spontaneous cure if the anemia is relieved. 7. After some years there is a tendency to im- 
 provement of the symptoms. The ozenic 
 symptoms disappear as the atrophy be- 
 comes more complete. 
 
 8. Olfaction is often lost. 
 
 Olfaction not affected. 
 
 9. No characteristic odor. 9. Breath typically ozenic. 
 
 10. Little or no incrustation: if present, is lim- 10. Crusts are distributed over the entire mu- 
 
 ited to the anterior third of the middle cous membrane, 
 
 turbinates 
 
 11. Headache and dizziness absent. 11. Frontal headache and dizziness often pre- 
 sent. Occipital headache may be present 
 when the sphenoidal sinus is involved. 
 
 Treatment. — When seen in the early stage the treatment should 
 aim at (a) the removal of the causes of the inflammation that produces 
 the sclerotic process, and (b) intranasal cleanliness. 
 
 (a) The Removal of the Causes. — The causes of the inflammation 
 are numerous. Some have already been considered under acute catarrhal 
 hyperplastic rhinitis, chronic suppurative sinuitis, and the congenital 
 primitive nose with its pavement epithelium. Other causes are trauma- 
 tism, deflections, and other obstructive lesions of the septum. By the 
 removal of these predisposing causes of the inflammation, the sclerotic 
 process may be modified or stopped altogether. 
 
 From the foregoing statements concerning focal suppuration within 
 the sinuses and elsewhere in the nasal chambers, it is evident that in 
 
158 THE NOSE AND ACCESSORY SINUSES 
 
 many cases the treatment should be addressed toward the cure of the 
 suppuration of the sinuses, rather than to the atrophy resulting from it. 
 
 (b) Intranasal Cleanliness. — Intranasal cleanliness is obtained by the 
 use of antiseptic douches containing a liberal amount of mild alkalies 
 to soften and dissolve the crusts and tenacious mucopus. A solution 
 of 8 grains of sodium bicarbonate to the ounce of water as hot as can be 
 borne should be forcibly injected into the nostrils at frequent intervals 
 during the day. A fountain syringe is well adapted for this purpose. 
 The patient should be instructed to clear the nose by blowing after 
 each injection. The injections may be administered by the physician 
 at first, as the patient will not or cannot thoroughly cleanse his nose. 
 To free the nostrils from crusts and tenacious mucus, a warm antiseptic 
 aqueous solution of borax, sodium bicarbonate, oil of eucalyptus, carbolic 
 acid, glycerin, and alcohol should be injected into the nostrils. A two- 
 ounce hard-rubber or an Alpha and Omega bulb syringe is well adapted 
 for this purpose, as considerable force is necessary to dislodge the crusts. 
 
 Personally, I prefer to pack the nose with cotton-wool saturated with 
 a 10 per cent, aqueous solution of ichthyol, which should be removed 
 in from twenty to thirty minutes. The crusts, being softened, are easily 
 detached by blowing the nose or by the use of a cotton-wound probe. 
 This course of treatment, if faithfully carried out, will afford great 
 relief. Mild astringent stimulating solutions, or powders, are of value in 
 reducing the local infection. A powder containing 5 to 20 per cent, of 
 silver nitrate, or a 1 to 2000 trichloracetic acid solution may be used for 
 this purpose. The associated sinus diseases should be treated as de- 
 scribed under the Accessory Sinuses. Indeed, this is often the only 
 method of treatment attended with success. Even this fails if the 
 atrophy is far advanced. 
 
 Paraffin Injections in Atrophic Rhinitis. — Paraffin injections beneath 
 the mucous membrane of the inferior turbinated body and of the septum 
 have been used with great improvement of the symptoms. The crusts 
 are either diminished or disappear altogether. Some writers recommend 
 the use of paraffin in melted form, although the danger of thrombosis 
 is ever present. More recently paraffin has been used in solid form 
 in order to obviate this danger. A special syringe, adapted to the use 
 of semisolid paraffin, has been devised by Dr. J. C. Beck for this 
 purpose. With this device the danger of thrombosis is reduced to the 
 minimum. 
 
 The injections should be made under local anesthesia. The amount 
 injected at each sitting varies with the friability of the mucous mem- 
 brane. In some cases only one or two minims or grains should be 
 injected, as to exceed this amount would tear the mucous membrane. 
 In other cases as much as one to two drams may be injected. The injec- 
 tions should be made at intervals of from five to ten days, enough time 
 being allowed between the sittings for the subsidence of the reaction. 
 
 Either the inferior turbinal (nasal concha) or the septum may be 
 chosen for the site of the injections. The needle should be introduced 
 a half-inch or more beneath the mucoperiosteum, and a small amount 
 
SUPPURATIVE RHINITIS; NASAL SUPPURATION 159 
 
 of paraffin injected. It should then be withdrawn, a quarter of an inch 
 and more of paraffin injected, and so on until the needle is removed. 
 
 The effects produced are a lessening or the disappearance of the crusts, 
 a thinning of the secretions, a sense of air passing through the nasal 
 chambers, and occasionally edema of the eyelids. The good effects 
 have remained for a period of two years and the indications are that they 
 may last much longer. The lumen of the nasal chambers is diminished, 
 thus accounting in a measure for the lessened desiccation of the secre- 
 tions. It is also quite probable that the irritation of the paraffin, a 
 foreign body in the tissues, produces an increased hyperemia and leuko- 
 cytosis. Whatever the explanation may be, it appears that paraffin 
 injections beneath the mucoperichondrium of the nasal septum and 
 beneath the mucoperiosteum of the inferior turbinate materially improves 
 the symptoms in atrophic rhinitis with incrustations. In those cases 
 wherein the sinus origin of the suppuration and crusts is in doubt, and 
 wherein the patient refuses operative interference on the sinuses when 
 they are known to be the focal centre of the disease, paraffin injections 
 may be used with the reasonable assurance of an improvement of the 
 symptoms, though a cure may not result. 
 
 SUPPURATIVE RHINITIS; NASAL SUPPURATION. 
 
 (A symptom, not a primary disease.) 
 
 Suppurative rhinitis has been described by various authors, notably 
 by Bosworth in his work on the Diseases of the Nose and Throat. He 
 described suppurative rhinitis in children as a primary disease, which, 
 when neglected, results in atrophic rhinitis in adults. The trend of 
 opinion is gradually relinquishing the view that primary suppuration 
 of the nasal mucous membrane is often found. On the contrary, it 
 is believed that it rarely exists except secondarily to sinuitis. Personally, 
 I hold the latter view. 
 
 Pus in the nasal chambers is present in the later stages of acute coryza, 
 which is an infectious disease and is usually complicated by a purulent 
 infection of the sinuses. Purulent secretions may also accompany 
 syphilitic, tuberculous, and gonorrheal processes in the nose. The 
 specific exanthematous fevers are characterized by a purulent inflam- 
 mation of the nasal and accessory sinus membranes. The various 
 accessory sinuses, when affected by a purulent inflammatory process, 
 discharge their purulent secretions into the nasal passages. Generally 
 speaking, if after the nasal chambers are cleared of pus by mopping with 
 a cotton-wound applicator, the pus reappears within a few minutes in the 
 middle meatus, it comes from the sinuses discharging into this meatus, 
 namely, the frontal, anterior ethmoidal (including the bulla ethmoidalis), 
 and the sinus maxillaris (antrum of Highmore). Occasionally one of 
 the anterior ethmoidal cells discharges through the inner or median wall 
 of the middle turbinate into the olfactory fissure or superior meatus. 
 
160 THE NOSE AND ACCESSORY SINUSES 
 
 When the pus appears in the superior meatus, it is probably from the 
 sinuses opening into the meatus, namely, the posterior ethmoidal and the 
 sphenoidal sinuses. An occasional exception to this is when the sinus 
 maxillaris (antrum of Highmore), the posterior and superior median 
 wall of which is in relation to the superior meatus, discharges through a 
 perforation into the superior meatus. Such a condition is rare, hence pus 
 in this meatus as seen in the olfactory fissure is generally indicative of 
 suppuration of the posterior ethmoidal and the sphenoidal sinuses. It 
 is barely possible that there may be a focalized ulceration of the nasal 
 mucous membrane in the superior meatus, and that the pus is from the 
 meatus rather than the sinuses. It appears, therefore, that nasal suppura- 
 tion is rarely, if ever, a primary disease, but that it is always, or nearly 
 always, secondary to some other disease of the mucous membrane and 
 bony walls of the nasal chambers or the accessory sinuses of the nose. 
 Suppuration of the nose as a primary disease will not, therefore, be 
 described, but the other diseases to which it is secondary are described, 
 and the reader is referred to them for further information. 
 
PLATE I 
 
 Anterior Reconstruction. On account of the multiplicity of 
 lines, the individual ethmoidal cells are not shown; however, 
 the two groups are represented, the anterior being lined hori- 
 zontally and the posterior perpendicularly. The left sphenoidal 
 sinus lies far above the right; its inner wall extends almost as 
 far to the right as the outer wall of the right sphenoidal sinus. 
 (H. W. Loeb.) 
 
PLATE II 
 
 Left Lateral Reconstruction. In this and Plate I the frontal 
 sinus is colored yellow, the maxillary purple, the sphenoid 
 green, and the ethmoid red, the anterior group being lined hori- 
 zontally and the posterior group perpendicularly. The ethmoidal 
 cells are to be noted in two groups, the anterior two in number, 
 and the posterior three. The first anterior cell is shown dis- 
 placing the anterior wall of the frontal. The frontal is seen 
 opening into the frontonasal canal. The antero-inferior wall of 
 the second ethmoid constitutes the bulla ethmoidalis. (H. W. Loeb.) 
 
PLATE III 
 
 Fig. 1 
 
 Fig. 2 
 
 Large right frontal and a -mall left frontal sinus 
 (From author".- skiagraph.) 
 
 Absence of the frontal sinuses in a patient 
 aged twenty-nine years. Small anterior eth- 
 moidal cell- are shown. This patient had exten- 
 sive necrosis of the ethmoidal and sphenoidal 
 bones, and secondary mastoiditis complicated by 
 a brain abscess in the motor area for the arm 
 ami leg. The arm and leg on the opposite side 
 were partly paralyzed. The ethmoidal and sphe- 
 noidal sinuses, mastoid and brain absce-- were 
 successively operated upon without result. 
 (Author's case.) 
 
 Fig. 3 
 
 Fig. 4 
 
 Very large frontal sinuses. (From author's skia- 
 graph.) 
 
 Very large irregular right frontal and a small left 
 frontal sinus. (From author's skiagraph.) 
 
 The Distribution of the Frontal Sinuses as Shown by 
 
 Skiagraphy. 
 
PLATE IV 
 
 Fig. 1 
 
 Fig. 2 
 
 Large frontal sinuses and an anterior ethmoidal 
 cell extending well over the right orbit. (From 
 author's skiagraph.) 
 
 Narrow longitudinal frontal sinuses, the right 
 having an ethmoidal cell encroaching upon its 
 floor. (From author's skiagraph.) 
 
 Fig. 3 
 
 Fig. 4 
 
 Very large left frontal sinus, almost divided by 
 a septum. The left sinus extends about one-half 
 inch beyond the median line. (From author's 
 skiagraph.) 
 
 Large right frontal sinus with an anterior eth- 
 moidal cell (bulla frontalis) encroaching upon its 
 floor. (From author's skiagraph.) 
 
 The Distribution of the Frontal Sinuses as Shown by 
 
 Skiagraphy. 
 
PLATE V 
 
 Fig. 
 
 Fig. 2 
 
 Side view of frontal sinus with great depth and 
 upward extension. A small anterior ethmoidal 
 cell, the bulla frontalis, encroaches upon its floor. 
 (From author's skiagraph.) 
 
 Another large frontal sinus with marked back- 
 ward extension over the orbit. (From author's 
 skiagraph.) 
 
 Fig. 3 
 
 Fig. 4 
 
 Side view of the frontal sinus with limited up- 
 ward extension and moderate backward extension. 
 (From author's skiagraph.) 
 
 An unusual downward extension of the frontal 
 sinus. (From author's skiagraph.) 
 
 The Anteroposterior Extension of the Frontal Sinuses as 
 Shown by Skiagraphy. 
 
PLATE VI 
 
 Fig. 1 
 
 Fig. 2 
 
 Frontal sinus with extreme extension backward, 
 and with a large anterior ethmoidal cell encroaching 
 upon the posterior portion of its floor. (From 
 author's skiagraph.) 
 
 Side view showing absence of the frontal sinuses 
 in a patient aged twenty-nine years. Anterior 
 view shown in Plate III, Fig. 2. (From author's 
 skiagraph.) 
 
 Fig. 3 
 
 Fig. 4 
 
 Side view showing a frontal sinus of moderate 
 depth. (From author's skiagraph.) 
 
 An extremely large and deep frontal sinus. (From 
 author's skiagraph.) 
 
 The Anteroposterior Extension of the Frontal 
 Shown by Skiagraphy. 
 
 Sinuses as 
 
CHAPTER IX. 
 
 THE INDIVIDUAL SINUSES. 
 
 The sinuses are divided for clinical purposes into two groups, namely, 
 the anterior and the posterior sinuses. The anterior group is composed 
 of the frontal, the anterior ethmoidal, and the maxillary sinuses. Hajek 
 calls this group Series I. The posterior group is composed of the 
 posterior ethmoidal and the sphenoidal sinuses, and is called Series II. 
 
 Our knowledge of the etiology, symptomatology, pathology, and sur- 
 gical treatment of the sinuses has increased so greatly during the last 
 ten years that it seems proper to depart from the traditional manner 
 of presenting this subject, wherein each sinus is separately described 
 and treated. As a matter of fact, a single sinus is rarely diseased, two 
 or more being commonly affected at the same time. Indeed, it is not 
 uncommon to find all the sinuses on one side of the head affected. The 
 maxillary sinus is perhaps more often affected singly than either of the 
 other sinuses. This is accounted for by the fact that in about one-half 
 of the cases it is infected from the teeth rather than from the nose, whereas 
 the other sinuses are nearly always infected from the nose. Having a 
 common source of infection, they are, therefore, more often simultane- 
 ously diseased. 
 
 For this reason a general discussion of inflammation of the sinuses is to 
 be preferred to a discussion of each sinus individually. Nevertheless, it 
 will be advantageous to present the peculiar symptoms and other con- 
 siderations of each sinus separately. The following considerations are 
 therefore to be read in conjunction with the general description which 
 follows. 
 
 SERIES I. 
 
 The Frontal Sinus. — The frontal sinus is an extension upward of the 
 ethmoidal cells between the plates of the frontal bone. The extension 
 occurs at about the age of puberty, hence in infants and young children 
 the frontal sinuses are absent. The size and shape of the frontal sinuses 
 vary greatly in different individuals, and indeed the two sinuses often 
 vary greatly in the same individual. References to Plates I, II, III, IV 
 and V show some variations in the frontal sinuses, the drawings being 
 taken from skiagraphs of some of the author's cases. These variations 
 are of surgical interest, as the difference in size will often determine 
 the method of operating. If there is a large and deep frontal sinus, great 
 external deformity may follow the complete removal of the anterior wall. 
 In such a subject the operation may be so executed as to avoid, or to 
 greatly reduce, the probability of marked disfigurement. 
 11 
 
162 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 H. W. Loeb's projections of the sinuses (Plate I and II) show more 
 clearly than any other work the relations of the sinuses to one another 
 and to the structures of the nose. The anteroposterior and lateral pro- 
 jections are shown. Plates III, IV, V and VI also give a good idea of 
 the distribution of the sinuses. 
 
 Skiagraphy. — The skiagraphic plate affords good information con- 
 cerning the presence or absence of disease in all except the sphenoidal 
 sinus if the exposure is properly made. It is not yet known what causes 
 the cloudy appearance when the sinus is diseased. Coakley says it 
 is not known whether it is due to the thickness of the inflamed membrane, 
 to the presence of pus, or to the changed condition of the bone. I have 
 a skiagraph of a patient affected with a severe chronic catarrhal sinuitis 
 upon whom I performed a double Killian operation, in which the right 
 
 The correct method of making pressure under the floor of the frontal sinus. Pressure is often 
 made under the supra-orbital ridge, whereas it should be made much deeper. 
 
 frontal sinus as shown by the plate was cloudy, but less so than the left. 
 Upon operating the right sinus was found to be free of pus, and its 
 periosteum and mucous membrane were entirely gone. The bone was 
 chalky white and slightly roughened. The left sinus was free of pus, 
 but was filled with granulation tissue and viscid mucous secretion. 
 The patient had complained for several months of an acrid secretion 
 which irritated the nasal mucosa. This case is cited here, as it is unique, 
 and demonstrates that a frontal sinus devoid of membrane periosteum, 
 and purulent secretion gave a cloudy effect in the skiagraph, though not 
 so pronounced as that given by the sinus in which the membrane and 
 granulations were present. Pus was not present in either sinus. 
 
 Tenderness upon Pressure. — Tenderness over the frontal bone is rarely 
 present in frontal sinuitis except in very acute cases with obstructed 
 drainage. Tenderness is often present, however, when pressure is made 
 
THE INDIVIDUAL SINUSES 103 
 
 against the floor of the affected sinus near the inner angle of the orbital 
 cavity (Fig. 124). The finger tip should be placed well under the roof 
 of the orbit and the pressure directed upward. Pain is thus often elicited 
 even in chronic catarrhal cases. Tenderness in this region does not, 
 however, always indicate disease of the frontal sinus, as the anterior 
 ethmoidal cells sometimes project beneath the floor of the sinus. 
 
 When such an anatomical deviation is present the surgeon may be 
 led to a wrong conclusion. This difficultv may be obviated bv having 
 a skiagraph made, as it will aid in determining the position and condition 
 of the frontal and anterior ethmoidal cells. 
 
 The tenderness present in frontal sinuitis is so nearly in the same posi- 
 tion as that in ethmoidal sinuitis that a careful distinction should be made. 
 In ethmoidal sinuitis the tenderness is usually located a little above the 
 median palpebral commissure (inner canthus) of the eye and a little 
 deeper in the orbital cavity than the canthus. The pressure should be 
 made inward toward the median line, rather than upward, as in testing 
 the frontal sinus. 
 
 Redness and Swelling. — Redness and swelling over the frontal region 
 are only present in severe acute inflammation of the frontal sinus where 
 the bone is affected by an infective osteomyelitis and the skin has yielded 
 to the inflammatory process. There are perhaps a hundred cases of 
 frontal sinuitis in which the redness and swelling are absent to one in 
 which they are present. The day is past when a surgeon should wait 
 for such symptoms before deciding to operate upon the frontal sinus. 
 There are other positive indications of disease of the sinus to guide him 
 to a diagnosis and to a choice of the mode of treatment. 
 
 Mucous Discharge. — While catarrhal inflammation of the sinuses is 
 generally referred to in text-books, no clear idea of the symptomatology 
 and diagnosis is given. The presence of pus in the nose has generally 
 been considered an essential requirement in making a diagnosis. I 
 have found it almost as easy to diagnosticate sinuitis without pus as with 
 it. The symptoms are much the same as those in purulent sinuitis, 
 except that pus is absent. The secretion is mucous or seromucous in 
 character, and might easily escape observation. The patient often 
 complains of a burning sensation in the anterior portion of the nasal 
 passages or of fissures or excoriations at the margin of the nostrils as a 
 result of the acrid catarrhal discharge. 
 
 Headache. — The patient generally complains of frontal headache, 
 which is limited to, or originates on, the side affected. The headache 
 is often more severe during the night, especially upon awaking while in 
 bed, or in the morning, than at other times. It is often confounded with 
 eyestrain. Headache due to eyestrain is generally relieved upon closing 
 the eyes, especially upon retiring for the night. The headache caused 
 by frontal sinuitis (catarrhal or suppurative) is not aggravated by theatre- 
 going; whereas if due to eyestrain, it is thereby aggravated. 
 
 Dizziness; Vertigo. — Dizziness or vertigo of slight degree is present 
 in most cases, severe in others. It is often present in simple catarrhal 
 inflammation, as well as in suppurative inflammation of the frontal and 
 
164 THE NOSE AND ACCESSORY SINUSES 
 
 ethmoidal sinuses. It is especially aggravated by stooping, or, if in a 
 stooping posture, upon assuming the erect posture. Careful inquiry is 
 often necessary to elicit this symptom, as the patient does not consider 
 it of any significance. 
 
 Ocular Symptoms. — According to Fish, Zeim, Wood, Stucky, Coffin, and 
 others (Eye in Relation to the Sinuses), inflammation of the frontal or 
 any other sinus may give rise to morbid processes in any of the structures 
 of the eye. This is accounted for by the free anastomosis of the veins of 
 the sinuses with the ophthalmic vein. Congestion in the sinuses causes 
 a like condition in the eye. Infection and toxemia are thereby favored; 
 papillitis, choroiditis, optic neuritis, iritis, keratitis, etc., thus becoming 
 established. 
 
 Intracranial Complications. — Extradural and brain abscess, meningitis, 
 and sinus thrombosis may arise from sinuitis. Inasmuch as the posterior 
 wall of the frontal sinus is thinner than the external or anterior wall, it is 
 curious that intracranial complications are so rare. The superior, longi- 
 tudinal, and the cavernous sinus occasionally become thrombosed in 
 frontal sinuitis. Meningitis, which has its origin in the sinuses, is more 
 frequently reported now than formerly, a fact significant of a better 
 understanding of the subject. 
 
 The Anterior Ethmoidal Sinuses. — The anterior ethmoidal cells 
 vary in number from two to eight, and are smaller than the posterior cells. 
 They all drain into the middle meatus. According to Logan Turner, the 
 frontonasal canal opened in the infundibulum in about one-half of the 
 specimens examined, and directly into the middle meatus in the remainder. 
 The anterior cells are separated from the posterior cells by a thin trans- 
 verse bony partition. The attachment of the middle turbinated body to 
 the external wall of the nose also marks the line of division between 
 the anterior and the posterior group of cells. The anterior cells lie in 
 front of and below it, while the posterior cells lie above and behind it. 
 Clinically the two groups of ethmoidal sinuses are, therefore, divided into 
 anterior and posterior cells. The anterior cells belong to Series I, while 
 the posterior cells belong to Series II. 
 
 Accessory ethmoidal sinuses are sometimes present in the middle 
 turbinate and in the uncinate process, and when present drain into the 
 middle meatus and belong to the anterior group or Series I. 
 
 The upper wall of the ethmoidal cells is a rather dense but thin plate 
 of bone. The cribrifrom plate is not covered by the cells, but is freely 
 exposed in the attic of the nose. While the bone is dense and not easily 
 fractured by ordinary force exerted during an operation, its numerous 
 openings render it a possible atrium for the conveyance of infection to 
 the meninges. The outer wall of the ethmoidal sinuses is the os planum 
 or lamina papyracea of the ethmoidal and the lacrymal bones. These 
 plates of the bone are extremely thin, and form the inner wall of the orbital 
 cavity. Should this plate of bone be perforated, orbital cellulitis, with 
 protrusion of the eyeball, might result. In two of my cases orbital 
 emphysema followed the ethmoidal operation. 
 
 In Fig. 125 is shown a case of ethmoidal suppuration in which the 
 
THE INDIVIDUAL SINUSES 
 
 165 
 
 lacrymal bone was carious and perforated. When first seen there was 
 a large nipple-like projection of the skin at the inner angle of the orbit, 
 or lateral wall of the nose, in this region. The right eyelid was swollen 
 and closed, while the left was less swollen and partially closed. The 
 upper and lower lids of both eyes were discolored purple. Protrusion of 
 the eyeballs was absent, as orbital cellulitis was not present. Had the 
 perforation occurred more posteriorly through the os planum, orbital 
 cellulitis would in all probability have occurred. 
 
 The patient had a similar attack one year previous to this one. The 
 swelling subsided, but the nasal discharge continued, and the eye was 
 uncomfortable. 
 
 Fig. 125 
 
 Fig. 126 
 
 Empyema of the ethmoidal sinuses, with 
 perforation through the lacrymal plate at the 
 inner canthus of the right eye and marked 
 bulging at this point. Both upper eyelids are 
 edematous and purple. The right eye is en- 
 tirely closed, the left almost. One year pre- 
 viously had a similar attack following scarlet 
 fever. (Author's case.) 
 
 Same case six days after operation. External 
 wound gradually filled in by granulation and 
 became closed in two months. (Author's case.) 
 
 Skiagraphs showed marked cloudiness in the ethmoidal region on the 
 right side, while on the left it was less cloudy. The frontal sinuses were 
 absent, or if present were very small. The lower meatus of the nose was 
 quite open. Frontal headache and dizziness were prominent symptoms. 
 
 The nipple-like projection was incised at once and discharged a half- 
 ounce of thick yellow pus. On the following day, under general anes- 
 thesia, the region was exposed by an external skin incision extending 
 from a point below the nipple-like tumefaction to the middle of the right 
 eyebrow. The lacrymal bone was almost entirely destroyed by necrosis. 
 The frontal process of the maxilla was removed with rongeur forceps, 
 thus fully exposing the anterior ethmoidal cells to operative interference. 
 The entire ethmoidal labyrinth, including the middle turbinate, was 
 
166 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 removed. A curette (Fig. 127) was also used through the anterior 
 nasal opening, to make sure that no remnants of the cells were left. 
 The cranial plate and the os planum were carefully but thoroughly 
 curetted until they were smooth. 
 
 The left side was operated on through the nose, the middle turbinate 
 and the ethmoidal cells being removed in their entirety, in so far as they 
 could be reached with the curette by this route. 
 
 Fig. 127 
 
 & 
 
 The author's ethmoid curette. 
 
 Fig. 128 
 
 Fig. 125 shows the patient one week after operation. The edema and 
 discoloration of the eyelids had entirely disappeared, and the wound 
 in the lacrymal region on the right side permits of a clear view of the 
 
 interior of the nose. The marked change 
 in the facial expression is suggestive of the 
 improved condition of the patient. 
 
 The Maxillary Sinus (Antrum of High- 
 more). — The maxillary sinus, the third and 
 last sinus belonging to Series I, is the largest, 
 and, according to the prevailing opinion, is 
 more frequently diseased than either of the 
 other sinuses in both series. Personally, I 
 question this statement, as according to my 
 own observations the ethmoidal and frontal 
 sinuses are more frequently involved. Our 
 knowledge of the symptomatology of disease 
 of the sinuses in general has greatly increased 
 during the past five or ten years, with the 
 result that ethmoidal, sphenoidal, and frontal 
 sinuitis are diagnosticated twenty times as 
 often as they were ten years ago. While 
 the antrum is still a frequent seat of disease, 
 the ethmoidal and the frontal sinus occupy 
 a more important place. The diagnosis of 
 antral inflammation has been understood for 
 many years, and this has given rise to the 
 impression that it is much more common than 
 inflammation in the other sinuses. It may 
 be infected from the nose or the teeth, the 
 cases probably being about equally divided 
 between these two sources of infection. On 
 account of the dental origin of so many cases 
 of maxillary sinuitis, it is more often affected singly than either of the 
 other sinuses, in which the infection is almost always of nasal origin. 
 
 Showing the thin orbito-eth- 
 moidal wall partially destroyed. 
 During ethmoiditis this wall may 
 be broken or perforated, and give 
 rise to orbital cellulitis. (Author's 
 specimen.) 
 
THE INDIVIDUAL SINUSES 167 
 
 When the infection is of nasal origin, quite naturally more than one 
 group of sinuses is simultaneously affected. 
 
 The ostium maxillare is situated in the upper portion of the naso- 
 antral wall as far removed from the floor of the sinus as possible. This 
 apparently renders the drainage of the secretions quite difficult or impos- 
 sible, except as they overflow when the antrum is filled. This is not the 
 case, however, as there is but little secretion in the sinus in health — only 
 enough to keep the mucous membrane moist. The epithelium of the 
 antral mucous membrane is of the modified ciliated columnar variety, 
 though it is but slightly developed and in patches. The wave-like motion 
 of the cilia? aids in carrying the scanty secretions to the ostium maxillare 
 at the top of the sinus,' where it is discharged through the infundibulum 
 into the middle meatus. 
 
 In the course of severe or long-continued inflammation of the mucous 
 membrane of the antrum, the cilise are injured or destroyed, and the 
 secretions are retained in the antrum because they are not carried to the 
 ostium maxillare. The secretions are greatly increased in quantity, a 
 fact which still further tends to promote the accumulation within the 
 sinus. 
 
 The second bicuspid and the first and second molar teeth are in close 
 relation to the floor of the sinus. Indeed, they sometimes project into 
 the bony cavity, being only covered by mucous membrane. A suppura- 
 tive process around the root of either of these teeth might easily affect 
 the mucous membrane of the sinus through the lymphatics and blood- 
 vessels. Indeed, an infection of the crown of the teeth may extend 
 through the lymphatics to the antrum. 
 
 The superior wall or roof of the sinus is crossed in its central portion 
 by the infra-orbital nerve, which lies in a groove on the broad inferior 
 side of the plate of bone. It is covered by mucous membrane, and may 
 be easily injured during the curettement of the sinus. 
 
 As it is a nerve of sensation rather than of motion, it regenerates 
 readily after being injured, even if long portions of it are removed. Motor 
 nerves do not thus readily repair. 
 
 SERIES II. 
 
 Series II is composed of the posterior ethmoidal and the sphenoidal 
 sinuses, and their ostei open into the superior meatus of the nose. 
 
 The Posterior Ethmoidal Sinuses. — The posterior ethmoidal are 
 usually fewer in number and larger in size than the anterior ethmoidal 
 cells. Sometimes they occupy nearly all the ethmoidal labyrinth, ex- 
 tending to the anterior portion of the nose, and sometimes the anterior 
 cells extend backward almost to the sphenoidal bone. 
 
 The ostia open into the posterior portion of the superior meatus and 
 drain upon the posterior half of the middle nasal concha (turbinated 
 body). As the middle turbinate slopes slightly downward and backward, 
 the secretion flows toward the posterior choana, though it also flows 
 over the median border of the turbinate through the olfactory fissure or 
 
168 THE NOSE AND ACCESSORY SINUSES 
 
 space between the turbinate and the septum, hence a purulent secretion 
 in the olfactory fissure is usually indicative of posterior ethmoidal suppu- 
 ration. It may, however, indicate sphenoidal disease, or a combined 
 empyema of the ethmoidal and sphenoidal sinuses. The secretions may 
 also be forced into this position from the middle meatus by snuffling the 
 nose. 
 
 The ostia of the posterior cells are not visible by either anterior or 
 posterior rhinoscopy, nor are they accessible to the probe or cannula. 
 
 The symptoms of posterior ethmoidal suppuration are not so distinct 
 as those in either of the cells comprising Series I. As the posterior 
 cells are deeply situated, external tenderness is not present. Exoph- 
 thalmos may result from the retention of the purulent secretion in the 
 cells, the os planum forced outward behind the eyeball, causing it to 
 protrude forward. This also gives rise to diplopia and strabismus 
 and to a circumscribed visual field, especially for colors. The ocular 
 disturbances are extremely rare in proportion to the number of cases in 
 which the posterior ethmoidal cells are diseased. According to my 
 own clinical observations, the ethmoidal sinuses (anterior and posterior) 
 are more often diseased than the maxillary sinus, which is generally 
 regarded as the most frequently affected. The ethmoidal sinuses are so 
 situated in the upper and narrow portion of the nasal chambers that a 
 moderate deviation of the septum or an enlargement of the middle tur- 
 binate closes the olfactory fissure and thus blocks ventilation and drainage 
 of the superior meatus and accessory cells. For these reasons the 
 posterior ethmoidal cells are often the seat of disease. 
 
 The secretion in the posterior portion of the olfactory fissure is sig- 
 nificant of ethmoidal suppuration, though the pus may come from the 
 sphenoid. Indeed, the posterior ethmoidal and sphenoidal cells are so 
 closely associated that when one is diseased both are often affected. A 
 postrhinoscopic examination showing purulent secretion on top of the 
 middle turbinate is almost certain evidence of disease of the posterior 
 ethmoidal and sphenoidal cells. Crusts and secretions in the vault of the 
 epipharynx are likewise indicative of the same affection. 
 
 The Sphenoidal Sinus. — The ostium sphenoidale is situated in the 
 anterior wall of the sphenoidal sinus near the top of the cavity, though it 
 is occasionally a little lower down. It is near the septum of the nose and 
 is hidden from view by the close approximation of the middle turbinate 
 to the septum. If there is marked atrophy of the turbinate, or if the sep- 
 tum deviates to the opposite side, it may be seen by anterior rhinoscopy. 
 The opening varies from i to 4 mm. in diameter. 
 
 The purulent secretion flowing from the ostium either drains directly 
 through the posterior choana into the epipharynx or on to the posterior 
 end of the middle turbinate. Ocular inspection can usually only be 
 made after the removal of the entire middle turbinated body. 
 
 The pain or headache occurring in sphenoidal inflammation is usually 
 felt in the occipital region on the affected side, though in some cases 
 it is diffused and ill defined. Catarrhal inflammation causes the same 
 headache as suppurative inflammation, though it may not be so severe. 
 
DIFFERENTIAL DIAGNOSIS 169 
 
 The ocular symptoms usually ascribed to suppuration of the sphe- 
 noidal sinus are those dependent upon the compression of the optic 
 and oculomotor nerves. The optic nerve passes over the roof of the 
 sinus, hence in closed empyema in which the thin bony wall of the roof is 
 softened, compression or even destruction of the optic nerve may take 
 place. Optic neuritis may be followed by atrophy and blindness. Optic 
 neuritis may be toxic in origin, the noxa originating in the infected 
 sinuses. I have seen several cases of neuritis and blindness which were 
 apparently of toxic origin, as there was no retention of secretion. If the 
 pressure reaches the sphenoidal fissure, the oculomotor nerves, the third, 
 fourth, and sixth, become involved and strabismus in some form follows. 
 Intense neuralgia may result from a neuritis of the ophthalmic division of 
 the fifth nerve. 
 
 Other ocular lesions arising in the course of inflammatory diseases of 
 this and all the other sinuses are referred to in the paragraph on the 
 Eye in Relation to the Sinuses. 
 
 DIFFERENTIAL DIAGNOSIS. 
 
 To illustrate the methods of differential diagnosis, a series of hypo- 
 thetical cases will be given, assuming the symptoms characteristic of 
 the simple and combined empyemas of the various sinuses in the open, 
 closed, and latent forms. 
 
 Simple empyema refers to those cases which are limited to one group of 
 cells, as the maxillary sinus, frontal, anterior ethmoidal, posterior ethmo- 
 moidal, or the sphenoidal sinus. 
 
 Open empyema refers to an empyema, either simple or combined, in 
 which the ostia are open and permit of drainage and ventilation. 
 
 Closed empyema refers to those cases in which the ostia are closed by 
 pathological changes and the secretions are retained and cause pressure. 
 
 Latent empyema refers to those cases in which the ostia are open, but 
 the secretion is so slight that it is not demonstrable, except by irrigation 
 of the affected sinus. 
 
 The ostia of the sinuses are so situated that they drain into either the 
 middle or the superior meatus of the nose. The sinuses situated an- 
 teriorly drain into the middle meatus, while those situated posteriorly 
 drain into the superior meatus. 
 
 The anterior group, or those draining into the middle meatus, are the 
 antrum, the frontal and the anterior ethmoidal cells. These have been 
 designated by Hajek as Series I. 
 
 The posterior group, or those draining into the superior meatus, are 
 the posterior ethmoidal and the sphenoidal sinuses. These are desig- 
 nated as Series II. For the sake of brevity and clearness these terms 
 will be continued. Having defined the terms, we are ready to recite a 
 series of hypothetical cases, illustrative of the symptoms and procedures 
 necessary to arrive at a positive differential diagnosis between empyema 
 of the various sinuses or combinations of them. 
 
170 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Case I. — (a) Unilateral discharge from the nose. 
 (6) No pain. 
 
 (c) Subjective fetid odor. 
 
 (d) There is an ulcer at the root of the second bicuspid tooth on the 
 side of the nasal discharge. 
 
 (e) Anterior rhinoscopy shows pus in the middle meatus. 
 
 The conclusion, based upon the above data, is that one or more of the 
 anterior group of cells, Series I, is involved. While the ulcerous bicuspid 
 suggests the antrum as the sinus most probably affected, it is by no 
 means proved nor are the frontal and anterior ethmoidal sinuses known 
 to be free. To differentiate still further the focal centre of infection 
 the following procedure must be instituted: 
 
 Fig. 129 
 
 Introducing a trocar and cannula into the maxillary antrum beneath the inferior turbinate 
 
 for diagnostic purposes. 
 
 Remove the secretions from the middle meatus with the douche or 
 a cotton- wound probe, and place the patient in Escat's position, i. e., 
 the head thrown forward with the affected side turned upward to help 
 the flow of pus from the antrum. After the patient has remained in this 
 position for a few minutes the middle meatus should be reexamined, 
 and if pus is found, the antrum is probably involved. This is not ab- 
 solutely established, however, as the pus might have come from the 
 frontonasal canal. To establish still further the diagnosis, introduce a 
 cannula and trocar through the naso-antral wall in the inferior meatus 
 (under cocaine anesthesia) (Fig. 129) and irrigate the antrum. If pus 
 is found the antrum is involved. The diagnosis is not yet complete, 
 as it remains to be demonstrated whether the frontal and anterior eth- 
 moidal cells are affected. If after thorough irrigation of the antrum pus 
 does not reappear in the middle meatus, the probabilities are strongly in 
 favor of a simple empyema of the antrum. This is true in view of the fact 
 that the flow of pus from the frontal sinus is nearly constant, as its outlet 
 when the patient is in a sitting posture is usually in the most dependent 
 
DIFFERENTIAL DIAGNOSIS 171 
 
 portion of the sinus. In this case pus does not reappear in the middle 
 meatus for several hours, unless the patient assumes Escat's position, 
 hence the condition is probably a simple empyema of the antrum. 
 
 To strengthen the diagnosis still further transillumination of the antrum 
 and frontal sinus should be performed. If the side involved shows 
 opacity over the lower eyelid, a non-luminous pupil, and the absence 
 of the sense of light with the eyes closed, empyema of the antrum is 
 indicated. If, in addition, transillumination of the frontal sinus is 
 negative, the diagnosis of a simple empyema is fairly well established. 
 
 The anterior ethmoidal cells are still to be considered. Transillumina- 
 tion does not help us here. The bulla ethmoidalis belongs to the anterior 
 ethmoidal cells, and if it is enlarged toward the septum, or downward 
 against the uncinate process, it is probably that the anterior ethmoidal 
 cells are involved. 
 
 If pus is removed by irrigation from the frontal sinus, the case is one 
 of combined empyema of Series I. Skiagraphy shows the frontal and 
 ethmoidal areas clear while the antrum upon the affected side is cloudy. 
 
 Diagnosis. — Simple, open empyema of the maxillary antrum. 
 
 Case II. — (a) Unilateral discharge of pus from the nose. 
 
 (b) Dull aching pain in the left cheek bone. 
 
 (c) Pus in the middle meatus. 
 
 ((f) Slight tenderness over the cheek bone on pressure. 
 
 (e) Case under observation for several days; pus not always found in 
 the middle meatus. 
 
 (/) Outer nasal wall on left side bulges toward septum. 
 
 {(j) Pus occasionally discharged in great quantities, after which the dull 
 ache in the malar region is relieved. 
 
 After performing the procedures described in Case I the purulent 
 secretion is excluded from the frontal and anterior ethmoidal cells, and 
 is localized in the maxillary antrum. The retention of the purulent 
 secretion gives rise to the pain and tenderness over the left cheek bone 
 and to the bulging of the outer nasal wall toward the septum. At times 
 the pressure of the purulent secretion was great enough to force it either 
 through the ostium maxillare of the accessory ostia, which were closed 
 by the swollen mucous membrane. The pain caused by the pressure was 
 relieved after each spontaneous discharge. 
 
 Diagnosis. — This is a case of simple, closed empyema of the antrum. 
 
 Case III. — (a) Xo nasal discharge. 
 
 (6) There is a previous history of nasal discharge from the right side. 
 
 (c) Frequent attacks of frontal headache on the right side. 
 
 (d) Mental depression. 
 
 (e) Aprosexia. 
 
 (/) Transillumination of antrum and frontal sinus is negative. 
 (g) Pus not present in either the middle meatus or the olfactory slit. 
 ( h ) Irrigation of the sinus through a puncture in the inferior meatus 
 (Fig. 128) shows a very small amount of pus. 
 
 (i) Irrigation of the frontal and anterior ethmoidal cells is negative. 
 (J) Irrigation of antrum continued until pus disappears. 
 
172 THE NOSE AND ACCESSORY SINUSES 
 
 (k) Supra-orbital pain, mental depression, and aprosexia disappear. 
 (I) Skiagraph shows cloudiness of antral area, while the frontal and 
 ethmoidal are clear. 
 
 Diagnosis. — Latent empyema of the maxillary sinus. 
 
 Case IV. — (a) Unilateral nasal discharge. 
 
 (6) Supra-orbital pain and tenderness on percussion. 
 
 (c) Pressure on the roof of the orbit (floor of frontal sinus) elicits pain. 
 
 (d) Pus present in the middle meatus. 
 
 (e) When wiped away it reappears after a few minutes. 
 
 (f) Escat's position of the head has no influence on the flow of pus. 
 
 (g) Lying upon the back checks the flow. 
 
 (h) Frontal headache beginning on the affected side, more marked in 
 the morning. 
 
 (i) Dizziness upon stooping. 
 
 (J) Transillumination shows the crescentic light over the lower eyelid, 
 the red pupillary reflex, and the sense of light in both eyes with the lids 
 closed. 
 
 (k) Transillumination of the frontal sinus seems to show diminished 
 luminosity on the affected side, although the difference between the 
 two might easily be accounted for by anatomical variations. 
 
 (/) Puncture of maxillary sinus through the inferior meatus negative. 
 
 Fig. 130 
 
 Frontal sinus cannula. 
 
 (m) The cannula (Fig. 130) is introduced into the frontonasal canal 
 and irrigation through it brings pus. Pus reappears in the middle 
 meatus in a few minutes. 
 
 (n) Skiagraphs show cloudiness of the frontal sinus, the ethmoidal 
 and antrum being clear. 
 
 Diagnosis. — Simple open empyema of the frontal sinus. 
 
 Case V. — (a) Constant nasal discharge, right side. 
 
 (6) Supra-orbital headache on the right side. 
 
 (c) Tenderness and swelling over the right eyebrow. 
 
 (d) Anterior rhinoscopy. Septum deviated to right, in the region of 
 the middle turbinate. Polpyi in the middle meatus on right side. 
 
 (e) Probe shows polypi attached to uncinate process and the middle 
 turbinal. 
 
 (/) Provisional diagnosis: Series I involved, probably localized in the 
 frontal or the frontal and anterior ethmoidal sinuses. 
 
 (g) Transillumination of maxillary sinus shows faint crescent and 
 pupillary reflex. Frontal sinus opaque. 
 
 (h) Polypi removed. 
 
 (i) Maxillary sinus punctured through inferior meatus and odorless 
 pus is washed out. 
 
DIFFERENTIAL DIAGNOSIS 173 
 
 (y) Frontal sinus irrigated through cannula. Pus abundant. 
 
 (k) Frontal sinus irrigated daily, maxillary occasionally; pus absent 
 in maxillary after the first irrigation. 
 
 (Z) At end of six weeks frontal sinus still discharges pus. 
 
 (m) Radical external operation; caries and polypi found in frontal 
 sinus. 
 
 Diagnosis. — Empyema of frontal sinus with secondary involvement of 
 the maxillary sinus, which acts as a reservoir, but is not a focal centre of 
 disease. 
 
 Case VI. — (a) Patient complains of purulent crusts in the right 
 nostril and in the epipharynx on rising. Hawks up crusts from the 
 epipharynx. 
 
 (6) Dull headache variously located; sometimes it is frontal, then 
 vertexial, and then occipital. 
 
 (c) Mental depression and aprosexia. 
 
 (d) Anterior rhinoscopy: Septum deviated to right in region of 
 middle turbinal. Olfactory slit narrow and filled with pus and crusts. 
 Small polypi springing from above the middle turbinal. 
 
 (e) Posterior rhinoscopy shows purulent secretions flowing over the 
 posterior end of the right middle turbinal and the posterior epipharyngeal 
 wall. Crusts not found, as they form at night when the position of the 
 head and the quietness of sleep favor accumulation. 
 
 (J) Middle meatus free from pus. 
 
 (g) Provisional diagnosis: Empyema of Series II. 
 
 (K) A cannula is passed into the sphenoidal sinus through its ostium. 
 Irrigation shows no pus. 
 
 (i) A curved silver probe introduced through the olfactory slit shows 
 bare rough bone in the superior meatus. 
 
 Diagnosis. — Open empyema of the posterior ethmoidal cells. The 
 irrigation of the sphenoidal sinus eliminates it from consideration, 
 and as Series II is only composed of the sphenoidal and posterior eth- 
 moidal sinuses, the empyema is located by exclusion in the posterior 
 ethmoidal cells. This is still further substantiated by the presence of 
 rough, bare bone in the superior meatus. 
 
 Case VII. — (a) Patient complains of the formation of crusts in the 
 epipharynx, also of postnasal " dropping." 
 
 (6) A subjective sense of odor is present, even in the absence of such 
 an odor. 
 
 (c) Vertexial and occipital headache. 
 
 (d) Field of vision, especially for colors, diminished. 
 
 (e) Mental depression. 
 
 (J) Anterior rhinoscopy; olfactory slit occasionally filled with pus, 
 though it is usually clear. 
 
 (g) Probing shows the mucous membrane of the superior meatus 
 intact, while probing of the sphenoid sinus shows roughened bone and 
 bleeding. 
 
 (h) Posterior rhinoscopy; purulent secretions on posterior end of 
 right middle turbinated body and upon the posterior wall of epipharynx. 
 
174 THE NOSE AND ACCESSORY SINUSES 
 
 (i) Irrigation of the sphenoidal sinus shows pus in considerable 
 quantities. 
 
 (f) Transillumination of maxillary and frontal sinuses negative. 
 (k) Examination of the fundus oculi shows slight papillitis. 
 Diagnosis. — Open empyema of Series II, probably focalized in the 
 
 sphenoidal sinus. If the treatment of the sphenoid is followed by the 
 disappearance of all symptoms, the diagnosis is positive. If the purulent 
 discharge continues the posterior ethmoidal cells should be removed, 
 and if a cure follows, the diagnosis of combined empyema of the 
 sphenoidal and posterior ethmoidal sinuses is established. 
 
 Case VIII. — (a) Intense headache at the vertex and occiput. 
 
 (6) Crust formation and postnasal dropping, yellow in color. 
 
 (c) Subjective sense of odor. 
 
 (d) Sudden blindness in the right eye. 
 
 (e) Great mental depression and aprosexia. 
 (/) Dizziness complained of. 
 
 (g) Anterior rhinoscopy shows pus and crusts in the olfactory fissure. 
 (h) Transillumination of the maxillary and frontal sinuses is negative. 
 (i) Probing of the middle and superior meatuses is negative. 
 
 (j) Cannot locate the ostium of the sphenoidal on account of the great 
 swelling. 
 
 (k) The middle turbinate is removed and the ostium sphenoidalis is 
 filled with granulation tissue bathed in pus. 
 
 (I) The anterior wall of the sphenoid is removed, the cavity curetted, 
 and granulation tissue and pus are found in considerable quantities. 
 
 (m) After the removal of the middle nasal concha (turbinated body) 
 no pus is seen coming from the region of the posterior ethmoidal cells 
 
 Diagnosis. — Simple closed empyema, granulations, and caries of the 
 walls of the sphenoidal sinus on the right side. 
 
 The sudden blindness may be accounted for by pressure upon and 
 inflammation of the optic nerve, or by venous stasis or toxemia. 
 
 Case IX. — (a) Supra-orbital, vertexial, and occipital headache. 
 
 (b) Purulent discharge from the right nostril into the epipharynx. 
 
 (c) Subjective sense of odor. 
 
 (d) Strabismus of the right eye. 
 
 (e) Transillumination shows opacity of the right lower eyelid (left 
 negative) and absence of red pupillary reflex, also opacity over the right 
 frontal sinus. 
 
 (/) The bulla ethmoidalis is enlarged downward and inward, and 
 there are polypi in the middle meatus, 
 
 Provisional diagnosis of empyema of Series I and II is made. It 
 is still a question as to the exact localization of the suppuration. It 
 seems probable that all the sinuses in Series I and II are involved, 
 although this is not yet proved. 
 
 (g) The blunt probe is used, and shows bare rough bone in the 
 superior meatus and in the region of the uncinate process (the inner and 
 inferior lip of the hiatus semilunaris). This makes it quite probable 
 that the posterior ethmoidal, anterior ethmoidal, and the antrum are 
 
DIFFERENTIAL DIAGNOSIS 175 
 
 involved. When the bulla ethmoidalis is enlarged downward the dis- 
 charge of pus is blocked in the infundibulum and is pent up in the anterior 
 ethmoidal and the frontal sinuses. The pus under these circumstances 
 often breaks through the lateral wall of the nose into the antrum. The 
 enlargement of the bulla (one of the anterior ethmoidal cells) is in itself 
 significant of a diseased process in this group of cells. 
 
 (h) The anterior end of the middle turbinal and the polypi in the 
 middle meatus are removed. 
 
 (i) The maxillary sinus is irrigated through a puncture in the inferior 
 meatus and much pus removed, but it continues to discharge. 
 
 (f) The frontal sinus is irrigated through a cannula and a copious 
 discharge of pus follows and persists. 
 
 (k) The bulla is broken down with a curette, and pus wells from its 
 interior. A polypus also protrudes from its cavity. The remainder of 
 the middle turbinate is resected and the posterior ethmoidal cells are 
 thoroughly removed by curettement. After a time the discharge of pus 
 ceases. 
 
 Having demonstrated the persistent presence of pus in all the sinuses 
 embraced in Series I and II a positive diagnosis may be made. 
 
 Diagnosis. — Combined empyema of all the accessory nasal sinuses 
 of one side of the head. A radical external operation and intranasal 
 operations may or may not be indicated. All the sinuses may be drained 
 by operative procedures through the nose and a cure effected without 
 external operations in many cases. 
 
 Xote. — While the foregoing series of hypothetical cases does not 
 exhaust the list of possible and actual combinations of empyema of the 
 accessory nasal sinuses, it illustrates fairly well the data and methods 
 of procedure necessary to arrive at a diagnosis. Nor should it be under- 
 stood that the data used in the above series is in strict accord with the 
 clinical aspect of every case having the diagnosis given above. Other 
 symptoms and pathological conditions are found, and great anatomical 
 asymmetry often complicates the diagnosis. What is given above is in 
 the main true. Much that is left unsaid is also true. It is obvious that 
 in a limited number of hypothetical cases all the clinical and pathological 
 data cannot be given. 
 
CHAPTEE X. 
 
 GENERAL CONSIDERATIONS IN REFERENCE TO THE SINUSES. 
 
 The nasal accessory sinuses in man are the residual olfactory organs. 
 In his primeval state the acute sense of smell was necessary, as it is in 
 some lower animals. In the process of evolution the large distribution 
 of the olfactory nerve has become less and less necessary, hence the 
 sinuses are being gradually closed off from the nasal chambers until only 
 small openings are present in man. Inflammation of the lining mucous 
 membrane of the walled-off spaces becomes, therefore, a frequent patho- 
 logical process. If the sinuses were open more to ventilation and drain- 
 age, inflammatory processes within them would occur less frequently, 
 because the perpetuity and destructiveness of the process depend very 
 largely upon the lack of normal ventilation and drainage. It follows, 
 therefore, that when inflammation of the sinuses is present the first 
 principle of treatment is to establish ventilation and drainage. This may 
 only mean that the swollen and inflamed mucous membrane around 
 the cell openings should be depleted by the application of adrenalin, 
 cocaine, or antipyrine, or it may mean that some surgical procedure 
 should be instituted for their relief. Whichever may be necessary, 
 ventilation and drainage of the sinuses is of prime importance, and 
 the removal of the morbid material is secondary to this. 
 
 Etiology. — The etiology of the inflammatory diseases of the nasal 
 accessory sinuses of the nose, like that in other mucous-lined cavities 
 of the body, is largely embraced in those conditions which interfere with 
 the drainage and ventilation of the cavities. (See Etiology of Inflamma- 
 tions of the Nose and Accessory Sinuses, Chapter VI.) When there is 
 good drainage and ventilation, inflammation is rare, except in those cases 
 subjected to a virulent infection or in which the resistance is lowered by 
 some dyscrasia. The local expression of a constitutional dyscrasia, as 
 syphilis, tuberculosis, etc., or a carious process in some contiguous organ, 
 as a tooth, may cause inflammation of a sinus, even though the drainage 
 and ventilation of the cells is normal. Aside from these and other local 
 and constitutional diseases which cause sinuitis, it may be said that 
 the anatomical configuration of the interior of the nose, whereby the 
 drainage of the secretions and the ventilation of the sinuses are interfered 
 with, plays an important role in the etiology of inflammation of the 
 sinuses. 
 
 The constitutional diseases having most to do with the causation of 
 sinuitis are syphilis and tuberculosis. When there is a granulomatous 
 infiltration in the outer wall of the nose, the ulcerative process may 
 invade the sinuses and give rise to inflammatory symptoms, as pain, 
 
GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 177 
 
 tenderness, suppuration, headache, dizziness, etc. Likewise, when 
 tuberculous infiltration and subsequent degeneration are focalized in the 
 outer wall of the nose, the sinuses may participate in the process, or 
 the ostia of the sinuses may become closed from swelling of the mucous 
 membrane, and thereby obstruct the drainage and ventilation. 
 
 Diseases of the contiguous anatomical structures, as the teeth, hard 
 palate, and outer wall of the nose, may give rise to inflammation of the 
 mucous membrane of the sinuses by an extension to these cavities, and 
 by blocking the cell openings or the infundibulum, so that drainage and 
 ventilation are impaired or altogether lost. 
 
 Caries of the root of a tooth located beneath the floor of the maxillary 
 sinus (antrum of Highmore) may cause empyema of the antrum by 
 infection through the carious fistula thus formed, or by way of the vessels 
 and lymphatics. It has been estimated that nearly one-half of all 
 empyemas of the antrum have their origin in diseased teeth, while the 
 remainder are due chiefly to intranasal diseases and anatomical deformi- 
 ties of the nose. Xasal polyp is also regarded as a cause of sinuitis, 
 although I believe the polyp is more often the result than the cause. 
 However this may be, it is certain that the presence of a nasal polyp 
 aggravates an existing sinuitis, and that its removal is often attended 
 by an apparent rather than a real cure of the inflammation. 
 
 Foreign bodies in the nasal passages may cause sinuitis by erosion 
 and subsequent infection of the nasal mucosa, by directly blocking 
 the cell openings, or by erosion through the outer nasal wall into the 
 sinuses. 
 
 Nasal operations may result in sinuitis by reactionary infection and 
 inflammation, which may extend directly through the outer nasal wall 
 or via the cell openings into the sinuses. In hospital practice particularly, 
 infection from other patients may give rise to sinuitis. 
 
 Nasal dressings may cause a damming up of the secretions which 
 undergo decomposition and infection, and thus give rise to inflammation 
 of the sinuses. Too much emphasis cannot be laid upon the untoward 
 results of intranasal tamponing, as it is a fruitful source of inflammatory 
 disease of the nasal and sinus mucous membranes. Personally, I have 
 abandoned intranasal dressings except in those cases in which there is 
 severe hemorrhage, and in which a dressing must be introduced to hold 
 the septum in position after certain operations for the correction of 
 deviations. Even then they should not be left in position an hour 
 longer than is absolutely necessary to accomplish their purpose. 
 
 Venous stasis from intranasal pressure may cause sinuitis. The 
 pressure may be due to some anatomical or pathological departure from 
 the normal, as a deviation of the septum pressing against the outer wall 
 of the nose, or to gummatous swelling of the septum. 
 
 These and other pathological lesions of the adjacent structures may 
 cause sinuitis. All cases should, therefore, be carefully studied in order 
 to determine the predisposing cause of the inflammation. 
 
 The Exciting Causes. — The exciting causes of inflammation of the 
 sinuses are the various microorganisms causing the exanthematous and 
 12 
 
178 THE NOSE AND ACCESSORY SINUSES 
 
 other infectious fevers. It is well known that coryza is often one of the 
 early phenomena in this class of cases, and that it is due to micro- 
 organisms and their toxins. The inflammation usually extends to the 
 sinuses, where it may remain in a latent or chronic form. In some cases 
 it is only after many years that the involvement of the sinuses becomes 
 obvious enough to attract the attention of either the patient or the 
 physician. 
 
 It is probably true that the inflammation thus started is more likely 
 to become chronic in those cases in which the cell openings are more 
 or less blocked by anatomical deviations of the septum or other obstruc- 
 tive lesions of the nose. If, for example, the septum in its upper portion 
 is deviated to one side, and lies against the middle turbinate, the sinuitis 
 which develops during an attack of one of the infectious fevers is 
 more likely to continue into the chronic form than it is where no such 
 obstructive deformity of the septum exists. 
 
 Hajek has emphasized the causative relation of influenza to inflamma- 
 tion of the sinuses. Indeed, he claims that it is probably the most 
 frequent source of infection. 
 
 Pathology. — The pathological changes which occur in the mucous 
 membrane and bony walls of the sinuses in the course of suppurative 
 inflammation are what might be expected in a mucous-lined cavity. 
 Much discussion has arisen on this subject between anatomists and 
 clinicians. Anatomists have found less marked changes, probably 
 because they only examined such cases as came to them from the dead- 
 house, while clinicians describe much more extensive changes in living 
 cases, from whom specimens were removed during life, or upon the 
 postmortem table. I prefer to base the pathology upon the clinical 
 rather than upon the anatomical data. 
 
 Acute inflammation of the sinuses may be divided into the exudative 
 and the diphtheritic, although the latter is rarely present and is not a 
 true diphtheritic membrane. 
 
 The exudative inflammation may be serous, fibrinous, seropurulent 
 or purulent in character, according to the intensity of the inflammatory 
 process. 
 
 For didactic purposes the changes which occur in the tissues may be 
 studied in the following order, which represents the usual sequence of 
 the pathological events: 
 
 (a) The submucous tissue is infiltrated with serum, while the surface 
 is dry. Leukocytes also fill the meshes of the submucous tissue. 
 
 (6) The capillaries are dilated, and the mucous membrane is red in 
 consequence. 
 
 (c) After a few hours, or a day or two, the serum and leukocytes 
 escape through the epithelial covering of the mucosa, where they become 
 admixed with bacteria, epithelial debris, and mucus. In some instances 
 capillary hemorrhage occurs and blood becomes mixed with the secre- 
 tions. The secretions, at first thin and watery, later become thicker 
 and tenacious, on account of the coagulation of the fibrin of the 
 serum. 
 
GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 179 
 
 (d) In many cases resolution by the absorption of the exudate and 
 the cessation of the discharge of the leukocytes takes place in from 
 ten to fourteen days. 
 
 (e) In other cases, however, the inflammation passes from the catarrhal 
 to the purulent type, the leukocytes being thrown out in immense numbers. 
 Resolution is still possible, although not probable, as the tissue changes 
 are not yet of a fixed type. Unless the process is speedily arrested the 
 tissue changes become permanent and chronicity is established. 
 
 (J) If the ostia of the sinuses are open the discharge of pus may con- 
 tinue indefinitely with little or no pain. If, on the contrary, they are 
 closed, the purulent secretion is retained, and pressure symptoms, as 
 pain, swelling, and tenderness, arise. If the discharge cannot escape 
 through the ostia the point of least resistance bulges before the pressure 
 of confined pus. The points of least resistance vary in different cases, 
 although there is reasonable constancy in their location. 
 
 The points of least resistance in the sinuses are as follows, due allow- 
 ance being made for anatomical variations : 
 
 (a) In the frontal sinus the inferior wall is the thinnest, especially 
 three-quarters of an inch from the median line over the anterior ethmoidal 
 cells, hence the frequent involvement of these cells in frontal empyema. 
 Clinically, we often see cases in which there is a sudden gush of pus into 
 the nasal chamber, after which the pain and other pressure symptoms are 
 relieved. It is probable that in these cases the floor of the frontal sinus 
 yielded to the pressure of the pent-up pus, which may have discharged 
 through the anterior ethmoidal cells, though it may have escaped 
 through the frontonasal canal. 
 
 (b) In the antrum the most vulnerable point in the nasal walls is 
 the pars membranacea?, the membranous portion of the middle meatus. 
 The anterior and superior walls are sometimes thin, and may bulge, 
 or become perforated by the pressure of the retained pus. One of the 
 characteristic symptoms of antral empyema is the tenderness and swell- 
 ing over the anterior (canine fossa) wall. Bulging of the upper or orbital 
 wall causes an interference with the external muscular apparatus of the 
 eyeball. Perforation in the orbital wall, or roof of the antrum, gives 
 rise to an abscess of the orbit, or orbital cellulitis. 
 
 (c) In the ethmoidal sinuses the point of least resistance is, perhaps, 
 difficult to define, on account of the complexity of the ethmoidal laby- 
 rinth, it being composed of several pneumatic spaces. The lamina 
 papyraceaB (paper plate) separating the cells from the orbital cavity is 
 quite thin, as its name implies, and may be the seat of bulging and 
 perforation. The pressure may extend toward the orbit and give rise 
 to a lack of balance of the external muscles of the eyeball, strabismus 
 being the most common expression. The inner or nasal aspect of the 
 ethmoidal cells is more thin, and in empyema may be distended until 
 it presses against the septum. 
 
 (d) In the sphenoidal sinus the point of least resistance is in the upper 
 wall, or roof, which is in close relationship to the optic nerve; hence, 
 the ocular disturbances often found in closed empyema of this sinus. 
 
180 THE NOSE AND ACCESSORY SINUSES 
 
 In chronic inflammation by far the greater number of observations 
 have been made on the antrum, because it is more accessible to inspection 
 and operation through the canine fossa. There is no particular reason, 
 however, why similar changes may not occur in the other sinuses. I will 
 therefore describe in general the pathological changes which occur in the 
 entire sinus labyrinth, pointing out the changes peculiar to each group of 
 cells, in addition to the changes common to them all. In general, it may 
 be said that the pathological changes in the accessory sinuses of the nose 
 correspond with the descriptions in general pathology. 
 
 The slighter changes are quite like those in acute suppurative inflam- 
 mation affecting other mucous membranes and bone tissue. The mucous 
 membrane may present a granular surface, villous and fungoid excres- 
 cences, granular, cushion-like thickening, etc. In the older cases there 
 is thickening from deposit of hyperplastic and pyogenic membrane. 
 The membrane may be destroyed in spots by ulceration, exposing 
 smooth, bare bone, or it may be soft or rough from caries. In 
 some cases necrosis and bone sequestra are present, or they may be 
 absorbed. A microscopic examination of the secretions of the mucous 
 membrane sometimes shows a loss of the epithelium and glands, which 
 are replaced by connective tissue. Ulcerations of the membrane are 
 often surrounded by granulation tissue, especially if there is necrosis 
 of the bone. Granulation buds may encroach upon the periosteum 
 and thus unite the bone and mucous membrane. When this happens 
 the bone is superficially absorbed and somewhat roughened in conse- 
 quence. Osteophytes, or bony scales or plaques, resulting from plastic 
 exudation sometimes form on the surface of the bone. 
 
 Polypi have been found in all the sinuses, although they are more 
 common in the antrum and ethmoidal cells. They are much more 
 common in the ethmoidal cells than is generally supposed. Their hidden 
 location within the small ethmoidal spaces renders their diagnosis rather 
 difficult. In the antrum, however, they are more easily diagnosticated, 
 as they may be exposed through the canine fossa. As this sinus is 
 quite large, the polypi are easily seen and diagnosticated. They have 
 been found in the frontal and sphenoidal sinuses, although not so fre- 
 quently as in the antrum and ethmoidal cells. The polypi in the eth- 
 moidal cells are usually quite small, on account of the limited space 
 within the cells, whereas in the antrum they are much larger. In 
 empyema of the ethmoidal cells the thin lamina papyracese separating 
 the cells from the orbital cavity may be perforated or entirely destroyed 
 by the suppurative process. The same is true of the cranial plate 
 separating the cells from the anterior hemisphere of the brain. In the 
 latter case the meninges are exposed to infection, and may be the seat 
 of meningitis, brain abscess, or epidural abscess. Such an exposure 
 of the meninges may exist in cases of latent ethmoidal empyema, with 
 no other symptoms than a slight headache and mental irritability. A 
 slight intranasal operation, especially on the middle turbinated body, 
 may light up the slumbering fires and rapidly lead to a dangerous, or 
 even a fatal, meningitis. The cases of meningitis occurring after intra- 
 
GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 181 
 
 nasal operations are probably to be explained in this way, as has been 
 shown by Grunwald in his work on Nasal Suppuration. 
 
 Thrombosis of the longitudinal and cavernous sinuses occasionally 
 complicates ethmoidal empyema. Retrobulbar suppuration, or ocular 
 cellulitis, is a comparatively infrequent complication of ethmoidal 
 empyema. 
 
 In frontal empyema the floor and posterior wall are most often the 
 seat of destructive changes. The floor near the median line is in apposi- 
 tion with the anterior ethmoidal cells and nasal septum, hence the cells 
 and septum are frequently more or less involved in the carious and 
 necrotic retrograde changes. The anterior ethmoidal cells are always 
 filled with pus in cases of frontal empyema. 
 
 Symptomatology. — The Objective Symptoms. — The objective symp- 
 toms may be extranasal or intranasal. 
 
 The extranasal symptoms are those changes in the appearance of 
 the skin of the face, and of the fundus of the eye as shown by ophthal- 
 moscopical examination. In addition to the objective signs, the results of 
 transillumination and of skiagraphy afford important objective informa- 
 tion. 
 
 The intranasal objective signs of disease of the sinuses are those 
 changes in the appearance of the outer walls of the nasal chambers and 
 the location of the secretion as it drains from the affected cells. 
 
 The Extranasal Objective Symptoms. — (a) When any of the sinuses 
 contiguous to the skin of the face are involved (frontal, anterior ethmoidal, 
 or antrum) there may be redness, swelling, and heat of the skin covering 
 the affected area. If, for instance, the frontal sinus is acutely inflamed 
 there may be swelling, redness, and heat of the skin in the frontal region ; 
 likewise in the malar region in antral disease and at the inner angle 
 of the orbit in anterior ethmoidal disease (Fig. 125). Tenderness upon 
 pressure (a subjective symptom) is also present when redness and swelling 
 are found. 
 
 (b) The fundus of the eye sometimes affords very useful and important 
 objective evidence of inflammation. 
 
 (c) Transillumination of the face affords objective information as to 
 the condition of the maxillary sinus, and sometimes of the frontal sinus, 
 but none in reference to the other sinuses. In transillumination of the 
 antrum three points should be noted, namely: (1) the red pupillary 
 reflex, (2) the crescent of light corresponding to the position of the 
 lower eyelid, and (3) the sense of light in the eye when closed. If 
 the red pupillary reflex and the crescent of light are absent the antrum 
 is probably affected. Note both sides at once, and thus determine 
 which one, if either, is affected. A comparison of the lower portion 
 of the field of illumination may be very misleading, as the anterior 
 wall of the antrum varies greatly in density, irrespective of the disease 
 present. The orbital or upper wall of the antrum is, however, more 
 nearly uniform in its density in all cases, and affords a fair opportunity 
 for a comparison of the transilluminated light through the two orbital 
 plates; that is, when both orbital plates of the antrum are healthy the 
 
182 THE NOSE AND ACCESSORY SINUSES 
 
 amount of light transmitted through them is about equal; whereas 
 when one is thickened it interferes with the transmission of light, hence 
 the crescent of light is dimmed or altogether absent. Likewise when 
 both orbital plates are healthy (antral disease absent) the light transmitted 
 into the interior of the eyeball is shown in the red pupillary reflex in each 
 eye; whereas if one antrum is involved the pupillary reflex is absent 
 upon that side and present on the other. The sense of light (eyes closed) 
 is present on the healthy side and absent upon the diseased side in maxil- 
 lary diseases. 
 
 Transillumination of the frontal sinuses is an uncertain means of 
 diagnosis, as the anterior wall often varies so much in thickness on the 
 two sides in the same individual. The hooded lamp should be placed 
 under the floor of the frontal sinus at the upper and inner angle of the 
 orbit and the two sides compared. Dr. Birkett has devised a double 
 lamp (Fig. 131), so that both sides can be illuminated at once, to facilitate 
 
 Fig. 131 
 
 Birkett's transilluminator for the simultaneous illumination of both frontal sinuses. 
 
 comparison. If the lamp is not placed well under the supra-orbital 
 ridge the skin transmits the light and may thus lead to a false deduction. 
 Taken as a whole, transillumination of the frontal sinuses is not a reliable 
 procedure. 
 
 Skiagraphy. — Skiagraphy of the accessory sinuses of the nose should 
 be a routine practice when access is had to a competent radiographer. 
 Prof. Gustav Killian first practised it in diseases of the nasal accessory 
 sinuses. Dr. C. G. Coakley has, perhaps, used it more extensively than 
 anyone else in this field of work. Dr. J. C. Beck and the author have 
 also made skiagraphs of about 300 cases. The great difficulty has 
 been to find a radiographer who understands the technique well enough 
 to produce clear skiagraphic plates. Dr. Caldwell recently published 
 his technique, the essentials of which are herewith given. 
 
 To get a plate with clearly defined outlines of the sinuses, and with a 
 clear definition of their area, it is necessary so to place the x-raj tube 
 as to avoid the heavy bone of the floor of the cranium, as it would interfere 
 with the passage of the rays through the head. The #-ray tube should 
 be applied, therefore, to the back of the head at a point above the occiput 
 
GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 183 
 
 and floor of the cranium, as shown by the line A in Fig. 132. If the tube 
 is applied at B, the rays would have to pierce through the dense bone 
 of the occiput and the long axis of the plate of bone forming the floor of 
 the cranium before reaching the frontal and ethmoidal sinuses, thereby 
 interfering with the formation of a clear shadow of the dense bone form- 
 ing the walls of the sinuses and the production of a clear definition of the 
 area of the sinus cavities. If, however, the .r-ray tube is applied at A, mid- 
 way between the occiput and the vertex, the rays have an unimpeded 
 course to the frontal and ethmoidal sinuses, and the outline and area of 
 normal sinuses will be clear and well modulated. The delineation of the 
 maxillary sinuses is not so clear, as the rays must pass through more bone 
 tissue to reach it. A clear skiagraph of this sinus is not so essential, as 
 
 Fig. 132 
 
 Z5--1 
 
 Schema showing the proper position for making a skiagraph of the frontal and ethmoidal sinuses 
 A, the proper angle for passing the x-rays through the head; B, the improper angle, as the rays must 
 pass through a great deal of dense bone (D) to reach the sinus; C, an 8 x 10 inch photographic 
 plate against which the forehead should rest ; E, the table upon which the patient lies. The forehead 
 should be placed upon a triangular block with an inclination of twenty-five degrees, as this is 
 more comfortable to the patient and renders the line (.4) perpendicular to the table. 
 
 this sinus is easily and successfully examined by transillumination with 
 an electric lamp in the mouth. 
 
 The advantages derived from skiagraphy of the accessory sinuses in 
 diagnosis are: 
 
 (a) If a sinus is healthy, its outline on the plate or negative is clear 
 and distinct (light) and its area is clear and dark. If the sinus is diseased, 
 its outline is less clear and distinct and its area is cloudy or hazy upon 
 the negative or plate. Prints from the plates are rarely satisfactory 
 for diagnostic purposes. 
 
 (6) The dimensions of the frontal sinuses are clearly defined, thus 
 affording the surgeon positive information as to the extent of exposure 
 
184 THE NOSE AND ACCESSORY SINUSES 
 
 necessary before he begins an external operation. A skiagraph through 
 the lateral dimensions of the head shows the depth of the frontal sinus, 
 thus affording the surgeon additional data as to the probable deformity 
 to be expected should the Killian operation be performed. The wider 
 and deeper the frontal sinus the greater is the deformity following the 
 complete removal of the anterior bony wall of the sinus. The information 
 gained from the two views of the frontal sinus may cause the operator 
 to determine either to select or reject a given method of operating. If, 
 for example, the skiagraph shows a small, shallow frontal sinus, the Kil- 
 lian operation might be chosen in preference to other methods, as it is 
 a thorough and satisfactory method of operating, and would in such a 
 case be followed by little or no external deformity. If, on the other hand, 
 the plates show a large and deep frontal sinus the surgeon might be 
 influenced to adopt some other method of operating which would not be 
 attended by such marked external deformity. 
 
 (c) In some instances, when the frontal sinus seems to be involved, 
 the skiagraph will show a total absence of it, information of no small 
 consequence to both the surgeon and the patient. 
 
 Remark. — According to my observations the skiagraph does not 
 differentiate between a catarrhal and a suppurative sinuitis. 
 
 The Intranasal Objective Symptoms. — (a) The contour of the outer 
 nasal wall sometimes affords information as to the condition of the 
 sinuses. In closed empyema of the antrum the inner wall of the antrum 
 may be pushed toward the septum. Likewise in empyema of the bulla 
 ethmoidalis its median wall may be distended so as to close the hiatus 
 semilunaris, and impinge against the external surface of the middle turbinal. 
 
 (6) The texture of the mucous membrane of the nose, especially that 
 portion of it covering the middle turbinated body, is sometimes indicative 
 of sinus disease; that is, when the mucosa of the anterior end of the 
 middle turbinate is boggy and velvety in texture, it usually signifies the 
 existence of an inflammation of the ethmoidal cells. 
 
 (c) Polypi are often associated with disease of the sinuses, and are, I 
 believe, usually secondary to the inflammation. 
 
 (d) Pus within the nasal chambers is usually significant of empyema 
 of the sinuses. The nasal mucosa is rarely the focal centre of suppurative 
 inflammation, whereas the sinuses are commonly the focal centre of such 
 an inflammation. The presence of pus in the nasal chambers should, 
 therefore, excite suspicion of the existence of an inflammation of the 
 sinuses. To determine which of the sinuses is involved, see General 
 Diagnosis. 
 
 In a general way it may be stated that pus in the middle meatus signi- 
 fies an involvement of the frontal, anterior ethmoidal, or the maxillary 
 sinus, as these cells drain into the middle meatus. If pus is seen in the 
 olfactory fissure (between the septum and middle turbinate) the posterior 
 ethmoidal or the sphenoidal cells are involved, as these cells drain into 
 the superior meatus above the middle turbinate. 
 
 The Subjective Symptoms. — The subjective symptoms of inflammation 
 of the sinuses have reference to the sensations of pain and of pressure, the 
 equilibrium of the mind, and the impairment of the special senses. 
 
GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 185 
 
 (a) Pain referable to the region of the sinus involved may or may 
 not be present. In active inflammation of the antral or frontal sinus 
 pain is often distinctly referred to the region involved. In the deeper 
 sinuses, as the ethmoidal and sphenoidal, the pain is vaguely deep 
 seated in the head, or it is referred to the periphery of the head without 
 reference to the location of the sinus. For example, sphenoidal inflamma- 
 tion may give rise to pain in the occipital or to the frontal region. As a 
 matter of fact, inflammation in any or all of the sinuses usually causes 
 pain in the frontal region. These pains are almost universally called 
 headaches by the patient. 
 
 (b) Headache is, therefore, one of the most common and significant 
 signs of sinuitis, though it may be present when the middle turbinal 
 presses against the septum. This condition is often mistaken for eye 
 strain. Refraction is rarely satisfactory, and only when the anterior 
 end of the middle turbinate is removed is the headache relieved and 
 glasses accepted. In many cases glasses are not necessary. Head- 
 ache has multitudinous causes, and is not, therefore, pathognomonic 
 of inflammatory or other diseased conditions of the sinuses. Headache 
 may signify eyestrain, but in this case it is usually bilateral, whereas 
 in sinus disease it is more often unilateral, or, if not unilateral, more 
 pronounced on one side, or it begins as a unilateral headache and extends 
 to the other side. The headache which originates in a sinus is increased 
 upon stooping forward and upon sudden jarring of the body. It may 
 persist upon closing the eyes upon retiring, or in a darkened room; 
 whereas if it is of ocular origin it disappears under such conditions. 
 
 The headache of ocular origin is greatly increased upon prolonged 
 reading and upon attendance at the theatre. The headache caused by 
 attendance at the theatre is so characteristic of ocular disturbance that 
 it may be termed "theatre pain." This type of pain is not characteristic 
 of sinus disease. 
 
 The pains and headache due to disease of the frontal sinus may 
 assume the form of sharp, shooting pains through the eyes, or they 
 may be dull and heavy, and nearly constant; or they may consist of a 
 dull feeling in the forehead, which is aggravated by leaning forward, 
 and which in females is especially well marked during each menstrual 
 period (H. M. Fish). Pressure under the floor of the sinus at the inner 
 angle of the orbit usually elicits pain in these cases. 
 
 (c) Tenderness upon Pressure. — Tenderness and pain upon finger 
 pressure may be present in disease of those sinuses contiguous to the 
 surface of the face, viz., the frontal, anterior ethmoidal, and the maxil- 
 lary sinuses. 
 
 For the examination of the frontal sinus, pressure should be made 
 over the anterior wall above the supra-orbital ridge, and under the floor 
 of the sinus near the inner angle of the orbit. 
 
 In the examination of the anterior ethmoidal cells, pressure should 
 be made at the inner angle of the orbit against the orbital plate of the 
 ethmoid. 
 
 In the examination of the antrum of Highmore, pressure should be 
 made over the canine fossa of the superior maxilla. 
 
186 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Fig. 133 
 
 (d) Disturbance of Equilibrium. — Giddiness and vertigo or a momen- 
 tary sense of blurred or darkened vision and imminent fainting are 
 frequently present in disease of the sinuses. All these symptoms may 
 be aggravated or produced by stooping forward. The patient should 
 be carefully questioned in regard to these symptoms, as otherwise they 
 may be overlooked. 
 
 (e) Disturbances of the Special Senses. — The olfactory, visual, and 
 auditory senses are frequently disturbed or altogether lost in sinuitis. 
 
 The olfactory sense may be perverted (parosmia), the patient appar- 
 ently perceiving odors that are not in evidence to normal noses. A 
 more common symptom is the loss of olfaction (anosmia). This is 
 accounted for by the blocking of the olfactory fissure by the tissues 
 in the region of the middle turbinate. The ventilation of the superior 
 
 meatus of the nose is thereby pre- 
 vented, hence the loss of the sense 
 of smell. In some cases this may 
 be due to the degeneration of the 
 terminal filaments of the olfactory 
 nerve, although in most cases coming 
 under my observation the sense of 
 smell is regained after opening the 
 olfactory fissure either by removing 
 the obstructive tissues or by resort- 
 ing to some surgical procedure, as 
 the removal of polypi, a portion of 
 the middle turbinate or correcting a 
 deviation of the septum. 
 
 The ocular function may be dis- 
 turbed or altogether lost in the course 
 of sinus disease. The disturbance 
 may be due to either arterial or 
 venous congestion, and to toxins, or 
 to thrombosis of the veins intercom- 
 municating between the sinuses and 
 the eye. The morbid process in the eye may take the form of a 
 papillitis, neuroretinitis, retrobulbar disease, keratitis, errors of refrac- 
 tion or of accommodation, photophobia, epiphora, choroiditis, marginal 
 blepharitis, iridocyclitis, conjunctival injection, restricted field or loss of 
 vision. 
 
 The Relation of the Eye to Disease of the Sinuses. — The intimate rela- 
 tion between the veins of the nose and accessory sinuses and of the eye 
 (Fig. 132), as demonstrated by Dr. H. M. Fish, Dr. W. C. Posey, and 
 others, shows how reasonable is the assumption that many of the ocular 
 lesions heretofore attributed to auto-intoxication from the intestines, 
 gonorrhea, syphilis, and rheumatism, may, in many instances, be due 
 to an extension of the disease from the sinuses to the ocular apparatus 
 via the veins and lymphatics. 
 
 According to Posey, the extra-ocular muscles may become paretic 
 
 Schema showing the venous connections 
 of the ethmoidal cells with the eyeball. 
 a, a, a, a, anterior and posterior ethmoidal 
 cells; b, eyeball; c, the superior ophthalmic 
 vein; d, the posterior ethmoidal vein; e, the 
 anterior ethmoidal vein. 
 
GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 187 
 
 or paralyzed from inflammation of the sinuses, because the nerves which 
 supply the muscles are in close anatomical relationship with the walls 
 of the sinuses and may be paralyzed by pressure or by toxic influences. 
 The levator, superior oblique, and superior rectus muscles are in relation- 
 ship with the floor of the frontal sinus, and paralysis of them is indicative 
 of disease of the frontal sinus. The internal rectus muscle is in relation- 
 ship to the inner orbital or ethmoidal wall and paralysis of this muscle 
 is indicative of disease of the ethmoid cells. The inferior oblique and 
 the inferior rectus muscles are in relationship to the superior wall of the 
 antrum (floor of the orbit) and paralysis of either of these muscles is 
 indicative of disease of the antrum. As the nerves which supply all 
 these muscles pass in apposition or close approximation to the sphenoid 
 sinus, disease of this sinus may involve one or more of the muscles, 
 hence, each case must be carefully studied before the location of the 
 inflammation can be determined. Paresis of either of these muscles 
 causes a type of diplopia or squint. Diplopia may also be due to retro- 
 orbital pressure causing displacement of the eyeball. 
 
 Optic neuritis or other diseases of the uveal tract is frequently due to 
 disease of the nasal accessory sinuses, more particularly the ethmoid 
 and sphenoid sinuses. C. R. Holmes reviewed the literature on the 
 subject and found several cases on record. In one case the patient died 
 of cerebral hemorrhage and at the autopsy it was found that the roof of 
 the sphenoid, including the bone and dura, was destroyed. 
 
 Three cases of optic neuritis with partial and complete blindness 
 have come under my observation and operative treatment within the 
 past two years. The first. case was referred to me by Dr. J. G. Huizinga 
 with the diagnosis of optic neuritis due to ethmoidal and sphenoidal 
 disease. His diagnosis was confirmed by Drs. C. A. Wood and 
 G. F. Suker. The patient was thirty-five years of age and was single; 
 syphilis had been excluded. His vision was -^ir- The defective 
 vision had been present for four months. I performed an ethmoidal 
 exenteration, and removed the anterior wall of the sphenoidal sinuses 
 upon both sides. The vision rapidly improved to J^, where it has 
 remained two years after the operations. 
 
 The second case had been under treatment with electricity, etc., for 
 eighteen months and the vision had gradually declined. At the end 
 of this time the case was referred to me by Dr. J. E. Colburn for opera- 
 tion upon the ethmoidal and sphenoidal sinuses. After the operation 
 vision continued to decline. 
 
 The third case was referred to me by Dr. G. F. Suker for operation 
 upon the ethmoidal and sphenoidal sinuses. The patient was forty- 
 two years old; syphilis was excluded. He was totally blind, not being- 
 able to see a lighted match. The blindness had been present for two 
 weeks. I operated upon the right ethmoidal and sphenoidal sinuses at 
 once and the vision began to improve. Ten days later I operated upon 
 the left side. The vision receded for two or three days and then began 
 to improve rapidly, until at the end of six weeks it was normal. 
 
 The auditory functions may be more or less disturbed by disease of a 
 
188 THE NOSE AND ACCESSORY SINUSES 
 
 sinus. The discharge from the sinuses into the epipharynx may cause 
 infection of the mucous membrane of the Eustachian tube and middle 
 ear. Sinuitis may indirectly be the cause of catarrh of the middle ear 
 or of suppurative otitis media and mastoiditis. In addition to the fore- 
 going aural complications, there is another symptom which I have not 
 seen mentioned in the literature, namely, a momentary roaring accom- 
 panied by a fulness in the ears and dulness of hearing. These phenomena 
 are especially likely to occur on bending forward. 
 
 The Principles of Treatment. — The cure of inflammation of a sinus 
 depends upon two things, namely, (a) the establishment of free drainage 
 and ventilation, and (b) the removal of the morbid material. 
 
 In those cases in which the interference with drainage and ventilation 
 is due to a simple hyperemia of the mucous membrane the local applica- 
 tion of cocaine, antipyrine, or adrenalin may be quite sufficient to estab- 
 lish a cure. In such subjects the morbid material is the secretion, hence 
 drainage removes it. On the other hand, in those cases in which there 
 is a marked obstruction due to a deviation of the septum or to hyperplasia 
 or cystic enlargement of the middle turbinate, it is often necessary to 
 resort to surgical measures in order to give relief. Furthermore, in those 
 cases in which the sinus is filled with granulation tissue and the bony 
 walls are necrosed the establishment of drainage even by surgical means 
 may not effect a cure; the morbid material (granulations and necrotic 
 bone) must also be removed. 
 
 The Indications. — An appreciation of these fundamental principles 
 enables the surgeon to decide upon the method of treatment in each case. 
 In the following discussion of the treatment the foregoing principles will 
 be constantly referred to with a view to enabling the student and prac- 
 titioner to elect the proper mode of treatment in the cases coming under 
 his observation. Before entering upon a detailed description of the 
 various modes of treatment a general discussion of the varying conditions 
 to be met will be given. 
 
 Acute catarrhal sinuitis is usually an extension of a similar inflamma- 
 tion of the nasal mucosa to the sinus, in the course of a coryza or cold 
 in the head. The mucous membrane of the nose and sinuses is hyperemic 
 and swollen. The cell openings and the infundibulum may be closed 
 from swelling of the mucous membrane. The obvious indication is to 
 relieve the swelling by the local application of certain drugs; surgical 
 intervention is rarely necessary. 
 
 Acute suppurative sinuitis occurring in the course of coryza is charac- 
 terized by hyperemia and swelling of the mucous membrane of the nose 
 and sinuses, and the indications are to reduce the swelling by local medi- 
 cinal applications, as in the acute catarrhal variety. 
 
 Chronic catarrhal sinuitis due to pressure in the middle turbinate 
 region necessitates the removal of the tissue which causes the pressure. 
 If the mucous membrane is chronically swollen, temporary relief may 
 follow the application of antiphlogistic drugs, as adrenalin. If the 
 secretions have dried and blocked the cell openings, probing may afford 
 temporary relief. In most cases the middle turbinate is enlarged from 
 
GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 189 
 
 hyperplasia or from cystic formation which blocks the infundibulum. 
 In some cases, therefore, it is necessary either to straighten the septum 
 or remove a portion of the middle turbinate in order to give permanent 
 relief. The bulla ethmoidalis may also block the infundibulum and 
 prevent drainage and ventilation of the sinuses in Series I. 
 
 Chronic suppurative sinuitis, with obstructive lesions, necessitates their 
 removal, whether they be of septal, turbinal, or other origin. In this 
 case there is simple obstruction, and no morbid material other than pus 
 is present ; hence, the removal of the obstructive lesion permits of drainage 
 which removes the pus. The foregoing statement does not apply, how- 
 ever, to all cases, as the drainage of pus from the cells is not altogether 
 dependent upon free cell openings, because in most of the cells the 
 opening is near the upper limit. The ciliated columnar epithelium which 
 lines the cells, though limited in distribution, carries the secretions up to 
 the cell openings, where it is discharged into the nasal cavity. If, there- 
 fore, the cilise are destroyed by the inflammatory process, the removal 
 of the obstructive lesions does not necessarily establish free drainage. 
 In such cases it may be necessary to institute operative procedures in 
 order to open the cells at their most dependent portion, or to exenterate 
 them in their entirety (ethmoidal). In some cases the mucous membrane 
 and the ciliated epithelium can be restored to their normal integrity 
 and functional activity by lavage, or by negative air pressure, as recom- 
 mended by Bier. 
 
 Chronic suppurative sinuitis, without obstructive lesions of the septum 
 or the middle turbinated body, implies a degeneration of the mucous 
 membrane with a loss of the columnar ciliated epithelium of the sinuses, 
 at least in certain areas. The treatment should therefore either be 
 directly toward the regeneration of the mucous membrane by negative 
 pressure, and the resultant hyperemia and increased nutrition, or by 
 opening the cells and establishing free drainage by some operative 
 procedure. 
 
 Chronic suppurative sinuitis, with granulations, polypi, or necrosis of 
 the bone, is only amenable to surgical treatment. No treatment other 
 than this will establish drainage and ventilation and remove the morbid 
 material. 
 
 Treatment. — The principles of treatment having been given, only 
 the technique will be described in this section. 
 
 Treatment of Acute Catarrhal Sinuitis. — Acute catarrhal sinuitis usually 
 involves all the accessory sinuses, and the indications call for the 
 reduction of the swelling of the mucous membrane for the purpose of 
 opening the ostia of the sinuses. The following technique is usually 
 successful : 
 
 (a) Apply adrenalin, 1 to 2000, on thin pledgets of cotton, to the 
 swollen middle and inferior turbinates to reduce the swelling. 
 
 (b) Apply a 4 per cent, solution of cocaine to reduce the swelling and 
 to relieve the hypersensitiveness of the mucous membrane. 
 
 (c) Apply a 10 per cent, solution of antipyrine over the same area to 
 prolong the ischemic effects of the adrenalin and cocaine. 
 
190 THE NOSE AND ACCESSORY SINUSES 
 
 (d) Use a 0.5 per cent, solution of menthol or other bland aromatic 
 oily solution with a nebulizer every two or three hours. 
 
 The solutions of adrenalin, cocaine, and antipyrine should be used as 
 often as the nasal chambers feel "stuffy," or the headache and sense 
 of pressure return. 
 
 In addition to the foregoing local remedies, those which are usually 
 given in acute coryza may be administered, but they are of value only 
 in the early stage. (See Treatment of Coryza.) 
 
 Heat from a 500 candle-power lamp applied over the face some- 
 times affords speedy relief. The lamp should be passed back and 
 forth before the closed eyes, at a distance of from twelve to eighteen 
 inches, for twenty to thirty minutes. The good effects are due to the 
 increased hyperemia and leukocytosis, and to the improvement of the 
 nutrition. While germicidal properties are claimed for the light of this 
 lamp, the effects are probably due to the increased leukocytosis and 
 nutrition of the tissues. I have thus treated chronic cases in which the 
 purulent discharge and pain ceased, but returned after a few weeks. 
 Whether persistent use of the light will cure these cases I am not 
 prepared to state. 
 
 Treatment of Chronic Catarrhal Sinuitis. — This is a more difficult type to 
 treat successfully on account of its chronicity, which of itself may imply 
 that anatomical barriers existed during the acute stage which prevented 
 resolution. These barriers, if present, must be overcome before a cure 
 can be permanently established. The anatomical barriers to resolution 
 may consist of hypertrophic or hyperplastic changes in the mucous mem- 
 brane of the nose, especially in the region of the cell openings and the 
 olfactory fissure, or they may be due to ethmoidal cells in the middle 
 turbinate or to deviations of the upper portion of the nasal septum. 
 
 The swelling of the mucosa may be somewhat reduced by the local 
 applications of adrenalin, cocaine, and antipyrine. In addition to this 
 the hypertrophic or hyperplastic rhinitis should be surgically treated 
 after the manner described under these diseases. 
 
 If these measures fail, more radical surgical procedures, such as are 
 used in obstinate cases of suppurative sinuitis, may become necessary. 
 Probing of the frontonasal canal sometimes affords relief, although the 
 removal of the anterior end of the middle turbinate and the curettement 
 of the ethmoidal cells may be necessary. 
 
 Treatment of Chronic Suppurative Sinuitis.— In the simpler form of 
 sinuitis, that is, when there are no granulations nor carious bone, the 
 lavage of the affected sinus with antiseptic, alkaline, or stimulating solu- 
 tions is sometimes followed by a cure. The lavage of the frontal sinus 
 may be performed through the frontonasal canal, except in those cases 
 in which it is absolutely closed by an enlarged bulla or by an enlarged 
 middle turbinated body. 
 
 Lavage of the Frontal Sinus. — An understanding of certain anatomical 
 peculiarities of the region of the infundibulum and the frontonasal 
 canal will materially aid in the lavage of the sinuses. The hiatus semi- 
 lunaris, the infundibulum, and the frontonasal canal will be clearly 
 
GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 191 
 
 defined, as much confusion appears in the literature concerning them. 
 The terms are often used as synonymous, whereas they are distinct 
 anatomical entities. 
 
 The hiatus semilunaris is a slit-like crescentic-shaped opening in the 
 outer wall of the nose. It is the opening of the infundibulum into the 
 middle meatus. Its inner lip is the upper margin of the uncinate process 
 of the ethmoid bone. 
 
 The infundibulum is a deep, narrow groove or gutter in the outer wall 
 of the nose (Fig. 134, /), the inner wall of which is the uncinate process. 
 The frontonasal canal drains into the infundibulum in about one-half 
 of the subjects, whereas in the remainder it drains a little anterior to 
 it directly into the middle meatus (Turner). 
 
 The frontonasal canal is a closed tubular duct extending upward and 
 forward from the middle meatus or the infundibulum, as the case may be, 
 to the frontal sinus. Its opening into the floor of the frontal sinus is 
 known as the ostium frontale. In rare instances the ostium opens high 
 upon the posterior wall of the sinus. 
 
 Having defined the parts concerned in probing or irrigating the frontal 
 sinus, certain anatomical peculiarities which influence the procedure 
 will be given brief notice. 
 
 The hiatus semilunaris is the key to the probing, as it is the opening 
 into the infundibulum, which must be entered to reach the frontonasal 
 canal in about one-half of the cases. The bulla ethmoidalis is situated 
 just above the hiatus, and when large it encroaches upon the slit-like 
 opening and partially or completely closes it. Occasionally there are 
 accessory cells in the uncinate process, which also obstruct the hiatus. 
 In other cases the middle turbinate closely hugs the outer wall of the 
 nose and blocks the hiatus (Sluder). When either of these anatomical 
 peculiarities is present the introduction of the probe or the cannula is 
 rendered difficult or impossible. If the frontonasal canal opens in front 
 of the infundibulum the probe or cannula may be passed into it even 
 though the hiatus is closed. 
 
 Another difficulty sometimes encountered in probing is, that the probe 
 may enter the ostium of one of the anterior ethmoidal cells instead of 
 the frontal sinus. Some of the anterior cells may open into the infun- 
 dibulum on its outer wall, while others open into the frontonasal canal. 
 The anterior cells are usually located external to the infundibulum and 
 the frontonasal canal and their ostia open into the infundibulum and 
 frontonasal canal, through the outer wall. In probing, therefore, the 
 point of the probe should be kept against the inner or mesial wall of 
 the frontonasal canal in order to avoid the ostia on its outer wall. 
 
 Probing is generally more difficult in those subjects in which the 
 frontonasal canal empties into the infundibulum than when it empties 
 directly into the middle meatus. In the former case the canal is often 
 tortuous and narrow, while in the latter it is usually straighter and of 
 larger caliber. 
 
 The middle turbinate is sometimes so close to the hiatus, especially 
 when the turbinate contains an accessory cell, that it is difficult to enter 
 
192 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 it with a probe or cannula. In this event the removal of the anterior 
 third of the middle turbinate overcomes the difficulty. 
 
 The Technique of Probing the Frontal Nasal Canal. — First cocainize 
 the parts. Then introduce a fine silver probe (Fig. 135), bent at its 
 distal end to an angle of about 135 degrees, between the anterior third 
 of the middle turbinate and the outer wall of the nose. Keep the tip of 
 the probe against the outer surface of the turbinate and pass it forward 
 and upward through the hiatus into the infundibulum, where it readily 
 enters the frontonasal canal even to the ostium frontale (Fig. 134). 
 After engaging in the middle meatus it should be passed into the infun- 
 dibulum and canal for about 6 to 8 cm. to reach the frontal sinus. 
 
 
 Fig. 134 
 
 i 
 
 h % \ 
 
 \ 
 
 \ 
 
 Probing the frontal sinus. The anterior half of the middle turbinated body is removed to 
 show the anatomical landmarks, a, a, the probe in the first position beneath the middle turbinate 
 and posterior to the bulla ethmoidalis; b, the probe in the second position beneath the middle tur- 
 binate and in front of the bulla ethmoidalis; c,c, the probe in the third position introduced through 
 the frontonasal canal into the frontal sinus; d, the nasal end of the frontonasal canal; e, the lip of 
 the uncinate process; f, the inner wall (uncinate process) of the inf undibulum ; g, the ostium bulla 
 ethmoidalis; h, the ostium maxillare; i, an accessory opening into the maxillary sinus. (Drawing 
 from a specimen loaned by Dr. Ira Frank.) 
 
 Irrigation of the frontal sinus is accomplished through a silver 
 cannula, which is introduced in the same manner as described for the 
 introduction of the probe. The syringe is attached to the cannula, 
 and the sinus gently irrigated with warm normal salt or boric acid 
 solution. 
 
 Lavage of the Maxillary Sinus. — This can rarely be effected through 
 the cell opening on account of its hidden position in the infundibulum, 
 and on account of its forward and downward direction from the 
 infundibulum to the antrum. The opening into the antrum is not 
 directly through the lateral wall of the nose, but it is more like a canal 
 extending obliquely downward and forward through the thickness of 
 
GEXERAL COXSIDERATIOXS IX REFEREXCE TO S1XUSES 193 
 
 the wall. The canal or opening is furthermore somewhat hidden by 
 the unciform process, or lip, of the hiatus semilunaris. Some writers 
 have claimed that they could irrigate the antrum through its normal 
 opening, but a casual study pf the anatomical peculiarities of the region 
 will convince anyone that it is a physical impossibility, except in rare 
 instances. In a certain number of cases there are accessory openings 
 into the antrum (Tig. 134, ?'), which when present may be utilized 
 for purposes of irrigation. Then, too, the lamina membranacea of the 
 naso-antral wall may be perforated with the tip of the cannula and irriga- 
 tion performed through it. In view of the foregoing facts it is rarely 
 possible to irrigate the antrum through the normal ostium, hence an 
 artificial route should be chosen, the most available one being beneath the 
 inferior turbinated body, a curved trocar and cannula being used for the 
 purpose. 
 
 Fig. 135 
 
 Holme?' malleable frontal .-inns probe. 
 
 The technique is as follows: 
 
 (a) Anesthetize the mucous membrane of the inferior meatus with 
 a 5 per cent, solution of cocaine. 
 
 (6) Introduce the trocar and cannula beneath the inferior turbinate 
 posterior to the anterior antral wall, and direct it upward and outward, 
 a little above the floor of the nose, in order to avoid the thick wall of 
 bone at this point. In some cases, especially when a maxillary cyst is 
 present, the floor of the antrum is quite high and it is not possible 
 to introduce the trocar beneath the inferior turbinate. 
 
 (c) After penetrating the naso-antral wall remove the trocar, leaving 
 the cannula in position. 
 
 (d) Attach the rubber hose of the syringe to the cannula and irrigate 
 with normal salt or other solution chosen for the purpose. 
 
 (e) By cocainizing the area daily the irrigations may be continued 
 indefinitely through the artificial opening. 
 
 Lavage of the Antrum through the Alveolar Process. — This may be 
 done after having performed the Cooper operation, so named after Sir 
 Astley Cooper, who introduced it to the profession. 
 
 The technique is as follows: 
 
 (a) Select a place where a tooth has been extracted below the antrum, 
 or if a tooth is decayed beyond repair, extract it for the purpose, and 
 drill a canal into the floor of the sinus. This is Cooper's operation. 
 
 (b) Through this opening a cannula is introduced and the antrum 
 irrigated with normal salt or any solution desired. 
 
 13 
 
194 THE NOSE AND ACCESSORY SINUSES 
 
 (c) The canal thus made should be kept open by means of a hard or 
 soft rubber or gold tube made for the purpose. The tube should be 
 flanged on the lower end to prevent it slipping upward into the 
 antrum. 
 
 (d) A plug should be introduced into the tube to prevent the entrance 
 of food into the antrum. This method is obsolete. 
 
 Lavage through a Canal External to the Teeth. 
 
 (a) Cocainize the gums. 
 
 (b) Drill a canal through the upper and external part of the alveolar 
 process at a point between the first and second bicuspids, avoiding the 
 roots of the teeth. This method is practically obsolete. 
 
 (c) Proceed thereafter as in the Cooper operation. 
 
 This procedure is generally chosen rather than the Cooper operation, 
 as the teeth are usually present, and, even if diseased, are amenable 
 to dental treatment. Neither method is recommended. 
 
 Lavage of the Ethmoidal Cells. — This is often impossible except in 
 the case of the anterior cells which drain into the frontonasal canal. 
 The bulla ethmoidalis, one of the anterior cells, does not drain into 
 the frontonasal canal, but drains directly into the middle meatus, and 
 its ostium is situated at its upper median wall beneath the attachment 
 of the middle turbinated body. 
 
 The technique for the lavage of the anterior cells opening into the 
 frontonasal canal is the same as for the frontal sinus, this being intro- 
 duced into the canal only to the second position (Fig. 134); indeed, 
 both sets of cells are often irrigated at the same time. Their ostia are 
 bathed with the irrigating fluid and the accumulated pus in the canal 
 is removed, thus facilitating the drainage of the cells. 
 
 Lavage of the sphenoidal sinus is possible when the middle turbinate, 
 or a deflection of the septum, does not prevent the introduction of the 
 sphenoidal cannula into its opening. When such an obstruction is present 
 it may become necessary to first remove it by some surgical procedure 
 before the irrigations can be practised. I generally use a silver Eustachian 
 catheter in place of a sphenoidal cannula, and find the curve used for 
 the inflation of the ear the correct one for irrigation of the sphenoidal 
 sinus. Myle's cannula may be bent to reach any sinus, and is smaller 
 than the Eustachian catheter. A. H. Andrews has devised a curved 
 cannula (Fig. 136), which can be introduced into the sphenoidal 
 sinus without the preliminary removal of the middle turbinated body. 
 This is a decided advantage, as it renders the treatment of empyema 
 of this sinus a very simple procedure. Should granulations be 
 abundant it may be necessary first to remove the middle turbinate and 
 then the anterior wall of the sphenoidal sinus, and curette its interior. 
 
 The special curve of Andrews' cannula enables the operator to insin- 
 uate it through the olfactory fissure into the spheno-ethmoid fossa, and 
 by rotating it to engage the tip in the ostium sphenoidale (Fig. 137). 
 When it has been introduced, the patient should be instructed to lean 
 forward and open his mouth; then the hose of the syringe should be 
 attached to the cannula and the sinus irrigated. If the patient's head is 
 
GENERAL CONSIDERATIONS IN REFERENCE TO SINUSES 195 
 
 inclined forward and the mouth open the fluid will not enter the Eusta- 
 chian tube. 
 
 General Remarks Concerning Lavage or Irrigation of the Sinuses. — 
 Lavage of the sinuses in suppurative inflammation is, upon the whole, 
 an unsatisfactory therapeutic measure. Formerly it was in vogue with 
 
 Fig. 13G 
 
 ^OQ 
 
 16 • 17 • 18 . |9 
 
 /^* 
 
 Andrews' sphenoidal probe cannula and knives. 
 
 dentists and surgeons for the treatment of antral empyema. Many 
 cases were thus treated daily, for weeks and months, and some were 
 cured, or apparently cured, while others continued to suppurate uninter- 
 ruptedly. 
 
 Fig. 137 
 
 Irrigation of the sphenoidal sinus with Andrews' curved cannula. 
 
 If lavage is useful at all it is in the simple suppurative cases uncom- 
 plicated by granulations and necrosis. The removal of the purulent 
 secretions gives the ciliated epithelium a chance to regenerate. It should 
 also be borne in mind that the mucous membrane does not tolerate 
 lavage indefinitely, as it is not accustomed to the presence of large 
 
196 THE NOSE AND ACCESSORY SINUSES 
 
 quantities of aqueous solution, hence irrigation is a doubtful procedure. 
 If after a few days' or weeks' trial the case does not greatly improve, 
 irrigation should be discontinued and some other method of treatment, 
 probably surgical in character, instituted. 
 
 Treatment by Negative Air Pressure. — Bier has demonstrated the 
 therapeutic value of this method of treatment in inflammations. Sonder- 
 mann, Brawley, and others have also reported favorably upon the use 
 of negative pressure by means of an exhaust pump. The rationale of 
 this method of treatment consists chiefly in the increased hyperemia of 
 the mucous membrane lining the cells. The local nutrition is thereby 
 improved, the cell resistance and leukocytosis increased, and the infective 
 process checked. That such changes do take place in some cases thus 
 treated is probably true. It is not claimed that all cases are amenable 
 to this treatment. Let it be understood, therefore, that negative air 
 pressure should be used only as a tentative measure, and if a cure does 
 not follow within a few weeks it should be abandoned and some other 
 treatment substituted for it. 
 
 Technique. — (a) The apparatus necessary for producing negative 
 pressure in the sinuses consists of either a hand pump or other device 
 for exhausting the air in the nasal chambers. Brawley 's apparatus is 
 operated by attaching it to a faucet of the washbasin, the negative 
 pressure being regulated by the amount of water turned on. 
 
 (6) Insert the nasal tips into the nostrils and bring the soft palate 
 into apposition with the pharyngeal wall by swallowing. With practice 
 the patient soon learns to maintain this condition for several minutes. 
 
 (c) While the air is thus exhausted the pus is drawn from the sinus 
 into the rubber tubing, from whence it flows into the reservoir bottle. 
 In this way several drams or ounces of pus may be removed in the course 
 of a half-hour. 
 
 (d) Daily seances should be maintained until improvement begins, 
 or until the surgeon is convinced that this method of treatment is inade- 
 quate for the case. 
 
 Drs. Dabney and Pynchon have each devised an exhaust apparatus, 
 having the appearance of a spray tube, which is operated with a 
 compressed-air tank. There are ingenious and practical instruments. 
 
 With either apparatus the patient is instructed to swallow, thus closing 
 off the pharynx from the epipharynx and nose. The suction, after 
 a little practice on the part of the patient, maintains the palate muscles 
 in this position for an indefinite period of time. The patient during this 
 process breathes through the mouth. 
 
CHAPTER XL 
 
 THE SURGERY OF THE ACCESSORY SINUSES. 
 
 THE "KEY" TO DISEASES OF THE SINUSES, OR THE "VICIOUS 
 CIRCLE" OF THE NOSE. 
 
 In the chapter on the Etiology of the Inflammatory Diseases of the 
 Xose and Accessory Sinuses it was shown that the chief predisposing 
 cause of inflammation of the sinuses is an obstruction in the region of the 
 middle turbinated body and the hiatus semilunaris. The obstructive 
 lesion may be a deflection of the nasal septum, an enlarged or cystic 
 middle turbinate, an enlarged bulla ethmoidalis, or cells in the uncinate 
 process (the median wall of the infundibulum). (Figs. 137 to 143.) As 
 the frontal, anterior ethmoidal, and the maxillary sinuses drain into the 
 infundibulum (exceptions noted, p. 164), an obstruction in this region 
 may occlude either or all of these sinuses. When either of them is the 
 seat of inflammation it is always advisable to make a careful examination 
 of this region. The area to be thus examined is shown in Fig. 144 within 
 the circle. These structures may be designated the "key" to inflamma- 
 tion of the sinuses, or the " vicious circle" of the nose. Being the key to 
 the etiology of infection, it is also the key to the treatment of the infection; 
 that is, if the obstruction predisposing the sinuses to infection is located 
 within the area of the circle, it is obvious that if this area is freed from 
 obstruction the chief etiological factor will have been removed, and 
 having been removed the infectious process tends to subside. 
 
 The following principle may, therefore, be given as a working basis 
 in the treatment of inflammatory diseases of the sinuses composing 
 Series I. (See Chapter IX.) 
 
 Remove the obstruction within the "key," or "vicious circle," before 
 attempting more radical measures. 
 
 By so doing the drainage of the sinuses may be established and a cure 
 result. This principle is of so nearly universal application that it forms 
 a good working basis, and, if observed, will prove of inestimable value, 
 as it will often obviate the necessity of resorting to the more radical 
 operations in the treatment of the sinuses. Should the recommendations 
 given above fail to relieve the disease, the more radical operative pro- 
 cedures may be performed in due time. 
 
 Various writers have made clinical observations that meningitis 
 is more likely to follow the radical external operation if an intranasal 
 operation is performed a few days prior to the radical operation. The 
 following deduction is, therefore, obvious: 
 
 Never perform a preliminary intranasal operation a jew days before a 
 radical operation on a sinus. 
 
Fig. 138 
 
 Fig. 139 
 
 A high deviation of the septum, causing 
 closure of the infundibulum. a, high deviation 
 of the septum; b, inner wall of the bulla eth- 
 moidalis; c, middle turbinate crowded against 
 the outer wall of the nose and blocking the 
 drainage of the infundibulum. 
 
 Cross-section through the nose, a, hyper- 
 plasia of the middle turbinated body, which 
 crowds upon the uncinate process (c) and closes 
 the infundibulum. 
 
 Fig. 140 
 
 Fig. 141 
 
 Edema of the mucous membrane of the 
 middle turbinate, blocking the infundibulum. 
 a, edematous middle turbinate; b, bulla ethmoi- 
 dalis; c, uncinate process or inner wall of the 
 infundibulum. 
 
 A large cell in the middle turbinated body, 
 occluding the infundibulum. a, cell in middle 
 turbinate; 6, the inner wall of the bulla ethmoi- 
 dalis; c, the uncinate process or inner wall of 
 the infundibulum or gutter. 
 
Fig. 142 
 
 Fig. 143 
 
 Cell in the uncinate process (6) blocking the The middle turbinated body (a) clinging to 
 
 infundibulum; a, bulla ethmoidalis; c, middle the outer wall of the nose and blocking the in- 
 turbinated body. fundibulum; b, inner wall of the bulla ethmoi- 
 
 dalis; c, uncinate process or inner wall of the 
 infundibulum. 
 
 Fig. 144 
 
 Enlargement of the bulla ethmoidalis, blocking the infundibulum. a, the inner and dis- 
 tended wall of the bulla ethmoidalis, crowding inward and downward against the uncinate pro- 
 cess and blocking the infundibulum; b, the uncinate process; c, the middle turbinate, which, on 
 account of the bulging bulla, appears to be the cause of the blockage, whereas the bulla blocks. 
 
200 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Several days or a few weeks should elapse between them, to allow a 
 wall of protecting granulation tissue to be formed. An additional reason 
 for delaying the radical operation is, to allow sufficient time to elapse to 
 determine whether the intranasal operation is adequate to cure the dis- 
 ease. I have seen serious cases cured most unexpectedly under such 
 treatment. I wish to state most emphatically, however, that, having 
 found the simple intranasal operation ineffective, the surgeon should 
 unhesitatingly perform a more radical operation. My plea is for rational- 
 ism rather than against radicalism. I do not plead for so-called "con- 
 
 Fig. 145 
 
 The "vicious circle" of the nose; b, the spheno-ethmoidal fossa; c, the superior turbinated body; 
 d, posterior ethmoidal cells; e, bulla ethmoidalis; f, anterior ethmoidal cells draining into the 
 frontonasal canal; g, frontal sinus; h, the ostium of the bulla ethmoidalis; %, hiatus semilunaris; 
 k, the uncinate process or outer wall of the infundibulum or gutter on the outer wall of the nose 
 into which the frontal, anterior ethmoidal, and maxillary sinuses usually drain. The high 
 light below and anterior to j and k indicates the inferior boundary of the infundibulum or 
 gutter into which the sinuses drain. The middle turbinated body is removed to exhibit the 
 anatomical details beneath it. 
 
 servatism," a term which has been used to justify timidity and surgical 
 inefficiency. The true conservative is a rationalist who dares to refrain 
 from radical procedures, and yet who dares to undertake them when 
 indicated. 
 
 THE SURGERY OF THE FRONTAL SINUS. 
 
 The surgical treatment of frontal sinuitis may be divided into (a) 
 intranasal, and (b) extranasal operations. 
 
 The intranasal operations consist in the removal of obstructions within 
 the "key," or "vicious circle," and in the more extensive operations of 
 Halle, Good, and Ingals. 
 
THE SURGERY OF THE FROKTAL SINUS 201 
 
 The Indications for Intranasal and External Operations upon the 
 Frontal Sinuses. — There are four intranasal operations for the drainage 
 and ventilation of the frontal sinus which appear to have some merit 
 in a large number of selected cases, and there are cases in which only an 
 external operation, preferably the Killian, should be used. Skiagraphy, 
 which is now so extensively used in the diagnosis of disease of the sinuses, 
 is leading rhinologists more and more frequently to recognize frontal 
 sinuitis, and to attempt its cure. The question arises as to the significance 
 of the skiagraph. According to my observations there is little if any 
 difference between a skiagraph of a catarrhal and a suppurative inflam- 
 mation of the frontal and ethmoidal sinuses, or between a skiagraph of a 
 latent and an active suppurative frontal sinuitis. According to these 
 observations the skiagraph is only of value in determining the dimensions 
 of the frontal sinus and that the sinuses are inflamed; but is of little or no 
 value in determining the character of the inflammatory process. A 
 skiagraphic plate showing a cloudy frontal sinus should not, per se, be 
 taken as an indication that the frontal sinus should be opened by an 
 external operation. Other symptoms must be considered in determining 
 this point. According to my experience, not more than 5 per cent, of the 
 cases in which the skiagraph shows inflammation of the frontal sinus 
 has it been necessary to perform an external operation. Indeed, my 
 records show that only 2.5 per cent, of cases needed the external 
 operation, whereas in 97.5 per cent, satisfactory results followed my 
 operation with the "vicious circle of the nose." Ingals reports equally 
 good results from his operation. Certainly the external operations show 
 no better statistics. Notwithstanding these facts there are cases in which 
 all intranasal methods of operating would fail. 
 
 The skiagraph may throw some light upon the nature of the operation 
 required, especially when viewed in conjunction with the other clinical 
 data. If, for example, the skiagraph shows septa or subdivisions of the 
 involved frontal, the efficiency of an intranasal operation should be 
 seriously questioned, especially if the purulent discharge is profuse and 
 there are external signs of empyema, as tenderness, redness, and swelling 
 over the anterior wall of the sinus. In such a case an intranasal operation 
 of any description would probably fail because the septa could not be 
 broken down and only a subdivision of the sinus would be drained. 
 Furthermore, the presence of frontal tenderness, redness, and swelling 
 point to great edema, and to a granulomatous condition of the mucous 
 membrane of the frontal sinus. In such a case an external operation is 
 imperative. If the skiagraph shows the anterior ethmoidal cells extend- 
 ing well outward under the floor of the frontal sinus (over the orbit) an 
 intranasal operation would probably fail to establish drainage, at least 
 of the anterior ethmoidal cells, as they would be inaccessible through the 
 nose. If, however, the sinuitis is catarrhal an intranasal operation should 
 be performed. If purulent, the operation should be extranasal. If it 
 is not urgent an intranasal operation may be tried, and if after several 
 weeks or months it does not prove successful, an external radical opera- 
 tion may be resorted to. 
 
202 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 THE AUTHOR'S OPERATIONS WITHIN THE "VICIOUS CIRCLE." 
 
 Intranasal Operations for Frontal, Anterior, Ethmoidal, and 
 Maxillary Sinuitis. — (a) Local cocaine anesthesia should generally be 
 depended upon, though general anesthesia is preferable in certain cases. 
 
 (b) Remove the middle turbinated body or such part of it as obstructs 
 the area within the circle shown in Fig. 145. Even though the middle 
 -turbinate does not actually obstruct the hiatus and infundibulum, it may 
 be necessary to remove a portion of it to expose the field to surgical 
 intervention. Physiologically there is little objection to the removal of 
 this structure. The olfactorv nerve is not distributed to its mucous 
 
 Fig. 146 
 
 Fig. 147 
 
 Showing a large bulla etkmoidalis (a) en- 
 croaching upon the hiatus semilunaris; (b) the 
 hiatus semilunaris. The middle turbinate has 
 been removed. (Dr. W. A. Fisher's specimen.) 
 
 The anterior cell is the frontal sinus; the pos- 
 terior one is one of the anterior ethmoidal cells 
 extending half-way across the orbital cavity, 
 and is inaccessible to operation except by bent 
 curettes through the nasal chambers. The 
 author recently operated on three such cases. 
 (Dr. W. A. Fisher's specimen.) 
 
 membrane, and the "swell bodies" are rudimentary. The method of its 
 removal should be selected with reference to the anatomical conforma- 
 tion and the individual preference of the surgeon. The author's turbinal 
 knife is usually well adapted to the purpose. 
 
 (c) Remove all of the anterior ethmoidal cells that can be reached 
 with the curette, Griinwald forceps, or other instruments. Owing to 
 the wide variation in the distribution of the anterior ethmoidal cells, 
 the area of curettement varies in each case. In some subjects all the 
 cells are not accessible to the curette. Occasionally one of the cells 
 extends over the orbital roof posterior to the frontal sinus, as shown 
 in Fig. 147. In other cases a cell encroaches upon the floor of the frontal 
 
THE AUTHOR'S OPERATIONS WITHIN THE "VICIOUS CIRCLE" 203 
 
 sinus and forms the so-called bulla frontalis, as shown in Fig. 148. The 
 dense bone of the frontonasal spine of the superior maxillary bone 
 often shields some of the most anterior of the cells from the curette. 
 For these reasons the total exenteration of the anterior ethmoidal cells 
 with the curette is not always possible by the intranasal route. As a 
 consequence the frontonasal canal and the infundibulum cannot always 
 be cleared of obstructive lesions. Drainage and ventilation of the frontal 
 sinus are not, therefore, always possible by this method of operating. 
 
 Should the subsequent course of the frontal sinuitis prove the inade- 
 quacy of the operation, either the Halle, Good, or Ingals or one of the 
 external operations is recommended. After an experience in more than 
 four hundred cases operated on via the "vicious circle" of the nose, 
 I am convinced that but few cases of frontal and ethmoidal sinuitis 
 
 Fig. 148 
 
 Showing the nasal sinuses of the right side of the head. The naso-antral Avail, inferior turbinate 
 and the middle turbinate are removed. One of the anterior ethmoidal cells (a) projects into the floor 
 of the frontal sinus and forms the so-called bulla frontalis. (Author's specimen.) 
 
 require more radical surgical interference. In only 3 per cent, of the 
 cases was it necessary to perform an external operation. As the infun- 
 dibulum is the outlet of the drainage system of the sinuses comprised in 
 Series I, and as the anatomical deformities of the septum, middle turbinate, 
 and bulla ethmoidalis often obstruct the drainage and ventilation of the 
 infundibulum, it is a rational conclusion that if the obstructive anatomi- 
 cal lesion is removed, drainage will be restored and the infection and 
 inflammation cured. 
 
 Hemorrhage is the most troublesome complication attending this 
 operation. The parts are chiefly supplied by the anterior and posterior 
 ethmoidal and a branch of the sphenopalatine artery (Fig. 3). They 
 are of considerable size and may bleed freely, though in my experience 
 they rarely do so. The hemorrhage, though not profuse, usually con- 
 tinues for about twenty-four hours. A firm tampon of gauze in the 
 
204 THE NOSE AND ACCESSORY SINUSES 
 
 upper portion of the nasal cavity readily checks it. Fortunately it is rarely 
 necessary to introduce a tampon for this purpose. The presence of the 
 tampon may prove as serious as the operation, as it may fracture the 
 orbital plate and expose the orbital contents to infection. A tampon 
 should not, therefore, be introduced except in case of severe hemorrhage. 
 Drainage is of more importance than the control of a slight hemorrhage. 
 Place the patient in a hospital if possible, as the hemorrhage can be kept 
 under better control than it can if the patient is at home. 
 
 After-treatment. — Instruct the patient to introduce a pledget of cotton 
 in the vestibule of the nose and to remove and renew it as often as it 
 becomes soiled with blood and secretions. This protects the denuded 
 surfaces from being irritated by the inspiratory current of air and prevents 
 the blood trickling over the upper lip. A dusting powder of bismuth- 
 iodine should be insufflated once or twice daily. Healing usually occurs 
 in about fourteen days, and if the exenteration is complete the space 
 in the ethmoidal region should be free and roomy. For a few days after 
 the operation small pledgets of cotton, saturated with a 10 per cent, 
 aqueous solution of ichthyol, should be introduced every four hours into 
 the attic of the nose to promote osmosis and asepsis of the surgical field. 
 
 HALLE'S OPERATION ON THE FRONTAL SINUS. 
 
 Max Halle, of Berlin, secures entrance to the frontal sinus by the 
 intranasal route by means of burrs and a protector to the internal plate 
 of the frontal bone. The chief source of danger attending this operation 
 is the injury of the internal plate of the frontal bone, thereby opening 
 an avenue of infection to the meninges and brain. The grooved pro- 
 tector is intended to prevent injury of this plate, and it should always 
 be used. 
 
 The anatomical barrier to the removal of the floor of the frontal sinus 
 is the backward projection of the spina nasofrontalis of the superior 
 maxillary bone. This dense, heavy bone was regarded as an insur- 
 mountable barrier to the floor of the frontal sinus by the intranasal 
 route, until Halle recently called attention to his method of operating. 
 
 Indications. — The Halle operation is indicated in those cases of frontal 
 and anterior ethmoidal sinuitis which have resisted the removal of the 
 anatomical obstructive lesions within the " vicious circle" of the nose, 
 and in which there are no fulminating symptoms, as meningitis, orbital 
 abscess, and external perforation. When these symptoms are present 
 an external operation should be performed. 
 
 Technique . — (a) Induce local anesthesia with cocaine. 
 
 (b) Introduce a probe into the frontonasal canal for a distance of 
 2J to 3 cm. after it enters the infundibulum or hiatus semilunaris, as 
 when it is passed upward and forward this distance it has entered the 
 frontal sinus. 
 
 (c) Introduce the protector beside the probe for the same distance. 
 
HALLE'S OPERATION ON THE FRONTAL SINUS 
 
 205 
 
 (d) Next engage the pointed drill (Fig. 149) against the under 
 and posterior border of the spina nasofrontalis, just in front of the 
 protector. Direct the drill forward and upward and remove enough 
 of the bone to allow the blunt-pointed drill to be introduced. The 
 sharp-pointed drill should only be used to make an opening large 
 enough to permit the introduction of the blunt-pointed one, as to use 
 it further might lead to injury of the internal plate of the frontal bone. 
 The blunt drill will not do this. 
 
 (c) With the blunt drill remove enough of the bone to permit the 
 introduction of the pear-shaped drill (Fig. 150), the thickened portion 
 of which is rounded and polished. According to Halle, the blunt or 
 
 Fig. 149 
 
 Halle's frontal sinus drills and handle. 
 
 bulbous drill can inflict no serious injury to the meninges or brain 
 provided the least care is exercised. The entire floor can be drilled 
 away with it, and so large a part of the external plate of the frontal 
 bone in a downward direction that the instrument can be felt from 
 without. It is necessary that the assistant take the precaution to push 
 his finger well into the orbit, so that he can control the head of the 
 instrument (drill) and prevent it going too far to the front or the sides. 
 
 The mucous membrane of the frontal sinus may thus be exposed to 
 ocular inspection and treatment through the nose if enough of the bone 
 is removed, as shown in Fig. 152. 
 
 (d) The after-treatment consists in first packing the sinus with iodo- 
 form gauze, and the subsequent use of alcohol, protargol, or the nitrate 
 
206 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 of silver to retard granulations and to promote the formation of epithe- 
 lium. At a later period Halle instructs the patient to introduce a large 
 
 Fig. 150 
 
 Fig. 151 
 
 Halle's first step in removing the nasal process 
 which forms the floor of the frontal sinus at 
 its inner extremity. A metal protector (a) 
 is introduced into the frontonasal canal to 
 prevent injury to the inner or cranial Avail of 
 the frontal sinus. The pointed burr is only 
 used to begin the operation, after which blunt, 
 smooth-tipped burrs are used, as they will not 
 penetrate the inner or cranial bony wall of the 
 sinus if they should accidentally come in con- 
 tact with it. 
 
 The round-tipped burr removing the floor 
 of the frontal sinus by the intranasal route. 
 The protector is in position and the rounded, 
 polished tip of the burr renders injury to the 
 cranial wall of the sinus improbable. 
 
 Fig. 152 
 
 cannula several times a day to prevent the formation of granulations and 
 adhesions, though this should preferably be done by the removal of the 
 granulations, caustic applications, etc., by the surgeon. 
 
 (e) The anterior ethmoidal 
 cells and middle turbinated body 
 of the " vicious circle" are also 
 removed in this operation. The 
 posterior cells may also be re- 
 moved at the same time by either 
 of the methods described else- 
 where in this chapter. 
 
 Good's Operation. — The first 
 step of this operation is the re- 
 moval of the anterior portion 
 of the middle turbinated body, 
 a procedure which, as I have 
 shown, will often effect a cure 
 of the frontal sinuitis, especially 
 if it is of the simple catarrhal 
 type, and is characterized by 
 exacerbations of acute coryza. 
 
 The intranasal operation of Halle completed. 
 The floor of the frontal sinus is widely opened 
 and permits curettage and free drainage of the 
 
GOOD'S OPERATION ON THE FRONTAL SINUS 
 
 207 
 
 The second step of the operation consists in the introduction of the 
 guard and guide into the frontonasal canal (Fig. 153, b). The guard 
 should have the normal curve of a frontal sinus probe or cannula, and is 
 introduced with the same technique. 
 
 The third step of the operation consists of the introduction of the 
 curved frontal sinus rasp into the frontonasal canal, in front of the 
 guide which is slightly hollowed or grooved. It may be necessary to 
 use a little force, as the canal is too narrow to admit the rasp without 
 crushing some of the anterior ethmoidal cells along its outer side. The 
 rasp should be introduced until its tip emerges in the cavity of the 
 frontal sinus (Fig. 153). The file-edge of the rasp should face anteriorly 
 and outward, while the smooth surface should face posteriorly and 
 medianward. The object of the rasp is to enlarge the frontonasal canal 
 by removing some of the anterior ethmoidal cells, and to remove the 
 floor of the frontal sinus. 
 
 Fig. 153 
 
 Good's intranasal frontal sinus operation, a, Good's rasp removing the floor of the frontal sinus; 
 b, the guide and protector in position. 
 
 The After-treatment. — When the frontonasal canal has been enlarged 
 and the floor of the frontal sinus removed, the wound may be maintained 
 in a patulous condition by the use of a gold filigree tube, or, if a sufficiently 
 large opening is made, the tube may be omitted. When the tube is not 
 used the area should be closely watched for exuberant granulations, 
 which if found should be reduced with a bead of fused chromic acid 
 crystals. The frontal sinus should be irrigated daily with boric acid 
 solution until the purulent secretion ceases. 
 
 This operation should not be undertaken unless it has first been 
 demonstrated that a frontonasal probe will enter the frontal sinus via 
 the frontonasal canal. If this cannot be done the rasp file might be 
 misdirected, the posterior wall of the frontal sinus penetrated, and 
 meningitis incited. 
 
208 THE NOSE AND ACCESSORY SINUSES 
 
 The Ingals Operation.— According to E. Fletcher Ingals, the author 
 of this operation, from 95 to 98 per cent, of all cases of empyema of the 
 frontal sinus may be cured by his operation. This accords with the 
 results obtained by my intranasal operations. (See "Vicious Circle" of the 
 Nose and the Exenteration of the Middle Turbinate and the Ethmoidal 
 Cells en masse, and the various operations upon the tissues within the area 
 of the "vicious circle".) As my experience broadens I am inclined to 
 modify my original opinion as to the percentage of cures by operations 
 via the intranasal route. I still believe, however, that a large percentage 
 can be cured in this way. 
 
 The objections offered to the Ingals operation are : (a) that the internal 
 plate of the frontal sinus may be injured, which would give rise to menin- 
 gitis, though the guard and guide now used with the instrument will 
 probably prevent such an accident, as with it the burr may be drawn 
 forward away from the internal plate; (b) injury of the fossa ethmoidalis, 
 which is a point in the anterior fossa near the cribriform plate to which 
 the dura is closely adherent, and which is regarded as especially sus- 
 ceptible to meningitis. 
 
 The Technique. — Ingals has performed all his operations under cocaine 
 anesthesia, though a general anesthetic may be administered. The 
 cocaine (20 per cent, in 2 to 1000 adrenalin) is injected into the fronto- 
 nasal canal with a small curved cannula fitted to a hypodermic syringe. 
 The cannula is inserted by the same technique which is used in prob- 
 ing the canal, to the floor of the frontal sinus. From \ to \xxy is then 
 injected, the cannula slightly withdrawn, and the same amount again 
 injected. This process is repeated until the whole length of the fronto- 
 nasal canal is cocainized. Two or more introductions of the syringe- 
 cannula may be necessary to produce complete anesthesia. 
 
 If the anterior end of the middle turbinate has not been previously 
 removed this region should also be cocainized. 
 
 1. Remove the anterior end of the middle turbinate. This should 
 be done two or more weeks before the Ingals operation, or else just 
 preceding it, preferably the former, because this procedure alone is 
 sometimes followed by a cure of the empyema of the frontal sinus. (See 
 "Vicious Circle" of the Nose.) 
 
 2. Introduce the probe-pilot into the frontonasal canal. 
 
 3. Slip the pilot-burr over the probe-pilot until the burr is at the 
 lower extremity of the frontonasal canal. If it is desirable to protect 
 the internal plate of the frontal bone from injury, the pilot-burr may be 
 protected by a guard, as shown in Fig. 154. With this device the pilot- 
 burr may be drawn forward, away from the posterior wall of the frontal 
 sinus. 
 
 4. When all the parts of the instrument are adjusted the burr is gently 
 pressed upward. It usually cuts its way into the frontal sinus in two or 
 three seconds. It may be passed up and down through the opening 
 thus made two or three times to insure a clear passage. 
 
 5. Introduce a one-inch strip of sterile gauze saturated in a 20 per 
 cent, solution of the chloride of zinc into the enlarged frontonasal canal. 
 
INGALS' OPERATION ON THE FRONTAL SINUS 
 
 209 
 
 having previously swabbed the nasal mucous membrane with vaseline. 
 Leave the gauze in place for about five minutes, to insure its caustic 
 action. The gauze should be introduced through a suitably curved 
 uterine packer. 
 
 6. A gold drainage tube is introduced into the enlarged frontonasal 
 duct as follows: 
 
 The wire applicator of the uterine packer is first enveloped with the 
 flexible spiral shield. The drainage tube is then slipped on the end of the 
 applicator and introduced into the lower opening of the canal. The 
 spiral shield is then pressed upward against the drainage tube, forcing 
 
 Fig. 154 
 
 The Ingals intranasal frontal sinus operation. 1, the pilot-probe over which the pilot-burr is 
 placed; 2, the pilot-burr; 3, the guide with which the pilot-burr is drawn forward away from 
 the posterior wall of the frontal sinus; 4, the flexible shaft; 5, the frontonasal canal. 
 
 it to the full depth of the canal. The applicator and spiral tube are 
 withdrawn and the operation thus completed. Before introducing the 
 gold drainage tube its spring ends are capped with a No. 2 gelatin capsule, 
 which is further protected by a coat of vaseline to prevent it melting 
 too rapidly when it comes in contact with the tissues. The capsule holds 
 the flaring segments of the tube in position while it is being introduced. 
 The capsule is dissolved in about five minutes and the segments of the 
 tube spring apart and hold it in position. 
 
 The tube should be worn for about four months, though to wear it 
 for a much longer period would not cause great inconvenience. 
 
 The frontal sinus should be irrigated daily through the tube. 
 
 External Surgery of the Frontal Sinus. — On account of its location, 
 the frontal sinus is sometimes less successfully treated by the intranasal 
 route than by either of the other sinuses. It is, therefore, necessary to 
 resort to external methods of operating in a considerable number of 
 chronic cases. The method of Hajek-Luc, or Ogston-Luc, as it is 
 sometimes called, is one of the most efficient in uncomplicated cases of 
 14 
 
210 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 chronic empyema of the frontal sinus. This method is not adapted, 
 however, to those cases in which the anterior ethmoidal cells are to be 
 exenterated. In such cases it is necessary to remove the floor of the 
 frontal sinus and the processus frontalis of the superior maxillary bone 
 to give access to the anterior ethmoidal cells. The posterior ethmoidal 
 and sphenoidal cells are accessible by the intranasal route. 
 
 The Hajek-Luc Operation. — (a) The skin of the forehead and around 
 the eye should be thoroughly cleansed and covered with a moist dressing 
 twenty-four hours previous to the operation. 
 
 (b) The patient is placed upon the operating table and anesthetized. 
 
 (c) The dressing is then re- 
 FlG - 155 moved and the parts again 
 
 washed. It is not necessary to 
 shave the eyebrow, as it can 
 be easily cleansed and is useful 
 as a landmark; though I prefer 
 to shave it, because it interferes 
 with the removal of the stitches. 
 
 (d) An incision is made, be- 
 ginning at the temporal end of 
 the eyebrow and extending to 
 the face of the nose (Fig. 155). 
 A second incision may be started 
 where the first leaves off, and 
 extended upward as far as the 
 upper limit of the frontal sinus, 
 a fact which should be deter- 
 mined beforehand by skia- 
 graphy. 
 
 (e) The skin and periosteum 
 within this triangular incision 
 are turned upward, thus expos- 
 ing the outer plate of the frontal 
 bone. 
 
 (/) A liberal portion of the 
 bone is then chiselled away, thus 
 exposing the frontal sinus to in- 
 spection and curettage. 
 (g) After determining the outline of the sinus and the character 
 and location of pathological lesions, the morbid material is removed 
 with a curette, and if bony septa are present they are broken down 
 (Fig. 155). 
 
 (h) The frontonasal canal must be enlarged as much as possible, to 
 establish free drainage into the nose. This is done by breaking down 
 fhe anterior ethmoidal cells with a curette, through the floor of the 
 trontal sinus. 
 
 (i) A large rubber tube is inserted into the enlarged frontonasal canal 
 and left in position for several weeks, or until all discharge ceases. The 
 
 The Hajek-Luc operation. The anterior wall of 
 the frontal sinus is removed, and the anterior eth- 
 moidal cells are being removed through the floor of 
 the frontal sinus with a curette. The left side has 
 been operated on, a gauze wick introduced through 
 the anterior ethmoidal wound and drawn out 
 through the nostril. 
 
EXTERNAL OPERATIONS ON THE FRONTAL SINUS 211 
 
 nasal end of the rubber tube is seized with forceps from time to time, 
 and moved up and down, to prevent adhesions. When all discharge 
 ceases the tube is withdrawn through the nose. 
 
 (y) After inserting the rubber tube into the frontonasal opening the 
 external wound is closed and allowed to heal by primary intention. 
 
 Advantages of the Operation. — The advantages of this method of 
 operating are: (1) it avoids disfigurement, as the wound heals by primary 
 intention; (2) the frontonasal canal is enlarged, the anterior ethmoidal 
 cells eradicated; and (3) as they are invariably involved in frontal sinu- 
 itis, this operation is advantageous, because they are opened and drained 
 in its performance. 
 
 Disadvantages of the Operation. — Relapse occurs in about 50 per cent, 
 of the cases, because the curettement cannot be done thoroughly, as 
 the ethmoidal cells are not accessible through the frontal wound. Sup- 
 puration of the scalp has been reported, and the operation has been 
 followed by sinuitis on the opposite side. Severe intracranial complica- 
 tions have also been reported. Tilley cites one death in 5 cases. 
 
 Lermoyez reports 9 cases in which there were 8 relapses; 5 of the cases 
 were subsequently cured by Kuhnt's operation, 1 by the repetition of the 
 Hajek-Luc operation, while 2 died of meningitis (slow septicemia). It 
 appears, therefore, that this method, while apparently very simple, is 
 sometimes followed by very serious sequela?. In view of these facts, it is 
 usually better to adopt Kuhnt's operation, or at least a combination of the 
 two. I believe this operation fails in such a large percentage of cases 
 because the obstruction in the "vicious circle" of the nose is not removed ; 
 indeed, it is probable that this latter procedure alone would have given 
 far better results than that given in the above statistics for the Hajek-Luc 
 operation. 
 
 Kuhnt's Operation. — The object of Kuhnt's operation is to obliterate the 
 frontal sinus by granulation from the bottom of the cavity. He resects 
 the entire anterior wall (Hajek-Luc removes only a portion of it) and a 
 portion of the floor or superior orbital wall. Curettement is thoroughly 
 performed, but the frontonasal canal is not disturbed, as to do so he 
 thinks may lead to reinfection of the sinus from the nasal fossa. Kuhnt 
 does not close the external wound, but leaves it open for the intro- 
 duction of the dressings and for drainage. A cure takes place in from 
 three to six weeks. Relapse and sequelae, according to Kuhnt, are rare, 
 and recovery is the rule. 
 
 Disadvantages. — (1) External drainage and dressings must be con- 
 tinued for several weeks. (2) When a cure is accomplished the patient 
 is more or less disfigured. (3) The anterior ethmoidal cells are unopened, 
 though they are always simultaneously involved. (4) Diplopia has 
 frequently followed, from injury of the pulley of the superior oblique 
 muscle, or from inflammatory infiltration about the pulley or within the 
 muscle. 
 
 The Kuhnt-Luc Operation. — This operation is a combination of the 
 method of Kuhnt and Hajek-Luc and consists in the free removal of 
 the anterior wall of the frontal sinus, the enlargement of the frontonasal 
 
212 THE NOSE AND ACCESSORY SINUSES 
 
 canal, and the introduction of the funnel-shaped rubber tube, together 
 with the closure of the primary skin incision. This gives a fairly good 
 cosmetic result with frontonasal drainage and a partial ablation of the 
 anterior ethmoidal cells, as in the Hajek-Luc operation, while it avoids, 
 in a measure, the disfigurement attending external drainage, as practised 
 by Kuhnt. There is more or less depression of the skin, which is caused 
 by the removal of the bone, but this can be corrected, in a measure, by 
 subsequent paraffin injections. 
 
 Kuster's Osteoplastic Operation. — A modification of the operation just 
 detailed consists of making an osteoplastic flap instead of chiselling 
 away the outer bony wall. The bony flap is formed by making a narrow 
 incision with a V-shaped chisel along the upper border of the supra-orbital 
 ridge for the whole length of the sinus. The incision is then extended 
 upward into either end of the supra-orbital incision in directions corre- 
 sponding to the outline of the sinus as shown by a skiagraph previously 
 made. This incision may also be made with a narrow-bladed rongeur 
 forceps, or the De Vilbiss bone-cutting forceps. After the bony incision 
 above the supra-orbital ridge is made it is enlarged somewhat at 
 either extremity to admit two rongeur forceps by means of which the 
 bony plate is broken off and left attached to the soft tissue above. 
 Considerable care must be exercised in handling the bony flap and soft 
 tissues while they are being retracted, lest they be separated. The 
 next step in the operation consists of the incision of the membranous 
 lining of the sinus and the removal of the floor of the sinus. This is 
 followed by a very thorough curettement of the anterior ethmoidal 
 sinuses through the floor of the frontal sinus. After carefully cleansing 
 the sinuses the wound is packed with gauze moistened with the compound 
 tincture of benzoin. The external wound is closed with sutures, and on 
 the fifth or sixth day two of the centre stitches are removed and the 
 dressing taken out. 
 
 The object of this method of operating is the same as that of Kuhnt's 
 operation. The eye symptoms are also the same. As Canfield has 
 pointed out, there may be some deformity on account of the osteoplastic 
 flap being lifted outward at its lower border by adhesions at the upper 
 border of the bone flap to the posterior wall of the sinus, and subsequent 
 contraction of the same. Again, the lower border of the osteoplastic 
 flap is lifted outward somewhat by the removal of the gauze dressing. 
 The lower border of the osteoplastic flap thus dislocated sometimes forms 
 a ridge, which may be removed or corrected by a secondary operation. 
 I see no reason why the wound should be packed as described. A better 
 plan would be to pass a small wick of gauze through the enlarged fronto- 
 nasal opening, to maintain its patency for a few days, and then to with- 
 draw it altogether. This would obviate opening the external incision, 
 as recommended, and would give a better cosmetic effect. A thorough 
 exenteration of the anterior ethmoidal cells and the establishment of 
 good drainage as recommended by me will nearly always be followed 
 by a cure of the disease without an external operation. (See "Vicious 
 Circle.") 
 
EXTERNAL OPERATIONS ON THE FRONTAL SINUS 213 
 
 Beck's Double Osteoplastic Operation. — The method of procedure is as 
 follows : 
 
 1. An incision is made through the skin and subcutaneous connective 
 tissue through the upper margins of the eyebrows, then downward and 
 inward as far as is usually done in the Killian operation. These two 
 incisions are then joined by means of a transverse incision across the 
 bridge of the nose. 
 
 2. This skin and subcutaneous flap are then dissected upward until the 
 upper limits of the frontal sinuses are exposed. This is determined by 
 means of a celluloid tracing of" the radiogram placed upon the frontal 
 bone. 
 
 The Preparation of the Celluloid Tracing. — Take a piece of ground 
 celluloid film about three inches square, place over the radiogram (glass 
 plate) negative, which is either in the transilluminating box or against 
 a window glass. Trace the outlines of the sinuses with ink. The outline 
 of the supra-orbital margins is made for the purpose of getting a fixed 
 point. The celluloid model can be sterilized in bichloride of mercury 
 and alcohol. 
 
 If the sinuses extend very high on the forehead, it may become 
 necessary to make two small perpendicular incisions at the extreme 
 limits of the flap over the external canthi. 
 
 3. Place the celluloid tracing of the radiogram over the frontal region 
 and incise the periosteum all around the upper and lateral margins of the 
 same, but not over the supra-orbital borders or at the root of the nose. 
 
 4. With a flat chisel the external table of the frontal sinus is then 
 penetrated along the whole course of the above described tracing through 
 the periosteum; this also severs the attachment of the septum of the 
 frontal sinuses from the posterior surface of the external table. 
 
 5. This osteoperiosteal flap is then slightly pried open by means of 
 a chisel, and a Gigli saw is inserted beneath the bone flap and carried 
 down to its supra-orbital attachment. 
 
 6. The saw should be made to cut from within outward; a few strokes 
 severing the bone, care being taken to preserve the periosteum intact. 
 Great care must be taken not to cut through this structure; indeed, the 
 entire thickness of bone should not be sawn through, as it will readily 
 break when it is everted downward over the nose. The skin flap is then 
 reflected upward and the periosteal bone flap downward, thus exposing 
 both frontal sinuses. The right side (Fig. 156) shows the granulations 
 removed, and the drill in operation enlarging the frontonasal canal. 
 The left side shows the cavity filled with granulations and pus. 
 
 7. If only one sinus is to be exposed, the technique varies only in the 
 osteoperiosteal flap, and in making the incision within the limits of the 
 frontal sinus septum and the lateral limit of the sinus. The skin flap 
 may be made by making a perpendicular incision from the internal 
 angle of the orbit to the height of the frontal sinus, as indicated by the 
 radiogram. 
 
 8. Thoroughly eradicate the diseased mucous membrane, but do not 
 curette it; and enlarge the natural opening into the nose, using the 
 
214 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Halle trephine or Good's rasp for this purpose. Also remove the most 
 anterior ethmoidal cells as completely as possible through the floor of 
 the sinus. This can only be done by opening through the lateral wall 
 of the nose, as in Killian's operation. This constitutes the weakness of 
 Beck's operation. 
 
 9. Introduce a large rubber tube with a wick of gauze in its lumen 
 into the enlarged frontonasal canal. The upper end of the wick is 
 loosely folded within the cavity of the frontal sinus, while the other end 
 is brought down to the floor of the nose, so that a small portion protrudes 
 through the vestibule. 
 
 Fig. 156 
 
 Beck's osteoplastic operation upon the frontal sinus. The right side shows the probe in the 
 frontonasal duct, and the frontal sinus freed of granulations and pus. The left sinus is still filled 
 with granulations and pus. 
 
 10. Replace the osteoplastic flap in its natural position. Bring the 
 skin flap to its natural position and suture with silkworm gut, using the 
 Halsted subdermal suture, with a few horsehairs, over the bridge of the 
 nose. 
 
 The After-treatment. — The gauze should be removed on the day 
 following the operation and on the third or the fifth day a gold or silver 
 filigree tube should be inserted. In one case Dr. Beck used no tube, 
 and four months after the operation, the opening was sufficiently large 
 to permit ventilation and drainage, the patient finally recovering. 
 
 The use of douches and blowing the nose should be avoided for 
 several days after the operation. Indeed, the patient should snuff the 
 secretions from the nose. 
 
EXTERNAL OPERATIONS ON THE FRONTAL SINUS 215 
 
 If this operation fails it may be converted into the Killian operation 
 at a subsequent time. 
 
 Fig. 157 
 
 Killian's incision with cross-cuts for guides in suturing. 
 
 Showing the retraction of the skin flaps in the Killian frontal sinus operation. P, the periosteal 
 incision 5 mm. above the skin incision: *S, the skin incision 5 mm. below the periosteal incision; 
 P 1 , the periosteal incision at the side of the nose. 
 
 The Killian Operation. — Technique. — After having prepared the field 
 of operation, and having administered a general anesthetic, an incision 
 is made through the eyebrow (previously shaved), beginning at its temporal 
 
216 THE NOSE AND ACCESSORY SINUSES 
 
 end, extending to the median line at the root of the nose, and then curving 
 downward and outward below the base of the nasal bone (Fig. 157). 
 
 The periosteal incisions are two in number. The upper one is made 
 parallel with the supra-orbital margin and 5 mm. above it, and extends 
 from the temporal end of the incision to the median line of the nasal 
 bones. The second periosteal incision begins internal to the attachment 
 of the pulley of the superior oblique muscle (Fig. 158, p 1 ), passes inward 
 and then curves downward and outward, following the direction of the 
 incision of the skin around the inner canthus of the eye. This incision 
 passes over the processus frontalis of the maxillary bone. 
 
 The soft parts, including the periosteum, are lifted from the bone, thus 
 forming the skin and periosteal flaps, with the exception of the peri- 
 osteum covering the superciliary ridge, where it is left intact to prevent 
 the dislodgement of the pulley of the superior oblique muscle. 
 
 Fig. 159 
 
 The Killian frontal sinus operation completed. P, the periosteal incision 5 mm. above the super- 
 ciliary skin incision; S, The superciliary skin incision 5 mm. below the periosteal incision; P 1 , 
 the periosteum elevated and everted along the side of the nose. 
 
 The frontonasal process and a portion of the nasal bone are chiselled 
 away, thus exposing the anterior ethmoidal cells, which are removed 
 through the opening. The entire anterior wall of the frontal sinus is 
 completely removed with a chisel and rongeur forceps (Fig. 159). 
 
 The cavity of the sinus thus exposed should be thoroughly inspected 
 and curetted in all its ramifications. Killian insists that when the an- 
 terior bony wall is removed the mucous membrane should not at once 
 be disturbed, but that it should be left intact as long as possible, so as to 
 
EXTERNAL OPERATIONS ON THE FRONTAL SINUS 217 
 
 avoid unnecessary infection of the external wound. He makes a small 
 preliminary opening through the bone, and then with a probe, introduced 
 between the bone and mucoperiosteum, determines the limitations of the 
 frontal sinus. A skiagraph, previously taken, would obviate the necessity 
 of this procedure. Having done this, he proceeds to remove all the bone 
 necessary for its complete exposure. He then opens the membranous 
 sinus and proceeds to inspect and curette it according to the conditions 
 present. All septa are removed. 
 
 The next step in the operation consists in the removal of the floor 
 of the sinus with a curette. As the operation is one wherein there is 
 some danger of injuring the pulley of the superior oblique muscle, great 
 care should be exercised to avoid it. As the pulley is variously located, 
 this is not an easy matter. Dr. Ostrum has devised a pulley marker 
 (Fig. 160), which may be applied to the tissues marking the location of 
 the pulley, so that in the event of its detachment it may be sutured to 
 the marked point, and thus prevent strabismus. 
 
 The opening around the processus frontalis may be enlarged upward 
 and backward, to afford a better field for the curettement of the other 
 sinuses, especially the ethmoidal and sphenoidal. Indeed, this opening 
 
 Fig. 160 
 
 Ostrum's localizer for the pulley of the superior oblique muscle. 
 
 should be united with the one in the floor of the frontal sinus, as shown 
 in Fig. 158. Still exercising great care not to injure the nasal mucous 
 membrane, the surgeon should introduce the curette through the opening 
 made by the removal of the processus frontalis, and perform the curette- 
 ment of the ethmoidal and sphenoidal cells. The limits of the ethmoidal 
 cells are not difficult to determine with the curette, as the septa between 
 them are usually very thin and easily broken down. The bone of the os 
 planum and of the cranial plate is of greater density and resistance, and 
 need not be mistaken for the septa between the cells. Personally, I 
 prefer to remove the middle turbinate and posterior ethmoidal cells by 
 the intranasal route. I also open the sphenoid by the intranasal route. 
 
 As the hemorrhage is considerable, the operator must depend upon his 
 knowledge of the anatomical relations, the conditions of the diseased 
 parts, and his sense of touch, rather than upon sight in exenterating the 
 ethmoidal and sphenoidal cells. The wound should be thoroughly 
 cleansed by irrigation with normal salt or boracic acid solution, then 
 dusted with bismuth powder or bismuth paste, and the skin and 
 periosteal incisions closed with sutures. 
 
 A point in the after-treatment insisted upon by Killian is, that the 
 
218 THE NOSE AND ACCESSORY SINUSES 
 
 patient should be placed upon his healthy side and forbidden to blow 
 his nose. He must aspirate the secretions from the nose, and the nasal 
 cavity should be inspected daily, carefully dressed, and exuberant granu- 
 lations touched with nitrate of silver. If a double operation is performed 
 the patient should lie upon his back and sniff the secretions from his nose. 
 
 A few days after the operation, if pus still comes from the sinus, 
 gentle pressure over the skin should be made to force them into the nasal 
 cavity. The patient should sniff or aspirate them into his throat. He 
 should not be allowed to blow his nose, as to do so might force infected 
 matter from the nose into the frontal cavity. The deformity following 
 the operation is usually of moderate degree, and often becomes less 
 conspicuous after a few months. The frontal sinus becomes more and 
 more filled with granulation tissue, and the orbital fat pushes upward 
 through the open floor of the sinus. In this way the depression becomes 
 fairly well rilled, except when the sinus is very large and deep, in which 
 case the disfigurement may be very great. 
 
 This radical method of procedure is less likely to injure the pulley 
 of the superior oblique muscle than the Kuhnt-Luc operation, or the 
 Kuhnt operation, on account of the manner in which the periosteal 
 incision is made, the periosteum over the superciliary ridge serving 
 to hold the pulley in its place. 
 
 Taking all the facts into consideration, if the case is complicated by 
 ethmoidal and sphenoidal disease and an external operation is deemed 
 necessary, the Killian operation is the most effective and least disfiguring 
 of the external operations. 
 
 Of one hundred and twenty-five cases of frontal sinuitis in which the 
 clinical diagnosis was confirmed by skiagraphy, in only twelve (10 per 
 cent.) did I find it necessary to perform the Killian operation, the others 
 being cured by giving surgical attention to the structures within the 
 ' Vicious circle" of the nose. Of the twelve Killian operations performed 
 by me, ten resulted in cure, two did not, as I failed to remove all of the 
 anterior ethmoidal cells at the primary operation. The deformity was 
 almost nil except in one case. 
 
 THE SURGERY OF THE MAXILLARY SINUS. 
 
 Intranasal Operations. — The intranasal surgery of the antrum 
 may include (a) the structures within the "key," or "vicious circle," 
 (b) the inferior turbinated body and the naso-antral wall, and (c) the 
 removal of the uncinate process. If the infundibulum is blocked by 
 morbid tissue or by anatomical peculiarities, they should be removed. 
 In exceptional cases this will be sufficient to establish a healthy con- 
 dition of the mucous membrane of the sinus. If, however, the mucous 
 membrane has undergone marked degenerative changes, it is usually 
 necessary to remove the anterior end of the inferior turbinated body 
 and the naso-antral wall, or to perform an extranasal operation, as the 
 Caldwell-Luc or the Denker operation. 
 
THE SURGERY OF THE MAXILLARY SINUS 
 
 219 
 
 Removal of the Naso-antral Wall. — This operation was first performed 
 by Myles, and has had many advocates since then. Clinical experience 
 has shown that a small opening in the naso-antral wall quickly closes, 
 whereas a large one remains open permanently. Puncture and irrigation 
 through a Krause cannula (Fig. 162) are often sufficient to effect a cure in 
 
 Fig. 161 
 
 Krause's antrum trocar with obturator. 
 
 acute and subacute inflammation of the sinus. The puncture should 
 be made beneath the inferior turbinated body. The cannula may be 
 introduced daily under cocaine anesthesia, with little discomfort to the 
 patient. The irrigating solution may range all the way from normal 
 salt and boric acid solutions to the more irritating solutions of zinc and 
 
 Fig. 162 
 
 Vail's operation on the maxillary antrum. The fragment of the turbinate extending over the naso- 
 antral opening should be removed with biting forceps. Vail prefers his method, whereby a portion 
 of the inferior turbinate is removed with the saw. 
 
 iodine. The usefulness of this procedure is largely limited to diagnosis, 
 though it has some therapeutic value. 
 
 Many instruments have been devised for the removal of the naso- 
 antral wall, some of which enable the operator to do the work with ease 
 and precision. The instruments which have given the best satisfaction 
 
220 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 are Vail's saw, Ostrum's forward cutting forceps, Wells' trocar and 
 cannula rasp, Corwin's chisel, and Bishop's trephines. 
 
 Vail's Operation. — Vail's is perhaps the most ingenious and practical 
 method for the removal of the naso-antral wall. His saw is slightly 
 curved upon the flat, and when introduced obliquely through the naso- 
 antral wall, makes a circular or oval incision, thus removing a large 
 portion of the wall (Figs. 162 and 163), separating the nasal chamber 
 from the antrum. 
 
 Fig. 163 
 
 The removal of the naso-antral wall with Vail's convex saw. A mucous membrane flap is 
 dissected from the naso-antral wall to be turned on to the floor of the antrum. 
 
 Technique. — (a) Induce local anesthesia of the inferior turbinal and 
 of the inferior and middle meatuses. 
 
 (b) Remove the anterior half of the inferior turbinated body with 
 the swivel knife or with scissors, or with the saw as it removes the naso- 
 antral wall (Fig. 162). 
 
 (c) Puncture the naso-antral wall near the floor of the nose with 
 Vail's perforator. 
 
 Fig. 164 
 
 Vail's antrum saw. 
 
 (d) Introduce the saw (Fig. 164) through the puncture and then make 
 the circular or oval incision shown in Figs. 162 and 163. While the 
 saw has a tendency to describe a circle, the size of the opening may be 
 regulated by the operator, as the bone is thin. The opening should be 
 made as large as possible, to overcome the tendency to close. 
 
 (e) If a flap of mucous membrane is to be turned into the antrum to 
 cover its floor, its anterior and posterior boundaries should be incised 
 
THE SURGERY OF THE MAXILLARY SINUS 
 
 221 
 
 with a right-angle knife. The upper boundary of the flap is made when 
 the inferior turbinate is removed (Fig. 162). The mucoperiosteal flap 
 should be separated from the bone with a small periosteal elevator. 
 Having separated the flap, the saw is introduced and the button of bone 
 removed as described in the preceding paragraph, after which the flap is 
 turned on to the floor of the antrum, which has been previously curetted. 
 The flap hastens the process of regeneration and epidermization. 
 
 (/) The first dressing consists of iodoform gauze loosely packed in the 
 maxillary sinus. It should be removed in from twenty-four to forty- 
 
 eight hours. 
 
 Fig. 165 
 
 L 
 
 fi 
 
 The author's right-angle knife. 
 
 (g) In the after treatment gauze dressings should not be used. The 
 cavity should be left open for drainage and ventilation. Every time the 
 patient blows his nose he blows through the antrum. The case should be 
 watched, and if exuberant granulations form, they should be promptly 
 reduced by the application of dehydrated chromic acid crystals or with 
 some other caustic. 
 
 Fig. 166 
 
 The author's method of removing the naso-antral wall with the right-angle knife after the re- 
 moval of the anterior portion of the inferior turbinated body. The knife is introduced through 
 the naso-antral wall at b, cuts upward and then forward to a, with the right-angle blade turned 
 horizontally into the maxillary antrum. When the anterior wall of the antrum is reached at a the 
 blade is rotated downward, as shown in the illustration, and pulled forward, making the cut 
 indicated by the perpendicular dotted line. 
 
 The Author's Operation with Right-angle Knife. — (a) Local anesthesia. 
 
 (b) Remove the anterior half of the inferior turbinate with the author's 
 
 right-angle knife (Fig. 165). The knife should engage the turbinate 
 
222 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 at about its middle point, and then be drawn forward to its anterior 
 extremity, thus removing the anterior half with one cut of the instrument, 
 (c) Introduce the same knife through the naso-antral wall at the 
 posterior limit of the antrum near the floor of the nose. Then make 
 an upward cut, a forward and a downward cut, as shown in Fig. 166. 
 The upward and forward cuts are made with the blade of the instru- 
 
 Fig. 167 
 
 Completing the removal of the naso-antral wall (e) with the author's knife. The right-angle 
 blade is introduced at the inferior ^portion of the posterior perpendicular incision c, and drawn 
 forward along the floor of the nose to d. 
 
 ment at right angles to the naso-antral wall. When the forward cut 
 is made the blade should be turned downward parallel with the naso- 
 antral wall, and pulled through it. The inferior incision remains to be 
 made, and is done with the reverse knife (the knives are made in pairs). 
 The knife is introduced into the posterior perpendicular incision (Fig. 
 
 Fig. 16S 
 
 W.R.GRADY CO. 
 
 Corwin's antrum chisel. 
 
 Fig. 169 
 
 W. R.GRADY CO. 
 
 Corwin's antrum chisel. 
 
 167) at the floor of the nose, and drawn forward along the floor of the 
 nose to the anterior perpendicular incision, thus completing the removal 
 of the naso-antral wall. The thickened lower portion of the wall may be 
 removed with the Griinwald or other bone forceps. 
 
 (d) Pack the antrum loosely with iodoform gauze for from twenty- 
 four to forty-eight hours. 
 
THE SURGERY OF THE MAXILLARY SINUS 
 
 223 
 
 (e) The after-treatment consists in the reduction of exuberant granula- 
 tion tissue with caustics. 
 
 Corwin's Operation. — Corwin's chisels (Figs. 168 and 169) are admir- 
 able instruments for removing the wall. The projecting points enable 
 the operator to engage them at an acute angle in the bony wall. Chisels 
 without these points are not easily engaged, as they would glide over the 
 surface of the mucous membrane (Figs. 170 and 171) 
 
 Fig. 170 
 
 Corwin's operation upon the antrum a, a, chisel making upper horizontal cut; b, b, lower 
 
 horizontal cut. 
 
 Fig. 171 
 
 Corwin's operation, second step, showing the chisel making the posterior perpendicular incision, 
 the anterior one being already made. 
 
 Ostrum's forward cutting forceps (Fig. 172) may be used after 
 puncturing the naso-antral wall at its posterior portion. It possesses 
 the advantage of the forward cut, a point of no inconsiderable impor- 
 tance in view of the fact that the anterior angle of the antrum is usually 
 
224 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 the seat of the greatest morbid lesion. Hajek's sphenoidal forceps may 
 also be used for this purpose. 
 
 ^Wells' combination antrum perforator and rasp file (Fig. 173) answers 
 admirably for the purpose of making an opening in the naso-antral wall. 
 After perforating the wall the sharp obturator is removed and the rasp is 
 used to remove the remaining portion of the wall, which it does completely. 
 The fragments of mucous membrane which remain are removed with 
 sharp biting forceps. 
 
 Fig. 172 
 
 Ostrum's forward cutting antrum forceps. 
 Fig. 173 
 
 Wells' trocar cannula rasp for removing the naso-antral wall. 
 
 Bishop's trephine (Fig. 174), the Nobel-Cordes forceps (Fig. 175) 
 and Stein's hand gouge or chisel (Fig. 176) are also admirable instru- 
 ments for removing the naso-antral wall. 
 
 With Stein's gouge two cuts are made: one beginning just posterior 
 to the anterior attachment of the inferior turbinate and extending above 
 its attachment to the posterior wall of the antrum, the other from the 
 
THE SURGERY OF THE MAXILLARY SINUS 
 
 225 
 
 same point and extending backward along the floor of the nose to the 
 posterior wall of the antrum. The two incisions thus make a large 
 tongue flap, including the anterior half or two-thirds of the inferior 
 turbinate. This is then removed with heavy forceps. In my hands this 
 method of operating leaves the largest possible opening in the naso- 
 antral wall. The only objection to it is that by it too much of the 
 inferior turbinate is removed. 
 
 Fig. 174 
 
 The removal of the naso-antral wall with a trephine. 
 
 Fig. 175 
 
 Removing the naso-antral wall with the Nobel-Cordes forceps. 
 
 Extranasal Operations.— (1) Alveolar; (2) Kuster; (3) Caldwell-Luc; 
 (4) Denker. 
 
 1. The Alveolar or Cooper Operation. — The alveolar operation was for a 
 long time a popular procedure. Tilley, of London, reports that of 300 
 cases of antral disease seen during ten years, only one had sound teeth, 
 15 
 
226 THE NOSE AND ACCESSORY SINUSES 
 
 and that of 27 cases drained by the alveolar route, 15 were obliged 
 to use the tube and irrigation for from six months to ten years. Of 
 these, 5 afterward elected the radical operation, which was followed by 
 complete cure. Of 37 cases operated on by the radical method, 34 were 
 successful. He also says that the alveolar route is indicated in recent 
 cases (of a few months' standing) and in chronic cases as a preliminary 
 measure. 
 
 Of the alveolar methods, the removal of a carious tooth, usually the 
 second bicuspid or the first or second molar, is attended with the most 
 happy results. It is obvious, however, that this method is only applicable 
 when there is positive evidence that the tooth is diseased beyond hope 
 of repair. The conditions are rare, indeed, that justify the removal of 
 a tooth that could be successfully treated by a dentist. Even should 
 it be admitted that more perfect drainage can be obtained by the removal 
 of a tooth, there are still other methods of establishing good drainage 
 which do not require the interference with an important physiological 
 organ, or other essential structure of the head. Drainage by the re- 
 
 Fig. 176 
 
 Stein's antrum gouge. 
 
 moval of a tooth should, therefore, be limited to those cases in which a 
 competent dentist states that the tooth cannot be saved, or it can be 
 demonstrated that there is a carious fistula extending from it to the antral 
 cavity. In such cases the tooth may be removed, and the opening thus 
 made enlarged and its walls rendered smooth. Daily irrigations with 
 warm boric acid solution may be used until the discharge ceases. The 
 alveolar opening should be closed with a strip of gauze, saturated with 
 the compound tincture of benzoin, until healing occurs, or with a tube 
 made for the purpose. 
 
 2. The Kuster Operation. — This operation has been in much favor, as 
 the interior of the antrum of Highmore is thereby exposed, permitting 
 inspection and curettement of its cavity. The operation consists of the 
 removal of the anterior wall of the antrum, as shown in the Caldwell-Luc 
 operation. The opening is usually limited to the area of thin bone of the 
 canine fossa, and should be large enough to admit the introduction of the 
 index finger. With the head mirror, light is reflected into the cavity and 
 its walls examined. The portion of the cavity which cannot be inspected 
 should be thoroughly explored with a curved probe. 
 
 If necrotic areas and granulation tissue are found they should be 
 removed by thorough curettement. The preliminary step of the operation 
 consists in the elevation of the upper lip and an incision at the labiogingi- 
 val junction (Fig. 177). The incision is carried through the periosteum, 
 and should be one and one-half inches in length. The periosteum is then 
 dissected upward over the canine fossa and the upper lip pulled toward 
 
THE SURGERY OF THE MAXILLARY SINUS 
 
 227 
 
 the eye with a retractor, after which the anterior wall should be removed 
 with a chisel and rongeur bone forceps. The cavity should then be 
 explored with a probe and the diseased mucous membrane and necrotic 
 bone removed with the curette. If the antrum is divided by septa they 
 should be broken down to convert it into one large cavity. 
 
 Having thoroughly removed the morbid tissue the sinus should be 
 loosely packed with gauze saturated with the compound tincture of ben- 
 zoin. The end of the gauze should protrude through the labiogingival 
 incision to prevent closure of the wound. If there is marked suppuration 
 the cavity should be irrigated daily and a wick of gauze introduced to 
 promote drainage. When complete healing has taken place the dressings 
 are discontinued and the labiogingival opening allowed to close. This 
 operation is not as good as the removal of the naso-antral wall, the 
 Caldwell-Luc, and the Denker operations. 
 
 Fig. 177 
 
 Fig. 178 
 
 The labiogingival incision in the Kuster and 
 Caldwell-Luc operations. 
 
 Applying the dressing after the Caldwell-Luc 
 operation, a, the anterior or canine wall re- 
 moved; c, c, the gauze wick in the antrum and 
 extending through the naso-antral opening into 
 the nasal chamber. 
 
 3. The Caldwell-Luc Operation.— This operation is, in most cases, 
 preferable to the Kuster operation. By it the antrum is exposed as 
 in the Kuster operation, and a large opening made through the naso- 
 antral wall. The opening may be made with forceps, VaiPs saw, Corwin's 
 chisels, or Myles' barbed cannulas through the nasal orifice. Preliminary 
 to this, however, the anterior two-thirds of the inferior turbinal should 
 
228 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 be removed. In making the naso-antral opening shown in Fig. 178, 
 care should be exercised to avoid injuring the lacrymal canal which 
 opens beneath and near the anterior end of the inferior turbinated 
 body and passes forward and upward to the inner canthus of the eye 
 (Fig. 180, 1). 
 
 Having completed the removal of the canine and naso-antral walls, and 
 having removed all diseased tissue from the antrum, the cavity should be 
 lightly packed with a strip of gauze, the end of which is brought out 
 
 Fig. 179 
 
 Fig. 180 
 
 Closing the labiogingival incision in the 
 Caldwell-Luc operation, a, the suture; b, the 
 Revidan needle. 
 
 Showing the relation of the ductus lacry- 
 malis to the inferior turbinated body. 1, the 
 ductus lacrymalis; 2, the maxillary sinus; 3, the 
 inferior turbinated body. (After Bardeleben.) 
 
 through the nose. The labiogingival incision should be sutured (Fig. 
 179) and allowed to heal by first intention. After the first dressing is 
 removed it is usually unnecessary to repack the antrum, drainage being 
 very successfully accomplished through the naso-antral wound. At the 
 end of the second day the gauze dressing should be removed through the 
 nose. The secretions may be removed by forcibly blowing the nose and 
 by irrigation. 
 
 It has been claimed that it is unnecessary to do either the Kuster or 
 the Caldwell-Luc operation, the simple opening through the naso-antral 
 wall being quite sufficient. That the naso-antral opening is sufficient 
 in a number of cases is true. In other cases, in which a pronounced 
 
THE SURGERY OF THE MAXILLARY SINUS 
 
 229 
 
 degeneration of the mucous membrane and caries of the bony walls of 
 the antrum are present, it is necessary to do the Kuster operation first, 
 and to explore the antrum by ocular inspection and curettement, a 
 procedure which cannot be successfully done through the nose. The 
 Caldwell-Luc operation should, therefore, be elected in those cases in 
 which there is pronounced suppuration with granulation tissue or polypi 
 in the middle meatus of the nose. If these procedures are properly 
 carried out and the suppuration continues, it is probable that the 
 ethmoidal and possibly the frontal sinuses are also involved, and that 
 some of the secretions from them drain into the antrum. In that event 
 proper attention should be given to the other sinuses. A skiagraph 
 would prevent this mistake being made. 
 
 4. The Denker Operation. — Indications. — This operation is indicated 
 in obstinate inflammatory disease of the maxillary sinus, which does not 
 yield to either the intranasal or „ 101 
 
 1 /"I 1 1 11 T • Fl °- 181 
 
 to the Caldwell-Luc operation. 
 In such a case the mucous mem- 
 brane of the sinus may be very 
 edematous and the seat of ex- 
 tensive granulations. 
 
 The anterior angle of the sinus 
 adjacent to the nose is often in- 
 accessible to the curette, either 
 through the nasal or the canine 
 fossa wound, hence the failure 
 of the intranasal and the Cald- 
 well-Luc operations. As the 
 edematous membrane and the 
 granulations must be thoroughly 
 removed to effect a cure, an 
 operation should be adopted 
 that will thoroughly expose the 
 entire cavity to curettement. 
 The Denker operation does it, 
 and it accordingly has a place 
 in the treatment of selected ob- 
 stinate cases. 
 
 Technique. — (a) A general 
 anesthetic should be given. 
 
 (b) The patient should be placed in Rose's position, with the head 
 hanging over the end of the table. 
 
 (c) Postnasal tampons should be introduced to keep the blood from 
 the throat and trachea. 
 
 (d) The labiogingival incision should be made as in the Caldwell-Luc 
 operation, but should extend to the median line. 
 
 (e) Elevate the soft tissues and periosteum over the canine fossa. 
 
 (f) Remove the anterior wall (canine fossa) of the maxillary sinus 
 as in the Kuster and Caldwell-Luc operations, and then remove the bridge 
 
 The Denker antrum operation, a, the area of 
 bone removed in the Kuster and the Caldwell-Luc 
 operations. In the Denker operation additional 
 bone is removed from b to the pyriform aper- 
 ture. 
 
230 THE NOSE AND ACCESSORY SINUSES 
 
 of bone between the canine fossa and the lower portion of the pyriform 
 opening of the nose, as shown in Fig. 181. By thus extending the bony 
 wound the anterior angle of the sinus is exposed to operative interference. 
 
 (g) Through the opening thus made remove the edematous membrane 
 and granulation tissue. 
 
 (h) Elevate the mucoperiosteum of the inferior meatus of the nose, 
 and of the inferior turbinated body, with a small flat elevator so curved 
 as to adapt it to the anatomical configuration of the parts. 
 
 (i) Incise the mucoperiosteum thus elevated and convert it into a 
 rectangular flap to be turned outward on the floor of the sinus. 
 
 (j) Remove the bony wall and the anterior portion of the denuded 
 inferior turbinated bone with bone-cutting forceps, the mucoperiosteal 
 flap being turned into the nasal chamber to prevent injuring it with 
 the bone forceps. The opening through the naso-antral wall should be 
 quite large, as in the Caldwell-Luc operation. Otherwise it will soon 
 become closed and defeat the purpose of the operation. 
 
 (k) Turn the mucoperiosteal flap on to the floor of the sinus and 
 hold it in position for twenty-four to forty-eight hours with a bismuth 
 gauze dressing. 
 
 (/) The after-treatment, as in the Caldwell-Luc operation, consists 
 in watching the case and reducing exuberant granulations with caustics 
 as soon as they appear. 
 
 THE PARTIAL REMOVAL OF THE ETHMOIDAL CELLS. 
 
 In some cases a single ethmoidal cell may be the seat of infection and 
 inflammation, and it alone may require surgical interference. The bulla 
 ethmoidalis is sometimes affected while all the other cells are apparently 
 healthy. Less frequently one of the other ethmoidal cells is involved, or 
 the anterior cells may be the seat of infection while the posterior cells are 
 free from it, or the posterior cells may be affected and the anterior cells 
 be normal. 
 
 When the location of the infection has been determined, the middle 
 turbinated body (middle concha), or a portion of it, may be removed 
 and the exposed wall of the diseased cells broken down with a curette 
 or a Griinwald biting forceps. The cells thus opened may close by 
 granulation in the process of repair and thus necessitate repeated 
 curettements before a cure is established. 
 
 If after repeated attempts a cure is not effected, it may become neces- 
 sary to perform a more complete operation. 
 
 Turbinectomy with the Author's Knife. — Inasmuch as the partial or 
 complete removal of the middle turbinated body is frequently necessary 
 to relieve muscular asthenopia (lack of balance of the extra-ocular or 
 intra-ocular muscles), and to establish drainage and ventilation of the 
 nasal accessory sinuses, I have endeavored to devise some simple means 
 to accomplish it. The turbinotome (Fig. 184), herewith presented, in a 
 measure solves the problem. 
 
THE PARTIAL REMOVAL OF THE ETHMOIDAL CELLS 231 
 
 Fig. 182 
 
 Curettage of the ethmoidal cells after the removal of the middle turbinated body. The cutting 
 edge of the curette is directed upward and removes the cells from the cranial plate as far forward 
 as the dotted line. 
 
 Fig. 183 
 
 Curettage of the ethmoidal sinuses. Second step. The curette is turned outward against the 
 orbital plate and breaks down the intercellular walls of the ethmoid cells, including the bulla eth- 
 moidalis x and the line of attachment of the middle turbinated body. 
 
 Fig. 184 
 
 The author's turbinotome. 
 
232 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Technique of Turbinectomy. — (a) Cocaine anesthesia. 
 
 (b) Introduce the curved blade of the knife beneath the middle tur- 
 binate at the posterior extremity of the turbinated body (Fig. 185). 
 
 (c) Then draw it forward along the line of attachment to the anterior 
 end of the middle turbinate, thus removing it in its entirety (Fig. 186). 
 
 (d) Remove the severed turbinate with dressing forceps. 
 
 Fig. 185 
 
 The first step of the removal of the middle turbinate with the author's turbinotome. 
 
 Fig. 186 
 
 The removal of the middle turbinate with the author's turbinotome. 
 
 (e) As the anterior and posterior ethmoidal arteries supply the middle 
 turbinate, hemorrhage may be free and persistent. If the patient is in a 
 hospital, no dressing other than a dusting powder of bismuth or bismuth- 
 iodine need be applied. If, however, the patient is at home, and is 
 not easily accessible to the operating surgeon or his assistant, the space 
 between the line of attachment of the turbinate and the septum should 
 be firmly packed with a strip of sterile gauze dusted with bismuth. 
 This may be left in position for twenty-four hours. The nasal chamber 
 should subsequently be kept free from secretions by frequent irrigations 
 with sterile normal salt solution or by packing the nose lightly with a 
 10 per cent, aqueous solution of ichthyol, which should be removed 
 after twenty or thirty minutes. 
 
THE AUTHOR'S COMPLETE ETHMOIDAL OPERATION 233 
 
 Meningitis has occasionally occurred after turbinotomy, probably on 
 account of the tampon introduced. 
 
 The Author's Method of Removing the Ethmoidal Cells and Middle 
 Turbinal En Masse. — The operation for the complete exenteration 
 of the ethmoidal cells en masse was devised by the auther four years 
 ago for the purpose of obtaining the specimens for examination. I have 
 long believed that a better understanding of the local pathology might 
 be had if the diseased conditions were thus exposed, than if the tissues 
 were removed piecemeal or with a curette. I also think, that, though 
 postmortem observations are valuable and instructive, those made 
 upon specimens removed en masse from living subjects are much more 
 so. With these motives in mind I have endeavored to obtain material 
 upon which to base conclusions concerning sinuitis complicated with 
 polypoid growths in the ethmoid region. 
 
 Lateral view of the middle turbinate and ethmoidal cells removed en masse by the author's 
 operation. P, P,P,P,P, polypi; A, beginning polypoid degeneration. 
 
 A Specimen. — The specimen shown in Fig. 187 consists of the 
 right middle turbinated body, five posterior ethmoidal cells, the bulla 
 ethmoidalis, and five polypi. Three of the polypi grew from beneath 
 the anterior end of the middle turbinated body, above the hiatus semi- 
 lunaris, just anterior to the upper anterior border of the bulla ethmoidalis. 
 The other and smaller polypi were within the ethmoid cells. The fact 
 that some of the polypi were concealed within the posterior ethmoid 
 cells, illustrates the futility of only removing the visible tumors, and 
 explains why the removal of the exposed growths is so frequently 
 followed by the appearance of others in the same or in a closely 
 related region. 
 
 The Author's Operation. — The general method of procedure is based 
 upon the anatomical observation that the ethmoidal cells have but three 
 planes of attachment (Fig. 188), namely: (a) to the anterior wall of the 
 sphenoid bone, (b) to the cranial plate, and (c) to the outer or orbital 
 wall of the nose. If, therefore, these three planes of attachment are 
 incised, a large portion of the lateral half of the ethmoid body (including 
 the posterior ethmoidal and one or more of the anterior ethmoidal cells, 
 and the middle turbinated body) is detached within the nasal chambers, 
 from which it may be readily removed. 
 
234 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 The instrumentarium (Figs. 189, 190 and 191) required for this 
 operation consists of one instrument, supplemented by two others, which 
 are only occasionally required. The important one consists of a short 
 blade set at a right angle to a longer blade which is parallel with the 
 shank of the instrument. The short blade makes the incision along the 
 
 anterior wall of the sphenoid, and 
 Fig. 188 is then drawn forward and makes 
 
 the incision along the cranial plate; 
 when instrument is drawn forward 
 the long blade makes the incision 
 along the orbital wall and thus com- 
 pletes the excision of the ethmoid 
 cells and middle turbinated body. 
 
 Technique. — (1) Anesthesia is in- 
 duced by massage of the mucous 
 membrane of the middle and supe- 
 rior meatuses and the corresponding 
 portion of the septum with a small 
 cotton-wound applicator, the cotton 
 being slightly moistened and dipped 
 in powdered cocaine. The applica- 
 tions should be made at intervals of 
 from five to ten minutes to the areas 
 previously named until complete 
 anesthesia is induced. If preferred, 
 the operation may be done under 
 general anesthesia. 
 (2) The exenteration is accomplished by the following procedures: 
 
 (a) Introduce the author's ethmoid knife (Fig. 189) with the short 
 blade turned upward through the middle meatus until it impinges against 
 the lower portion of the anterior wall of the sphenoid bone, or until 
 it engages the posterior end of the middle turbinated body (Fig. 193). 
 During this procedure the handle of the instrument is turned horizontally 
 across the opposite side of the face (Fig. 192, position a). The short 
 blade is then forced outward into the tissues in front of the sphenoid. 
 This procedure is facilitated by moving the instrument backward and 
 forward over a distance of about one-fourth of an inch, as these move- 
 ments cause the short blade to penetrate the tissues to the depth of the 
 orbital wall and thus cut the ethmoid cells from their anterior attachment 
 to the sphenoid body. These movements also engage the short blade 
 behind the posterior end of the middle turbinated body. 
 
 (b) The handle of the instrument is then rotated forty-five degrees, 
 to position b, Fig. 192. The short blade is then forced upward to the 
 junction of the anterior wall of the sphenoid with the cranial plate, care 
 being taken to have the long blade pass between the middle turbinated 
 body and the outer wall of the nose. When the operator is assured that 
 the blades of the knife are in their respective positions he should work 
 them upward parallel with the anterior wall of the sphenoid until the 
 
 Scheme showing the chief attachments of 
 the ethmoidal cells (E E) to the cranial plate 
 of the frontal above and to the inner orbital 
 walls on the outer aspect. The ethmoid is 
 not attached to the cribriform plate. It is 
 obvious that if these planes of attachment 
 are severed that the ethmoidal cells and the 
 middle turbinates will be entirely detached. 
 
THE AUTHOR'S OPERATION ON THE ETHMOID CELLS 235 
 
 cranial plate is reached. The short right-angle blade should be forced 
 upward in front of the anterior wall of the sphenoid until it strikes 
 against the cranial plate, the long perpendicular blade resting against 
 
 Fig. 189 
 
 
 The author's angular ethmoid knives. 
 
 Ficj. 190 
 
 The author's hook ethmoid knife. 
 
 Fig. 191 
 
 The author's middle turbinal knife. 
 
236 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 the orbital wall of the nose. The blades are not drawn forward as in 
 making a clean cut, but are wiggled or rotated slightly in their respec- 
 tive axes. This is done in order to fracture the cell walls in front of 
 
 Fig. 192 
 
 \ ,'b 
 
 Showing the three positions (a, b, c) of the ethmoid_knife, in the successive steps of the author's 
 exenteration of the middle turbinate and ethmoid cells en masse. 
 
 Fig. 193 
 
 Fig. 194 
 
 The first step of the author's exenteration 
 of the middle turbinate and ethmoid cells and 
 polypi en masse. The instrument in position 
 a, Fig. 192. 
 
 The second step of the author's ethmoida 
 operation. The instrument in position b, Fig. 
 192. 
 
 the blades, which then readily cut the mucous membrane. The instru- 
 ment is thus brought forward to the anterior attachment of the middle 
 turbinated body (Figs. 194 and 195). 
 
THE AUTHOR'S OPERATION ON THE ETHMOID CELLS 237 
 
 (c) As the nasal chamber is quite narrow in its anterior portion, the 
 handle of the instrument should be rotated another forty-five degrees, 
 position c (Figs. 192 to 195). This turns the short right-angle blade 
 downward into the nasal chamber and away from the septum. The 
 knife should then be drawn forward and downward to complete the 
 severance of the tissues. This being accomplished, the instrument is 
 withdrawn through the vestibule of the nose. This movement of the 
 instrument usually delivers the severed ethmoid mass from the nose; 
 otherwise, it should be gently seized with forceps and withdrawn. 
 
 If it is found that the specimen is still attached to the nasal walls by 
 some fibers the blunt hook knife (Fig. 190) should be introduced between 
 the specimen and the outer wall of the nose and the attachments severed 
 with it. 
 
 (d) The blood should be mopped from the nasal chambers and the 
 remaining fragments of cells should be broken down with the curette. 
 This completes the operation. 
 
 The Dressing. — If there is serious hemorrhage the upper or ethmoidal 
 region of the nasal chamber should be packed with a one and one-half 
 inch strip of gauze impregnated 
 
 with the subnitrate of bismuth fig. 195 
 
 powder. The bismuth prevents 
 decomposition and infection, and 
 thus wards off the dangers of 
 septic absorption. The gauze 
 should be introduced against the 
 anterior wall of the sphenoid, 
 and folded and packed until the 
 upper half of the nasal cavity is 
 completely filled with it. Stout 
 dressing forceps should then be 
 introduced beneath the dressing, The third and finaI ste ^ of the author' 
 
 „.i ii 1 1 i-f?, ] • 1 enteration of the middle turbinate and the eth- 
 
 and the whole lifted in order moid ceUs m masse . The instrument in position 
 
 to compress it into the area c, Fig. 192. 
 which has been operated on. The 
 
 dressing should be removed in from one to twenty-four hours. The 
 subsequent treatments consist in lightly packing the nose with cotton 
 tampons saturated with a 10 per cent, aqueous solution of ichthyol or 
 of argyrol. These applications should be repeated daily and left in 
 place twenty minutes. This mode of treatment is more effective in 
 removing the secretions and sterilizing the wounded surface than irri- 
 gations. 
 
 Never introduce nasal tampons unless forced to do so on account 
 of profuse hemorrhage, as they may cause infection and meningitis. 
 Firmly packed dressings are dangerous. Personally, I rarely pack the 
 nose, as I find severe hemorrhage rare. 
 
 The Complications. — Hemorrhage. — (a) Hemorrhage nearly always 
 attends the operation, and it may either persist, or appear later as* a 
 secondary hemorrhage, though the latter is comparatively rare. When 
 
 S ex- 
 
238 THE NOSE AND ACCESSORY SINUSES 
 
 we remember that the ethmoidal region receives its blood supply from 
 the anterior and posterior ethmoidal and the sphenopalatine arteries 
 the possibility of a severe hemorrhage is apparent. By packing the nose 
 as described, this complication may be controlled. A slight sero- 
 sanguineous oozing may continue for twenty-four to forty-eight hours 
 in spite of the gauze packing, though it is of no serious consequence. 
 If the patient is operated on in a hospital and remains there for three 
 days, it will rarely be necessary to pack the nose. The activity incident 
 to leaving the physician's office and going home increases the blood 
 pressure, and, as a consequence, the chances of hemorrhage are greatly 
 increased, whereas if the patient remains quiet in a hospital the danger 
 is greatly diminished. 
 
 (b) Emphysema of the Orbital Tissues. — The lamina papyracea of the 
 orbital wall may be fractured in the operation, and upon blowing the 
 nose may admit air into the cellular tissue of the orbit. This occurred 
 twice in my practice but in neither instance did it inconvenience the 
 patient, as it disappeared in one or two days. 
 
 (c) Orbital Infection, Cellulitis. — It is within the range of possibility 
 for infection of the orbital tissues to occur subsequent to an ethmoid 
 operation, though I have never observed it in an experience embracing 
 four hundred operations. The orbital plate while thin is very resilient 
 in the living, and is not easily fractured. 
 
 (d) Meningitis. — Meningitis following the ethmoid operation is rare. 
 The cribriform plate of the ethmoid and the cranial plate of the frontal 
 bone are not easily fractured and in my experience have never been 
 fractured. The chief point to be mentioned concerning them is that the 
 operation should not be performed if a latent chronic meningitis is 
 already present, as it may cause an acute exacerbation and extension 
 which may prove fatal. The chief subjective symptom of latent 
 meningitis is a severe headache. When this is present the operation 
 should be postponed until it has been proved that it is not due to 
 meningitis. If there is any doubt Quincke's spinal puncture should 
 be made, some of the spinal fluid withdrawn, and subjected to the 
 proper examinations. In one case of this description meningitis was 
 demonstrated to be persent. 
 
 (e) Nasal Stenosis from Swelling of the Nasal Mucous Membrane. — 
 This complication has occurred several times in my practice and has 
 always been due to a partially severed fragment of the middle turbinated 
 body which has been left in the nasal chamber. This was especially 
 true of my earlier operations in which I had not perfected the technique 
 in its present form. Since performing the operation as described in this 
 section this complication has not occurred . 
 
 I wish to say in conclusion that the operation has given me greater 
 satisfaction, and in properly selected cases has given better results than 
 I have been able to obtain by any other method of operating. 
 
EXTERNAL OPERATIONS UPON THE ETHMOID SINUSES 239 
 
 EXTERNAL OPERATIONS UPON THE ETHMOID SINUSES. 
 
 Moure's External Ethmoid Operation. — This operation may be per- 
 formed in those cases in which extensive necrosis and polypi are present 
 in the ethmoidal region upon both sides, as it exposes the field of operation 
 better than any other method. It may also be used to expose large 
 tumors in this region. 
 
 Technique. — (a) The operation should be performed under general 
 anesthesia, though it may be done under local injections of Sehleich's 
 mixture combined with local cocaine anesthesia of the nasal mucous 
 membrane. 
 
 (6) Insert postnasal tampons, one in either nostril, to prevent the blood 
 entering the trachea. 
 
 Fig. 196 
 
 Moure's operation upon the anterior ethmoidal cells. The dotted line a indicates the area of bone 
 removed from the lateral wall of the nose to expose the cells. 
 
 (c) Make an incision along the ridge of the nose from a point midway 
 between the eyebrows, extending downward to the nasal opening on 
 the side to be operated on, at the junction of the cutaneous septum 
 with the ala or wing of the nose. 
 
 (d) Elevate the soft tissues, including the periosteum, as shown in 
 Fig. 196. 
 
 (e) Resect the nasal bone and the frontal process of the maxilla, as 
 shown in the area encircled by the dotted line (a) in Fig. 196 
 
 (/) When the ethmoidal labyrinth has been thus exposed, the entire 
 ethmoid region may be thoroughly exenterated with a curette 
 
 If the disease is well advanced, that is to say, if there are polypi and 
 granulations, every vestige of the cells should be removed. The cranial 
 plate, the os planum (paper plate of ethmoid) or orbital wall, and the 
 lacrymal bone which is adjacent to the anterior cells should be gently 
 but thoroughly curetted until they are smooth. In addition to these 
 
240 THE NOSE AND ACCESSORY SINUSES 
 
 surfaces the ethmosphenoidal wall (posterior limit of the ethmoidal 
 cells) should also be thoroughly curetted. If all these surfaces are cleared 
 with the curette and the anterior and posterior ethmoidal labyrinths are 
 separated from their attachments, the cells and the middle turbinated 
 body may be removed through the nasal wound or through the anterior 
 naris. 
 
 (g) The space from which the cells have been exenterated may be 
 packed with a strip of gauze in front of the postnasal tampon on the 
 side operated upon, and the postnasal tampon removed from the 
 other side. 
 
 (Ji) The skin and periosteal incision should be closed with fine silk- 
 worm sutures. 
 
 Fig. 197 
 
 Exposure of the anterior ethmoidal cells through the inner wall of the orbit. This method of 
 procedure is adapted to those cases complicated by orbital cellulitis. 
 
 (i) Watch the case, and should granulations form at any point touch 
 them lightly with carbolic or chromic acid. Should points of suppuration 
 be found, probing should be done with a view to tracing them to their 
 sources. If the cause is found to be a cell which, through error, was 
 not removed, or which was inaccessible, as an anterior ethmoidal cell 
 extending over the orbital cavity or a posterior ethmoidal extending to the 
 lateral side of or behind the sphenoidal sinus, steps should be taken to 
 maintain a patulous opening for drainage purposes. All granulations 
 should be removed from the point of suppuration as rapidly as they 
 appear. Persistent after-treatment as described above will often be 
 rewarded by a cure of the case. 
 
 Orbit o- ethmoid Operation. — (a) Make the Killian incision and elevate 
 the tissues and periosteum at the inner aspect of the orbit, as shown 
 in Fig. 197. (b) Remove the nasoorbital plate of bone and curette the 
 
THE SPHENOIDAL OPERATION 
 
 241 
 
 ethmoidal cells through the opening. The orbital tissue should also be 
 explored and the pus evacuated if present. Maintain external drainage 
 until the discharge ceases, and allow the wound to heal by granulation 
 from the bottom. 
 
 THE SPHENOIDAL OPERATION. 
 
 The preliminary operative procedure for reaching the sphenoidal 
 sinus consists of the complete removal of the middle turbinated body, 
 thus exposing the ostium sphenoidale to view. 
 
 I use Hajek's sphenoidal forceps because they are strong and remove 
 the anterior wall completely. One forceps cuts upward and the other 
 downward. If the osteum sphenoidale is small it should first be enlarged 
 with a curette. The upward 
 
 cutting forceps should then be FlG - 198 
 
 introduced and the upper por- 
 tion of the wall removed. By 
 turning the forceps to either 
 side the lateral portion of the 
 wall may be removed. Next 
 introduce the downward cut- 
 ting forceps (Fig. 198) and re- 
 move the lower portion of the 
 wall. The wall near the floor 
 of the sinus is quite thick, but 
 is readily removed with Hajek's 
 forceps. When the wall is en- 
 tirely removed the opening is 
 often one-half by three-fourths 
 of an inch in area, and the 
 interior of the sinus may be 
 inspected by reflected illumina- 
 tion. When the mucous mem- 
 brane is normal it is pale, and by contrast with the nasal mucous mem- 
 brane appears almost white. Under probe pressure, it is thin, firm, 
 and slightly resilient. When diseased, it is more red, edematous, and 
 thickened. In some cases the sinus is filled with granulation tissue or 
 polypi. 
 
 When the anterior wall is removed and the mucous membrane is 
 diseased it should be thoroughly curetted. 
 
 The after-treatment consists of irrigations and the topical applications 
 of a 10 per cent, aqueous solution of ichthyol. As there is a marked 
 tendency for the mucous membrane to reform over the opening in the 
 sinus, it may be necessary to remove it from time to time to maintain 
 ventilation and drainage. This is easily accomplished, as the middle 
 turbinate has been previously removed and the tissue to be removed is 
 membranous. The after-treatment may extend over many weeks. 
 16 
 
 Removing the anterior wall of the sphenoidal 
 sinus with the Hajek forceps. The distal blade of 
 the forceps is introduced through the osteum sphe- 
 noidale and the bony wall removed by successive 
 bites. 
 
CHAPTEE XII. 
 
 NASAL NEUROSES. NASAL HYDRORRHEA. CEREBROSPINAL 
 
 RHINORRHEA. 
 
 NEUROSES OF OLFACTION. 
 
 The neuroses of olfaction are characterized by either (a) a perverted 
 sense of smell (parosmia), (6) oversensitiveness to olfactory stimuli 
 (hyperosmia), (c) a partial loss of the sense of smell (hyposmia), or 
 (d) total loss of the sense of smell (anosmia). 
 
 Parosmia. — Parosmia is characterized by a perception of imaginary 
 odors and may be due to pathological changes in the olfactory brain 
 centre. Inflammatory disease of the mucous membrane in the attic 
 of the nose may also produce parosmia by overstimulating the nerve 
 endings. It usually accompanies lesions of the central brain, although 
 it occasionally occurs in hysteria, hypochondria, epilepsy, insanity, and 
 syphilis. 
 
 Hyperosmia. — Hyperosmia is characterized by an oversensitiveness 
 to olfactory stimuli — that is, the perception of odors is exaggerated. 
 The most delicate perfumes or odors not ordinarily perceived are recog- 
 nized even to the point of unpleasantness. In some cases the perception 
 of odors persists after the source of the odor is removed, and in this 
 respect the condition approaches parosmia. 
 
 It may be due to an irritation of the olfactory lobes, hysteria, neuras- 
 thenia, hypochondria, sexual disorders in women (especially at the 
 menstral period), and to the lowered nervous forces accompanying 
 wasting diseases. 
 
 Hyposmia. — Hyposmia is characterized by a partial loss of smell, 
 either from an impairment of the mucous membrane of the attic of the 
 nose, the nerve endings, the bulb, or the brain centre. The impairment 
 is only great enough to obtund the perception of odors without totally 
 destroying it. 
 
 Anosmia. — xAnosmia is characterized by a total loss of the sense of 
 smell, the pathological lesion being more extensive than that found in 
 hyposmia. 
 
 I have often seen cases in which the total loss of smell was due to 
 a blocking of the olfactory fissure by an enlargement of the middle tur- 
 binate, which was relieved by its removal. These cases were also com- 
 plicated by ethmoiditis and sphenoiditis, but the loss of the sense of 
 smell was not due to the inflammatory disease, as the ability to perceive 
 odors was immediately restored by the removal of the middle turbinate. 
 If it had been due to disease of the mucous membrane, considerable 
 
SENSORY, VASOMOTOR AND REFLEX NEUROSES 243 
 
 time would have elapsed before regeneration could have taken place. A 
 cold in the head is a frequent cause of transient anosmia. 
 
 Odors reach the attic of the nose by either the anterior or the posterior 
 nares, hence any condition of the septum or of the tissues of the outer wall 
 of the nose wdiich blocks the anterior or posterior nares may produce 
 anosmia. The lesion may be in the nerve endings, as in atrophic rhinitis, 
 in the nerve, or in the olfactory brain centre. Anosmia of intranasal 
 origin may be unilateral or bilateral according to the location of the 
 obstructive lesion. In such cases the sense of smell may be restored by 
 the proper surgical procedure within the nose. If, however, the lesion 
 is in the olfactory nerve or brain centre a cure is scarcely possible. 
 
 SENSORY, VASOMOTOR AND REFLEX NEUROSES. 
 
 Hyperesthetic Rhinitis; Hay Fever— Hyperesthetic rhinitis, or hay 
 fever, is characterized by annual paroxysms of sneezing accompanied by 
 a severe and prolonged coryza and asthma. 
 
 Etiology. — The Predisposing Causes. — The predisposing causes of 
 hyperesthetic rhinitis are constitutional, local, climatic, geographical, 
 racial, and altitudinal. 
 
 (a) The constitutional causes are a neurotic temperament, chemical 
 changes in the glands which secrete mucus (D. Braden Kyle), and gout 
 and rheumatism. 
 
 The neurotic temperament is difficult to define, but seems to be an 
 unstable condition of the nervous system, wherein there is either an 
 excess or a decrease in the nervous energy. Some physicians claim that 
 the nervous disturbance is due to a faulty metabolism whereby certain 
 toxic substances are liberated in the blood current. Thus a gouty or a 
 rheumatic diathesis is held to be the basic cause. It is obvious, however, 
 that there must be a reason for the gouty or rheumatic expression. It 
 appears impossible in the present state of our knowledge to define clearly 
 the conditions which cause a nervous temperament. That hay fever 
 subjects are neurotic is generally accepted. Why they are neurotic 
 is a much mooted question, concerning which many ingenious theories 
 have been advanced, but none of which are convincing. 
 
 (b) The local causes of hyperesthetic rhinitis are various. A perfectly 
 healthy nasal mucous membrane on a normally placed bony frame- 
 work is not often affected by hay fever. On the other hand, an apparently 
 healthy mucous membrane on a normally placed bony framework may 
 be affected. I have seen cases in which there was no obstructive septal 
 deformity and no absolute occlusion of the olfactory fissure by turbinal 
 enlargement. The only noticeable morbid lesion was a slight redness 
 of the mucous membrane over the anterior end of the middle turbinated 
 bone. These cases were also subject to occasional attacks of severe 
 coryza with copious purulent discharge. During the interim between 
 the attacks of coryza no symptoms were complained of, but an examina- 
 tion of the nose showed the reddened and slightly boggy edematous con- 
 
244 THE NOSE AND ACCESSORY SINUSES 
 
 dition of the anterior portion of the middle turbinate. While I do not care 
 to promulgate a new theory as to the etiology of hay fever, I have been 
 impressed with the possible relationship of catarrhal sinuitis, particularly 
 ethmoidal and frontal, to hay fever. In some cases the surgical treat- 
 ment of the sinuitis was followed by a relief of the hay fever. It is possible 
 that the catarrhal discharge so irritates the nasal mucous membrane 
 as to make it susceptible to the irritation of the pollen of certain plants 
 and grasses. The difficulties in the way of diagnosticating catarrhal 
 sinuitis have been so great that it has usually been unrecognized. With 
 our present knowledge its detection should be more often made. It is 
 now possible, therefore, to study the relationship existing between 
 sinuitis and hay fever, and I have some confidence that such a relation- 
 ship will be satisfactorily established. 
 
 The late Dr. Schadle recently called attention to the possibility of 
 relationship between maxillary sinuitis and hay fever. Whether or 
 not such a relationship actually exists, we must recognize the fact that 
 the local hyperesthesia probably has an anatomical or inflammatory 
 origin. The hypersensitiveness does not "happen," but has a definite 
 cause. Inasmuch as sinuitis, either catarrhal or suppurative, is often 
 associated with hay fever, it seems plausible to conclude that the irri- 
 tation attending the discharge of the secretions over the nasal mucous 
 membrane may be the cause. The hypothesis is still further supported 
 by the clinical fact that some cases of hay fever are cured by successful 
 treatment of the sinuitis. 
 
 While the above hypothesis is based upon clinical observations, they 
 are too meagre to warrant final conclusions. They are sufficient, how- 
 ever, to justify the closest scrutiny of the sinuses in every case of hyper- 
 esthetic rhinitis (hay fever). Such a scrutiny should include the examina- 
 tion of the middle turbinal, the olfactory fissure, and the septum; trans- 
 illumination, and a skiagraph of the sinuses. In addition the patient 
 should be closely questioned concerning the presence of headache (chiefly 
 frontal), dizziness, especially upon stooping forward, and unilateral 
 disturbances of the ocular apparatus. The ocular disturbances may 
 include errors of refraction, ulcer of the cornea, or lesions of the retina 
 or other portions of the optic tract, and of any other of the structures 
 of the eyeball. The composite picture thus elicited should show con- 
 clusively either the presence or absence of an associated disease of the 
 sinuses. 
 
 Deflection of the septum, especially in the region of the middle turbinate, 
 or enlargement of the middle turbinate, causing contact between the 
 two, is another local factor in hyperesthetic rhinitis. 
 
 The "sneezing area" of the nose is at the points of contact between 
 the middle turbinate and the septum, hence the sneezing which is so 
 characteristic of this disease. As a rule, the sneezing ceases as soon as 
 the pressure is relieved. 
 
 Sensitive areas on the nasal mucous membrane of the septum and 
 the outer walls of the nose, which are reddened and slightly elevated 
 above the surface of the mucous membrane, predispose to the hyper- 
 
SENSORY, VASOMOTOR AND REFLEX NEUROSES 245 
 
 esthetic paroxysms. Whether they are due to some concurrent inflamma- 
 tion of the accessory sinuses, or to some change in the sensitive nasal 
 branches of the sphenopalatine ganglion, is not established. It is reason- 
 able to suppose that an inflammatory disease of the nose, attended with 
 an irritating secretion, which is characteristic of catarrhal sinuitis, might 
 affect the filaments of the terminal sensitive nerve and render them 
 extremely hypersensitive. The local vasomotor disturbance in the 
 same areas would cause their elevation above the surface of the mucous 
 membrane. 
 
 Polypi have long been considered a local predisposing cause of hay 
 fever. As these morbid growths are often secondary expressions of 
 sinuitis, the possibility of the causative relationship of this disease is 
 thereby strengthened. The polypi are usually found in the region of the 
 hiatus semilunaris, the border of the middle turbinate, or the posterior 
 ethmoidal cells. In the latter case they protrude through the olfactory 
 fissure into the middle meatus or are lodged above the middle turbinate 
 in the superior meatus. It is evident that the mere removal of the 
 polypi may not suffice to eradicate the irritation. The diseased sinuses 
 should also receive appropriate treatment. 
 
 (c) The climatic influence upon hay fever is well recognized as being 
 confined to the neighborhood of the forty-fifth parallel of the northern 
 hemisphere. The territory a few degrees either north or south of this 
 latitude is comparatively free from this disease. This is probably due to 
 the absence of the flora, the pollen of which is the chief exciting cause. If 
 a map of the United States were divided into four belts by lines drawn 
 through it from east to west the majority of the cases of hay fever would 
 be included within the third belt from the bottom, although many cases 
 would be found in the other belts. 
 
 (d) The geographical distribution of hay fever is instructive. It is 
 more prevalent in the United States than in any other country; England 
 ranks second. It is also present in Germany and France, though in 
 less degree. 
 
 (e) The racial influence in the predisposition to hay fever is marked. 
 It is more common in the English speaking races of the northern hemi- 
 sphere than among the French or Germans, though it is more or less 
 prevalent among them. 
 
 (/) Altitude has considerable influence in the causation of hay fever. 
 The disease is more prevalent in the low portions of the country than in 
 the higher altitudes, which are comparatively free from it. The annual 
 pilgrimages which are made into the mountains in the northern portion 
 of the Eastern States and into the cold, bracing atmosphere along the 
 shores of Lake Superior and the northern shores of Lake Michigan are 
 indicative of the benefits derived from altitudinal and climatic migrations. 
 
 (g) Age is an important factor in the causation of hay fever; it is 
 most common in persons between the twentieth and fortieth years of 
 life. 
 
 The Exciting Causes. — It is generally believed that the exciting causes 
 of hay fever or hyperesthetic rhinitis are the emanations from certain 
 
246 THE NOSE AND ACCESSORY SINUSES 
 
 plants and animals. It was at one time thought that all cases were 
 of vegetable origin in the haying season, hence the name. Subsequent 
 observations have shown that the exciting cause may emanate from 
 various plants and animals, chiefly the following: Graminaceae, solidago 
 virgo aurea (goldenrod), ambrosia artemisisefolia (rag- weed), cats, 
 dogs, horses, and cows. The emanation from grasses and other plants, 
 which cause the paroxysmal symptoms, is probably their pollen. In 
 1873 Blackley conducted a series of experiments with glycerin-covered 
 glass plates and observed the rise and fall of the intensity of the symp- 
 toms with the increase and decrease in the quantity of pollen within a 
 given area on the plates. From these observations he proved that the 
 pollen of certain plants was an exciting cause of the disease. Since then 
 many observers have reported that the emanations from animals are 
 also exciting causes. 
 
 The season has a characteristic influence upon the occurrence of 
 the paroxysmal attacks of hyperesthesia. This is due to the fact that 
 there are no emanations from plants except during the time they throw 
 off their pollen. The disease occurs most frequently in August and 
 September and less frequently in June, when the roses are in bloom. 
 
 An analysis of the causes of hyperesthetic rhinitis resolves the etiology 
 into three groups as follows: (1) A constitutional or neurotic habit. 
 (2) Local morbid lesions of the nose and accessory sinuses. (3) The 
 pollen of certain plants and emanations from certain animals. 
 
 Pathology. — The structural changes in the affected nasal mucous 
 membrane consist of hyperemia, edema, and (after repeated attacks) 
 hyperplasia of the turbinated bodies. The presence of nasal polypi in 
 a hay fever case is scarcely to be considered a pathological lesion of this 
 disease, but rather a result of inflammation of the sinuses. The elevated 
 hypersensitive areas are chiefly found at the terminal endings of the 
 sensitive branches of the sphenopalatine ganglion, and are due to the 
 increased hyperemia in these areas, while the hypersensitiveness is due to 
 the irritation of the sensitive endings of the nerve fibers. 
 
 If the disease were a pure neurosis there would be other nervous 
 phenomena somewhat proportional to the intense paroxysms of the 
 hay fever, whereas if it were a true inflammatory disease there would be 
 greater structural changes. The disease is probably a combination 
 of a moderately severe neurosis, with local morbid changes which give 
 rise to the local irritation of the nerve endings of the sensitive branches of 
 the sphenopalatine ganglion, upon which, at favorable seasons of the year, 
 the pollen of certain plants and the emanations from certain animals 
 lodge, and give rise to the phenomena characteristic of hyperesthetic 
 rhinitis. 
 
 Symptoms. — The symptoms of hay fever are those of an acute coryza, 
 as malaise, elevation of temperature, sneezing, serous discharge, head- 
 ache, etc., to which are added an itching in the region of the soft palate 
 and the median palpebral commissures (inner canthi) of the eyes, and 
 asthma. The sneezing is paroxysmal and may be excited by slight 
 draughts of air, bright sunlight, particles of dust, and psychical impres- 
 
SENSORY, VASOMOTOR AND REFLEX NEUROSES 247 
 
 sions, such as the consciousness of being observed by another person, 
 or the thought of his own condition. The sneezing is accompanied by 
 profuse lacrymation and serous nasal secretion and by suffusion of the 
 conjunctiva. The profuse serous discharge from the nasal mucosa is 
 followed by a contraction of the swollen mucous membrane, which 
 brings temporary relief. 
 
 The serous secretion from the nose is acrid, and excoriates the ala? 
 of the nose and the upper lip. (I have observed the same phenomena 
 in some cases of inflammation of the ethmoidal cells when pus was 
 absent.) The secretions become seromucous and in some cases puru- 
 lent in character. 
 
 Intermittent and alternate stenosis of the nose is present. During the 
 continuance of the nasal stenosis the patient suffers from the paroxysmal 
 sneezing and asthma, and from headache, lacrymation, and diffidence. 
 The diffidence is extreme, and the patient dreads the approach of another 
 person, especially if he is a stranger or someone with whom he is ill at 
 ease. 
 
 The pharynx is often dry and painful upon deglutition. The tonsils 
 are not usually inflamed, although they may be. 
 
 Tinnitus aurium is frequently present, and is due to a swelling of the 
 mucous membrane of the Eustachian tubes. 
 
 The appetite is impaired, and there is a corresponding loss of weight. 
 
 Prognosis . — A conservative prognosis should always be given. So 
 many methods of treatment have been promulgated, with the assurance 
 of sucess, and have proved wholly inadequate, that I doubt the value of 
 nearly all of them. Upon theoretical grounds it appears that if either one 
 of the three major causes of the disease is removed a cure must follow. 
 If, for instance, the local morbid lesions of the nose are overcome, the 
 patient should be freed from the hay fever; if the neurotic habit is over- 
 come, the hay fever should be cured; and if the patient is removed from 
 the influence of the pollen, or is rendered immune by serums or antitoxins, 
 he should be cured. Many a patient has been treated and operated upon 
 with a view to the total removal of the local morbid lesions, but the hay 
 fever paroxysms continued from year to year without abatement. Many 
 a hay fever sufferer has been persistently treated for neurosis, and 
 the various dyscrasias causing it, without effect upon the hay fever; 
 and many a patient has been sent year after year to the mountains or to 
 the northern lakes without preventing the recurrence of the paroxysms 
 the following year. On the contrary, a few patients have been cured 
 permanently by recourse to one or more of the foregoing methods of 
 treatment. The same is true of other methods; a few are cured, though 
 many are not benefited at all. A remedy that is efficacious for one subject 
 is totally ineffective when applied to another. 
 
 Either the existing ideas concerning the etiology, or our methods 
 of diagnosis of the local morbid lesions are wrong — probably both. 
 Nevertheless, we can only act upon present knowledge. We must, there- 
 fore, continue to remove the local morbid lesions from the nose and 
 accessory sinuses, for this is the most hopeful method of treatment, 
 
248 THE NOSE AND ACCESSORY SINUSES 
 
 unless the patient is removed to a place where the pollen or other irritant 
 peculiar to his case is absent; or we must administer a serum that is an 
 antidote to the pollen in question. In the meantime our knowledge of 
 the morbid processes in the nose and accessory sinuses is rapidly ad- 
 vancing, and it may be that we will soon be able to cure this elusive and 
 distressing disease. 
 
 Treatment. — The treatment may be divided into five groups: namely, 
 (a) the treatment of the dyscrasias; (6) the removal of the local morbid 
 processes in the nose and the accessory sinuses; (c) the removal of the 
 patient from the influence of the pollen or other emanations which act as 
 the exciting cause of the disease; (d) the immunization of the patient; 
 and (e) the relief of acute symptoms. 
 
 The Treatment of the Neuroses and Dyscrasias. — The treatment of 
 the neuroses and dyscrasias due to modern civilization is a very difficult 
 undertaking. We are in a domain of pathological entities the forms 
 of which are shadowy and the definitions obscure. We are dealing with 
 unknown quantities upon hypotheses not yet proved. Failure is the 
 almost inevitable result. While all this is true, something may still be 
 done to improve rheumatic and gouty diatheses and the ill-defined 
 neurotic manifestations. The intestines and stomach can be flushed by 
 lavage and by saline cathartics. The kidneys and skin can be made to 
 eliminate more freely, and the hemoglobin of the blood can be raised so 
 as to attract more oxygen. These and other processes may be stimulated 
 or modified so that the neurotic state of the nervous system and the 
 various constitutional disorders are in a degree improved. Indeed, the 
 treatment should include some of these measures, although a cure may 
 never be effected by them. According to Major Woodruff, excessive 
 exposure to sunshine is a cause of neurasthenia, and this may in a 
 measure account for the greater prevalence of hay fever in America. 
 
 Treatment of the Local Morbid Lesions. — (a) The circumscribed sensi- 
 tive areas should be cauterized with a flat electrode at white heat, 
 without the use of a local anesthetic. The use of an anesthetic would 
 make it impossible to find the sensitive areas, and, furthermore, the 
 cauterization is superficial and lasts only a fraction of a second. The 
 current should be turned on until the point of the electrode is almost 
 instantly brought to a white heat. It should then be introduced cold 
 into the nose, a sensitive area found with it, and the current turned 
 on by pressing the button on the handle. The moment the white heat 
 is seen in the nose the button should be released and the electrode 
 removed. Another sensitive area should be found and cauterized in 
 like manner. From four to five sensitive areas may be cauterized at a 
 sitting. The treatment may be repeated in from five to seven days. 
 
 (b) Nasal catarrh, if present, should be treated during the period 
 of quiescence; that is, when the hyperesthetic rhinitis is not active. (See 
 various forms of Chronic Rhinitis.) 
 
 (c) Nasal polypi should be removed during the period of quiescence, 
 although they may be removed during the acute paroxysms. (See Nasal 
 Polypi or Myxoma.) 
 
SENSORY, VASOMOTOR AND REFLEX NEUROSES 249 
 
 (d) Deviations of the septum which cause any type of rhinitis, or which 
 contribute to the causation of sinuitis, should be corrected during the 
 period of quiescence, according to the methods described under Devia- 
 tions of the Septum. 
 
 (e) Sinuitis, either catarrhal or suppurative, should be treated during 
 the period of quiescence, according to the methods described under the 
 Inflammatory Diseases of the Nasal Accessory Sinuses. 
 
 The late Dr. Schadle has reported that irrigation of the maxillary 
 sinus results very favorably. At first a saponaceous substance is washed 
 away, but the fluid finally comes away perfectly clear. Dr. Schadle 
 believed that the ostium maxillare is so large that it admits the irritating 
 substances which excite the paroxysmal attacks, and that when washed 
 from the antrum the symptoms are relieved. I doubt this explanation, 
 and am inclined to believe the relief is due to the lessened irritation of 
 the nasal mucosa bv the discharge from the antrum. 
 
 «/ o 
 
 I have known equally good results following the total exenteration of 
 the ethmoidal labyrinth via the nose. One patient was compelled for 
 three months each year to sleep in a sitting posture with her head upon 
 a table. Since the radical removal of her ethmoidal sinuses the only 
 manifestation of the old trouble is a mild asthma, which is present for 
 short intervals at any season of the year. I have since performed a 
 double Killian operation upon the frontal sinuses of this patient with 
 complete sucess. This operation has apparently had no influence on 
 the slight asthma. 
 
 It is obvious that it is inadvisable to treat the local morbid lesions 
 by surgical measures during the acute exacerbations, as to do so might 
 subject the nasal tissues to violent reactionary inflammation and to 
 septic infection. 
 
 The Protection of the Patient from the Pollen or Other Emanations which 
 Excite the Acute Paroxysms. — (a) Small, soft sponges may be worn 
 in the vestibules of the nose to filter the pollen and other irritating sub- 
 stances from the inspired air. They are sometimes effective, but, on 
 the whole, are unsatisfactory. A moistened handkerchief may also be 
 utilized for the same purpose by holding it close to the nasal openings. 
 At best, these devices afford temporary relief, and cannot be depended 
 upon throughout the paroxysmal period. 
 
 (6) The geographical treatment consists in the removal of the patient 
 to a place where the exciting emanations are absent. Lake Superior 
 or the Muskoka region in Canada and the Adirondack Mountains are 
 favorite resorts for many patients in the United States and Canada. 
 An extended ocean or lake trip is also a satisfactory method of escaping 
 from the emanations of the irritating pollen, etc. 
 
 While the geographical treatment is not always effective, it is nearly 
 always so if protracted over the entire period of the acute exacerbations. 
 Some patients may return before the expiration of this period without 
 experiencing a recrudescence of the acute symptoms, although this is 
 rarely so. Others are not relieved by a change of geographical location ; 
 at least, all cases are not relieved by a change to the same locality. Each 
 
250 "THE NOSE AND ACCESSORY SINUSES 
 
 patient must learn by experience the place best suited for him. On the 
 other hand, he may find relief for a number of seasons in one locality, 
 and upon returning the following year may experience but little or no 
 relief. Under these circumstances he should try another locality. If, 
 for instance, he has been going to the Lake Superior region or the 
 Muskoka Lake region, he should be sent to a higher altitude, as the 
 Adirondacks or the Rocky Mountains. 
 
 The Palliative Treatment. — Various local and internal remedies have 
 been advocated, but none of them are of universal value. They may 
 be tried in series in individual cases until one is found that gives relief. 
 
 (a) The extract of the suprarenal gland is often successfully used. 
 It should be prepared, according to Dr. H. L. Swain, by adding 10 to 20 
 grains of the powdered gland to one-half dram of cold, sterile water. 
 After stirring thoroughly, it should be filtered and a few drops of alcohol 
 added to prevent early decomposition. Boric acid, cinnamon- water, and 
 camphor-water may also be used to prevent decomposition. When 
 thus prepared it should be applied to the nasal mucous membrane with 
 a spray tube, or with thin pledgets of cotton pasted over the surface of 
 the mucous membrane. It is harmless, except in those occasional cases 
 in which it excites irritation and sneezing. S. Solis Cohen has used it 
 internally with success. 
 
 (6) Insufflation of the powdered sulphate of quinine into the nose has 
 been recommended. I have used it in a few cases with complete success, 
 and in many others without result. When it is effective the nasal mucous 
 membrane becomes dry and the turgescence disappears. The absorption 
 of the drug causes tinnitus. In one case two insufflations of 5 grains 
 each were followed by complete relief which lasted throughout the 
 paroxysmal season. This case was a mild one, beginning the latter 
 part of August. 
 
 (c) Alkaline and oleaginous solutions may be sprayed into the nose, 
 with temporary relief. In some cases a postnasal douche of boric acid 
 solution is soothing. Oil with menthol in 0.5 per cent, solution, or with 
 0.1 per cent, of formaldehyde, sometimes gives relief to the inflamed 
 membrane. The formaldehyde burns for a few seconds and is followed 
 by a grateful sense of relief. 
 
 (d) The itching at the inner canthi of the eyes may be relieved by 
 irrigating with boric acid or normal salt solution. 
 
 (e) The rays of the 500 candle-power incandescent lamp applied 
 for ten to twenty-five minutes over the face with the eyes closed, 
 at a distance of from twelve to eighteen inches, increase the speed of 
 the arterial venous currents. The passive congestion and edema are 
 thereby reduced and the relief is considerable. (See Leukodescent 
 Light and the Technique of Application.) The light should be applied 
 from one to four times daily. In those cases in which its use is attended 
 by marked relief a lamp may be installed in the patient's home. A lower 
 power than 500 candle-power is not recommended, nor is a cluster of 50 
 candle-power lamps as efficacious as a single 500 candle-power lamp. 
 The therapeutic value of the light is chiefly determined by the candle- 
 
SENSORY, VASOMOTOR AND REFLEX NEUROSES 251 
 
 power of a single lamp, no matter how many are connected in a series 
 or in a group. 
 
 (J) Powdered diphtheria antitoxin has been used locally with gratifying 
 results (Pierce). Numerous other local remedies have been recommended 
 from time to time, but have proved of little value after more extensive 
 trial. 
 
 (g) Antilithemic remedies, as the salicylate of soda, have been ex- 
 tensively used to counteract the uric acidemia with indifferent success 
 except in occasional cases. 
 
 Serum Treatment. — The serum treatment recently introduced by 
 Dunbar, while not perfected, affords relief in some cases. Sir Felix 
 Semon, Liebreich, and Lobe indorse Dunbar's serum treatment, with the 
 proviso that all the conditions recommended by him be observed. The 
 serum is prepared in liquid and powdered form, the powder being the 
 more stable and reliable. The solution may be applied to the conjunctiva 
 or the nasal mucous membrane. The object of the serum is to afford 
 immediate relief and ultimately to establish immunity. The conditions 
 attending its use are so complex that it is at present a rather unsatis- 
 factory remedy. 
 
 In my opinion, serum treatment will not solve the problem of the 
 management of hay fever or its kindred types of hyperesthetic rhinitis. 
 The predisposing factors are ignored in this method of treatment. There 
 are conditions which render the mucous membrane of the nose suscep- 
 tible to irritation by the toxins of the pollen and other substances which 
 excite hay fever. Heretofore we have regarded the neuroses and con- 
 stitutional dyscrasias, the various obstructive lesions of the septum, and 
 the catarrhal affections of the nasal mucous membrane as the predis- 
 posing causes. The treatment applied in accordance with these ideas 
 has generally been disappointing. In my opinion we must look beyond 
 the nasal chambers to the accessory sinuses for the real conditions 
 which predispose the mucous membrane of the nose to the irritation by 
 the pollen of certain grasses, flowers, etc. The irritation caused by the 
 more or less constant discharge from the sinuses is, I think, a rather 
 common cause of hay fever. Schadle has called attention to the relief 
 afforded by the irrigation of the maxillary sinuses. According to my 
 observations the exenteration of the ethmoidal sinuses (including the 
 removal of the middle turbinate) has apparently resulted in a cure 
 extending over three years. The sinuitis may or may not be purulent. 
 Indeed, the catarrhal type is often more irritating than the purulent, as 
 shown by the excoriations and fissures at the margin of the vestibules 
 of the nose. 
 
 In view of these facts I believe that the ultimate cure of hyperesthetic 
 rhinitis and asthma will not be found in the serum treatment, but in the 
 proper comprehension and treatment of catarrhal and suppurative 
 sinuitis. This will include the obstructive lesions of the septum and the 
 structures within the "vicious circle" of the nose. The neurotic element 
 is often so marked in these cases that any method of treatment may fail. 
 
 According to O. J. Stein the injection of a few drops of alcohol into 
 
252 THE NOSE AND ACCESSORY SINUSES 
 
 the mucous membrane of the nose at the point where the sensitive 
 branches of the sphenopalatine ganglion enter the nasal chambers (Fig. 2) 
 controls the acute symptoms in hay fever subjects. Three to four injec- 
 tions at intervals of a few days suffice to control the attack throughout 
 the season. 
 
 According to O. J. Stein, but two factors are necessary for the causa- 
 tion of hay fever, namely: (a) an internal irritant, which affects the 
 sensitive nerve filaments; and (6) an external irritant, as dust, cold, 
 light, the pollen of certain plants, etc., which affects the fifth nerve 
 supplying the nasal chambers. 
 
 The internal irritant is the result of faulty metabolism, which causes 
 what may be called the susceptibility of the individual, i. e. } a disturbance 
 of the normal functional equilibrium. 
 
 The external irritant may be dust, pollen, a draught, light, cold, heat, 
 pungent odors, the discharges from infected sinuses, etc. It need not 
 enter the nose to produce irritation, as any area supplied by the fifth 
 nerve may be the origin of the reflex symptoms. Hence a bright ray of 
 light entering the eye may irritate the hyperesthetic ciliary nerve filaments 
 and cause reflex symptoms in the nose, or a draught of air striking the 
 side or back of the head may produce nasal reflex phenomena. 
 
 The Technique. — (a) First correct any disturbance of metabolism and 
 nutrition that may be present. 
 
 (b) Remove the local and external causative irritating factors, such 
 as spurs and ridges of the septum, secretions from the sinuses and 
 sensitive areas, and protect the patient from the particular pollen that 
 poisons him, by instructing him to wear sponges in the vestibules of the 
 nose, or by sending him to some place where this pollen is absent. If 
 the eyes are the source of irritation, the patient should wear dark glasses. 
 
 (c) Reduce or temporarily abolish the sensibility of the nasal portion 
 of the fifth nerve. This may be accomplished in some measure by the 
 administration of certain drugs, as morphine, the bromides, atropine, 
 cocaine, etc. The action of these drugs is transient, and they may have 
 deleterious effects, and are not recommended, but on the contrary their 
 use for this purpose is condemned. 
 
 Stein's Treatment. — Dr. Stein recommends that the nasal branches 
 of the fifth nerve be desensitized by the injection of alcohol into the 
 nasal chambers. The nerve enters through the most anterior perfora- 
 tion in the cribriform plate (Fig. 199), and the needle should puncture 
 this point and be made to penetrate the nerve sheath. The method of 
 procedure is as follows: 
 
 (a) Apply a 10 per cent, solution of cocaine to the cribriform and 
 spheno-ethmoidal regions of the nasal chambers. 
 
 (b) The straight needle, previously sterilized, is attached to the glass 
 syringe which contains the alcohol. It is then carefully inserted into the 
 tissues just posterior to the nasal bone, i. e., the anterior extremity of the 
 cribriform plate (Fig. 199, a). Five drops of alcohol are then injected 
 and the needle is withdrawn. The other nostril is then similarly treated. 
 The posterior group of nerves is seldom treated at the first sitting, as in the 
 
ACUTE CIRCUMSCRIBED EDEMA OF THE NOSE 253 
 
 majority of cases Dr. Stein has found that the injection of alcohol into 
 the anterior group will control the symptoms. If, however, after a few 
 days no relief is experienced the posterior group of nerves may be given 
 an injection. For this purpose a longer needle with a curved tip is used, 
 as shown in Fig. 199, c. The posterior nerves may be reached by direct- 
 ing the curved needle tip outward, upward, and slightly backward at the 
 posterior extremity and lower border of the middle turbinate. After one 
 
 Fig. 199 
 
 Stein's method of treating hay fever, (a) The anterior point where the needle is inserted. (6) The 
 hypodermatic syringe filled with alcohol, (c) The posterior point where the needle is inserted. 
 
 to four treatments, the patient should have relief through the hay fever 
 season. No ill effects have occurred other than a slight hemorrhage, 
 and pain and dizziness of short duration. This treatment does not pro- 
 tect against the recurrence of the symptoms the following season. 
 
 Killian has suggested and successfully practised the injection of 
 cocaine into these nerves to produce anesthesia preliminary to intranasal 
 operations. 
 
 ACUTE CIRCUMSCRIBED EDEMA OF THE NOSE. CORYZA EDEMA- 
 TOSA. ACUTE CIRCUMSCRIBED EDEMA. 
 
 This affection may involve both the pharynx and larynx in the same 
 case. It is not an inflammatory affection, but is an edema of neurotic 
 origin, and probably results from some disturbance of the digestive tract. 
 It is quite like urticaria, though it involves the mucous membrane. It is 
 usually associated with other symptoms or diseases, as hay fever, urticaria 
 of the skin, headache, gastro-intestinal disturbances (as watery vomiting 
 and colicky pains), and itching. In Matas' case a distinct periodicity 
 was present, the edema recurring regularly between 11 and 12 a.m. 
 daily. In this case the toxin was probably the malarial plasmodium. 
 
254 THE NOSE AND ACCESSORY SINUSES 
 
 I reported a case in 1896 in which the angioneurotic edema came on 
 during an attack of hay fever. Gastro-intestinal disturbance was also 
 present. The edema involved the nose, soft palate, and hypopharynx. 
 The mucous membrane was swollen, gray, and semitranslucent. The 
 suffocative symptoms were severe, although at no time was there 
 imminent danger from this source. 
 
 Numerous punctures of the edematous membrane were made and 
 cocaine applied, after which the edema gradually disappeared. Free 
 saline catharsis should be induced. 
 
 NASAL HYDRORRHEA. RHINAL HYDRORRHEA 
 
 Nasal hydrorrhea is a symptom of some other nasal lesion rather 
 than a disease, and is characterized by thick, viscid, and slightly opales- 
 cent secretion more or less rich in mucin. The amount of discharge 
 varies from a few ounces to a pint or more in twenty-four hours. Accord- 
 ing to St. Clair Thompson, the secretion contains amorphous matter 
 and mucous corpuscles. The secretion when tested with alcohol or 
 acetic acid throws down a stringy precipitate like mucin. When the 
 precipitate is boiled with dilute sulphuric acid, a sugar-like material is 
 formed; this is probably due to the presence of mucin. The proteid is 
 coagulated by heat; it does not reduce Fehling's solution. Peptones and 
 proteoses are absent. The alcohol extract of the secretions contains no 
 reducing substance. The secretion may be distinguished from normal 
 cerebrospinal fluid by the presence of mucin and the absence of a 
 reducing substance. 
 
 Symptoms. — The clinical picture of nasal hydrorrhea shades off 
 in one direction into cases of what are generally called hay fever, with 
 symptoms of intense local irritation, while in the other direction it 
 may consist of a passive and almost painless watery discharge from the 
 nose. It is apparently a disease of adult life, which affects males and 
 females equally. Although it may be more marked on one side of the 
 nose than on the other, the flow usually comes from both nostrils. 
 When handkerchiefs are soaked with it they generally become stiff when 
 dry. In cerebrospinal rhinorrhea, on the other hand, the discharge is so 
 watery that handkerchiefs dry quite soft; and in this affection the dis- 
 charge is limited entirely to one nostril, unless there happens to be 
 some obstruction on the affected side, when it may make its way to the 
 opposite nasal fossa. When the fluid is of arachnoid origin, headache 
 or other mental symptoms are frequent, but are relieved by the discharge. 
 The disease is not accompanied by lacrymation or suffusion of the con- 
 junctiva, and photophobia, and it may occasionally give rise to sneezing, 
 especially in the morning. 
 
 In nasal hydrorrhea the feeling of malaise begins with the discharge 
 and only stops with its cessation. It is frequently ushered in with sneez- 
 ing, photophobia, and lacrymation. It rarely continues during sleep, 
 while cerebrospinal rhinorrhea continues day and night. It is very erratic 
 
CEREBROSPINAL RHINORRHEA 255 
 
 in its onset and in its intermissions, and is very dependent on external 
 influences and on conditions of health. Moritz Schmidt states that 
 some cases have been observed which were dependent on ulcer of the 
 stomach or biliary lithiasis. He defines the disease as a vasomotor rhinitis. 
 McBride recognizes the diversity of the conditions of which nasal hydror- 
 rhea may be but a symptom. I have seen cases in which the reactions 
 given by St. Clair Thompson were present, thus differentiating • the 
 condition from cerebrospinal rhinorrhea. 
 
 Treatment. — The treatment should be addressed to the morbid 
 nasal lesions, such as are found in hay fever or other forms of hyper- 
 esthetic rhinitis, or to any other pathological condition present in the 
 nose and accessorv sinuses. 
 
 CEREBROSPINAL RHINORRHEA. 
 
 St. Clair Thompson, in 1899, made a notable contribution to rhino- 
 logical literature when he described for the first time the escape of cerebro- 
 spinal fluid from the nose. Such cases had been previously regarded as 
 nasal hydrorrhea. Thompson's analysis of his and other cases, recorded 
 in the literature under various names, made the differential diagnosis 
 between cerebrospinal rhinorrhea and nasal hydrorrhea quite clear. 
 The subarachnoid fluid may, under conditions not yet clearly demon- 
 strated, escape from the cranial cavity through the nose without 
 apparent harm to the patient. The fluid is clear and watery in con- 
 trast to the slightly opalescent and viscid fluid of nasal hydrorrhea. 
 The dripping is constant and is free from taste, sediment, odor, 
 albumin, and mucin. It reduces Fehling's solution. 
 
 Etiology. — The etiology is as yet but little understood, although 
 Thompson is inclined to believe that there is some pathological change 
 in the contents of the skull leading to increased intracranial pressure. 
 In 17 out of 21 cases recorded there were cerebral symptoms, and 8 
 showed retinal changes. The following table prepared by St. Clair 
 Thompson gives the essential tests for cerebrospinal fluid: 
 
 1. The fluid is perfectly transparent like water, and contains no 
 sediment. 
 
 2. It is faintly alkaline in reaction, and either tasteless or slightly 
 salt. 
 
 3. The specific gravity is between 1005 and 1010. 
 
 4. It is not viscid, and gives no precipitate (mucin) on adding acetic 
 acid. 
 
 5. On boiling there is not more than a trace of coagulum of serum 
 globulin and serum albumin. 
 
 6. Cold nitric acid gives a precipitate which disappears on heating, 
 and separates again on cooling. 
 
 7. Saturation with magnesium sulphate should give a precipitate. 
 Saturation with sodium chloride should also produce a precipitate. 
 Ammonium sulphate should be tried if the abqve salts fail, 
 
256 THE NOSE AND ACCESSORY SINUSES 
 
 8. The liquid should give a pink or rosebud color with a trace of 
 copper sulphate and excess of caustic potash. 
 
 9. When boiled with Fehling's solution there should be a reduction 
 of the copper (due to pyrocatechin or some similar body). 
 
 10. The reducing substance may be obtained by evaporating to 
 dryness an alcoholic extract of the fluid. It is then found in the form 
 of needle-like crystals. 
 
 11. The aqueous solution of this residue does not ferment with yeast. 
 If applied to suspected cases, these tests will in future avoid any 
 
 question as to the true nature of cerebrospinal fluid when it escapes 
 from the nose. 
 
 Treatment. — The successful treatment of cerebrospinal rhinorrhea is 
 obviously almost impossible. Whatever may be done, extreme care 
 should be exercised to avoid infection of the nose, which might be com- 
 municated to the meninges or to the cerebrospinal fluid of the brain and 
 spinal cord. 
 
 ASTHMA. 
 
 Asthma may or may not be of nasal oirgin. The bulbar nuclei of the 
 fifth nerve has an anatomical connection with the vagus, hence it is 
 possible for an irritation in the nose to excite reflex phenomena in the 
 lower respiratory tract. The most common cause of asthma of nasal 
 origin is ethmoiditis accompanied by nasal polypi. In other cases 
 hypertrophy, hyperplasia, and other morbid lesions appear to cause it. 
 On the other hand, these conditions are often present without exciting 
 asthma. 
 
 Treatment. — The treatment of asthma of nasal origin consists in the 
 correction of the nasal morbid lesions, especially ethmoiditis, polypi, or 
 hypertrophy of the turbinated bodies. (See Ethmoid Operations.) 
 
 A useful test as to the curability of the case is to apply a solution of 
 cocaine to the mucous membrane of the nose, and if the asthma is greatly 
 relieved or altogether checked, it is probable that the removal of the 
 morbid lesions will result in a cure, though this cannot be positively 
 promised, nor can it be stated how long the relief will continue. 
 
 EPILEPSY OF NASAL ORIGIN. 
 
 Epilepsy of nasal origin has been reported by various authors. Watson 
 Williams refers to a case which was brought on by cauterizing the nose 
 for nasal polypi. He also cites two cases reported by Baron, one of 
 which had nasal polypi, the removal of which was followed by marked 
 alleviation of the epileptic seizures; the other case was a young unmar- 
 ried woman who had had epileptic fits at her menstrual periods from 
 the time menstruation began. Her inferior turbinated bodies were 
 greatly hypertrophied, and she was always troubled with nasal stenosis 
 during the menstrual periods, and it was at these times only that the 
 
EPILEPSY OF NASAL ORIGIN 257 
 
 fits occurred. Removal of the hypertrophied tissue was followed by a 
 cessation of the fits for seven or eight months, and when they began again 
 the turbinal hypertrophy was found to have returned. 
 
 I have a patient who has sarcoma of the nose, upon which I operated 
 in April, 1903, and who has had repeated epileptic fits since the operation. 
 Following each fit I have found a sequestrum of bone in the ethmoid 
 region near the cribriform plate, after the removal of which the fits 
 did not return for several weeks or a few months. 
 
 Nasal Tachycardia. — Watson Williams, in his treatise on Diseases 
 of the Upper Respiratory Tract, cites the experiments of Gruber, and the 
 reports of several cases as follows : 
 
 Of the 43 subjects tested by Gruber, 13 with normal noses and 
 30 with nasal disease, the irritation of the nasal mucosa was negative. 
 Watson Williams has never seen a case of reflex effect on the heart 
 from nasal disease, though Spencer Watson reports one apparently 
 due to polypi. Charsley observed, after cauterization of the inferior 
 turbinate, temporary exophthalmos with tachy ardia, the pulse ranging 
 as high as 110 per minute, lasting for a period of three months. B. 
 Friinkel and Hack report cases simulating Graves' disease, with goitre 
 and tachycardia, which disappeared after curing the existing nasal 
 disease. 
 
 17 
 
CHAPTER XIII. 
 
 NEOPLASMS OF THE NOSE. 
 MYXOMA, OR NASAL POLYPUS. 
 
 Myxoma, or nasal polypus, is usually a pedunculated tumor of con- 
 nective tissue which most often grows from the middle turbinated body, 
 the uncinate process of the ethmoid bone or the ethmoidal cells, though 
 it is not infrequently present in the maxillary frontal and sphenoidal 
 sinuses. It is usually significant of a preexisting catarrhal or suppurative 
 inflammation of the sinuses. Some writers believe that the tumor is 
 primary and the inflammation of the sinuses secondary. Such a belief 
 probably results from an indefinite conception of the symptoms of 
 catarrhal sinuitis. Fortunately, catarrhal inflammation of the sinuses 
 is now well understood, and I believe that clinical experience will show 
 that the inflammation exists prior to the formation of the myxomatous 
 tumors. 
 
 Etiology. — While it has not been definitely proved that nasal polypi 
 are directly due to sinuitis, they nevertheless often appear to be secondary 
 to such an inflammation. If the cases are carefully studied, it will often 
 bs found that the patients complain of a vague frontal headache, pressure 
 between the eyes, dizziness, especially upon stooping forward, irritability 
 of the eyes upon prolonged reading, or difficulty in securing a proper 
 refraction of the eyes. Some or all of these and other symptoms are 
 present in catarrhal as well as in suppurative sinuitis. It is claimed that 
 repeated attacks of coryza may cause polypi. This is practically equiva- 
 lent to saying that they are due to sinuitis, as the distressing symptoms of 
 coryza are usually due to the associated inflammation of the accessory 
 sinuses. Clinically we know that polypi are often associated with sup- 
 purative sinuitis and with caries of the bone in the immediate neighbor- 
 hood of the tumors. Some writers state that polypi are found in the less 
 obstructed nasal cavity, and use this as an argument against the previous 
 existence of sinuitis. I believe that a careful examination of the nose 
 will show that the polypi are usually present on the side of the nose in 
 which there is the greatest obstruction in the region of the middle tur- 
 binated body, or " vicious circle" of the nose. A casual examination of 
 these cases often shows a concavity on the side of the polypus, but the 
 concavity is in the lower portion of the nasal chamber, while there is a 
 convexity high up on the opposite side. It is easy to understand how 
 the examination might show an open nostril on one side in this 
 instance, if only the lower portion of the nose were taken into con- 
 sideration. If, however, the upper portion is considered, the obstruc- 
 tive lesion is readily discovered on the side where polypi are present. 
 
MYXOMA, OR NASAL POLYPUS 259 
 
 One of the most frequent causes of nasal polypi is a preexisting inflam- 
 mation of the membrane of the nasal sinuses and of the nasal mucosa in 
 the region of the cell openings. The irritation and pressure give rise 
 to a passive congestion and a proliferation of cells. A serous or edema- 
 tous infiltration is a later manifestation. The connective-tissue cells 
 subsequently become filled with the serum, thus leading to a hydropic 
 degenerative change in some cells, and a myxomatous or gelatinous 
 change in others (D. Braden Kyle). 
 
 The tissue thus degenerated becomes pendulous and in most instances 
 pedunculated. Such a tumor is known as a polypus. 
 
 Other causes of hyperplastic inflammation of the nasal mucous mem- 
 brane, especially in the region of the middle turbinate, may develop 
 into nasal polypi. If, for instance, a foreign body is lodged in the nasal 
 chamber for a long time, or any other continued source of irritation 
 is present, it may result in nasal polypi. Some writers claim that the 
 suction of the inspiratory current of air produces the tumors. D. Braden 
 Kyle has pointed out that the ingoing current of air exerts as much 
 pressure as it does suction. As a matter of fact, the presence or absence 
 of suction depends largely upon the location of the obstructive lesion of 
 the septum in relation to the polypi. If the polypus is posterior to the 
 obstructive lesion, it is subject to suction from the rarefied or negative air 
 pressure posterior to the obstruction. If there is no anterior nasal obstruc- 
 tion, the polypi are subjected to pressure rather than to suction. Suction 
 may have something to do with the formation of polypi in some cases, 
 but it is not probable that it is often if ever the sole cause. 
 
 Pathology. — While polypi are usually called myxomata, they are, 
 as a rule, fibromyxomata. Pure myxoma is rare, and when found con- 
 sists of an epithelium-covered connective-tissue sac, which contains a 
 mucoid fluid, some bipolar spindle cells, and a fine network of con- 
 nective tissue. The fibromyxoma, the usual type, is much richer in 
 connective tissue, and less so in mucoid fluid. The tumors are supplied 
 with bloodvessels and nerve filaments which do not penetrate the sub- 
 stance of the tumor, but are limited to the mucous membrane covering 
 it. They contain plasma cells, which stain with polvdrome, methylene 
 blue, and eosin. Robert Levy reports a case of multiple cystic polypus 
 richly supplied with bloodvessels, as shown in Fig. 201. 
 
 Symptoms. — The symptoms of nasal polypi are often complex on 
 account of the nasal obstruction (middle turbinal region) and the asso- 
 ciated inflammation of the nose and sinuses, which usually co-exist. 
 
 The symptoms caused by the polypi are largely dependent upon their 
 location, size, and the amount of obstruction produced. If pedunculated, 
 and hanging into the lower portion of the nose, they give rise to the 
 sensation of a movable foreign body. The patient can sniff and blow 
 them back and forth in the nose at will. If sessile, they cannot be 
 thus moved, but cause a feeling of tightness or of fulness across the 
 bridge of the nose. The voice has the nasal twang in proportion to the 
 obstruction produced. The voice is often muffled, owing to the almost 
 total loss of nasal resonance. 
 
260 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Upon examination a grayish semitranslucent tumor is seen hanging 
 in the middle meatus of the nose. If pedunculated, it may move with 
 the inspiratory and expiratory currents of air. Pressure with a probe 
 shows a soft and yielding mass freely movable in the nasal chamber. 
 There may be single or multiple tumors, but the latter are the more 
 frequent. H. W. Loeb reports a case from which he removed 308 polypi 
 at one sitting. They vary in size from that of a pinhead to such pro- 
 portions as to protrude from the nose. 
 
 Fig. 200 
 
 Fig. 201 
 
 The apparently open nostril, only open in its 
 inferior portion. The obstruction in the upper 
 portion interfering with drainage and ventila- 
 tion of the sinuses, hence it gives rise to sinuitis, 
 and later to polypi. Nasal passage obstructed 
 in its lower portion. Open in the upper portion, 
 hence drainage and ventilation of the sinuses 
 are good; sinuitis and polypi absent. Polypus 
 likely to form on the apparently open side, but 
 in reality on the side where there is an obstruc- 
 tion in upper or sinus portion of the nose. 
 
 A polypus of the cyst adenoma type removed 
 from the nose: 4 cm. long, 2.5 cm. wide, 1.25cm. 
 thick, weight 8 grams, color pinkish white, solid 
 and elastic. The section shows numerous cavi- 
 ties filled with colloid and caseous material 
 Some of the cysts are lined with ciliated epi- 
 thelium; others have a degenerated columnar 
 cubical or flattened epithelium, and in some 
 the epithelium s entirely lost. Some areas are 
 infiltrated with inflammatory round cells, a, 
 bloodvessel; b, cyst. (Robert Levy's specimen.) 
 
 Various reflex symptoms, as cough and asthma, may be caused by 
 polypi. I have seen a case in which the cough and asthma were so 
 persistent as to compel the patient to sleep every night for three months 
 at a time with the head on a table. This and other similar cases were 
 relieved by the removal of the polypi and the total exenteration of the 
 ethmoidal cells. External signs of nasal polypi are not always present, 
 excepting the inclination to keep the lips parted, in order to supplement 
 the nasal breathing. In rare cases the tumors are of such aggregate 
 magnitude as to broaden the bridge of the nose. 
 
 The sense of smell may be impaired or lost, owing to the closure of 
 the olfactory fissure. The pharynx may be dry on account of the loss 
 of the nasal respiratory functions, or from the thick, tenacious mucopus 
 which is discharged into it. 
 
MYXOMA, OR NASAL POLYPUS 261 
 
 Caries and necrosis of the bone of the middle turbinal and of the eth- 
 moidal cells may be found in some cases by the use of a heavy blunt- 
 pointed probe. A small probe should not be used, because it might 
 readily pass through the degenerated mucosa and lead to a mistaken 
 conclusion as to the condition present. The probe should be gently 
 passed over the mucous membrane of the middle turbinal, the ethmoid 
 space above, and along the lip of the hiatus semilunaris (uncinate pro- 
 cess), as these are the most frequent sites of nasal polypi. 
 
 The symptoms of the associated disease of the sinuses are headache, 
 dizziness, especially upon stooping or sudden jarring, irritability of the 
 eyes upon prolonged reading, or occasionally unilateral blindness. 
 (See Diseases of the Sinuses.) 
 
 Prognosis. — The prognosis of nasal polypi is good if they are removed, 
 and the preexisting disease of the nose and sinuses which causes them is 
 also remedied. In those cases in which the cause is a slight nasal inflam- 
 mation the removal of the polypi followed by cauterization of their 
 points of attachment will effect a cure. If the polypi are removed and 
 the cauterization is neglected they are likely to recur. In those cases 
 which are due to severe catarrhal or suppurative inflammation of the 
 sinuses, it may be necessary not only to remove the polypi, but to exen- 
 terate the ethmoidal sinuses also. If caries of the bone is present the 
 operative procedure should include it as well as the polypi. 
 
 Treatment. — In view of the tendency of the polypi to recur, the treat- 
 ment is not as simple as is ordinarily supposed. The average practitioner 
 regards his duty as being performed when he removes the growth, or 
 growths, and establishes a fair degree of nasal respiration. The aim 
 should be, however, to not only remove the growth, but to remove the 
 tissue from which it springs, and to remove the disease process (sinuitis), 
 which is often the cause. Whether or not bony necrosis is always present, 
 clinical experience teaches us that polypi are much less likely to return if 
 a portion of the periosteum and bone from which they spring is removed. 
 The use of the galvanocautery or fused chromic acid upon the stumps of 
 the polypi effectually prevents their recurrence in some subjects. 
 
 The surgeon should ascertain as nearly as possible the points from 
 which they spring, so that he may determine the difficulties likely to be 
 encountered in the operation, and formulate a correct prognosis if the 
 operation is refused by the patient. 
 
 Surgical Classification. — I. If polypi spring from the free border of the 
 middle turbinated body their removal and after treatment are compara- 
 tively simple. In this location it is not difficult to engage the snare around 
 the growths in such a way as to include also a portion of the middle 
 turbinate from which they spring, or the turbinal tissue may be removed 
 with Holmes' scissors. Thus in a single operation it is sometimes 
 possible to eradicate both the growths and their points of attachment. 
 
 II. If they have their origin above the middle turbinated body there 
 is a strong probability that they come from the posterior ethmoidal 
 cells. Here the treatment is much more complicated. It may become 
 necessary to remove all, or a large part, of the middle turbinated body, 
 
262 THE NOSE AND ACCESSORY SINUSES 
 
 and to exenterate the ethmoidal cells. After this is done the case may 
 require occasional attention for several weeks. 
 
 III. When they have their origin in and around the hiatus semilunaris, 
 either the maxillary, anterior ethmoidal, or the frontal sinus may be 
 the seat of infection, and it may be necessary to perform a radical opera- 
 tion upon them to effect a cure. 
 
 IV. In other cases they spring from the anterior ethmoidal cells, in 
 which case these cells and the frontal sinus may be seriously involved. 
 
 It is evident, therefore, that the simple removal of the polypi, or myxo- 
 matous growths, does not constitute the whole duty of the attending 
 surgeon. Such treatment is usually only palliative and temporary. 
 The presence of the polypi should be regarded as an indication that 
 hyperplasia of the mucous membrane and bone and sinuitis are present. 
 The principles of treatment for inflammation of the middle ear apply 
 with equal force here. They are, briefly, (1) to establish free drainage; 
 (2) to remove the morbid material; and (3) to maintain asepsis of the 
 parts while healing is in progress. 
 
 Operative Technique. — I. Polypi springing from the free border of 
 the middle turbinated body are perhaps the most easily and successfully 
 treated of the types enumerated above. They are accessible and are 
 attended with less involvement of the deeper tissues than those which are 
 in either of the other locations. The method of procedure is as follows: 
 
 (a) Wash the nasal cavity with a warm antiseptic spray and apply 
 adrenalin and a 4 per cent, solution of cocaine. This is most effectively 
 applied on a thin pledget of cotton saturated with the solution and intro- 
 duced with an applicator and adjusted over the operative field. The 
 pledget should be left in position for about seven minutes. 
 
 (6) Carefully inspect the polypus by the aid of reflected light, and 
 determine as nearly as possible its point of attachment. Having deter- 
 mined that it springs from the free border of the middle turbinated body, 
 the next step is to examine for evidences of other diseased processes. 
 
 (c) With a large blunt probe the point of attachment and the neighbor- 
 ing parts should be examined for bare, rough bone. If a small probe is 
 used, it may penetrate the unbroken tissue and thus come into contact 
 with bony tissue. It is quite important, therefore, that a large one be 
 used. It is not always possible to detect denuded bone, but if the examina- 
 tion is made in every case it will often be found where it is not otherwise 
 suspected. 
 
 (d) The wire loop of the snare should now be introduced, so as to 
 encircle the pendent tumor. It should be held so that both sides of 
 it are against the septum, the lower portion of the loop being on a 
 level with or lower than the inferior portion of the polypus. It should 
 then be turned so that its inferior part passes outward under the polypus, 
 and then in an upward direction until the polypus is encircled. The 
 procedure is often facilitated if the loop is also moved slightly in a for- 
 ward and backward direction while engaging the polypus. 
 
 (e) Care should be exercised to carry the loop so as to include the 
 point of attachment and a portion of the middle turbinated body if 
 
MYXOMA, OR NASAL POLYPUS 
 
 263 
 
 possible. If the growth is on the anterior portion of the turbinate it is 
 usually easy to include the anterior third of it. The loop passes back- 
 ward under and on either side of the turbinate, while the cannula (Fig. 202) 
 is firmly placed in the notch formed by the anterior attachment of the 
 turbinate to the anterior wall of the nose. 
 
 (/) Firm pressure of the cannula into the notch being maintained, 
 the loop is tightened until the tissues are engaged. It is still further 
 tightened until the anterior portion of the turbinate, to which the growth 
 is attached, is severed. 
 
 (g) With a blunt probe the wounded surface is examined for evidences 
 of carious or necrotic bone. 
 
 (h) If softened or necrotic bone is found it should be removed by 
 curettement. 
 
 (i) If none of the middle turbinated body is removed the fibrous base 
 of the polypus should be cauterized at the next sitting three or four days 
 later. 
 
 Fig. 202 
 
 Removing a polypus and anterior end of the middle turbinate with a snare. 
 
 (j) The after-treatment should consist of the use of warm antiseptic 
 douches or sprays and the insufflation of bismuth-iodine powder. If the 
 douche is used, the Birmingham nasal douche is preferable to any of the 
 pressure or fountain douches, as they are likely to force the solution into 
 the middle ear and excite severe inflammation. The douche should be 
 used twice daily. 
 
 II. When the polypi have their attachment above the middle turbinated 
 body they usually spring from the posterior ethmoidal cells, and the treat- 
 ment is correspondingly more difficult. One may be able to remove a 
 portion of the growths, but it is difficult to reach their points of 
 attachment. It therefore becomes necessary to remove the anterior 
 half or all of the turbinated body. This is not objectionable, as the 
 ethmoid cells contained therein and those in the body of the ethmoid 
 bone are probably more or less diseased. If necrotic bone is present it 
 should be removed by curettement. In cases of this class my method 
 
264 THE NOSE AND ACCESSORY SINUSES 
 
 of procedure is the same as for the removal of the ethmoid cells and 
 middle turbinate en masse. 
 
 III. If the polypi spring from the hiatus semilunaris or infundibulum 
 it may become necessary to open the maxillary antrum, which may also 
 be the seat of similar growths. 
 
 These should be removed with the cold-wire snare and their bases 
 cauterized. If upon further observation the antrum is found to be 
 affected, the Caldwell-Luc or Denker operation should be performed. 
 
 IV. When the polypi are attached to the border of the hiatus semi- 
 lunaris, mouth of the infundibulum, there is probably an involvement 
 of the anterior ethmoidal and the frontal sinuses. The treatment is 
 much like that described in I, in so far as the removal of the polypi is 
 concerned. Subsequently it may become necessary to remove the anterior 
 half of the middle turbinated body. 
 
 After this is done the diseased area is exposed to further examination, 
 and, if necessary, to more extensive operation by curettement. In other 
 words, the obstructions within the " vicious circle" should be obliterated. 
 
 No arbitrary rules can be laid down in a text-book for the guidance 
 of the surgeon. He must study the facts in each case, and arrive at a 
 conclusion as to the best course to pursue. The foregoing operations 
 are sometimes advisable if it is hoped to effect a permanent cure of the 
 nasal polypi. These operations are usually only described in connection 
 with the subject of empyema of the nasal accessory sinuses. I have 
 described them in connection with polypi in order to emphasize the 
 significance and importance of these growths, as pointing to conditions 
 much more important than the polypi themselves. While in some cases 
 it may not be shown that the polypi have much significance, nevertheless, 
 in my experience, the more nearly I have treated polypi as though necrosis 
 and suppuration were associated with them, the more satisfactory have 
 been my results. 
 
 For timid patients non-surgical treatment may be recommended, as 
 the injection of a saturated solution of the sulphate of zinc, or a solu- 
 tion of tannic acid into the substance of the polypi. I have occasionally 
 used tannic acid with satisfactory results. A few minims should be 
 injected with a hypodermic syringe into the body of the tumor. Within 
 two or three days it shrinks and sloughs away. In the aged or the infirm 
 it is usually inadvisable to recommend measures more radical than 
 the simple removal of the polypi, as the danger from shock and acute 
 infection is greater in these subjects. 
 
 Papilloma. — Papilloma of the nose is rare, but when it occurs it appears 
 as a corrugated red mass growing either from the inner or inferior sur- 
 face of the inferior turbinated body, the septum, or the posterior end 
 of the inferior turbinated body. The subjective symptoms are those 
 of a partial nasal stenosis; the patient often consults the physician only 
 on account of nasal "catarrh." 
 
 Treatment. — The treatment consists in the complete removal of the 
 growth with a snare or nasal scissors. The surrounding tissue should 
 be anesthetized by the local application of a 5 to 10 per cent, solution 
 
MYXOMA, OR NASAL POLYPUS 
 
 265 
 
 Fig. 203 
 
 of cocaine, after which the tumor is excised. After the bleeding has 
 ceased the wounded surface should be mopped dry and cauterized with 
 the galvanocautery. This is done to prevent a recurrence of the growth. 
 When papilloma recurs in a patient forty or more years of age, the 
 possibility of carcinoma should be suspected. 
 
 Fibroma. — Fibroma of the nose is characterized by the presence of a 
 dense fibrous growth containing bloodvessels and no mucous glands, 
 with slowly increasing nasal obstruction. The growths vary in size, are 
 smooth and pale pink in color. They are firm to the touch or probe 
 pressure, though not as dense as bone or cartilage. They may be sessile 
 or pedunculated (Fig. 203). If pedunculated, 
 they are movable like a polypus, though their 
 consistency is quite different. 
 
 They are usually attached to the septum, 
 the floor of the nose, or to the turbinated 
 bodies. They sometimes have multiple sec- 
 ondary attachments, owing to the inflamma- 
 tory reaction excited by their presence. 
 
 Treatment. — The treatment consists in their 
 complete removal with a snare or cutting 
 forceps. In those cases in which the tumor 
 is pedunculated and comparatively small, the 
 removal with the cold-wire snare or the 
 author's turbinotome is the easiest and best 
 method to pursue. 
 
 When the growth is sessile and large it 
 may be removed piecemeal with cutting for- 
 ceps, or at least so much of it that the snare 
 can be passed over the remainder. This pro- 
 cedure may be done under cocaine anesthesia. 
 
 When the growth is so large that it invades 
 the surrounding structures of the nose, and 
 
 Fibromyxoma removed from 
 the epipharynx. Actual size. 
 (Specimen kindly loaned by A. 
 G. Wlppern.) 
 
 extensive adhesions are present, it may become 
 necessary to resort to a temporary resection 
 of the superior maxilla to eradicate it. 
 
 The operation as given in Surgical Tech- 
 nique, by Drs. von Esmarch and E. Kowalzig, is as follows: Osteo- 
 plastic, or temporary, resection of the upper jaw (von Langenbeck, 
 1861) is performed for the removal of non-malignant fibrous or caver- 
 nous tumors which originate from the base of the skull, fill the nasal 
 part of the pharynx (nasopharyngeal space), and force themselves into 
 the maxillary sinus, or through the sphenomaxillary fossa into the 
 temporal fossa (retromaxillary tumors). 
 
 By reflecting a portion of the upper jaw upward, which has been 
 sawn through, but which remains in connection with the soft parts, 
 the tumor is completely exposed, so that it can be cut off from the base 
 of the skull with a knife or scissors; this portion of the upper jaw is then 
 replaced and the skin is sutured over it. 
 
266 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Von Langenbeck proceeds as follows: 1. An external incision is made 
 down to the bone in the form of a curve from the external angle of the 
 nostril to the middle of the zygomatic ar.h (Fig. 204). 
 
 2. The insertion of the masseter muscle is separated from the lower 
 margin of the malar bone portion of the buccal fascia. 
 
 3. After the lower jaw has been pressed downward by a gag inserted 
 at the angle of the mouth on the healthy side the right index finger is 
 forced into the sphenomaxillary fossa between the tumor and the upper 
 jaw and then through the distended sphenopalatine foramen as far as the 
 nares; an elevator is carried along the finger, and on it a fine metacarpal 
 saw is introduced into the pharynx. The left index finger, introduced 
 from the mouth into the pharynx, catches the point of the saw. 
 
 Fig. 204 
 
 Fig. 205 
 
 The incision for the temporary resection of the 
 superior maxilla. 
 
 Von Langsnbeck's operation for the tem- 
 porary excision of the superior maxilla, a, b 
 (Fig. 204), the external skin incision; c, the 
 zygomatic arch is first sawed through from 
 within outward; d, next, the frontal process of 
 the malar bone is severed with a metacarpal 
 saw as far as and into the inferior orbital fissure, 
 the orbital plate of the inferior maxilla as far 
 as the lacrymal bone closely below the lacrymal 
 fossa, and, finally, the middle of the nasal pro- 
 cess of the superior maxilla as far as the nasal 
 bones are divided. The contents of the lacrymal 
 canal should be carefully guarded from injury. 
 b, horizontal division, with a saw, of the superior 
 maxilla above the alveolar process as far as and 
 into the pyriform aperture. 
 
 4. Horizontal division is obtained by sawing the upper jaw above the 
 alveolar process as far as and into the pyriform aperture (Fig. 205, b). In 
 operations on the right upper jaw, the left index finger is forced into the 
 maxillary fossa, and the operator saws toward it from the nasal passage. 
 
 5. Make the external incision down to the bone in the form of a curve 
 from the root of the nose along the lower orbital margin, meeting the 
 first skin incision at the zygomatic arch (Fig. 204). 
 
 6. After the external lower angle of the orbit and the angle between 
 the temporal and the frontal process of the malar bone have been freed 
 from the soft parts the zygomatic arch is sawed through in the middle 
 
MYXOMA, OR NASAL POLYPUS 267 
 
 from within outward; next, the frontal process of the malar bone as far 
 as and into the inferior orbital fissure, the orbital plate of the upper jaw 
 as far as the lacrymal bone closely below the lacrymal fossa, and, finally, 
 the middle of the nasal process of the upper jaw as far as the nasal 
 bone are divided with a metacarpal saw; the organs which constitute 
 the lacrymal duct should be protected. 
 
 7. By means of an elevator inserted under the malar bone the excised 
 piece of the upper jaw is lifted up toward the median line, like the lid 
 of a box. The sutural connection between the nasal bone and the upper 
 jaw, in most cases, breaks during this maneuver. 
 
 8. With a broad elevator the tumor, now laid bare, is lifted out of the 
 sphenomaxillary fossa, and the base is detached from the under surface 
 of the skull with a knife, scissors, or thermocautery. Finally, the resected 
 portion of the upper jaw is replaced in its former position and the skin 
 is closed by sutures. 
 
 Adenoma. — Adenoma bleeds so readily upon examination with a 
 probe that sarcoma is at once suggested. A microscopic examination, 
 however, reveals the true character of the growth. This type of tumor 
 grows from the septum or the ethmoidal region and produces rapidly 
 increasing nasal stenosis. Adenoma, like polypi and papilloma, has 
 a strong tendency to recur unless completely removed. It consists of a 
 simple hyperplasia of gland structure having its type in the acinous or 
 tubular glands. It also has a tendency to malignant degeneration. 
 
 Treatment. — The treatment should consist in the total removal of the 
 tumor. In order to insure this, its base should be cauterized or curetted. 
 The bleeding which attends the removal of adenomata is considerable, 
 but may be readily controlled by a nasal tampon of bismuth gauze. 
 
 Lymphoma. — Lymphoma of the nose is characterized by a smooth 
 mass, pinkish red in color, and less dense in consistency than fibroma. 
 It is not common and a microscopic examination is necessary for a positive 
 diagnosis. The treatment is the same as for polypus and fibroma. 
 
 Angioma. — -Angioma of the nose is rare (Harry Kahn), and consists of 
 a distention of existing bloodvessels rather than of newformed ones. 
 According to D. Braden Kvle the distention is due to changes in the 
 walls of the bloodvessel from deficient nutrition rather than to mere 
 congestion. 
 
 Symptoms. — The symptoms are those of more or less nasal obstruction, 
 epistaxis, and a reducible and pulsating tumor. The nasal obstruction 
 is proportionate to the size of the growth. Pressure upon the growth 
 materially reduces its size. The pulsation is greater when the tumor 
 is attached to a large artery than if it is attached to a vein, when the 
 pulsation is much less and the color is blue, whereas if it is connected 
 with both vein and artery the color will be a dark red. 
 
 Treatment. — The treatment consists in strangulation at the base of 
 the tumor. The object of the strangulation is to cause closure of the 
 bloodvessels which supply the tumor. If the strangulation is performed 
 too quickly the vessels will not close and hemorrhage from their severed 
 ends results; by gradually tightening the wire loop the vessels close and 
 bleeding does not follow. 
 
268 THE NOSE AND ACCESSORY SINUSES 
 
 The galvanocautery loop is also adapted to the removal of these 
 growths, when easily accessible and pedunculated, as it sears over the 
 ends of the vessels and prevents subsequent hemorrhage. When the 
 growth is sessile, silk ligatures may be passed through it and tied, thus 
 strangulating a portion with each ligature. Cocaine anesthesia by 
 injection is all that is necessary for either of these procedures. 
 
 Osteoma. — Osteoma 1 of the nose and the accessory sinuses is rare. 
 It may occur in any of the accessory sinuses, but is more common in the 
 frontal. It may invade the nasal and orbital cavities when growing 
 from the sinuses. It sometimes springs from the inferior turbinated 
 bone and occludes the nasal chambers. Cases have been reported 
 in which the tumor had its origin in the nasal process of the superior 
 maxilla. 
 
 Pathology. — Osteoma is usually composed of dense, compact, can- 
 cellous, horny tissue on a congenital or postnatal matrix of osteoclasts, 
 and usually has its growth from the periosteum, though it may grow 
 from the medullary portion of the bone. Some osteomata are soft and 
 spongy, with a dense capsule of bone, while others are dense throughout 
 their substance. The spongy type occurs most frequently. They are in 
 some instances pedunculated, the pedicle being composed of either 
 spongy bone or soft connective tissue and mucous membrane. They 
 vary from the size of a small walnut to that of a goose egg. 
 
 Symptoms. — As the nasal chambers are usually invaded, nasal obstruc- 
 tion is a prominent symptom. The growth of the tumor externally 
 produces more or less marked deformity, and in some instances the 
 resemblance to horns is so great that the cases are referred to as " horned 
 men." In some instances they present the "frog-face" type of counte- 
 nance, especially when both sides of the nose are involved in the region of 
 the infra-orbital ridge, as in O. J. Stein's case. Palpation of the tumor, 
 whether intranasal or extranasal, yields a sense of bony hardness. The 
 lacrymal duct may be occluded. The mucous membrane covering the 
 tumor is usually pale, thin, and not eroded. Transillumination of the 
 maxillary sinus may show obstruction to the rays of light. If constant 
 mouth breathing is present it gives rise to epipharyngeal catarrh. In 
 Stein's case there was inability to rotate the left eye inward. There 
 was external divergence of two lines, the pupil was widely dilated and 
 fixed, and did not respond to either light or accommodation. The fundus 
 was normal. 
 
 Diagnosis. — The diagnosis is largely based upon the microscopic 
 examination of the tissue. 
 
 Treatment. — In cases of syphilitic origin the iodides are of value. The 
 removal of the bony growth is usually the best treatment. The tech- 
 nique of the operation varies with each case. Boenhaupt reported 23 
 cases in which the tumor grew from the frontal sinus, in 11 of which it 
 communicated with the cranial cavity. It is obvious, therefore, that 
 
 1 I am indebted to Dr. Otto Stein's paper on Symmetrical Osteoma of the Nose for most of 
 the data on this subject. 
 
MYXOMA, OR NASAL POLYPUS 
 
 269 
 
 osteoma of this region is the most serious from a clinical and surgical 
 point of view. 
 
 In the removal of osteoma, if there is no pedicle, it is better to enucleate 
 the tumor rather than to attempt to chisel or drill into its substance, 
 as it is often so dense as to resist the instruments. 
 
 In one of my cases of osteoma of the epipharynx, the posterior choanal 
 were completely blocked. The bone was so dense that it could not be 
 removed with a chisel. The only instrument that would penetrate it 
 
 Fig. 206 
 
 Lipoma of the tip of the nose. (Pynchon's case. 
 
 was a trephine. With this a large portion of the tumor was removed 
 through the nose, and nasal respiration was successfully reestablished. 
 One year later the nasal occlusion returned. This case should have been 
 treated by temporary resection of the superior maxilla. 
 
 Lipoma. — Lipoma of the nose may be external or internal, and is 
 usually pendulous. When external it generally affects the alse of the 
 nose. The case illustrated involves the tip of the nose (Fig. 206). The 
 treatment consists of the excision of the growth. 
 
270 THE NOSE AND ACCESSORY SINUSES 
 
 MALIGNANT NEOPLASMS OF THE NOSE. 
 
 Carcinoma. — Carcinoma of the nose is more rare than sarcoma, and 
 usually begins in the anterior portion of the nasal structures, at which 
 point there is the greatest physiological irritation. 
 
 Diagnosis. — The diagnosis is based upon (a) the presence of an in- 
 tense irregular lancinating pain; (b) a mucopurulent secretion, which 
 if ulceration is present is admixed with blood; (c) the characteristic 
 ozena or stench of cancer; (d) nasal stenosis more or less marked accord- 
 ing to the stage in which the disease is observed; (e) impairment of vision 
 if the ethmoid cells are involved; (/) ulceration of the growth if in an 
 advanced stage; and (g) cachexia, (h) In addition to the foregoing 
 clinical symptoms it is usually necessary to remove a portion of the 
 growth for microscopic examination. D. Braden Kyle properly calls 
 attention to the necessity of observing two precautions in securing the 
 specimen, namely: (1) that there should be as little laceration and 
 irritation of the parts as possible; (2) that the portion removed should 
 not involve directly the ulcerated area, which will contain inflammatory 
 embryonic connective tissue, and, as pointed out by J. Bland Sutton, this 
 cannot be differentiated from sarcoma or from a simple inflammatory 
 process with ulceration. If, however, the specimen is taken early, 
 before ulceration has occurred, this source of error may be obviated. 
 
 Prognosis. — The prognosis is always grave. 
 
 Treatment. — The surgical treatment of carcinoma of the nose, except 
 in the very early stage, is contra-indicated. 
 
 The palliative treatment consists in the local application of orthoform 
 powder to ease the pain, and local applications of dilute hydrochloric acid 
 and formalin to the ulcerated areas. 
 
 Sarcoma. — Sarcoma of the nose is of slow growth, and is less malig- 
 nant than sarcoma in other parts of the body. Unlike carcinoma it 
 occurs most often before the fortieth year of life, and is not uncommon 
 in infancy and childhood. 
 
 Diagnosis. — The diagnosis is based upon (a) progressive nasal stenosis; 
 (b) a mucopurulent nasal secretion, which, in the advanced stage, becomes 
 sanguinolent; (c) more or less slight pain in strong contrast to the intense 
 pain in carcinoma, (d) The age of the patient, if below forty years, 
 is also of diagnostic significance, though carcinoma occasionally occurs 
 before this age; (e) finally, the diagnosis must be made by submitting 
 a specimen of the growth to microscopic examination. 
 
 Prognosis. — The prognosis is grave, though not as grave as carcinoma. 
 When operated early there is a fair chance of recovery. In one of my 
 cases operated on by Ollier's method (Fig. 207) there has been no recur- 
 rence of the sarcoma after six years. 
 
 Treatment. — The treatment in the early stage is surgical, especially in 
 view of the slighter malignancy of nasal sarcoma. The growth may 
 be removed with a curette, or galvanocautery through the nasal orifices, 
 or, if extensive, an external operation may be required. 
 
MALIGNANT NEOPLASMS OF THE NOSE 
 
 271 
 
 Oilier s Operation. — This operation is performed under general anes- 
 thesia, with the head of the patient hanging over the end of the table 
 in Rose's position. Postnasal tampons should be introduced to pre- 
 vent entrance of the blood into the epipharynx and larynx. An incision 
 extending from the left ala of the nose, upward over the bridge of the 
 nose, and thence downward to the right ala of the nose, should be made 
 through the cutaneous tissue (Fig. 207). A Gigli saw should then be 
 placed at the bridge of the nose and all the bony structures along the 
 cutaneous incision severed. 
 
 The nose, thus temporarily resected, is then turned downward over 
 the mouth. This having been done, the growth should be enucleated 
 by blunt dissection, if possible, or if this cannot be done it should be 
 removed by dull curettage. A sharp curette should not be used, as it 
 leaves the lymphatic vessels open and may cause septic infection and 
 extension by metastasis. The hemorrhage may be considerable, hence 
 the postnasal tampons, introduced before beginning the operation, serve 
 as bases against which strips of gauze may be packed to check it. 
 
 Fig. 207 
 
 Ollier's incision for exposing the nasal cavities for operative purposes. 
 
 In my case, illustrated in Fig. 207, the hemorrhage was very profuse 
 and necessitated the use of normal salt enemata. The transfusion of 
 normal salt solution would have been better, but as arrangements had 
 not been made for it the enemata were substituted. This patient was 
 thirteen years old when I first saw her, and was fourteen when I per- 
 formed the Oilier operation. She is now twenty years of age, and is 
 free from the growth. Bony sequestra have been removed from time 
 to time, and but little ozena is present. 
 
 Having removed the tumor the incision should be closed by sutures, 
 and the tip of the nose raised into position and fixed with adhesive 
 strips. The stitches should be removed on the fifth day. The nasal 
 wound should be packed with gauze impregnated with bismuth or the 
 compound tincture of benzoin, to prevent decomposition and sapro- 
 phytic infection. The intranasal 'dressing should be removed and 
 renewed daily. 
 
CHAPTER XIV. 
 
 EPISTAXIS (NASAL HEMORRHAGE). RHINOSCLEROMA. 
 FURUNCULOSIS. SCREW-WORMS. 
 
 EPISTAXIS (NASAL HEMORRHAGE). 
 
 Epistaxis is a nasal hemorrhage, that is, a bleeding from the interior 
 of the nose, While the hemorrhage is usually from the anterior portion 
 of the septum (90 per cent, of the cases, according to Casselberry), it may 
 occur from any portion of the nasal mucosa. The bleeding is not often 
 serious in character, though several deaths have occurred therefrom. It 
 is most serious in bleeders, or hemophiliacs, and in arteriosclerosis, 
 valvular heart lesion (right side), sarcoma, and pressure on the veins of 
 the neck by aneurysm, bronchocele, and intrathoracic tumors. 
 
 Etiology. — (a) Anterior deflection of the septum is the predisposing 
 cause of hemorrhage in a large majority of the cases. This portion of 
 the septum is richly supplied with blood from the septal artery, a branch 
 of the superior coronary, and is exposed to the ingoing current of air, 
 which is often loaded with foreign particles. The air, furthermore, 
 dries the secretions on the anterior portion of the septum, especially 
 if it is deflected in this location. The membrane is quite thin in this 
 area. Slight erosion of the mucosa readily gives rise, therefore, to nasal 
 hemorrhage. 
 
 (b) Catarrhal inflammation causes chronic hyperemia of the mucous 
 membrane, hence the increased supply of blood in the parts contributes 
 to the epistaxis. 
 
 (c) A number of febrile diseases are often attended by epistaxis. 
 The diseases most commonly thus characterized are typhoid and diph- 
 theria. " Black diphtheria," or hemorrhagic nasal diphtheria, is at- 
 tended with a destructive degeneration of the nasal mucosa, submucous 
 hemorrhage, and epistaxis. 
 
 (d) The veins on the anterior portion of the septum are sometimes 
 varicosed and give rise to hemorrhage. 
 
 (e) Obstruction to the portal circulation may be attended by nasal 
 hemorrhage. 
 
 (/) Suppression of the menstrual flow and a severe hemorrhoidal 
 hemorrhage is sometimes attended by a vicarious nasal hemorrhage. 
 
 (g) Traumatic epistaxis may result from picking the nose with the 
 finger nail or violently blowing it with a handkerchief. Intranasal 
 surgery is frequently followed by severe nasal hemorrhage. This is 
 especially true after operations upon the middle turbinate, the ethmoidal 
 cells, and the (t swell bodies" or erectile tissue of the inferior turbinated 
 
EPISTAXIS 273 
 
 body. The middle turbinated and the ethmoidal cells receive a generous 
 blood supply from the anterior and posterior ethmoid arteries (Fig. 3). 
 External violence to the nose is often followed by epistaxis or the so-called 
 "bloody nose." 
 
 (/i) A perforating ulcer of the septum frequently gives rise to epis- 
 taxis. The vessel walls are broken down in the destructive process, 
 and the granulation tissue upon the border of the perforation bleeds 
 upon slight cause. 
 
 (i) Certain constitutional diseases, as hemophilia, Bright's disease, 
 purpura, scorbutus, chloremia, leukemia, and arteriosclerosis are char- 
 acterized by nasal hemorrhage, for obvious reasons. Syphilis and tuber- 
 culosis of the nose also give rise to epistaxis. 
 
 (j) Sarcoma of the nose, like sarcoma elsewhere, is often attended 
 with hemorrhage. 
 
 Treatment. — The treatment of nasal hemorrhage in most cases is 
 very simple, as the local application of cocaine or of adrenalin readily 
 stops it. In other cases, however, when the cause is a constitutional 
 disease, a growth pressing on the veins of the neck, or when the trunk of 
 one of the larger septal arteries, as the anterior ethmoidal, is severed in 
 an intranasal operation, the bleeding is not so easily checked. 
 
 The hemorrhage may usually be checked by one of the following 
 procedures : 
 
 1. Hot nasal irrigation is quite effective in many of the cases when 
 the epistaxis is not due to some grave disease. The temperature of the 
 water or normal salt solution should be as high as can be tolerated, or 
 about 130°. 
 
 2. Ice-water may also be injected into the nose with advantage in oper- 
 ative hemorrhage while the patient is under an anesthetic. Only two or 
 three injections of four ounces each should be used, as a greater quantity 
 might produce serious shock to the brain by sudden or excessive chilling. 
 I have frequently resorted to this method of treatment at the close of 
 nasal operations when the hemorrhage was profuse, with the most 
 gratifying results. 
 
 3. The local application of cocaine or adrenalin often checks the 
 hemorrhage when it is of capillary origin. If blood clots are present, 
 the nose should first be cleared. The adrenalin extract may be given 
 internally for its hemostatic effect. 
 
 4. Blood clots are sometimes allowed to remain in the nose, with the 
 idea that they will finally check the hemorrhage. This procedure is 
 based upon an erroneous idea. The blood clots only serve to shield 
 the bleeding area from such local medicaments as may be used, thus 
 hiding the bleeding point from view. The bleeding usually continues 
 beneath the clots, hence they should be thoroughly removed at once in 
 order to expose the bleeding area to inspection and to make it possible to 
 apply such local remedies as may be deemed necessary. 
 
 5. Astringent remedies, such as the nitrate of silver in 5 to 20 per cent, 
 solutions, may be made from time to time when the oozing is persistent. 
 
 6. The application of the actual cautery has sometimes proved to be a 
 18 
 
274 THE NOSE AND ACCESSORY SINUSES 
 
 speedy and efficient means of controlling the bleeding; a flat-pointed 
 electrode should be used at a cherry-red heat for this purpose. 
 
 7. Local pressure over the bleeding point for a few minutes will 
 sometimes control the bleeding. 
 
 8. Tampons in the nose should only be resorted to in those cases in 
 which the bleeding persists in spite of all other measures. Their use, 
 as a general rule, should be avoided, as they are likely to give rise to condi- 
 tions favorable to sepsis. The more completely the nasal chambers 
 are packed with gauze the greater the danger. Hence a postnasal 
 tampon, with one anterior to it, is the most dangerous of all. This 
 method of packing the nose in epistaxis should be avoided except in an 
 extreme emergency. 
 
 When bleeding occurs from the anterior portion of the septum, and 
 it becomes necessary to introduce a tampon, I would advise the use of 
 a Bernay tampon cut into the form of a nasal splint, as recommended by 
 Simpson. It absorbs less of the secretions, and is easily introduced and 
 removed without further injury to the diseased mucous membrane. 
 The interior of the nose should first be covered with subnitrate of 
 bismuth by insufflation to prevent decomposition of the secretions. 
 
 RHINOSCLEROMA. 
 
 Synonyms. — It is probable that a rare lesion described as chorditis, 
 chronic hypertrophica inferior, and what is known as Stoerk's blennor- 
 rhea are identical with rhinoscleroma. 
 
 Definition. — Rhinoscleroma is characterized by a cartilage-like hard- 
 ness and nodular enlargement of the nose and other portions of the 
 upper air passages. The affected tissues have no tendency to ulceration 
 or to inflammatory reaction either in the growth or in the contiguous 
 parts, although rhinoscleroma frequently affects the other divisions of 
 the respiratory tract. 
 
 Etiology. — But little is known of the etiology of the disease beyond the 
 fact that it is due to a specific microorganism, the bacillus of rhinoscle- 
 roma, and that it is chiefly confined to Austria and southwestern Europe. 
 About 800 cases have been reported, and of these, about 20 occurred in 
 America, but a large majority of these were born in Poland and Austria. 
 It usually begins in youth, and most cases are observed between the 
 ages of fourteen and forty-five. Sex seems to have no influence. Heredity 
 seems to be a negative factor, though there is apparently a family pre- 
 disposition to the disease. It is now generally regarded as a contagious 
 disease. 
 
 Bacteriology. — The hard, cartilage-like nodules may affect the skin and 
 the mucous membrane of the nose, pharynx, larynx, and trachea. They 
 spread with greater freedom in the mucosa than in the skin. The hard, 
 nodular masses, or plaques, contain the encapsulated bacillus of rhinoscle- 
 roma, which is similar to Friedlander's bacillus, though the latter is not 
 always encapsulated. The bacillus of rhinoscleroma is more rod-shaped 
 
RHIXOSCLEROMA 
 
 It,) 
 
 and stains by Gram's method, is motile, non-spore bearing, and aerobic. 
 It always has a capsule in culture, as well as in the tissues. It occurs 
 singly and in pairs. Gelatin plates show yellowish-white granular 
 bodies in two or three days. In gelatin tubes the growth appears along 
 the needle track as a whitish granular line, with an almost hemispherical 
 elevation on the surface. The growth in the tube has the appearance 
 of a round-headed nail. When grown upon agar it appears as a dirty 
 whitish moist layer on either side of the needle track. On potato the 
 growth is creamy white. It grows rather rapidly at a temperature of 
 37° C. It is pathogenic for mice, guinea-pigs, and rabbits. 
 
 Pathology. — The histological changes are inflammatory in character 
 and usually begin on the nasal septum, trachea, or larynx. In rare 
 instances the reverse course is pursued. The skin and mucous membrane 
 of the nose assume a smooth nodular appearance of cartilage-like consist- 
 ency, which pits little, if at all, upon probe pressure. The parts are 
 sensitive to the touch, but are otherwise free from pain. Kaposi has 
 likened the external appearance of the nose to keloid. According to 
 Goodale the affected tissues consist histologically of certain typical 
 elementary lesions. The substance of the swelling is composed of large 
 plasma cells, irregularly distributed in all layers of the mucous mem- 
 brane, and in the submucous tissue. They accompany the bloodvessels 
 in the new portions of the growth. The plasma cells do not contribute 
 directly to the hypertrophy, but it is possible that they become changed 
 partly into spindle cells, and then give rise to the formation of new 
 fibrillary tissue. Two forms of retrograde metamorphosis occur in the 
 plasma cells. These may be transformed into swollen, hydropic, 
 so-called Mikulicz cells, or into hyaline degenerated cells, probably 
 identical with the so-called Russell's fuchsinophiles, described under 
 Colloid Degeneration. The hydropic cells lie close together, have a 
 distinct contour and spongy cytoplasm dilated into large masses, in 
 which there is a smaller mass within a faceted nucleus. In this stage 
 one often sees from six to eight bacilli in the cells near the nucleus 
 which lie always at regular distances. 
 
 This stage appears, however, to be rapidly finished, and when the 
 cell membrane breaks, the fluid contents, together with some of the 
 bacilli, find an exit and fill some of the nearest lymph spaces. These 
 cells are, however, intimately related to the direct action of the bacilli. 
 
 Symptoms. — The changes in the external appearance of the nose, 
 while presenting many of the characteristics of keloid, are, nevertheless, 
 rather easily differentiated from it by the whole symptom complex. 
 The tissue at the tip of the nose becomes infiltrated, hard, and nodular. 
 The nose broadens and becomes firmly fixed to the face. The tissues 
 become more and more thickened, until the breathing is more or less 
 occluded. The color of the skin varies from a red to a bluish or brown- 
 ish red. The skin is traversed by small bloodvessels, and is usually 
 slimy, though it may be finely wrinkled. The extension of the growth 
 is rather slow, requiring several months to reach the epipharvnx. The 
 infiltration often interferes with the movements of the lips, the fauces, 
 
276 THE NOSE AND ACCESSORY SINUSES 
 
 and the larynx, and very rarely with that of the eyes and ears. There is 
 no tendency to ulceration and discharge, or to edema and inflammation of 
 contiguous parts. 
 
 Laryngeal stenosis may give rise to serious or even fatal dyspnea, 
 otherwise the disease does not materially affect the general health. 
 
 Diagnosis. — Rhinoscleroma should be differentiated from syphilis, 
 epithelioma, and keloid. The disease is exceedingly rare in this country, 
 hence it is natural to infer that a suspected case in a native-born 
 American is probably not rhinoscleroma, but that it is either syphilis, 
 epithelioma, or keloid. Rhinoscleroma presents a hard, nodular growth, 
 which usually begins at the anterior end of the nose and spreads 
 gradually to the deeper recesses of the respiratory tract, without pain, 
 but with some tenderness upon pressure, and without tendency to 
 ulceration or inflammation of the surrounding tissues. In syphilis 
 there is inflammation, while in epithelioma there is pain, ulceration, 
 and discharge. In keloid the similarity is often so striking that it may 
 be necessary to demonstrate the absence or presence of the germ of 
 rhinoscleroma in order to make a differential diagnosis. 
 
 Treatment. — Thus far the extirpation of the diseased tissue has been 
 tried with negative results as to the cure of the disease. The surgical 
 extirpation of the diseased tissue has almost invariably been followed 
 by recurrence. Tracheotomy should be performed when suffocation 
 is imminent. Thiosinamin apparently softens the tissue (Glass), as it 
 does in keloid; it may, therefore, be of some therapeutic value. A reliable 
 method of treatment, however, has not been discovered. Freudenthal 
 suggests the injection of Coley's fluid, as in sarcoma. The iodides and 
 mercury have been tried with but little success. The axrays have been 
 used by Emil Mayer with apparent success, though it is probable that this 
 mode of treatment will prove disappointing, as have all other methods. 
 
 FURUNCULOSIS OF THE NOSE. 
 
 Definition. — Furunculosis of the nose is a superficial abscess forma- 
 tion which may occur in any part of the nose, and does not differ 
 materially from the same process in the other parts of the body. 
 
 Etiology. — The abscess is usually located on the anterior portion of 
 the septum, i. e., that portion covered by the vestibular skin, and is usually 
 due to an injury, as from picking the nose. One or more furuncles may 
 be present at a time or they may occur in quick succession. The hair 
 follicles of the vestibule offer favorable sites for the infection. If they 
 recur frequently the cartilaginous septum becomes involved. Recur- 
 rence most commonly take place in the young or the middle aged, 
 especially in those in whom an impoverished state of the blood exists. 
 The infectious fevers are often attended with nasal furunculosis. 
 
 Symptoms. — There is more or less throbbing pain, swelling, redness, 
 and tenderness. Elevated areas characteristic of boils may be seen 
 upon inspection. When they are well advanced the centre of the eleva- 
 
SCREW-WORMS IN THE NOSE 277 
 
 tion is yellowish from the contained pus. The pain is often intense, on 
 account of the closely attached and unyielding nature of the tissue 
 composing the parts. 
 
 Treatment. — If seen early, before pus formation, the application of a 
 50 per cent, solution of ichthyol or a 10 per cent, glycerin solution of 
 carbolic acid on a pledget of cotton will often abort the process. If 
 pus has formed, they should be incised from within the nasal cavity 
 with a sharp bistoury. After incision their cavities should be irrigated 
 with warm boric acid solution and the tincture of iodine applied. 
 
 PHLEGMONOUS RHINITIS. 
 
 This is somewhat different from furunculosis, in that it is an abscess 
 formation affecting the nasal mucous membrane. The condition is 
 rare except as the result of an operation or other traumatism. (See 
 Abscess of the Septum.) 
 
 FOREIGN BODIES IN THE NOSE. 
 
 Foreign bodies in the nose may be animate or inanimate. 
 
 SCREW- WORMS IN THE NOSE. 
 
 Screw-worms in the nose have been reported by M. A. Goldstein, 
 Hal Foster, and J. S. Steele in most interesting and instructive articles, 
 wherein it is shown that their invasion of the human being; is not as 
 rare as might be supposed. (See Foreign Bodies in the Ear.) 
 
 The screw-worm fly is attracted by a foul-smelling discharge from the 
 nose or the ear, and it need be in the nose but for a moment in order 
 to deposit its eggs. Dr. Steele narrates a case illustrative of this point. 
 A railway engineer, while walking across the plaza of a Mexican city, 
 inhaled a fly into one nostril, which he immediately blew out through the 
 other. Twenty-four hours later fulness and pain between the eyes was 
 noted, which increased for three days, when he came under observation. 
 He was affected by syphilitic rhinitis with necrosis of the nasal septum, 
 which accounted for the fly being attracted to his nose. About one 
 hundred worms were removed with the douche and forceps. Calomel 
 fumes were inhaled, which seemed to exterminate all that remained, 
 as they gave rise to no further symptoms. 
 
 Foster removed two hundred and seven worms from the nose of an 
 old Irish woman who was subject to epileptic fits, during which she would 
 fall to the ground. Following one of these seizures she noted an itching 
 of the nasal mucosa, w T hich was accompanied by headache and sneezing. 
 She was told that she had hay fever, and large doses of quinine were 
 administered. Two days later the nose began to bleed and to give forth 
 
278 THE NOSE AND ACCESSORY SINUSES 
 
 a very offensive discharge. The eyes were closed from swelling of the 
 subcutaneous tissue of the face, and she was in such discomfort that she 
 was unable to sleep. 
 
 Upon examination the nostrils were found to be entirely filled with 
 worms. Inhalations of chloroform were administered, which rapidly 
 rendered them lifeless, after which they were readily removed with 
 forceps. The live worms clung with tenacity to the tissues when force 
 was applied in their removal. There was great destruction of tissue, 
 and the temperature reached 102°. There was a bulging of the anterior 
 part of the nose as a result of the penetration of the worms at this point. 
 
 Goldstein's case was that of a farm laborer who slept outdoors in 
 a hammock. He was affected with syphilitic rhinitis, which offered an 
 ideal attraction to the Texas screw-worm fly. When examined, the nose 
 was found to be filled with the eggs of the fly; five hundred were removed 
 with the curette. The curettage was thoroughly done, considerable 
 tissue being removed with the eggs. Forty-eight hours later the patient 
 suffered excruciating pain in the nostrils, which were completely occluded. 
 The skin over the frontal sinus was red and tightly drawn. On the 
 sixth day there was swelling over the dorsum of the nose near its centre. 
 This was incised and considerable pus evacuated. Several worms were 
 subsequently removed through this opening. 
 
 Chloroform is the most effective remedy, and may be administered by 
 inhalation or in diluted solution with a syringe. Calomel fumes are 
 also of value, but do not act as quickly as chloroform. Steele's case 
 shows that its effects were apparent after about four hours, whereas 
 chloroform is effective within a few seconds or minutes. 
 
 Inanimate foreign bodies include almost every kind of inert substance 
 small enough to be introduced into the nose, and some that are too large 
 to be introduced into the nose, at least through the nasal opening. One 
 such case was under my care and gave the history of having received a 
 wound thirty years previously from the explosion of a musket. The left 
 eye was destroyed at the time. Upon removal of the foreign body it 
 proved to be the breech pin of the musket which exploded thirty years 
 previously. The mass of iron, as large as the first joint of the thumb, 
 still preserved its mechanical form, as the screw threads and the tubular 
 space for the flash powder. The cap pin was also intact. In most in- 
 stances the foreign body is voluntarily introduced by the patient. Young 
 children have an inordinate desire to introduce such substances into their 
 noses, hence most cases occur in young children. Idiots and the insane 
 also delight in putting foreign substances into their noses. 
 
 The removal of the foreign body may be accomplished through the 
 anterior nasal opening without the use of a general anesthetic, though 
 in some cases this may be necessary. Forceps with good, grasping tips 
 should be used to seize it and, after dislodging it, to remove it. 
 
CHAPTER XV. 
 
 THE SURGICAL CORRECTION OF EXTERNAL NASAL 
 DEFORMITIES. 
 
 The surgery of external deformities of the nose is being more and 
 more relegated to rhinologists, for various reasons, chief among which 
 are: (a) the rhinologist has a more intimate knowledge of the structures 
 of the nose and can therefore more intelligently conserve and utilize 
 them in reconstructing the nose; and (b) the rhinologist of modern 
 times is better trained and more skilled in surgical principles and practice 
 than formerly. For these and other reasons a chapter on some of the 
 simpler nasal deformities, especially those which can be corrected by 
 intranasal and subcutaneous routes, is introduced in this treatise. 
 
 Fig. 208 
 
 
 Taumatic lateral displacement of the nose to the right: a, depressed left nasal bone. 
 
 The Twisted or Crooked Nose. — This type of deformity may be due 
 to the congenital maldevelopment of the structures of the nose and 
 face, but it is generally caused by external violence to one side of the 
 nose, which results in an irregular lateral displacement of the septum 
 and the tip of the nose. The nasal bone upon the side receiving the 
 blow may also be dislocated laterally, or depressed (Fig. 208, a). 
 
 The Author's Operation. — First Operation. — To correct this deformity 
 the septum should first be straightened by the submucous resection of 
 
280 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 the deformed cartilage and perpendicular plate of the ethmoid bone. 
 The cartilage forming the ridge of the nose should be left wide, as it will 
 be needed in the third operation. If the vomer is deformed it should 
 also be included in the submucous resection. 
 
 Second Operation. — The depressed nasal bone (Fig. 208, a) should 
 be fractured from its attachment and reset in its normal position. This 
 should be done two or more weeks after the submucous resection. The 
 technique is as follows: 
 
 Fig. 209 
 
 Fig. 210 
 
 The intranasal incision at the tip of the left 
 nasal bone. One blade of the steel forceps is 
 inserted through this between the skin and the The Steel septum forceps grasping the nasal 
 nasal bone, the other grasps the tissue anterior bone (a) to fracture it preliminary to resetting 
 to the middle turbinated body (a). in its normal position. 
 
 An intranasal incision should be made with a small scalpel through 
 the mucous membrane of the outer and anterior wall of the nose at the 
 inferior border of the nasal bone (Fig. 209, a). Hajek's semisharp sep- 
 tum periosteal elevator should then be introduced through the incision, 
 and the skin and periosteum over the nasal bone stripped loose. 
 
 The Steel, Asch, or other stout septum forceps should be introduced 
 into the nostril thus prepared, and one blade insinuated through the 
 incision and between the skin and nasal bone, while the other remains 
 free in the nose (Fig. 210). 
 
 The nasal bone should then be firmly grasped between the blades of 
 the forceps, and rotated upon the axis of the blades, and the nasal bone 
 completely fractured from its attachments. 
 
 The nasal bone should be reset in its normal position and held there 
 until union takes place, by means of an intranasal cotton tampon im- 
 pregnated with powdered bismuth; this may be removed in three or 
 four days. Carter's nasal splint is, however, the best device for this 
 purpose. 
 
THE SURGICAL CORRECTION OF NASAL DEFORMITIES 281 
 
 Third Operation. — At a subsequent time the union of the septal 
 cartilage with the nasal bones should be overcome via the nasal route. 
 The incision should be made through the mucous membrane and carti- 
 lage, beginning at the junction of the nasal bones and the cartilaginous 
 septum just beneath the skin at the ridge of the nose. If the cartilage 
 has previously been removed by submucous resection the lower end of 
 the incision should extend to the area of the removed cartilage (Fig. 211). 
 The mucous membrane on the opposite side of the cartilage need not be 
 included in the incision unless greater mobility is to be thereby gained. 
 The incision should extend entirely through the cartilage, which other- 
 wise will not remain in the new position in which it is to be placed. 
 
 Push the tip of the nose forcibly beyond the median line, and note 
 whether it tends to return to its former malposition. If it does, ascertain 
 where the point or points of resil- 
 iency still exist. If at the floor Fig. 211 
 of the nose, sever the attachment 
 at this point and so continue until 
 the whole portion of the nose below 
 the nasal bones remains in the 
 median line without support. If 
 the vomer is still present it should 
 be fractured from the premaxillary 
 bone by twisting it with the Asch 
 septum forceps until it is perfectly 
 pliable. Having done this, the 
 vomer should be reset and sup- 
 ported in such a position as to 
 favor the correction of the external 
 deformity. 
 
 If the skin and cartilage at the 
 ala on the side toward which the 
 tip of the nose formerly inclined 
 interferes with the displacement 
 toward the opposite side, an in- 
 cision should be made at the junc- 
 tion of the ala and skin of the 
 cheek, and the ala and cartilage 
 
 elevated from the bone at the margin of the pyriform opening until 
 they no longer interfere with the lateral displacement of the nose. 
 When the tip of the nose is displaced laterally a crescentic wound is 
 left (Fig. 211, a). This area may be allowed to heal by granulation or it 
 may be covered by a Thiersch graft, after two or three days, when new 
 granulation tissue has covered the denuded area. 
 
 The whole lower portion of the nose, being thus rendered perfectly 
 mobile, should be fixed in the median line, or rather beyond it, as the 
 tendency will be for it to return to its former position. To hold the nose 
 in its new position the author's septum clamp (shown in Fig. 211, b) is 
 placed astride the cartilage along the ridge of the nose, the blades approxi- 
 
 The nasal splint {b) held in position by the 
 anchor cord (c) fixed behind the ear. a, the 
 crescentic area left after the nose is reset in the 
 median line. 
 
282 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 mated by tightening the milled screws, and a stout linen cord looped over 
 the distal end of the clamp. The other end is then looped behind the ear 
 and the knot drawn until the nose assumes the position desired by the 
 surgeon. The portion of the thread which goes behind the auricle 
 should be passed through a small rubber tube to prevent it from cutting 
 the skin (c). This splint should be worn for one week or even longer to 
 allow union of the tissues in the new position. The tension of the loop 
 should be regulated daily. The splint may be removed and reinserted 
 if it becomes necessary to cleanse the nasal chambers. A bandage should 
 be placed around the head to hold the auricle in position. 
 
 Dislocated Nose. — Violent force, as a cyclone, may cause the lower 
 portion of the nose and the upper lip to be dislocated downward, as shown 
 
 Fig. 212 
 
 Fig. 213 
 
 External operation for the removal of the 
 "hump" from the nose. 
 
 in Fig. 212. In this case the nose 
 and upper lip were dislocated 
 downward and had united to the 
 tissues beneath. The openings 
 of the nostrils were on a level 
 with the gums, hence the nostrils 
 s^were almost completely obstruct- 
 ed. The triangular space shown 
 in the figure was filled with scar 
 tissue, which is shown dissected 
 away with the skin. The upper 
 lip and cheeks were freely dissected loose and the sutures intro- 
 duced, beginning at the lower angles of the triangular wound. When 
 the sutures were tied the end of the nose and upper lip were drawn into 
 their natural position. Large rubber drainage tubes were then placed in 
 each nasal chamber for three or four days to prevent adhesions and to 
 sustain the nose in its new position. Irrigation with warm normal salt 
 solution were continued until crusts ceased to form. 
 
 Operation for the correction of traumatic dislo- 
 cation of the nose and upper lip: a, the area of 
 tissue dissected loose to permit the displacement 
 of the lip and nose. (Author's case.) 
 
THE SURGICAL CORRECTION OF NASAL DEFORMITIES 283 
 
 The Aquiline or Hump Nose. — Occasionally the possessor of an 
 aquiline nose, especially if the "hump" is quite prominent, is anxious 
 to have the "hump" removed or reduced. This may be done by external 
 incision, or subcutaneously through the nose. Preference should be 
 given to the intranasal route, because it does not produce a visible scar. 
 I cannot conceive of a deformity of this kind that may not be removed 
 via the nasal chambers. 
 
 External Operation. — If, however, an external operation is preferred, 
 it should be made in the median line of the nose, over the area of deformity. 
 The skin and the periosteum should then be raised on either side, 
 exposing the prominent nasal bones (Fig. 213). The elevated flaps 
 should be pulled aside with retractors by an assistant. The surgeon 
 should then carefully remove enough of the projecting nasal bones to 
 reduce the deformity to the degree suggested by the patient. The 
 cutanoperiosteal flaps should then be coapted with adhesive strips and 
 allowed to heal by first intention. Stitches should be avoided if pos- 
 sible, as they add to the prominence of the linear scar in the median line 
 of the nose. The adhesive strips may be removed at the end of from 
 three to five days. 
 
 Intranasal Operation by the Author's Method. — This method of operating 
 should usually be chosen, as it is not attended with an external scar. 
 
 Technique. — (a) Local or general anesthesia. 
 
 (6) Thoroughly irrigate the nasal chambers with warm salt or boric 
 acid solution, or otherwise clear the nose of the crusts, secretions, and 
 bacteria. 
 
 (c) Introduce a scalpel into one nasal chamber until its point reaches 
 the lower border of the nasal bone, then make an incision through the 
 mucous membrane and pass the blade of the knife between the nasal 
 bone and the skin covering it (Fig. 2C9, a). 
 
 (d) Withdraw the knife and introduce a small elevator of the Freer 
 type and separate the skin from the anterior portions of both nasal bones. 
 
 (e) Withdraw the elevator and introduce the author's reverse chisel 
 (Fig. 214), and with a downward and forward pull (parallel with the 
 ridge of the nose) shave the anterior borders of the nasal bones until 
 the hump is sufficiently reduced (Fig. 215). 
 
 (/) The skin over the operative field should be gently massaged every 
 three hours to prevent the deposit and organization of a plastic exudate 
 over the bones previously reduced. Heat, or the application of the 
 leukodescent light over the nose, will also control the amount of inflam- 
 matory deposit. 
 
 (g) Compression with a nasal pad and a roller bandage may be used 
 instead of massage, heat, etc., if these are not available. 
 
 The Long or Drooping Nose. — This type of nose is occasionally 
 seen. I have twice corrected the deformity. The method pursued by 
 me has been the resection of a wedge-shaped piece of the nasal septum 
 through the nasal orifice. 
 
 Technique. — (a) Cocaine anesthesia as for the submucous resection 
 of the septum. 
 
284 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 (b) Make two incisions through the mucous membrane and cartilage 
 to the opposite mucous membrane as shown in Fig. 216. Connect the 
 divergent ends of the incisions at the ridge of the nose by an intersect- 
 ing incision, which should separate the cartilage from the skin of the 
 nasal ridge. 
 
 (c) Remove the triangular piece of cartilage with an elevator. 
 
 (d) Draw the whole end of the nose upward with a sling composed 
 of strips of adhesive plaster. 
 
 (e) At the end of from four to eight days remove the adhesive strips. 
 
 Fig. 214 
 
 The author's reverse chisel for subcutaneous correction of nasal deformities. 
 
 Fig. 215 
 
 Fig. 216 
 
 The author's method of removing the ' 'hump" 
 from an excessively aquiline nose. 
 
 The author's method of shortening a long 
 overhanging nose. The triangular piece of 
 cartilage (a) is removed via the nostril and the 
 gap closed by lifting the tip of the nose up- 
 ward and securing it in place with adhesive 
 straps applied externally. At the end of four 
 to eight days the straps are removed, union 
 being complete. 
 
 After-treatment. — To prevent local infection and assure firm union of 
 the septal wound, introduce pledgets of cotton saturated with a 10 per 
 cent, glycerin solution of ichthyol every four hours for three days. 
 The ichthyol is antiseptic and the glycerin promotes osmosis of serum 
 from the bloodvessels which washes away any bacteria that chance to 
 invade the region of the wound. 
 
 Remarks. — When the nose is shortened in this way there is no redun- 
 dancy of skin as it contracts until the normal tension is established. 
 
 Paraffin Injection. — The use of paraffin has passed the stage of experi- 
 mentation, and is, in fact, a well-established procedure in surgery, espe- 
 cially in nasal work. It is used principally in the correction of congenital 
 
THE SURGICAL CORRECTION OF NASAL DEFORMITIES 285 
 
 Fig. 217 
 
 and acquired deficiencies. One of the most important locations for its 
 use is the bridge of the nose for cosmetic purposes, that is, the character- 
 istic saddle nose. The various locations and conditions where paraffin 
 has been used about the ear, nose, and throat are as follows: 
 
 1. Saddle noses following trauma, syphilis, and cretinism. The case 
 shown in Fig. 217 was due to cretinism. The patient is a graduate 
 of the High School of Chicago, 
 
 and is an intelligent young woman, 
 twenty-four years old. 
 
 2. Following operations on the 
 frontal sinus to correct the frontal 
 deformity. 
 
 3. To overcome the collapse of the 
 alae nasi. 
 
 4. Intranasal injections into the 
 inferior turbinated body in rhinitis 
 trophica. 
 
 5. Following resection of the 
 superior maxillae to' fill up the defect. 
 
 6. Partial reconstruction of the 
 inferior maxillae following necrosis 
 and resection for malignancy. 
 
 7. Secondary repair of harelip, 
 when there is great atrophy of the 
 premaxillary bone. 
 
 8. In the region of the postnasal 
 space when defect of speech (rhino- 
 lalia pata) results from the operation 
 for cleft or immovable palate. 
 
 9. Following mastoid operations to fill up large retro-articular 
 deformities. 
 
 The paraffin may be injected either hot or cold, depending upon the 
 firmness of the paraffin required. The hot becomes the firmer after 
 cooling, hence for the correction of a saddle nose the hot paraffin may 
 be used, although the cold is preferable and less dangerous. Cold 
 paraffin should be used intranasally to build up the inferior turbinated 
 body. 
 
 The instrument required for these procedures is the paraffin syringe 
 (Fig. 218), which may be used for either the hot or cold paraffin. 
 
 The paraffin which is to be injected hot is kept in an ounce bottle, 
 the cold in tubes which are especially prepared for the syringe. 
 
 Technique. — If hot paraffin is to be used, place the bottle in boiling 
 water until the content liquefies, then fill the syringe with it by withdraw- 
 ing the piston. Then turn the screw head from left to right until the 
 paraffin comes out of the needle in the shape of a thread. Then intro- 
 duce the needle into the cavity to be injected and continue to turn the 
 piston slowly until the desired amount has been injected. If the cold 
 paraffin is used it is not necessary to heat it. Insert a cylinder of it in the 
 
 Congenital saddle nose due to cretinism. 
 
286 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 syringe and by turning the screw handle of the syringe force the paraffin 
 through the needle into the subcutaneous tissue until the desired amount 
 is deposited. An assistant should turn the screw handle while the 
 surgeon moulds the paraffin beneath the skin. The needle should be 
 introduced one-half inch above the upper limit of the depression to 
 avoid the subsequent extrusion of the paraffin. 
 
 Fig. 218 
 
 Beck's paraffin syringe. 
 
 The opening caused by the introduction of the needle is sealed up by a 
 small pledget of cotton moistened with collodion. Considerable bleeding 
 from this point sometimes occurs, and pressure should be applied for a 
 few minutes or until bleeding ceases. It should then be sealed up. 
 
 In submucous injections an antiseptic gauze pad should be inserted for 
 a few hours to control the slight oozing and prevent possible infection. 
 
THE SURGICAL CORRECTION OF NASAL DEFORMITIES 287 
 
 To prevent the spread of paraffin into the neighboring tissues, especially 
 where a great deal of loose areolar tissue is present, as in the eyelid, in 
 injecting the bridge of the nose, it is good practice to have an assistant 
 hold his fingers firmly against the underlying bone on each side of the 
 area to be injected. Before complete hardening of the paraffin takes place 
 it should be molded to the desired form. The operation may be per- 
 formed in one or more sittings according to the discretion of the surgeon. 
 It is safer to inject paraffin at several sittings, because one can always 
 add to the amount, but if too much is injected it is very difficult to 
 remove it. 
 
 The complications following injection are: 
 
 1. Infection. 
 
 2. Hematoma. 
 
 3. Embolism. 
 
 Each is comparatively rare. The first complication should be guarded 
 against by observing the strictest antiseptic precautions in sterilizing 
 the paraffin, the syringe, the field of operation, and the hands of the 
 operator and assistants. 
 
 Hematoma is controlled by pressure, and if it is very large it may 
 require evacuation, followed by the application of ice and afterward 
 warm applications, to cause absorption. 
 
 Embolism has been reported twice in the literature, and in both cases 
 ether was injected hypodermically in dram doses. The operation was 
 successful. 
 
 The change that takes place in the injected mass is at first a reactive 
 inflammation forming a fibrous capsule, which soon throws out tra- 
 becular, which ramify the paraffin mass in all directions, until the latter 
 is held in a meshwork of fibrous tissue. It has been found that after 
 a period of six months or a year considerable paraffin has been absorbed, 
 the connective tissue having taken its place. In cases injected several 
 years ago the mass has remained about the same size as when first injected. 
 Such a mass after organization is known as paraffinoma. Exposure to 
 excessive heat, as in foundries, and during high and long-continued fevers, 
 as typhoid and pneumonia, has very little effect on the injected mass; 
 traumatism, however, such as a blow on the nose, has changed the 
 contour and location of the paraffin mass. 
 
 Special Technique. — Saddle nose and other malformations of the nose. 
 
 1. To fill up a defect: Thoroughly prepare the field of operation and 
 place the patient in a recumbent posture. Introduce the needle of the 
 syringe beneath the skin from above and fill up the defect either at one 
 or in several sittings. Do not dissect the skin loose from the under- 
 lying bone, as a hematoma will form and may become infected. 
 
 Stop oozing by compression and after the paraffin is injected close the 
 puncture with collodion cotton. No after-treatment is required (Figs. 
 219, 220, and 221). 
 
 2. To stiffen collapsed alar of the nose: The needle point is intro- 
 duced between the cartilage and the skin along the whole alar area; inject 
 a very small particle of paraffin to bring about the desired effect. 
 
288 THE NOSE AND ACCESSORY SINUSES 
 
 3. To reconstruct the inferior turbinated body following atrophic rhin- 
 itis : Thoroughly cleanse the mucous membrane of pus and crusts. Anes- 
 thetize with a 5 per cent, solution of cocaine that portion of the turbinated 
 body which is to be penetrated by the needle. If a stronger solution 
 is used, too much contraction will follow. Inject slowly by turning the 
 screw head from left to right, and as the needle is withdrawn a track 
 of paraffin is left along the course of the needle. Apply an intranasal 
 tampon for a few hours. Keep the parts thoroughly clean. It is at 
 times necessary to reinject the different areas. The mucous membrane 
 may be too thin from atrophy to retain the paraffin. 
 
 Fig. 219 Fig. 220 Fig. 221 
 
 / 
 
 irV 
 
 "'■ : : : ■■'™' : W& 
 
 Traumatic saddle nose: a, a, showing the needle intro- Showing the depression filled 
 
 point at which the needle duced one-half inch above the with paraffin, 
 
 should be introduced. upper margin of the deformity. 
 
 4. To correct the deformity following the frontal sinus operation: 
 Cleanse the skin, introduce the needle point in different directions, 
 and insert the paraffin, as the scars are usually very firm and are not 
 easily elevated. Extreme care must be taken not to pass the needle too 
 deep, as the posterior table may be injured. 
 
 5. To correct the defects after the mastoid operation: Make a pre- 
 liminary dissection of the skin, which is usually firmly adherent to the 
 bone. This may be done by making a small incision through which 
 a small elevator is introduced. Squeeze out all the blood and fill the 
 cavity with paraffin. Close the incision by one or two horsehair sutures 
 or adhesive plaster. 
 
 6. To correct defects caused by excision or disease of the upper or 
 lower jaw : One must be guided by the disease present and apply the prin- 
 ciples mentioned above. One of the most common defects is caused by 
 necrosis following decayed teeth, and secondary periostitis. 
 
COLLAPSE OF THE ALJE NASI 
 
 289 
 
 COLLAPSE OF THE AL-ffi NASI. 
 
 Etiology. — Collapse of the wings of the nose is sometimes associated 
 with prolonged nasal obstruction and mouth breathing. Lambert 
 Lack suggests that the open mouth, with the resultant drag on the sides 
 of the nose, and the atrophy of the dilator muscles of the alse from pro- 
 longed disuse are the chief factors in producing the condition. The 
 condition may also be due to senile changes. 
 
 Symptoms. — The nasal orifices are greatly narrowed, often mere slits, 
 and the alse are flaccid and collapse upon inspiration. Under normal 
 conditions the alse dilate and are firm and resilient. 
 
 Treatment. — If the collapse is due to unilateral nasal obstruction, the 
 cause of this obstruction should be removed. In some instances this 
 is followed by a cessation of the collapse, especially if the condition is 
 of comparatively recent occurrence. In older cases the collapse of the 
 alse persists. 
 
 Fig 2^2 
 
 Fig. 223 
 
 Walsham's operation: Collapse of the ala 
 nasi corrected by a roll of mucous membrane 
 from the septum. 
 
 Schema showing Lambert Lack's method of 
 overcoming collapse of the ala? nasi. The 
 flaps a and b are made from the septum, and 
 are about one-eighth of an inch wide. The 
 upper surface of each flap is denuded of mucous 
 membrane, and the nasal walls against which 
 they are reflected are curetted to encourage 
 adhesion. The flaps are held in position by a 
 single suture in each flap. 
 
 Lack advises that the patient practise dilating the nostrils against 
 resistance. He urges them to stand before a mirror for five or ten 
 minutes twice a day and lightly compress the alse with the thumb and 
 finger, and dilate the nostrils to their fullest extent. This method gives 
 results in recent cases, whereas in chronic ones, in which there is 
 complete paralysis of the dilator muscles, it is ineffective. (See Paraffin 
 Injections.) 
 
 Soft- and hard-rubber rings (Guye) have been worn to keep the nostrils 
 patulous, but the discomfort attending their use is quite objectionable. 
 
 YYalsham recommends elevating a narrow strip of mucous membrane 
 from the anterior portion of the septum with an attachment above, and 
 19 
 
290 THE NOSE AND ACCESSORY SINUSES 
 
 then rolling it into a mass at the upper angle of the nostril (Fig. 222), 
 stitching it in position where it mechanically prevents the collapse of the 
 ala. Lambert Lack suggests the most ingenious and apparently the best 
 method in obstinate and troublesome cases. "The operation consists 
 in turning up a piece of cartilage as well as mucous membrane from the 
 septum and stitching it across the top of the nostril at right angles to 
 the septum, so as to push the ala forcibly outward. An L-shaped in- 
 cision is made through the mucous membrane on one side of the nasal 
 septum and the mucous membrane detached from the cartilage. A 
 small piece of mucous membrane at the top, and extending a little on to 
 the outer wall of the nostril, is then cut away so as to leave a bare surface 
 to which the cartilaginous flap becomes adherent. The knife is then 
 passed completely through the septum, and a small quadrilateral piece 
 of the septum, with the mucous membrane on the opposite side left intact, 
 is cut. This flap should be about one-half inch long and one-eighth inch 
 broad. It is fixed to the roof and outer wall of the nostril with a single 
 stitch. A similar piece is then turned up on the other side (Fig. 222)." 
 
CHAPTEE XVI. 
 
 CHRONIC GRANULOMATA OF THE NOSE, THROAT, AND EAR. 
 LUPUS OF THE NOSE. 
 
 Definition. — Lupus vulgaris is a chronic disease of the skin and 
 mucous membrane, characterized by the formation of nodules of granu- 
 lation tissue. It passes through a number of phases, and terminates 
 by ulceration or atrophy with scar formation. The cause of the disease 
 is the tubercle bacillus. 
 
 Etiology. — Lupus of the nose and upper air passages is practically 
 always associated with, or is secondary to, a lupoid condition of the skin 
 of the face. Rare instances of primary lupus of the pharynx and larynx 
 have been reported by Emil Mayer, Rubenstein, and others. 
 
 Females are more often affected than males, and it is more common 
 in the country than in the city. It is most common in middle life, though 
 it occurs at all ages. An abraded or diseased mucous membrane predis- 
 poses to its development. While lupus is due to the tubercle bacillus, 
 there is a clinical distinction between it and tuberculous ulceration. 
 Lupus is slow and insidious in its development, and is not necessarily 
 associated with pulmonary tuberculosis. It has a tendency to heal, 
 cicatrize, and recur, and does not often result in death from pulmonary 
 involvement. 
 
 Symptoms. — Lupus of the nose generally begins on the anterior por- 
 tion of the cartilaginous septum or upon the skin around the nasal orifice. 
 It may spread from the septum to the inner wall of the ala. It appears 
 as small nodules which coalesce and ulcerate, and it may disappear by 
 absorption. The reparative process takes place but feebly at the margins 
 of the ulcer, thus forming a pale-bluish, smooth cicatrix. The ulcers 
 reappear and then disappear. This process may continue for years 
 without spreading to other regions. The nodules are firm and well 
 marked. The disease rarely attacks the cartilage and never the bones. 
 One or both nostrils may be affected, and there may or may not be 
 stenosis. The discharge varies with the stage of ulceration. At the 
 onset it is thin and watery, and later becomes thick and even fetid, 
 especially after crusts appear. Pain and tenderness may be present, 
 though I have seen cases in which they were absent. Itching is some 
 times complained of. 
 
 Deformity may be present if the alse are involved; when limited to the 
 septum it is rarely present. 
 
 Treatment. — Spontaneous recovery may take place, though this is 
 exceptional. It does not readily yield to treatment. Local escharotics, 
 
292 THE NOSE AND ACCESSORY SINUSES 
 
 curettage, the galvanocautery, serumtherapy, surgical removal, and 
 radiotherapy have all been tried with varying success. 
 
 The escharotics which have been used are lactic acid, carbolic acid, 
 chromic acid, the arsenic paste, and other destructive chemical agents. 
 Curettage has also been tried, usually with little result. Curettage 
 followed by the local application of an escharotic affords somewhat better 
 results, though even this is far from satisfactory. Local cauterization with 
 the galvanocautery is a procedure often resorted to, though usually with 
 negative results. Serumtherapy has been attended with some success, but 
 its limited use, thus far, does not afford a sufficient basis for a fair con- 
 clusion as to its efficacy. Surgical removal by excision of the diseased 
 area is also as ineffectual as the measures just mentioned. Radiotherapy 
 has proved of the greatest value in these cases. 
 
 Radiotherapy. — Radiotherapy consists in the local application of heat 
 and light rays endowed with biochemical energy. Generally speaking, 
 the blue-violet rays are the most potent, though the ultra-violet and 
 x-rays are also effective. The energy may be applied by the a>ray 
 tube, the Finsen apparatus, the leukodescent lamp, and radium. 
 
 LUPUS OF THE PHARYNX AND LARYNX. 
 
 Posey and Wright quote H. Myngid's report of 20 patients with 
 lupus of the skin in which the larynx was affected in 10 to 20 per cent, 
 of the cases. Fifteen of the cases were females and 5 were males. Hunt 
 in 411 cases of external lupus found either the pharynx, larynx, or the 
 nose involved in 20 per cent, of the number. In 173 cases of lupus 
 o' the mucous membranes in Doutrelpont's clinic, only 6 were free 
 from cutaneous lesions. The nose was affected in 75 cases, the palate in 
 31 cases, and the larynx in 13 cases. The lesion often appears before 
 puberty. (See Lupus of the Nose for a more general discussion of lupus.) 
 
 LUPUS OF THE AURICLE. 
 
 Lupus of the auricle manifests itself in all the forms found in other 
 parts of the body, namely, hypertrophic, macular, papillary, and ulcer- 
 ous, and is usually an extension from the face. 
 
 It begins with tubercles the size of a pinhead or larger, which are 
 brownish in color, and slightly scaly on their surface. They are arranged 
 in groups, and are surrounded by a slight efflorescence. The skin 
 is contracted around the diseased areas. The scarred appearance 
 is due to the deep penetration of the tubercles. Keloid formations are 
 quite common. 
 
 The ulcerous type is rare and is characterized by ulcerations covered 
 with thick crusts beneath which there is a spongy base. The edges of 
 the ulcers are undermined and pale, with an occasional typical nodule. 
 
 Treatment. — The treatment of lupus has been so uniformly suc- 
 cessful under the Finsen phototherapy, the Rontgen-ray, and the leuko- 
 
TUBERCULOSIS OF THE NOSE 
 
 293 
 
 descent light that the older methods of treatment have become almost 
 obsolete. 
 
 Hollander reports excellent results following the application of hot 
 air to the diseased surfaces. The method is worthy of trial, especially 
 if the Finsen, Rontgen-ray, and leukodescent light treatments are not 
 available. 
 
 If simpler methods of treatment fail the lupous areas may be excised 
 and a subsequent plastic operation performed to overcome the defor- 
 mity resulting from the primary operation. Another form of treatment, 
 much in vogue in Europe, is first to curette the granulating areas and 
 then apply a paste, the base of which is arsenic. This mode of treat- 
 ment has been much vaunted in this country by charlatans as a means 
 of curing cancer, most of the cancerous cases being, however, one or 
 the other types of lupus heretofore mentioned. 
 
 TUBERCULOSIS OF THE NOSE. 
 
 Fig. 224 
 
 Tuberculous infection of the nose is characterized by either a low-grade 
 slightly depressed ulcer on the anterior portion of the septum or floor 
 of the nose, or a sessile, wart-like tumor in which the tubercle bacilli 
 are present. 
 
 Tuberculous lesions of the nose may be primary, or secondary to a 
 similar process in the lungs. It is generally secondary, though cases are 
 not rare in which the process is limited to the nose. I reported a case 
 which was under the care of the late 
 Dr. Max Thorner, of Cincinnati, for 
 about four years. It was subsequently 
 under my care for about the same time, 
 and is now under the care of a confrere, 
 who informs me that the ulcerous con- 
 dition has yielded to applications of the 
 high-frequency currents of electricity. 
 It should be noted, however, that the 
 patient spent the winter in the South, 
 and that while under my care the ulcer 
 disappeared spontaneously each sum- 
 mer. (The case has more recently been 
 reported as cured with bismuth paste, 
 this conclusively proving the apparent 
 cures to have been remissions rather 
 than cures.) 
 
 The case has thus been under nearly 
 constant observation for about eighteen 
 
 years. The patient is about forty-five years of age, and is in robust 
 health, never having had any pulmonary symptoms. She says her 
 brother has a similar condition in his nose. I inoculated a guinea- 
 pig with the tissue removed by curettage, and in six weeks the post 
 
 Author's case of tuberculous ulcer of 
 the cartilaginous portion of the septum. 
 
294 THE NOSE AND ACCESSORY SINUSES 
 
 mortem showed extensive tuberculous lesions in the neighborhing glands 
 and in the mesentery. The tuberculous ulcer (Fig. 224) was superficial, 
 irregular in outline, and had a somewhat nodular surface covered with 
 crusts. It bled easily upon probing, was painless, and disappeared 
 during the summer months, leaving a whitened, rather smooth cicatricial 
 surface. It reappeared in the autumn of each year, only to disappear 
 the following summer. This case seems to be primary in the nose, and 
 shows little or no tendency to spread. There is no lupous lesion of the 
 skin. 
 
 Varieties: (a) Superficial ulceration, (b) Wart-like or sessile tumors. 
 
 The superficial ulcers are the most common. 
 
 The wart-like growths are hyperplastic, and, like the ulcerous variety, 
 bleed easily. The removal of either variety is followed by rather slow 
 healing and by subsequent recurrence. 
 
 The complications are perforation of the septum and extension to the 
 skin of the upper lip, and in extremely rare instances to the nasal accessory 
 sinuses. Kyle suggests that the low resistance of the tissues affords a 
 suitable soil for all forms of microorganisms of chronic granulomata. The 
 treatment consists in curettage and the application of arsenical paste. 
 The ulcer or tumor should be anesthetized with a 5 to 10 per cent, solu- 
 tion of cocaine, after which the diseased area should be thoroughly 
 curetted. A light application of the arsenical paste may then be made 
 to insure the destruction of remaining fragments of tuberculous tissue. 
 The radiant energy of the leukodescent lamp, Finsen light, or some other 
 source of radiant energy may be tried, although I am not informed as to 
 their beneficial effects in this type of tuberculosis. 
 
 In spite of all forms of treatment, there is a strong tendency for the 
 tuberculous lesion to persist, and if it disappears, to return. 
 
 TUBERCULOSIS OF THE PHARYNX AND THE FAUCES. 
 
 Tuberculosis of the pharynx and fauces is rare and is probably always 
 secondary to pulmonary or laryngeal tuberculosis. It is usually asso- 
 ciated with, and is probably an extension from, tuberculous laryngitis. 
 It has no point of attack, but may begin in the soft palate, uvula, tonsils, 
 lingual tonsils, or the pharyngeal mucosa. Unlike nasal tuberculosis, 
 it tends to spread to adjacent parts. 
 
 The part affected presents a worm-eaten appearance, the ulcers being 
 surrounded by an area of congestion. The ulcers are superficial and 
 covered with a dirty grayish secretion. They bleed easily upon probe 
 pressure. There is little or no induration except at the borders of old 
 chronic ulcers. When the lingual or faucial tonsils are the seat of ulcera- 
 tion the depth of the ulcer is great; even the whole tonsil may be destroyed. 
 Cases are reported in which the faucial tonsils were the seat of primary 
 infection and infiltration. It is, perhaps, impossible to estimate the 
 proportion of cases that are primary in the tonsils, though it is perhaps 
 larger than is generally supposed. In other portions of the pharynx and 
 
TUBERCULOSIS OF THE LARYNX 
 
 295 
 
 fauces it is rarely primary. The infection occurs either through the lymph 
 channels or by the contact of the infected sputum with the mucous 
 membrane. 
 
 Symptoms. — The symptoms vary with the anatomical location and 
 extent of the lesion. If the soft palate is involved the proper approxi- 
 mation of the palatal muscles to the posterior wall of the pharynx is 
 interfered with, and fluids and solid food may enter the nose upon deg- 
 lutition. The same condition allows the secretions to accumulate and 
 dry in this portion of the pharynx which leads to hawking and nausea 
 in the effort to dislodge it. An infiltration of the uvula may cause pain 
 and a tickling cough. As the secretions are thick and the parts often 
 exceedingly painful upon movements, the secretions are often allowed to 
 accumulate. The voice is muffled and hoarse, or aphonic. 
 
 Diagnosis. — Syphilis is about the only disease with which tuberculosis 
 of the pharynx may be confounded. The following tables adapted 
 from Lennox Browne will aid in the diagnosis. 
 
 Tuberculous ulcers. 
 
 1. Superficial moth-eaten surface. 
 
 2. Mildly red areola. 
 
 3. Ragged, ill-defined edges. 
 
 4. Indistinct demarcations. 
 
 5. Grayish ropy secretion. 
 
 6. Scanty secretion. 
 
 Syphilitic ulcers. 
 
 1. Deep red and angry surface. 
 
 2. Angry red areola. 
 
 3. Sharply cut edges. 
 
 4. Distinct demarcations. 
 
 5. Purulent yellow secretion. 
 
 6. Profuse secretion. 
 
 Prognosis. — The prognosis is grave. In those cases in which it is 
 primary in the tonsils it is not serious. When we remember that tuber- 
 culosis of the pharynx is nearly always secondary to pulmonary involve- 
 ment the gravity of the disease is apparent. Kanasugi regards pharyngeal 
 tuberculosis as being more grave than any other localized type, and 
 the primary more than the secondary. 
 
 Treatment. — Curettage followed by the application of pure lactic acid 
 is a common form of treatment. It is doubtful if climatic or outdoor 
 treatment is as effective, as the pulmonary involvement is usually well 
 advanced. Forced feeding on raw eggs and milk should be a part of 
 the treatment of all tuberculous diseases when there is loss of weight and 
 strength. The local application of a 2 to 10 per cent, solution of formal- 
 dehyde should be tried as in laryngeal tuberculosis. The pain should 
 be controlled by the local application of cocaine, the administration of 
 opiates, or the leukodescent light or other radiant energy. Painful 
 deglutition is relieved by the application of cocaine immediately before 
 meals. 
 
 TUBERCULOSIS OF THE LARYNX. 
 
 Synonyms. — Consumption of the larynx; consumption of the throat; 
 laryngeal phthisis; tuberculous laryngitis. 
 
 Definition. — Tuberculosis of the larynx may be primary or secondary, 
 and is characterized by an infiltration of the glands and connective tissue 
 of the larynx. It gives rise to dysphagia, aphonia, and dyspnea. 
 
296 THE NOSE AND ACCESSORY SINUSES 
 
 Etiology. — The view that laryngeal tuberculosis is always secondary 
 is held by almost all observers, and is proved by the findings of autopsies, 
 there being very few recorded cases of death by laryngeal tuberculosis 
 in which either a healed or active pulmonary involvement has not been 
 found. The opponents of this view are very few in number, the most 
 prominent of them being Dr. Gleitsmann, whose researches have been 
 extensive, and who reports two cases of primary laryngeal and pharyngeal 
 tuberculosis in his own practice which were cured. In the report of his 
 cases he quotes Demme, E. Fraenkel, Prof. Rebinski, Orth, Coghill, 
 J. S. Cohen, Dehio, and Lancereaux in support of his view. 
 
 Goodale has seen many cases of tuberculous laryngitis which he 
 thought were primary, and which for a time seemed to yield to treatment; 
 but the subsequent progress of the disease always proved fatal through 
 the associated pulmonary tuberculosis. It is possible in a suspected in- 
 stance of tuberculous laryngitis, where the pulmonary signs are negative, 
 that a radiograph may disprove or substantiate the presence of pulmonary 
 tuberculosis. Demme, in 1883, reported the case of a boy, aged four 
 and one-half years, who died of tuberculous meningitis; the necropsy 
 showed the presence of laryngeal ulceration with tubercle bacilli, the 
 thorax and abdominal organs being at the same time free of tuberculous 
 disease. He says many other cases in which such a condition was sus- 
 pected have also been recorded; and it may now be considered as an 
 accepted fact that tuberculous disease may not only attack the larynx 
 primarily, but may cause death without the lungs being affected. 
 
 The disease is more common in men than women, and occurs especially 
 between the ages of twenty and forty years. 
 
 Knight quotes Heinze's statistics, and adds that of the laryngeal 
 lesions more than one-half were ulcerative, a proportion confirmed by the 
 Brompton Consumption Hospital, nearly twice as large a percentage as 
 that given by many other investigators. The mode of invasion of the 
 larynx is either by direct infection through the inspired air or by the 
 expectorated sputum, or indirectly by conveyance of bacilli from the 
 tuberculous foci in the lungs through the blood current or lymph channels, 
 which is doubtless the more frequent route. If the contrary were true, 
 tuberculous laryngitis would be much less rare than it is. The apparent 
 immunity of the larynx against primary infection is difficult to explain. 
 There is no essential difference between the mucous membrane of the 
 larynx and the nose and other portions of the upper respiratory tract, 
 excepting the pharynx. The mucosa of the nose is more exposed to the 
 irritating influence of the atmosphere, and to trauma from picking crusts 
 from the vestibule, and in this respect the abrasions offer a favorable site 
 for the infection; the larynx is also subject to abrasions in the course of 
 chronic laryngitis and in excessive use of the voice, but it remains to 
 be proved that under these conditions it becomes the seat of primary 
 tuberculosis. Shurley contends that the ventricles of the larynx afford 
 a sheltered, quiet place for the development of the tubercle bacilli, and 
 that in spite of this fact they do not readily develop here. The hidden 
 recesses of the crypts of the tonsils also afford an ideal place for the 
 
TUBERCULOSIS OF THE LARYNX 297 
 
 growth of the bacilli, and, according to Mayo, 8 per cent, of all tonsils 
 removed by him are tuberculous. Robertson's statistics support Mayo's. 
 There is the necessary temperature, quiet, and protection from the 
 currents of air to favor such a process. The tonsils are undoubtedly a 
 common source of infection. Having gained entrance to the lymphatic 
 circulation by this route, they travel downward to the lymphatic glands 
 of the anterior triangle of the neck, thence to the lymphatic glands of 
 bronchial tubes, and from there to the substance of the lung. I believe 
 that the explanation of the apparent infrequent primary involvement 
 of the larynx is to be found in inherent resistance of all mucous mem- 
 branes to the invasion of the tuberculous germs, and that the exceptions 
 to the rule are in the nasal mucous membrane of the anterior portion of 
 the cartilaginous septum, and the mucosa of the tonsil crypts, where 
 the abrasions are so often present, and where the conditions are excep- 
 tionally favorable for the growth of the bacilli. The site for the tuber- 
 culous infection of the nose is at the point where it is or may be daily 
 denuded of its epithelial covering, and where the deposit of tubercle 
 bacilli is abundant. It would be strange, indeed, if tuberculous infection 
 did not occur under these circumstances. The tonsillar crypts form 
 ideal sites for the growth of the bacilli, being warm, practically without 
 motion, and plugged with secretion, food, and desquamated epithelium. 
 In these hidden recesses the bacilli nourish and remain constantly in 
 contact with the mucous membrane. The crypts are also the site of 
 frequent inflammations, during which the epithelium may be impaired, 
 thus affording a favorable condition for the invasion of the tubercle bacilli 
 into deeper lymphatic tissue. Indeed, during inflammations the inter- 
 cellular spaces become larger and permit the bacilli to pass through. 
 It is more than probable that when the bacilli are indefinitely lodged on 
 a mucous membrane they may penetrate through these spaces without 
 an abrasion being present. The favorable conditions existing in the 
 nose and tonsils are not present in the larynx, hence the tubercle bacilli 
 rarely primarily infect the larynx. When, however, pulmonary tuber- 
 culosis is established, and the expectorated sputum constantly bathes 
 the laryngeal mucous membrane, the conditions for infection are much 
 more favorable. The constant presence of the bacilli, the mechanical 
 irritation, the abrasions produced by coughing, and the lowered resistance 
 of the cellular structures in general combine to favor such an infection. 
 It is probable, therefore, that infection is usually secondary to the pul- 
 monary involvement, and not primary. 
 
 Pathology. — The first apparent change in the larynx may be an 
 ischemia of the mucous membrane. This is usually referred to as an 
 "ashen-gray" color, which is said to be pathognomonic of tuberculosis. 
 It is not always so, however, as it may occur in any general anemia. 
 I have in several instances been enabled to make a diagnosis of tuber- 
 culosis by the "ashen-gray" color before the stethoscope showed positive 
 evidences of the disease in the lungs. I referred these cases back to 
 their physician, with the suggestion that the tuberculin test be tried, 
 and in each instance a typical reaction occurred. I contend, therefore, 
 
298 
 
 THE NOSE AND ACCESSORY SINUSES 
 
 Fig. 225 
 
 that while the " ashen-gray"color is not pathognomonic of tuberculosis, 
 it is, nevertheless, a valuable early sign in many cases, especially when 
 there is a pulse of 100 or more and a daily rise of temperature. It should 
 be stated that the mucous membrane of the larynx is not always of an 
 "ashen-gray" color in tuberculosis, but, on the contrary, it may be 
 quite red, inflamed, and indurated. The vocal cords may be hyperemic 
 and swollen until their identity is lost in the reddened mucous mem- 
 brane, or they may be lax, flabby, and nodular. 
 
 The histological changes occur chiefly in the aryteno-epiglottidean 
 folds, the interarytenoid space, and the epiglottis. The cartilages may 
 become involved, thus giving rise to perichondritis and chondritis. 
 Cicatricial contraction takes place as the healing process progresses. 
 This may give rise to more or less dyspnea. 
 
 When the arytenoid cartilage is affected the clubbed-shaped infiltra- 
 tion tumor is present (Fig. 225). When the infiltration extends to the 
 
 aryteno-epiglottic ligament the picture 
 is quite characteristic of tuberculosis 
 of the larynx. 
 
 The epiglottis is often involved in 
 the process, and when infiltrated 
 presents the turban shape so often 
 referred to. The infiltration may 
 extend to both sides of the larynx or 
 be limited to one. When both are 
 affected the view of the deeper por- 
 tions of the larynx is hidden. The 
 tendency to ulceration is quite con- 
 stant. It is rare for a well-advanced 
 case of laryngeal tuberculosis to be 
 free from it. The ulcers may be of 
 any size within the limits of the 
 area involved, and may be superficial 
 or may extend to the cartilages. They 
 may be discrete or confluent, single 
 or multiple, and on one or both sides. When the cartilage is involved 
 by ulceration there is a purulent discharge from the mixed infection. 
 Tuberculous ulcers develop more slowly than syphilitic ulcers, are 
 less destructive, and are followed by less cicatricial contraction. 
 W Symptoms. — The symptoms of an ordinary case of laryngeal tuber- 
 culosis are characteristic. As the laryngeal involvement is usually 
 secondary to the pulmonary, the preceding history may afford an excel- 
 lent index. There is more or less cough, often without expectoration, 
 and there may be a sense of prickling or dryness in the throat. The 
 voice may be hoarse or aphonic, especially when the infiltration is exten- 
 The dyspnea is in proportion to the degree of infiltration and the 
 
 Tuberculosis of the larynx. (Author's case.) 
 
 sive. 
 
 cicatricial contraction. Pain may or may not be present. In some cases 
 it is quite severe, and local applications of cocaine and orthoform, or 
 injections of morphine, are necessary to control it. 
 
 In one of the author's 
 
TUBERCULOSIS OF THE LARYNX 299 
 
 cases, illustrated in Fig. 225, though the patient is aphonic, and has 
 been for several years, there is on pain. Dyspnea is a constant factor, 
 though not alarming in severity. During the past ten years the patient 
 has gained twenty-six pounds in weight. Difficult or painful degluti- 
 tion has been a more or less prominent symptom. The laryngoscopic 
 examination shows the lesions described under pathology. 
 
 Diagnosis. — Laryngeal tuberculosis must be differentiated from 
 syphilis, carcinoma, and lupus. 
 
 Syphilis of the larynx presents a " punched-out" ulcer with a yellowish 
 exudate upon a dark red base. It spreads rapidly. The voice is low- 
 pitched and hoarse, or raucous, but rarely aphonic. Pain is present 
 upon phonation. The tuberculous ulcer is superficial and its base is 
 covered with a grayish exudate. It spreads rather slowly, is painful 
 upon deglutition, and the voice is weak and softly hoarse or aphonic. 
 
 In carcinoma the base of the ulcer is raised by the crowding of the 
 deeper infiltration; it is red and constantly painful, and the voice is 
 continuously hoarse. 
 
 In lupus there is usually no pain, ulceration, edema, or discharge; 
 dyspnea is slight or absent, the general health good, and a lupoid lesion 
 is usually present upon the skin. 
 
 Prognosis. — The prognosis in laryngeal tuberculosis is grave, though 
 not necessarily fatal. According to Harpy there were 14 spontaneous 
 recoveries in 3000 cases. Under appropriate treatment the percentage of 
 recoveries is increased. As a rule, however, the patient may be expected 
 to live only for a comparatively short time — a few months or years. 
 Death may occur from inanition, suffocation, or hemorrhage. 
 
 Treatment — The treatment of laryngeal tuberculosis, excepting the 
 local symptoms, is the same as that of pulmonary tuberculosis. At 
 present the " outdoor" treatment, especially in the earlier stages, is 
 enthusiastically recommended. The buildings should be so arranged 
 that the patients practically live outdoors the year round. While this 
 at first thought seems impossible during the winter months, it is, 
 nevertheless, being done with comparative comfort. The house or 
 tent affords protection from the severe cold and from the winds, while 
 fires make life not only tolerable, but cheerful and comfortable. The 
 object is to keep the patients in a pure circulating atmosphere as much 
 as possible. The whole system is thus invigorated and the lungs are 
 supplied with fresh oxygen. The vital forces are augmented and the 
 reparative processes are often quickly and permanently restored. In 
 mild cases, and in the incipient stage, little or no medicinal treatment 
 is required, the "outdoor" treatment being quite sufficient. In well- 
 advanced cases where there is great infiltration and ulceration of the 
 laryngeal tissues the "outdoor" treatment is as ineffectual as any other. 
 
 Innumerable remedies are recommended for the cure and relief of 
 laryngeal tuberculosis, among them being the following: 
 
 For the relief of cough: Codeine, \ to J grain every three hours 
 Morphine sulphate, ^ to 1 1 g- grain every three hours. 
 
 For the relief of pain: Spraying the larynx with a 0.5 per cent, solu- 
 
300 THE NOSE AND ACCESSORY SINUSES 
 
 tion of cocaine. If there is painful deglutition, a 2 to 8 per cent, solution 
 of cocaine may be applied locally, just before eating. Insufflations of 
 orthoform powder may relieve the pain, is non-poisonous, and its effects 
 last longer than those of cocaine. 
 
 For curative effects, Gallagher, Levy, Lockard, and Johnson recom- 
 mend local applications of formaldehyde to the larynx. Gallagher was 
 one of the first to report beneficial results from this treatment. It should 
 be used in solutions gradually increasing in strength from a 0.5 per cent, 
 to a 10 per cent, solution. The patient may be intrusted with a 1 to 500 
 solution for home treatment, but greater strengths should be applied 
 by the attending physician. 
 
 Gallagher reports excellent results with the following method of 
 treatment : 
 
 1. Anesthesia slight. 
 
 2. Cleanse, spray with 1 to 3 per cent, formaldehyde solution. 
 
 3. Local application, 5 to 10 per cent, formaldehyde. 
 
 4. R — Orthoform 7 parts 1 . -, , . 
 
 r . . , , i ' l r insufflation. 
 
 Aristol 1 part J 
 
 5. Deep intratracheal injection of 
 
 1$ — Menthol gr. x 
 
 01. eucalyptus 5J-3iJ 
 
 01. cinnamon gtt. j-gtt. x 
 
 Glycerol q. s. ad §j 
 
 The above daily. Curettage is used when deemed necessary. 
 
 Menthol is another remedy of positive value. It may be used in 
 combination with camphor and orthoform. Freudenthal uses it in 
 emulsion in the following mixture: 
 
 1^ — Menthol 1 to 15 parts. 
 
 01. amyg. dulc 30 parts. 
 
 Vitelli ovarum 25 parts. 
 
 Orthoform ... 12J^ parts. 
 
 Aquse des q. s. ad 100 parts. 
 
 Ft. emulsio. 
 
 The above is injected intratracheally and often yields excellent results. 
 
 Lactic acid has had and still has its advocates. Begin with a 10 per 
 cent, solution and increase to 75 per cent., or even to full strength. It 
 should only be used when there are ulcerations, or after curettement. 
 It should be rubbed into the ulcerated or raw surface with a cotton- 
 wound applicator at intervals of from five to ten days. The pain is severe 
 and continues for four or five hours. 
 
 Radiotherapy. — According to Gleitsmann the Finsen light and the 
 ultra-violet rays are less penetrating than the Rontgen rays, and yet the 
 latter has not produced the expected results in laryngeal diseases. The 
 bacilli are at first increased, and only after a prolonged use of a low 
 vacuum tube is improvement noticeable. The Cooper Hewitt light, 
 or mercurial waves, the search light, the actinolight, and the leukodes- 
 cent lamp may be used to relieve the pain, and in some instances 
 actual improvement follows. It is too early to predict marked curative 
 power from these sources. I have used the leukodescent lamp, but 
 
TUBERCULOSIS OF MIDDLE EAR AND MASTOID PROCESS 301 
 
 my experience with it is too limited to state that it does more 
 than relieve the pain. The chief value of the leukodescent lamp is 
 in the blue-violet rays and the radiant heat. These in combination 
 exert a favorable influence in acute catarrhal and suppurative inflam- 
 mations, hence are of service in combating the mixed infection usually 
 present in tuberculosis. The use of radium as reported by J. C. Beck 
 relieves the pain just as other forms of radiant rays do. The direct rays 
 of the sun, if concentrated, act in much the same way. 
 
 Curettage should be limited to the ulcerated areas, while the parts 
 which are simply infiltrated and have an unbroken surface should be 
 carefully avoided. It has been conclusively shown that the infiltrated 
 areas may remain quiescent indefinitely. When the tuberculous ulcer 
 has been curetted, the sluggish process stimulated, and the overlying 
 necrotic tissue removed, the local treatment given in the preceding para- 
 graphs should be continued. 
 
 TUBERCULOUS LARYNGITIS IN PREGNANT WOMEN. 
 
 Lohnberg observed 5 cases in two years. In 2 there was no evidence 
 of tuberculosis elsewhere, and in the others the laryngitis was the principal 
 lesion. This was true in the cases reported by Tiirck. Lohnberg has 
 collected 21 similar cases from the literature. The evidence is in favor 
 of the assumption that pregnancy affords a predisposition to this affection 
 and whips the latent process to a gallop. Furthermore, he says that 
 every pregnant woman with diffused laryngeal tuberculosis is imme- 
 diately doomed, and possibly also those with only a single tubercle. 
 The only treatment is the palliative use of menthol-orthoform emulsion, 
 formaldehyde, etc., but these lose their efficacy after a time, and relief 
 is only obtained from morphine and tablets of cocaine. 
 
 Pregnant women should be carefully examined on the slightest sus- 
 picion of trouble in the throat, and should be placed upon the treatment 
 outlined above, and especially the outdoor treatment. Every woman 
 affected with tuberculosis should be warned that the tuberculous process 
 may be aggravated by pregnancy. It therefore follows that an unmarried 
 woman suffering from tuberculosis should not marry until a cure has 
 been effected. 
 
 TUBERCULOSIS OF THE MIDDLE EAR AND MASTOID PROCESS. 
 
 Tuberculosis of the middle ear may be primary or secondary. A. W. 
 Milligan believes the primary form, especially in young children, is 
 more common than is generally supposed. Secondary tuberculosis of 
 the middle ear is usually a complication of a tuberculous process in some 
 other part of the upper respiratory tract, rather than a complication of 
 a similar disease of the bones, glands, or abdominal viscera. In a series 
 of cases reported some years ago Milligan found 16 per cent, of all adenoid 
 
302 THE NOSE AND ACCESSORY SINUSES 
 
 cases to be tuberculous. This is a possible explanation of the frequent 
 involvement of the middle ear. 
 
 Symptoms. — The symptoms of tuberculosis of the middle ear vary 
 with the acuity, intensity, or the chronicity of the process; also with a 
 simple or a mixed infection. 
 
 The acute variety is characterized by some redness of the drum 
 membrane, slight pain, and multiple perforations. The hearing is con- 
 siderably impaired. The facial nerve may be paralyzed. If the infection 
 becomes mixed, the nature of the disease is obscured by the greater 
 intensity and destructive character of the inflammatory process. 
 
 Diagnosis. — The chronic variety, which is the usual form, is readily 
 diagnosticated, as it runs a slow course and is characterized by little 
 impairment of hearing (though this is variable), tinnitus, a sense of 
 fulness in the affected ear or ears, and an almost or quite complete 
 absence of pain. In the early stage there are multiple perforations, 
 each of which is the site of a tubercle which has broken down. Later 
 these coalesce and form larger perforations, which often result in a 
 complete destruction of the membrana tympani. 
 
 To confirm the diagnosis, the secretions and the granulation tissue 
 should be examined for the tubercle bacilli and giant cells. Should they 
 not be found, a guinea-pig should be inoculated with some of the tissue 
 and at the end of five to eight weeks examined for the results of the test. 
 In one of my cases the microscopic findings were negative, but the 
 inoculation experiment was positive. Climatic treatment in Colorado 
 and permanent residence there resulted in an apparent cure. 
 
 Milligan draws the following conclusions: 
 
 (a) A final and exact diagnosis is imperative both from the point of 
 view of prognosis and of treatment. 
 
 (b) The disease is most frequently found as secondary to a tuberculous 
 process in other regions of the body. 
 
 (c) Primary tuberculous disease of the middle ear is probably of more 
 frequent occurrence than is usually supposed. 
 
 (d) The prognosis is always grave, but in a certain proportion of cases 
 suitably planned surgical intervention will eradicate the disease. 
 
 (e) In many cases it is advisable to conduct the treatment in stages. 
 (/) When less than 10 per cent, of the hearing power remains no 
 
 attempt should be made to preserve the ear as an organ of sense. 
 
 (g) When more than 10 per cent, of the hearing power remains in a 
 patient otherwise in apparent health, a definite attempt should be made 
 to preserve the remaining hearing power. 
 
 (h) When the tuberculous origin of the ear disease has been scientific- 
 ally demonstrated, the case should be regarded as infectious and precau- 
 tions taken accordingly. 
 
 Robert Levy, who has had exceptional opportunities to study middle 
 ear diseases in tuberculous patients in Colorado, summarizes as follows: 
 
 Any of the usual affections may affect the tuberculous as well as the 
 non-tuberculous. 
 
TUBERCULOSIS OF MIDDLE EAR AXD MASTOID PROCESS 303 
 
 The usual modifications of an acute otitis in a tuberculous subject 
 are manifested in the course of the disease. 
 
 It is doubtful whether the Bacillus tuberculosis is present as a dis- 
 tinctly etiological factor or as an accident. 
 
 Clinical tuberculous otitis occurs with moderate frequency in Colorado, 
 being secondary to lesions of the respiratory organs. 
 
 Tuberculous otitis may develop when the general symptoms of tuber- 
 culosis have been arrested and the patient's condition is unusually good. 
 
 Tubercle bacilli may find their way into the middle ear through the 
 Eustachian tube, the lymph channels, and the blood current. 
 
 Unusual care must be exercised in the application of the nasal douche 
 in tuberculous patients. The discharge may be temporarily arrested. 
 
 It must be exceedingly rare for miliary tuberculosis to develop from an 
 otitis as the focus of infection. 
 
 Serumtherapy is apparently of some, though uncertain, value. 
 
 Prognosis. — Generally speaking the prognosis is unfavorable. There 
 are, however, numerous exceptions to the rule. 
 
 Unfavorable . — (a) It is especially unfavorable in acute cases. 
 
 (6) Rapid destruction of bony tissue of the labyrinth and mastoid 
 process is another unfavorable sign. 
 
 (c) Mixed infection adds to the destructive nature of the process. 
 
 (d) Well-advanced pulmonary tuberculosis renders the prognosis 
 unfavorable. 
 
 (e) Marked general debility from any cause is an unfavorable sign. 
 More Favorable. — (a) In children the disease is often local or secondary 
 
 to diseased tonsils and cervical glands. The removal of the tonsils and 
 glands, and the diseased centre in the mastoid process is usually followed 
 by complete recovery. 
 
 (b) In adults otherwise healthy the prognosis under simple treatment 
 is good. 
 
 Treatment. — General and climatic treatment must be conscientiously 
 carried out. 
 
 Goldstein reports four cases which he considers primary tuberculous 
 infections. All of these cases, he says, were seen more than three years 
 previous to his report; three are still living, and careful physical examina- 
 tion fails to show any tuberculous infection. There were no evidences 
 in the histories of these cases or in their clinical development either of an 
 acquired or hereditary tuberculosis. Of the four cases, three involved 
 the mastoid cells extensively and showed an unusually active and rapid 
 invasion. All of the cases developed from a preexisting otitis media 
 suppurativa chronica, and appeared to him as direct infection by the 
 Bacillus tuberculosis. In the three cases in which the mastoid operation 
 was performed the wounds healed by firm granulations, and all evidence 
 of tuberculosis ceased with the removal of the local process. This 
 is in direct contrast to the healing of wounds in patients in whom the 
 systemic tuberculous invasion is present. The data which has been 
 furnished in the cases herein reported point to a definitely localized 
 specific infection of the cavum tympani and mastoid cells, with the 
 
304 THE NOSE AND ACCESSORY SINUSES 
 
 characteristic development of a tuberculous process as it occurs in bone 
 tissue, and with the definite demonstration of the Bacillus tuberculosis 
 in one case. 
 
 The treatment should be selected with reference to the type of mani- 
 festation, the age, and general health of the patient. 
 
 (a) In primary tuberculosis of the mastoid process, good results may 
 be obtained by the mastoid operation, especially in children. In children 
 it may be necessary to remove the tonsils and cervical glands, as failure 
 to do so subjects the patient to the chance of a return of the process. 
 
 (b) When the pulmonary tuberculosis is not advanced the mastoid 
 operation is indicated, and may be followed by very satisfactory results. 
 These cases also do well in a suitably selected climate or in tent colonies, 
 with adequate nourishment and with local treatment. The tuberculin 
 treatment is of value if Koch's new tuberculin is given under opsonic 
 control. 
 
 (c) When the pulmonary tuberculosis is well advanced, operative 
 treatment is useless. Even in the more favorable cases the operation may 
 be followed by only temporary improvement. If the patient is greatly 
 debilitated from any cause, operative treatment is contra-indicated. 
 In such cases the necrotic process usually continues, and the bony walls 
 remain denuded and covered with pus. 
 
 (d) When there is mastoid swelling or redness an early operation for 
 the relief of the abscess is indicated, regardless of the general character 
 of the disease. 
 
 (e) Climatic or open-air treatment and reconstructive remedies should 
 be used in those cases in which there is little or no involvement of the 
 lungs; outdoor air in a cloudy climate is recommended. 
 
 O. J. Stein recommends the use of formaldehyde, a few minims of 
 which are dropped on a gauze dressing which is placed in the meatus 
 and auricle. This should be covered with a thin layer of cotton and 
 sealed with collodion to prevent external evaporation. The fumes of 
 the formaldehyde penetrate to the diseased area and exert a favorable 
 influence upon it. (See Treatment of Laryngeal Tuberculosis.) 
 
 SYPHILIS OF THE NOSE, PHARYNX, FAUCES, AND TONSILS. 
 
 The fauces and pharynx are second only to the skin as sites for the 
 manifestation of constitutional syphilis, particularly in the secondary 
 stage. This may be accounted for in part by the presence of a large 
 number of lymphoid glands, the excessive friction, and the complex 
 embryological union of tissues in this region. 
 
 Congenital syphilis is more common in the pharynx than in the nose. 
 In the cases shown in Figs. 228 and 227 the pharynx and nose were 
 involved. John Mackenzie says that 50 per cent, of the congenital cases 
 develop in the first year of life, 33J per cent, within the first six months. 
 
 Primary lesion of the pharynx and tonsils is second in frequency to 
 that of the genitalia, owing to the number of syphilitic nurses and sexual 
 
SYPHILIS OF THE NOSE, PHARYNX, FAUCES AND TONSILS 305 
 
 perverts, and to the use of unsterilized surgical instruments in office prac- 
 tice. In one of my cases the primary lesion occurred on the left tonsil, 
 which was incised for quinsy by a practitioner who was syphilitic. 
 
 When I first saw the patient there was an ugly superficial ulcer with 
 indurated edges on the upper portion of the tonsil. Within a few days 
 the typical secondary rash appeared, thus confirming the diagnosis. 
 
 Females are more often affected than males, and one or both tonsils 
 may be the seat of the primary lesion. 
 
 The primary lesion is usually of short duration, though when it occurs 
 on the tonsils the inflammation may be so great as to extend the period of 
 ulceration to the second stage. This has been true in some of my cases. 
 
 Ftd. ?26 Fig. 227 
 
 
 
 Syphilitic scars of the fauces and pharynx causing Author's case of congenital syphilis of 
 a partial constriction of the isthmus between the the nose, 
 
 epi- and mesopharynx. (Author's case.) 
 
 The secondary lesion consists of the usual erythema of the face and 
 body and mucous membranes. It may appear from six to eight weeks 
 after the initial lesion or even as late as several months. The erythem- 
 atous patches in the throat have been described as ulcerations, though 
 Lennox Browne claimed that they are not true ulcers, but simple 
 abrasions of the surface epithelium. 
 
 The tertiary lesions appear from three to twenty-five years after the 
 primary manifestation, and may be ulcerative, gangrenous, or gumma- 
 tous, and very destructive to both soft and bony tissues. 
 
 Symptoms. — The symptoms of the primary stage are ulcers with 
 indurated edges, which cause pain in the ear if the arch of the fauces is 
 20 
 
306 THE NOSE AND ACCESSORY SINUSES 
 
 affected. If the inflammation extends to the pharyngeal orifice of the 
 Eustachian tube there is some deafness and tinnitus. The lymphatic 
 glands of the neck are usually enlarged. 
 
 In the secondary stage there may be cough or a tickling sensation in 
 the throat. In some cases pain or a dull aching is complained of. Dys- 
 phagia and a pseudomembranous angina, accompanied by a slight 
 elevation of temperature, may be present. There may also be erythema- 
 tous patches on the skin and in the throat, those in the throat often being 
 mistaken for superficial ulcerations. Upon close examination they are 
 found to be mere abrasions or elevations of the superficial epithelium. 
 
 In the tertiary stage the odor is characteristic, and is known as syphilitic 
 ozena. There is some pain, but it is not as severe as the lesion seems 
 to warrant. The pain is increased upon deglutition. 
 
 SYPHILIS OF THE LARYNX 
 
 The primary, secondary, and tertiary manifestations of syphilis may 
 appear in the larynx, though the primary lesion is extremely rare. Syphilis 
 of the larynx is estimated as comprising from 1 to 15 per cent, of all cases 
 of syphilis. Its occurrence in the pharynx is given as about 10 per cent., 
 and in the nose as nearly 3 per cent, of all cases. About one-fifth of all 
 the cases of syphilis appear, therefore, to affect some portion of the 
 upper respiratory tract. 
 
 Syphilis of the larynx occurs most frequently between the twentieth 
 and fiftieth years of life. In the congenital form it appears either in the first 
 few months of life or at about the age of puberty. When it occurs soon 
 after birth the lesions are usually secondary. If the second stage is com- 
 pleted in utero the disease may only become manifest in the third stage 
 after the lapse of several (usually from two to fifteen) years. 
 
 Secondary erythema of the larynx usually occurs as an accompani- 
 ment of the same process in the pharynx, but whether hereditary or 
 acquired it is in the tertiary stage that relief is usually sought. Males 
 are more often affected than females. 
 
 Gross Pathology. — The lesion is usually bilateral and appears upon 
 the true and false cords as a catarrhal inflammation with hyperemic 
 spots and abraded epithelial areas. Condylomata may occur on the 
 epiglottis or upon the laryngeal mucous membrane, and cause consider- 
 able stenosis. 
 
 Symptoms. — Though the ulceration takes place very rapidly the pain 
 is usually slight. The lesion first appears in the form of a clear-cut, deep 
 ulcer. Induration is not always present, though there may be slight 
 thickening at the edges of the ulcer. Edema is not a marked feature. At 
 the bottom of the ulcer the cartilage may be necrosed and may be the seat 
 of suppuration; that is, perichondritis and chondritis of the laryngeal 
 cartilages may be present. The mucous membrane is hyperemic and 
 darkly congested. The condition is improved by the administration of 
 the iodides, though this may be temporary. Hemorrhages sometimes 
 occur, and in rare instances endanger life. 
 
SYPHILIS OF THE EXTERNAL EAR 3()7 
 
 The vocal changes are unilateral paralysis (though it may be bilateral), 
 with a raucous hoarseness or aphonia. Cough is in some subjects an 
 early symptom. Dysphagia may or may not be present. If the syphilitic 
 lesion is located on the posterior aspect adjacent to the mouth of the 
 esophagus of the larynx, dysphagia is usually a marked symptom. 
 
 Prognosis. — Syphilis of the larynx usually yields to treatment, though 
 it may leave the vocal apparatus somewhat impaired as to its anatomical 
 and physiological integrity. Life is not usually in any great danger, 
 except in those cases in which the hemorrhage is unusually severe, 
 or in which the stenosis causes suffocation. When on account of the 
 suffocation it becomes necessary to perforin tracheotomy the patient 
 should be warned that in all probability he will have to wear a tracheal 
 tube the balance of his life. 
 
 Treatment. — The general treatment should be as for syphilis elsewhere 
 in the body. Local treatment to relieve the cough or pain may become 
 necessary. In case perichondritis and necrosis of the laryngeal carti- 
 lages is present it is best to first administer the iodides in full doses, in 
 order to diminish the acute pathological process, and then, if necessary, 
 to remove the fragments of diseased cartilage. This may be done by 
 direct laryngoscopy, or by laryngofissure (see Laryngoscopy and Laryngo- 
 fissure); the former is preferable, for if the other method is adopted, 
 it may become necessary to repeat the operation a number of times. 
 
 In cases of extreme stenosis, tracheotomy should be performed and a 
 tracheal cannula introduced. 
 
 SYPHILIS OF THE EXTERNAL EAR. 
 
 Primary chancre of the external ear is so rare that less than half a 
 dozen cases have been reported in the literature. 
 
 The secondary manifestations may be papular, pustular, macular, 
 ulcerous, or condylomatous. The entire auricle may be destroyed by 
 extensive ulcerations, or it may be greatly deformed. The manifestations 
 in the ear are usually secondary to a similar affection of the adjacent skin. 
 
 Condyloma of the meatus is rare; it occurs in the proportion of about 
 1 to every 240 cases of general syphilis (Depres and Buck). 
 
 The course of condyloma in the external meatus is as follows: 
 
 (a) In the beginning there is a red efflorescence of the skin, other 
 symptoms being absent. 
 
 (b) A little later, diffuse swelling of the walls of the meatus occurs. 
 
 (c) The skin begins to be slightly broken and secretion is thrown upon 
 the surface. 
 
 (d) Finally, warty growths, of a grayish-red color, form in the carti- 
 laginous portion of the auditory meatus, and, more rarely, in the osseous 
 portion. They may be large enough to block the meatus. 
 
 (e) Pain usually develops with the appearance of the condyloma, 
 especially if the skin is ulcerated. It is intensified by movements of 
 the lower jaw, as the glenoid fossa is in very close relation to the antero- 
 
308 THE NOSE AND ACCESSORY SINUSES 
 
 inferior wall of the meatus. Deafness and tinnitus develop in propor- 
 tion to the degree of the meatal obstruction. Fever is exceptional. 
 
 (/) Resolution may take place either with extensive destruction of 
 the tissue or with little or no changes whatsoever. In some cases the 
 ulceration continues for many months. Under general treatment resolu- 
 tion takes place quickly, and little or no scar tissue forms. Stricture of 
 the meatus is rare. 
 
 Diagnosis. — The diagnosis should be based upon the history of specific 
 disease elsewhere in the body, the characteristic glandular swelling, 
 and the appearance of the local lesion. 
 
 Prognosis. — The prognosis of condyloma and the other secondary 
 forms of syphilitic manifestation is favorable under the internal admin- 
 istration of mercury and iodides. 
 
 Gummatous formations of the external ear are usually simultaneous 
 in their appearance with the same process in the middle ear. They may 
 appear later as deep ulcers with elevated margins. 
 
 Treatment. — The local treatment of the primary chancre should con- 
 sist in cleansing the parts with black wash and then applying the follow- 
 ing ointment: 
 
 1^ — Unguent, hydrargyri, 
 
 Lanolin aa 5iv — M. 
 
 Sig. — To be applied with cotton pads held in place with a light bandage. 
 
 Mercury should also be given internally, or it may be rubbed into 
 the skin in the form of blue ointment. 
 
 Condylomata and other secondary syphilitic manifestations should 
 be treated by the internal administration of mercury and the local appli- 
 cation of a powder composed of equal parts of calomel and the oxide 
 of zinc, which should be applied once or twice daily. 
 
 To reduce the exuberant granulations, apply a strong solution of the 
 nitrate of silver. 
 
 Gumma should be treated by the internal administration of mercury 
 and the iodide of potash or iodonucleoid to the point of toleration. 
 
 LEPROSY. 
 
 Synonyms. — Elephantiasis graecorum; leontiasis; satyriasis; French, 
 la petse; German, der Aussatz; Norwegian, spedalskhed. 
 
 Leprosy is a chronic infectious disease caused by the Bacillus leprae. 
 It is characterized by the presence of tuberculous nodules in the skin and 
 mucous membranes (tuberculous leprosy), or by changes in the nerves 
 (anesthetic leprosy). At first these forms may be separate, but ulti- 
 mately they exist in combination. In the characteristic tuberculous form 
 there are disturbances of sensation. 
 
 It is customary to divide leprosy into two general forms, the tuberculous 
 and the anesthetic, lepra tuberosa or tuberculous leprosy, and lepra anes- 
 thetica seu nervosa. It is also sometimes subdivided into: 
 
LEPROSY 309 
 
 (a) Tuberculous nodular. 
 
 (b) Non-tuberculous. 
 
 (c) Mixed tuberculous. 
 
 Etiology. — Geography. — In Europe it is most common in Norway, the 
 Swedish, Finnish, and Russian Coasts, the East sea; then in Asia, India, 
 China, Africa, Egypt Abyssinia, Morocco; and in America (California 
 and Mexico). It is also found in Australia and the Sandwich Islands. 
 
 The Bacillus leprae was discovered by Hansen, of Bergen, in 1871, 
 and is universally recognized as the cause of the disease. 
 
 Modes of Infection. — There are three possible modes of infection, viz.: 
 
 (a) Inoculation. — It has not been proved that leprosy is contracted by 
 accidental inoculation, though it is highly probable. 
 
 (b) Heredity. — For years it was thought to be transmitted, though it is 
 probably not. 
 
 (c) By Contagion. — The disease is contagious. The bacilli are given 
 off from the nasal secretions, open sores, and the excretions of the body. 
 Osier says it is probable that the bacilli may enter the body in many 
 ways through the mucous membranes and through the skin. Sticker 
 believes that the initial lesion is the ulcer upon the cartilaginous part 
 of the nasal septum. If this is true the disease assumes greater impor- 
 tance to the rhinologist and suggests the advisability of maintaining 
 thorough cleanliness of the nose on the part of those associated with 
 leprous patients. 
 
 Pathology. — The Bacillus lepra? has many points of resemblance to 
 the tubercle bacillus, but can be readily differentiated from it. It is 
 cultivated with extreme difficulty, and, in fact, there is some doubt as to 
 whether it is capable of growth on artificial media (Osier). Lepra 
 tuberosa, or tuberculous leprosy, attacks chiefly the integument and the 
 mucous membrane of the nose, palate, roof of the mouth, larynx, and 
 pharynx. On the skin the first changes show themselves in the form of 
 infiltrations; the skin in one or more places over areas of several centi- 
 meters becomes elevated and assumes a brownish-red or dull red color. 
 In the region of the infiltration the sensibility disappears, partly or 
 completely, and on hairy parts the hair of the affected area falls out. 
 On mucous membranes the lesions show themselves either as small 
 patches or tubercles, or as round, flat infiltrations, which become ulcerated 
 and heal with cicatricial contraction. The results are often conspicuous 
 disturbances of the affected part, the disappearance of the cartilaginous 
 nasal septum, the soft palate, and the epiglottis. Stenosis of the larynx 
 is one of the most common occurrences. Characteristic tubercles also 
 often develop on the conjunctiva bulbi, especially at the corneal 
 borders. The disease has a remarkably regular and progressive course, 
 inasmuch as new lesions are always appearing. The outbreaks arise 
 with the initial eruptions. Under febrile action the erythematous red- 
 dening of the affected parts develops, and is soon followed by the forma- 
 tion of tubercles and nodules. At the site of the older lesions, usually 
 at the time of the fresh outbreaks, changes take place, and miliary 
 abscesses or blebs develop, either of which may end in ulceration. It 
 
310 THE NOSE AND ACCESSORY SINUSES 
 
 is deserving of mention, that at the time of these fresh outbreaks the 
 lepra bacillus may be demonstrated in the blood, in which, at other 
 times, it is absent. 
 
 Lepra Anesthetica seu Nervosa. — Anesthetic leprosy is characterized by 
 sensibility and trophic disturbances of the skin and muscles. The forma- 
 tion of new tissue, which produces the nodular growths of the tuber- 
 culous form, is small or entirely absent. The disease begins as a leprous 
 polyneuritis. Anesthetic leprosy, in typical cases, has no resemblance 
 to tuberculous leprosy. It usually begins with pains in the limbs, and 
 areas of hyperesthesia, or of numbness. Bullae may form very early, 
 maculae appear on the trunk and extremities, and, after existing for a 
 variable length of time, disappear, leaving areas of anesthesia, though 
 anesthesia may develop independently of the maculae. Superficial 
 nerve trunks may be large and nodular. The bullae change to destruc- 
 tive ulcers. The fingers and toes are likely to contract and necrose. 
 This type runs a very chronic course and may not be severe in its results 
 (Osier). 
 
 Mixed tuberculated lepra is the least common form; it constitutes 
 about one-sixth of all cases, about one-half of which are apparently 
 hereditary each parent often having had a different form. It begins 
 with either a tuberculous or a non-tuberculous symptom; most fre- 
 quently the latter are more prominent for a few months, fever and the 
 usual phenomena of tuberculization then occurring. Destruction of the 
 cartilage of the nose sometimes ensues; the soft palate also may be 
 destroyed by ulcerations. The balance of the symptoms are a com- 
 pound of the other varieties. 
 
 Prognosis. — The disease is very chronic, progressive, and probably 
 incurable. The tuberculous form is destructive. The nervous form 
 may not greatly impair the patient's usefulness, as in the case of the 
 clergyman who continued his career for thirty years after contracting 
 the disease. 
 
 There are no specific remedies for the disease. General tonics should 
 be combined with local treatment to meet the indications, and this is 
 all that can be done. 
 
 GLANDERS. 
 
 Synonyms. — Equinia maliasmus; malleus; malleus humidus; farcy; 
 morve; farcin; rotz. 
 
 Glanders is a contagious disease affecting horses and asses. It is 
 communicable to man. It is caused by the bacillus mallei. When it 
 affects the mucous membrane it is called glanders, and when it affects 
 the skin and lymphatic glands it is called farcy. 
 
 Etiology. — Glanders originates in horses and asses, but is communi- 
 cable to man, and from man to man. It is naturally more often found in 
 men engaged in occupations which bring them in contact with beasts of 
 burden. Though the bacillus may gain entrance through the follicles of 
 the skin, it more often does so through an abraded or a wounded surface. 
 
GLANDERS 311 
 
 Cases are reported of surgeons being infected while operating upon 
 patients who had the disease. 
 
 Pathology. — There are numerous closely associated nodules of low 
 grade embryonal or granulation tissue, which readily break down and 
 suppurate. The ulcers thus formed have undermined edges, which are 
 the remnants of the wall of the preceding abscess. The process spreads 
 by continuation, though later it may be carried to distant parts. It 
 usually appears first in the skin, and then extends to the mucous mem- 
 brane of the nose, though it may have its origin in the mucosa. Baum- 
 garten says it is a disease which stands midway between abscess and 
 tuberculosis. 
 
 The nasal lesions are usually in the form of numerous closely grouped 
 granulation nodules in the submucous tissue. There is a profuse pro- 
 liferation of leukocytes and connective-tissue cells, with which are 
 admixed numerous bacilli of glanders. The proliferation continues until 
 the pressure diminishes the nutrition of the mass, especially at its centre, 
 liquefaction necrosis then ensues and the nodules become abscesses. The 
 outer wall soon breaks down and the contents are discharged into the 
 nasal cavities. The abscesses are thus converted into open ulcers with 
 undermined edges. Cross-sections of the masses before breaking down 
 show them to be composed almost entirely of leukocytes, connective- 
 tissue cells, and fibrous tissue. Many Bacilli mallei are embedded 
 in the masses of proliferated cells. In the acute form there are numerous 
 multinuclear leukocytes in the adjoining tissue. In the chronic form 
 the bone and deeper structures may be destroyed. Gangrene of the 
 softer tissues may occur. 
 
 Symptoms. — In the acute form the period of incubation is from three 
 to four days. The acute symptoms often simulate rheumatism or typhoid 
 fever in its initial stage. A little later the nodules appear either upon 
 the skin or the nasal mucosa, according to the point of infection. They 
 rapidly increase in size, as described under pathology, until (in nasal 
 glanders) the purulent contents empty into the nose. The upper air 
 passages are not often involved primarily in man. The progress of 
 the disease is rapid, and usually leads to a fatal issue in a few days, or in 
 two or three weeks. 
 
 The chronic form is fatal in about 50 per cent, of the cases after two 
 months to two years. This type bears a close resemblance to syphilis 
 and tuberculosis. The lymph glands of the neck are often much enlarged 
 in the acute form. Chronic glanders often presents the symptoms of a 
 persistent coryza. The diagnosis is difficult. It may be necessary 
 to inoculate a male guinea-pig with the nasal secretions to determine 
 the diagnosis. At the end of two days, in a positive case, the testicles 
 of the pig are swollen and the skin of the scrotum reddened. The testicles 
 continue to increase in size and finally suppurate. After two or three 
 weeks death occurs, and the postmortem reveals nodules in the viscera. 
 The use of "mallein" is highly recommended for diagnostic purposes. 
 It is used in the same manner as the tuberculin test in tuberculosis. 
 In all suspected cases remove a piece of the tissue and examine sections 
 
312 THE NOSE AND ACCESSORY SINUSES 
 
 with the microscope; make agar cultures and inject them into the peri- 
 toneal cavity of a guinea-pig, and watch the reactions. Also use injec- 
 tions of mallein, and watch the results. Above all, study the clinical 
 phenomena, and from all the evidence obtainable arrive at a diagnosis. 
 
 Prognosis. — The prognosis in the acute form is grave, for nearly all 
 cases die in a few days. In the chronic form the mortality is about 50 
 per cent., and death occurs in from two months to one or more years. 
 
 Treatment. — In acute cases there is little hope of recovery. If seen 
 early the tissue around the point of original infection should be either 
 extensively cauterized or removed en masse. The wound thus created 
 should be frequently bathed in a solution of the chloride of zinc (one to 
 eight). All animals and horses suspected of being infected should be 
 killed and their bodies burned. In chronic cases, tonics and the iodide 
 of potash should be given, though no specific remedies are known. 
 
 Glanders of the pharynx is usually an extension of the same process 
 from the nose, though it may be primary in the pharynx. Nodules 
 form here, as in the nose, and are attended by about the same general 
 symptoms. The cervical and sublingual glands are early involved, 
 break down and suppurate, and discharge externally. 
 
 The chronic form is not attended with the same distinct phenomena, 
 and is often mistaken for granular pharyngitis. The nodules are mis- 
 taken for the lymphoid masses which occur in chronic follicular pharyn- 
 gitis, though, if watched long enough, they will be seen to grow gradually 
 larger and larger, until serious mechanical obstruction results. Such a 
 process in the pharynx should arouse a suspicion of glanders, and the 
 mallein test, or guinea-pig experiment as given under Symptoms should 
 be made. 
 
 Glanders of the larynx is rare, and when present is associated with 
 the same process higher up in the respiratory tract. 
 
 ACTINOMYCOSIS OF THE NOSE. 
 
 Synonyms. — Lumpy jaw; holdfast, or wooden tongue 
 Definition. — Actinomycosis is a parasitic, infectious, and incurable 
 disease which was first observed in cattle and later in man. It is charac- 
 terized by the manifestations of chronic inflammation, with or without 
 suppuration. It often results in the formation of granulation tumors, 
 especially about the jaw and neck. 
 
 Etiology. — The exciting cause is the ray fungus or actinomyces. 
 The predisposing causes are an abraded mucous surface, or a diseased 
 membrane. The infectious material may be carried by water or food, 
 and by straws, chaff, grain, needles, etc. The fungus probably grows 
 upon wheat and oats, hence farmers should be cautioned against chew- 
 ing wheat and oat straws, as they seem to be a prolific source of infection. 
 Shoemakers occasionally contract the disease from the habit of holding 
 a needle or awl in the mouth. Kissing may be the means of transmis- 
 sion from one person to another. It occurs chiefly in young adults. 
 
ACTINOMYCOSIS OF THE PHARYNX AND TONSILS SYS 
 
 Pathology. — The aetinomyces were formerly thought to be mold 
 fungi, but Bostroem, in 1885, proved by cultivation that they are a 
 variety of cladothrix, belonging to the schizomycetes. The diseased 
 mass is made up of granulation tissue, which, except for the ray fungus, 
 would be mistaken for round-cell sarcoma. Epithelioid elements and 
 giant cells are sometimes present. In the granular mass, or in the 
 pus, the fungus itself appears in the form of small, yellow, brown, or 
 green masses, about the size of a pinhead, which, upon microscopic 
 examination, are found to be composed of a central interwoven mass 
 of threads, from which radiate club-shaped ended rays. In man the 
 clubbed bodies are frequently absent (Senn). The histological lesions 
 are alike in the actinomycotic nodule, and in the tuberculous follicle, 
 only the germ body differs. Water, or a weak solution of sodium chlo- 
 ride, causes the rays to swell enormously and lose their shape ; ether and 
 chloroform have no action upon them. The gross pathological anatomy 
 of the disease is everywhere associated with chronic indurations, with 
 softening and liquefaction, and with resulting sinuses and cysts. The 
 head, neck, and especially the jaw, and the cervical fascia are the sites of 
 the disease. In the cervical fascia the disease gives the neck a brawny 
 hardness. The lymphatic glands are not, as a rule, extensively involved. 
 In the ox the tongue is often affected. 
 
 The lesion may be self-limited, as in tuberculosis, by cicatricial 
 envelopment. 
 
 The kernel-like nodules are usually multiple. They may coalesce, 
 and the resulting masses may "heal out." When bone tissue is affected, 
 the destruction is central, while peripherally there is hyperplasia. 
 
 ACTINOMYCOSIS OF THE PHARYNX AND TONSILS. 
 
 Symptoms. — The symptoms vary according to the part involved. The 
 affection is chronic, but occasionally runs a rapid course. The granula- 
 tion tissue is abundant and the mass resembles a tumor. Previous to 
 suppuration it is quite firm, and if progressing rapidly it is surrounded by 
 diffuse edema. Pain and tenderness are rarely present. When suppura- 
 tion occurs the mass increases rapidlv in size. 
 
 The frequency of occurrence in different parts of the body in 500 cases, 
 as collected by Poucet and Berard, is as follows: Head and lungs, 55 per 
 cent.; thorax and lungs, 20 per cent.; abdomen, 20 per cent.; other parts, 
 5 per cent. In France the face and neck were affected in 85 per cent, of 
 the 66 cases reported. 
 
 The symptoms may be grouped in two classes: (a) Those referable to 
 local tumefaction and purulent discharge, and (b) those referable to the 
 general intoxication of the system by the suppurative products, or their 
 metastatic spread, and which do not differ from those of chronic sup- 
 puration. The local symptoms are of slow development, and are largely 
 those of gradual mechanical interference of the pharyngeal function. At 
 the site, or sites, of inoculation a small rounded and reddish elevation 
 
314 THE NOSE AND ACCESSORY SINUSES 
 
 appears, and is accompanied by the usual subjective annoyances of 
 an attending pharyngitis. The adjacent tissues become swollen and 
 tumefied, and the evidences of an acute inflammation soon change to the 
 more permanent engorgement and solidity of a chronic condition. The 
 swelling is irregular, but well outlined, firm to probe palpation, and 
 not oversensitive, and slowly increases in size. Suppuration and the 
 formation of angry-looking sinuses follow, from which issue a puru- 
 lent discharge, in which are the small yellowish pellets, or masses, com- 
 posed largely of the typical ray fungus. The discharge is persistent, 
 and the sinuses extend deeply and produce extensive destruction of 
 tissue. The spread of the process does not, as a rule, occur, and it shows 
 a tendency, if it occurs elsewhere, to do so as an isolated swelling rather 
 than as a connected overgrowth from the original pharyngeal focus. 
 Pain is a variable quantity, and depends largely upon the seat and 
 extent of the peculiar swelling. Usually there is a more or less continuous, 
 heavy ache which is felt locally, and this may, at times, be eased or 
 intensified into acute distress. Fetor of the breath and gastric disturb- 
 ances from the purulent discharge are often present. The appearance 
 of the disease elsewhere by metastasis is to be expected, especially in the 
 lungs or the alimentary tract, though no portion of the body is free from 
 possible invasion. The systemic symptoms may be severe or slight, 
 according to the degree of involvement and the exit of the suppurative 
 products, and do not differ in their character from those usually observed 
 in any other suppurative condition. Death occurs from slow exhaustion, 
 or through some intercurrent affection or complication (Kyle). 
 Diagnosis. — Actinomycosis should be differentiated from: 
 
 (a) Sarcoma. 
 
 (b) Tuberculous infection. 
 
 (c) Carcinoma (of the tongue). 
 
 (d) Syphilis. 
 
 (e) Epulis (in jaw). 
 (/) Lupus. 
 
 It is, perhaps, impossible to make a positive clinical diagnosis of 
 actinomycosis. A microscopic examination showing the ray fungus, 
 or inoculation of a guinea-pig, may be necessary to establish it. The 
 presence of the yellowish particles in the purulent discharge is quite 
 characteristic, though not conclusive. Actinomycosis is probably not as 
 rare as is generally supposed, as it is sometimes mistakenly diagnos- 
 ticated as sarcoma, carcinoma, osteomyelitis, syphilis, etc. 
 
 (a) Sarcoma is histologically quite similar to actinomycosis. A careful 
 microscopic examination will, however, in actinomycosis show the 
 presence of the ray fungus and some giant cells. Sarcoma does not 
 break down and suppurate so early. Both occur quite frequently in 
 the young. 
 
 (b) Tuberculous disease is attended by an enlargement of the regional 
 lymphatics. In actinomycosis the regional glands are not enlarged. 
 An examination of the sputum or the inoculation of a guinea-pig will 
 show the tubercle bacilli if present. 
 
ACTINOMYCOSIS OF THE MIDDLE EAR 315 
 
 (c) Carcinoma of the tongue is usually found near the base, whereas 
 actinomycosis affects the tip. Then, too, in carcinoma there are lancin- 
 ating pains, ulceration, and cachexia. 
 
 (d) Syphilis, in the gummatous stage, is more amenable to treatment 
 by means of the iodides. The general history of the case is also an aid 
 in the differential diagnosis. Acute progressive actinomycosis may very 
 strikingly resemble acute phlegmonous inflammation and osteomyelitis. 
 
 Treatment. — The iodides are efficacious in recent cases. In old cases 
 in which there is a mixed infection they are less efficient. The remedy 
 should be given until marked iodism results. The injection of a 5 per cent, 
 solution of the permanganate of potash into the cysts, when present, has 
 produced good results. Cauterization of the skin and soft parts with the 
 solid stick of silver nitrate is a valuable aid in those cases in which there 
 is a fistula and suppuration. Gautier reports excellent results from the 
 injection of a 10 per cent, solution of the iodide of potash into the mass. 
 Electric needles may be inserted in the tumor, and 50 milliamperes of 
 current passed through it. Every minute a few drops of the iodide of 
 potash solution should be injected until a total of 20 minims is used. 
 The electric current decomposes the iodide solution into nascent iodine 
 and potash. The chemicals thus liberated in the actinomycotic tissue 
 act as a deterrent to the further progress of the disease. A general 
 anesthetic should be administered for this treatment. It should be 
 repeated in eight days. 
 
 The surgical treatment of actinomycosis varies from simple incision 
 to the complete removal of the entire mass. The disease is best suited 
 to surgical treatment before the stage of suppuration and extension to 
 the regional glands. When it has progressed thus far it is no longer 
 simple actinomycosis, as it is complicated by a mixed or streptococcal 
 and staphylococcal infection. A simple incision is sometimes effectual, 
 as is, indeed, spontaneous rupture. Should excision be resorted to, it 
 should be complete, and followed by the thermocautery, to prevent 
 the spread of infection to the exposed lymph spaces. After suppuration 
 is established, treat as for tuberculosis, i. e., curette and pack with 
 iodoform gauze. 
 
 The disease seems to be self-limited by the formation of a capsule of 
 connective tissue and by spontaneous rupture. 
 
 Iodide of potash or iodonucleoid are probably the most reliable internal 
 remedies. 
 
 ACTINOMYCOSIS OF THE MIDDLE EAR. 
 
 Actinomycosis of the middle ear is very rare, and the only literature 
 on the subject is the clinical report of a case by Zaufal, of Prague, and a 
 more extended report of the same case, with the postmortem findings, 
 by J. C. Beck, of Chicago, and a second case of Mojocchi, of Italy. The 
 clinical aspect of Beck's case was as follows : Carl J. was fifty-four years 
 old, a farmer, always healthy, with a negative history of aural, nasal, and 
 pharyngeal disease, until six months previous to the examination. At 
 
316 THE NOSE AND ACCESSORY SINUSES 
 
 that time there was a swelling back of the left ear and left side of the neck. 
 The swelling, at first hard, soon softened, and was never painful. Later 
 a third swelling appeared on the left side of the neck, which opened 
 and discharged pus through a fistula. At this time the hearing became 
 defective. The functional tests of hearing showed a negative Rinne, 
 and Weber lateralizing to the left side, thus showing middle ear disease. 
 There was no secretion from the external auditory meatus, but the post- 
 superior wall, at the fundus, sagged as in mastoiditis. A swelling the 
 size of the palm of the hand was situated over the mastoid and the region 
 posterior and inferior to it. It did not fluctuate. A smaller swelling, 
 anterior to this, had a fistulous opening in the region of the tip of the 
 mastoid process. Compression expelled a greenish pus, containing 
 small granules. The subsequent microscopic findings showed the ray 
 fungus of actinomycosis in abundance. A radical mastoid operation 
 was performed, but the healing process was unsatisfactory. Five weeks 
 later the patient died from an intracranial hemorrhage, due to the ulcera- 
 tion of a large bloodvessel in the region of the actinomycotic process. The 
 post mortem was held by Chiari, who found the muscles of the neck on 
 the left side and the upper cervical vertebra infiltrated with pus contain- 
 ing yellowish particles. There was no suppurative process in the cavum 
 tympani. A fistulous tract was traced with a fine probe from the cavum 
 tympani toward the exposed incissure mastoidei. The left sigmoid 
 sinus was filled with a substance of a light yellow color, and was adherent. 
 The cervical glands on the left side were enlarged, and cross-sections 
 showed whitish discolorations. Sections of the tonsils and the contents 
 of the lacuna? were negative as to actinomycosis. The ulcerated artery 
 causing the fatal hemorrhage was examined microscopically by Beck, 
 who found the ray fungi in its walls. This is the first reported case 
 in which the ray fungus has been found in the wall of a bloodvessel. 
 
 The only other case of actinomycosis of the middle ear on record 
 is reported by Majocchi, of Italy. In his case the primary infection 
 was in the lung, and the infection of the ear probably occurred during a 
 fit of coughing. 
 
PART II. 
 THE PHARYNX AND FAUCES. 
 
 CHAPTER XVII. 
 
 DISEASES OF THE EPIPHARYXX AND BASE OF THE TONGUE. 
 
 ACUTE LACUNAR INFLAMMATION OF THE PHARYNGEAL TONSIL. 
 
 According to Felix Peltesohn, the pharyngeal tonsil consists of six 
 fairly symmetrical folds separated by deep furrows running in a sagittal 
 direction, which may be separated from each other like the leaves of 
 a book. Posteriorly and sometimes anteriorly there is a curved fold 
 connecting all of them. In the middle there is a deep fissure — the 
 recessus medius — to which, in some instances, a blind canal leads, and 
 which was formerly erroneously described as an independent structure, 
 the bursa pharyngea. which, when infected, is known as Thornwaldt's 
 disease. 
 
 Bickel, in defining a tonsil, says it is characterized (a) by its well- 
 defined shape, (b) by a diffused infiltration of lymph cells and follicles, and 
 (c) by crypts or lacuna?, that is, mucus pockets lined with epithelium, 
 around which the lymphatic tissue is arranged. 
 
 If we take his definition literally only the pharyngeal and faucial tonsils 
 are real tonsils, as the lymphoid tissue in the other parts of the so-called 
 ''tonsillar ring" do not have crypts or lacuna?. The faucial tonsil 
 also has a distinct fibrous investing capsule. 
 
 Symptoms. — Angina lacunaris of the pharyngeal tonsil, like that of 
 the faucial tonsils, is an infectious disease. It is rarely recognized as 
 such by physicians on account of its hidden location back of the post- 
 nares and the soft palate. The condition may be seen, however, with a 
 postnasal mirror. The crypts or lacuna? are filled with a yellowish-white 
 exudate, composed of epithelium, inflammatory exudate, and pus cocci. 
 An inexperienced physician might easily arrive at the erroneous con- 
 clusion that the spots were "ulcers;" indeed, the same error has often 
 been made concerning the faucial tonsils. During the acute stage the 
 pharyngeal tonsils are red and swollen. 
 
 That the disease is infectious is shown by the clinical data — namely, 
 the initial chill, the rise of temperature, the prostration, swelling of 
 
318 THE PHARYNX AND FAUCES 
 
 the spleen and cervical glands, the prolonged convalescence, and the 
 presence of a great variety of infectious germs. 
 
 The secretion is often so fluid as to ooze from the crypts and coalesce 
 with that from an adjoining crypt. 
 
 Acute lacunar inflammation of the pharyngeal tonsil does not occur as 
 often as acute lacunar inflammation of the faucial tonsils. This is 
 probably due, in part, to the filtrating function of the vibrissa? and moist 
 mucous membrane of the nose. 
 
 It occurs most often during the first twenty years of life, because the 
 lymphoid (adenoid) tissue is more developed and more sensitive during 
 this period of life. It has a strong tendency to recur. The nose becomes 
 obstructed and there is pain upon swallowing, but it is not definitely 
 located as when the faucial tonsils are diseased. The voice becomes 
 nasal, or void of resonance, as in hypertrophy of adenoids. The glands 
 at the angle of the jaw and in the deep cervical region are swollen and 
 painful upon pressure. 
 
 The fever is cyclical, being less severe of mornings and greater 
 at night. It continues for several days and leaves the patient quite 
 exhausted. The pharyngeal tonsils continue swollen for some time, often 
 permanently after the fever subsides, and cause more or less nasal 
 obstruction. 
 
 To one not accustomed to examining the epipharynx the following 
 suggestion by Peltesohn is of great value in making a diagnosis: If 
 the tongue is drawn far enough forward with a tongue depressor to see 
 behind the palatine arch, the salpingopharyngeal fold, the so-called 
 "lateral column," may be found to be deeply reddened and studded 
 with yellow follicles. This condition is characteristic of angina lacu- 
 naris of the pharyngeal tonsil. As the space between the soft palate 
 and the posterior pharyngeal wall is still quite wide in young people, 
 the postrhinoscopic examination may be easily made. 
 
 Patients frequently complain of a feeling of fulness and pressure in 
 the ears, but do not often have active inflammation of the middle ear. 
 The nasal secretions are acrid, and often cause nasolabial excoriations. 
 
 Diagnosis. — (a) Initial infective fever, chill, and cyclical fever. 
 
 (b) Obstructed nasal passages and non-resonant voice. 
 
 (c) Most important of all, the red and swollen follicles of the "lateral 
 column" (follicles just back of the posterior faucial pillar), from which 
 a yellowish secretion is exuding. 
 
 These signs, together with the postrhinoscopic examination, will lead 
 to a correct diagnosis. 
 
 Treatment. — Experience teaches us that during the course of the acute 
 or febrile stage local applications irritate and should not be attempted; 
 even gargles should not be used. The patient should be kept in bed 
 until the fever abates, or a few days longer, as the prostration is severe. 
 He may be given pieces of ice to hold in the mouth, as this seems to 
 afford some relief. Only a light diet should be allowed. 
 
 After complete recovery the adenoids, whether large or small, should 
 be thoroughly removed, as otherwise recurrence may take place. In 
 
ADENOIDS 319 
 
 adults the recurrences' are characterized by the formation of crusts in 
 the epipharynx. The crusts, therefore, indicate the need of an adenoid 
 operation. 
 
 ADENOIDS. 
 
 Synonyms. — Adenoid vegetations; pharyngeal adenoids; pharyngeal 
 tonsils; epipharyngeal tonsils. 
 
 Definition. — Adenoids are hypertrophied lymph glands which nor- 
 mally exist in the epipharyngeal space. They are chiefly located on the 
 superior and posterior walls of the epipharynx, though they may extend 
 into the fossae of Rosenmuller and to the mouth of the Eustachian tubes 
 (tuba auditiva Eustachii). 
 
 The edges of the walls of the recessus medius sometimes become 
 agglutinated during acute inflammatory processes, and thus convert the 
 groove into a sinus, which becomes infected and continually discharges 
 its secretions into the pharynx (Thorn wait's disease). 
 
 Etiology. — The chief cause of adenoids is the irritation and inflamma- 
 tion which occur in the epipharynx during attacks of one of the exanthem- 
 atous fevers. It is a well-known pathological law that the lymphatic 
 structures of children become enlarged or hypertrophied in response to 
 bacterial stimulation, whereas the same stimulation in adults does not 
 cause lymphoid hypertrophy to a corresponding degree. 
 
 As the exanthematous fevers occur chiefly in early childhood while 
 the special susceptibility exists, it is but natural to find adenoids most 
 frequently during this period of life. 
 
 According to the statistics on this subject by McBride and Turner, 
 adenoids are most frequently found between the sixth and the fifteenth 
 years of life, though they may occur at any period. In children who 
 were otherwise normal it has been variously estimated that they were 
 present in from 1 to 9 per cent, of all cases examined. In deaf-mutes 
 they are present in from 50 to 73 per cent, of all cases examined. 
 
 While it cannot be said that adenoids are hereditary, they are, never- 
 theless, in many instances a family characteristic, perhaps on account 
 of a similar environment and similar anatomical conformations pre- 
 disposing to infection of the epipharyngeal tissues. 
 
 Climate probably plays but a small part in the causation of adenoids, 
 though it should be said that a cold, damp, changeable climate subjects 
 the mucosa,, as well as the general system, to repeated shocks which lower 
 the vitality and render the lymphoid tissue an easy prey to infection. 
 
 Pathology. — The distribution of adenoid tissue in the epipharynx 
 is chiefly on the upper and posterior walls, though it may extend to the 
 fossae of Rosenmuller and to the orifices of the Eustachian tubes. Ade- 
 noids are composed of lymphoid tissue enmeshed in a definite though com- 
 paratively delicate reticulum of fibrous connective tissue. The essential 
 pathology of adenoids consists in the hypertrophy of the lymphoid tissue 
 of the epipharynx, which is normally present there. 
 
 According to McBride and Turner, the pharyngeal tonsil is a peripher- 
 
320 THE PHARYNX AND FAUCES 
 
 ally placed lymphatic gland, from which efferent ducts pass to the nearest 
 glands in the cervical chain. Like similar glands elsewhere, the pharyn- 
 geal adenoid tissue consists of a fibrous connective-tissue framework, 
 supporting masses of lymphoid cells, but owing to its peripheral position 
 it differs from the more deeply placed lymphatic glands in having an 
 epithelial covering upon its free surface. The supporting framework 
 consists of fibrous septa passing through the substance of the gland, 
 from which a very delicate connective-tissue network ramifies in all 
 directions toward the surface. It carries in it the bloodvessels and the 
 lymphatics, while here and there, lying in clusters in the septa, may be 
 seen many mucous glands whose ducts open on the surface. In the 
 meshes of the delicate network lie masses of leukocytes or lymphoid cells, 
 constituting the lymphoid tissue which forms the main bulk of this tonsil. 
 Groups of these cells are specially differentiated in the form of more or 
 less rounded or oval-shaped areas, having centres of a pale appear- 
 ance, while their margins are more darkly colored. These areas are 
 the follicles or germ centres of Goodsir. Covering the free surface of 
 the tonsil, and clipping down into its recesses and crypts, is a layer of 
 ciliated epithelium, continuous with that lining the respiratory part of 
 the interior of the nose and the adjacent mucous membrane of the epi- 
 pharynx. The epithelium consists of more than one layer of cells, the 
 superficial ciliated cells being columnar in type, while the deeper cells 
 forming two or three layers are smaller, and rest upon a well-defined 
 basement membrane. 
 
 The Epithelium. — The normal epithelial covering undergoes a certain 
 amount of variation, as might be expected when a growth of this kind, 
 itself subject to variations in size, fills to a varying extent a cavity 
 like the epipharynx, more or less completely surrounded by firmly 
 resisting bony walls, and whose size is intermittently changing through 
 the movements of the soft palate which constitutes its floor. The 
 epithelium is not always of uniform thickness. While preserving its 
 ciliated columnar type its thickness varies in parts, so that the lining 
 of some of the crypts presents an irregular outline. In a certain 
 number of the preparations examined, however, there is a marked 
 change in the character of the epithelium, becoming of the stratified 
 squamous variety and of a very considerable thickness. This change 
 and thickness is not general, but is confined to certain areas on the 
 surface of the hypertrophy. It is not normal to this part of the upper 
 respiratory tract, because the whole of the mucous membrane of the 
 pharynx as low as the level of the lower border of the soft palate is covered 
 with ciliated epithelium, and it is from within the area so covered that 
 the epithelium thus altered and thickened shows that these changes occur 
 among the youngest of the patients examined. With two exceptions 
 at the age of twelve, all were under ten years of age, and in two cases 
 where the thickening was most marked the patients were only four years 
 old. On the other hand, in the sections of the growths removed from 
 patients of fifteen years and upward, with one exception no thickening 
 of the epithelium was observed, so that we are naturally led to the 
 
ADEXOIDS 321 
 
 conclusion that this change in the epithelium is not one necessarily 
 dependent upon the prolonged existence of the hypertrophy. Occurring, 
 as the examination shows that it does, in the younger patients, it is more 
 reasonable to conclude that it is due to pressure of the growth upon the 
 walls in the smaller epipharynx of the young child. Its presence on the 
 surface and in patches only and less frequently in the crypts are further 
 points in favor of such a view being held. Unfortunately, we are unable 
 to say whether, in those cases in which the epithelium has changed to 
 the pavement type, the adenoid masses were large and more or less 
 completely filled the epipharynx. Such a change in the type of the 
 epithelium as noted here has been observed before, as the result of press- 
 ure, and is a point of some histological interest. The pressure to which 
 these growths is subject is intermittent, and is caused chiefly by the 
 elevation of the soft palate in the act of deglutition, pressing the soft, 
 pliant mass upward against the walls of the space, and releasing it again 
 when the act is completed. 
 
 The Fibrous and Lymphoid Tissues. — A considerable variation was 
 found to exist in the relative proportion of lymphoid and fibrous tissue 
 in the growths examined; and McBride and Turner endeavored, by a 
 comparison of the appearances observed in patients of different ages, 
 to seek some explanation of the gradual disappearance or shrinking 
 which takes place in the hypertrophied adenoid tissue in course of 
 time. An overgrowth of fibrous tissue around the bloodvessels forms 
 by a process of perivascular sclerosis; at any rate, it is in the neigh- 
 borhood of these vessels that the fibrous thickening is most evident. If 
 an area be examined in which this change is taking place, some of the 
 bloodvessels present a normal appearance, others again show distinct 
 thickening of their walls in concentric rings, with diminution in the 
 size of the lumen. One specimen showed, in a remarkable manner, 
 many of the bloodvessels completely obliterated, partly owing to the 
 great thickening of the walls and partly to the contraction of the 
 fibrous tissue outside. Round the vessels there is fibrous tissue form- 
 ation, varying both in amount and in density, according to the stage 
 of development that has been reached; in this way the lymphoid 
 tissue becomes gradually invaded and areas of cells are isolated by the 
 process. There can be no doubt that it is by fibrous-tissue formation 
 that the gradual shrinking of the adenoid mass occurs. In order to 
 ascertain what relation such a process might bear to the age of the patient, 
 a comparative study of the various growths was made with this end 
 in view. 
 
 From such an analysis it would appear that a development of 
 fibrous tissue takes place in the substance of the adenoid hypertrophy, 
 commencing round the bloodvessels invading the lymphoid tissue, and re- 
 placing it. This process, however, is independent of the age of the patient, 
 and is not one that necessarily commences at or after puberty, but may 
 occur at all ages, and be even more marked in the very young child than in 
 the adult. The observations of McBride and Turner coincides with that 
 of M. Brindel. The practical deduction drawn from these facts was, that 
 21 
 
322 
 
 THE PHARYNX AND FAUCES 
 
 we cannot say in any given case that a growth may be satisfactorily left to 
 disappear per se. It may or it may not do so at some early period, but 
 because a patient is approaching puberty or adult life it does not follow 
 that the adenoid hypertrophy will in a short time cease to exist. As 
 we have already stated, such growths do, in certain cases, disappear at 
 puberty, but it is quite possible that here a purely physical, as opposed 
 to a purely histological, explanation may be called to our aid. Obviously, 
 in the small epipharynx of the child the growth may entirely fill the space, 
 while, as adult life is approached, a free space will be left between the 
 adenoid hypertrophy and the palate. In the former case, each respira- 
 tion will exercise suction upon the mass, while in the latter this physical 
 effect will be much diminished, if not quite absent. 
 
 The foregoing findings should be 
 given wide circulation among the 
 medical profession, as physicians 
 too often advise their patients "to 
 wait for puberty," as the adenoids 
 will "shrink" at that time. " Wait- 
 ing" for adenoids to "shrink" is al- 
 ways a foolish and dangerous thing. 
 While waiting, the attending in- 
 flammation is ever progressing, and 
 may, and actually does in 66 per 
 cent, of all cases, invade the Eus- 
 tachian tubes and middle ear. 
 Furthermore, it is shown that the 
 atrophy does not occur after puberty 
 any more than at a younger age ; in- 
 deed, the atrophy is independent of 
 the age of the patient. Why wait, 
 therefore, for a process of shrinking 
 which has no definite period of 
 occurrence ? 
 Symptoms. — The symptoms of adenoids may be divided into: 
 
 (a) Objective. 
 
 (b) Subjective. 
 
 (c) Collateral. 
 
 Objective Symptoms. — The objective symptoms are those which are 
 appreciated through the special senses of the attending surgeon. 
 
 By inspection the physician notes the open mouth, thick, short upper lip 
 (Fig. 228), the comparatively expressionless countenance, and with the 
 laryngeal mirror he finds the epipharynx more or less filled with the 
 adenoid masses. 
 
 By the sense of touch he distinguishes a gelatinous, worm-like mass in 
 the epipharynx. The finger should be anointed with vaseline before 
 it is introduced into the epipharynx, so as to reduce its frictional qualities 
 to the minimum. Even then great care should be exercised lest the deli- 
 cate mucous membrane of the epipharynx be injured. In spite of these 
 
 Fig. 228 
 
 
 ;^jfe'>- 
 
 
 
 
 I ' ^1 
 
 (jJwtet&K*, 
 
 An adenoid face. 
 
ADENOIDS 323 
 
 precautions the finger is often streaked with blood upon its removal. I 
 find the digital examination of more value than the one with the mirror in 
 a majority of the cases. It need occupy but a few moments for its per- 
 formance. 
 
 The examining surgeon should stand in front of and to the right of 
 his patient, encircling his head with the left hand and arm to steady 
 it, while the index finger of the right hand is introduced into the epi- 
 pharynx. McBride and Turner have suggested that if the thumb of 
 the examiner is just outside the patient's right cheek, he can prevent 
 biting by pressing the thumb against the cheek wall. The soft tissues 
 being thus forced between the patient's teeth, he will not bite the exami- 
 ner's finger. 
 
 The faulty development of the chest walls is also characteristic of 
 mouth breathing in children. 
 
 The sense of smell should also be utilized in the examination for 
 adenoids, as a fetid breath is sometimes present. 
 
 The auditory sense should also be utilized in the diagnosis, as the 
 patient's voice is often characteristic. The articulation is muffled and 
 the resonance of the voice is diminished. 
 
 The Subjective Symptoms. — Restlessness during the night is a promi- 
 nent symptom; the patient often throws the covers off during the uncon- 
 scious rolling and tossing which is so characteristic of mouth breathers. 
 Night terrors are also frequently complained of, especially if the child is 
 troubled with enuresis. I have often noted that night terrors or horrible 
 dreams immediately precede nocturnal urination. 
 
 Night terrors are not present in all cases, perhaps not in more than 
 one-third of them; they are in all probability due to reflex causes and to an 
 excess of the half-way products of metabolism. These dreams are often 
 of the most terrible nature, and are often indelibly impressed upon the 
 memory. 
 
 Daytime restlessness is also a characteristic sign of adenoids. The 
 child is fretful and peevish, or is inclined to turn from one amusement to 
 another, or from an imposed duty to play. 
 
 The mental faculties are often much impaired in adenoid subjects. 
 Aprosexia, or difficult attention, first described by Guye, of Amsterdam, 
 is very often present. The child is listless and has difficulty in applying 
 himself continuously to his play, studies, or other tasks, of which he 
 soon tires. He has fits of abstraction. I once knew of a boy in school 
 who was afflicted with ideal abstraction, though he had a fairly good 
 mind. In those cases, however, in which there is little obstruction, the 
 mental faculties are but little affected. 
 
 Taste and smell are sometimes impaired, which is not strange, in view 
 of the fact that the sense of smell and of taste are so intimately associated, 
 and the epipharynx is blocked with adenoids, thus compelling the child 
 to breath through its mouth. 
 
 The breath is often fetid, from the decomposition of the retained secre- 
 tions and from the disordered stomach which is so often complained of. 
 
 Bilious attacks sometimes complicate the case. 
 
324 THE PHARYNX AND FAUCES 
 
 An elevated temperature is not an uncommon symptom, as the 
 adenoid growth is frequently the seat of a lacunar or catarrhal 
 inflammation. 
 
 Epipharyngeal catarrh is an almost constant accompaniment of 
 adenoids. Indeed, it is doubtful if adenoids of any considerable size 
 are present without a concomitant chronic epipharyngitis, or what is 
 commonly spoken of as a pharyngeal catarrh. This symptom or com- 
 plication is one of the strongest arguments in favor of the removal of 
 adenoids, as the catarrhal inflammation has a tendency to extend by 
 continuity of tissue into the Eustachian tube and middle ear. In case 
 of an acute infectious exacerbation the middle ear and even the mastoid 
 cells are likely to become involved. 
 
 Collateral Symptoms. — Defective speech is a symptom of considerable 
 diagnostic and economic significance. The voice is muffled and articu- 
 lation is imperfect. The resonance, or timbre, of the voice is greatly 
 impaired. 
 
 Aural complications are present in a majority of the cases. According 
 to McBride and Turner, who analyzed 307 cases, 255 had involvement 
 of the ear. Of the 255 cases, 144 were suppurative and 111 were more 
 or less deaf with non-suppurative ear disease. They say: "We have 
 more than once noticed in children (affected with adenoids) suffering 
 from non-suppurating otitis media that in those in whom the mem- 
 brana tympani had assumed an appearance which can but be likened 
 to that of ground glass, especially when there was a permanent pinkish 
 tinge, the prognosis as to improvement by subsequent treatment was 
 not good, sometimes positively bad." 
 
 It appears, therefore, that the aural complications, whether of the 
 suppurative or non-suppurative type, may be serious. 
 
 Diagnosis. — The diagnosis in most cases is so obvious that it scarcely 
 warrants special mention. There are exceptional cases, however, in 
 which an error may be made. It may be stated as an almost universal 
 rule that when the tonsils are hypertrophied adenoids are also present. 
 Conversely, it cannot be said that when adenoids are present the tonsils 
 are also hypertrophied, as statistics show that only 30 per cent, of the 
 cases with adenoids had apparent enlargement of the tonsils. It appears 
 that the adenoids most easily undergo enlargement, the tonsils next, 
 and the lingual less than either of the other lymphatic structures com- 
 posing Waldeyer's ring. 
 
 The fringe of the adenoids on the posterior wall of the pharynx, just 
 below the line of the soft palate, is quite characteristic. When these 
 nodules are present in a child, I am quite certain of the diagnosis, even 
 without further examination, though I do not recommend that the 
 examination should stop here. 
 
 The epipharyngeal mirror should be used, when possible, to enable 
 the surgeon to see the adenoids and their distribution. In many cases 
 this method of examination cannot be adopted on account of the reflex 
 closure of the palatal muscles against the posterior pharyngeal wall. 
 
 When the mirror cannot be used the index finger of the right hand 
 
ADENOIDS 325 
 
 should be introduced through the mouth into the epipharynx for the 
 purpose of detecting the gelatinous worm-like mass of adenoid tissue. 
 
 It is not sufficient to merely determine the presence of a large adenoid 
 cushion in the vault, or on the superior posterior wall of the epipharynx, 
 but the examiner should determine whether the fossae of Rosenmuller 
 or the tubal orifices are covered by the growths. Adenoids are not 
 removed merely because they are enlarged, but because of the epipharyn- 
 gitis which almost always attends them and on account of their presence 
 in the fossae of Rosenmuller and the Eustachian orifices, even though they 
 are small. 
 
 Fibrous tumors of the epipharynx are sharply defined and are dense 
 in texture, whereas adenoids are not sharply defined and are soft in 
 texture, hence there need be no difficulty in making a differential diag- 
 nosis. 
 
 Malignant tumors of the epipharynx can scarcely be mistaken for 
 adenoids if an ordinarily careful examination is made. The hemorrhage , 
 cachexia, and other symptoms readily distinguish the cancerous growths. 
 
 Tuberculous and syphilitic granulomata rarely simulate adenoid 
 growths. Carel has reported two cases of tertiary syphilis, and 
 Lermoyez a case of tuberculosis of the epipharynx, which closely re- 
 sembled, in general symptomatology, adenoid growths. 
 
 Prognosis. — The prognosis from the standpoint of the mentality of the 
 patient varies from slight retardation to an almost complete arrest of 
 mental development. The improvement in the mental growth after oper- 
 ation is often marvellous, provided the operation is performed during the 
 natural period for such development, e. g., during infancy and childhood. 
 If the removal of the growth is delayed until the individual has prac- 
 tically attained full growth, the mind will rarely develop as it would 
 had they been removed at an earlier period. 
 
 The general health rarely improves during infancy and childhood so 
 long as adenoids remain. If, however, they are removed, the blood 
 becomes red from free oxygenation and all the vital energies are quick- 
 ened and increased. 
 
 The " facial or adenoid expression" improves somewhat with advancing 
 years, though it often remains as a permanent disfigurement through 
 life. If the adenoids are removed sufficiently early in life the "adenoid 
 expression" often disappears, or its further development is prevented. 
 
 The early removal of adenoids often prevents serious aural complica- 
 tions, improves the general health, and beautifies the face. 
 
 Treatment. — There is but one treatment worthy of the name, and that 
 is the surgical removal of the growth. x\stringent applications have been 
 and are still advocated by some writers, but in my opinion their use is 
 but a means to postpone the day when their removal must take place. I 
 can conceive how a congestion and inflammation of the lymphoid masses 
 might be relieved and greatly improved by the local use of alkaline and 
 astringent washes, but when true hypertrophy has occurred the curette or 
 forceps offer the best means of treatment. 
 
 Adenoids may be removed with the Meyer ring curette through the 
 
326 
 
 THE PHARYNX AND FAUCES 
 
 nose, though this is an almost obsolete method. A more rational and 
 effective method is with a Boeckmann curette or some modification of it. 
 During the last few years I have depended more and more upon adenoid 
 forceps of the Brandegee pattern (Fig, 229). 
 
 Fig. 229 
 
 Brandegee's adeno'd forceps. 
 Fig. 230 
 
 y 
 
 The correct position of the patient under general anesthesia tor the removal of adencids 
 
 and tonsils. 
 
 Fig. 231 
 
 Technique.- — The following technique may be employed for simple 
 adenectomy, while in combined adenectomy and tonsillectomy anesthesia 
 by ether is preferable (Figs. 230 and 231). 
 
 (a) Nitrous oxide anesthesia. 
 
 (b) The removal of the ade- 
 noids with the Brandegee forceps : 
 The instrument is introduced 
 closed through the mouth in 
 much the same manner as it is 
 used in introducing the curette; 
 that is, the curved tips are turned 
 behind the posterior pillar of the 
 patient's right side and then 
 passed upward behind the soft 
 
 Furguson-Pynchon mouth gag. palate and rotated toward the 
 
ADENOIDS 327 
 
 median line as they engage behind the soft palate. The biting tips are 
 then widely opened and forced upward against the vault of the epi- 
 pharynx, the handles meanwhile being held against the upper teeth. 
 Having forced the tips against the vault, they should be pushed backward 
 into Rosenmuller's fossae. The blades should then be closed, care being 
 taken to hold the handles against the upper teeth. The rocking motion 
 used with the curette is to be studiously avoided when using the forceps. 
 Should the handle of the instrument be lowered while the blades are open 
 in the epipharynx, they will engage the posterior end of the septum and 
 injure it. 
 
 Having closed the forceps, it should be removed with a downward 
 pull, bringing the adenoid mass out between the cutting blades. The 
 instrument may be introduced more than once if necessary. 
 
 (c) Introduce the curette (Fig. 232) in the same manner and engage 
 the mass at the anterior portion of the vault just behind the posterior 
 end of the septum, as the forceps often fail to remove the adenoid tissue 
 in this position (Fig. 233, a). 
 
 (d) Introduce the right index finger into the epipharynx and rub 
 away any shreds and remnants of adenoid tissue which may remain. Also 
 explore Rosenmuller's fossae with the finger tip and remove the fibrous 
 adhesive bands should they be present. 
 
 (e) The patient's head should then be held over the fountain cuspidor 
 until bleeding stops or consciousness is restored. 
 
 During the operation the patient should be in the sitting posture, 
 preferably in the lap of an assistant. He should be wrapped tightly with 
 a sheet in order to prevent his arms getting in the way during anesthesia. 
 
 I sometimes do the operation without a general anesthetic if the 
 patient is old enough to submit without resistance. The pain is not 
 great and the danger from an anesthetic is obviated. It should be said, 
 however, that the danger from nitrous oxide gas is practically nil, whereas 
 the records show that several cases have died under chloroform. 
 
 Stubb's Method. — According to Stubbs the blade of the curette should 
 be drawn forward against the septum, lifted upward against the vault, 
 and then pushed directly backward until the posterior wall is reached. 
 The blade of the curette should then be drawn downward over the 
 posterior wall and quickly brought forward into the cavity of the mouth 
 (Fig. 232). If the curette is as wide as the epipharynx, one introduc- 
 tion of the instrument usually removes the entire growth. Stubbs has 
 modified the Boeckmann curette, in order to adapt it to this technique. 
 
 According to Moure, the epipharyngeal space varies greatly in shape, 
 a fact which largely determines the completeness with which adenoids 
 may be removed with the usual form of curette and forceps. If the 
 epipharyngeal space is normal in shape (Fig. 234), the curette and 
 forceps will completely remove the adenoids. If there is a recess in the 
 vault (Fig. 235) these instruments will fail to remove all the tissue. If 
 there is a recess in the posterior wall of the epipharynx (Figs. 236 and 
 237), the forceps and curette of the usual type will fail to remove all the 
 tissue. These facts may account for the non-success of many adenoid 
 
328 
 
 THE PHARYNX AND FAUCES 
 
 operations. If there is a recess in the upper wall of the epipharynx, a 
 specially designed curette (Fig. 238) should be used to complete the 
 operation. If there is a recess in the posterior wall of the epipharynx, 
 the Meyer ring curette (Fig. 239) introduced through the nose, or 
 Pynchon's modification of Golding-Bird's curette shown in Fig. 240, 
 or Quinlan's forceps, should be used to complete the operation. 
 
 Fig. 232 
 
 The removal of adenoids with the Boeckmann-Stubbs curette. The arrows indicate the three 
 movements necessary for the complete operation in a normal epipharynx. 
 
 Fig. 233 
 
 •XI 
 
 The removal oi adenoids with the Brandegee forceps. The remnant (a) left in the anterior 
 portion of the vault just posterior to the septum should be removed with the Stubbs modification 
 of the Boeckmann curette. 
 
 George L. Richards advises the removal of adenoids under general 
 anesthesia with the Shutz adenotome. He believes that by this method 
 a more complete removal is attained. The adenotome is inserted into 
 the epipharynx and pressure is exerted upward and backward while 
 the blade is being closed. This method has the advantage of pre- 
 
ADENOIDS 
 
 329 
 
 serving the specimen intact for inspection. H. Gradle's adenotome 
 is also a good instrument, and is preferred by some operators. The 
 objection to all such instruments is that they do not adapt them- 
 selves to the peculiar conformation of the epipharynx shown in Figs. 
 
 Fig, 234 
 
 1, normal vault of the epipharynx from which adenoids may be removed with Boeckmann's 
 curette; 2, posterior wall of the pharynx; 3, posterior end of vomer in its normal relation to the 
 hard palate; 4, uvula; 5, hard palate; G, sphenoid sinus. 
 
 An epipharynx with an angular superior pouch, from which adenoids could be removed with 
 a Boeckmann curette, excepting, possibly, the upper angle of the pouch. This region might neces- 
 sitate the use of a special curette. 1, 2, 3, 4, 5, and 6 refer to anatomical points (Fig. 234). 
 
 234 to 237. They also fail to remove the portion of the growth located 
 in the lateral portions of the pharynx. If, however, the adenotome is 
 followed by the use of a suitable curette, as Stubb's modification of 
 Boeckmann's model, the result is good. 
 
330 
 
 THE PHARYNX AND FAUCES 
 
 Whatever method of removal is used, the ultimate aim should be the 
 complete removal of the adenoids, as otherwise they will probably 
 recur. 
 
 Fig. 236 
 
 An epipharynx with a shallow posterior pouch from which the adenoids could be removed with 
 Boeckmann curette, except in the posterior portion of the pouch. 1, a slight recess in the pos- 
 terior wall of the vault of the epipharynx in which adenoids are inaccessible to the Boeckmann 
 curette; 2, 3, 4, 5, and 6 refer to anatomical points. (After Moure.) 
 
 Fig. 237 
 
 An epipharynx with a deep pouch in the posterior wall, from which adenoids could not be removed 
 with the Boeckmann curette. Such cases should be operated on through the nose with Wilhelm 
 Meyer's ring curette (Fig. 239), or with a special curved curette (Fig. 240). 
 
 Sequelae. — The Face. — The development of the face is often materially 
 modified by the presence of adenoids. The open mouth, the absence of 
 the nasolabial folds, the short upper lip, the protruding and twisted 
 central incisors of the upper jaw, the broad, flat, upper half of the nose, 
 and the narrow, slit-like nasal openings, all conspire to form the so-called 
 "adenoid face." The general expression is one of stupidity. The 
 
ADENOIDS 
 
 331 
 
 degree of the facial disturbance varies greatly in different cases, usually 
 in proportion to the degree of the nasal respiration, rather than the 
 actual size of the adenoid growths. According to J. E. Schadle, the 
 average capacity of the epipharynx is about 17 c.c, and its lateral is 
 longer than its anteroposterior diameter. If the capacity of the epi- 
 pharyngeal space is diminished, or its anteroposterior diameter is con- 
 tracted, a small adenoid mass may produce a greater nasal obstruction 
 than a larger growth in a more roomy epipharynx. The facial expression 
 is more modified in the former than in the latter instance. It should 
 not be deduced from the foregoing statements that the indications for 
 treatment are in proportion to the degree of nasal obstruction per sc, 
 as there are several other conditions resulting from small as well as 
 large adenoids that necessitate their removal. 
 
 Fig. 238 
 
 Special curette for reaching the recesses in the vault of the pharynx 
 Fig. 239 
 
 Meyer's ring curette. 
 
 c^-^ 
 
 Fig. 240 
 
 £*A.hABDY & CO. CHICAGO. 
 
 Pynchon's modification of Golding-Bird's curette. 
 
 The Interior of the Nose. — The interior of the nose is also modified in 
 its development. J. S. Thompson called attention to this fact in an 
 article wherein he states that the loss of the physiological stimulation 
 incident to nasal respiration results in underdevelopment of the turbinals, 
 and that deviated septa are common. Such individuals are subject 
 to intranasal disease, for obvious reasons. 
 
 The Hard Palate. — Adenoid subjects usually have a palate which is 
 "gothic" or arched, especially in its anterior portion. The arch is ap- 
 parently higher than normal, though, as Newkirk has shown by numerous 
 casts, the increased height is apparent rather than real. The illusion 
 arises from the fact that the lateral diameter of the upper jaw contracts 
 while the height of the arch remains the same; this produces a marked 
 disproportion between its width and height. 
 
332 THE PHARYNX AND FAUCES 
 
 The Teeth. — The contraction of the lateral diameter of the arch some- 
 times causes the central incisors to protrude and to be twisted upon their 
 axes so as to cause their posterior surfaces to face each other. The teeth 
 are often irregular, and the services of a dentist are required to regulate 
 them. 
 
 Epipharyngeal Inflammation. — When adenoids are present the epi- 
 pharyngeal mucous membrane is almost always the seat of local inflamma- 
 tions of both the acute and the chronic type. The low resistance of the 
 adenoid tissue, the rarefied or abraded cylindrical epithelium, the reten 
 tion of the secretions, and the insufficient ventilation of the epipharyngeal 
 space all promote inflammatory processes. The inflammation may 
 be lacunar, either acute or chronic, or it may be a diffused catarrhal 
 inflammation which affects the mucosa covering the adenoids and the 
 adjacent structures. 
 
 The Auditory Apparatus. — Adenoids are a prolific source of inflamma- 
 tion in the Eustachian tube, middle ear, and mastoid process. It is a 
 
 common clinical experience that 
 Fig 241 children with adenoids who com- 
 
 plain of recurrent attacks of earache 
 are relieved by tympanic inflation. 
 The Eustachian tubes are closed 
 by catarrhal swelling, or " plugged" 
 with thick, tenacious mucous, and 
 the air in the tympanic cavity be- 
 comes absorbed and rarefied. 
 
 The drumhead is retracted and 
 the mucous membrane which lines 
 the tympanic cavity is hyperemic. 
 Catarrh of the tubes and middle 
 ears is thus established. 
 
 Suppurative otitis media is also 
 caused by adenoids. The infective 
 material from the epipharynx enters 
 the tubes and middle ears during 
 the acts of coughing, sneezing, or 
 other violent movements of the phar- 
 yngeal and palatine murcles. Then, 
 too, the ciliated columnar epithelium 
 of the tubes may become atrophic 
 or broken down by the pressure of 
 the opposed walls from the catarrhal 
 swelling. The absence of the cilise 
 permits easy ingress of the infected 
 secretions into the middle ear, and 
 Deformity of the chest due to adenoids. infection thus becomes established 
 
 in the tympanic cavity. 
 Having gained a foothold in the tympanic cavity, it is but another 
 step for the infection to invade the mastoid cells. The inflammation of 
 
ADENOIDS 333 
 
 the middle ear and mastoid process is usually proportionate to the viru- 
 lency of the microorganisms which cause it. The labyrinth may also 
 become involved in the infective inflammations of the middle ear, though 
 such an occurrence is rare. Deafness, in some degree, is always present 
 in the foregoing aural complications of adenoids. 
 
 The Respiratory System. — The anterior nasal openings are narrow and 
 slit-like, while the turbinated bodies are underdeveloped. The conditions 
 are favorable for the development of catarrhal inflammation of the mucosa 
 of the nose. The lateral walls of the chest are contracted (Fig. 241), 
 thus throwing the ensiform cartilage into prominence. This character- 
 istic deformity is known as " pigeon chest." The lungs are also under- 
 sized and respiration is shallow. The transfusion of gases through 
 the walls of the air vesicles is impaired. Too little oxygen passes into 
 the blood, and too little carbon dioxide is thrown off. The patient is 
 both anemic and nervous, and is often irritable to a marked degree. 
 
 Fig. 242 
 
 Pharyngeal scissors. 
 
 The Bones. — Frederick Coolidge called attention to the apparent 
 relationship existing between adenoids and the various forms of club foot. 
 I have often confirmed the saying that "if you will show me a bow- 
 legged man I will show you one who had adenoids in infancy." Adenoids 
 affect the nutrition, partly through anemia and partly through an excess 
 of carbon dioxide in the blood. These two conditions cause faulty 
 metabolism and nutrition. The bones are deficient in lime salts, hence 
 are soft and bend easily under the weight of the body. 
 
 The Blood. — Adenoid patients are usually anemic. The red blood 
 corpuscles are deficient in number and in hemoglobin. Carbon dioxide 
 is present in excess. The nutrient elements are diminished in quantity 
 and quality. 
 
 Thornwaldt's Disease. — This condition is characterized by a suppura- 
 ting canal in the recessus medius or groove between the lateral halves 
 of the adenoids. It is due to the inflammatory adhesion of the median 
 borders of the adenoid masses. That is, the recessus medius, a groove 
 between the lateral halves of the adenoids, becomes converted into a 
 canal. The lining membrane of the canal becomes infected and dis- 
 charges a purulent secretion. The symptoms are those of chronic pharyn- 
 gitis attended with a cough. 
 
334 THE PHARYNX AND FAUCES 
 
 The canal may be seen by the use of a throat mirror, and a curved 
 probe may be passed upward into it. 
 
 The author's method of treating it is to introduce one blade of the 
 curved pharyngeal scissors (Fig. 242) into the canal and then to cut off 
 one lateral half of the adenoid mass (Fig. 243). This is a better 
 way than to attempt to remove the adenoids in the usual manner, 
 as the fibrous canal is so dense that it can be cut with difficulty. 
 The posterior and remaining portion of the canal wall should be 
 thoroughly curetted to remove the pyogenic membrane. 
 
 The operative treatment of Thornwaldt's disease: a, the left blade of the pharyngeal scissors 
 introduced into the suppurating sinus between the lateral halves of the adenoids; b, the right blade 
 of the scissors at the border of the adenoid tissue. When the blades are closed the lateral half 
 of the adenoids upon this side is severed. The scissors are then transferred to the other lateral 
 half of the adenoid tissue and closed. This completely severs the lower portion of the adenoid 
 tissue, and obliterates the suppurating sinus. The remaining upper portion of the adenoids, c c d, 
 is then removed with the scissors or with a curette. 
 
 THE LINGUAL TONSIL. 
 
 The lingual tonsil is situated on the base of the tongue between the 
 faucial tonsils, and extends anteroposteriorly from the circumvallate 
 papilla? to the epiglottis. It is divided in the median line by the median 
 glosso-epiglottic ligament. The tonsil consists of numerous rounded 
 or circular crater-like elevations which are composed of lymphoid tissue, 
 which at their circumference are surrounded by connective tissue. In 
 the centre of each crater the mouth of the duct of a mucous gland opens. 
 The crater or crypt is lined by stratified pavement epithelium. 
 
THE LINGUAL TONSIL 335 
 
 The lingual tonsil usually reaches its greatest development in young 
 children, and, like the other tonsillar structures, may begin to atrophy 
 at the age of puberty, though in adults these structures are often 
 undiminished in size. In the adult the number of the masses is 
 generally greatly reduced, though they may be greatly hyper trophied. 
 
 Here, as in the other portions of the tonsillar ring surrounding the 
 oropharynx, leukocytes are thrown out in great abundance. 
 
 Acute Catarrhal Lingual Tonsillitis. — Acute catarrhal inflammation 
 of the lingual tonsil is characterized by a moderate rise of temperature, 
 painful deglutition, and a burning, pricking sensation in the throat. 
 There may be some tenderness on pressure in the region of the great 
 cornu of the hyoid bone. Upon inspection the pharynx and the pillars 
 of the fauces may be slightly reddened, while the faucial tonsils may 
 appear normal. The laryngeal mirror shows the masses on the lingual 
 tonsil to be greatly reddened and swollen. (Lennox Browne.) 
 
 Treatment. — The treatment consists in brushing the inflamed masses 
 with a 20 to 50 per cent, solution of the nitrate of silver. 
 
 Acute Lacunar Lingual Tonsillitis. — The symptoms of acute catar- 
 rhal inflammation are present, and in addition the craters or crypts are 
 lined with a whitish exudate, epithelial debris, and microorganisms quite 
 similar to the accumulations found in acute faucial lacunar tonsillitis. 
 
 Treatment. — The treatment consists of the local application of a 20 to 
 50 per cent, solution of the nitrate of silver. 
 
 Acute Phlegmonous Lingual Tonsillitis. — This process is usually 
 characterized by a purulent accumulation beneath the lymph nodules at 
 the base of the tongue, and is usually limited to one side. The tempera- 
 ture is elevated and the pain upon deglutition is severe. The patient 
 complains of soreness and great tenderness upon pressure in the region 
 of the great cornu of the hyoid bone upon the affected side. Inspection 
 with the throat mirror shows great swelling and redness at the base of the 
 tongue upon the affected side. Palpation with the finger may or may not 
 elicit fluctuation. 
 
 Phlegmonous inflammation here, as in the faucial tonsil, may undergo 
 resolution without the formation of an abscess. 
 
 Treatment. — Treatment consists of incisions into the swollen tissue. 
 
 Hypertrophy of the Lingual Tonsil. — Hypertrophy of the lingual 
 tonsil is rare in children. It usually occurs between the twentieth and 
 the fortieth years of life. It is more common in females than in males. 
 It is probably caused by repeated or continued infection of the lymph 
 structures of the pharynx, fauces, and epipharyngeal tonsils. 
 
 Symptoms. — The symptoms are sometimes absent, though the sensa- 
 tion of a foreign body in the throat is usually complained of. There is a 
 pricking sensation, as though a splinter had lodged in the fauces, or 
 the patient complains of the sensation of a lump, a hair, or other foreign 
 body in the throat. Paresthesia of the pharynx presents the same symp- 
 toms (Ball), and hence neurosis of the pharynx must be differentiated 
 from this condit on. So also must foreign bodies. According to Lennox 
 Browne, troublesome fits of coughing are often present. 
 
336 
 
 THE PHARYNX AND FAUCES 
 
 During meals the symptoms disappear. Pain is rarely complained of, 
 but the disagreeable sensation already referred to is present. The use 
 of the voice increases the symptoms, and often gives rise to the pricking 
 sensation and the cough. 
 
 Upon examination with the throat mirror a few enlarged masses are 
 seen upon the base of the tongue. The involvement is usually on both 
 sides, but may be limited to one. The masses may be so large as to push 
 the epiglottis backward or even to overhang it. 
 
 According to Ball, Seifert emphasizes the value of the use of the probe 
 and of cocaine in the diagnosis between paresthesia of the pharynx 
 and hypertrophy of the lingual tonsil. With a probe the patient is enabled 
 to locate the sensitive areas giving rise to the symptoms, and the applica- 
 tion of cocaine causes these areas upon probing to give forth no symptoms. 
 
 The removal of the lingual tonsil with heavy scissors. 
 
 Treatment. — The treatment is essentially surgical. Local applications 
 of glycerin iodine, gr. xx to xxx to the ounce, afford relief by reducing 
 the swelling and sensitiveness. Linear cauterization of the masses is 
 an effective treatment, though the removal of the masses with stout, 
 curved scissors has proved to be the best treatment in my experience 
 (Fig. 244). 
 
 Lingual Varix; Varicose Veins. — Lennox Browne, in his treatise 
 on the Throat and Nose, says that varix occurs in 10.6 per cent, of the 
 cases at the Central London Throat, Nose, and Ear Hospital. As 
 early as 1863, G. Lewin, of Berlin, reported that the symptoms of pharyn- 
 gitis varicosa were sensations of scraping, burning, and dryness of the 
 pharynx. Since then many writers have reported similar cases, so that 
 its existence as a rather common form of disease is well established. 
 
THE LINGUAL TONSIL 337 
 
 I have seen cases in my own practice which presented the clinical picture 
 described by Browne and others. It occurs more frequently in males, 
 according to Browne (69 per cent.), though Swain and Seiss found it 
 more frequently in females, while Seifert found it equally prevalent among 
 both. Excessive and improper use of the voice is an exciting cause. 
 It is rare in childhood and most common between the twenty-fifth and 
 forty-fifth years. Infectious inflammations of the pharynx and faucial 
 tonsils and infection of the lymphoid tissue of the lingual tonsil prob- 
 ably are the chief etiological factors. On account of the greater resist- 
 ance to these influences possessed by the lingual tonsil, hypertrophy in 
 this region does not occur as early in life as it does in the faucial and 
 pharyngeal tonsils. Hence, chronic infectious processes are often neces- 
 sary to establish the hypertrophy of the lingual tonsil and varix of the 
 veins. Browne believes that a constitutional or acquired debility of the 
 vasomotor system is the chief cause. Some cases are reported as occur- 
 ring at the period of the menopause. Constipation and an obstructed 
 portal circulation are etiological factors of some importance. 
 
 Pathology. — I am indebted to Escat for the information that, accord- 
 ing to Verneuil, ''superficial varices only make their appearance when the 
 deep varices have acquired a certain development." Escat also says: 
 "Many kinds of neuralgia, otherwise inexplicable, are today attributed 
 to circulatory troubles in the satellite veins of the nerves, and to a con- 
 secutive neuritis." Quenu has thus explained certain neuralgias: "The 
 trunk of the lingual nerve, the evident seat of a glossodynia, is in effect, 
 according to Foucher, accompanied by a satellite vein, and even by two, 
 according to Zuckerkandl." This anatomical fact is held by Escat to 
 support his hypothesis, and that of Piotrawski, that all neuroses in this 
 situation may be attributed to varices, superficial and deep. 
 
 Symptoms. — As lingual varix is usually associated with hypertrophy 
 of the lingual tonsil, the symptoms are about the same. Upon inspection, 
 tortuous veins, bluish in color, are seen at the base of the tongue partially 
 hidden by the hypertrophied tonsil. 
 
 Treatment. — The treatment consists in the application of the galva no- 
 cautery to the enlarged veins, and the removal of the hypertrophied 
 lymphoid masses with the cautery point or with scissors. I have fre- 
 quently resorted to these methods of treatment with satisfactory results. 
 The after-treatment consists in gently massaging the wounds with a 
 cotton-wound applicator dipped in a mixture of equal parts of glycerin, 
 tr. ferri chloridii, and tr. iodini, at intervals of twenty-four hours. This 
 prevents exuberant granulations, and promotes healing with a smooth 
 wound and a minimum of cicatricial contraction. 
 
 22 
 
CHAPTEK XVIII. 
 
 INFLAMMATORY DISEASES OF THE MESOPHARYNX AND FAUCES. 
 SIMPLE ACUTE CATARRHAL PHARYNGITIS. 
 
 This form of acute pharyngitis is usually accompanied by acute 
 rhinitis, or ''cold," though the pharynx may be chiefly affected. 
 
 Etiology and Pathology. — The etiology and pathology is the same 
 as that of acute rhinitis. Digestive disorders are an important factor 
 in causing the disease. 
 
 Symptoms. — The onset is characterized by malaise and a slight rise 
 in temperature, as in acute rhinitis. The borders of the soft palate and 
 the uvula are slightly red, while the adjacent mucous membrane is normal 
 in appearance. As the disease progresses the uvula becomes slightly 
 edematous and the secretions are increased; it may become markedly 
 edematous and painful, though this is not common. The tonsils are 
 not usually involved, though they may be in severe cases. Pain is usually 
 present, especially upon swallowing, and stiffness and aching of the 
 muscles of the neck are complained of. Dysphagia or painful swallowing 
 is a constant symptom. 
 
 Diagnosis. — The erythema of secondary syphilis may be confounded 
 with this disease. The differential points are : (a) the darker or dusky 
 color (in syphilis) of the mucous membrane; (b) the more marked involve- 
 ment of the tonsils and soft palate, the diminished secretion; (c) the 
 line of demarcation between the inflamed area and the hard palate; 
 (d) the dusky symmetrical patches on the anterior pillars; (e) the opales- 
 cent appearance of the mucous membrane of the tonsils and the per- 
 sistence of the disease, as contrasted with the evanescence of acute 
 catarrhal pharyngitis. 
 
 Treatment. — As the acute affection is somewhat dependent upon the 
 presence of chronic rhinitis and sinuitis, these conditions should receive 
 appropriate attention. The methods of treatment given for acute rhinitis 
 are also of value, as the morbid process is almost identical. 
 
 The anatomical peculiarities and the associated digestive disorders, 
 however, render special modes of treatment necessary. 
 
 Local treatment should vary according to the stage of the inflammation. 
 Broadly speaking, astringents should be used in the first and third stages 
 and sedatives in the second stage (Parker). They may be applied as 
 gargles, sprays, paints, or lozenges. Gargles are suited to inflammations 
 of the soft palate, uvula, and anterior pillars of the fauces. Sprays and 
 paints are especially good methods of making local applications. Pre- 
 liminary to all local treatment the alimentary tract should be evacuated. 
 
CHRONIC PHARYNGITIS 339 
 
 From 5 to 10 grains of calomel, and six hours afterward a tablespoonful 
 of castor oil, should be given. The following morning a tablespoonful 
 of Epsom salt should be given to flush the bowels (Stucky). After this, 
 the patient's condition is favorable for a speedy recovery under simple 
 local treatments. 
 
 The following mixture is recommended by Parker : 
 
 1$ — Borax gr. xxiv 
 
 Glycerin ttl xxiv 
 
 Tincture of myrrh HI xxiv 
 
 Aquae des q. s. ad 3J 
 
 Sig. — Use every hour as a gargle. 
 
 If preferred, a gargle composed of 6 grains of alum, 15 grains of chlorate 
 of potassium, to the ounce of water, may be used. 
 
 The patient may be supplied with lozenges containing krameria or 
 catechu, with instructions to disolve one of them in his mouth every 
 three hours. A cold compress should be worn across the front of the 
 neck. 
 
 After twelve hours red gum lozenges, which are very sedative, may 
 be substituted for those containing krameria and catechu. A simple 
 gargle containing 15 grains of the chlorate of potash to the ounce of water 
 may also be used every three hours. 
 
 The inhalation of steam charged from a croup kettle with the com- 
 pound tincture of benzoin, one tablespoonful to the pint of boiling water, 
 should be used if the throat is painful. 
 
 Pastils containing 3 grains of bismuth and J grain of the acetate of 
 morphine may also be dissolved in the mouth every three hours to relieve 
 a painful throat. 
 
 Should edema of the uvula occur, it should be scarified or amputated. 
 
 CHRONIC PHARYNGITIS; GRANULAR PHARYNGITIS; LACUNAR 
 PHARYNGITIS, OR CLERGYMAN'S SORE THROAT. 
 
 This disease may or may not be characterized by severe subjective 
 symptoms, such as irritability and dryness of the throat. 
 
 Etiology. — The chief factors in the etiology of this disease are gouty 
 and rheumatic diatheses, smoking, improper breathing (public speakers 
 and singers), and the presence of morbid processes in the nose, accessory 
 sinuses, and the epipharynx. Gouty or rheumatic patients complain 
 of throat symptoms, whereas if they are free from gout and rheumatism 
 they often make no such complaint. These conditions probably not 
 only aggravate the pharyngitis, but to a certain extent influence its 
 occurrence. Excessive smoking also aggravates and produces the inflam- 
 mation. Clergymen, singers, auctioneers, and hucksters, who breathe 
 through their mouths and abuse the vocal apparatus, are frequently 
 affected by chronic pharyngitis. Chronic rhinitis, and especially sinuitis, 
 affecting the posterior ethmoidal and sphenoidal cells is very frequently 
 the chief cause of the disease. The changed respiratory functions of the 
 
340 THE PHARYNX AND FAUCES 
 
 nose in these diseases subject the pharynx and the lower respiratory 
 tract in general to irritation. Of even greater importance is the discharge 
 of heavy mucous or mucopurulent secretions from the nose and accessory 
 sinuses into the pharynx. The secretions are charged with pathogenic 
 bacteria, and undergo decomposition, whereby certain irritating chemical 
 products are liberated, and as the secretions flow over the pharynx the 
 pathogenic bacteria attack the weakened mucous membrane and excite 
 inflammatory reactions. The chemical irritation also adds to the reaction. 
 
 I wish, therefore, to emphasize the importance of making a careful 
 examination of the nose and accessory sinuses in all cases of chronic 
 pharyngitis. 
 
 Pathology. — The changes in the mucous membrane consist at first 
 of an increased hyperemia and local leukocytosis, and later of the deposit 
 of the least differentiated cells or connective-tissue cells. That is, hyper- 
 plasia of the mucous membrane occurs. The lymph tissues around 
 the tubular glands of the pharynx are enlarged and are raised above 
 the surface of the mucous membrane. Occasionally the tubular glands 
 in the centre of the lymphoid masses are filled with a whitish exudate 
 or cheesy material. 
 
 Symptoms. — Subjective symptoms are not always present, especially 
 if the patient is not gouty or rheumatic, or if he does not misuse his voice. 
 In gouty and rheumatic patients who smoke to excess or breathe im- 
 properly the subjective symptoms are usually present. 
 
 Subjective Symptoms. — In aggravated cases the voice becomes hoarse 
 after moderate use, especially in public speakers, though the cords are 
 neither red nor inflamed. According to Lennox Browne, the hoarseness 
 is due to a spasm of the muscles of the pharynx and irritation of the 
 superior laryngeal nerve, which supplies the thyroarytenoideus, one of 
 the tensor muscles of the cords. 
 
 Smokers complain of a dryness or of the sense of a foreign body in 
 the throat. They have a constant desire to hawk and expectorate. 
 
 Cough may be present, though it is often absent. When present it 
 is irritable and hacking in character. 
 
 The secretions in the early stage of the disease are excessive, thick 
 and tenacious. At a later stage the glandular functions become impaired 
 and the throat dry and glazed. 
 
 The digestive tract is disordered, the breath foul, and constipation is 
 generally present. 
 
 Objective Symptoms. — Upon examination of the pharynx the mucous 
 membrane appears redder than normal, at least in certain areas. In 
 other areas it is pale and fibrous in appearance, especially in old chronic 
 cases. Enlarged bloodvessels often extend across the posterior pharyn- 
 geal wall. The secretion is often thick, heavy, and mucopurulent, though 
 in the later stages it may be scanty and only form a film over the surface. 
 In these cases the patient complains of dryness of the throat. The 
 uvula is often relaxed and elongated (Fig. 246), and should be amputated. 
 
 The lymph follicles of the posterior wall and of the lateral walls behind 
 the posterior pillars of the fauces are enlarged. This condition is often 
 
EDEMA OF THE UVULA 
 
 341 
 
 Fig. 245 
 
 referred to as pharyngitis hvperplastica lateralis, a needless subdivision 
 of chronic pharyngitis. The follicles are sparsely distributed on the 
 posterior wall of the pharynx, but are closely grouped along the lateral 
 walls. They appear as yellowish red raised areas on the posterior wall 
 and as nodular elongated masses behind the posterior faucial pillars. 
 
 Prognosis. — In the early congestive stage simple astringent and 
 demulcent local remedies combined with the regular use of a mild aperient 
 mineral water will effect a cure. In the more advanced cases in which 
 hyperplasia of the mucous membrane has occurred, and in which the 
 lymph follicles are hypertrophied, improvement will only follow the 
 destruction of the tubular glands around 
 which the lymph masses are located. 
 
 Treatment. — In mild cases and during 
 the early stage of the disease, or before 
 marked hyperplastic and hypertrophic 
 changes have taken place, the remedies 
 given under acute catarrhal pharyngitis 
 may be used with some success. 
 
 Aperient salines should be given daily 
 for a long period to eliminate the gouty 
 and rheumatic toxic material and to free 
 the stomach and intestines of putrefactive 
 substances. 
 
 In well-advanced cases the lymphatic 
 nodules, whether discrete or massed, as 
 they may be on the lateral walls behind the 
 posterior pillars of the fauces (pharyngitis 
 hvperplastica lateralis), should be punc- 
 tured with a cherry-red cautery electrode 
 (Fig. 245). The mucous membrane should 
 
 be brushed once or twice with a 10 per cent, solution of cocaine, and 
 from four to five hyperplastic follicles burned out with the electrode. 
 A spray of Setter's solution, to soothe the burned areas, should then be 
 used. At the end of the fifth or sixth day, four or five more follicles 
 may be treated in a similar manner, and so on until they are all destroyed. 
 This course of treatment is often very beneficial, though it may fail 
 if the gouty or rheumatic diatheses are not also corrected. The uvula 
 should be amputated if it is elongated. 
 
 Showing the cautery point applied 
 to pharyngeal follicular glands in the 
 treatment of follicular pharyngitis. 
 From four to five follicles may be 
 thus treated at a sitting under 
 cocaine anesthesia. 
 
 EDEMA OF THE UVULA. 
 
 Acute inflammation of the faucial structures, especially of the periton- 
 sillar tissue, is frequently attended by edema of the uvula (Fig. 246). 
 
 The methods of treatment generally recommended are scarification or 
 multiple punctures, which allow the excess of serum to escape. A more 
 rational procedure would be to promote a freer flow of the blood through 
 the tissues, and thus remove the obstruction to the blood current 
 
342 THE PHARYNX AND FAUCES 
 
 through the veins. The application of the rays of light and heat from 
 a 500 candle-power electric lamp to the neck at the angle of the lower 
 jaw acts admirably in this way. The lamp should be suspended 
 at a distance of eighteen inches from the patient and slowly passed 
 back and forth over the neck for from fifteen to thirty minutes, three 
 times daily. The patient's neck should then be sponged with ice-water 
 in order to prolong the hyperemia. 
 
 Astringent lozenges containing krameria and alum will be found 
 efficacious in giving comfort to the patient. 
 
 ELONGATED UVULA. 
 
 Elongation of the uvula is not a disease per se, but is a symptom of a 
 chronic pharyngitis, especially epipharyngitis. The relaxed pendulous 
 condition of the uvula is due to the irritation resulting from the epi- 
 pharyngeal discharge and to the changed nutrition attending the epi- 
 
 Fig. 246 
 
 Edema of the uvula. 
 
 pharyngeal infection and inflammation. The uvula may be slender and 
 pendulous, or it may be enlarged (hypertrophied) and pendulous. An 
 elongated and elastic uvula is sometimes observed as an idiopathic con- 
 dition, as shown in the author's case (Figs. 247 and 248). 
 
 Symptoms. — In robust subjects it causes but slight symptoms or none 
 at all. In sensitive patients it often causes a reflex cough when it touches 
 the epiglottis or the base of the tongue. The cough may be spasmodic, 
 and is usually dry. Nausea and vomiting, especially early in the morning, 
 are sometimes complained of. Patients have applied to me for relief 
 from the persistent hacking cough, fearing that they had tuberculosis. An 
 examination of the lungs failed to reveal disease in that region, whereas 
 an examination of the throat showed the presence of a long pendulous 
 uvula. The amputation of the lower relaxed portion of the uvula imme- 
 diately stopped all symptoms. 
 
ELONGATED UVULA 
 
 343 
 
 Treatment. — In simple cases astringent remedies, such as lozenges 
 containing krameria, afford relief. The uvula may also be painted with 
 astringent solutions of alum, tannic acid, or with adrenalin. In the 
 
 Fig. 247 
 
 Fig. 248 
 
 Author's case of elastic uvula. Note the spiral 
 arrangement of the mucous membrane of the uvula 
 when the muscle of the uvula is contracted. (See 
 Fig. 248.) 
 
 Fig. 249 
 
 Author's case of clastic uvula, evinc- 
 ing no tendency to elongation when at 
 rest. (See Fig. 247.) 
 
 The amputation of the elongated tip of the uvula just below the lower extremity of the muscle 
 The scissors are so applied that the posterior surface of the uvula will be the wounded surface. 
 This prevents irritation in swallowing food and in breathing through the mouth. 
 
 more severe cases amputation is indicated. In all cases the epipharynx 
 and the mesopharynx (oropharynx) should be examined and the diseased 
 conditions treated. 
 
 Surgical Treatment. — (a) The uvula should be painted with a 10 per 
 cent, solution of cocaine. 
 
344 
 
 THE PHARYNX AND FAUCES 
 
 (b) The tip of the uvula is then seized with forceps and drawn directly 
 forward. 
 
 Three views of the amputated uvula: a, anterior view; 6, lateral view; c, posterior view. 
 
 Fig. 251 
 
 I. 
 
 Casselberry's operation for elongated 
 uvula. 
 
 (c) While in this position it should 
 be operated upon with heavy blunt 
 scissors, as shown in Fig. 249. 
 
 By cutting the uvula from in front 
 while drawn anteriorly, the bevelled 
 cut surface of the stump faces pos- 
 teriorly. This is a point of practical 
 importance, as in swallowing solid 
 food the raw surface is not irritated 
 by it (Fig. 250). 
 
 Casselberry's Operation. — Dr. Wm. 
 E. Casselberry recommends the fol- 
 lowing technique in the amputation 
 of the uvula: 
 
 (a) Secure anesthesia by painting 
 the uvula with a 10 per cent, solution 
 of cocaine. 
 
 (b) Seize the tip of the uvula with 
 forceps and draw it directly forward. 
 
 (c) While in this position an up- 
 ward and medianward cut is made 
 with scissors to the central axis of 
 the uvula. A similar cut is made on 
 the opposite side, thus removing a 
 wedge-shaped piece of the uvula, as 
 shown in Fig. 251. 
 
 (d) The anterior and posterior cut 
 edges of the wound are then secured 
 with two or three black silk sutures, 
 black thread being used, because it 
 
RETROPHARYNGEAL ABSCESS 345 
 
 is easier to see at the time of its removal. Yankauer's needles may 
 be used with advantage. 
 
 (e) The sutures should be removed at the end of three days. 
 
 The advantages claimed for this method of operating are that the cut 
 surfaces are sealed and not likely to be irritated by the ingested food, nor 
 infected by ingested and inhaled pathogenic bacteria. 
 
 Hemorrhage has been reported after uvulotomy. This may be avoided 
 by limiting the amputation to the portion of the uvula below its muscular 
 fibers; that is, only the thin relaxed portion should be removed, as the 
 bloodvessels of the uvula do not extend beyond the muscular fibers. 
 
 RETROPHARYNGEAL ABSCESS. 
 
 Abscess of the posterior wall of the pharynx may be acute or chronic. 
 It may be situated in the mesopharynx, the hypopharynx, or the epi- 
 pharynx. 
 
 Etiology. — There is an infection beneath the mucous membrane. 
 The morbid germs gain entrance through the lymph vessels, the. atrium 
 of invasion being in one of the neighboring tissues which is diseased. 
 Tonsillitis, a postoperative tonsillar wound, a tuberculous tonsil, tuber- 
 culous cervical glands, caries of the vertebra, and syphilis of the throat 
 may be the immediate predisposing causes. The author observed one 
 case which followed the complete excision of the tonsil in an adult. Most 
 of the chronic cases occur in tuberculous and strumous children. Post- 
 pharyngeal abscess is often associated with tuberculous glands of the 
 neck. The glandular involvement is probably secondary to the pharyn- 
 geal abscess, or both may be secondary to a tuberculous affection of some 
 other structure. 
 
 Symptoms. — The patient complains of painful deglutition, and, if the 
 swelling is in the hypopharynx, of dyspnea, which may threaten life 
 or even cause death. Cough is constantly present. The voice is much 
 the same as in quinsy. In acute cases the temperature may be elevated 
 from 1° to 2°, whereas in chronic ones it is little altered. 
 
 Diagnosis. — The abscess should be differentiated from aneurysm, 
 malformation of the vertebrae, and inflammatory swelling of the mucous 
 membrane. 
 
 Aneurysm of an artery in this region has been mistakenly diagnosticated 
 as retropharyngeal abscess, a fatal issue following the incision. The 
 pulsation and bruit present in aneurysm should be sought for in all cases 
 of suspected abscesses of the pharynx. The pulsation may be noted 
 with the eye or finger, while the bruit may be distinguished with the 
 stethoscope introduced through the mouth. 
 
 Malformation of the posterior wall of the pharynx, causing bulging 
 of one side, is occasionally found. The hard, firm character of the mass 
 readily distinguishes it from the soft baggy mass which is present in 
 abscess formation. 
 
 Acute infectious inflammations of the pharyngeal mucous membrane 
 
346 
 
 THE PHARYNX AND FAUCES 
 
 sometimes simulates retropharyngeal abscess. The difference in the 
 resistance upon digital examination will determine which of the pro- 
 cesses is present. 
 
 Prognosis. — The danger in very young subjects is chiefly due to 
 suffocation, and to strangulation upon the spontaneous rupture of the 
 abscess. In older patients this danger is not so great, as their reflexes 
 enable them to ward it off or to anticipate it. Under treatment the 
 prognosis is nearly always good except when the disease is due to tuber- 
 culous caries of the vertebrae. 
 
 Fig. 252 
 
 The oral operation for retropharyngeal abscess. The finger is used as a guide to the fluctuating 
 area and as a tongue depressor, while a short-bladed scalpel is used to open the abscess. 
 
 Treatment. — The most important object to be accomplished is the 
 immediate evacuation of the pus. This may be done by (a) the internal 
 or (6) the external route. The internal operation should always be 
 tried first, and followed by the injection of iodoform glycerin emulsion 
 (Esmarch and Kowalzig). Should simple puncture and evacuation, 
 followed by the injection of the iodoform emulsion, fail, the external 
 operation should be performed. 
 
 Technique. — Internal Operation. — (a) Place the patient upon a table 
 with his head lowered to prevent the larynx being bathed in pus. With 
 children this precaution is especially urgent, because their reflexes are 
 not sufficiently trained to prevent suction of the infected secretions into 
 the trachea and lungs, where it might cause aspiration pneumonia. 
 
RETROPHARYNGEAL ABSCESS 
 
 347 
 
 (6) Introduce the left index finger into the mouth and place the tip 
 against the soft fluctuating tumor. 
 
 (c) Introduce a short-bladed scalpel, or a longer one, the proximal end 
 of which is wrapped with a strip of adhesive plaster or cotton, into the 
 mouth, using the above-mentioned finger as a guide (Fig. 252). 
 
 (d) Incise the abscess wall by the side of the finger. The pus then 
 flows through the incision into the pharyngeal cavity, from which it may 
 be removed with moist gauze sponges, grasped by artery forceps; or it 
 may be expectorated by the patient. 
 
 (e) After all the pus has been thus removed, irrigate the cavity with 
 warm boric acid solution and inject the iodoform glycerin emulsion into 
 the wound. The injections may be repeated every day or two, and if 
 steady improvement follows, a cure may be expected. If, however, im- 
 provement does not follow, the external operation should be performed. 
 
 The external operation for retropharyngeal abscess. The fascia enclosing the abscess is punctured 
 
 and opened with artery forceps. 
 
 External Operation. — Generally speaking, the external operation 
 consists in making an incision either anterior or posterior to the sterno- 
 mastoid muscle, and extending it inward by blunt dissection to the 
 anterior wall of the vertebral column, where the abscess cavity is located. 
 
 If only the retropharyngeal abscess is to be included in the operation 
 the incision should be made posterior to the sternomastoid muscle; if, 
 however, there are diseased cervical glands to be removed at the same 
 time, the incision should be made anterior to the muscle (Fig. 253). 
 
 The following steps in the operation should be observed: 
 
 (a) The field of operation should be shaved and cleansed. 
 
 (b) General anesthesia. 
 
 (c) An incision two or three inches long should be made through the 
 skin over either the anterior or the posterior border of the sternomastoid 
 muscle on a plane with the retropharyngeal abscess. The dissection 
 
348 THE PHARYNX AND FAUCES 
 
 should be continued until the deep cervical fascia is opened and the 
 border of the sternomastoid muscle is brought to view. 
 
 (d) The sternomastoid muscle is then separated by blunt dissection 
 from the adjacent tissues, and is drawn forward with a retractor to 
 expose the operative field. 
 
 (e) Still using blunt dissection, the carotid sheath with its vessels and 
 nerves is separated from the vertebra and carefully drawn forward. 
 
 (/) The dissection is carried in front of the vertebra to the abscess 
 wall. 
 
 (g) The abscess wall is punctured with closed artery forceps; the 
 forceps is then introduced into the cavity, the blades spread apart, and 
 withdrawn from the cavity (Fig. 253). The abscess is thus freely opened 
 and evacuated. 
 
 (K) Digital examination of the cavity should be made for necrosed 
 bone, and to note the condition of the soft tissues and abscess contents. 
 If the secretions are thick and caseous, they may be removed by gentle 
 curettage. 
 
 (i) Irrigation with warm boric acid or the glycerin-iodoform solution 
 completes the evacuation of the contents of the abscess. 
 
 (y) Introduce a cigarette drain into the wound. This may be with- 
 drawn a little each day after the discharge has ceased, and its use may 
 be abandoned altogether at the end of ten days or two weeks, after 
 which the external wound closes from the bottom by granulation. 
 
 If cervical glands are to be removed, or if the abscess points anteriorly 
 to the sternomastoid muscle, the incision should be made anterior to the 
 muscle. The group of glands involved should be removed en masse, as 
 to leave some of them almost surely means a secondary operation. 
 
 MALFORMATIONS OF THE PHARYNX; STENOSIS OF THE PHARYNX. 
 
 Malformations of the pharynx may be either (1) congenital or (2) 
 acquired. 
 
 Those of congenital origin may be in the form of an imperforate 
 pharynx, from a failure in the embryological development of the anterior 
 end of the foregut, and the invagination of the ectoderm, which forms 
 the cavity of the mouth. The embryological structures in this region are 
 very complex, and it is remarkable that congenital malformations are 
 not more frequent. They usually occur in the form of a constriction 
 or pouch, or of a complete closure. 
 
 Acquired malformations are due to inflammatory and degenerative 
 changes in the walls of the pharynx. Syphilis is the most common 
 cause. In the tertiary stage there is more or less destruction of the uvula 
 and soft palate, which is followed by cicatricial contraction and adhesion 
 to adjacent parts. The soft palate in these cases is usually adherent to 
 the posterior wall of the pharynx, and may cause almost complete sepa- 
 ration of the mesopharynx from the epipharynx. In one of my cases 
 due to congenital syphilis there was a small opening, about the size of a 
 
MALFORMATIONS OF THE PHARYNX 349 
 
 lead pencil, which communicated with the epipharynx. The scars in 
 syphilis are stellate in their arrangement, i. e., they radiate from the site 
 of the original ulceration. The ingestion of scalding fluid and caustic 
 drugs may produce scar tissue and cicatricial contraction. (See Syphilis 
 of the Pharynx.) 
 
 Treatment. — The treatment of syphilitic scar tissue and adhesions 
 result in failure in the majority of cases. The scar tissue may be 
 removed and the adhesions broken down, though they speedily reform 
 and readhere. Obturators have been used in the isthmus between the 
 mesopharynx and epipharynx, to keep the channel open and to prevent 
 adhesions, with occasional success. The tendency for syphilitic scar 
 tissue to reform, in spite of all that can be done, is the chief hindrance to 
 the successful treatment of these cases. If the constriction involves 
 the hypopharynx and dyspnea develops, tracheotomy should be per- 
 formed. 
 
CHAPTER XIX. 
 
 THE FUNCTIONAL NEUROSES OF THE PHARYNX. 
 
 Neuroses of Sensation. — The train of symptoms in pharyngeal neuroses 
 of sensation is about the same as in the larynx, many of them being 
 due to reciprocal lesions. (See Neuroses of the Larynx.) 
 
 Anesthesia of the pharynx is not of any great clinical significance, 
 excepting, perhaps, when it accompanies progressive bulbar disease. 
 Insane patients generally have it, even though no form of paralysis is 
 present in the pharynx or elsewhere in the body. In cases of marked 
 anesthesia involving the whole pharynx, the soft palate and larynx are 
 usually likewise anesthetic. Diphtheria often causes it, and it sometimes 
 accompanies the other exanthematous fevers. It may be present in local 
 inflammations of the pharyngeal mucosa. 
 
 (For treatment, see Anesthesia of the Larynx.) 
 
 Hyperesthesia of the pharynx is the most frequent of the pharyngeal 
 neuroses. It often occurs in those who are otherwise healthy. These 
 cases do not tolerate the laryngoscopic mirror in throat examinations. 
 They also resist the introduction of the Eustachian catheter. The most 
 sensitive areas in the pharynx are the arch of the soft palate and the 
 vault of the epipharynx. 
 
 Hyper sensitiveness accompanies both acute and chronic inflammation 
 of the pharynx. It is also a frequent manifestation of hysteria. It is 
 more common in men than women. Habitual smokers and drinkers 
 are subject to it. It is but rarely a symptom of central brain disease. 
 The hypersensitive areas sometimes appear on the tongue. 
 
 Paresthesia occurs about as frequently as anesthesia, and less fre- 
 quently than hyperesthesia, and often baffles the skill of examiners and 
 operators. Tonsillar disease is often the cause of it, hence these organs 
 should be thoroughly examined for diseased conditions. The passage 
 of a bolus of food or foreign body may cause an abrasion, which may be 
 followed by the sense of a foreign body in the throat. The menopause 
 is frequently attended by perverted sensations in the pharynx. Patients 
 at this period sometimes complain of the sensation of a rope or hairs 
 in the throat. Hyperplasia of the lingual tonsil seems in some cases to 
 cause it. The same is true of elongation of the uvula, though the elon- 
 gated uvula is usually a sign of epipharyngitis, and the paresthesia 
 may be due to the " dropping" from the epipharyngeal region. Granu- 
 lar pharyngitis, especially when it involves the lateral walls (pharyngitis 
 hypertrophica lateralis), gives rise to an irritation between the posterior 
 pillars and the pharyngeal wall, which is sometimes accompanied by 
 paresthesia. It is occasionally associated with globus hystericus. 
 
 The perverted sensations complained of are cold, heat, a foreign body, 
 itching, tickling, and the dislocation of the essential parts of the fauces 
 
THE FUNCTIONAL NEUROSES OF THE PHARYNX 351 
 
 and pharynx. Patients sometimes complain of swallowing the soft 
 palate, etc. Most of the female cases seen by me have suffered from 
 melancholia during the menopause, and have had a suicidal tendency. 
 One patient committed suicide by drowning some months after she 
 passed from under my observation. The paresthesia may be so marked 
 as to cause a distressing cough and laryngeal or esophageal spasm. 
 
 Neuralgia of the pharynx is difficult to differentiate from muscular 
 rheumatism. Neuralgia is not painful upon pressure, while rheumatism 
 is painful with or without pressure. Anemia and chlorosis are often 
 the cause of neuralgia, whereas rheumatism is more often associated 
 with plethora. Enlarged single pharyngeal follicles may become so 
 painful as to simulate neuralgia. Localized pressure upon the follicles 
 causes pain in rheumatic pharyngitis. 
 
 The treatment of neuralgia should be addressed to the cause when it 
 can be determined, as well as to the relief of the pain. Iron, strychnine, 
 arsenic, bitter tonics, and the regulation of the bowels should be the 
 basis of the treatment in those cases in which anemia is the cause. In 
 chlorosis, enemata should be given to unload and cleanse the rectum 
 and lower bowel, to stop the absorption of putrefactive material and 
 bacteria into the circulatory system. Exercise in the open air, especially 
 upon cloudy days, is of the greatest value in these cases. Excessive 
 exposure to sunshine is injurious, as it is too stimulating. Oxygen 
 rather than sunshine is the desideratum. Patients should be encour- 
 aged to play golf or other outdoor sport, or to work in the flower or 
 vegetable garden, or in the poultry yard. The outdoor exercise should 
 have a constant and alluring motive, or it will soon be abandoned. 
 
 Neuroses of Motion. — Neuroses of motion of the pharyngeal muscles 
 may, like that of the larynx, be divided into two general classes: 
 
 1. Akinesis, or paralysis, which may be unilateral or bilateral. The 
 akinesis, or paralysis, may be still further subdivided into: (a) Paralysis 
 due to bulbar disease (central paralysis), (b) Paralysis due to diph- 
 theria (peripheral paralysis), (c) Paralysis due to or complicating faucial 
 paralysis (central or peripheral paralysis), (d) Paralysis of the pharyn- 
 geal constrictors. (Lennox Browne.) 
 
 2. Hyperkinesis, or spasm. 
 
 Paralysis Due to Bulbar Disease; Central Paralysis. — The following 
 central lesions may give rise to pharyngeal paralysis: acute and chronic 
 bulbar myelitis, hemorrhage, tumors, embolism, and basilar meningitis. 
 
 Acute Bulbar Paralysis ; Central Paralysis. — Symptoms. — In acute bulbar 
 myelitis the symptoms develop rapidly, a fatal issue soon following. 
 The symptoms are as follows : 
 
 (a) Sudden attack. 
 
 (b) Severe headache. 
 
 (c) Dysphagia. 
 
 (d) Respiratory embarrassment. 
 
 (e) Difficulty in articulation. 
 (/) Giddiness. 
 
 (g) Unsteady gait. 
 
352 THE PHARYNX AND FAUCES 
 
 Prognosis. — The prognosis is extremely grave. 
 
 Treatment. — While these cases are almost necessarily hopeless, they 
 should be treated, as there is a chance that the diagnosis may be erroneous. 
 Bloodletting by cupping or leeching should be early and freely done to 
 relieve the inflammatory process at the base of the brain. Ice should be 
 applied to the pharynx and to the nape of the neck. The blood tension 
 should be lowered by the administration of cathartics and such other 
 remedies as are employed for spinal myelitis. 
 
 Chronic Bulbar Paralysis; Central Paralysis. — Undue exposure to cold, 
 prolonged violent excitement, extreme fatigue, and lack of nutrition are 
 etiological factors. Heredity seems also to largely influence its occur- 
 rence. It is more common in males than in females, and is rarely ob- 
 served before the age of thirty-five. In rare cases it may be due to an 
 injury or to sunstroke. Syphilis and tuberculosis should also be included 
 as causative agents. 
 
 Symptoms. — Pharyngeal paralysis may be the first symptom of pro- 
 gressive bulbar disease, though the tongue is usually the first organ 
 affected. The tongue is first involved in a typical case, and this is followed 
 by paralysis of the lips and of the pharyngeal and laryngeal muscles. 
 This order of involvement is almost always present. The paralysis, at 
 first slight, gradually increases in severity. 
 
 Diagnosis. — In the beginning the disease may be mistaken for bilateral 
 facial paralysis, though the history of a sudden onset, followed by 
 progressive chronic paralysis of the tongue, pharynx, and larynx, together 
 with the lips, should render the diagnosis of bulbar paralysis almost 
 certain. In bilateral facial paralysis the tongue, pharynx, and larynx 
 are not affected. In rare cases the tongue and fauces are not involved. 
 
 Prognosis. — The prognosis is usually grave, though there may be 
 remissions before death occurs. Patients often succumb to inanition or 
 pneumonia. 
 
 Treatment. — Galvanism has been used to combat the degeneration 
 o" the nerves, and faradism to maintain the muscular vigor, with but 
 little success. Strychnine and arsenic are of greater value. In syphilitic 
 cases the iodides are indicated. 
 
 Diphtheritic Paralysis; Peripheral Paralysis. — Paralysis of the pharyngeal 
 muscles is often an early sequel of diphtheria and of pseudomembranous 
 sore throat. The muscle fibers undergo more or less degeneration from 
 the presence of the bacterial toxins, and there is a mechanical hindrance 
 from the cellular infiltration of the tissues. In addition, there is a degener- 
 ation of the peripheral nerve fibers from the same causes. 
 
 Symptoms. — The voice undergoes great changes on account of the 
 paralysis of the pharyngeal muscles, as they are utilized in articulation 
 and voice placement. The voice has the so-called "nasal quality," 
 closely resembling that present in cleavage of the hard and soft palates. 
 The velum and uvula are relaxed and can only be raised by forced 
 inspiration. One side or both may be affected. The paralysis occurs 
 on or about the fifteenth day after convalescence, at which time ocular 
 symptoms may also develop. 
 
THE FUNCTIONAL NEUROSES OF THE PHARYNX 353 
 
 Treatment. — The prophylactic treatment consists in the administration 
 of antitoxin during the diphtheria. After the paralysis has developed, 
 galvanism, faradism, and rectal feeding should be adhered to in order 
 to maintain muscular and nervous tone while the degenerated nerve 
 fibers are being restored. Thick soups, grape juice, etc., may be given 
 per rectum. 
 
 Paralysis of the Pharynx Complicating Facial Paralysis. — According to 
 Ziemssen and Bouche, when the lesion is above the geniculate ganglion 
 the pharyngeal is often associated with facial paralysis. The uvula does 
 not move upon phonation and is deflected to one side. The symptoms 
 are the same as those in diphtheritic paralysis, and include such structures 
 as are supplied by the seventh nerve. 
 
 Paralysis of the constrictor muscles of the pharynx is always accom- 
 panied by paralysis of the esophagus. The dysphagia is, therefore, 
 exceedingly well marked, and is often the only distinctive symptom. 
 
 Hyperkinesis, or Spasm of the Pharynx. — Etiology. — Spasm of the 
 muscles of the pharynx is a rare affection. It may occur from insig- 
 nificant causes, as uvulitis, foreign bodies, globus hystericus, enlarged 
 pharyngeal follicles, neuralgia, and local chronic inflammations, or 
 it may be an early symptom of a serious central lesion. 
 
 The more dangerous form of spasm of the pharynx is encountered 
 in hydrophobia, edema of the glottis, brain tumors, paralysis agitans, 
 and other affections of the nerves. 
 
 Symptoms. — Chronic spasm of the pharynx involving the soft palate 
 and uvula may be the chief symptom. The levator palati is the muscle 
 affected. The spasm of this muscle draws the soft palate upward a 
 number of times in rapid succession, after which it relaxes. During 
 the spasm there is a clicking noise as the palate leaves the pharyngeal 
 wall. The click is audible to those near by. 
 
 Prognosis. — The prognosis is fair in those cases due to simple causes, 
 provided appropriate treatment is instituted. If due to a serious central 
 lesion, hydrophobia, edema of the glottis, brain tumor, or paralysis 
 agitans, it is grave. 
 
 Treatment. — If the spasms are due to a foreign body, it should be 
 removed. If due to local inflammation, appropriate remedies, else- 
 where described, should be used. When due to saprophytic absorption 
 from the rectum, the lower bowel should be flushed by enemata, outdoor 
 exercise advised, and a nutritious but unstimulating diet followed. When 
 due to hydrophobia this should be treated rather than the spasms of the 
 pharynx which are incidental to the disease. Stimulants of any sort 
 should be avoided in all cases. 
 
 23 
 
CHAPTER XX. 
 
 NEOPLASMS OF THE PHARYNX. 
 BENIGN NEOPLASMS. 
 
 (a) Papillomata. — Papillomata rarely occur on the walls of the 
 pharynx, but are common in the faucial region. They are most fre- 
 quently found upon the uvula, the free borders of the pillars of the fauces, 
 and the tonsils. The histological differences between the mucous mem- 
 brane of the posterior wall of the pharynx and the mucosa of the uvula, 
 pillars, and tonsils account for the location of the tumors. The posterior 
 wall of the pharynx is covered by squamous epithelium, whereas the 
 other structures are covered by columnar, and in many places by 
 columnar ciliated epithelium. In spite of the varying structural differ- 
 ences, papillomata appear in all parts of the pharynx and fauces, though 
 more frequently in the fauces. 
 
 They may be single or multiple, sessile or pedunculated. Behind 
 the fauces, or in the pharynx proper, they are rarely pedunculated, and 
 are chiefly limited to the ragged excrescences following syphilitic and 
 lupous inflammations. Papillomata are composed of elevations of epi- 
 thelial cells which contain a connective-tissue core more or less richly 
 supplied with bloodvessels. The epithelial elevations grow outward 
 while in epitheliomata they grow inward. The elevations vary from 
 tumors as small as a pinhead to those of considerable size. They often 
 contain "pearls" or "nests," which may be mistaken for the nests or 
 pearls of epitheliomata. The cells in papillomata are uniform, whereas 
 in epitheliomata they are multiform. Epitheliomata are likely to be 
 mistakenly diagnosticated as papillomata, and vice versa. 
 
 Primary papillomata are usually surrounded by an inflammatory area. 
 Secondary papillomata are the result of a preexisting inflammation, 
 as syphilis (Fig. 254). 
 
 The presence of a papillomatous growth in the fauces or pharynx 
 often excites a reflex cough, with a sense of fulness and tickling in the 
 throat. 
 
 Treatment. — The treatment of papilloma of the pharynx is usually 
 so simple that a detailed description of the procedures need not be given. 
 The tumor should be removed to its base with a knife, snare, cutting 
 forceps, or cautery. The base of the growth should be removed or 
 cauterized with solid silver or the galvanocautery. If this is not done 
 they are likely to recur. 
 
 (b) Teratomata.— Lennox Browne says: The connection between 
 teratomata and cystomata is so intimate and their origin so obscure 
 
BENIGN NEOPLASMS 355 
 
 that it is expedient to describe them together. I shall not do this, but 
 will attempt to characterize them as distinct pathological entities. 
 
 Teratomata are usually congenital and consist of tissue growths 
 springing from two or three embryological germinal layers. They appear, 
 therefore, most frequently in those regions where the various germinal 
 layers are in close apposition (Browne). The pharynx, which develops 
 from the junction of the neural and the dermal epiblasts with the hypo- 
 blasts of the foregut is, therefore, a suitable location for the growth of 
 teratomata. Bland-Sutton called attention to this fact in 1886. 
 
 Teratomata generally occur in the epipharynx, though in quite a few 
 recorded cases they were in the meso- and hypopharynx. They were 
 sometimes called " hairy pharyngeal polypi," as they are usually pedun- 
 culated cysts filled with hair and other histological structures. 
 
 Conitzen reported 11 "hairy polypi," or 
 teratomata, which were cystic and contained FlG - 254 
 
 hair, cartilage, skin, and bone. The cysts 
 are usually pedunculated, and may be at- 
 tached to any part of the pharynx. 
 
 Treatment. — The treatment consists in 
 the removal of the growth with the snare, 
 knife, or cautery. Cauterization of the base 
 seems to prevent recurrences. Wf%\ 
 
 (c) Cystomata. — They usually occur ^ T 
 after the twentieth year of life, more often ,. Auth f* c f s , e of iom ^ r to °f n " 
 
 . . ,. _ 1 •> ' litis and syphilitic papilloma arising 
 
 in middle and advanced age. Ihey are from the left supratonsiiiar fossa, 
 usually retention cysts or mucoceles, due 
 
 to the closure of the mouths of the pharyngeal follicles, either by 
 inflammatory contraction, epithelial plugs, or by the flaccid folds of 
 membrane in advanced life. The cysts contain a glairy fluid, though 
 in some cases it is inspissated and much thickened. They are usually 
 superficially located, though Raugi speaks of the occurrence of a cyst 
 in the submucous tissue. This tumor was difficult to see, and he thinks 
 this type must occur much more often than is generally believed. 
 
 Cysts are usually sessile, and often give rise to the symptoms described 
 under reflex neuroses, as asthma, migraine, etc. 
 
 Treatment. — The treatment consists in the enucleation of the cyst 
 membrane, though thorough cauterization of the lining of the sac is 
 usually followed by the obliteration of the tumor. 
 
 (d) Lymphomata, or Lymphadenomata. — This variety of benign 
 tumor is the most frequent growth in the pharynx. This is to be expected 
 on account of the widely disseminated lymphoid tissue and the numerous 
 lymphoidal vestiges. The matrix of the tumor is connective tissue, 
 in the meshes of which are aggregated the lymphoid cells. The cell 
 groups are often crowded together and vary greatly in size. They, 
 like lymphoidal tumors elsewhere, have a strong tendency to multiply. 
 They may be attended with or may follow mediastinal complications of 
 a like nature (Villar). A single tumor, especially when pedunculated, 
 at times offers some diagnostic difficulties. But when we take into 
 
356 THE PHARYNX AND FAUCES 
 
 consideration that the adjacent lymphatic glands in the neck are enlarged 
 and soft, the tumor in the pharynx, though pedunculated, should be 
 suspected to be lymphomatous. 
 
 (e) Myxomata. — Myxoma of the pharynx is exceedingly rare. 
 Browne in his large experience never saw a case. Closely allied to them, 
 however, are the so-called mucoceles due to dilatations of the mucous 
 glands. The mucoceles are important as they are readily recognized 
 and are easily eradicated by excision or the actual cautery. 
 
 (/) Fibromata. — After lipomata, fibromata occur next in order of fre- 
 quency. The structural arrangement is often so like that of sarcomata 
 that it is difficult to differentiate them. The clinical history is, therefore, 
 the guide in diagnosis. In very rare instances a myxomatous tumor 
 may have the tendencies and aspects of a fibroma, just as primary fibro- 
 mata may become mucoid in character. Fibromata are rare in advanced 
 age, but are quite common in young and middle adult life. This seems 
 to be true of nearly all neoplasms springing from the mesoblast. 
 
 Fibromata may be sessile, but are more often pedunculated. They 
 are composed of densely packed spindle cells, with an undeveloped 
 matrix of connective tissue. They are encapsulated, and often attain 
 a large size. Bruns reports a case in which the entire fauces was 
 filled by a fibroma. They are usually single and of slow growth. 
 They have their origin in the fibrous tissue and the periosteum of any 
 part of the pharynx. The covering of the basilar process of the occip- 
 ital bone and body of the sphenoid are favorite sites. As the ptery- 
 goid plate of the sphenoid and the perpendicular plate of the palate 
 bone, the posterior ends of the upper turbinated bodies, and the posterior 
 portion of the vomer are all covered with fibrous tissue and perios- 
 teum, fibromata usually develop in this region. Large fibromata are 
 frequently attended with inflammatory processes, hence adhesion to the 
 adjacent structures is common. 
 
 Etiology. — They are rare in females. Age is a decided factor in their 
 occurrence, adolescence being the favorite period. As age advances there 
 is a tendency for the growths to recede or undergo spontaneous cure. In 
 this respect they resemble adenoids and other lymphatic enlargements. 
 
 Symptoms. — The early symptoms are those of epipharyngeal catarrh, 
 with more or less hemorrhage. The bleeding sometimes becomes an 
 alarming complication. The voice becomes "flat" or "dead" in quality, 
 and respiration and deglutition are impeded as the process advances. 
 At a later stage, there is pain and mucopurulent discharge. When the 
 growth has attained considerable size the "frog face" becomes well 
 marked, the maxillary bones are separated, and exophthalmos becomes 
 a prominent symptom. Aprosexia and drowsiness are often present. 
 In one of the author's cases the patient often dropped into sleep or slight 
 stupor while in the treatment chair. Greville Macdonald reports vomit- 
 ing as an annoying symptom. 
 
 If the growth extends upward it may encroach upon the cranial con- 
 tents and give rise to such symptoms as paralysis, etc. ; this is followed 
 in nearly every instance by death. 
 
BENIGN NEOPLASMS 357 
 
 The foregoing symptoms increase in severity as the growth extends, 
 until the absorption of bony tissue is considerable, unless the tumor 
 extends beyond the nasal and pharyngeal chambers, as into the cranial 
 cavity. In this event the pressure necrosis of the bony tissue is not 
 so great. 
 
 Examination shows the tumor to be a rounded mass, of a pinkish or 
 dark purple color. The veins are frequently varicosed, hence the exam- 
 ination by digital or instrumental aids should be done carefully, to 
 avoid injuring them. The growth may project into the posterior nares, 
 or its direction may be toward the antrum and other sinuses. Under 
 finger pressure it is firm and elastic, and if small its base may be out- 
 lined. If pedunculated, it is movable, unless it has become fixed by 
 inflammatory adhesions. If it extends through the sphenomaxillary 
 fissure it may be felt under the zygoma. As adhesions are usually present, 
 its outline is difficult to distinguish. 
 
 Fig. 255 
 
 Author's ease of soft fibroma of the epipharynx, springing from the base of the sphenoid and 
 sending finger-like prolongations into the nasal chambers. 
 
 In Fio-. 255 is shown a soft fibroma of large size in a lad aged fourteen 
 years. It had its origin from the base of the sphenoid bone and extended 
 into the nasal chambers by three finger-like processes. Numerous 
 inflammatory adhesions were present around the choanal. A general 
 surgeon of repute made five futile attempts to remove the growth 
 because he was not intimately familiar with the anatomy of the 
 pharynx. (See Treatment.) 
 
 Diagnosis. — The histological resemblance to sarcoma is often so close 
 that a differentiation is difficult, unless the age, sex, and origin are such 
 as to point to its fibrous nature. Sarcoma is rarely or never, whereas 
 soft fibroma is frequently pedunculated. Hard fibromata are usually 
 sessile. 
 
 Prognosis. — The prognosis is favorable in proportion to its early recog- 
 nition and extirpation. It is also favorable as the age of the patient 
 
358 THE PHARYNX AND FAUCES 
 
 exceeds twenty-five years. In other words, small fibromata which do not 
 fill the epipharyngeal space are more favorable under operative treatment 
 than those which completely fill it. The tendency of the growth to 
 undergo retrograde changes after the twenty-fifth year accounts for 
 the more favorable prognosis in those cases in which it occurs after this 
 period. 
 
 Some patients even recover spontaneously. It is advisable in nearly 
 all cases to remove the growth by surgical interference, as it is too great 
 a risk to wait for a spontaneous cure. An additional reason for oper- 
 ating is to relieve the patient as speedily as possible of the pain and 
 other distressing symptoms characteristic of these growths. 
 
 Treatment. — Small growths, especially if they are pedunculated, and 
 those limited to the epipharyngeal space may be removed with a heavy 
 snare or ecraseur, either through the nose or mouth, or with adenoid 
 forceps. The galvanocautery snare may also be used through these 
 routes. When the growth is large and sessile, and has extensive inflam- 
 matory adhesions to the adjacent structures, it may be necessary to 
 perform an external or more radical operation. Large soft pedunculated 
 fibromata like the author's case shown in Fig. 255 may be removed as 
 follows : 
 
 (a) Prepare the patient for a major operation. General anesthesia. 
 
 (b) Place the patient in Rose's position 
 
 (c) Be prepared to ligate the external carotid artery, and to introduce 
 postnasal tampons. In the author's case the hemorrhage was very 
 great and necessitated the ligation of the external carotid artery. Res- 
 piration ceased at the same time, and artificial respiration was prac- 
 tised while the carotid artery was being ligated. The hemorrhage 
 occurred when the inflammatory adhesions around the choanse were 
 being broken down with the finger. The patient was emaciated and 
 anemic, which doubtless rendered the bleeding more severe. 
 
 (d) Break down the inflammatory adhesions around the choanse with 
 the finger, which should be introduced through the mouth. 
 
 (e) Introduce curved pharyngeal scissors (Fig. 242) through the mouth 
 into the epipharynx posterior to the body of the tumor until the pedicle 
 of the tumor is reached, and sever it, if possible. If the tumor is very 
 large, this may not be possible. In the case shown in Fig. 255, I 
 succeeded in partially severing the pedicle. 
 
 (/) If the pedicle cannot be severed with the scissors, introduce strong, 
 gently curved adenoid forceps through the mouth into the vault of the 
 epipharynx, seize the pedicle, and cut it from its attachment to the base 
 of the sphenoid bone. By this method I removed the fibroma shown in 
 Fig. 255. The growth was removed through the mouth; the finger-like 
 extensions into the nasal chambers came away with the body of the 
 tumor, as the adhesions within the nose were not firm. 
 
 The patient made a slow, but uneventful recovery, and one year after 
 the operation is in excellent health. 
 
 (g) Lipomata. — Lipomata of the pharynx are rare. When they occur 
 they are usually small and sessile, especially when they develop from dense 
 
MALIGNANT NEOPLASMS OF THE PHARYNX 359 
 
 tissue. When they spring from loose tissue they may attain large size, 
 and are generally pedunculated and multiple. They are oval, smooth, 
 and elastic, hence are sometimes mistaken for retropharyngeal abscess. 
 A puncture readily clears the diagnosis. They usually occur in advanced 
 age. Lennox Browne says that the sessile and deeply seated ones are 
 more often congenital than otherwise. 
 
 (h) Angiomata. — Because of Cruveilhier's submucous plexus, situated 
 at the back of the pharynx, and the rather rich, both superficial and 
 deep, blood supply, we might naturally expect many angiomata. But, 
 on the contrary, they are of rare occurrence. Moritz Schmidt does not 
 cite a case in his excellent review of the tumors of the upper respiratory 
 tract. Guyon had one patient in whom digital examination caused 
 profuse hemorrhage. Electrolysis checked the hemorrhage, and sub- 
 sequently caused atrophy of the growth. Angiomata of the pharynx, 
 like similar growths elsewhere, are usually cavernous and often erectile 
 in character. Farlow reports five cases of enlarged pulsating arteries 
 in the pharynx. The red-currant-like clusters occasionally seen in the 
 pharynx are, strictly speaking, angiomatous. 
 
 Treatment. — Most physicians favor non-interference unless the tumors 
 bleed. This attitude is attended by some risk, because a serious hemor- 
 rhage may occur at any time. If large, they should be deprived of their 
 arterial blood supply by ligatures around the efferent vessels If small, 
 they may be treated by electrolysis or by ligation. 
 
 Electrolysis is performed as follows: (a) Anesthetize the tumor with 
 local applications of a 10 per cent, solution of cocaine. 
 
 (6) Introduce the needles, connected with the positive pole of the 
 galvanic battery, into the growth. 
 
 (c) Turn on from 10 to 25 ma. of current for five minutes. Repeat 
 the seances at intervals of about seven days until the growth is obliterated. 
 
 The positive pole of the battery liberates nascent oxygen and coagu- 
 lates the tissue, hence it is the pole which should be applied to a soft 
 growth. If it is desired to reduce a hard or fibrous tumor, the negative 
 pole is applied to the growth, because it liberates hydrogen, which softens 
 the tissue. 
 
 Ligation or strangulation may be performed as follows: (a) Anes- 
 thetize the growth by the local application of a 10 per cent, solution of 
 cocaine. 
 
 (6) Pass a ligature through the tissues, including an artery at the 
 margin of the angioma, and tie it. Yankaure's needles should be used. 
 
 (c) Continue thus to tie off the larger vessels until the nutrient sources 
 are closed. 
 
 (d) After three or four days the ligatures should be removed. 
 
 MALIGNANT NEOPLASMS OF THE PHARYNX. 
 
 General Pathology. — Clinically it is an advantage to make a distinct 
 demarcation between the fauces and the pharynx in treating malignant 
 
360 THE PHARYNX AND FAUCES 
 
 growths. However, as is well known, their tendency to spread by con- 
 tinuity of tissue and by metastasis, and their insidious beginning, does 
 not permit of an absolute anatomical division. Oftentimes they origi- 
 nate on the border-line between the two regions. It should be borne 
 in mind that when these tumors spring from the larynx they are likely 
 to extend to the pharynx, but that those arising from the pharynx seldom, 
 if ever, extend downward to the larynx. Even those which occur in 
 the hypopharynx have an upward rather than a downward tendency. 
 This is partially explained by the difference in the tissues composing the 
 two parts. In the larynx there is little soft tissue, and the glandular 
 element is less, whereas in the pharynx the soft tissues and lymph glands 
 are more abundant. 
 
 Embryologically the pharynx and the larynx have different origins, 
 and the tendency to extension is thereby somewhat impeded. 
 
 The general symptoms are much the same as those of cancer of the 
 larynx. The special symptoms are dependent upon the anatomical and 
 physiological differences in the two regions. 
 
 The lower portion of the pharynx is more often the seat of malignancy 
 than the upper. Men are more often affected than women. Carcino- 
 mata here, as elsewhere, are more frequent in the old. This is in obe- 
 dience to the physiological law, that mesoblastic structures are more 
 active in the young, while the epi- and hypoblastic structures are more 
 active in the old. An effort is made by some writers to differentiate 
 between the malignancy of sarcoma and carcinoma. This is of no 
 practical or clinical value, as either is usually the cause of death in whom- 
 soever it occurs. True carcinoma, because of its glandular structure, 
 more readily involves contiguous structures, and more frequently extends 
 by metastasis. 
 
 Carcinoma of the pharynx is more frequent than sarcoma. The 
 former is more likely to involve the glandular structures, subjected as 
 it is to persistent irritation, especially in the pharynx. Sarcoma may, 
 however, be due to traumatism. 
 
 It is often difficult to differentiate profuse scar tissue from sarcoma, 
 as both are closely allied to embryonal tissue. The clinical phenomena 
 are, therefore, often more reliable than the microscopic findings. 
 
 Varieties of Sarcoma. — The various types of sarcoma which appear 
 in the pharynx in their order of frequency are: 
 
 1. Round-cell sarcoma. 
 
 2. Spindle-cell sarcoma. 
 
 3. Myxosarcoma. 
 
 4. Lymphosarcoma. 
 
 1. Round-cell Sarcoma. — The round-cell sarcomata are of two types: 
 (a) large round-cell sarcoma, and (b) small round-cell sarcoma. Their 
 structure is characterized by an aggregation of cells, intercellular cement, 
 and numerous bloodvessels. Occasionally a few fibrous trabecule are 
 distributed through the mass of cells. Lymph channels are also found 
 in the cellular masses. The cells vary considerably according to their 
 age and original site of growth. The older part of the tumor is in a 
 
MALIGNANT NEOPLASMS OF THE PHARYNX 361 
 
 state of degeneration, while the newer part is intact. The small round- 
 cell sarcoma is softer than the large round-cell growth, which has more 
 intercellular cement substance. The cells of the large round-cell sar- 
 coma often have oval nuclei, and form the most malignant type of 
 sarcoma. Its local ravages are extensive and the constitutional mani- 
 festations are severe. 
 
 2. Spindle-cell Sarcoma. — This, like the round-cell variety, is divided 
 into two classes: (a) small spindle-cell sarcoma, and (b) large spindle- 
 cell sarcoma. The general structure of this variety is quite like the 
 round-cell sarcoma, except that the cells are often arranged in bundles. 
 Lymph spaces are absent, whereas they are present in the round-cell 
 variety. The vascular supply is accordingly greater than in the round- 
 cell variety. Many spindle-cell sarcomata have a tendency to undergo 
 degeneration in patches, and are less malignant than the round-cell 
 variety. The spindle-cell sarcoma more often occurs in adults, while the 
 round-cell variety is more often present in the young. The spindle- 
 cell sarcoma develops slower than the round, is firmer, and less likely 
 to ulcerate. It may be pedunculated, while the round-cell variety is 
 seldom or never pedunculated. It is encapsulated and "shells out," 
 while the round-cell is not encapsulated. 
 
 The local malignancy is greater than in the round-cell variety, while 
 the general malignancy is not so great. The spindle-cell sarcoma usually 
 springs from the posterior wall of the pharynx, though it may arise 
 from the lateral wall. 
 
 3. Myxosarcoma. — -Myxosarcoma is originally either spindle- or 
 round-cell, which, having undergone an early mucoid change is con- 
 verted into the myxomatous type. It is locally malignant, rather than 
 constitutionally; that is, it has a tendency to recur, but seldom gives 
 rise to metastasis. It arises most frequently in the loose cellular tissue 
 of the lateral wall of the pharynx, though it may occur in the fauces and 
 the glosso-epiglottic fold. 
 
 4. Lymphosarcoma. — Lymphosarcoma is a variety of round-cell sar- 
 coma. It possesses a very delicate reticulum, which gives it the appear- 
 ance of a lymphoid structure. It usually originates in the lymphoid 
 tissue of the pharynx, which is, perhaps, another reason for its resem- 
 blance to normal lymphoid or adenoid tissue. When the growth is 
 traversed by numerous fibrous connective-tissue bands it is more dense 
 in structure. It is necessary to differentiate this neoplasm from benign 
 hyperplasia and lymphoma, which is directly due to inflammatory 
 processes. 
 
 Lymphosarcoma grows rapidly, and when removed invariably recurs. 
 It usually involves everything in its course, especially that type which 
 starts in the lymphatic glands. Pharyngeal ymphosarcoma is quite 
 often observed in Hodgkin's disease, which is a true lymphosarcoma. 
 
362 THE PHARYNX AND FAUCES 
 
 TRYPSIN TREATMENT OF MALIGNANT NEOPLASMS. 
 
 According to J. T. Campbell, the trypsin treatment of malignant 
 neoplasms is based upon the statistical findings of von Bergmann, 
 wherein he states (1) that cancer of the stomach stops abruptly at the 
 pylorus; (2) that the small intestine is but rarely the site of cancer; 
 and (3) that cancer of the large intestine and rectum for the most 
 part increases in frequency the farther the distance from the duo- 
 denum. In 10,537 cases of cancer of the alimentary tract the stomach 
 was involved 4288 times, the small intestine 20, the large intestine 224, 
 and the rectum 1204 times. The natural and comparative immunity 
 of the duodenum and small intestine, together with the slower rate of 
 growth of cancer of the large intestine, would, therefore, appear to 
 support the treatment of inoperable cancer by preparations of the 
 pancreas, bile salts, intestinal gland extracts, and ferments alone or 
 combined. In November, 1905, Dr. Wade, at the solicitation of Dr. 
 F. Beard, began experiments, first, to determine the action of trypsin 
 upon the living cells of carcinoma, such as Jensen's mouse tumor (an 
 adenosarcoma) ; second, to test the truth of the conclusion advanced by 
 Beard in 1902 that cancer was an irresponsible trophoblast; and third, 
 the length of treatment and number of injections of trypsin necessary 
 to destroy the tumor. 
 
 The results were such as to appear to show that the trypsin caused a 
 degeneration of the cancer cells, a shrinkage of the tumor, and an improved 
 condition of the system in general. Since then several cases of cancer 
 in the human body have been reported wherein trypsin caused apparent 
 shrinkage of the growth, a cessation of the pain, marked gain in weight, 
 and great improvement in the health of the patients. It appears, how- 
 ever, that the improvement was temporary, in some of the cases a 
 recrudescence of the neoplasm occurring later, with a rapid fatal ter- 
 mination. It is too early to accurately judge the merits of the trypsin 
 treatment. It is, however, worth trial in inoperable cases. An oper- 
 able case should be operated early and thoroughly. Delay and partial 
 removal by operation are dangerous procedures. An early operation 
 and complete removal offer the best chance of a cure. The operation 
 may be followed by the trypsin treatment. 
 
 Technique of Trypsin Treatment. — The trypsin comes in sealed am- 
 poules, of 20 minims each, of a glycerin extract prepared from the pan- 
 creatic glands, and with such a proportion of the ingredients of the 
 normal salt solution that when diluted with two volumes of sterilized 
 distilled water the medium corresponds in this respect to the normal 
 salt solution; greater dilution may be employed if desired. 
 
 At first 5 minims of the trypsin solution diluted with 10 minims of 
 sterilized distilled water should be injected through the skin of the 
 buttocks deep into the subcutaneous tissue, but not into the muscles. 
 The injections may be given every other day, gradually increasing the 
 dose to 10 minims. 
 
THE EXCISION OF THE EXTERNAL CAROTID ARTERY 363 
 
 The skin should be cleansed with soap and alcohol, and in sensitive 
 patients 0.1 grain of eucaine may be injected a few minutes before the 
 injection of the trypsin. 
 
 Some writers recommend the administration of holadin in 3 grain 
 capsules three times a day during the trypsin injections. Holadin is 
 an extract of the entire pancreas gland, containing all the constituents 
 of the digestive and internal secretions of the gland. 
 
 THE EXCISION OF THE EXTERNAL CAROTID ARTERY AND ITS 
 
 BRANCHES FOR INOPERABLE CANCER OF THE UPPER 
 
 RESPIRATORY TRACT. 
 
 The excision of both external carotid arteries and their eight branches 
 may be performed for the purpose of depriving inoperable malignant 
 growths of the nose and pharynx of their blood supply, thereby starving 
 the growths. Malignant tumors require a large blood supply, hence 
 this operation seems to offer some degree of hope. Dawbarn reports 
 encouraging results in a number of cases of inoperable cancer of the 
 head. The operation should never be performed when the growth can 
 be successfully extirpated. The ligation of the external carotids and 
 their branches should be adopted as a last resort. While it may not 
 cure the case it may prolong life. 
 
 The Position of the Head. — The shoulders should be placed upon a 
 block or sand cushion, the chin well elevated and everted to the opposite 
 side to expose the region of operation. 
 
 The Incision. — The incision should extend from the tip of the mastoid 
 process close behind the angle of the jaw to the level of the middle of 
 the larynx. At either extremity the incision is exactly over the external 
 carotid artery. Dawbarn recommends that the incision be curved 
 medianward about 1.5 cm., as the safety of the operation lies anterior 
 to the artery, while danger lies posterior to it. 
 
 Exposure of the Artery. — Work from below upward, first exposing the 
 superior thyroid artery, which extends downward to the thyroid gland. 
 By tracing this back to the carotid the external is distinguished from the 
 internal. Pass a chromicized catgut loosely around the external carotid. 
 Examine the carotid and be sure that it bifurcates into the external and 
 internal branches. If it does not it should not be ligated, as the blood 
 supply to the brain would be cut off and death result. 
 
 If it does not bifurcate into the external and internal branches, only 
 the branches supplying the external portions of the head should be ligated, 
 the carotid being untied. Having determined that the common carotid 
 bifurcates as usual, continue the dissection upward, exposing each branch 
 and tying it in two places and dividing it. The dissection is thus con- 
 tinued upward until the level of the twelfth cranial nerve is reached, and 
 all the branches of the artery but the terminal two have been controlled. 
 .The external carotid is itself tied twice and divided between. The 
 ligature placed loosely around the external carotid below the superior 
 
334 THE PHARYNX AND FAUCES 
 
 thyroid branch should not be tied until all the branches are ligated. 
 It should not be tied sooner because the artery would collapse and 
 render the dissection difficult. The ligature is placed in position early, 
 ready for use in case of accidental hemorrhage in the course of the 
 dissection higher up. The upper portion of the artery should be dis- 
 sected as it passes under the transverse loop of the twelfth nerve and 
 the conjoined stylohyoid and posterior belly of the digastric and on 
 into the substance of the parotid gland. It should be followed to its 
 bifurcation when possible. The dissection should be done with dis- 
 secting forceps or scissors and not with a sharp knife, as it might divide 
 some of the lower branches of the pes anserinus and cause facial 
 paralysis, or else, by cutting through some of the smaller ducts of the 
 parotid gland, cause a salivary fistula (Dawbarn). Use gentle down- 
 ward traction during the blunt dissection, and when as high as possible 
 seize the artery with artery forceps and tie as high above it as possible 
 and then sever the artery below the forceps. 
 
 Close the wound by sutures, leaving a cigarette drain at its lower 
 angle, or make a counteropening an inch and a half below the angle 
 and insert the drain through this, entirely closing the original wound. 
 
 At the end of five or six days the drain may be discontinued and the 
 counteropening allowed to heal by granulation. 
 
 Structures to be avoided : The internal jugular, internal carotid, pneu- 
 mogastric, the superior laryngeal nerve, the pharyngeal branch of the 
 pneumogastric, and the glossopharyngeal nerves. They all lie behind 
 and deeper than the external carotid artery. Careful dissection should 
 be done. 
 
 The opposite carotid should be operated in like manner after an 
 interval of ten days, though both may be done at one time if the patient 
 is in vigorous health. The death rate of this operation is considerable. 
 
CHAPTER XXI 
 
 DISEASES OF THE FAUCES AND TONSILS. 
 THE TONSILS AS PORTALS OF INFECTION. 
 
 Since Strassmann reported 13 cases of tuberculous tonsils in 21 tuber- 
 culous cadavers the tonsils have commanded considerable attention as 
 channels of infection. The opinions of various observers since then 
 have differed somewhat, especially in reference to the tuberculous pro- 
 cess in the tonsils. There has been but little questioning of the fact, 
 however, that the tonsils are portals of systemic and glandular infection. 
 There is not, after all, a great divergence of opinion as to whether the 
 tonsils are frequently a path of pathogenic infection; the difference 
 is a question as to certain details, rather than as to the general theory 
 itself. For example, some observers have failed to find tubercle bacilli, 
 or the characteristic tuberculous changes in the tissue of the tonsils, 
 which have been reported by other writers. Notwithstanding this, 
 practically all writers agree that various pathogenic organisms do gain 
 an entrance to the deeper tissue of the tonsils, the lymphatic glands, 
 the lungs, the heart, and, indeed, to the whole system through these 
 organs. 
 
 In view of the growing interest and more exact information on this 
 subject, the tonsils have gained a prominence in medical literature which 
 they did not have a quarter of a century ago. A brief resume of the cur- 
 rent thought on this subject will, therefore, be given in connection with a 
 study of the diseases of these organs. 
 
 In reference to primary tuberculosis of the tonsils, there is a divergence 
 of opinion; some hold that the tuberculous process in these glands is 
 direct, while others contend that the infection reaches them from the 
 lungs through the lymphatics and the bloodvessels, or by the flow of 
 the bronchial secretions over them. Both views are probably correct 
 in selected cases. It is probable, however, that tuberculous infection 
 of the cervical lymphatic glands is usually due to the entrance of the 
 bacilli and other microorganisms through the tonsils. This is borne 
 out clinically by the fact that suppurating or tuberculous glands of the 
 neck are rarely found in phthisical patients. Whereas if they occurred 
 secondarily to pulmonary infection they would be frequently found in 
 such patients. 
 
 That a latent tuberculous process may exist in the tonsils or in adenoids 
 without presenting distinctive clnical signs thereof is suggested by the 
 reports of a few cases in which a fatal pulmonary tuberculosis followed 
 the removal of tonsils and adenoids. Friedreich suggests that the removal 
 
366 THE PHARYNX AND FAUCES 
 
 of the tonsils may have excited a recrudescence of a latent tuberculous 
 tonsillitis in these cases. It seems to me that these cases point strongly 
 to the conclusion that there is such a condition as latent tuberculosis 
 of the tonsillar ring, which may continually infect the lymphatic glands 
 of the neck, as well as the deeper structures in the thoracic cavity. Latent 
 tuberculoiss of the tonsils is not per se a serious menace to the health 
 or the life of the patient, but the danger arises from the extension of 
 the infection to the contiguous organs. 
 
 The experiments of Dieulafoy show that of 96 guinea-pigs inoculated 
 with pieces of tonsils and adenoids, 15 developed tuberculosis. While 
 these experiments are not conclusive in their scope or character, they are, 
 nevertheless, suggestive. We know that tubercle bacilli are found on 
 healthy mucous membranes, and it is possible, though not probable, 
 that in these experiments the infection may have come from the accidental 
 presence of surface bacilli. If it is admitted that the germs giving rise 
 to the infection in the guinea-pig were within the tonsillar epithelium 
 we practically admit the major proposition, namely, that the tonsils are, 
 or may become under favorable conditions, the portals of systemic or 
 circumscribed infections in the contiguous glands and organs. In many 
 instances this is also shown by the caseation or the suppuration which 
 takes place in the tonsils. That there is not a close functional connection 
 between the cervical and the pulmonary lymphatic glands appears 
 clinically in the rarity of the extension of the tuberculous infection from 
 the cervical lymphatics to the lungs. 
 
 The facility with which the invasion of pathogenic microorganisms 
 is accomplished through the tonsils depends upon the following factors: 
 
 (a) The virulency of the invading microorganisms. 
 
 (b) The pathogenicity of the microorganisms. 
 
 (c) The general health of the patient. 
 
 (d) The existence or the absence of the strumous diathesis. 
 
 (e) The condition of the epithelium of the mucous membrane cover- 
 ing the tonsillar crypts, and the condition of the tonsillar tissue. 
 
 Piera has shown that bacteria are much more readily absorbed by 
 the tonsils than is the coloring matter with which Goodale experimented. 
 The germs pass into^ the interior of the tonsil, while the coloring matter 
 is absorbed in the clefts of the lacunar epithelium. He also found that 
 the pathogenic germs were more readily absorbed than the non-patho- 
 genic, and that healthy tonsils absorb better than the fibrous. He does 
 not intend to convey the idea, however, that healthy tonsils are a menace 
 to the system, for, on the contrary, they have a protective function. If 
 the healthy tonsil readily absorbs the pathogenic germs, it also has the 
 power of destroying them. 
 
 It has been thought that the tonsils are vestigial organs which once 
 had a function that is now more or less obsolete. Packard has called 
 attention to the fact that tonsils have been traced in the lower animals 
 from the reptiles up to man; and that they are more complex in man, and 
 cannot, therefore, be said to be vestiges. On this subject Watson Wil- 
 liams says that if the tonsils are in some measure a protection against 
 
THE TONSILS AS PORTALS OF INFECTION 367 
 
 the invasion of microorganisms, their protective power is limited, and 
 when this limit is passed they are a positive source of danger. The crypts 
 and fissures of the tonsils may become "traps" for microbes, and the 
 peculiar anatomical arrangement of their investing epithelium, described 
 by Stohr, opens the gates to their invasion into the tissues of the 
 tonsil, whence through the lymphatic channels and vessels they may 
 gain an entrance into the system. 
 
 Williams also refers to the researches by von Babes, wherein he proves 
 that in pulmonary gangrene the infection may enter through the tonsils 
 as well as through the bronchi. He also says, primary tuberculosis of 
 the tonsils is less rare than is generally believed, and the failure of the 
 faucial tonsils to arrest the development of the bacilli results in tuber- 
 culosis of the cervical glands, so commonly observed in weakly children. 
 
 It has long been held that rheumatic fever has its origin in infection 
 through the tonsils. Clinical observation certainly supports this view, 
 as acute articular rheumatism is commonly observed following an attack 
 of acute tonsillitis. 
 
 Dawson advances the ingenious theory that scarlet fever has its primary 
 lesion in the tonsils. Whether or not this view will be supported by 
 future observations remains to be seen. It has been shown by Kocher 
 that acute suppurative osteomyelitis may be due to an infection by the 
 same route. 
 
 Acute tonsillitis may be due to pneumococci, streptococci, and staphy- 
 lococci, which are almost constantly present in the crypts of the tonsils. 
 
 Wright and Walsham have failed to find the tuberculous process in 
 removed tonsils, but this does not necessarily prove that they are not 
 pathways of infection. I have already shown that the tuberculous 
 infection may exist in a latent form; that is, the bacilli may be presenl 
 within the follicles without giving rise to distinct histological changes. 
 By the term follicles is not meant the crypts or lacunae, but the lymphoid 
 nodules. 
 
 The lines of defence against microbic invasions through the upper 
 respiratory tract may be classified as follows: 
 
 (a) The mucous secretions are regarded as having in some degree 
 bactericidal properties as they are rich in leukocytes. 
 
 (b) The epithelial covering of the mucous membrane of the upper 
 respiratory tract is a mechanical barrier. 
 
 (c) The lymphatic tissue composing Waldeyer's ring (tonsillar ring). 
 
 (d) The cervical lymphatic glands. 
 
 (e) The bronchial lymphatic glands. 
 
 (/) The endothelial lining of the bloodvessels. 
 
 (g) The endothelial lining of the lymphvessels. 
 
 (h) The serum of the circulating blood. 
 
 (i) The leukocytes in the circulation. 
 
 It will be seen by the foregoing that the system is pretty well guarded 
 against the invasion of pathogenic microorganisms. Should the first 
 or the second barrier be overcome, the remaining ones are still ready 
 to bar the further progress of the morbific bacteria. 
 
368 THE PHARYNX AND FAUCES 
 
 In tuberculous infection of the cervical lymphatic glands the germs 
 excite the reaction of inflammation, as shown by the enlargement of the 
 glands. Under favorable conditions they are harmless on account of 
 the phagocytic action of the leukocytes, which Stohr has shown are 
 thrown out from the clefts in the epithelial covering of the crypts. 
 
 Acute endocarditis, septic thrombophlebitis, and pyemic infarcts of the 
 lungs have also been shown to be due to the absorption of microorganisms 
 through the lymphatic ring. 
 
 Recapitulation. — (a) Tuberculous tonsils have been found in subjects 
 who died of tuberculosis. 
 
 (b) Some observers have failed to find the tuberculous process in tonsils 
 and adenoids removed from living patients, while others have been able 
 to demonstrate it. 
 
 (c) Primary tuberculosis of the tonsils, while not common, cannot be 
 said to be rare. 
 
 (d) Secondary tuberculosis of the tonsils has been demonstrated. 
 
 (e) Latent tuberculosis may exist in tonsils and adenoids without 
 presenting distinctive clinical signs. 
 
 (/) The removal of tonsils and adenoids is sometimes followed by 
 pulmonary tuberculosis. (This is doubtless a mere coincidence.) 
 
 (g) There are several barriers to the invasion of pathogenic micro- 
 organisms into the system. 
 
 (h) The invasion of the pathogenic microorganisms is promoted by the 
 virulency of the germ, and by certain local and constitutional conditions. 
 
 (i) The tonsil is a barrier against the invasion of microorganisms, 
 its power in this capacity being limited by the age of the patient and the 
 condition of the tonsil. 
 
 (j) Rheumatic fever, acute endocarditis, septic thrombophlebitis, 
 pulmonary gangrene, and other infective conditions have their initial 
 lesions in the tonsils. 
 
 Practical Applications. — In view of the facility with which micro- 
 organisms, especially of the pathogenic type, gain entrance into the 
 system through the tonsils, it becomes necessary under certain conditions 
 to remove the tonsils in their entirety. 
 
 I have seen cases in which repeated attacks of acute follicular tonsillitis 
 and concurrent cervical lymphadenitis had taken place. After tonsil- 
 lectomy, i. e., the complete removal of the tonsils, the tonsillitis necessarily 
 ceased to recur, and there was no further recurrence of the lymphadenitis. 
 It may be logically concluded that the diseased tonsils acted as a perma- 
 nent incubator for the streptococci, and the staphylococci, and the 
 incubator being removed, the cervical lymphadenitis disappeared. 
 
 When a latent tuberculous process is present in the tonsils, the cervical 
 glands are infected and give rise to repeated enlargement and caseous 
 degeneration of the glands. After the complete ablation of the tonsils, 
 including the capsule, great improvement of the glandular disease should 
 occur. While it may not always be advisable to perform tonsillectomy; 
 it is usually advantageous to do so in those cases in which the cervical 
 glands are enlarged. 
 
THE CLINICAL ANATOMY OF THE TONSIL 369 
 
 It is also advisable to perform complete ablation when there is an active 
 tuberculous process in the tonsils with an incipient involvement of the 
 lungs. I have removed tonsils in this condition with the most satis- 
 factory results. 
 
 Singers and public speakers with a troublesome subacute laryngitis, 
 and whose tonsils are small and fibrous, or enlarged, may be benefited 
 by the complete removal of the tonsils, whereby a possible source of 
 irritation of the larynx through the absorption of microorganisms and 
 septic matter is removed. 
 
 THE CLINICAL ANATOMY OF THE TONSIL. 
 
 The tonsil is situated in the sinus tonsillaris between the faucial pillars, 
 and has its origin in an invagination of the hypoblast at this point. Later 
 the depression thus formed is subdivided into several compartments 
 which become the permanent crypts of the tonsil. Lymphoid tissue 
 is deposited around the crypts, and thus the tonsillar mass is built up. 
 The inner or exposed surface, including the cryptic depressions, is covered 
 with mucous membrane, while the outer or hidden surface is covered 
 by a fibrous capsule. 
 
 According to Landois and Stirling, the development of the faucial 
 tonsil is most easily studied in the rabbit, where the single primary 
 crypt generally remains without branches through life, and there the 
 tonsil first appears in embryos | inch long (occipitosacral measure- 
 ment), or of about twelve days as a shallow epithelial fold whose apex 
 points directly backward into the connective tissue concentrically con- 
 densed around the pharynx. At this stage there is no infiltration of 
 the leukocytes in the connective tissue around the crypt, and it is not 
 until the embryos are about twenty-one days old (ly (i inches long) that 
 the leukocytic infiltration becomes evident. The crypt has then become 
 much deeper and broader, and by its ingrowth has produced a condensa- 
 tion of the connective tissues at right angles to the original peripharyngeal 
 condensation, as well as a great increase in the number of capillary 
 bloodvessels. From this stage the elongation of the crypt, the condensa- 
 tion of the connective tissue, the increase in the number of bloodvessels 
 and the amount of leukocytic infiltration go on pari passu until the 
 adult condition is reached. As soon as the leukocytes appear in numbers 
 in the submucous tissue they proceed to escape through the epithelium, 
 as Stohr has described. 
 
 In the fetus of the pig the condensation of the connective tissue, 
 especially at the apex of the tonsillar crypts, and the consequent massing 
 of leukocytes, mainly at these points, is particularly well shown. 
 
 In the human fetus the process is the same, though complicated by 
 the early ramification of the original epithelial crypt and the appearance 
 of fresh ones. The crypts become so deep that the cells from the surface 
 layers of their epithelium cannot at once be thrown off into the mouth, 
 and remain as a concentrically arranged mass of degenerated cornified 
 
 24 
 
370 THE PHARYNX AND FAUCES 
 
 cells filling up the lumen of the crypt; this mass is ultimately forced out 
 by the vis a tergo of the leukocytes emigrating through the epithelium. 
 It will at once be seen how closely this resembles the formation of the 
 concentric corpuscles of the thymus. 
 
 The prime factor in the formation of the tonsils is the epithelial 
 ingrowth, which partly mechanically compresses the meshes of the 
 connective tissue, and partly causes proliferation of the connective cells 
 and vessels by the slight irritation it produces, thereby making it easier 
 for the leukocytes to escape from the thin-walled capillaries and veno- 
 capillaries so formed, and, when they have escaped, causing them to be 
 detained in the finely meshed connective tissue longer than in other 
 situations. As the leukocytes are well supplied with nutriment, they 
 divide by mitosis in large numbers, as Flemming and his pupils first 
 showed, and at a late stage in development (with great variations in 
 individuals) "germ centres" are formed, where a special arrangement 
 of connective tissue and vessels favors the process of division. 
 
 The lingual and pharyngeal tonsils develop in the same way as the 
 faucial. His shows that all the tonsils arise behind the membrana pharyn- 
 gis, and, consequently, all these epithelial ingrowths pass into connective 
 tissue already condensed around the primitive alimentary canal (G. L. 
 Gulland). 
 
 It will be observed that the tonsil is an encapsulated organ, and that it 
 is characterized by from eight to twenty crypts or tubular depressions. 
 Many practitioners have confused the tonsil with the follicular tissue 
 immediately surrounding it. So long as they were able to remove follicular 
 tissue through the wound in the sinus tonsillaris, they thought they were 
 removing tonsillar tissue. In this they were mistaken, as the lymphoid 
 tissue immediately surrounding the tonsil is not encapsulated, nor 
 is it characterized by cryptic depressions, and is therefore not tonsil 
 tissue. 
 
 The tonsil does not always completely fill the sinus tonsillaris, the 
 unoccupied space above it being known as the supratonsillar fossa, 
 into which several crypts usually open. 
 
 The outer aspect of the tonsil is loosely attached to the superior con- 
 strictor muscle of the pharynx, thus subjecting it to compression with 
 every act of deglutition. The palatoglossus and palatopharyngeus 
 muscles of the pillars also compress the tonsil. Grober cites authorities 
 who claim that the compression of the muscles forces food and bacteria 
 into the crypts, rather than out of them. 
 
 The Crypts. — The crypts are usually tubular and almost invariably 
 extend the entire depth of the tonsil to the capsule on its outer surface. 
 Some, however, are compound, i. e., they divide below the surface into 
 two or more tubules. They are usually comparatively straight, though 
 they may be tortuous in their course. I have examined many hundreds 
 of tonsils which have been removed with their capsules intact, and have 
 never found crypts that did not extend through the follicular tissue to the 
 capsule. Those opening in the supratonsillar fossa usually extend down- 
 ward and outward, whereas in the lower portion of the tonsil their direc- 
 
PLATE VJI 
 
 Section of a Tonsil radically removed on account of Chronic 
 Lacunar Disease. (Lumiere's process photograph.) 
 
 1 . Margo supratonsillaris. 
 
 2. Fibrous capsule of tonsil. 
 
 3. Trabeculae or sept; 
 
 4. Degenerated and mechanically lacerated crypt. 
 
 5. Dilated tonsillar crypt. 
 
 6. Epithelial surface. 
 
 7. Lymphoid tissue. 
 
THE CLINICAL ANATOMY OF THE TONSIL 371 
 
 tion is outward. The area occupied by the mouths of the supratonsillar 
 crypts constitutes, according to Killian, the hilus of the tonsil. Clinically, 
 the crypts seem to be the source of the greatest amount of local and con- 
 stitutional disturbances, as they often become filled with food, tissue 
 debris, and bacteria. This is especially true of those capped over by 
 an overlying membrane, as the plica supratonsillaris, and the antero- 
 inferior portion of the tonsil which is covered by the plica tonsillaris. 
 The plica supratonsillaris does not, in all cases, enfold the hilus, or 
 supratonsillar crypts, as the tonsil often fails to fill the supratonsillar 
 space. In other instances it closely hugs the upper end of the tonsil, 
 thereby completely closing the mouths of these crypts. It is in these 
 cases, particularly, that the contents of the crypts are retained. 
 
 Reasoning from a mechanical point of view, one would reach the 
 conclusion that the retention of the infected secretions must necessarily 
 give rise to infectious inflammatory processes. Clinically, we know 
 that this is not always true. The crypts are often found filled with food, 
 tissue debris, and pathogenic bacteria, without any appreciable inflamma- 
 tory reaction. Nevertheless, as I shall exemplify later, the mechanical 
 closure of the crypts by the plica supratonsillaris and the plica tonsil- 
 laris adds greatly to the tendency to inflammatory and other morbid 
 local and general processes. 
 
 It may be stated as a general law in physiological pathology that 
 mechanical obstruction to the drainage of any secreting cavity tends to 
 result in local morbid processes and in toxic or infectious manifestations 
 in remote parts of the body. 
 
 The Epithelium. — The free surface of the tonsil, including the crypts, 
 is covered with stratified pavement epithelium, the deeper layers of 
 which are columnar in type, while the superficial are pavement. Goodale 
 has shown that certain coloring matter, when dusted in the crypts, is 
 readily absorbed into the interior of the tonsil. He claims that the absorp- 
 tion probably takes place through the interspaces between the cells. 
 From this the inference might be made that bacteria are absorbed with 
 equal facility. This conclusion does not, however, coincide with either 
 physiological or clinical data. 
 
 Jonathan Wright has shown that there is a vast difference in the 
 absorptive power of the tonsil for dust and for bacteria. He intro- 
 duced carmine powder and bacteria into the crypts of the tonsils and 
 excised them in fifteen minutes. The microscope showed the carmine 
 particles in great abundance beneath the epithelium and within the inter- 
 cellular spaces, whereas no bacteria were found beneath the surface. He 
 also observed that the carmine dust remaining on the outside of the tonsil 
 was easily washed away, while the bacteria were more difficult to remove. 
 The adherence of the bacteria to the live animal membrane and their 
 failure to pass through it he ascribed to the viscosity of the bacteria, a 
 biomechanical property of microorganisms. The mechanical affinity 
 existing between the bacteria and a living mucous membrane he con- 
 sidered as one of their defensive and offensive properties of a biomechani- 
 cal kind, as distinguished from their biochemical products, the toxin and 
 
372 THE PHARYNX AND FAUCES 
 
 endotoxin. Dust or carmine powder does not possess this adhesive 
 property, hence it is readily absorbed, whereas the bacteria are not. 
 
 We know, however, from abundant clinical experience, that there are 
 conditions under which the bacteria are absorbed through the cryptic 
 epithelium in sufficient numbers to excite marked local and constitutional 
 disturbances. Apparently the adhesive property of the bacteria has been 
 overcome, or the toxin of the microorganisms within the crypts has con- 
 verted the live epithelium into inert matter, through which it readily 
 passes. Wright says from the experiments of Goodale and others 
 with colored granules, and from his own observations of dust particles 
 passing the epithelial layer in health, and bacteria passing it in dis- 
 eases, it is evidence that there must be something beyond mechanical 
 obstruction which, under ordinary conditions of health, keeps the tissue 
 beneath the epithelium free of bacterial life, which swarms in some of 
 the crypts on the outer side of the epithelial cells. Hitherto the revela- 
 tions of the antitoxic power of the blood sera have been insufficient to 
 explain the problem. That explains the nullification of the toxic power 
 of the pathogenic germ after it passes within the tissues, but it does not 
 explain immunity from infection — to translate literally, the freedom 
 from the carrying in of the germ. It seems probable from experimenta- 
 tion with various forms of protoplasm that the animal organism evolves 
 defensive properties to destroy by lysis, when the system through lack 
 of excretory power becomes embarrassed by their presence. 
 
 Wright also says that bacterial protoplasms may excite bacterio- 
 lytic ferments in the epithelial cells, a property heretofore referred by 
 Metchnikoff to the leukocytes only. In these ways he attempts to 
 show the existence of equilibrium between immunity and infection. 
 A lack of balance or equilibrium is effected by a loss of local tonicity 
 or health, and infection then takes place. 
 
 In the epithelial lining of the crypts we find, therefore, the following 
 properties : 
 
 (a) A biomechanical resistance to the invasion of the microorganisms, 
 viscosity. 
 
 (b) A biochemical destruction or taming of the microorganisms in 
 the crypts through the agency of a ferment thrown out by the epithelium 
 under the stimulus of the retained bacteria. This process is known 
 as bacteriolysis. 
 
 As long as the epithelium of the crypts is in a state of tonicity or health, 
 an equilibrium between immunity and infection is maintained. When 
 the cellular tonicity is impaired, the equilibrium between immunity 
 and infection is lost and infection occurs. When the crypts are closed 
 by the plica supratonsillaris and the plica tonsillaris, or by concretions 
 in the mouths of the crypts, a very active warfare between the retained 
 microorganisms and the epithelial cells is begun. The cells throw out 
 a poisonous ferment, whereas the bacteria throw off a toxin for the pur- 
 pose of impairing the tonicity of the epithelium. If the siege is continued 
 sufficiently long, the cells give way, and the infectious host penetrates 
 the epithelial barrier and enters the deeper tissues of the tonsil. 
 
THE CLINICAL ANATOMY OF THE TONSIL 373 
 
 The Sinus Tonsillaris. — The anterior pillar contains the palatoglossus 
 muscle and forms the anterior boundary, whereas the posterior pillar 
 contains the palatopharyngeus muscle and forms the posterior boundary 
 of the sinus. The pillars meet above to unite with the soft palate. In- 
 feriorly they diverge and enter into the tissues at the base of the tongue 
 and the lateral wall of the pharynx respectively. The outer wall of the 
 sinus tonsillaris is composed of the superior constrictor muscle of the 
 pharynx. The sinus tonsillaris is, therefore, a triangular depression 
 on the lateral wall of the fauces which partially envelops the tonsil. 
 
 My clinical observations show that the tonsil is loosely attached 
 to the sinus; that is, the so-called adhesions are not present. The extent 
 of the attachment varies in different subjects. Patterson has shown 
 that the supratonsillar fossa may extend downward so as to admit a 
 bent probe between the outer side of the tonsil and the superior con- 
 strictor muscle of the pharynx, as far as the inner surface of the lower 
 jaw. Even when the attachment is general it is not usually so firm 
 as to greatly interfere with the enucleation of the tonsil. The "adhesion" 
 to the anterior pillar so often spoken of is, in my opinion, a myth. It 
 is true that the tonsil has an anatomical connection with the anterior 
 pillar, but the union is not of that firm, fibrous nature usually implied 
 by the term. Indeed, the term "adhesion" is often used in reference 
 to the plica tonsillaris which covers the anteroinferior portion of the 
 tonsil, and which is often attached to the tonsil at its inferior extremity. 
 One writer even speaks of the plica triangularis as an hypertrophy 
 of the anterior pillar, whereas, in fact, it is an embryological structure, 
 which in some of the lower animals develops into the tonsil itself. 
 
 The anterior limit of the sinus tonsillaris often extends well under the 
 anterior pillar, thus concealing a large portion of the tonsil. The outline 
 of the tonsil may be readily determined by digital examination or by 
 seizing it with the forceps and drawing it toward the median line of the 
 throat. When thus drawn the anterior shoulder of the tonsil may be 
 seen outlined beneath the anterior pillar, and if still more forcibly drawn 
 inward, the body of the tonsil slips from underneath the pillar, thus 
 showing that it is not markedly adherent, but that, on the contrary, it is 
 loosely attached and by proper procedures may be readily enucleated. 
 
 The Lymphatics. — The relation of the tonsil to the lymphatic vessels 
 is somewhat different from that which exists between the lymphatic glands 
 and vessels. The difference in the relationship consists in the fact that 
 the lymphatic vessels have their origin in the tonsil, whereas they pass 
 through the lymphatic glands. The question of chief clinical importance 
 is the course and termination of the tonsillar lymphatic vessels which 
 drain into the deep cervical chain underneath the sternocleidomastoid 
 muscle, from thence to the thoracic glands, and finally into the thoracic 
 duct. By this route infection is carried to all parts of the body. The 
 tonsil, under certain conditions, being peculiarly susceptible to infection, 
 becomes, therefore, the atrium of infection for a great variety of diseases 
 extraneous to itself. The literature is rich with clinical reports of dis- 
 eases illustrating this fact (Fig. 258). 
 
374 
 
 THE PHARYNX AND FAUCES 
 
 In reference to the tonsil as the portal of infection in tuberculous 
 processes, it is generally admitted that this often takes place through the 
 tonsil, and extends thence through the lymphatics of the deep cervical 
 chain on into the thorax. It then passes through the hilus of the lung 
 into the visceral pulmonary lymphatics. The apex of the right lung 
 is the most frequent seat for the inception of the pulmonary tuber- 
 culous disease. This has, heretofore, been attributed to the fact that 
 this area is less directly in line with the respiratory air current, and that 
 this portion of the lung has less motion than other portions of either lung. 
 It forms, therefore, a peculiarly favorable location for the development 
 of the tubercle bacillus. 
 
 Fig. 256 
 
 ADEN0ID5 
 
 The lymphatic glands and vessels of the neck which drain the teeth, tonsils, adenoids, pharynx, 
 
 and mastoid region. 
 
 Dr. J. Grober has questioned the existence of this route of pulmonary 
 infection, or at least he has advanced a rival hypothetical explanation, 
 based upon a series of experiments upon lower animals. He reports the 
 following three suggestive experiments out of a total of twenty-eight: 
 
 First experiment, September 16, 1902. A young rabbit was anesthe- 
 tized by ether and chloroformed, and 1 c.c. of a sterilized emulsion of 
 black Chinese paint injected into the left tonsil. 
 
 September 23, 1902, the autopsy showed black particles in the blood. 
 
THE CLINICAL ANATOMY OF THE TONSIL 375 
 
 Behind the left tonsil there was a mass composed of the coloring matter 
 and leukocytes. The lymph glands on the left side of the neck, as far as 
 the upper border of the thyroid cartilage, were stained black. The micro- 
 scope demonstrated that the lymph vessels were filled with free coloring 
 matter, as well as leukocytes which inclosed small particles of pigment. 
 
 The glands and lymph vessels were fairly packed with the coloring 
 matter. Beyond the zone of the lymph glands and vessels little coloring 
 matter was found. 
 
 Second experiment. A small dog was narcotized by morphine injec- 
 tions. Six and one-half c.c. of the sterilized emulsion of black pigment 
 was injected into the tonsil. 
 
 The autopsy, after complete exsanguination, showed the following 
 conditions: Very little coloring matter in the leukocytes, none being free 
 in the blood. The tonsil and the loose connective tissue containing 
 the afferent lymphatic vessels of the tonsil were of a deep black color. 
 
 Along the muscles of the neck, as far as the hyoid bone and to the 
 median line, there were streaks of pigment. The pigmented area also 
 spread downward below the hyoid bone, where it extended 1 cm. beyond 
 the median line. The coloring matter was traced to the bony opening 
 of the thorax and to the parietal pleura, which, when stripped off and 
 examined by transmitted light, showed the black pigmentation. The 
 lymph vessels of the paratraeheal connective tissue and of the esophagus, 
 as far as 2 or 3 cm. above the bifurcation of the trachea, were also colored, 
 whereas on the left or uninfected side no such phenomenon was found. 
 All the lymph glands on the lateral wall of the pharynx, hyoid bone, 
 larynx, along the deep vessels of the neck and supraclavicular fossa 
 on the right side were black. The parietal pleura at the apex showed 
 an exudate, but no adhesion to the visceral pleura. 
 
 The microscope showed that in all the above-mentioned organs there 
 were no other changes. In the glands the coloring matter occupied 
 the paravascular spaces. In the lymph vessels between the supra- 
 clavicular glands and the parietal pleura of the apex there was a large 
 number of leukocytes which were filled with coloring matter. Free 
 coloring matter was also present in this region. In the apex of the lung 
 there were no signs of an inflammatory reaction. The coloring matter 
 here seemed to be freely deposited within the connective tissue. In the 
 above-mentioned exudate at the apex there was coloring matter in the 
 leukocytes. 
 
 Third experiment, April 4, 1903. A small dog was placed under 
 morphine narcosis and 5 c.c. of coloring matter injected into the tonsil. 
 April 13, the same experiment was performed on the opposite side. 
 
 May 10, the autopsy, after exsanguination, showed a large amount of 
 coloring matter free in the blood; the leukocytes, the tonsil and connec- 
 tive tissue, and the connective tissue of the neck on both sides along the 
 larynx to the aperture of the thorax were colored symmetrically. The 
 lymphatic glands along the large bloodvessels, as well as those in the 
 supraclavicular region, were deeply stained. The coloring matter was 
 also found within the lymphatic vessels and in the paravascular spaces. 
 
376 THE PHARYNX AND FAUCES 
 
 A fibrous exudate was found in the apices of both lungs, thus forming a 
 bridge of inflammatory material from the parietal to the visceral pleura. 
 The coloring matter was also present in the exudate. The microscopic 
 appearance, of the apices presented a light grayish coloration. The 
 glands in the mediastinum were stained on the left side, as were also the 
 bronchial glands. In the left lung there were three other small fibrinous 
 exudates in which the coloring matter was present. 
 
 From these experiments Grober builds the hypothesis that tuberculous 
 infection of the apex of the lung may take place via the deep lymphatic 
 chain, the supraclavicular glands, and thence to the parietal lymphatic 
 vessels, where an inflammatory exudate is thrown across to the visceral 
 pleura. The tubercle bacilli travel across this inflammatory bridge and 
 enter the apex of the lung. 
 
 While these experiments are not conclusive, they are interesting and 
 open a field for further observations. 
 
 The Blood Supply. — The tonsillar artery, a branch of the facial, is 
 the chief vessel to the tonsil, though the ascending palatine, another 
 branch of the lingual, sometimes takes its place. The tonsillar artery 
 passes upward on the outer side of the superior constrictor muscle, 
 through which it passes and gives off branches to the tonsil and soft 
 palate. The palatine, another branch of the lingual, also sends branches 
 through the superior constrictor muscle to the tonsil. The ascending 
 pharyngeal also passes upward outside of the superior constrictor, and 
 when the ascending palatine artery is small it gives off a tonsillar branch 
 which is correspondingly larger. The dorsalis linguae, a branch of the 
 lingual artery, ascends to the base of the tongue and sends branches 
 to the tonsil and pillars of the fauces. The descending or posterior 
 palatine artery, a branch of the inferior maxillary, supplies the tonsil 
 and soft palate from above, forming anastomoses with the ascending 
 palatine. The small meningeal artery sends more branches to the tonsil, 
 though they are of minor importance. 
 
 Clinical Application.— Without reviewing the literature, which is 
 rich in reports of cases showing the tonsil to be the portal of infection 
 for many diseases in remote parts of the body, I have attempted to 
 show under what conditions it becomes the portal or atrium of infec- 
 tion. Under conditions of local equilibrium or health of the epithe- 
 lium lining the tonsillar crypts, infection does not take place, whereas 
 when the local equilibrium is lost, infection occurs. That the local 
 equilibrium of the cryptic epithelium is frequently lost is apparent to 
 every clinician. In addition to the diseases arising through the tonsil as 
 a portal of infection, there are those limited to, or having their focal 
 centre in, the tonsil itself. Perhaps the strongest indictment against the 
 tonsil is that it is often the atrium of infection in pulmonary tuberculosa. 
 Whether the route of infection is via the deep lymphatics and the hilus 
 of the lung, or the deep lymphatics and the parietal pleura at the apex, 
 as shown by analogy in the experiments of Grober, is immaterial. The 
 question of prime importance is, Do pulmonary or other types of tuber- 
 culosis have their origin through the tonsil as a portal of infection ? In 
 
THE CLINICAL ANATOMY. OF THE TONSIL 377 
 
 view of my own observations, and of others, I must answer in the affirma- 
 tive. Just what percentage has not been fully determined. Various 
 writers report that from 4 to 10 per cent, of tonsils (removed) show local 
 tuberculous lesions such as tubercle bacilli and giant cells. 
 
 The structures of the tonsil which seem to favor infection are the 
 crypts, especially those in the supratonsillar fossa and those covered 
 by the plica tonsillaris. Wright has suggested that the imperfect drain- 
 age of the crypt leads to the ultimate loss of tonicity (equilibrium) in 
 the epithelial cells which line them, thereby opening the way to systemic 
 infection through the tonsil. 
 
 The question naturally presented at this juncture is, What is the 
 rational method of procedure to protect the system from further infection ? 
 The choice of remedial measures seems to lie between internal medica- 
 tion, local applications, and surgical interference. 
 
 As to the first and second methods of treatment, it may be said that 
 there are cases which may be satisfactorily treated by them; especially 
 by relieving the distressing local inflammatory symptoms; indeed, many 
 cases may be practically cured by such treatment. There are many 
 others, however, in which such measures are wholly inadequate, either 
 to relieve immediate symptoms or to ward off future attacks. In these 
 cases we have usually resorted to some surgical procedure, such as open- 
 ing the crypts and plunging the cautery point obliquely across them, 
 decapitation (partial removal of the tonsil), and the complete removal of 
 the tonsil. 
 
 The literature shows a wide divergence of opinion as to what consti- 
 tutes the best method of surgical treatment, although it shows that nearly 
 all writers agree that some sort of surgical procedure is indicated. 
 
 What does the anatomy indicate? It shows certain crypts so situated 
 as to afford poor drainage of their contents, even though the superior 
 constrictor, palatoglossus, and palatopharyngeus muscles compress 
 the tonsil with each act of deglutition. This is especially true of those 
 crypts which discharge into the supratonsillar fossa. Kauffmann has 
 suggested that the supratonsillar crypts be opened with a sharp knife, 
 and that the incised surface be painted with 5 to 20 per cent, trichloracetic 
 acid. By thus opening the crypts their contents are drained. The 
 applications of acid excite a violent inflammatory reaction which results 
 in the contraction of the tissue of the tonsil. The process is often an 
 extremely painful one, and may result in cellulitis and the formation of 
 scar tissue. Furthermore, it does not always prevent further infection 
 through the tonsil. It is, therefore, often necessary to repeat the incisions 
 and applications of acid. 
 
 The patient is entitled to immunity from tonsillar infection if it can 
 be established without seriously jeopardizing either his health or life. 
 When the tonsil becomes a well-established atrium of infection, the 
 physical economy of the patient i* constantly menaced by conditions 
 ranging all the way from a follicular tonsillitis to endocarditis and pul- 
 monary tuberculosis. Measures should, therefore, be adopted which 
 will insure future freedom from infection through the tonsil. 
 
3?8 THE PHARYNX AND FAUCES 
 
 It has been shown by abundant clinical experience that cauterization 
 of the lumen of the crypts or obliquely across them into the surrounding 
 follicular tissue does not adequately meet the indications. 
 
 The same is true of "decapitation/' or partial removal of the tonsil. 
 Decapitation leaves the deep and more diseased portion of the crypts, 
 and, while it may afford some relief of the symptoms, it is often followed 
 by recurrent infections and by the reformation of the tonsillar tissue. 
 
 The complete removal of the tonsil with its capsule intact is, so far as 
 I know, the only surgical procedure that guarantees immunity from 
 infection through the sinus tonsillaris. 
 
 The function of the tonsil and the effect of its complete removal upon 
 the general condition of the patient must be considered; so, also, must 
 the question of hemorrhage. In reference to the effect of the removal 
 of the tonsil upon the general system, it may be said that there is little 
 evidence that it has any deleterious result. Masini, however, believes 
 that the tonsil has an internal secretion comparable with that given 
 off by the suprarenal gland. He arrived at this conclusion after experi- 
 ments with the aqueous extract of the tonsil, intravenous injections 
 of which gave the same results as those obtained from the injection of 
 suprarenal extract. 
 
 The last word concerning the treatment of the tonsil cannot be spoken 
 until its exact function is established. Clinically, there is little to show 
 that its removal causes evil effects, whereas there is much evidence to 
 show that good results, especially from its complete removal. 
 
 I have attempted its complete removal with the capsule intact in 
 about 3000 cases during the past seven years, and, barring one or two 
 instances in which there was a temporary paresis of the palatopharyngeus 
 muscle, one case of cervical cellulitis, and a half-dozen moderately 
 severe hemorrhages, I have seen no unfortunate result. The general 
 health of many patients was greatly improved and recurrent septic 
 inflammation within the sinus tonsillaris was eliminated. Recur- 
 rence of the tonsillar tissue has not taken place in a single instance. 
 Should it grow again, this is almost prima facie evidence that the entire 
 tonsil was not removed. 
 
 When the tonsil has been completely removed, with its fibrous 
 envelope, the source of infection is removed. It is, of course, possible 
 for the follicular tissue which surrounds the tonsil to become diseased, 
 but this should be differentiated from tonsillar disease. When the 
 tonsil is not removed with its capsule intact, it is difficult to determine 
 whether it has been entirely removed; and if a part of it is left, regenera- 
 tion is likely to occur. The tonsil, if removed in its entirety, should show 
 a distinctly defined mass of lymphoid tissue enveloped within a smooth, 
 glistening, fibrous capsule on its outer, and with mucous membrane on 
 its median, aspect. Lymphoid tissue which is not thus characterized is 
 not tonsillar tissue. 
 
 Hemorrhage. — -The danger from hemorrhage is, perhaps, the greatest 
 objection to the operation. Is this a real or an imaginary obstacle? It 
 is both in adults. It is real in that severe hemorrhage does occasionally 
 
THE CLINICAL ANATOMY OF THE TONSIL 
 
 37§ 
 
 occur in operations on the tonsils. It is imaginary as to the reputed 
 frequency of its occurrence and the degree of danger attending it. A 
 knowledge of the possible sources of hemorrhage will enable the operator 
 to largely exclude its occurrence. Furthermore, there are certain matters 
 in the technique of local anesthesia, and in the after-treatment which, 
 if properly applied, will greatly reduce the frequency and severity of 
 hemorrhage. Clinically, I have observed that the most frequent site 
 of arterial hemorrhage is at about the middle portion of the sinus tonsil- 
 laris, where the tonsillar branch of the facial pierces the superior con- 
 strictor muscle of the pharynx. Other points of hemorrhage are usually 
 limited to the inferior portion of the sinus tonsillaris, where the tonsillar 
 venous plexus is located, and to the anterior and posterior pillars. 
 
 Fig. 257 
 
 a, subdivisions of the tonsillar artery; b, superior constrictor muscle of the pharynx; c c, fibrous 
 capsule of the tonsil; d, lymph follicles or substance of the tonsil; e, plica supratonsillaris; f, supra- 
 tonsillar fossa. 
 
 In another part of this chapter I have referred to the fact that three 
 arteries, the tonsillar, the ascending palatine, and the ascending pharyn- 
 geal, pass upward on the outside of the superior constrictor muscle, which 
 they pierce as they turn inward to ramify the tonsil and faucial pillars. 
 Just before entering the tonsil they break up into several branches 
 (Fig. 257). It is obvious that the smaller the branches cut during an 
 operation, the less serious the hemorrhage. The clinical application of 
 this fact is that if the arterial branches are severed as they enter the 
 capsule of the tonsil, the chance of hemorrhage is reduced to the mini- 
 mum; whereas if they are severed on the outer aspect of the superior 
 
380 THE PHARYNX AND FAUCES 
 
 constrictor muscle before they are broken up into smaller branches, 
 the danger from both primary and secondary hemorrhage is greatly 
 increased. It may be said that the operator should not injure the 
 superior constrictor muscle in this operation, and this is true. Indeed, 
 if he thoroughly appreciates the clinical significance of the anatomy of 
 the tonsillar region, he probably will not injure it. 
 
 As to the anterior pillar, it should be borne in mind that there are 
 arterial twigs coursing through it. The main trunks of the arterial 
 branches are external to the palatoglossus muscle. Hence it follows 
 that in order to injure them it is necessary either to pass the instrument 
 behind the muscle or to include the musculature of the anterior pillar 
 in the grasp of the tonsillotome, knife, blunt dissector, or scissors, and 
 thus sever the muscle and vessels of the anterior pillar. The same 
 statements may be made in reference to the posterior pillar. 
 
 The technique should, therefore, be such as to avoid injuring the 
 muscles bounding the sinus tonsillaris, namely, the superior constrictor 
 of the pharynx, the palatoglossus and the palatopharyngeus muscles, for 
 by such technique only the small branches of the tonsillar arteries are 
 injured. 
 
CHAPTER XXII. 
 
 THE INFLAMMATORY DISEASES OF THE TONSIL. 
 
 General Considerations. — The inflammatory diseases of the tonsils 
 are usually subdivided into various types, according to whether the 
 process is acute or chronic, and is limited to the crypts or extends to 
 the substance or parenchyma of the tonsil. As a matter of fact, this 
 classification is somewhat artificial, as it is now well established that all, 
 or nearly all, inflammations of the tonsil are due to infection through the 
 epithelium of the crypts. The manifestation may be acute or chronic 
 in type; it may appear as an acute or chronic lacunar inflammation, with 
 the typical exudate at the mouths of the lacunae or crypts; or it may be 
 manifested in the form of a parenchymatous inflammation, in which the 
 whole substance of the tonsil is involved. Inflammations of the tonsils 
 are not surrounded by any profound mysteries other than those of a 
 biochemical nature, which are common to all inflammatory processes. 
 The fact of chief importance is that in all types of tonsillar inflammation 
 there is a lesion of the epithelium which lines the crypts, and that some 
 form of pathogenic bacteria has penetrated it. The determination of 
 the type and virulence of the microorganisms is of even greater importance 
 than the determination of the type of tonsillar inflammation under the 
 older classification. The bacteriological findings at least afford some 
 useful information as to the virulence of the infecting microorganism, 
 and, therefore, influence the mode of treatment to a certain extent. If the 
 virulence is marked, immediate surgical procedure is contra-indicated; 
 indeed, the presence of an acute inflammation would of itself constitute 
 a contra-indication to operative interference. 
 
 Much remains to be lerned concerning inflammations of the tonsils. It 
 may still be questioned whether it is good practice to remove tonsils 
 in the wholesale manner now in vogue. The function of the tonsil in 
 a child and in an adult is still an open question. When does its function 
 cease or become so altered by disease as to justify its removal? Should 
 the tonsil be partially or completely removed? When removed, what 
 organ performs its functions? These and other questions are not fully 
 answered. We know from clinical experience that when a tonsil shows 
 a tendency to become the seat of recurrent inflammations the patient's 
 health and life are conserved by its entire removal. Are there other 
 methods of treatment that will better conserve the health and life of the 
 patient? It is doubtful, though this is still an open question. The 
 removal of the debris from the crypts, from time to time, would no doubt 
 avert many acute exacerbations; the topical application of solutions 
 of silver might also prevent acute manifestations, but in the long run 
 
382 THE PHARYNX AND FAUCES 
 
 such methods of procedure must fail. The complete removal of the 
 tonsil during a quiescent period must always succeed in preventing 
 inflammations of the tonsil for all time to come. Will a tonsil thus 
 removed recur? Never, if it is completely removed. Can it be removed 
 by dissection with its capsule intact? Yes; with the most happy results. 
 
 ACUTE LACUNAR TONSILLITIS. 
 
 Synonyms. — Acute follicular tonsillitis; infective tonsillitis; cryptic 
 tonsillitis. 
 
 Etiology. — The chief causes of this and other forms of tonsillitis are 
 the local impairment of the epithelium of the crypts and the invasion 
 of certain pathogenic bacteria, as has been shown in the Tonsils as 
 Portals of Infection and the Clinical Anatomy of the Tonsil. There are 
 other factors which enter into the etiology, and they will be discussed in 
 the following analysis : 
 
 The Local Lesion of the Tonsil. — As shown by Goodale and Wright 
 the crypts of the tonsil are the seat of absorption for dust and micro- 
 organisms, whereas the surface epithelium of the tonsil has but little 
 part in this process. They have shown that dust, as carmine powder, is 
 readily absorbed through the healthy epithelium of the crypts, whereas 
 bacteria are not. Bacteria are only absorbed through dead or impaired 
 cryptic epithelium. Hence, the prime requisite for tonsillar infection 
 is an impairment of the cryptic epithelium. This condition may be 
 brought about by the retention of exfoliated epithelium and other 
 debris in the crypts of the tonsil. The retention is formed by the con- 
 striction of the mouths of crypts from previous inflammation, and by 
 the plica supratonsillaris and the plica tonsillaris which cover the 
 mouths of some of the crypts in such a manner as to prevent the expul- 
 sion of their contents. The toxin thrown out by the imprisoned micro- 
 organisms causes the death of the cryptic epithelium and thus opens 
 the way for 'the invasion of the microorganisms into the tonsil and the 
 general lymphatic and circulatory systems, hence the constitutional 
 symptoms in this disease. 
 
 The Bacteriology. — The bacteriology of acute tonsillitis embraces 
 several pathogenic microorganisms, including the Streptococcus pyogenes, 
 the Staphylococcus aureus and albus, the pneumococcus, and the lepto- 
 thrix. 
 
 Age. — The disease is most common in young adults between the 
 twentieth and thirtieth years of life. It is also common in children, and 
 more rare after the fortieth year of life. 
 
 Catching Cold. — Tonsillitis is frequently the immediate result of catch- 
 ing cold, though this is but one way in which the resistance may be 
 lowered, which favors the growth of the pathogenic bacteria. 
 
 Surgical Trauma.— The inflammations following surgical procedures 
 in the nose and epipharynx frequently extend to the tonsil, and are of 
 bacterial origin. 
 
PLATE VIII 
 
 Acute Lacunar Tonsillitis. 
 
 This di 
 
 30 may usually he cured by one application of a 90 per eenr 
 solution of the uitrate of silver. 
 
ACUTE LACUNAR TONSILLITIS 383 
 
 Specific Fevers. — Tonsillitis is often associated with the specific fevers, 
 such as scarlatina and diphtheria, and is of bacterial origin. 
 
 Pathology. — In acute lacunar tonsillitis the tonsil is swollen, though 
 the chief changes occur in the crypts, where there is an accumulation of 
 leukocytes and dead epithelial cells intermixed with pathogenic bacteria. 
 The transudation of leukocytes occurs chiefly through the cryptic mem- 
 brane rather than the surface mucosa. The accumulated material in 
 the crypts or lacunae is sometimes entangled in a fibrous exudate or 
 pseudomembrane, though the pseudomembrane is not always present. 
 
 Symptoms. — The Subjective Symptoms. — In this, as in other acute 
 infectious processes, the onset is sudden and is attended by malaise and 
 fever. Chilly sensations or light rigors may mark the attack. The 
 temperature gradually rises until the end of the first to the third day to 
 102° or 103°, and in young children it may rise as high as 104° to 105°. 
 The febrile movement is accompanied by soreness upon swallowing, 
 which as the disease progresses may become quite painful. The inflam- 
 mation extends to the pharyngeal mucous membrane, and even, in 
 exceptional cases, to the Eustachian tube and the middle ear. There 
 may be pain in the ear through reflex sources without actual inflam- 
 mation in the tympanum. Tinnitis may also be present. The gland 
 under the angle of the jaw is usually swollen and tender, as it is in a 
 state of great physiological activity in its attempt to check the invading 
 host of bacteria which has passed through the impaired epithelial barrier 
 in the crypts of the tonsil. The swollen condition of the tonsil and 
 surrounding muscles renders rotary motions of the head somewhat pain- 
 ful. The same condition also renders articulation and phonation imper- 
 fect, the voice being thick and indistinct. The tongue is coated with a 
 yellowish brown fur, and the breath is fetid and offensive. Transient 
 albuminuria is sometimes present, especially if the attack is severe and 
 prolonged. Casts may also be found in the urine. Such a condition is 
 common to all acute infectious processes in any part of the body, and do 
 not necessarily point to grave results. 
 
 The acute symptoms rarely extend beyond the third, fourth, or the 
 fifth day. The febrile movement and the swelling and soreness rapidly 
 subside until the temperature is normal and the act of deglutition and 
 the rotation of the head may be performed with comfort to the patient. 
 The patient, though convalescent, is often left in a very weakened 
 condition. 
 
 The Objective Symptoms. — At the onset the tonsils are swollen and red, 
 while the crypts may not present the characteristic yellowish furred 
 appearance, especially in the central and posterior aspects of the tonsil. 
 The pharyngeal mucosa and the pillars of the fauces are usually redder 
 than normal. At a later period the tonsil and pharynx are still more 
 swollen, and a creamy discharge is seen extruding from the mouths of 
 one or more of the crypts. The patches are not usually true mem- 
 branous products, as found in pseudomembranous and diphtheritic 
 inflammations, but are the secretions and debris which completely fill 
 the crypts. (Plate VIII.) 
 
384 
 
 THE PHARYNX AND FAUCES 
 
 Occasionally a fibrinous exudate is admixed with the debris, which 
 gives it some of the characteristics of an inflammatory membrane. 
 The protruding secretion and debris are easily wiped away, in contra- 
 distinction to the diphtheritic membrane, which is closely adherent to 
 the epithelium. 
 
 I have seen cases of diphtheria which closely resembled acute follicular 
 tonsillitis, inasmuch as the membrane was loosely attached, on account 
 of the solvent action of antitoxin administered eighteen to twenty-four 
 hours previously. 
 
 Pharyngeal and lingual tonsils are usually simultaneously inflamed 
 with the faucial tonsil, and the yellowish exudate or debris peculiar to the 
 faucial tonsil is found in the shallow crypts of the pharyngeal tonsil and 
 still more shallow depressions of the lingual tonsil. The debris is similar 
 in composition to that found in the crypts of the faucial tonsils. If the 
 febrile symptoms continue after the faucial tonsil appears to be well, the 
 pharyngeal and lingual tonsils should be examined with a laryngeal 
 mirror for evidences of inflammatory processes. 
 
 Complications and Sequelae. — Complications and sequela? are com- 
 paratively rare. The case usually ends favorably in seven or eight days, 
 though it may cause acute articular rheumatism, endocarditis (I know 
 of two such cases), and other affections remote from the tonsils. Under 
 appropriate treatment the duration of the disease is often much shorter 
 than this; one application of a strong aqueous solution of silver nitrate 
 often terminates the disease within a few hours. Occasionally, when 
 only one tonsil is diseased, the other is affected at the close of the first 
 attack. When this is the case the febrile and other symptoms are repeated. 
 The follicular inflammation is rarely followed by a phlegmonous inflam- 
 mation of the tonsil or of the peritonsillar tissue (quinsy). The cervical 
 glands, beginning with the one under the angle of the jaw, may sup- 
 purate. Purulent otitis media, pericarditis, pleuritis, erythema nodosum, 
 and erythema multiforme have been reported as sequelae of acute tonsil- 
 litis. Transient albuminuria is a rather common complication. 
 
 Diagnosis. — The following table will aid in the differential diagnosis 
 between acute lacunar tonsillitis and diphtheria, although there are cases 
 in which the differential points are obscure and dependence must be 
 placed upon the bacteriological findings: 
 
 Acute lacunar tonsillitis. 
 
 1. Onset marked by a sharp rise of tempera- 
 
 ture. 
 
 2. Rapid, bounding pulse. 
 
 3. Depression not marked. 
 
 4. Exudation limited to the tonsil, especially 
 
 the mouths of the crypts. 
 
 5. Exudate not adherent. 
 
 6. Exudate soft and friable. 
 
 7. Exudate not distinctly membranous. 
 
 8. Swollen glands uncommon except in severe 
 
 cases. • 
 
 9. Albuminuria not common. 
 10. Klebs-Loeffler bacillus absent. 
 
 Diphtheria. 
 
 1. Onset, rise more gradual. 
 
 2. Slow, feeble pulse. 
 
 3. Depression marked. 
 
 4. Exudation extends beyond the tonsils and 
 
 is not, limited to the crypts. 
 
 5. Exudate closely adherent. 
 
 6. Exudate firm and leathery. 
 
 7. Exudate membranous and may be re- 
 
 moved in strips. 
 
 8. Swollen glands common even in mild cases. 
 
 9. Albuminuria common. 
 
 10. Klebs-Loeffler bacillus present. 
 
ACUTE LACUNAR TONSILLITIS 385 
 
 I have seen cases in which repeated examinations failed to show the 
 Klebs-Loeffler bacilli, which were finally shown at subsequent exam- 
 inations. Absolute dependence must not, therefore, be placed upon 
 negative microscopic findings; if, however, the Klebs-Loeffler bacilli are 
 found, the case should be pronounced diphtheria, even though the clinical 
 phenomena do not corroborate the microscopic findings. 
 
 Treatment. — This type of tonsillitis is more amenable to treatment 
 than any other. One application of a 50 to 90 per cent, solution of 
 nitrate of silver, if applied locally during the first twenty-four hours 
 of the disease, will in nearly every instance abort the attack. I have 
 repeatedly used silver in this way, and upon the following day the 
 disease is under complete control. A second application is rarely 
 required. The febrile and other symptoms rapidly decline and convales- 
 cence is quickly established. This may appear to be an overstatement 
 of the facts, but it is in accordance with my experience. I have tried 
 other remedies, but none of them have equalled the nitrate of silver. 
 This strength of silver may appear to be caustic in action and unsuited 
 for the treatment of acute tonsillar inflammation. As a matter of fact, 
 it unites with the mucin so readily that its caustic action is greatly 
 diminished before it reaches the mucous membrane. It coagulates 
 the secretions and blanches the mucous membrane, thereby checking 
 the inflammatory infiltration of the tissues. It also entangles the patho- 
 genic bacteria in the albuminate of silver and prevents further activity on 
 their part. It appeals to me as an ideal remedy in the early stage of 
 the disease, and is worthy of extended trial. 
 
 In applying silver to the tonsil the excess of fluid should be squeezed 
 from the cotton-wound applicator to prevent it trickling to the larynx, 
 where it will produce violent spasm of the intrinsic muscles. The 
 silver salts are not well tolerated by the motor nerves and muscles 
 of the larynx, and severe suffocative symptoms may be produced by 
 inattention to the technique of its application. I have seen cases in 
 which severe cyanosis resulted from this cause. A little attention on 
 the part of the physician will obviate this distressing occurrence. 
 Guaiacol, 25 to 50 per cent, in olive oil, is the next most effective 
 remedy. It should be applied locally two or three times daily for two 
 days. The effect is very beneficial, though not so immediate as that 
 of the nitrate of silver. It produces a hot, peppery sensation for about 
 thirty seconds, followed by a sense of relief. 
 
 The carbonate of guaiacol given internally in 5 grain doses every 
 three hours exerts a very beneficial action upon the course of the disease. 
 
 The tincture of the chloride of iron in eight parts of glycerin given in 
 teaspoonful doses every two hours is another good remedy. 
 
 The salicylate of sodium, the benzoate of sodium, and the chlorate of 
 potash are also recommended, but the silver solution is so much superior 
 to either of the other remedies mentioned that it should be used in nearly 
 all cases to the exclusion of the other remedies. 
 
 A laxative followed by a saline cathartic should be given early in the 
 course of the disease. 
 25 
 
386 THE PHARYNX AND FAUCES 
 
 If there is a history of repeated attacks of acute lacunar tonsillitis, 
 the tonsils should be removed by complete dissection during the interval 
 between the attacks. This procedure alone offers a considerable hope 
 of permanent relief from the attacks and their more serious complications 
 and sequelae. 
 
 CHRONIC LACUNAR TONSILLITIS. 
 
 Definition. — Chronic lacunar tonsillitis is characterized by the pres- 
 ence of caseous material composed of layers of desquamated epithelial 
 cells inclosing cholesterin crystals, fatty matter, leukocytes, micro- 
 organisms, and occasionally calcareous deposits. The masses vary in 
 size from that of a grain of wheat to that of a small bean. The crypts 
 most often involved are those which open into the supratonsillar fossa 
 and those covered by the plica tonsillaris, for the reasons already given 
 in the Clinical Anatomy of the Tonsil. The tonsil may or may not be 
 hypertrophied, though it is generally in that condition. 
 
 Etiology. — One of the chief causes of the disease is the retention of 
 the desquamated epithelium, bacteria, and debris in the crypts, which 
 in turn is due in part to the anatomical barriers afforded by the plicae 
 supratonsillaris and tonsillaris. In addition to this there is a diseased 
 condition of the epithelium lining the crypts, due to previous acute 
 inflammations. This disease usually occurs in adults. 
 
 Symptoms. — The subjective symptoms are not usually severe in 
 character. The patient may complain of pain upon swallowing saliva, 
 but not upon swallowing solid food (Ball). Neuralgic pains sometimes 
 shoot toward the ear. Some patients have the sensation, lasting perhaps 
 for only a minute or two, of a foreign body lodged in the tonsil. 
 
 The objective symptoms are more marked and characteristic than 
 the subjective ones. The patient coughs up the caseous masses, which 
 have a fetid odor, and he consults a physician, who upon examination 
 notes the fetid breath and the yellowish masses in the crypts of the 
 tonsil. Upon exerting pressure upon the tonsil with a flat instrument 
 the caseous masses are forced from the crypts. If they are full to over- 
 flowing, the yellowish spots appear at the mouths of the crypts much 
 as they do in the acute form of the disease. 
 
 The tonsils are usually enlarged, and are often greater than they appear 
 to be upon superficial examination, as they are covered by the plica 
 triangularis and plica supratonsillaris; indeed, some of the largest tonsils 
 I have ever removed were thus concealed from view. The plica tonsil- 
 laris is not an "adhesion" or inflammatory product, as some authors 
 state, but is an embryological structure, as stated in the section on the 
 Clinical Anatomy of the Tonsil. When the anterior and median surfaces 
 of the tonsil are completely covered by an unusually large plica tonsil- 
 laris, the mouths of the crypts cannot be seen without a throat mirror, 
 or putting the patient "on the gag" (Pynchon). By resorting to the 
 latter of these expedients the tonsil is rotated forward so that its median 
 surface may be seen by direct inspection. A blunt tonsil hook intro- 
 
CALCULUS OF THE TONSIL 387 
 
 duced into the crypts or into the pocket formed by the union of the 
 plica tonsillaris with the tonsil will remove the caseous plugs and develop 
 the fetid odor to its full extent. 
 
 Occasionally the mouth of a crypt becomes closed by inflammatory 
 adhesions (caseous encyst), and the yellowish color shows through the 
 thin membranous covering over the mouth of the crypt. 
 
 A tonsil thus affected is subject to acute exacerbations, generally 
 of a mild type, the mucous membrane becoming slightly reddened. 
 There is also some soreness upon swallowing. The temperature is but 
 little elevated and attracts no attention. The patient sometimes com- 
 plains of slight huskiness of the voice, and has fits of coughing which 
 result from the local irritation in the tonsil. During these attacks he 
 often coughs up the caseous masses. The repeated removal of the plugs 
 affords some relief, and their tendency to reform is diminished, though 
 a cure by this procedure does not often occur. 
 
 Treatment. — If the symptoms annoy the patient, and recur at fre- 
 quent intervals, or if the patient has had rheumatism, enlarged glands 
 in the neck, or other evidences of infection in a remote part of the body, 
 which may reasonably be assigned to absorption through the tonsils, 
 they should be removed in their entirety. 
 
 Slitting the crypt walls, followed by the application of a 20 per cent, 
 solution of trichloracetic acid or of strong solution of iodine, has been 
 strongly advocated by Kauffmann and Holinger. Personally, I do not 
 recommend this mode of treatment, as it is, at the best, a makeshift and 
 fails to meet the fundamental requirements of the condition. The tonsil 
 crypts are diseased, chronically infected, and have a tendency to continue 
 in a diseased state. The rational procedure is, therefore, to remove 
 the tonsil completely, preferably with its capsule intact. (For a descrip- 
 tion of the operations, see Surgery of the Tonsils.) 
 
 CALCULUS OF THE TONSIL. 
 
 Small quantities of calcareous or gritty particles are often found in the 
 centre of the caseous plugs filling the crypts of the tonsil in chronic 
 lacunar tonsillitis. They sometimes become quite large and fill the 
 crypts, and are known as calculi of the tonsil. The etiology is not clear 
 beyond the fact that they are usually found in tonsils affected by chronic 
 inflammation. 
 
 Symptoms. — The symptoms are identical with those of chronic lacunar 
 tonsillitis with caseous plugs in the crypts. That is, there are recurrent 
 attacks of mild tonsillitis with redness which is especially marked around 
 the affected crypts. 
 
 Treatment. — The treatment consists in the removal of the calculus, or 
 the removal of the tonsil as in chronic lacunar tonsillitis. If the calculus 
 is not easily disengaged from the crypt, an incision of the wall of the 
 crypt facilitates its removal, rain may be obviated by injecting a 4 per 
 cent, solution of cocaine into the substance of the tonsil in the region of 
 the calculus. 
 
388 THE PHARYNX AND FAUCES 
 
 PHLEGMONOUS TONSILLITIS AND PERITONSILLITIS (QUINSY). 
 
 Phlegmonous tonsillitis is an acute abscess within the substance 
 of the tonsil, whereas peritonsillitis is an acute abscess in the peritonsillar 
 tissue. The processes are the same, but the location of the purulent 
 accumulation is different. Peritonsillar abscess, or peritonsillitis (quinsy) 
 is much more common than phlegmonous tonsillitis. 
 
 Etiology. — The causation is about the same as that given under acute 
 lacunar tonsillitis. 1 Peritonsillitis (quinsy) probably results from an 
 infection of the crypts in the supratonsillar fossa, which are large, slit- 
 like cavities with irregular outlines, and which are in intimate relation- 
 ship with the posterior and outer aspect of the tonsil. The disease is 
 common in young adults and rare in children. 
 
 Symptoms. — Phlegmonous tonsillitis is more rare and less severe 
 than peritonsillitis. Otherwise the symptoms are much the same. The 
 onset of the peritonsillitis is gradual, though there may have been a pre- 
 ceding acute lacunar tonsillitis with its sudden onset and severe symp- 
 toms. The temperature rarely exceeds 99° or 100°, whereas in acute 
 tonsillitis it often rises to 103°. 
 
 The pain progressively increases with the extension of the purulent 
 accumulation until it is almost unbearable. The muscles of mastication 
 are encroached upon by the abscess, hence the patient has the greatest 
 difficulty in opening the mouth sufficiently wide to permit of an examina- 
 tion of the throat. Swallowing becomes difficult and very painful. The 
 disease is usually limited to one side. The saliva dribbles from the 
 mouth and forms one of the characteristic symptoms. Lateral move- 
 ment of the head produces pain on account of the infiltration of the tissues 
 of the neck in the region of the tonsil. 
 
 Thick viscid secretion forms in the throat, and it is with the greatest 
 difficulty that the patient succeeds in removing it. The tongue is heavily 
 coated and the breath fetid. Breathing is interfered with on account 
 of the swollen mucous and submucous tissue of the pharynx. The 
 patient has an anxious expression of countenance. During sleep he 
 often has suffocative attacks which awaken him. Laryngeal dyspnea 
 from extension of the edema to the laryngeal tissue is fortunately rare. 
 
 Objective Symptoms. — At the onset there is slight redness and swelling 
 upon one side. Both tonsils are rarely affected at the same time. If 
 both are affected, the second usually begins as the first subsides. If both 
 are affected at once, the suffocative symptoms are more severe and 
 alarming. As the disease progresses the redness, tenderness, pain, and 
 swelling increase in severity. If the abscess is in the tonsil, it is pushed 
 toward the median line or even beyond it. If the abscess is in the peri- 
 tonsillar tissue, the swelling often appears to be in the region of the 
 upper portion of the anterior pillar. As a matter of fact, the apparent 
 swelling in this region is often the anterior border of the tonsil projected 
 against the pillar by the pus behind the tonsil. Incisions in this region 
 often fail to reach the pus cavity for this reason; that is, thejncision^is 
 
PHLEGMONOUS TONSILLITIS AND PERITONSILLITIS 389 
 
 carried directly into the tonsil instead of into the pus cavity outside 
 of the tonsil. If the depth of the incision is carried beyond the outer 
 border of the tonsil, the pus will be more often found. It should be 
 remembered that the anterior third of the tonsil projects forward beneath 
 the anterior pillar; hence, in making an incision through the anterior 
 pillar to evacuate the pus, it should be made far enough anteriorly to 
 escape the anterior border of the tonsil, and should be directed in an out- 
 ward and a backward direction, outside of the capsule of the tonsil. If 
 these anatomical facts are borne in mind, the anterior incision will nearly 
 always evacuate the pus. If a posterior incision is to be made, it should 
 be directed outward through the posterior pillar, or in its immediate 
 vicinity, as the pus pocket often extends posteriorly to the tonsil. 
 
 The soft palate and uvula, as well as the pharyngeal mucous mem- 
 brane, are red and edematous. The region of the tonsil is of a deep, 
 dusky red color. The crypts are often filled with a pulp-like debris, 
 which was probably the original source of infection. The infection does 
 not originate in the peritonsillar tissue, but in the supratonsillar crypts 
 of the tonsil. 
 
 Digital examination of the tonsillar region shows more or less distinct 
 fluctuation. The focal centre of fluctuation is sometimes located about 
 one-quarter of an inch external to the free border of the anterior pillar; 
 at the junction of the upper third with the middle third of the tonsil; or 
 it may be posterior to the tonsil. 
 
 The duration of the disease embraces from five to fourteen days when 
 allowed to run its course, though it may extend over a longer period. 
 The termination is marked by the spontaneous or artificial discharge 
 of fetid pus. When the discharge is spontaneous it usually takes place 
 through the anterior pillar, though it occasionally occurs through one 
 of the crypts. 
 
 Complications and Sequelae. — Complications and sequelre are rare. 
 Cases are on record, however, in which the following conditions were 
 present: 
 
 (a) Edema of the glottis from the downward extension of the process. 
 
 (6) Strangulation from the spontaneous rupture of the abscess. 
 
 (c) Ulceration thrombophlebitis of one of the large veins of the neck. 
 
 (d) Ulceration of one of the large arteries in the submaxillary region. 
 
 (e) Chronic peritonsillitis with an intermittent flow of pus (Ball). 
 (/) Encysted abscess in the tonsil. 
 
 Treatment. — The Onset. — If the case is seen early when infiltration 
 and redness of the mucous membrane and the deeper tissues are present, 
 but no pus, cold applied in the mouth or externally at the angle of the 
 jaw diminishes the pain, and, indeed, may abort the attack. Cold 
 may be applied internally by means of iced gargles or by sucking cracked 
 ice. It should be applied externally with a Leiter coil. It should be 
 borne in mind that cold applications are indicated in the early stage 
 of acute inflammation, whereas hot applications are indicated in the 
 later stages. In very acute inflammation proliferation and local leuko- 
 cytosis are active, whereas in the later stages cell proliferation and 
 
390 THE PHARYNX AND FAUCES 
 
 local leukocytosis are lessened, though the proliferated cells remain 
 permanently; hence, heat is indicated to increase the leukocytosis, as 
 the lymphocytes are needed to clear up the inflammatory products 
 and the polynuclear leukocytes to destroy the bacteria. 
 
 Pain may be relieved by the inhalation of hot vapors or steam, or by 
 the application of hot poultices or a hot Leiter coil to the neck and 
 angle of the jaw. Local applications of cocaine may also be used for the 
 same purpose. The leukodescent 500 candle-power lamp, when avail- 
 able, provides an excellent mode of treatment. The rays of the lamp 
 should be applied over the neck and angle of the jaw upon the affected 
 side. The lamp should first be moved over the neck a few times at a 
 distance of six inches, and then more slowly for ten to thirty minutes at 
 a distance of eighteen inches. Such treatments will relieve the pain and 
 reduce the swelling more readily and certainly than cold applications, 
 as they promote the reaction of inflammation and convert the passive 
 into an active congestion. 
 
 Fig. 258 
 
 The author's dissection back of the capsule of the tonsil to evacuate a peritonsillar abscess. The 
 dissection is started as though the tonsil were to be removed. 
 
 Surgical Treatment. — When the process is well established the evacua- 
 tion of the pus is imperatively indicated. The point of the incision 
 (in quinsy) should be determined by the location of the pouching or 
 fluctuation. It is usually in front of the anterior pillar on a level with 
 the junction of the upper and middle thirds of the tonsil, though it may 
 be in the posterior pillar or through the tonsil. Some recent writers 
 have advocated the posterior pillar as the most favorable site for the 
 incision, whereas most of the earlier authors recommend the anterior 
 pillar. As a matter of fact, many of the failures to evacuate the pus 
 through the anterior incision are due to a failure to take into account 
 the fact that the tonsil often extends forward beneath the anterior pillar. 
 The incision as usually made, therefore, penetrates the tonsil instead of 
 the tissue outside of it (Fig. 258). 
 
HYPERTROPHY OF THE TONSIL 391 
 
 The Author's Operation. — (a) Inject a 4 per cent, solution of cocaine 
 through the anterior pillar into the peritonsillar tissue. 
 
 (b) Seize the anterior portion of the tonsil with forceps and pull it 
 medianward and forward to reverse the position of the anterior pillar. 
 
 (c) Make an incision at the junction of the anterior pillar and the 
 tonsil, thereby separating the pillar from the tonsil. 
 
 (d) Introduce a blunt dissector through the incision and separate the 
 capsule of the tonsil from the superior constrictor muscle (bed of the 
 sinus tonsillaris) until the abscess cavity is reached. 
 
 This method of operating can never fail to evacuate the pus. Other 
 methods are inaccurate and are often attended with failure. 
 
 HYPERTROPHY OF THE TONSIL. 
 
 This subject is closely akin to chronic lacunar tonsillitis, as in that 
 disease the tonsil is nearly always hypertrophied. Likewise the hyper- 
 trophic tonsil is nearly always subject to chronic lacunar inflammation. 
 Nevertheless, it is practical to consider hypertrophy of the tonsil as a 
 separate entity, as there are certain general considerations which justify it. 
 
 Hypertrophy of the tonsil usually begins about the second year of 
 life and continues until young adulthood. Instances have been noted 
 in which the babe seemed to have been born with enlarged tonsils. It 
 is therefore occasionally congenital. While the hypertrophic process 
 may continue into young adult life, it generally ceases to develop actively 
 after puberty, and often seems to undergo an atrophic change. The 
 connective-tissue element develops in excess of the other structures and 
 the tonsil becomes firmer and firmer and shrinks on account of the con- 
 traction of the connective tissue. The difference between a child's 
 tonsil' and that of an adult is thus explained: In a child the enlargement 
 is due to an increase in all the cellular structures composing the tonsil, 
 whereas in an adult the connective-tissue cells are increased in excess of 
 the other cellular elements (hyperplasia). In a child the tonsil is soft 
 and smooth in outline, whereas in an adult it is often much harder and is 
 nodular in outline. In some children the hypertrophied tonsil is so loosely 
 attached to the sinus tonsillaris that it can be easily removed in its 
 entirety, with its capsule intact, with the tonsillotome. In others it is 
 more firmly attached, and the tonsillotome only removes the superficial 
 portion. In a few adults the tonsil is loosely attached, though it is ordin- 
 arily more firmly attached than in children. The exact size of the tonsil 
 is not always shown by the ordinary examination, as only the super- 
 ficial portion (median) is visible. The greater portion of the tonsil 
 may be hidden beneath the anterior pillar, the plica tonsillaris and the 
 plica supratonsillaris. Wilson has shown by the examination of a number 
 of cadavers that the average height of the tonsil above the margo supra- 
 tonsillaris is about h inch. Hence, too much importance should not be 
 attached to the apparent size of the tonsil. It should be palpated with 
 the index finger through the mouth, and its boundaries defined and its 
 
392 THE PHARYNX AND FAUCES 
 
 movability (degree of attachment) determined. In this way a good 
 idea of the degree of enlargement and the ease with which it may be 
 removed may be estimated. 
 
 The so-called submerged tonsil (Pynchon) is one that has undergone 
 fibroid changes and is hidden behind the anterior pillar and the plica 
 tonsillaris. Pynchon speaks of the plica tonsillaris as" an hypertrophy 
 of the free border of the anterior pillar," whereas it is a normal structure 
 appearing in embryonal life, and in some of the lower animals develops 
 into the tonsil itself. There is no muscular tissue in the plica tonsillaris, 
 and it should be removed with the tonsil. When it is left in place it may 
 form a pocket or pouch where food and other debris collect, and is the 
 source of considerable local irritation. 
 
 The hypertrophic and hyperplastic tonsils may have healthy crypts, 
 but, as a rule, the reverse is true. The lining epithelium of some of the 
 crypts is usually of low vitality, often hornified, and is unable to resist 
 the invasion of pathogenic microorganisms. During the transitional 
 stage between hypertrophy and hyperplasia of the tonsil, hyperkeratosis 
 of the cryptic epithelium may take place (hyperkeratosis of the tonsil). 
 The leptothrix (mycosis tonsillaris) is an adventitious complication 
 and not a disease per se (G. B. Wood). The hyperkeratosis is a self- 
 limited condition, and usually disappears spontaneously in from one to 
 three years. 
 
 If an hypertrophied or hyperplastic tonsil gives rise to untoward 
 local symptoms, to constitutional disturbances, or to local morbid lesions 
 in remote portions of the body, it should be removed in its entirety. 
 
 Treatment. — Palliative treatment directed toward the removal of 
 the caseous plugs from the crypts, and from the pocket formed by the 
 union of the plica tonsillaris with the tonsil, may be instituted when 
 for any reason an operation cannot be performed. The incision of the 
 crypt walls and the application of acids or iodine, as advocated by 
 Kauffmann, Ball, and others, may also be tried, but the best results are 
 obtained by the complete removal of the tonsil with its capsule intact. 
 
 HYPERKERATOSIS OF THE TONSIL; MYCOSIS LEPTOTHRICIA. 
 
 According to Dr. George B. Wood, Hyperkeratosis of the tonsillar 
 tissues of the throat is a disease, or, better, a condition, characterized by 
 the appearance of numerous white projections not only from the cryptal 
 orifices of the tonsils proper, but also from the orifices of the lymph fol- 
 licles on the posterior and lateral pharyngeal walls and on the lateral 
 glosso-epiglottidean folds. This condition does not occur on portions of 
 the throat where there is no lymphoid tissue. The lymphoid tissue of the 
 upper respiratory tract, however, is so ubiquitous that occasionally we 
 may see the little white projections on almost any part of the mucosa. In 
 the large majority of cases the condition is limited to the faucial and 
 lingual tonsils. That it reaches its greatest development on the base 
 of the tongue and at a position just behind the lateral glosso-epiglottidean 
 
HYPERKERATOSIS OF THE TONSIL 393 
 
 folds and the posterior part of the inferior poles of the tonsils is due almost 
 entirely to mechanical reasons. The contractions of the muscles during 
 swallowing prevent food from coming in intimate contact with the 
 surface of these parts, and therefore permit the projections to grow 
 undisturbed. Although the horny material is quite resistant to trauma, 
 the bacterial accumulations which form the greater mass of the projections 
 are easily brushed off, so that the size of the growth is much greater 
 where it is protected from mechanical disturbances. 
 
 The symptoms caused by this condition of the throat are either 
 entirely wanting or very slight, and are due for the greater part to the 
 local irritation caused by the hard, horny plug. If they project from the 
 base of the tongue so as to come in contact with the epiglottis, there is an 
 irritating tickling sensation which causes a hacking cough. If they are 
 so placed as to be compressed during the act of swallowing, they may 
 give rise to a slight pricking pain. 
 
 Hyperkeratosis. Showing the typical appearance under low power. The horny mass is growing 
 from a comparatively small area of the crypfal epithelium, and the plug shows the ordinary fraying 
 of its edges, a, crystal epithelium; b, horny material; c, masses of bacteria; d, follicles. (Wood.) 
 
 Occasionally among the rich and various bacterial flora which grow 
 in such luxuriance on this horny material there may lurk a germ pos- 
 sessed of more or less pathogenic power, which may set up an accom- 
 panying inflammatory reaction in the tonsil or surrounding structures. 
 Hence the relation which some observers have noticed between acute 
 tonsillitis and this disease. 
 
 Dr. Wood also says that to understand correctly the pathology and 
 the etiology of lacunar hyperkeratosis we must turn our attention for 
 a few moments to the anatomy of the normal active tonsil. The tonsil 
 
394 THE PHARYNX AND FAUCES 
 
 consists of four chief elements: the connective tissue, the germinating 
 follicles, the interfollicular tissue, and the crypts. 
 
 1. The connective tissue, that is, the trabecule or reticulum, acts as 
 a supporting framework to the tonsil substance proper. The trabec- 
 ular carry bloodvessels, nerves, and lymphatics. 
 
 2. The germinating follicles are the centres wherein the larger mother 
 cells of the leukocytic group undergo karyokinesis and form young 
 lymphoid cells. 
 
 3. The interfollicular tissue is made up of lymphoid cells in various 
 stages of development. The cells making up this interfollicular tissue 
 differ in size and shape according to their location. They are greater in 
 number around the follicles, and show greater difference in their ana- 
 tomical construction in the immediate neighborhood of the crypts. 
 
 Hyperkeratosis, faucial tonsils. This specimen is from a case which had been vigorously treated 
 with antiseptics. There are practically no microorganisms. The black staining is due to nitrate 
 of silver which has been used in treating the patient, a, intact cryptal epithelium; &, keratoid 
 plug. (Wood.) 
 
 4. The crypt of the tonsil is its peculiar and most characteristic struc- 
 ture. It consists of an invagination of the epithelium from the surface 
 of the tonsil, which has undergone a very interesting anatomical change. 
 In the first place the subepithelial connective tissue which is present in a 
 marked degree beneath the surface epithelium disappears as soon as the 
 epithelium starts to form the crypts. This permits the epithelial cells 
 to come in direct contact with the lymphatic structures of the tonsil, 
 and very frequently it is impossible to distinguish a dividing line between 
 the epithelium of the crypt and the interfollicular tissue. The epithelium 
 of the crypt, unlike its progenitor which covers the surface of the tonsil, 
 does not form a compact unbroken barrier or protection. For the greater 
 
HYPERKERATOSIS OF THE TONSIL 
 
 395 
 
 part of its extent it presents an intact line only one or two or possibly three 
 cells in thickness. Toward the parenchyma the epithelial cells show a 
 peculiar condition. They are separated from each other by interposed 
 cells varying in type from slightly changed epithelial cells to well- 
 formed lymphocytes. The epithelial cells may also extend from the 
 crypt into the tonsillar substance, suggesting the ramifications of a 
 malignant epithelioma. The smaller terminal invaginations of the 
 cryptal epithelium are usually solid sprouts, frequently with central 
 keratosed cores. The lumen of the crypt is formed by the subsequent 
 exfoliation of the keratosed cells. 
 
 Fig. 261 
 
 Hyperkeratosis. Cross-section of a crypt filled with keratoid material and bacteria, a, intact 
 epithelium; b, hornified cells; c, lymphoid tissue. (Wood.) 
 
 "Turning now to hyperkeratosis, we find the epithelium of the crypts 
 showing characteristic changes. In hyperkeratosis the epithelium loses 
 its rarefied condition and becomes ordinary pavement squamous epithe- 
 lium similar to that covering the surfaces of the tonsil, except that gener- 
 ally it does not show the connective-tissue papillae. The crypt of the 
 tonsil is markedly dilated and filled with a horny mass, which merges 
 at various points into the epithelium, though in sections stained with eosin 
 and thionin there seems to be a more or less distinct line where the epi- 
 thelial cells become keratosed. The living cell has a nucleus which stains 
 with thionin, and its protoplasm is of a purplish color, due to the mixed 
 staining with eosin and thionin. The keratosed material stains only 
 with eosin, and is, therefore, of a bright pink color. Occasionally in the 
 keratoid mass a very faintly stained nucleus is found, indicating that the 
 material of which the mass consists has been originally derived from 
 epithelial cells. 
 
 "According to the mechanical circumstances by which the tonsil 
 is surrounded, the horny mass becomes sooner or later broken up into 
 
396 
 
 THE PHARYNX AND FAUCES 
 
 layers, between which multiply and grow organisms of all varieties. This 
 fraying of the cryptal plug may take place within the crypt itself, so that 
 the resulting fissures permit the bacteria at times to penetrate almost 
 but not quite to the living epithelium. Mytotic figures may be seen 
 in the epithelium at different places, but especially along the border 
 toward the parenchyma of the tonsil. The epithelium is, therefore, in a 
 state of active growth. This eccentric growth, however, which results 
 in the formation of the keratoid plug, is not equally distributed to all 
 parts of the epithelial lining of the tonsillar crypts. Take, for instance, 
 a single individual crypt: a portion of the epithelium may still persist in 
 its normal condition of partial disintegration without a discernible border 
 line between it and the tonsil parenchyma; in another part the epithelium 
 may exist simply as a barrier of cells with a very thin layer of subepi- 
 thelial connective tissue, and again in the same crypt we may see the 
 hyperkeratosis in its most beautiful and characteristic appearance 
 
 Fig. 262 
 a 
 
 , „„. / - . ... „ 
 
 L^w^BfK^t - *y#.ya<a&i 
 
 Hyperkeratosis. Cross-section of the terminal portion of a crypt showing the concentric arrange- 
 ment of the layers of horny material and the epithelium, which is still somewhat disintegrated. 
 a, epithelium; b, horny material in crypts; c, lymphoid tissue. (Wood.) 
 
 "This change in the epithelium of the crypts is the characteristic patho- 
 logical feature of hyperkeratosis. Besides this there are generally other 
 changes in the tonsil. The connective tissue extends from the surface 
 epithelium for some distance down along the crypt. The follicles are 
 small and much less numerous, and the surrounding zone of lymphocytes 
 has become comparatively insignificant. The mitotic figures in the 
 follicles, though present, are less numerous, and the whole aspect of the 
 organ is one of suppressed activity. We sometimes find, however, 
 signs of local irritation in the immediate neighborhood of the crypts, 
 
HYPERKERATOSIS OF THE TONSIL 397 
 
 as evidenced by the outwandering of polymorphonuclear leukocytes 
 from the capillaries and their penetration between the cells of the cryptal 
 epithelium. This irritation is easy to understand when we consider 
 that the crypts contain a large number of saprophytes and probably 
 also pathogenic microorganisms growing actively and receiving their 
 nutriment from the accumulated keratosed cells. 
 
 "The toxins elaborated by these organisms must be absorbed to a 
 greater or less extent by the tonsillar tissue. It is probably due to the 
 fact that the cryptal epithelium has become an impact protective barrier 
 that a more noticeable reaction is not a common result." 
 
 Hyperkeratosis is a condition peculiar to young adults, and is self- 
 limited, from two to three years being required for it to run its course. 
 Treatment is unnecessary, though if the horny masses cause irritation 
 they may be removed by cauterization. The electrocautery should be 
 used to destroy them, and the surrounding tissues should be penetrated 
 until only healthy tissue remains. From three to four masses may be 
 thus treated at each sitting at intervals of one week. 
 
CHAPTER XXIII. 
 
 THE SURGERY OF THE TONSILS. 
 
 It is being more and more recognized that the complete enucleation 
 of the tonsil within its capsule is the most satisfactory method of dealing 
 with diseased tonsils. It is true that in a certain number of cases the 
 distressing symptoms yield to less radical measures, such as the applica- 
 tion of the cautery to the crypts, the incision of the crypts, the removal of 
 the retained debris from the crypts, and the partial removal of the tonsil. 
 I believe that if these cases were observed for a period of five or more years 
 it would be found that the tonsil is still the seat of diseased processes not 
 unlike those present before the operations above named. In addition 
 to the diseased conditions it would also be found that in some instances 
 the tonsillar tissue had grown again, oftentimes in greater bulk than 
 before the operation. 
 
 If, on the other hand, the tonsil is removed in its entirety with its 
 investing fibrous capsule, the diseased processes in the tonsillar fossa 
 and the tonsillar tissue will never recur. F. E. Hopkins, in a review 
 of the literature since 1856, found several recorded cases of recurrence, 
 chiefly before the year 1870, though instances of recent date were also 
 cited. His conclusion coincides with that of Sir Morrell Mackenzie, 
 Sir Felix Semon, and the author, that recurrence is nearly always due 
 to incomplete removal of the tonsil. D. Braden Kyle expresses the 
 opinion that some cases of apparent recurrence after excision of the 
 tonsil are, in reality, the regrowth of an adenoma, the tonsil having 
 taken on that type of benign neoplastic development. N. L. Wilson 
 says that the complete removal of the tonsil may be followed by an 
 inflammatory process in the tonsillar fossa, but that such processes will 
 not often be found after a period of two years subsequent to the operation. 
 Tuberculous and specific taints no doubt cause some of the recurrences 
 after tonsillotomy. 
 
 It seems to me, therefore, after considering all the data obtainable, 
 including my own experience, that many of the conditions heretofore 
 regarded as necessitating only cauterization, incision, partial removal, 
 etc., should be operated on by the complete method, whereby the entire 
 tonsil with its investing fibrous capsule is removed. 
 
 Indications for Operation. — In the following paragraphs it should be 
 remembered that the indications stated have special reference to the 
 complete operation technically known as tonsillectomy: 
 
 (a) Nasal catarrh and (6) diseases of the ear are sometimes true indi- 
 cations for tonsillectomy. Pynchon says: "In a goodly number of those 
 cases applying for treatment for nasal catarrh, or for ear disease, in which 
 
THE SURGERY OF THE TONSILS 399 
 
 a plainly apparent hypertrophy of the faucial tonsils does not exist, it will 
 be found upon close inspection that there is present a certain degree of 
 fauciaL fulness which is markedly increased by causing the patient to gag. 
 Among the embellishments of this every-day picture an abnormal faucial 
 redness is observed, gradually increasing in depth of color from the normal 
 pale pink of the lowest point of the pharynx disclosed by the use of the 
 tongue depressor. There will also be observed a tendency for frothy 
 saliva to adhere to the parts." The relationship between nasal catarrh 
 and tonsillar disease is not perfectly clear, while that between the tonsil 
 and the ear is more apparent, as the palatopharyngeus muscle extends 
 to the pharyngeal orifice of the Eustachian tube, and inflammation 
 of the tonsils and pillars might readily extend along the pharyngo- 
 palatine fold to the mucosa of the tube and thence to the middle ear. 
 Repeated attacks of angina in this region may result in degeneration of 
 the palatopharyngeal muscle fibers and thus impair the muscular mech- 
 anism that controls the patency of the tube. Again, infectious material in 
 inflammation of the tonsil may gain entrance to the tube and middle ear, 
 either during coughing or vomiting, or in intense inflammation by the 
 destruction of the cilia? of the epithelium of the tube. Ordinarily the 
 cilia? with their wave-like motion carry the secretions from the middle 
 ear to the epipharynx. When they are destroyed, or their action is 
 inhibited by violent inflammation, the entrance of foreign matter, as bac- 
 teria, etc., into the middle ear is comparatively easy. Hence, in certain 
 diseases of the ear which have their origin in tonsillar inflammations, the 
 removal of the tonsil is indicated. 
 
 (c) Recurrent attacks of tonsillitis, which are independent of aural or 
 pharyngeal complications, usually justify the enucleation of the tonsils. 
 The operation should not, of course, be done during one of the acute 
 manifestations, as to do so might give rise to severe infection of the 
 wound and deeper structures. 
 
 (d) By referring to Fig. 256 it will be seen that the tonsils drain into the 
 deep glands of the neck. When these glands are enlarged and tender, 
 the tonsils are usually the source of the infection, and if there is a his- 
 tory of repeated glandular involvement the tonsils should be excised. 
 
 (e) When the crypts of the tonsils are examined and they are found 
 more or less filled with debris and bacteria, tonsillectomy should be 
 considered. If the debris is removed with a tonsil hook or with a tonsil 
 syringe, the inflammation is temporarily relieved, but in most instances 
 it returns. If after repeated trials the inflammation recurs, tonsil- 
 lectomy is indicated. 
 
 (/) Laryngitis with attacks of hoarseness is often due to tonsillar disease, 
 hence the tonsils should always be examined; and if the crypts are 
 diseased or the tonsils are hypertrophied, the tonsils should be removed. 
 
 (g) Hypertrophy of the tonsils is an evidence of a disease process, 
 for in a perfectly normal throat they are of small size. There is a 
 divergence of opinion upon this point; some writers hold that the tonsil 
 is an organ of the body, while others believe it to be a pathological 
 entity. Bacterial infection when long continued causes either hyper- 
 
400 THE PHARYNX AND FAUCES 
 
 trophy or hyperplasia. When thus changed its function as a lymphatic 
 gland is impaired or lost, and the physical economy is best served by 
 its complete ablation. 
 
 (h) Chronic follicular tonsillitis is an indication for tonsillectomy, as 
 there is little likelihood of curing it by simpler methods. Even if the 
 crypts are closed by the use of the cautery, the low vitality of the tissue 
 predisposes to infection and inflammation. 
 
 (i) Follicular pharyngitis is, according to George Troup Maxwell, 
 often caused by a chronic suppurative follicular tonsillitis. He claims 
 that after the tonsils are removed the follicular pharyngitis disappears. 
 
 (j) Tuberculous infection often begins in the tonsils, and when such 
 a process is demonstrated or strongly suspected, the tonsils should be 
 enucleated. 
 
 (k) Recurrent acute articular rheumatism following acute tonsillitis 
 is an indication for tonsillectomy. 
 
 OPERATIONS ON THE TONSILS. 
 
 There are so many methods of operating upon the tonsils for the cure 
 or relief of the morbid conditions affecting them and the neighboring 
 structures and organs, that it is impracticable to attempt to describe 
 all of them. I shall, therefore, select those methods which appeal to 
 me x as the most rational from a clinical and surgical standpoint, and 
 which have, after long trial, given the best results. Some of the proce- 
 dures to be described are not recommended as the best, but under some 
 circumstances they must be resorted to as preliminary or tentative 
 measures. Hemophilia, the reluctance and refusal of the patient to 
 submit to what seems to be the best method will occasionally lead the 
 surgeon to elect the incomplete method of operating. Hence both com- 
 plete and incomplete operative procedures will be described, and their 
 comparative merits stated as fairly as possible. 
 
 Complete Operations. — By the term "complete operations," I mean 
 those surgical procedures whereby the faucial tonsil is removed in its 
 entirety, either en masse or piecemeal. Clinical observations have clearly 
 shown that any procedure short of this is often followed by little or no 
 permanent improvement in the conditions for which it was done. Numer- 
 ous cases are on record, and doubtless many more are unrecorded, in 
 which there was a continuation of the pathological processes, and recur- 
 rence of the tonsillar tissue after incomplete operations. 
 
 As has been stated in a precding paragraph, even after the complete 
 removal of the tonsil, the sinus tonsillaris is sometimes the seat of an 
 inflammation, but it rarely persists for more than two years. I can say 
 from a personal experience covering about CC00 cases in which the 
 tonsils were removed in their entirety with the investing capsule intact, 
 that such subsequent inflammations have been exceedingly rare, while 
 recurrence of the tonsillar tissue has never taken place. 
 
 On the other hand, I can refer to a larger number of cases in which I 
 
OPERATIONS ON THE TONSILS 401 
 
 performed an incomplete operation, or what is known as ''clipping the 
 tonsils," with a Mathieu's tonsillotome or other instrument, in which the 
 subsequent tonsillar inflammation occurred comparatively frequently. 
 
 It seems, therefore, that the time has come when a text-book should 
 clearly recommend the complete operations upon the tonsils as the ones 
 that should be used if it is at all expedient to do so, and that the incom- 
 plete operations should be resorted to only when the peculiar conditions 
 of the patient contra-indicate either of the complete methods, or when 
 other circumstances prevent their adoption. 
 
 The Author's Complete Operation with Right-angle Knife and Ecraseur. 
 — While every detail in the following technique is not original with me, the 
 operation as a whole has been my own creation, especially with reference 
 to the removal of the entire tonsil with its capsule intact. In most cases 
 the diseased tonsil is composed of three lobes, or masses, each with 
 an investing capsule, the three lobes being held together by a fibrous 
 envelope, or secondary enveloping capsule. For all practical purposes 
 the tonsil may be regarded as one mass with an investing capsule, and 
 as such it may be removed in its entirety. 
 
 (a) Anesthesia may be either local or general. Personally, I prefer 
 local anesthesia, except in those cases in which, for various reasons, the 
 patient cannot be operated upon in the conscious state. This is a matter 
 that must be decided by each surgeon, as the personal element enters so 
 largely into its consideration. 
 
 Local anesthesia may be induced by swabbing the tonsils and the faucial 
 arches at intervals of five minutes with an aqueous solution containing 
 10 per cent, of cocaine and 5 per cent, of carbolic acid. Both ingredients 
 produce blanching and anesthesia. From five to ten applications are 
 usually required to produce complete anesthesia. In some cases a single 
 application of a 20 per cent, solution of cocaine should be applied. The 
 frequent use of a 20 per cent, solution is quite likely to produce toxic 
 results. 
 
 Robert E. Moss called my attention to the hypodermic injection of 
 4 per cent, cocaine in a 1 to 2000 solution of adrenalin (first published 
 by Heitzmann) as a speedy and satisfactory method of inducing local 
 anesthesia in the tonsillar region. I have used it with great satisfaction 
 in a large number of cases. 
 
 The solution is made by adding 4 per cent, of cocaine to a 1 to 2000 
 solution of adrenalin. 
 
 The solution should be injected into the tissues surrounding the tonsil 
 rather than into the tonsil itself. For instance, it should be injected at 
 the upper, middle, and lower portions of both anterior and posterior 
 pillars respectively, and just above the supratonsillar space. About 
 1 minim of the solution should be injected at each point. Street's syringe 
 (Fig. 263) is well adapted to the purpose. 
 
 Anesthesia is thus immediate and the operation may be performed at 
 once. After the first tonsil is removed prepare the other in the same 
 manner. 
 
 The adrenalin prevents severe hemorrhage during the operation, 
 26 
 
402 
 
 THE PHARYNX AND FAUCES 
 
 provided it is not performed until the tissues are thoroughly blanched. 
 The blanching occurs in from five to fifteen minutes after the injections. 
 The position of the patient is a matter of some importance. Under 
 local anesthesia the upright position in the operating chair should be 
 used. Under general anesthesia the patient is placed upon the operating 
 table, with his head either over the end of the table in the Rose position, 
 or upon his side (Fig. 230), according to the preferene of the surgeon. 
 A mouth gag (Fig. 231) should be used if a general anesthetic is given. 
 
 Fig. 263 
 
 ^=3si> 
 
 Street's tonsil hypodermic syringe. 
 
 In the further description of the technique I will assume that the patient 
 is conscious and in the upright position. 
 
 (b) Seize the tonsil with the vulsellum forceps (Fig. 264); the tip of 
 one prong should be placed in the supratonsillar fossa, and the other at the 
 base of the tonsil. When they are thus placed they should be pushed 
 deep into the tissues, closed and locked. In this way they engage the 
 fibrous capsule or deep surface of the tonsil, and will not tear loose 
 except in young children when traction is made. 
 
 Fig. 264 
 
 The authors tonsil forceps. 
 
 When the blades are closed the bulk of the tonsil lies between the shanks 
 of the instrument, as shown in Fig. 265. This has a distinct advantage 
 over a superficial grasp of the tonsil, as it enables the surgeon to dissect 
 it with greater ease. It also enables the operator to bring the posterior 
 pillar into easy reach of the tonsil knife. 
 
 (c) Dissect the anterior pillar from the tonsil and carry the incision 
 above the margosupratonsillaris, or the supratonsillar space, to the 
 posterior pillar (Fig. 266). The aim should be to dissect around the 
 upper half of the tonsil, removing the mucous membrane forming the 
 roof or dome of the supratonsillar fossa. These details are important 
 if it is the intention to remove the tonsil with its fibrous capsule intact. 
 The incision thus assumes the form of an inverted U. The instrument 
 
OPERATIONS ON THE TONSILS 
 
 403 
 
 used is a right-angle knife. It should be hooked into the mucosa at the 
 junction of the anterior pillar with the plica triangularis (Fig. 266). 
 It is then pulled toward the median line of the throat, thus severing the 
 pillar from the plica triangularis and the tonsil. Reintroduce the hook 
 
 Fig. 265 
 
 The tonsil is grasped with the author's vulsellum tonsil forceps, the upper prong tips being placed 
 in the supratonsillar fossa, and the lower prong tips at the base of the tonsil; thus grasped the 
 tonsil is drawn toward the median line of the fauces preparatory to removal by dissection. 
 
 blade into the incision thus made and engage it as before, and pull 
 toward the median line. Two or three such cuts are required to bring 
 the incision above the supratonsillar fossa. While the foregoing incision 
 is being made the tonsil is in the grasp of the vulsellum forceps, and it is 
 pulled forcibly toward the median line. This stretches the pillar and 
 greatly facilitates its separation from the tonsil with the hook knife. 
 
 Fig. 266 
 
 The primary incision being made with the right-angle crypt knife. The knife is introduced 
 through the mucous membrane at the junction of the anterior pillar, and the plica triangularis 
 upon being pulled forward makes the incision B; the knife is again introduced through the incision 
 as shown (A) in the illustration. The incision is thus completed by three or four cuts with the 
 knife. 
 
 The posterior pillar should next be separated in much the same man- 
 ner. This pillar is not as accessible as the anterior one, but it can be 
 brought into view by rotating the handle of the vulsellum forceps, thereby 
 turning the tonsil upon its lateral axis in such a way as to bring the 
 
404 
 
 THE PHARYNX AND FAUCES 
 
 posterior pillar forward, where it is readily accessible to the hook knife 
 (Fig. 267). _ 
 
 The two incisions should be united above the margosupratonsillaris. 
 Observe carefully the margin of mucous membrane forming the roof of 
 the supratonsillar space and make the incision just above it. 
 
 The combined incisions are thus converted into an inverted U-shaped 
 incision. 
 
 Ftg. 267 
 
 Showing the direction of the posterior pillar from the tonsil with the right-angle knife. The 
 tonsil is turned forward upon its lateral axis with the author's vulsellum forceps to bring the pillar 
 upon the upper surface, where it is accessible to the knife. 
 
 (d) Again seize the tonsil with the vulsellum forceps, with the upper 
 prong tip introduced into the supratonsillar portion of the incision and 
 the lower prong tip at the base of the tonsil. The tonsil is thus well 
 within the grasp of the forceps and is ready for the dissection with the 
 hook knife. 
 
 Fig. 268 
 
 The tonsil in the process of dissection with Kyle's crypt knife. During the dissection the tonsil is 
 forcibly drawn toward the median line of the fauces with the author's vulsellum tonsil forceps 
 
 (e) Pull the tonsil toward the median line, thereby putting the fibers 
 attaching it to the superior constrictor muscle upon a tension. With 
 the hook knife sever the fibrous bands (Fig. 268), following the external 
 contour of the tonsil to its inferior portion. It may be necessary to dry 
 
OPERATIONS ON THE TONSILS 
 
 405 
 
 the wound during the operation, even though cocaine-adrenalin solution 
 has been injected. If anesthesia has been induced by brushing the 
 tonsil with cocaine without adrenalin the hemorrhage may be con- 
 siderable. 
 
 Fig. 269 
 
 The author's tonsil ecraseur, a substitute for the snare. 
 Fig. 270 
 
 «, the tonsil in the grasp of the author's tonsil forceps b; the upper half of the tonsil a has 
 been enucleated by dissection with its capsule intact. 
 
 (/) At this stage of the operation the use of the knife may be abandoned 
 and the author's ecraseur tonsillotome substituted (Fig. 269) to complete 
 the operation. This shortens the time of operation, though it may be 
 completed with the knife. 
 
406 
 
 THE PHARYNX AND FAUCES 
 
 (g) Pass the forceps through the ring blade of the ecraseur and seize 
 the tonsil, then pass the ecraseur over the tonsil as shown in Fig. 271. 
 Close the instrument and thus complete the operation. The dull ring 
 blade of the ecraseur readily passes behind the tough fibrous capsule 
 of the tonsil and makes a clean dissection of its lower portion. 
 
 The wire snare, on the contrary, tends to cut through the capsule and 
 leave the lower portion of the tonsil in situ. 
 
 Fig. 271 
 
 The final step of the tonsillectomy as performed with the author's tonsil ecraseur, a substitute 
 
 for the tonsil snare. 
 
 If hemorrhage follows the operation, it may be controlled by swabbing 
 the sinus tonsillaris with a solution of the permanganate of potash, J to 
 1 grain to the ounce of water. The peroxide of hydrogen may also be 
 used for the same purpose. Stronger remedies are rarely required. 
 Continuous gargling with iced water often controls it. Tonsil clamp 
 forceps (Figs. 272 and 273) need rarely be used. 
 
 Fig. 272 
 
 Pynchon's tonsil hemostat. 
 
 The advantage of the author's tonsil ecraseur over the tonsil snare 
 is, that it is always ready for use, whereas the wire of the snare needs 
 adjustment each time it is used. When two tonsils are to be removed, 
 the wire for the snare must either be straightened or another one inserted 
 
OPERATIONS OX THE TOXSILS 
 
 407 
 
 before the second tonsil can be removed. This is not true of the ecra- 
 seur, as it is always ready for use, like an ordinary tonsillotome. The 
 edge of the fenestrated blade is round, thus conforming to the cutting 
 
 Fig. 273 
 
 Boetcher's tonsil hemost-at. 
 
 surface of a wire. (Sharp blades are 
 also furnished with the instrument.) 
 If little hemorrhage follows dull 
 dissection, the ecraseur meets this 
 requirement. The same is true of 
 the cold-wire snare. After many 
 dissections with the ecraseur, I have 
 rarely known it to fail to complete 
 the dissection of the tonsil with its 
 capsule intact. 
 
 This method of removing the ton- 
 sil with its capsule intact, while not 
 based upon as good surgical tech- 
 nique as the author's method with 
 a scalpel, is easier for the average 
 operator to perform than the dis- 
 section with the scalpel. I prefer 
 dissection by means of the scalpel 
 because I can do it in much less 
 time, with less hemorrhage, and 
 less discomfort to the patient. I 
 also prefer this method, because I 
 believe the wound after a clean dis- 
 section with a sharp knife heals more 
 kindly and quickly than the wound 
 after dull dissection. 
 
 Tonsillectomy with a Scalpel. — The 
 Author's Operation. — After having 
 tried almost every known method 
 of removing tonsils in the adult, the 
 simplest of all instruments has been 
 the purpose. A common scalpel (Fig 
 the mastoid and abdominal incisions, 
 
 Fro. 274 
 
 Schema showing the points of injection of 
 adrenalin and cocaine solution preliminary to 
 the removal of the tonsil with its capsule in- 
 tact. About 2 minims of the solution is in- 
 jected at each point. If a y% gr. solution is 
 used (infiltration anesthesia) 2 drams should 
 be injected. 
 
 found to be the best adapted for 
 . 275), such as is used in making 
 is the instrument now used in all 
 
408 
 
 THE PHARYNX AND FAUCES 
 
 cases. 
 
 The only other instrument required is the vulsellum forceps 
 (Fig. 264). A tongue depressor is not used, as the forceps crosses the 
 tongue and keeps it out of the way. 
 
 Technique. — (a) Induce anesthesia by the injection of the cocaine- 
 adrenalin or the infiltration solution (Fig. 274). 
 
 Fig. 275 
 
 The author's tonsil knife. 
 
 (b) Seize the tonsil with vulsellum forceps, one blade in the supra- 
 tonsillar fossa, the other at its base, as in the preceding method. Pull 
 the tonsil medianward and forward to dislodge the anterior shoulder 
 from beneath the anterior pillar. This pulls the posterior margin of 
 the pillar forward and facilitates the introduction of the scalpel between 
 it and the tonsil. 
 
 Fig. 276 
 
 The first incision in the removal of the tonsil with its capsule intact. The tonsil is drawn forward 
 and medianward from the sinus tonsillaris. The incision is extended upward over the margo- 
 supratonsillaris to the posterior pillar. 
 
 (c) Introduce the blade of the scalpel to a depth of about one-half 
 inch between the anterior pillar and the tonsil at the junction of the 
 pillar and plica tonsillaris (Fig. 276). Sweep the blade upward to the 
 margosupratonsillaris, and thence over the margosupratonsillaris to 
 the posterior pillar (Fig. 277). The knife should be very sharp for this 
 purpose. This completely severs the tonsil from the anterior pillar and 
 exposes the outer aspect of it to further dissection. By including the 
 margosupratonsillaris in the incision the upper portion of the tonsil con- 
 cealed in the supratonsillar fossa is freed from its attachments. If this 
 step of the operation is not observed, the dissection is more difficult. 
 
OPERATIONS OX THE TONSILS 409 
 
 Casselberry called attention to the advantage of dividing the mucous 
 membrane along the margosupratonsillaris. He claimed that this 
 procedure rendered the liberation of the velar lobe, or supratonsillar 
 portion of the tonsil, much easier and more certain. Without knowing 
 of Casselbery's recommendation, I arrived at the same conclusion, 
 though my technique is quite different from his. 
 
 By my method the mucous membrane is divided at the junction of the 
 plica tonsillaris and the anterior pillar, and the incision is then extended 
 along the margosupratonsillaris to the posterior pillar, as shown in Fig. 
 277. If this preliminary incision is thus made, the subsequent steps of 
 the operation will be more easily accomplished; indeed, the dissection 
 of the tonsil is nearly consummated by this procedure alone. 
 
 Fig. 277 
 
 Anatomical landmarks of the fauces, n, b, ilie incision liberating the pillars in the removal 
 of t lie tonsil; c, plica tonsillaris; d, anterior pillar; e, supratonsillar slit-like crypts, or hilum 
 of the tonsil; /, supratonsillar fossa; g, margosupratonsillaris. 
 
 (d) Continue to pull upon the tonsil with the forceps. Then intro- 
 duce the knife through the upper part of the incision, follow closely the 
 capsule of the tonsil, and sever it from its attachment to the superior 
 constrictor muscle, as shown in Fig. 278. The branches of the tonsillar 
 artery are severed in this step of the operation. They are small and do 
 not often give rise to hemorrhage. If, however, some of the fibers of the 
 superior constrictor muscle are accidentally removed, the main stem of the 
 artery is severed and the hemorrhage may be severe. If the hemorrhage 
 is severe, the bleeding points should be seized and twisted with artery 
 forceps. The edge of the blade should be slightly turned to the tonsil, 
 as this will avoid injuring the superior constrictor muscle of the pharynx. 
 
 (e) Disengage the vulsellum forceps from the tonsil and place the tip 
 of one prong in the anterior aspect of the wound, the other over the inner 
 aspect of the tonsil, and close them upon the tonsil (Fig. 279). Tract the 
 anterior border of the tonsil toward the median line of the throat, using 
 the posterior pillar as a hinge. 
 
410 
 
 THE PHARYNX AND FAUCES 
 
 (/) Then, having rendered the posterior pillar accessible, shave it 
 free from the posterior border of the tonsil with the scalpel (Fig. 279). 
 Great care should be taken to avoid injuring the muscular tissue of either 
 the anterior or posterior pillars during the dissection. If the muscles 
 are not injured, there is little chance of hemorrhage from these regions, 
 as the artery is within the muscular substance of the pillars. 
 
 Fig. 278 
 
 The tonsil being separated from the^bed of the sinus tonsillaris to which it is loosely attached, 
 the capsule is followed closely with the author's scalpel, care being exercised to avoid injuring the 
 superior constrictor muscle which forms the bed of the sinus tonsillaris. 
 
 (g) The tonsil is now only attacked at its inferior portion. While 
 still pulling the tonsil toward the median line of the throat complete the 
 dissection by cutting downward and medianward. The tonsil is thus 
 removed with its capsule intact. The first incision separates the anterior 
 
 Fig. 279 
 
 The tonsil is drawn toward the median line of the throat to expose the posterior pillar to the 
 knife. The pillar is incised to the bottom of the tonsil at its junction with the tonsil. 
 
 pillar and the plica supratonsillaris from the anterior and superior 
 surfaces of the tonsil. The second separates the outer surface of the 
 tonsil from the superior constrictor muscle of the pharynx. The third 
 
OPERATIONS ON THE TONSILS 411 
 
 separates the posterior pillar from the corresponding border of the 
 tonsil. The fifth incision completes the dissection by freeing the inferior 
 attachment of the tonsil from the pharyngeal wall. 
 
 Since adopting this method of operating I have seen no alarming 
 hemorrhages except in a few instances, in which I injured some fibers of 
 the superior constrictor muscle of the pharynx. The hemorrhage was 
 primary and was easily controlled by a solution of permanganate of 
 potash (J gr. to the ounce of water). 
 
 Drs. J. C. Beck and John M. West have modified my operation by 
 first separating the posterior pillar with a right angle knife (Fig. 280), 
 as they believe that by so doing the blood will not so quickly obscure 
 the operative field. They separate the anterior pillar with a straight 
 scalpel and unite the two incisions above the margosupratonsillaris. 
 The remaining steps of the operation are similar to those described in 
 my scalpel operation. 
 
 Fig. 280 
 
 The Beck-West method of beginning the enucleation of ths tonsil, i. e., by separating the 
 
 posterior pillar. 
 
 The Complete Removal of the Tonsil with a Tonsillotome and Punch 
 Forceps. — This method of operating is the simplest way to remove the 
 entire tonsil, and is especially recommended for children. It is also 
 recommended to general practitioners and inexperienced throat surgeons 
 in both children and adults on account of its simplicity and thoroughness. 
 I have used it in hundreds of cases with complete satisfaction. 
 
 Technique. — (a) Induce cocaine anesthesia, as shown in Fig. 274. 
 
 (6) Remove as much of the tonsil with the tonsillotome (Fig. 281) as 
 possible. (See Tonsillotomy.) 
 
 (c) Remove the remaining substance of the tonsil with the Ruault, 
 Rhodes, or Farlow punch forceps. The forceps should have a heavy 
 female blade with a wide flange to push the pillars away from the male 
 or punch blade (Fig. 282). The closed forceps should be introduced 
 between the pillars with the cutting surfaces at right angles to the pillars, 
 as in this position they may be opened and closed without cutting the 
 pillars. If introduced with the cutting surface of the blades parallel 
 with the pillars, the pillars may be injured or cut away. When 
 properly placed the forceps should be forced into the sinus tonsillaris 
 
412 
 
 THE PHARYNX AND FAUCES 
 
 and opened and closed until the remainder of the tonsil is completely 
 removed. I use the Ruault forceps and exert from five to twenty pounds 
 pressure upon the shank of the instrument with the left hand while it is 
 in action. I have never injured the superior constrictor muscle with it 
 nor have I failed to remove all the remaining tonsillar tissue with it. 
 
 Fig. 281 
 
 Tonsillotome. 
 
 (d) When the punch forceps are removed the index finger should 
 be introduced into the wound to search for fragments of the tonsil. 
 These fragments feel firm to the touch and in sharp contrast to the 
 smooth and soft bed of the sinus. If fragments of the tonsil still remain 
 in situ, introduce the punch forceps and remove them. 
 
 (e) Having completed the operation, mop the sinus tonsillaris free of 
 blood and search for bleeding points. If found, seize them with an artery 
 forcep and twist them. 
 
 Fig. 282 
 
 The removal of the tonsil with Uie iiuault tonsil punch forceps after the preliminary 
 separation of the pillars. 
 
 Robertson's Operation. — Robertson's method of removing the tonsil is 
 as follows : (a) A general or local anesthetic may be used. 
 
 (b) The anterior and posterior pillars are first separated from the tonsil 
 with a curved double-edged knife, or, if the pillar is adherent, with his 
 pillar scissors. 
 
 (c) The tonsil is then grasped with forceps and pulled forward and 
 inward, the scissors pushing the pillars back out of the way. The scissors 
 are then closed and the tonsil removed by a series of cuts (Figs. 283 and 
 284). The tonsil upon the opposite side shows the position of the tonsil 
 before it was pulled from its sinus. 
 
OPERATIONS ON THE TONSILS 
 
 413 
 
 This operation may also be performed under local anesthesia, as in 
 the author's method. The tonsil may also be removed in its entirety 
 with its capsule intact by this method, though Robertson did not 
 advocate this until recently. The tonsil scissors are made in pairs to 
 adapt them to either side. This method of removing the tonsils is 
 thorough and commendable. The prime question in reference to any 
 operation on the tonsils is that of its completeness. 
 
 Pynchon's Cautery Dissection Operation. — According to Pynchon, this 
 method of removing the tonsil in its entirety possesses the advantages of 
 (a) but slight or no primary hemorrhage, and (6) the sealing of the wound 
 by the eschar, thus preventing severe infection of the wound. Dr. 
 Pynchon was the first to systematically remove the tonsil in its entirety, 
 he having done this for twenty-five years. He did not, however, attempt 
 to remove it with its capsule intact as I have done for ten years. 
 
 283 
 
 Robertson's tonsil scissors. The scissors are made in pairs. 
 
 Technique. — (a) Induce local anesthesia by repeated swabbings, 
 first with a 10 per cent, solution of cocaine, and then with a 20 per cent, 
 solution. To each solution of cocaine should be added one-half as much 
 carbolic acid as cocaine. If preferred, the anesthesia may be induced 
 by injecting cocaine and adrenalin or the infiltration solution. 
 
 (b) Seize the tonsil with mouse-toothed forceps at about its central 
 portion and pull it inward and backward, thus putting the plica tonsil- 
 laris and the anterior pillar upon a tension. This renders the anterior 
 border of the tonsil easily discernible. 
 
 (c) With a nearly straight cautery electrode at a cherrv-red heat 
 puncture the membrane at the junction of the anterior pillar and the 
 plica tonsillaris about one-third the distance from the top of the tonsil, 
 and dissect downward to the tongue. Then dissect upward over the 
 margosupratonsillaris and a little way down the posterior junction of 
 
414 
 
 THE PHARYNX AND FAUCES 
 
 the tonsil and pillar (Fig. 285). In other words, make the incision 
 shown in Fig. 277. 
 
 (d) With a nearly right-angle electrode (Fig. 285) complete the dis- 
 section of the posterior pillar from the tonsil. 
 
 Fig. 284 
 
 The removal of the tonsil with Robertson's scissors. 
 
 (e) Pull the top of the tonsil inward and downward, and dissect it, 
 with the electrode, from its attachment to the superior constrictor muscle, 
 
 thus freeing it from the sinus tonsillaris. 
 
 Fig. 285 
 
 The removal of the tonsil by cautery dissection by Pynchon's method. 
 
 (f) The remaining pedicle, at the base of the tonsil, is severed by 
 stretching it over the heated electrode. 
 
 (g) Only one tonsil is removed at a sitting, the remaining tonsil being 
 removed in about two weeks, or after the first wound has healed. 
 
OPERATIONS ON THE TONSILS 415 
 
 (h) Applications of a 20 to 30 per cent, aqueous solution of the 
 nitrate of silver may be made from time to time during the operation 
 to check oozing hemorrhage. 
 
 (i) The after-treatment should consist in the use of alkaline and 
 aromatic gargles and the daily application of the following mixture : 
 
 1^— Tr. iron, 
 
 Glycerin aa §j 
 
 The above mixture should be rubbed into the wound with a cotton- 
 wound applicator to prevent infection and exuberant granulations. The 
 wound should heal with a smooth surface and without the formation 
 of cicatricial bands. If the muscular tissue of the pillars is injured, 
 contracture and disagreeable deformity of the fauces may result. 
 
 Tonsillotomy. — The author has elsewhere expressed his views as to 
 the inadvisability of removing a portion of the tonsil, but inasmuch 
 as it is a time-honored procedure, and is likely for various reasons to 
 be practised in the future, it will be described in this chapter. 
 
 Technique. — (a) The operation may be done under either local cocaine 
 or infiltration or general anesthesia. 
 
 (b) If the subject is an infant or a young child, and the operation 
 is to be performed under either local or nitrous oxide gas or bromide of 
 ethyl anesthesia, he should be held in the lap of an assistant. He should 
 be wrapped in a sheet tightly pinned around his body and one arm, 
 while his head should be grasped by the assistant's left arm and hand. 
 The legs of the assistant should be crossed over those of the child to 
 prevent struggling during the operation. If a general anesthetic is 
 administered, one arm should be left exposed to test the pulse and the 
 muscular reflexes. 
 
 (c) A mouth gag may or may not be used, according to the discretion 
 of the operator. 
 
 (d) Depress the tongue with a tongue depressor to expose the tonsil 
 to full view. 
 
 (e) Introduce the tonsillotome into the mouth of the child, place the 
 ring blade over the tonsil, and forcibly push it outward, and at the same 
 time move the ring blade up and down to engage the tonsil. 
 
 (/) When the tonsil protrudes through the ring blade close the instru- 
 ment and thus cut off as much of the tonsil as happens to protrude 
 through it. 
 
 It occasionally happens that the entire tonsil with its capsule intact is 
 removed by this method of operating. More often only a portion of it 
 is removed. The upper portion is often quite inaccessible to the ring 
 knife, and as this usually contains the more diseased crypts the operation 
 is but partially effective. 
 
 The Complications and Sequelae of Operations on the Tonsils. — 
 Inasmuch as tonsillectomy is, or should be, performed as often in adults 
 as in children, the question of postoperative hemorrhage and of infection 
 becomes an important one. In children hemorrhage and infection of 
 
416 THE PHARYNX AND FAUCES 
 
 a severe type are rare, whereas in adults they are much more common, 
 on account o^ the larger development of the vessels and the greater 
 abundance of fibrous connective tissue, which offers less resistance to 
 microbic infection. 
 
 Hemorrhage. — (See page 378.) 
 
 Infection. — The infection following operations on the tonsils is usually 
 more severe and prolonged in adults than in children. In children 
 the temperature is elevated J° to 2° for two or more days, whereas 
 in adults it is often more highly elevated for from two days to a 
 week or more. The soreness in children is usually limited to three or 
 four days, while in adults it often continues longer. If the infection 
 were only thus manifested it would be a matter of small importance. 
 Unfortunately, it is occasionally so severe as to be alarming, even to the 
 point of actual danger to life itself. While I have never seen a case result 
 in death, I have seen a few assume alarming symptoms. That is, I have 
 seen two, in about 9000 cases, in which the hemorrhage was so prolonged 
 that marked anemia and exhaustion resulted, and two of severe sepsis 
 from streptococcus infection. 
 
 If the cases with secondary hemorrhage had been operated upon in the 
 hospital, the bleeding could have been more quickly controlled and the 
 danger averted, or, indeed, it might not have occurred, as the patients 
 would have remained quiet in bed. 
 
 In one of the septic cases the removal of the tonsils was done by partial 
 dissection and completed with a snare, whereas in the other case the 
 dissection was done with a sharp scalpel. In the latter case the infec- 
 tion was the more severe of the two, a fact which apparently controverts 
 my previous statement that a clean-cut dissection is less apt to be followed 
 by infection than a dull-cut or crushing dissection with a snare. In spite 
 of the apparent discrepancy, I wish to reaffirm my previous statement 
 that dissection with a sharp instrument is less likely to be followed by 
 severe secondary infection than one made with dull-cutting or crushing 
 instruments. Another factor which must be taken into account is the 
 virulence of the infective microorganism causing the infection. If a 
 virulent type of streptococcus is the infective agent, the resulting infection 
 and sepsis will be severe, no matter what method of dissection is used. 
 Crushed tissue is less resistant than tissue cut with a sharp instrument, 
 hence it is more readily infected, though either may be the seat of infec- 
 tion. The whole question is one of the microorganism on one side and 
 of the tone or resistance of the tissues on the other. If the resistance of 
 the tissue is normal and the virulence of the microorganisms are great, 
 infection will follow. If the resistance of the tissue is low and the viru- 
 lence of the microorganism is low, there may or may not be infection, 
 according to the balance or lack of balance existing between the resistance 
 of the tissues and the virulence of the infecting microorganisms. It 
 follows, therefore, that the question of infection is not wholly dependent 
 upon whether the dissection is performed with blunt or with sharp 
 instruments, but that the general tone of the tissues previous to the 
 operation, the local tone as affected by either blunt or sharp instruments, 
 
OPERATIONS ON THE TONSILS 417 
 
 and the virulence of the invading microorganism each has its influence 
 in determining the severity of the infection and the resulting sepsis. 
 
 The practical deductions to be drawn from the foregoing statements 
 are as follows : 
 
 1. If the patient's vital forces are low, tonics and fresh air should be 
 prescribed for some time before the operation. It is true that it is not 
 often advisable to delay the removal of the tonsil until the general tone 
 of the system is elevated, as the tonsils may be the direct cause of the 
 lowered vitality of the patient, and should be removed to stop the toxemia. 
 Under such circumstances the risk of the infection and sepsis must 
 be assumed, and such measures adopted as will avert or minimize the 
 intensity of the two processes. 
 
 2. The resistance of the tissues is influenced by the previous local 
 disease, and by the character of the dissection. The local changes due to 
 previous disease of the tonsil cannot, perhaps, be eliminated, and, in 
 so far as this factor is concerned, the operation must be performed in 
 spite of them. In so far as the tone of the local structures is affected by 
 the character of the dissection, this is entirely under the control of the 
 operator. He can avoid the use of crushing instruments by substituting 
 sharp ones. While this precaution will not always prevent infection 
 and sepsis, it will reduce the number and severity of the infections. 
 
 3. The virulence of the local microorganisms in the throat may be 
 determined before the operation by the adoption of the routine prac- 
 tice of making cultures from the tonsils. This is not always practicable, 
 but when it is it should be done. Another way of arriving at much 
 the same result is to carefully inspect the tonsil, especially the crypts 
 in the supratonsillar fossa and those covered by the plica tonsillaris, 
 and note the local signs of irritation and inflammation, especially redness 
 of the mucous membrane. Still further information may be obtained 
 by questioning the patient as to the presence of soreness or pricking upon 
 swallowing. If these signs are present, it is wise to defer the operation 
 until the crypts are cleaned out and the local irritation and inflammation 
 have subsided. 
 
 There is a possibility that severe infection may follow the removal of the 
 tonsils, even in cases in which there is no apparent inflammation. Viru- 
 lent germs may be lodged in the bottom of the crypts without giving 
 rise to obvious symptoms. Close inquiry may elicit the statement 
 that the patient has a slight soreness upon swallowing, a sensation 
 of pricking. In one such case in the author's practice a most violent 
 and obstinate infection occurred. The patient, a rhinologist, came for 
 the removal of his tonsils, and inasmuch as I presumed that he knew 
 whether his throat was in a proper condition for the operation, the tonsils 
 were removed. After the occurrence of the infection he told me that he 
 had been suffering for a week from a slight soreness or pricking in the 
 throat. These facts show that the surgeon should not presume anything, 
 even though the patient is supposedly well informed concerning his con- 
 dition. All cases should be subjected to close scrutiny by the surgeon 
 before performing an operation. 
 27 
 
418 THE PHARYNX AND FAUCES 
 
 Should the examination show such soreness to be present, the operation 
 should not be performed. The crypts of the tonsils should be cleansed 
 of all debris by syringing (Fig. 286) with warm normal salt solution. 
 A curved cotton applicator moistened with the tincture of iodine should 
 be introduced into each crypt to allay any infection and inflammation 
 in them. Treatment thus carried out for one week will usually pre- 
 pare the tonsils so that the operation may be performed without the 
 danger of infection of tonsillar origin. It is urged, therefore, that the 
 surgeon should always prepare the tonsils for operation, just as he would 
 in any other part of the body. The same rule should be applied to the 
 nose, throat, and larynx, even though these regions are not susceptible to 
 absolute surgical cleanliness. The breeding or incubating foci can at 
 least be eradicated. 
 
 The author's tonsil syringe. 
 
 Is Tonsillectomy a Hospital Operation? — In young children it is not 
 necessarily a hospital operation, because it is rarely followed by either 
 severe hemorrhage or sepsis. In adults it should be a hospital operation, 
 on account of the possible hemorrhage and sepsis. 
 
 A prominent surgeon has said that the tonsil is of greater clinical 
 importance than the appendix; that it causes more suffering and more 
 deaths. If this is true, and I believe it is, the tonsil is worthy of the most 
 serious and painstaking study. 
 
 The technique of its removal should receive the same careful and 
 patient attention that has been devoted to the removal of the vermiform 
 appendix. In view of the importance of the tonsil from a clinical stand- 
 point, and in view of the possible complications and sequelse following 
 its removal, tonsillectomy should be regarded as a hospital operation. 
 If performed in a hospital the danger from primary or secondary hemor- 
 rhage is largely eliminated, and infection and sepsis may be diminished 
 in severity and in the frequency of their occurrence. 
 
 George L. Richards and Charles Richardson advocate the complete 
 removal of the tonsils by finger dissection. The pillars are partially 
 separated with a knife of some description, the finger inserted into the 
 incision and the tonsil separated from the sinus tonsillaris. The fibrous 
 pedicle at the root of the tongue is then severed with a snare or tonsil- 
 lotome. While this method of enucleation is old it has awakened new 
 interest on account of the enthusiastic indorsement of these eminent 
 and practical laryngologists. 
 
CHAPTER XXIV. 
 
 NEOPLASMS OF THE TONSIL. 
 BENIGN NEOPLASMS OF THE TONSILS. 
 
 Benign tumors do not occur as often in the tonsils as they do elsewhere 
 in the pharynx. Of the variety found in this region, papilloma is the 
 most common. 
 
 Papilloma. — Papilloma is more often multiple than single, and presents 
 the general outlines of a bunch of grapes. If single and large, it may 
 be mistaken for a supernumerary tonsil. Like all papillomata it has 
 a tendency to return, and is sometimes apparently converted into a 
 malignant growth. It should, therefore, be removed by clean surgical 
 excision, rather than by a crude crushing method, as with a snare or dull 
 forceps. It should be borne in mind that the transition from a benign 
 papilloma to a malignant epithelioma is, histologically, rather easy. The 
 epithelial growth in the papilloma is outward, whereas in epithelioma 
 it is inward. There are, of course, other histological differences. The 
 structural arrangements are, however, so similar as to warrant a certain 
 amount of caution and discretion in their diagnosis and surgical treatment. 
 
 In some instances there may be one pedicle with many papillomata 
 attached, whereas in others there may be many pedicles. 
 
 The growths, as a rule, give rise to no marked symptoms. A slight 
 hacking cough, a tickling sensation, and the feeling of a foreign body in 
 the faucial region are complained of. The only change noted in the 
 surrounding tonsillar tissue is an increased hyperemia around the attach- 
 ment of the tumor. Pain is never present. The tumors vary in size 
 from that of a pea to a large walnut. 
 
 Lipoma. — Lipoma of the tonsil is rare, though Atkinson, Farlow, 
 Ingals, and others have reported cases. They are benign fatty tumors. 
 
 Angioma. — Angioma of the tonsil is also quite rare. Flatau, Phillips, 
 Bosworth, Keimer, and others have reported a few cases. 
 
 Treatment. — The treatment is preferably by electrolysis. The positive 
 pole should be applied by means of gold-plated needles thrust into the 
 neoplasm. The strength of the current should vary from 5 to 25 ma., and 
 should be applied for from two to twenty-five minutes at each seance. 
 Repeat the applications once or twice a week until the vascular growth 
 is obliterated. 
 
 Fibroma. — Fibroma of the tonsil is a benign neoplasm next in fre- 
 quency of occurrence to papilloma. It very rarely becomes malignant. 
 Its growth is very slow, and is usually limited to one tonsil. Delevan 
 and others have suggested that fibrous tumors of the tonsils mav be 
 
420 THE PHARYNX AND FAUCES 
 
 mistaken for supernumerary tonsils. This is especially true if the super- 
 numerary tonsil acquires its fibrous tissue from the degenerative changes 
 due to a constant irritation from its exposed position in the fauces. Tech- 
 nically it is a fibroplastic fibroma. Some claim that it is only a fibroma 
 which incorporates some of the lymphoid tissue of the tonsil. 
 
 Etiology. — Fibroma of the tonsil occurs equally often in each sex, and 
 perhaps more often in the young than in middle and advanced life. 
 
 Pathology. — Fibroma is usually somewhat pedunculated, though it 
 may be sessile. The larger the fibroma, the larger the pedicle. It is 
 more often single than multiple. Being of connective tissue of meso- 
 blastic origin, it must of necessity have its origin from the trabecular 
 of the tonsil. Occasionally it undergoes cystic degeneration. Usually 
 it is firm and scantily supplied with bloodvessels. It is composed of 
 white fibrous tissue, the cells often being matted together, closely simu- 
 lating embryonic connective-tissue cells. 
 
 Symptoms. — Annoying symptoms are seldom present, except in the 
 large pedunculated type, in which it produces mechanical obstruction. 
 Its presence is not accompanied by discharge. It is characterized by 
 symptoms similar to those of enlarged or hypertrophied tonsils. 
 
 Diagnosis. — The diagnosis is usually easily made, and in case of 
 doubt a portion should be excised and submitted to microscopic 
 examination. 
 
 Treatment. — The treatment is purely surgical and consists in its 
 removal, a procedure easily accomplished if the growth is pedunculated. 
 Occasionally it may be adherent to the tonsil or to the neighboring struc- 
 tures as a result of repeated inflammations of the tonsil. 
 
 Surgical Technique. — (a) Cocainize the growth and the area around 
 the point of attachment with a 10 per cent, solution of cocaine by 
 repeated swabbings. 
 
 (b) Separate the points of adhesion with a scalpel or scissors. 
 
 (c) Pass a cold-wire snare around the tumor, engaging it at its pedicle, 
 or point of attachment. 
 
 (d) Sever the pedicle by closing the wire loop. 
 
 (e) Cauterize the stump of the pedicle, and if it penetrates the tonsillar 
 tissue, dissect it to its point of origin. 
 
 (f) Frequent cleansing with some antiseptic gargle should be practised 
 for about one week, or until healing takes place. 
 
 (g) Instead of using the wire snare as given in (c), the growth may be 
 seized with the vulsellum or other toothed forceps and dissected with 
 a scalpel from its attachment to the tonsil, or the tonsil may also be 
 removed. 
 
 Fibro-enchondroma. — A few cases have been described, and notable 
 among them is that of Cosolini, in which the growth was as large as 
 an orange and was readily enucleated. Grosvenor also reported one 
 case. 
 
 Cystoma. — Cystoma of the tonsil is rare. It may be either super- 
 ficially or deeply situated. Virchow reports having found them post 
 mortem. I have occasionally found them of small size when enucleating 
 
MALIGNANT NEOPLASMS OF THE TONSILS 42.1 
 
 hypertrophied tonsils. They vary in size, and may contain a quantity 
 of fluid or a mass of inspissated secretions and epithelial debris. 
 
 They give rise to no peculiar symptoms other than those usually 
 present in enlarged tonsils. 
 
 They may be eradicated by freely incising them with a bistoury and 
 curetting the lining membrane,and then swabbing the cavity with pure 
 carbolic acid to excite reactionary inflammation and agglutination of 
 the opposed walls. A still better method of treatment is to enucleate 
 the tonsil as described under Tonsillectomy. 
 
 Lymphadenoma in Hodgkin's Disease. — In every case of Hodgkin's 
 disease it is advisable to examine the tonsils, as they may be the seat 
 of a lymphadenoma such as is present in other parts of the body. In 
 the early stage of the disease it may be impossible to assert positively 
 that the tonsils are involved, though they may appear abnormally en- 
 larged. In the author's case the tonsils did not appear to be enlarged. 
 By keeping the case under observation their growth may become ap- 
 parent, and when it occurs is quite significant. Lymphadenoma of 
 the tonsil is only a local expression of a disseminated lesion of a similar 
 nature throughout the general lymphatic system. In my case the tonsils 
 were not apparently involved, though the neck glands were enormously 
 enlarged. The case improved markedly under the application of the 
 Rontgen rays. 
 
 MALIGNANT NEOPLASMS OF THE TONSILS. 
 
 Carcinoma of the Throat. — According to some authorities carcinoma 
 is more frequently found in the tonsils than sarcoma, while others hold 
 the reverse opinion. More than 100 cases have been recorded, and 
 according to Bosworth it occurs once in every 2000 cases of carcinoma 
 in all parts of the body. It is a disease of middle and advanced age, 
 though J. D. Bryant reports a case in a patient aged seventeen years. 
 Sarcoma may occur at any age, but more often in early life. The young- 
 est case coming under my observation occurred at the eighteenth month. 
 Cases of sarcoma have been reported as late as the eightieth year. The 
 average age at which carcinoma develops is about the fifty-second year. 
 
 Carcinoma of the tonsil is more malignant than sarcoma because of 
 the histopathological predominance of glandular epithelium. It is 
 rarely primary, but is usually secondary to carcinoma of the tongue or 
 pillars of the fauces. It is usually characterized by a squamous and 
 spindle-cell epithelium. It does not attain the large size of sarcoma of 
 the tonsils, but it involves the neighboring lymphatic glands at an earlier 
 period. 
 
 Symptoms of Carcinoma.— Early ulceration, a fetid breath, more or less 
 pain of a lancinating character, emaciation, and cachexia are the usual 
 symptoms. Before ulceration the secretions are of a heavy mucous 
 nature, while after ulceration they are often purulent in character. Slight 
 hemorrhage is a frequent symptom. It may, however, in exceptional 
 
422 THE PHARYNX AND FAUCES 
 
 cases, be very profuse and cause death. Edema of the glottis is frequently 
 present; indeed, one might say it is an almost constant concomitant 
 complication of carcinoma of the tonsil in the advanced stage. 
 
 Pain is always aggravated during the act of swallowing, and the voice 
 is either hoarse or aphonic. Secondary glandular involvement is an 
 early feature. The subjective symptoms are very little different from 
 those of sarcoma of the same region, except in the advanced stage, when 
 ulceration and pain are present. 
 
 Diagnosis. — Carcinoma of the tonsil is a disease of middle and advanced 
 life, while sarcoma more often occurs in the young. Ulceration occurs 
 early in carcinoma and later in sarcoma; carcinoma is nodular, while 
 sarcoma is smooth and round. Carcinoma has a fleshy pink hue and 
 is often fungoid, while sarcoma is blue in color and is crossed by rather 
 large arteries. 
 
 When in a state of ulceration carcinoma may be mistaken for syphilis, 
 particularly if the adjacent glands are not much involved. 
 
 The progress of the case and the administration of the iodides will 
 soon clear the diagnosis. 
 
 The pain in carcinoma is lancinating and sharp, while it is dull and 
 periodic in sarcoma. 
 
 Papilloma is painless, pedunculated, seldom ulcerates, and secondary 
 involvements by direct extension of metastases do not occur. There are 
 no constitutional symptoms, and the growth is multiple and presents 
 the appearance of a bunch of grapes. 
 
 Fibroma of the tonsil has a constricted base, grows very slowly, is 
 free from pain and glandular involvement, and does not recur when 
 removed. 
 
 A microscopic examination of the tissue should be made in differen- 
 tiating the various types of tumors. 
 
 Differential Diagnosis of Sarcoma and Carcinoma of the Faucial Tonsils. 
 
 Sarcoma. Carcinoma. 
 
 1. Any age, most often after fifteen. 1. Not in early life, usually after forty. 
 
 2. Frequently primary. 2. Rarely primary. 
 
 3. Glandular involvement late. 3. Glandular involvement early. 
 
 4. Frequently encapsulated. 4. Not encapsulated. 
 
 5. Vascular, hemorrhages, ulcerates 5. Not so vascular, scant hemorrhage, 
 
 late. ulcerates early. 
 
 6. Frequent in males. 
 
 Treatment. — The treatment of carcinoma and sarcoma of the tonsil is 
 palliative and surgical, though in most cases the latter affords little 
 encouragement. 
 
 EXTIRPATION OF THE TONSIL BY THE EXTERNAL ROUTE. 
 
 In malignant disease of the tonsils where the surrounding tissues 
 have become involved it may become necessary to remove the tonsil by 
 the external route, by von Langenbeck's method. 
 
EXTIRPATION OF THE TONSIL BY THE EXTERNAL ROUTE 423 
 
 Technique. — (a) A general anesthetic should be given. 
 
 (6) The external incision is in the form of a U, thus making a tongue- 
 shaped flap (Fig. 287). The flap thus made lies immediately over the 
 ascending ramus of the lower jaw. This portion of the jaw is to be 
 temporarily resected, so as to expose the tonsillar region to operation. 
 
 (c) The external maxillary artery (facial) is ligated to control the 
 hemorrhage. 
 
 (d) The periosteum corresponding to the anterior incision should be 
 divided preparatory to sawing through the bone. 
 
 (e) The jaw bone is sawn through along the line of the periosteal 
 incision just in front of the insertion of the masseter muscle. 
 
 (/) The connective-tissue attachments of the ascending ramus of the 
 jaw on its inner surface are then carefully dissected from the bone, care 
 being exercised to avoid injuring the muscles of mastication. 
 
 (g) The ascending ramus of the jaw is then lifted outward and up- 
 ward, thereby exposing the region of the tumor to view (Fig. 287). 
 
 Fig. 287 
 
 The temporary resection of the ramus vi ihc inferior maxilla to expose the fauces in 
 the removal of malignant tumor of the tonsil. 
 
 (k) The tumor is then exposed by dissection. The external carotid 
 artery lies externally and posteriorly. 
 
 (i) The tumor should be removed with knife and scissors, care being 
 exercised to avoid opening into the cavity of the mouth until the last 
 moment, so as to keep the secretions from entering the wound. 
 
 (y) The ascending ramus of the jaw is then returned to its normal 
 position and sutured with wire. 
 
 (k) The skin is then sutured with horsehair or with Harris' buried 
 suture. 
 
 (/) The wound is dressed through the mouth, healing taking place 
 by granulation, as after an ordinary tonsillectomy. 
 
PART III. 
 DISEASES OF THE LARYNX 
 
 CHAPTER XXV. 
 
 INFLAMMATORY DISEASES OF THE LARYNX AND EPIGLOTTIS. 
 ACUTE INFECTIOUS EPIGLOTTITIS. 
 
 Synonyms. — Angina epiglottidea anterior (Michel); acute infectious 
 epiglottitis (Theisen). 
 
 The disease is often primary, and is an acute infectious process. Clem- 
 ent F. Theisen reports three cases, and gives a most admirable review 
 of the literature on the subject. Michel, in 1878, first described an 
 inflammatory process, involving the anterior surface of the epiglottis, 
 under this name. It is usually accompanied by more or less circumscribed 
 edema. While the larynx may be somewhat involved in some cases, 
 Theisen claims that true angina epiglottidea occurs quite often as a 
 primary, separate, distinct condition. 
 
 Etiology. — In the diffuse type of inflammation the epiglottis may 
 become inflamed by an extension from acute tonsillitis, pharyngitis, or 
 lingual tonsillitis. In the true primary type its origin is not thus ex- 
 plained. In the cases reported by Theisen there was no history of coryza, 
 or other acute infectious condition of the upper respiratory tract. The 
 larynx was but slightly involved. The ages of the patients were thirty- 
 six, forty, and fifty-nine years respectively, one male and two females. 
 Hajek's experiments show that the submucosa of the anterior surface 
 of the epiglottis is abundant and the mucosa loosely adherent, while 
 on the laryngeal surface it is tightly adherent to the cartilage except 
 at the nodules, where there is some loose submucous tissue. These 
 anatomical facts explain why the edema does not extend to the larynx, 
 as one might at first expect it would do. In excessive edema it may, 
 however, extend to the larynx by way of the submucous tissue of the 
 pharyngo-epiglottic ligament, thence to the aryepiglottic folds. Injury 
 to the epiglottis or the neighboring tissue by swallowing foreign bodies 
 or irritating substances may cause the condition. Hot drinks, raw 
 spirits, or highly spiced liquids may also be regarded as possible predis- 
 posing etiological factors. In edema of the fauces due to large doses of 
 
426 DISEASES OF THE LARYNX 
 
 the iodide of potash the epiglottis may become involved. The infectious 
 fevers are also likely to give rise to this distressing condition. 
 
 Perichondritis, carcinoma, and ulcerative conditions due to syphilis 
 or tuberculosis may suddenly become complicated by it. 
 
 Bacteriological examinations made in 2 of Theisen's cases showed 
 Streptococcus aureus and pneumococcus in 1, and Staphylococcus albus 
 and pneumococcus in the other. The atrium of infection in some in- 
 stances seems to be a traumatic wound, in others it is an extension of 
 an acute inflammation from contiguous anatomical parts, and in a third 
 class it is a malignant tuberculous or syphilitic ulcer. The chief cause, 
 then, is a mixed infection, which may or may not be preceded by a gross 
 lesion of the anterior surface of the epiglottis. 
 
 Pathology. — From what has been given under Etiology and Symp- 
 tomatology, it may be inferred that the pathology is such as is common 
 to acute inflammation of mucous membranes covering loose submucous 
 tissue. This consists of inflammatory congestion, exudation, and edema, 
 which processes, in typical cases, are limited to the anterior surface of the 
 epiglottis. The bacteriological infection is usually the pneumococcus 
 with the Streptococcus aureus or the Staphylococcus albus. 
 
 Symptoms. — The onset is sudden and attended with fever, painful 
 deglutition, stiff, swollen tongue, and dyspnea, especially upon lying down. 
 In one case reported by Theisen the latter symptom was so severe as 
 to necessitate propping the patient up in bed. 
 
 The febrile symptoms are similar to infectious fevers in general. 
 
 Upon examination the anterior surface of the epiglottis is red and 
 swollen, while the adjacent tissues are usually but little, if at all, involved. 
 These symptoms continue with more or less severity for five or six days, 
 when they abate in intensity; the epiglottis, however, remains red and 
 swollen a few days longer. 
 
 Diagnosis. — If certain characteristic symptoms are borne in mind, 
 there need be but little difficulty in arriving at a correct diagnosis. These 
 symptoms are: (a) Sudden onset, (b) A febrile movement, (c) Red- 
 ness and swelling limited to the anterior or lingual surface of the epi- 
 glottis, (d) More or less painful deglutition. 
 
 Acute angioneurotic edema is unattended by fever, and the edematous 
 tissue is pearly gray instead of red. 
 
 It should be differentiated from acute miasmatic epiglottitis, which 
 follows exposure to salt marshes, as in hunting for ducks on the mud 
 flats of the California coast. Arnold has described this condition in 
 Burnett's system on the Nose, Throat, and Ear. (See Acute Miasmatic 
 Epiglottitis.) 
 
 Prognosis. — The prognosis in most cases is good, although deaths 
 have been reported by Tompkins, Louis, Gibb, Crisp, and Fredet. 
 Proper treatment exerts a favorable influence upon its course. 
 
 Treatment. — Early scarification of the edematous parts gives prompt 
 relief in some instances. It should be done freely. Meyjer recommends 
 the use of iced ichthyol sprays, which are prepared by putting cracked 
 ice into the spray tube containing the ichthyol solution. Theisen speaks 
 
ACUTE CATARRHAL LARYNGITIS 427 
 
 of using a 0.5 per cent, solution of ichthyol every twenty to thirty minutes 
 while the acute symptoms continue, and at longer intervals afterward. 
 It is important to give early relief, as the patient may not be able to 
 swallow even liquid food until this is done. Calomel and salines may 
 be given advantageously at the onset. 
 
 The physician should be prepared to do tracheotomy at any moment, 
 as suffocative symptoms may suddenly develop. 
 
 MIASMATIC EPIGLOTTITIS. 
 
 Arnold, in Burnett's System, describes an acute inflammatory process 
 which chiefly involves the epiglottis. It is attended by marked edema 
 of the epiglottis, painful swallowing (odynophagia), and dyspnea. 
 
 Etiology. — He attributes the cause "to some animal, vegetable, or 
 chemical poison in the exhalations of the salt marshes." He describes 
 six cases, all of which were men who had returned from hunting ducks 
 on the mud flats of the salt marshes on the California coast. It is 
 probable that the cases were due to a mixed infection from some nidus 
 of propagation in the marsh country along the coast. Whether the cases 
 should stand apart as illustrative of a separate and distinct disease is 
 perhaps doubtful. 
 
 Symptoms. — Epiglottic edema and inflammation may be severe, and 
 the adjacent structures somewhat involved. There is odynophagia 
 and dyspnea. In one case the suffocative symptoms became so alarming 
 that tracheotomy was performed. Pyrexia is more or less marked. 
 
 ACUTE CATARRHAL LARYNGITIS. 
 
 Synonyms. — Catarrhal laryngitis; acute catarrh of the larynx; simple 
 laryngitis; laryngitis catarrhalis acuta. 
 
 Acute catarrhal laryngitis is an acute catarrhal inflammation of the 
 laryngeal mucosa and of the vocal cords. It is characterized by hoarse- 
 ness or aphonia, and pain upon phonation. 
 
 Etiology. — The etiology of acute catarrhal laryngitis may be studied 
 under: (1) Systemic disturbances and diseases; (2) preexisting diseases 
 of the upper respiratory tract; (3) hygienic conditions and environment; 
 (4) traumatism; (5) age; (6) climate; (7) idiopathic causes. 
 
 1. Systemic Disturbances. — Systemic disturbances, such as "catching 
 cold," arthritis, the eruptive specific fevers, syphilis, and tuberculosis, 
 play an important role in the causation of catarrhal inflammations of the 
 larynx. "Catching cold" is a complex process difficult to explain, but in 
 general it may be said to include a lack of balance of the vasomotor nerves, 
 whereby the capillary vessels are erratically controlled. Increased 
 vascularity, or congestion, is thus a common disturbance. According to 
 Woakes and J. A. Stucky, the phenomena of "catching cold" are due to 
 digestive disturbances and the final results thereof, e. g., toxic products 
 
428 DISEASES OF THE LARYNX 
 
 in the circulation, which irritate the vasomotor nerves, thus establishing 
 a predisposition to " catching cold." Clinical observation seems to sup- 
 port the above theory in that acute laryngitis quite often follows or 
 accompanies digestive disorders. Arthritis also seems to have a causa- 
 tive relation to laryngitis, and, inasmuch as it is an inflammatory dis- 
 ease of infectious origin, it is easy to appreciate the fact that certain 
 toxins are in the circulation and affect the tonicity of the vasomotor 
 system, very much as in acute coryza, or "catching cold." The toxins of 
 syphilis and tuberculosis likewise irritate and disturb the vocal apparatus. 
 In addition, the pathological lesions are often localized in the larynx, and 
 are specific in character. The exanthematous or eruptive fevers are 
 often accompanied or followed by laryngitis. The specific microorgan- 
 isms peculiar to these diseases are especially profuse in the upper respira- 
 tory tract; indeed, they probably gain entrance to the system through 
 the mucosa of the nose and throat when the resistance is lowered, espe- 
 cially through the tonsils and adenoids; hence, the mucosa of the larynx 
 is subjected to the direct irritation from their presence, as well as to the 
 toxins in the blood. 
 
 2. Preexisting Diseases. — Preexisting diseases of the upper respiratory 
 tract are important predisposing etiological factors in laryngitis. This 
 is especially true in reference to diseases of the sinus, nasal stenosis, and 
 infectious inflammations of the tonsils. It may be stated as an axiom 
 that inflammatory processes in one part of the upper respiratory tract tend 
 to extend to contiguous parts. This is in part explained by the extension 
 by continuity of tissue, and in part by the simultaneous exposure of the 
 various structures to microbic and toxic irritation. The most vulnerable 
 area is first affected, the contiguous parts later becoming involved. The 
 tendency is for the inflammatory process to extend downward rather than 
 upward, probably because the flow of the lymph streams is in that direc- 
 tion. It is true, however, that there is a marked hesitancy in the down- 
 ward extension from the nose to the larynx. This is explained by the 
 difference in the character of the epithelium covering the mesopharynx. 
 Nearly the whole of the mucosa of the upper respiratory tract, except 
 the mesopharynx, is covered with ciliated columnar epithelium, whereas 
 the mesopharynx is covered with squamous epithelium. Inflammatory 
 processes do not readily extend from one kind of tissue to another, hence 
 the hesitancy. If, however, the nasal inflammation is severe and pro- 
 longed, or often repeated, the inflammation finally reaches the larynx. 
 Indeed, the "dropping" into the hypopharynx often leads to catarrhal 
 inflammation of the larynx by lowering the resistance of the laryngeal 
 mucosa, which subsequently becomes infected. In sphenoidal and 
 posterior ethmoidal sinuitis the secretion and the exudate are discharged 
 into the epipharynx and drop or trickle down the walls of the meso- 
 pharynx to the upper surface of the larynx, thus irritating its mucosa. 
 The mucous membrane of the larynx becomes lowered in resistance, and 
 infection and inflammation follow. In obstructive deflections of the 
 septum the respiratory functions of the nose, namely, moistening, warm- 
 ing, and filtering the air, are impaired. The pharyngeal and the laryn- 
 
ACUTE CATARRHAL LARYNGITIS 429 
 
 geal mucous membrane are, therefore, subjected to air that is irritating to 
 them. This in time causes lowered resistance, infection, and laryngitis. 
 
 We may say, then, in a general way, that diseases of the respiratory 
 tract above the larynx often predispose to catarrhal inflammations of the 
 larynx by (a) extension or continuity of tissue; (b) by contiguity of tissue; 
 (c) by lymphatic communication; (d) by irritation and lowered resistance 
 from secretions from the nose and accessory sinuses; (e) by simultaneous 
 exposure of the entire upper respiratory tract to microbic infection; 
 and (/) by the irritation from the toxins evolved by the bacteria in the 
 nose, the accessory sinuses, the epipharynx, and the tonsils. The chief 
 barrier to the downward inflammatory extension is in the squamous epi- 
 thelium of the mesopharynx. 
 
 3. Hygienic Conditions and Environment. — Under hygienic conditions 
 and environment as causative agents in catarrhal laryngitis are included 
 (a) the inhalation of noxious gases; (6) poor ventilation; (c) undue 
 exposure of feet and body; (d) improper bathing; and (e) the abuse of 
 the voice. 
 
 The inhalation of noxious gases, as in chemical laboratories, factories, 
 etc., may cause laryngitis by direct irritation, or it may lower the resist- 
 ance of the tissues and predispose to infection. Poor ventilation likewise 
 causes laryngitis, though not by direct irritation. In the latter instance 
 the vital energy is lowered by breathing impure air. Then, too, the 
 oxygen in the air is diminished in quantity. The vitiated atmosphere 
 irritates the endothelial lining of the air vesicles, and thereby causes 
 changes which interfere with the absorption of oxygen into the blood and 
 the expulsion of carbonic acid gas from the blood. These factors corn- 
 bins to deprive the patient of the normal amount of oxygen, and lead to 
 an overaccumulation of carbonic acid gas. The processes of metabolism 
 are thus deranged, and toxemia results. The vital energies are lowered, 
 and the patient is in prime condition to be affected by bacterial infection 
 and inflammation. Undue exposure of the body, especially the feet, is a 
 prolific exciting cause of laryngeal inflammation. The large vessels of 
 the feet give off large quantities of heat when the soles are insufficiently 
 protected from the cold ground. When this occurs there is a shock 
 to the terminal vascular system, which causes a lack of balance of the 
 physiological functions of the more delicate structures of the body. 
 The larynx in some cases is the vulnerable point, and reacts in the form 
 of a catarrhal laryngitis. The question of clothing is discussed more 
 fully under the etiology of the nasal inflammations. Suffice it to say, 
 therefore, that there is danger in an excessive amount of clothing, as well 
 as in too little. One accustomed to living in an open, poorly constructed 
 residence, and changing to a well-built city residence, which is over- 
 heated and poorly ventilated, is especially subject to catarrhal inflamma- 
 tions of the upper air passages. 
 
 Bathing, when judiciously practised, is a healthful and invigorating 
 procedure. When, on the contrary, it is injudiciously practised, it may 
 cause considerable mischief to the upper respiratory tract. What is good 
 practice for one may be bad for another. Hard-and-fast rules cannot be 
 
430 DISEASES OF THE LARYNX 
 
 laid down. For some a cold plunge or shower bath after a warm bath 
 is invigorating, while for others it throws them into a mild state of shock 
 from which they do not quickly react. A Turkish bath is often a harmful 
 procedure unless the bather remains for some hours in rooms of gradually 
 diminished temperature. Hyperemia of the superficial vessels is induced, 
 and if the bather goes out into the open air before the circulatory balance 
 is restored, he is likely to " catch cold." The abuse of the vocal apparatus 
 in singing and speaking disturbs the circulatory poise, and by mechanical 
 irritation excites inflammation of the cords and the mucous membrane. 
 
 4. Traumatism. — Chemical or mechanical injury of the cords or 
 adjacent mucous membrane may cause laryngitis. 
 
 5. Age. — Laryngitis is more common in young adults. 
 
 6. Climate. — Laryngitis is more common in the temperate zones, espe- 
 cially during the early spring and late autumn months, as the weather 
 conditions are very changeable, 
 
 7. Idiopathic. — In some cases the cause is unknown. In such cases 
 it is probable that certain cachexia are present though not well defined. 
 The iodides are usually beneficial in these cases, 
 
 Pathology. — The histological changes in acute catarrhal laryngitis 
 are the same as in inflammations of the mucosa of other portions of the 
 upper respiratory tract. The peripheral vessels are congested and the 
 tissues are infiltrated with round cells and leukocytes. If the inflamma- 
 tion runs a short course the infiltration disappears, leaving little or no 
 trace of its occurrence. Should the inflammation be phlegmonous, the 
 tissues become edematous and the surface epithelium eroded in patches. 
 The secretions at first thin and scanty, later become heavier and more 
 profuse. In severe cases they may become purulent and streaked with 
 blood from the superficial follicular ulcers. The pathology of laryngitis 
 secondary to the exanthematous fevers does not differ from ordinary 
 laryngitis except as to the microorganisms causing the disease and the 
 greater tendency to phlegmonous inflammation. The greatest swelling 
 in laryngitis is naturally in the most lax parts, namely, in the ventricles, 
 though the true cords are sometimes red and swollen like sausages. In 
 children the swelling is sometimes below the cords, and is a source of 
 extreme danger. 
 
 Symptoms. — Objective Symptoms. — The objective symptoms are a 
 change in the appearance of the cords, the mucosa, the secretions, the 
 exudate, and the presence of pathogenic bacteria. With the laryngeal 
 mirror and reflected light an inverted image of the larynx is shown. The 
 mucosa is red and more or less swollen from hyperemia and infiltration, 
 or edema, according to the virulency of the inflammatory process. The 
 cords are pinkish red, or even as red as the mucosa. Sometimes ecchy- 
 motic spots of extravasated blood may be seen on their upper surfaces, 
 or free borders. The secretions at first thin and scanty later become 
 thick, semitranslucent, or opaque, according to the amount of lympho- 
 cytes thrown out. They have a tendency to accumulate at the anterior 
 commissure and to some extent along the cords. They appear as opaque 
 plugs rather than as thin, diffused, glairy masses. 
 
ACUTE CATARRHAL LARYNGITIS 431 
 
 When follicular ulcers are present the denuded areas appear as slightly 
 roughened red spots, or, if covered with secretions, as whitish opaque 
 ones. In some cases there is a cloudy swelling of the epithelium in isolated 
 areas. These areas are the beginnings of ulcerations. They appear 
 as slightly elevated patches, with a grayish semitranslucent covering. 
 Hemorrhages may occur at the commissure of the cords, or on the ven- 
 tricular bands. At first the site of the hemorrhage is red, later almost 
 black. When the inflammation is severe the venous flow may be blocked 
 so that the parts are edematous. This condition is sometimes termed 
 hydrops laryngis. The temperature varies from a slight elevation to 
 one of several degrees, according to the severity of the inflammation and 
 the virulencey of the microorganisms contributing to the phenomena. 
 The paralysis or paresis of the intrinsic muscles of the larynx, which 
 sometimes occurs, may be due to a neurosis, though it is more often due 
 to a mechanical interference by infiltration and degeneration of the 
 muscles and the tissues immediately surrounding the nerve endings. 
 
 Subjective Symptoms. — The subjective symptoms are changes in 
 voice and respiration, and pain and cough. The voice may be hoarse 
 in any degree, or aphonia may be present. The hoarseness is due to 
 the swelling and infiltration of the cords and adjacent mucous membrane, 
 and to the paresis or paralysis of the muscles. The respiratory effort 
 may be slightly labored, on account of the diminished lumen of the 
 chink of the glottis, or to the paresis or paralysis of the abductor muscles. 
 
 In cases complicated by excessive edema the respiration may be 
 labored because of the edematous swelling. The respiration is shallow 
 because the cough is excited by deep breathing. The character of 
 the cough depends largely upon the individual, though it bears some 
 relationship to the stage and intensity of the disease. In the early stage 
 it is usually soft and husky, whereas later it is more heavy and harsh. 
 In those cases in which there is extensive infiltration and edema it is 
 spasmodic, hoarse, and wheezy, with but little tonal quality. If the 
 inflammation is limited to the interarytenoid space, hoarseness may be 
 absent. 
 
 Prognosis. — The prognosis depends somewhat upon the primary 
 cause, that is, whether the laryngitis is due to a chronic constitutional 
 disease, like syphilis, or to a simple exposure which causes temporary 
 lowered resistance of the tissues. If due to the former, the prognosis as 
 to the voice is bad. If to the latter, it is good. If the attack is primary, 
 it is good. If it is one of a series of acute attacks, the chances are in favor 
 of its recurrence, as the etiology is evidently a fixed factor. Again, the 
 prognosis depends largely upon the character of treatment administered. 
 It is obvious that if the cause is a nasal obstruction from septal malfor- 
 mation, the prognosis will depend upon the treatment instituted. If due 
 to nasal disease, and sprays, lozenges, and only medicated nebulae are 
 used, the prognosis is bad. If the nasal disease is corrected by suitable 
 treatment or an operation, the prognosis is good. Finally, and perhaps 
 of more importance than all other considerations, the prognosis depends 
 upon whether complete rest of the vocal apparatus is observed. If this is 
 
432 DISEASES OF THE LARYNX 
 
 done for from three to ten days, simple catarrhal inflammation will 
 subside, leaving the voice clear. 
 
 Treatment. — The successful treatment of the immediate symptoms 
 consists largely in giving the voice complete rest. Without this all other 
 methods are usually futile and the inflammation runs its full course. 
 The patient should be confined to his room, the temperature of which 
 should be maintained at from 67° to 70° F. The atmosphere should be 
 surcharged with steam from boiling water to which turpentine and 
 creosote have been added. The bowels should be kept open with calomel 
 and salines. The feet should be placed in a hot mustard bath, after 
 which hot lemonade should be administered. The patient should then 
 be wrapped in a woollen blanket and put to bed. Still further relaxation 
 may be induced by the administration of effervescing tablets of pilocar- 
 pine, t -J-q of a grain. One tablet should be given every hour until three 
 or four are taken. The inhalation of steam impregnated with the com- 
 pound tincture of benzoin, one teaspoonful to the pint of boiling water, 
 from the spout of a croup kettle, affords relief, and should be used every 
 two to three hours. Kyle recommends the following prescription: 
 
 I^— Acidi nitrici TT\ iij (0.18) 
 
 Tr. opii deodorati HI iij (0.18) 
 
 Cocaine phenati S r T o (0.006) — M. 
 
 Sig. — Give every hour until three or four doses are taken. 
 
 The application of an ice-bag to the neck exerts a favorable influence 
 in the phlegmonous variety, though it should not be applied longer than 
 a few minutes at a time. A compress of cold water applied over the 
 larynx beneath a flannel bandage also relieves the laryngitis, as it induces 
 hyperemia and leukocytosis just as heat does. It is an open question 
 as to whether the relief is due to the compress per se or to the constric- 
 tion of the bandage, according to Bier's principle. The constriction 
 also increases the local leukocytosis and thus frees the inflamed tissues of 
 the infectious agents and dead tissue cells. Whether the good results are 
 due to the water compress or to the constriction, the effects are favorable. 
 An oily spray of menthol, 1 to 2 grs. to the ounce, is a pleasant appli- 
 cation, affording temporary relief. Its frequent use, however, irritates 
 the mucous membrane, hence it should not be used more often than twice 
 a day. 
 
 In severe cases in which there is considerable obstruction to the breath- 
 ing it may be necessary to puncture the swollen laryngeal mucosa with 
 a laryngeal knife (Fig. 288). The serous fluid in the edematous mem- 
 brane is thus let out without serious damage to the parts, and in addition 
 the reaction of inflammation is promoted and the bacteria more rapidly 
 destroyed. In extreme cases it may become necessary to intubate or 
 to perform tracheotomy. (See Intubation and Tracheotomy.) 
 
 In infants the danger in acute laryngitis is much greater than in adults, 
 on account of the relatively smaller and more easily occluded chink 
 of the glottis. Then, too, the mucosa is much more richly supplied 
 with lymphatics and bloodvessels and is more loosely attached tG the 
 
ApUTE LARYNGITIS IN CHILDREN 433 
 
 deeper structures. For these reasons the mucosa is more likely to be- 
 come swollen or edematous and cause suffocation. A fatal issue is 
 possible. 
 
 For the relief of the cough, codeine sulphate, gr. T V to \, may be 
 administered every three hours until relief is afforded. 
 
 After the second week it may be advisable to touch the inflamed 
 cords with the solid stick of nitrate of silver. This should be done but 
 once. In the milder cases the larynx may be painted with a 2 to 4 per 
 cent, solution of the nitrate of silver. 
 
 Fig. 288 
 
 Laryngeal lancet. 
 
 The principles of treatment are: (a) Absolute rest of the voice, the 
 patient remaining in a warm room containing steam vapor, (b) Free 
 purgation to promote the elimination of the toxins and ferments, and 
 (c) relaxation of the peripheral vessels of the body by the administration 
 of pilocarpine and hot drinks, (d) Diaphoresis, aided by wrapping in 
 warm blankets, (e) The relief of cough by the use of codeine or other 
 sedatives. (/) Scarification, intubation, or tracheotomy in threatened 
 suffocation, (g) Caustic and astringent applications in the late stage. 
 
 ACUTE LARYNGITIS IN CHILDREN. 
 
 Synonyms. — Pseudocroup; false croup; Miller's asthma; laryngitis 
 stridulosa. 
 
 In children acute laryngitis is often characterized by a spasmodic, 
 croupy, or barking cough and suffocative fits. The subjective symptoms 
 are quite like those of tracheal diphtheria, hence the name pseudocroup. 
 Histologically it is a true catarrhal process. 
 
 Etiology. — The etiology of catarrhal laryngitis in children is in general 
 like that of catarrhal laryngitis in adults, though many of the exciting 
 causes may be absent, on account of the different habits of the child or 
 infant. The special etiology in children consists of the presence of 
 adenoids and the epipharyngitis which accompanies them, and in the 
 different anatomical construction of the larynx. In children the chink of 
 the glottis is both relatively and absolutely smaller, the lymphatic and 
 vascular structures are more abundant, and the mucosa is more loosely 
 attached to the underlying tissues. All these factors predispose the 
 larynx of the child to attacks of laryngitis; they also render the disease a 
 28 
 
434 DISEASES OF THE LARYNX 
 
 much more serious one on account of the tendency to suffocation. To the 
 foregoing facts should be added the greater susceptibility of children on 
 account of the unstable condition of the nervous system and glandular 
 tissues. A moderate amount of swelling of the mucosa, either above or 
 below the true cords, to which is added an irritation of the terminal motor 
 nerve filaments, is often sufficient to bring on severe and alarming fits 
 of dyspnea and suffocation, even to the point of death. 
 
 The disease in children may be divided into two varieties, namely, 
 (a) acute supraglottic laryngitis, and (b) subglottic laryngitis, or Miller's 
 asthma. 
 
 The symptoms of acute supraglottic laryngitis more nearly resemble 
 those of the adult type, though in many cases the spasmodic suffocative 
 fits are present on account of the extreme swelling and edema of the 
 mucosa and the paresis of the abductor muscles. 
 
 The subglottic variety is more dangerous because the swollen mucous 
 membrane is confined at its circumference by the cartilaginous rings 
 of the trachea. The swelling must, perforce, encroach upon the lumen 
 of the trachea, and close the breathway. 
 
 Symptoms. — The objective symptoms are about the same as in the 
 adult. (See Acute Catarrhal Laryngitis.) The subjective symptoms are 
 somewhat different on account of the greater swelling and the smaller 
 lumen of the chink of the glottis. The prodromal symptoms are those 
 of cold, the respiration becoming embarrassed toward evening. A dry 
 cough develops before bedtime, but is not severe enough to prevent 
 sleep. Toward midnight the child is suddenly seized with a laryngeal 
 spasm, and breathing becomes difficult. The cough is loud and harsh. 
 Inspiration is difficult, and is accompanied by stridor. The child becomes 
 cyanotic, and death is imminent. After a few minutes the symptoms 
 disappear and the child falls asleep. The following night, and perhaps 
 for two nights, the attack returns with diminishing severity, until after 
 a few days all signs of the disease disappear. In these cases there is a 
 true spasm of the muscles of the larynx, probably due to the natural 
 hypersensitiveness of the nervous system in infants and growing children. 
 In the subglottic variety the swollen mucosa beneath the true cords 
 may be seen through the chink of the glottis as beefy-red bands. These 
 cases closely resemble tracheal diphtheria in their subjective symptoms, 
 though an inspection of the larynx and a microscopic examination 
 of the secretion and exudate will clear the diagnosis. 
 
 Diagnosis. — Acute laryngitis in children should be differentiated 
 from diphtheria, pseudomembranous croup, laryngismus stridulus, 
 foreign bodies, and perichondritis. 
 
 Diphtheria is characterized objectively by a membranous deposit, 
 which may be seen upon laryngoscopic examination. It may be either 
 on the laryngeal mucosa or in the trachea, or both. Cultures show the 
 diphtheria bacilli. In acute laryngitis there is an absence of the false 
 membrane and the bacilli, while the mucosa is greatly swollen and red- 
 dened. If it is of the subglottic variety, the swollen red mucous mem- 
 brane may appear as round, reddened cords, parallel with and below 
 
ACUTE LARYNGITIS IN CHILDREN 435 
 
 the true cords. The temperature is usually higher in acute laryngitis 
 in children than in true diphtheria, while the prostration is not so great. 
 
 Pseudomembranous croup has a sudden onset, while acute laryngitis 
 begins with the symptoms of a cold. In pseudomembranous croup the 
 suffocative symptoms make steady progress with little or no remission. 
 The laryngoscopic image in pseudomembranous croup shows the pres- 
 ence of the membrane, whereas in acute laryngitis the mucosa is red 
 and swollen. The Klebs-Loeffler bacilli are absent in both diseases. 
 The systemic disturbance is less marked and not so severe. There are 
 no nocturnal exacerbations, as there are in acute laryngitis with the 
 laryngismus stridulus phenomena superimposed. 
 
 Foreign bodies in the larynx are differentiated by the history of the 
 accident, the sudden onset of the suffocative symptoms with no pro- 
 dromal history, and the image of the foreign body in the larynx. 
 
 Perichondritis of the cricoid cartilage is characterized by irregular 
 nodules in this region and the chronicity of the case. It is usually asso- 
 ciated with a tuberculous process in the lungs. 
 
 Prognosis. — The prognosis of acute laryngitis in children is favorable 
 in most cases, though a fatal termination is possible, especially in the 
 subglottic variety. The disease runs its course in from six to twelve 
 days. 
 
 Treatment. — Prophylactic measures should be instituted in those 
 cases in which there is a history of recurrent attacks. A child subject 
 to laryngitis with pulmonary complications, as bronchitis, should have 
 the tone of the system built up by daily cold sponge baths, followed 
 by brisk rubbing with a towel until the skin glows. During the summer 
 he should be kept in the open air as much as possible. At night 
 the room should be well ventilated. The food should be nutritious, 
 easily digested, and liberal in quantity. The clothing should be of linen 
 mesh next to the skin all the year round. In the winter light woollen 
 underwear should be worn over the linen mesh. If there are adenoids 
 or diseased tonsils, they should be removed. If suppurative rhinitis is 
 present, it should receive appropriate treatment. All other ailments 
 should be corrected as nearly as possible. In short, all disorders should 
 receive attention and a healthful vigor be established as soon as possible. 
 In this way laryngeal inflammation may be prevented. 
 
 In the beginning of the acute attack the bowels should be moved 
 by the administration of broken doses of calomel, followed by a saline 
 cathartic. During the acute stage the child should be confined in a 
 room kept at a temperature of about 70°, and the atmosphere surcharged 
 with steam. The feet should be placed in hot mustard-water for fifteen 
 minutes, after which the patient should be wrapped in a woollen blanket 
 and put to bed, to promote diaphoresis. If there is much mucus in 
 the throat and trachea, an emetic should be administered. If the secre- 
 tions are scanty or tenacious, the inhalation of menthol vapor from 
 a nebulizer, or from the crystals in boiling water, stimulates the secretions 
 and gives marked relief. 
 
 The external application of an ice-bag or a cold compress to the neck 
 
436 DISEASES OF THE LARYNX 
 
 often affords relief. The ice-bag should be covered with woollen cloth and 
 left in position for only a few minutes at a time. Counterirritation to the 
 neck with iodine, camphorated oil, kerosene, etc., is used to relieve the 
 swelling when it is great, and to promote the reaction of inflammation. 
 (See Chapter VII.) 
 
 In the later stage paregoric, Dover's powder, codeine, etc., may be 
 administered in small doses to relieve the cough. If the secretion is 
 heavy and accumulate in the larynx and trachea, an emetic should be 
 given to clear it away. 
 
 Surgical interference may be necessary when the symptoms become 
 alarming. If, upon laryngoscopic examination, the mucous membrane 
 above the cords is found to be greatly swollen, it should be punctured 
 with a laryngeal lancet (Fig. 288). Or if the cyanosis is marked and 
 does not yield to other methods of treatment, intubation or tracheotomy 
 should be performed to save the child's life. (See Intubation and Trache- 
 otomy.) These extreme measures are rarely necessary, but it is well to 
 recognize that in children this disease is sometimes attended with death 
 unless the breathing is maintained by medicinal, hygienic, or surgical 
 interference. 
 
 ACUTE PHLEGMONOUS LARYNGITIS. 
 
 Definition. — Acute phlegmonous laryngitis is a catarrhal inflamma- 
 tion of the laryngeal mucosa, to which is added an edematous effusion 
 which runs an inflammatory course, for example, serous, seropurulent, 
 and purulent stages. The mucous membrane becomes undermined 
 with purulent secretion. 
 
 Etiology. — The causes of this variety of laryngitis are about the same 
 as in acute catarrhal laryngitis, except that the infection is more virulent. 
 The disease is common among hospital attendants, on account of their 
 exposure to erysipelas and other infectious diseases. It is rarely primary, 
 but is usually secondary to some other infectious disease. It occurs 
 most frequently between the twentieth and the fortieth years of life. 
 
 Pathology. — The pathology is the same as in inflammatory edema 
 of mucous membranes elsewhere in the body. The mucous and sub- 
 mucous tissue are infiltrated with round cells, and there is an effusion 
 of serum and pus corpuscles. On account of the loose texture of the 
 mucous membrane in the aryepiglottic region, the ventricular bands, and 
 the subglottic region, there is great swelling and respiratory obstruction, 
 as in acute laryngitis of children. There is at first a vascular engorge- 
 ment, followed by a serous effusion. Later the effusion takes on a 
 seropurulent and finally a purulent character. General sepsis may 
 follow, and prove to be a serious complication. 
 
 Symptoms. — The symptoms during the first twenty-four hours are 
 about the same as in the acute catarrhal variety. A chill and elevation 
 of temperature are often the initial ones. The symptoms gradually 
 grow worse, and dyspnea often occurs within the first twenty-four hours. 
 Pain and soreness are usually complained of. Cough may or may not 
 be present. 
 
MEMBRANOUS LARYNGITIS 437 
 
 Objectively, the laryngoscopic mirror shows the mucous membrane 
 to be red, tense, and glassy, with three rounded, swollen masses above 
 the chink of the glottis. If the subglottic region is involved, the swollen 
 membrane may be seen projecting from below the true cords. 
 
 Prognosis. — The prognosis is grave on account of the rapid develop- 
 ment and the septic infection. If, however, the dyspnea persists longer 
 than thirty-six hours without severe sepsis or other untoward complica- 
 tion, the case will probably end in spontaneous resolution. The cases 
 should be closely watched during the first thirty-six hours. 
 
 Treatment. — The treatment consists in local depletion with ice-bags, 
 followed by the use of leeches and scarification. The ice-bag should be 
 applied for forty minutes, after which three or four leeches, two on either 
 side, should be applied to the skin over the larynx. The cold reduces 
 the swelling and thus establishes a more rapid flow of blood through the 
 inflamed tissues, and the leeches bring about an increased leukocytosis. 
 The cellular resistance is increased by the greater amount of blood 
 flowing through the tissues. The various reactions produced by the cold 
 and leeches establish ideal conditions for the destruction of the infec- 
 tious microorganisms. The administration of calomel and salines pro- 
 mote the elimination of the toxins. The atmosphere of the room should 
 be kept surcharged with steam. If scarification is resorted to, the laryn- 
 geal lancet (Fig. 2SS) should be used by the aid of the laryngeal mirror 
 and reflected light, or by direct laryngoscopy. The swollen mucous 
 membrane should be repeatedly punctured rather than scarified, as 
 the damage to the parts is less and the relief is equally great. The chief 
 benefit of scarification is in the increased leukocytosis excited by it. 
 It may be necessary to resort to tracheotomy if suffocation becomes 
 imminent. If sepsis is a severe complication, the administration of 
 alcoholic beverages and strychnine are indicated to support the system. 
 
 MEMBRANOUS LARYNGITIS. 
 
 Synonyms. — Croup; croupous laryngitis; hautige braune; diphtheritic 
 laryngitis; pseudomembranous croup; idiopathic membranous croup. 
 
 Definition. — Membranous laryngitis is characterized by an inflamma- 
 tion of the larynx, attended with the formation of a false membrane of 
 non-diphtheritic origin. Opinions differ as to the unity or duality of this 
 disease and true diphtheria. The evidence, however, seems to show 
 that they are two diseases, the latter being due to an infection from the 
 Klebs-Loeffler bacillus, while the former (croup) is due to an infection 
 from other microorganisms, usually the cocci, or to a caustic irritant. 
 When due to the latter the membrane is not of microbic origin, though it 
 may become infected secondarily. Under the microscope it presents the 
 same appearance as that due to cocci. 
 
 Etiology. — The causes of membranous laryngitis are microbic, chemi- 
 cal, and mechanical irritants. Exposure to damp and cold, and neuroses 
 are predisposing causes in young children. The cases of microbic 
 origin usually follow or attend scarlet fever, measles, smallpox, etc. 
 
438 DISEASES OF THE LARYNX 
 
 Exposure to damp and cold seems to precipitate attacks by lowering 
 the vital resistance, and thus establishing a suitable soil for the bacterial 
 growth. It appears that chemical and mechanical irritants cause the 
 membranous formation without bacterial influence, although this is 
 not certain. Some children seem to have a predisposition to a mem- 
 branous inflammation of the larynx, though in these cases I suspect that 
 adenoids and epipharyngitis may cause the susceptibility. It is essen- 
 tially a disease of young childhood, occurring chiefly between the ages 
 of two and eight. It is most prevalent in the winter season. 
 
 Pathology. — The membrane is in two layers, a superficial or epithelial, 
 and a deeper or fibrous layer. It is comparatively loosely attached to 
 the mucous membrane, whereas in diphtheria it is firmly attached. 
 The epithelial layer of the mucosa is rapidly proliferated, and enters into 
 the composition of the pseudomembrane. The mucous membrane is 
 hyperemic and red, and in places is denuded of its epithelium. The 
 bacteria causing the inflammation are chiefly cocci, for example, pneu- 
 mococcus, streptococcus, and staphylococcus, though other bacteria, 
 as the spirillum and the Bacillus pyocyaneus, are found and probably 
 contribute to the etiology. The membrane is not grayish white, as in diph- 
 theria, but is yellowish and of a soft, friable consistency. It is more 
 easily removed, and does not leave an ulcerated or bleeding surface, as in 
 diphtheria. 
 
 Symptoms. — The laryngoscope shows a free fauces, a coated tongue, 
 and hyperemia of the fauces and the larynx. The membranous forma- 
 tion appears on the aryepiglottic folds, on the ventricles, and occasionally 
 on the vocal cords. It is usually primary in the larynx, though it may 
 originate in the fauces and pharynx, and spread to the larynx. The 
 laryngoscopic image, therefore, shows a yellowish, friable membrane in 
 one or more of these regions. The temperature rapidly rises to 102° 
 or 103°. 
 
 The onset of the disease may be the same as in acute catarrhal laryn- 
 gitis, but in the course of an hour or two a loud, brassy cough develops, 
 which steadily increases until toward midnight, when it reaches its 
 climax. There is loss of appetite, and the patient complains of thirst. 
 The pulse is full and the skin is hot and dry. Deglutition becomes 
 painful. The cough, at first infrequent, becomes more and more frequent, 
 and is finally followed by laryngeal spasm. Great dyspnea then comes 
 on, and the child, in his endeavors to cough out the obstructing membrane, 
 clutches at his throat and tosses about in his bed. These symptoms 
 increase in severity as the membrane is formed in the larynx, until the 
 voice is aphonic (silent croup) and the inspiration through the narrowed 
 glottis gives rise to a peculiar crowing sound. The next morning the 
 symptoms are lessened in severity, only to be increased again in the 
 evening. Sometimes the climax is delayed until the third night. The 
 disease is progressive, whereas in laryngitis the obstructive symptoms 
 are spasmodic and are not steadily progressive. In case of marked 
 glottic obstruction the inspiratory and expiratory dyspnea and asphyxia 
 may necessitate intubation or tracheotomy. 
 
MEMBRANOUS LARYNGITIS 439 
 
 If the dyspnea continues, the pulse becomes weak, the temperature 
 falls, and the general strength rapidly ebbs away on account of the 
 diminished oxygenation of the blood and the increased amount of carbon 
 dioxide in the blood. When the membrane is thick in the region of the 
 soft palate there may be a regurgitation of fluid food through the nose. 
 This is not due to paresis of the palatal muscles, as in true diphtheria, but 
 is due to the mechanical interference of the false membrane with the 
 action of the muscles. 
 
 Laryngismus stridulus sometimes appears in the course of the disease, 
 and is to be regarded as a neurotic phenomenon. 
 
 Diagnosis. — Membranous croup resembles in some respects spas- 
 modic laryngitis, diphtheria, laryngismus stridulus, and retropharyngeal 
 abscess. 
 
 In spasmodic laryngitis there is a catarrhal inflammation with spasms 
 of the laryngeal muscles, which cause suffocative symptoms. They 
 disappear, however, in a few minutes and the child rests comfortably. In 
 membranous croup the suffocative symptoms come on gradually and 
 disappear as gradually. 
 
 In diphtheria the temperature does not rise so high or so rapidly. 
 The chief diagnostic points, however, are the culture of the Klebs-Loeffler 
 bacilli and the ashen-gray and firmly adherent pseudomembrane. After 
 its removal the mucous membrane is ulcerated and bleeding, whereas 
 in membranous croup it is smooth and does not bleed. 
 
 Laryngismus stridulus is a neurosis and not an inflammatory disease, 
 hence the laryngoscopic examination shows the absence of inflammation. 
 Then, too, there is a history of a healthy child who suddenly has a fit of 
 suffocation. In membranous croup there is a history of inflammation 
 and progressive dyspnea. 
 
 Retropharyngeal abscess may simulate membranous laryngitis in its 
 suffocative symptoms; otherwise there is little similarity. An examina- 
 tion of the throat reveals a fluctuating tumor on the posterior wall of 
 the hypopharynx, whereas in membranous laryngitis the tumefaction 
 is within the laryngeal zone. 
 
 Prognosis. — The prognosis is grave. Some authors report a mortality 
 of from 50 to 60 per cent, of the cases, while others report as low as 10 per 
 cent. This discrepancy in the reported death rate is probably due to the 
 difference in the diagnosis. Those who figure the death rate at 50 to 60 
 per cent, probably include cases of true diphtheria. The prognosis is 
 grave in inverse ratio to the age of the patients. The younger the patient 
 the more serious the prognosis. In adults the danger is greatly diminished, 
 as the lumen of the larynx is relatively and actually greater, and the 
 mucous membrane is more firmly attached. 
 
 Complications. — Membranous laryngitis may become complicated 
 with rapid edema of the bronchial mucous membrane or with cardiac 
 infection. In either event the case becomes one of great gravity. 
 
 Treatment. — The treatment consists in the administration of broken 
 doses of calomel until free catharsis is produced, and in the inhalation 
 of steam vapor charged with lime and turpentine. The child should be 
 
440 DISEASES OF THE LARYNX 
 
 put into a tent-bed and a pound of lime should be placed in a bucket of 
 water, to which has been added a tablespoonful of the spirit of turpen- 
 tine. The tent-bed is thus filled with the vapor, which is inhaled by 
 the child. The lime and turpentine seem to aid in loosening and expel- 
 ling the false membrane. The steam-tent seances should last about 
 fifteen minutes, and should be repeated every four or five hours. The 
 efficiency of the steam-tent baths is increased by the administration 
 of ipecacuanha wine or powder, which is a non-depressing emetic. 
 
 Calomel fumigations, as advocated by Corlin, have proved an efficient 
 method of treatment. He recommends the administration of one or 
 two grains of calomel before the fumigation begins. The patient should 
 then be placed in a completely closed tent-bed. It requires about ten 
 minutes to volatilize the calomel, and the patient should be exposed to 
 the fumes in the closed tent for about fifteen minutes. It is recommended 
 that fifteen grains be volatilized every two hours for two days and nights, 
 after which the intervals should be prolonged to three hours on the 
 third day, four hours on the fourth day, and three times daily thereafter 
 as long as indicated. Pure calomel thus used does not produce ptyalism, 
 though anemia may occur and should be combated by the administration 
 of iron. 
 
 EDEMA OF THE LARYNX. 
 
 Synonym. — Edema glottidis. 
 
 Edema of the larynx is an inflammatory process attended with an 
 edematous infiltration of the loose submucous tissue of the larynx 
 which is due to a more serious general disease of the heart, kidneys, or 
 the liver, though it may be caused by local conditions. 
 
 Etiology. — The local causes are mainly traumatic from the injudicious 
 use of caustics, laryngeal injections of creosote in tuberculous inflamma- 
 tions, operations, foreign bodies in the supraglottic region of the larynx, 
 the swallowing of hot liquids and the inhalation of hot steam, or the 
 inspiration of alcoholic or other irritating liquids into the larynx. The 
 prolonged or violent use of the voice, as in shouting, may bring on edema 
 of the larynx. Local diseases of the larynx, as tuberculosis, syphilis, 
 abscesses, neoplasms, perichondritis, and peritonsillitis may also cause 
 it. Abscess of the larynx may be accompanied by a non-inflammatory 
 edema. 
 
 The constitutional causes of simple edema of the larynx are Bright's 
 disease, diabetes, valvular lesions of the heart, sclerosis of the liver, and 
 Ludwig's angina. In the latter disease there is a neurotic paresis of the 
 bloodvessels of the neck, which causes engorgement and edema. Certain 
 drugs, as the iodide of potassium and the fumes of ammonia and bro- 
 mine, may cause it. 
 
 Pathology. — There is an effusion of clear serum into the laryngeal 
 submucous tissue, producing swelling of the aryepiglottic folds and of the 
 anterior and superior parts of the epiglottis. Sometimes the loose sub- 
 glottic tissue becomes edematous. In associated ulcerative processes 
 the serous infiltration may become seropurulent. 
 
ABSCESS OF THE LARYNX 441 
 
 Symptoms. — The onset is sudden and is characterized by the loss 
 of the voice and rapidly increasing dyspnea. In severe cases a fatal 
 issue may occur in from two to three hours by asphyxiation. There is 
 little or no pain or cough. The laryngoscopic image shows the mucosa 
 in the region of the aryepiglottic folds, the anterior and upper surface 
 of the epiglottis, and sometimes the subglottic region to be tumefied. 
 The surface of the mucous membrane is of a pale gray color, in marked 
 contrast to the tumefaction in phlegmonous or inflammatory edema of 
 the larynx, in which it is red. 
 
 Prognosis. — The prognosis is grave on account of the sudden develop- 
 ment of the edema, and the serious nature of the constitutional disease 
 back of it. If it is due to an extraneous irritation, the danger is less, 
 and the chance of recurrence is less. 
 
 Treatment. — If the disease is secondary to a serious constitutional 
 disorder, this should, of course, receive appropriate treatment. For 
 the immediate relief of the symptoms cracked ice should be dissolved in 
 the mouth, and the patient should be assured by the attending physician 
 that the dyspnea will disappear, as the sense of impending death only 
 aggravates the distress. Astringent applications of cocaine and adrenalin 
 should be made. Diaphoresis and catharsis should be induced by the 
 administration of Dover's powder, hot lemonade, etc., followed by a 
 twelve-ounce bottle of the citrate of magnesia. In addition to the 
 above, it may be necessary to puncture the edematous tissue with the 
 laryngeal lancet (Fig. 288). If suffocation is imminent, the patient 
 should be tracheotomized (see Tracheotomy), to prevent a fatal issue. 
 The surgeon should not hesitate to perform tracheotomy on a deeply 
 cyanotic case because he does not have with him the instruments 
 usually used for this purpose. A pocket knife, or a paring knife from 
 the kitchen, may be quickly sterilized and used to open the trachea. A 
 needle and thread may be used to retract the parts until a tracheotomy 
 tube is secured. In the meantime the patient's life has been saved, 
 whereas to have waited for suitable instruments would have jeopardized 
 his life. 
 
 ABSCESS OF THE LARYNX. 
 
 Etiology. — Abscess of the larynx is usually a complication of tuber- 
 culous perichondritis. Perichondritis of the laryngeal cartilages is 
 attended with ulceration of the mucous membrane. Infectious bacteria 
 gain entrance beneath the perichondrium and cause the formation of 
 pus. The accumulated pus causes a rounded tumor-like mass. This 
 is a laryngeal abscess. It has also been known to follow erysipelas of 
 the larynx, and it may be of traumatic origin. 
 
 Symptoms. — The abscess swelling encroaches upon the glottis, hence 
 there are loss of voice and intense suffocative symptoms. It is an infec- 
 tious inflammatory process, and causes febrile phenomena. There 
 is retention and pressure, hence pain in the larynx. The laryngoscopic 
 image shows a greatly swollen and reddened mucous membrane at the 
 
442 DISEASES OF THE LARYNX 
 
 site of the abscess. Upon puncturing it with the laryngeal lancet there 
 is a free flow of pus. 
 
 Treatment. — It is obvious that there is but one method of treatment, 
 namely, the evacuation of the pus with a laryngeal lancet (Fig. 288). 
 This may be done under cocaine anesthesia with the patient in the sitting 
 
 Sajous' laryngeal forceps applicator. 
 
 posture. The anesthesia is induced with a 10 to 20 per cent, solution 
 of cocaine applied repeatedly with Sajous' forceps (Fig. 289). The 
 curved laryngeal lancet should then be used with the aid of reflected 
 light and the laryngoscopic mirror, or by direct laryngoscopy and the 
 tumor-like mass freely incised. The relief is immediate. If suffocation 
 threatens, tracheotomy may be necessary. (See Tracheotomy.) 
 
 CHRONIC LARYNGITIS. 
 
 Definition. — Chronic inflammation of the mucous membrane of 
 the larynx includes the glandular, vascular, and connective-tissue layers. 
 It is usually secondary to acute attacks, or to inflammation in the 
 nose, epipharynx, and tonsils, though it occasionally seems to occur as a 
 primary affection. 
 
 The following classification meets both the clinical and the pathological 
 requirements : 
 
 1. Chronic hypertrophic laryngitis. 
 
 (a) Diffused hypertrophic laryngitis, sometimes called chronic 
 
 hyperemic laryngitis. 
 
 (b) Discrete or localized hypertrophy of the mucous membrane, 
 
 either supra- or subglottic. 
 
 (c) Chorditis nodosa, or trachoma of the vocal cords. 
 
 2. Atrophic laryngitis. 
 
 3. Hemorrhagic laryngitis. 
 
 Chronic Hypertrophic Laryngitis. — (a) Chronic Diffused Laryngitis. 
 — Each of the three varieties of chronic hypertrophic laryngitis presents 
 a distinct clinical and pathological picture, hence they will be described 
 separately. 
 
 Synonym. — It is sometimes called hyperemic laryngitis. 
 
 It is characterized by a diffused infiltration throughout the laryngeal 
 
CHRONIC LARYNGITIS 443 
 
 mucosa, no one part being affected more than another. As it is due to 
 irritations of a general character, rather than to those directed to one 
 part, it is easy to understand the diffusion of the hypertrophy and hyper- 
 emia. 
 
 Etiology. — It is extremely doubtful if there is a primary chronic laryn- 
 gitis, except from the improper use of the voice. It is always, or nearly 
 always, secondary to a preceding disease of the nose, epipharynx, or 
 the faucial tonsils. It is possible to conceive of a chronic laryngitis 
 following the excessive use of tobacco or alcohol, or even following 
 digestive disturbances. Clinically, however, it is rare to see cases in 
 which there is not an associated or a preceding disease higher up in 
 the respiratory tract. The diffused hypertrophic variety arises from 
 obstructed nasal breathing and from the discharge of secretion from 
 the sinuses into the pharynx. Other sources of irritation may also be 
 present, but they are generally incidental and of secondary importance. 
 
 The etiology may be classified under the following headings: 
 
 1. Improper preparation of the inspired air on account of disease 
 of the nose and sinuses. 
 
 2. Hematogenous irritation of the larynx in mouth breathing, hepatic 
 and digestive disorders. 
 
 3. Passive hyperemia in cardiac disease, thoracic tumors, and enlarged 
 glands. 
 
 4. Smoking, the inhalation of dust-laden air, the excessive use of 
 alcohol, and the violent use of the voice. 
 
 5. Climatic conditions. 
 
 6. Age and sex. 
 
 Mouth breathing, adenoids, deflections of the septum, turbinal hyper- 
 trophy, sinuitis, and polypi, also improper breathing by public speakers 
 and singers, lead to a diffused irritation of the laryngeal mucous mem- 
 brane. As the improperly prepared air and secretions pass over the 
 whole laryngeal mucosa, there is a diffused hypertrophy. As the air 
 in damp cold weather is more irritating than it is in warm and bright 
 weather, it follows that the symptoms are aggravated during the winter 
 and early spring months in the higher latitudes. This is especially true 
 in the region of the Great Lakes and on the northern Atlantic coast 
 of the United States. 
 
 The breathing of improperly prepared air results in deficient oxygena- 
 tion of the tissues and an excess of carbon dioxide in the blood. This 
 in turn disturbs the metabolic processes, and still further loads the blood 
 with deleterious material. This blood in circulating through the laryn- 
 geal mucosa irritates all its parts, and causes a diffused hyperemia and 
 hypertrophy. The excessive use of alcohol and tobacco similarly affects 
 the larynx. Smoking does it by direct irritation, and indirectly through 
 the blood. The ingestion of alcohol affects the larynx by direct irrita- 
 tion of neighboring parts, and through the circulation, to say nothing of 
 the digestive and metabolic disturbances thus aroused. The foregoing 
 etiological factors predispose the larynx to acute attacks, and the chronic 
 state is usually a sequel or a continuation of repeated acute inflammations. 
 
444 DISEASES OF THE LARYNX 
 
 I am of the opinion that through disease and obstruction in the nose the 
 laryngeal mucosa is kept in a state of irritability, and is made susceptible 
 to chronic inflammation by the inspiration of the improperly prepared 
 air and by the toxins in the blood. At the age of puberty boys are 
 subject to attacks of chronic laryngitis on account of the unstable condi- 
 tion of the vasomotor nervous system, the rapid development of the 
 larynx, and the consequent instability of the same. Any disease of the 
 heart, wherein there is an interference with the return circulation, may 
 cause huskiness of the voice and perhaps diffused hypertrophy of the 
 mucous membrane. Thoracic tumors, or enlarged thoracic and cervical 
 glands, also interfere with the return circulation, and lead to hypertrophic 
 changes. Stonecutters, tobacconists, metal workers, and workers with 
 certain chemicals are often affected by chronic laryngitis from the 
 inhalation of the contaminated air. Men are more often affected than 
 women, for obvious reasons. The aged are more subject to it on account 
 of the vascular and glandular changes accompanying senility. Indeed, 
 many old people living in the northern part of the United States are more 
 or less afflicted with chronic laryngitis. 
 
 Pathology. — There is a diffused hypertrophy of the laryngeal mucous 
 membrane, including the glandular and the connective tissue. The 
 bloodvessels are but little affected excepting a few small arteries on the 
 surface of the epiglottis and the vocal cords, where they may be enlarged. 
 
 Symptoms. — The objective symptoms of diffused hypertrophic laryn- 
 gitis, if carefully studied, are somewhat different from those of the other 
 two varieties of hypertrophic laryngitis, and are as follows : 
 
 Diffused hyperemia of the laryngeal mucous membrane, including 
 that of the epiglottis, is usually present. It may be more marked in 
 the ventricular pouches, on the epiglottis, the aryepiglottic folds, or on 
 the vocal and the ventricular bands. Indeed, it often spreads from one 
 part to another in the order given above, until in the later stages it is 
 general. In singers and speakers the hyperemia is generally greater on, 
 or is entirely limited to, the true cords. The color varies in different 
 individuals, and, indeed, in the same case at different times. The cords 
 may be the normal ivory white, or pinkish red, or they may be streaked 
 with red, or they may be of a pale, mottled brown or slaty gray color. 
 Enlarged bloodvessels are rarely seen, except upon the epiglottis and 
 the vocal cords. 
 
 The secretions are increased but little, indeed, in some cases they are 
 apparently decreased. The image may present, therefore, either a moist 
 or a dry membrane. The hyperemia is rarely demonstrable by laryngo- 
 scopy examination. The mobility of the cords is usually unaffected, 
 though in some cases there is a tardy action from the infiltration of the 
 intrinsic muscles. 
 
 The subjective symptoms have reference to the voice, the sense of 
 accumulated secretions, and the ease with which the vocal apparatus 
 becomes tired. The voice upon rising is often quite husky, or even 
 aphonic. During the day it becomes nearly or entirely clear, unless it 
 is used excessively. In this event it remains husky, and its use is attended 
 
CHRONIC LARYNGITIS 445 
 
 with aching in the larynx. The secretions are rarely increased and are 
 sometimes diminished in quantity. 
 
 The diffused hyperemia and hypertrophy give rise to the sense of 
 accumulated secretions and the desire to clear the throat. 
 
 Diagnosis. — The diagnosis is based upon the hoarseness or aphonia, 
 the diffused hyperemia in the later stage, the absence of discrete hyper- 
 trophy, and the small amount of expectoration, except when complicated 
 by bronchitis. 
 
 Prognosis. — The prognosis in the early stage is good, but when the 
 hyperemia has extended over the entire mucosa it is not so favorable. 
 If the laryngitis is due to the excessive use of alcohol or tobacco, or to 
 an excessive or violent use of the voice, the excesses should be corrected. 
 If it is due to nasal obstruction or to adenoids these conditions should 
 be corrected. No matter what the cause, the prognosis as to the voice 
 is bad if the hypertrophy is great. In these cases there may be an 
 infiltration of the thyro-arytenoidei interni muscles, thus giving rise 
 to a sluggish action of the cords. 
 
 Treatment. — From the foregoing description of the disease it is apparent 
 that the treatment must be addressed to (a) the correction of the pre- 
 existing disease of the nose and sinuses; (b) the removal of adenoids; (c) 
 the discontinuance of the use of tobacco and alcohol; (d) the correction 
 of digestive and hepatic disorders; and (e) the avoidance of excessive use 
 of the vocal organs. 
 
 When the nose and accessory sinuses are the seat of a catarrhal 
 or a suppurative inflammation, they should receive appropriate attention. 
 Deflections of the septum, turbinal hypertrophies, sinuitis, polypi, etc., 
 should be corrected or removed by surgical procedures. Adenoids, if 
 present, even though they are somewhat reduced by atrophy in adults, 
 should be removed, and the associated epipharyngitis treated with silver 
 applications. The faucial tonsils when enlarged or diseased should be 
 removed in their entirety. The use of tobacco and alcoholic beverages 
 should be forbidden, as but little benefit can be expected while the larynx 
 is subjected to their deleterious effects. Singers who practise improper 
 placement of the voice should either be forbidden to sing, or be taught 
 proper methods of voice placement. (See the Singing Voice.) Violent 
 use of the voice, either in singing or speaking, should be avoided. 
 
 The use of sprays, gargles, and oily nebulae by the patient are of little 
 value. These remedies, at most, can do no more than thin the secre- 
 tions and thus facilitate their expulsion. 
 
 Local applications of a 2 to 10 per cent, solution of the nitrate of silver 
 with Sajous' forceps should be made three times a week. The chloride 
 of zinc in the same strength should be tried, although I have found 
 nothing as efficacious as the nitrate of silver. Other preparations 
 of silver in my hands have proved disappointing. In making applica- 
 tions to the larynx the excess of fluid should be squeezed from the 
 cotton to prevent it trickling between the cords, where it excites spasm 
 of the laryngeal muscles. Should a spasm occur, instruct the patient 
 to take a number of deep breaths in rapid succession. Sustained efforts 
 
446 DISEASES OF THE LARYNX 
 
 of this sort quickly stop the spasms. Spasms of the larynx excited 
 by an excess of silver solution may be so violent as to cause cyanosis and 
 extreme apprehension on the part of the patient. 
 
 Constitutional remedies, as saline cathartics, calomel, and the iodide 
 of potash, should be given if syphilis is suspected. They are often of 
 value in small doses when syphilis is not present, as the cathartics 
 improve the elimination, while the iodide of potash stimulates the 
 glands. 
 
 The improvement following the correction of digestive and hepatic 
 disorders is often very gratifying. To this end I advise the daily use 
 of one of the bitter salines in small doses, and a five-grain dose of the 
 iodide of potash three times a day. In addition to these remedies it may 
 be necessary to use others, according to the needs of the case. If chronic 
 bronchitis is present, the administration of a ferruginous tonic, with five 
 grains of the iodide of potash three times daily for from three to six 
 months, will often effect a cure of both the laryngitis and the bronchitis. 
 One of my patients gained twenty pounds in five months under this 
 treatment. 
 
 The hygienic conditions should be good, the living and the sleeping 
 rooms ventilated, and proper clothing worn. Even with all these 
 precautions it is often impossible to greatly improve the quality of the 
 voice. 
 
 (b) Discrete or Localized Hypertrophic Laryngitis. — Synonyms. — Chronic 
 subjective laryngitis; laryngitis hypogiottica; chorditis vocalis hyper- 
 trophica inferior; Stoerk's blennorrhea. 
 
 Discrete or localized hypertrophic laryngitis is characterized by 
 hoarseness or aphonia, dyspnea, a brassy cough, and an infiltration of 
 the tissues in the subglottic space. 
 
 Etiology and Pathology. — The pathological changes are the same as 
 those given under the diffuse form, except that they are more localized. 
 
 Symptoms. — The subjective symptoms are about the same as those 
 given under the diffuse form, but are greatly exaggerated. The hoarse- 
 ness usually amounts to aphonia. The hypertrohpic tissue in the sub- 
 glottic space and the infiltration of the laryngeal muscles, interfere with 
 the normal movements of the cords to such an extent that approxima- 
 tion is often impossible. The dyspnea, or suffocative symptoms, are 
 due to obstruction below the glottis. The brassy cough is characteristic 
 of obstructive swelling and hypertrophy in the subglottic region. 
 
 The objective signs of this variety of laryngitis are quite characteristic. 
 The hypertrophied tissue below the cords appears in the form of two 
 sausage-like masses, nearly parallel with and beneath the true cords. 
 Their color varies from a pale grayish pink to the deep red of active 
 inflammation. The epiglottis is also congested, and enlarged blood- 
 vessels pass over its posterior surface. In some cases there is more or less 
 edema. In these cases deglutition is difficult, owing to the imperfect 
 closure of the glottis. The dyspnea in discrete hypertrophic laryngitis is 
 increased upon exertion. Patients sometimes complain of a sense of 
 stuffiness, or of a foreign body in the larynx. After the disease is well 
 
CHRONIC LARYNGITIS 447 
 
 advanced the above symptoms are fairly persistent, as the hypertrophic 
 swelling is a fixed factor. Upon attempted phonation the cords fail to 
 approximate, and instead of the free edges presenting straight lines they 
 are slightly concave or wavy, owing to the weakness of the abductor and 
 tensor muscles from infiltration. No doubt the hypertrophic masses in 
 the subglottic region also interfere with the movements of the cords. The 
 secretions are thick and whitish in color and are often accumulated in 
 the interarytenoid space, and over the sluggishly moving cords. 
 
 Diagnosis. — Rhinoscleroma presents some points of similarity, but in 
 view of the fact that it is a very rare disease in this country, and that if the 
 subglottic swelling is touched, under cocaine anesthesia, with a probe, 
 it is yielding, whereas in rhinoscleroma it is hard and resistant, there 
 is little difficulty in excluding rhinoscleroma. The removal of a piece 
 of the growth for microscopic examination may be practised in case 
 of doubt. This, when stained by Gram's method (see Rhinoscleroma), 
 shows the characteristic cell formation, and the bacillus of rhinoscleroma 
 if that disease is present. 
 
 Prognosis. — On account of the hypertrophic swellings below the cords, 
 the dyspnea may become so great as to require the performance of 
 tracheotomy (see Tracheotomy), and the wearing of a tube throughout 
 the remainder of life. The danger from suffocation and the pulmonary 
 complications incident to the wearing of the tracheal tube render it a 
 grave disease. 
 
 Treatment. — Before undertaking the treatment, the cause or causes of 
 the affection should be carefully studied. When the etiology has been 
 definitely determined an endeavor should be made to overcome the 
 predisposing causes of the disease. If rheumatism, gout, dyspepsia, 
 anemia, or constipation (Watson Williams) are present, appropriate 
 remedies should be given. The iodide of potash and the proto-iodide of 
 mercury should be given whether or not syphilis is suspected, as they 
 often promote more or less absorption of the deposit. Tonic remedies, 
 as iron, arsenic, quinine, gentian, and strychnine, should be given 
 to promote the general tone of the system and to innervate the laryn- 
 geal muscles. Obstructive lesions and inflammatory diseases of the 
 nasal chambers and of the epipharynx should be remedied by appropriate 
 medicinal and surgical measures. If the excessive use of tobacco and 
 alcohol enter into the etiology their use should be interdicted. The 
 local application of astringents, as the chloride of zinc (10 to 30 grains 
 to the ounce), nitrate of silver (10 to 30 grains to the ounce), alum (5 to 
 15 grains to the ounce), should be made with Sajous' laryngeal forceps 
 or with an atomizer during phonation. A change of climate or a sea 
 voyage is sometimes beneficial, though not curative. Last, but not of 
 least importance, is the absolute rest of the vocal organs. Great improve- 
 ment sometimes results when these precautions are faithfully observed 
 for a few days. 
 
 (c) Chorditis Nodosa. — Synonyms. — Trachoma of the vocal cords; 
 chorditis tuberosa; singers' nodules. 
 
 Chorditis nodosa is characterized by the formation of nodules along 
 
448 DISEASES OF THE LARYNX 
 
 the free border of one or both of the vocal cords. Some authors claim 
 that they are more often near the posterior third of the cords, though 
 others have observed them at the junction of the anterior and the middle 
 thirds of the cords. In my cases they have been in the former 
 position. 
 
 Etiology. — The nodules usually complicate chronic hypertrophic 
 laryngitis in singers and public speakers who use faulty methods of 
 respiration and voice placement (Curtis). Curtis insists that his patients 
 practise lower costal respiration with the upper ribs elevated, and that 
 they practise voice placement by attacking the initial tone with the 
 lips gently closed as in humming, so that when they are plucked with 
 the finger the tone flows therefrom. If the tone does not emit through 
 the lips when plucked, but comes through the nasal chambers, it is 
 an evidence of faulty voice placement. When such is the case there 
 is an overtension of the intrinsic and extrinsic muscles of the larynx. 
 This causes attrition of the cords in phonation, hence the nodules. 
 Chiari claims that chorditis nodosa is a typical pachydermia laryngis. 
 Hajek thinks the nodules are glandular hypertrophies. The term as 
 herein used refers to nodules from improper voice placement. 
 
 Pathology. — The nodules consist of layers of stratified squamous 
 epithelium surrounded by a circle of congested tissue. They are not 
 unlike corns which result from ill-fitting shoes. 
 
 Symptoms. — As the nodes accompany a diffused hypertrophic laryn- 
 gitis, the symptoms are sometimes similar to those described under that 
 condition. The special subjective symptoms are that the singer or the 
 public speaker is unable to strike the tone he desires, especially in the 
 middle register. When the cords are widely separated, as in the lower 
 register, no difficulty is experienced, as the opposing nodes do not touch. 
 When the higher register is attempted, the posterior thirds of the cords 
 are necessarily closely approximated and not in use, and the voice 
 is not greatly affected. When, however, the middle register is attempted, 
 the cords vibrate their entire length, and as the nodes touch they interfere 
 with voice production. Hence, a prominent symptom is the difficulty 
 in tone placement experienced by singers in attempting to use the voice 
 in the middle register. The laryngoscopic image shows a nodule on the 
 free border of one or both cords, usually at the junction of the posterior 
 and the middle thirds, though the nodules may occasionally form any- 
 where along their borders. If both cords are involved the nodules are 
 exactly opposite. A small area of hyperemia is often present at the base 
 of the nodule. If diffused hypertrophic changes are present, they may 
 not be apparent except as shown by the hyperemia. 
 
 Prognosis. — The prognosis in regard to the disappearance of the 
 nodules is good, provided the patient faithfully follows the instructions 
 contained in the chapter on the Singing Voice, or practises external 
 massage of the larynx, as recommended by Miller. 
 
 Treatment. — The treatment consists in refraining from singing and 
 loud speaking, and in practising proper methods of breathing and tone 
 placement. This should be done under an intelligent and appreciative 
 
CHRONIC LARYNGITIS 449 
 
 instructor, which, alas! is hard to find. I have treated a few cases of 
 "singer's nodules," according to Curtis' suggestions, with most excellent 
 results. In none of the cases did I resort to either local, medicinal, or 
 surgical treatment, as the nodules were apparently the result of faulty 
 methods of singing. 
 
 If advisable, the astringent remedies described under discrete hyper- 
 trophic laryngitis may be used. In extreme cases it may be necessary 
 to remove the nodules with an intralaryngeal cutting forceps introduced 
 by the direct or indirect method. This should be done only after failure 
 to cure by the other methods suggested. Miller recommends external 
 massage of the larynx with a mechanical vibrator as an adjunct to proper 
 training in tone building and voice placement. The massage improves 
 the circulation and nutrition of the mucous membrane, increases the 
 local migration of leukocytes, and relieves the associated laryngeal 
 inflammation. 
 
 Atrophic Laryngitis. — Synonym. — Laryngitis sicca. 
 Atrophic laryngitis is characterized by a burning or pricking sensa- 
 tion after exercising the voice, and by suffocative attacks (simulating 
 spasmodic croup and asthma) during the night. 
 
 Etiology. — The atrophic changes in the larynx are usually secondary 
 to the same process in the nose and pharynx. Bosworth believes that 
 some influence is brought to bear upon the mucous glands of the laryn- 
 geal mucous membrane which deprives them of their secretory power, 
 and that this influence is often independent of intranasal or pharyngeal 
 atrophy. According to my observation, atrophic laryngitis is often sec- 
 ondary to ethmoiditis and sphenoiditis, and I usually address therapeutic 
 measures to these cavities as well as to the larynx. 
 
 Pathology. — The mucous membrane undergoes a retrograde change, 
 and fibrous tissue finally replaces the normal elements constituting the 
 mucous membrane and submucous tissue. The mucous glands and 
 the bloodvessels disappear, or become greatly diminished in size. The 
 ciliated columnar epithelium is gradually replaced by squamous epithe- 
 lium. The secretions are diminished in quantity and changed in quality. 
 They are thicker and admixed with white corpuscles and epithelial 
 debris. The desiccated secretion appears as brownish, blackish, or 
 grayish crusts on the cords, and in the interarytenoid space. Ulceration 
 of the mucosa is not generally present, though it may be, especially 
 on the posterior wall. 
 
 Symptoms. — After using the voice there may be a burning or pricking 
 sensation in the throat. Cough, of a hoarse spasmodic character, is 
 excited by the presence of, and the attempt to remove, the crusts from 
 the larynx. The cough and hoarseness are more severe in the morning. 
 Dyspnea, simulating spasmodic croup or asthma, may occur at night 
 on account of the accumulation of the crusts over the vocal cords. Upon 
 laryngoscopic examination the mucous membrane appears pale and 
 dry, with discolored crusts on the cords, or in the interarytenoid space. 
 They may also be seen upon the posterior wall of the larynx in some 
 cases, especially if there is ulceration in this region. The cords are 
 29 
 
450 DISEASES OF THE LARYNX 
 
 dry and wrinkled and more or less covered with crusts. The trachea 
 may be dry and glazed or covered with crusts. 
 
 Prognosis. — The prognosis is bad except in those cases in which the 
 atrophic changes have progressed but little. In such cases the surgical 
 exenteration of the ethmoid and sphenoid sinuses may effect a cure or 
 an amelioration of the disease, provided, of course, the sinuses are 
 affected. 
 
 Treatment. — The internal administration of the iodides occasionally 
 stimulates glandular activity and thus affords relief. Pilocarpine may 
 also be given for the same purpose if the heart is strong. It should never 
 be given unless an examination of this organ has first been made. The 
 chloride of ammonium and cubebs stimulate the glands and thin the 
 secretions, rendering them easier to dislodge. The inhalation of aro- 
 matics in solution in olive oil, thrown into the larynx with a nebulizer, is 
 grateful and affords temporary relief. Medicated lozenges with a mucila- 
 ginous base may be used to protect the dry membrane. A warm, moist 
 climate or a sea voyage will ameliorate the symptoms. Careful attention 
 should be given to the condition of the nose, the accessory sinuses, 
 and the pharynx. If the nose is kept free from crusts and the secretions 
 are increased the larynx will undergo a corresponding improvement. 
 In empyema of the posterior ethmoidal and the sphenoidal cells the 
 secretions discharge into the pharynx and trickle downward into the 
 larynx, where they become dried and adherent to its posterior wall, or 
 lodge upon the cords. In such cases great improvement follows the 
 radical operative treatment of the sinuses. 
 
 Hemorrhagic Laryngitis. — Synonyms. — Spurious hemoptysis; laryn- 
 geal hemorrhage; bleeding in the throat; spitting blood. 
 
 By hemorrhagic laryngitis is meant a laryngeal inflammation accom- 
 panied by hemorrhage from the laryngeal mucous membrane. The 
 spitting of blood, or hemoptysis, is not always of laryngeal origin. It 
 may come from the nose, the pharynx, the trachea, the bronchi, or the 
 lungs. The term hemoptysis, or spitting of blood, should be limited to 
 hemorrhage from the lungs, and especially that which occurs in tuber- 
 culosis. 
 
 Etiology. — Hemorrhage which occurs in the course of laryngitis is due 
 to ulcerations, acute inflammations, and to excessive use of the voice. 
 Syphilis and tuberculosis of the larynx may be attended with laryngeal 
 hemorrhage. Albuminuria, diabetes, variola, typhoid fever, yellow 
 fever, leukemia, hemophilia, and malignant disease also predispose to 
 hemorrhages. 
 
 Symptoms. — If chronic laryngitis is present the usual symptoms of 
 such a condition are also present. (See Chronic Laryngitis.) The 
 patient also complains of a tickling sensation in the throat, followed by 
 cough and the expectoration of blood. The quantity varies from a mere 
 streak to a mouthful; usually, however, it is small. 
 
 The laryngoscopic examination shows one or more areas of extrav- 
 asated blood in the cords or mucous membrane, and some fresh fluid 
 blood may still cling to the surface of the laryngeal mucosa. 
 
CHRONIC LARYNGITIS 451 
 
 Treatment. — Ordinarily no treatment is required. Astringent sprays 
 and the external application of ice may be tried. If the cough continues, 
 it should be quieted by the administration of morphine by hypodermic 
 injection (Coakley). The act of coughing prevents coagulation and tends 
 to prolong the bleeding. 
 
 General Diagnosis of Chronic Laryngitis. — The differential diag- 
 nosis of chronic laryngitis from other laryngeal disease is not always 
 easily made. It may be confounded with laryngeal tuberculosis, syphilis, 
 adenitis, carcinoma, and certain benign growths. 
 
 Tuberculosis is characterized by a rapid pulse, elevation of tempera- 
 ture, loss of appetite, emaciation, and a general lowered vitality. These 
 symptoms are not present in chronic laryngitis. An examination of 
 sputum for tubercle bacilli will still further aid in the diagnosis. A 
 laryngoscopic examination does not always settle the diagnosis, unless 
 the larynx is the seat of the tuberculous infiltration. In most cases of 
 tuberculosis the laryngeal mucosa is ashen gray in contrast with the 
 diffused hyperemia of chronic laryngitis. In the inflammatory type of 
 laryngeal tuberculosis (mixed infection) the mucosa is red, but the 
 swelling of the arytenoid cartilages is too great to be mistaken for catar- 
 rhal inflammation. 
 
 If the tuberculous process is well advanced ulcerations may be 
 present. 
 
 Syphilitic affections of the larynx may present much the same appear- 
 ance as the edematous type of chronic laryngitis. Hyperplasia may be 
 present in both diseases, but is more often present in syphilis. Careful 
 inspection will often reveal small ulcers, which may lead to a mistaken 
 diagnosis of syphilis. An accurate history of the case is, therefore, 
 necessary in making the differential diagnosis. In the tertiary stage of 
 syphilis the diagnosis is easily made. The ulcers in hypertrophic 
 laryngitis are stationary, while those of syphilis and tuberculosis are 
 deep and spread rapidly. 
 
 Carcinoma in the subglottic region is distinguished from discrete 
 hypertrophic laryngitis by the nodular outline of the growth and the 
 cachexia. Perichondritis in this region more nearly simulates carcinoma 
 on account of the nodular outline of the tumor-like mass. 
 
 In lupus the surface of the membrane is markedly red and granular. 
 
 Sarcoma of the larynx presents a red and an uneven contour, whereas 
 in all forms of hypertrophy the swelling and purulent discharge come 
 before the perichondritis is well developed. 
 
 Enchondrosis of the laryngeal cartilages is differentiated from edema- 
 tous laryngitis by the sense of hardness on probe pressure and the uneven 
 contour of the swelling. 
 
 Paralysis of the posterior crico-arytenoid muscle may be mistaken 
 for subglottic hypertrophy unless a careful examination is made. In 
 paralysis the lagging movements of the cords reveal the nature of the 
 lesion. The paralysis may also be mistaken for pachydermia laryngis. 
 
 Prolapse of the ventricles is differentiated from superior hypertrophy 
 by marked pitting upon probe pressure. 
 
452 DISEASES OF THE LARYNX 
 
 Angina laryngis is differentiated from hemorrhagic laryngitis by the 
 elevated whorl of bloodvessels and the absence of hemorrhage. 
 
 Papilloma is distinguished from chorditis nodosa by the point of 
 attachment and the size and shape of the growth. 
 
 DIPHTHERIA; TRACHEOTOMY; INTUBATION. 
 
 Definition. — Diphtheria is an acute infectious disease, characterized! 
 by the presence of the Klebs-Loeffler bacillus. It is still further char- 
 acterized by a false membrane on a mucous surface or an abraded skin, 
 and is communicable, either directly or indirectly, from one person to 
 another. The lesion is usually located in the upper respiratory tract. 
 
 Etiology. — As to its geographical and racial distribution, it may be 
 said to be well-nigh universal. No climate, season, country, or race is 
 exempt from its ravages. It is, however, less prevalent in the summer 
 season in temperate and northern latitudes, on account of the open-door 
 life of the people at this season, and because, during the school vacations, 
 the overcrowding and the close contact incident to school life are tempor- 
 arily suspended. Statistics show that among the poor in crowded tene- 
 ments, and in badly ventilated schoolrooms, the disease is more prevalent. 
 A curious exception to this is shown by Walsh to exist among the negroes 
 of Washington. The percentage of diphtheria among 10,000 negroes 
 was 4.43, as against 15.25 per cent, among the same number of whites. 
 This may be due to an antitoxic state of the blood in the negro race, 
 or to a greater freedom from disease of the upper respiratory tract. 
 (Nasal obstruction is comparatively rare among negroes.) 
 
 Sanitation is an important factor in the development of the disease. 
 Sunshine and fresh air are twin sisters of charity in the prevention and 
 the amelioration of infectious diseases. In one of the great children's 
 hospitals of London, diphtheria was prevalent in one of the wards. As 
 soon as they were convalescent the patients were removed to another 
 ward and no recurrences were reported. An adjacent building was torn 
 down and the solid iron shutters of the convalescent ward were closed to 
 exclude the dust. Incidentally the sunshine and the fresh air were also 
 excluded, and there were many recurrences among the convalescents. 
 
 The overcrowded tenement districts in the great cities are usually 
 poorly ventilated and the rooms little exposed to the sunshine. When 
 many are in close contact, the opportunities for transmitting the infection 
 are multiplied; hence, for these and other reasons, the poor of the cities 
 are especially afflicted with diphtheria. 
 
 Defective plumbing, sewer gas, cesspools, etc., are often thought to 
 produce the disease. While these may indirectly influence the spread 
 of the contagion, it should be remembered that the Klebs-Loeffler bacillus 
 is absolutely essential to the production of the true disease. The presence 
 of sewer gas may produce lessened resistance to the diphtheria bacilli, 
 and thus predispose the patient to their ravages. 
 
 Bodily conditions have much to do with the susceptibility of the 
 
DIPHTHERIA 
 
 453 
 
 individual exposed to the Klebs-Loeffler bacillus. The "scrofulous 
 habit" lowers the tone of the cellular elements of the body, and thus 
 renders it less fit to cope with the inroads of the disease-producing germ. 
 Abraded or diseased surfaces in the upper respiratory tract also offer 
 local areas of lowered resistance to the growth of the bacilli. Hence 
 enlarged and diseased tonsils, adenoids, glandular enlargements of the 
 neck, and catarrhal diseases of the nose and throat favor the development 
 of the diphtheritic process. 
 
 Rich and poor are alike affected, the only difference being the more 
 favorable sanitary conditions surrounding the rich, who are, therefore, 
 relatively less often affected. 
 
 Age has a great influence on the prevalence of the disease. The blood 
 of nurslings is very antitoxic in its properties, hence children under 
 one year of age are comparatively exempt from the disease. After 
 the fourteenth year there is relatively slight predisposition to diph- 
 theria. Baginski shows by the statistics of 2711 diphtheritic cases that 
 
 Fig. 290 
 
 PERCENTAGE 
 OF CASES 
 
 YEAR 
 1 2 3 4 5 G 7 8 10 11 12 13 14 
 
 14 :< 
 13 * 
 12 1 
 11* 
 
 lost 
 
 9i 
 
 s * 
 
 7* 
 6£ 
 
 52 
 
 i.: 
 3; 
 2;; 
 1* 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ^ 
 
 •^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The above chart is arranged from the statistical data of Babinski, and shows at a glance the 
 relative prevalence of diphtheria from birth to fourteen years of age. 
 
 under six months the percentage of cases is 0.55; six months to one year, 
 2.5 per cent.; one to two years, 8.3 per cent.; two to three years, 11.6 
 per cent.; three to four years, 13.05 per cent.; four to five years, 12.4 
 per cent.; five to six years, 9.7 per cent.; six to seven years, 10.3 per 
 cent.; seven to eight years, 7.7 per cent.; eight to nine years, 6.4 per 
 cent.; nine to ten years, 5.5 per cent.; ten to eleven years, 3.7 per cent.; 
 eleven to twelve years, 2.9 per cent.; twelve to thirteen years, 2.02 per 
 cent.; thirteen to fourteen years, 2.6 per cent. (Fig. 290). 
 
 Modes of Infection, Direct and Indirect.- — The direct infection is from 
 the one affected to another, i. e., by breathing the atmosphere immediately 
 surrounding the patient, inhaling his breath, or receiving the mucus or 
 the saliva into the mouth or the nose during an act of coughing, spitting, or 
 sneezing on the part of the patient. Kissing is another mode of direct 
 infection, and is to be condemned when diphtheria is known to exist in 
 the family. All members of the family should refrain from this manifesta- 
 tion of affection during the term of diphtheritic infection, as there may 
 
454 DISEASES OF THE LARYNX 
 
 be a mild or an incipient infection without the knowledge of the indi- 
 vidual. Without doubt the disease is often transmitted by persons who 
 are not suspected of being infected. 
 
 The indirect mode of infection is not so easily traced as the direct; 
 nevertheless, it is well established that the bacilli may be transmitted 
 by domestic animals, as dogs, cats, chickens, rabbits, etc., which, being 
 directly exposed to the contagion, convey it to persons removed from the 
 direct source of infection. The author recalls a case which aptly illus- 
 trates this point. He was in a house of a minister when a member of 
 the parish called to make the funeral arrangements for his child, who 
 had just died of diphtheria. 
 
 The man was accompanied by a collie, which was hugged and fondled 
 by the four-year-old son of the minister. Within a few days the boy was 
 ill with diphtheria, having no doubt received the infection from the collie. 
 It may also be conveyed by towels, table-linen and dishes, bedding, books, 
 wall-paper, carpets, rugs, clothing, and all other articles bathed in the 
 germ-laden atmosphere surrounding a diphtheritic patient. Food, 
 especially milk, may be the source of infection. 
 
 The hands and the clothing of physicians, nurses, and parents should 
 be mentioned as sources of infection. 
 
 The custom of serving the elements at communion services in churches 
 from common cups is to be condemned as a possible mode of conveying 
 contagious diseases. Individual cups should be used, thereby minimizing 
 if not absolutely removing the danger. The church should be as cleanly 
 in its table manners as its individual members are in their homes. There 
 they do not think of drinking from a common vessel, each member and 
 each guest being provided with one for his individual use. The same 
 decent, cleanly, sanitary custom should prevail in ecclesiastical functions. 
 
 Diphtheria may be endemic, epidemic, or sporadic in its manifestations 
 in a community. The mode of manifestation is largely due to the density 
 and the numerical strength of the settlement. In large cities, where 
 large numbers are congregated in small areas, diphtheria is epidemic, 
 coming as a tidal wave of infection and carrying many away in its course. 
 The community may then be free from the disease for months or years. 
 The sporadic or isolated cases are more difficult to explain, but we 
 know that the Klebs-Loeffler bacilli must be present. They may live 
 under varying and peculiar conditions for a long time. The sporadic 
 cases are often caused by the germs, which suddenly become virulent 
 and give rise to the isolated attacks of the disease. 
 
 Bacteriology. — The Klebs-Loeffler bacillus being the specific cause of 
 diphtheria, its characteristics and the method for its detection are im- 
 portant. The announcement of Klebs in 1883 that he had discovered a 
 bacillus which was constantly present in the false membrane of diph- 
 theritic patients, marked an epoch in the history of medicine, and soon 
 revolutionized the methods of treating diphtheria. Loeffler in 1884 made 
 pure cultures of the bacilli, and inoculated the mucous membranes of 
 animals, getting the characteristic pseudomembrane of diphtheria. In 
 1888-89, Roux and Yersin reported the results of their experiments rela- 
 
DIPHTHERIA 455 
 
 tive to the toxins produced by this germ. Serumtherapy thus had its 
 beginning. 
 
 The Klebs-Loeffler bacilli vary greatly in size, shape, and curvature, 
 according to the medium in which they are grown, and often vary in the 
 same medium. They also vary with the fluidity, the age, and the tempera- 
 ture of the medium, but they generally present the appearance of narrow 
 rods, straight or curved, swollen at either extremity, and are found in 
 groups with a tendency to parallelism. They are not always parallel, 
 but may have a tangled, irregular arrangement, or be in broken chains. 
 
 The atypical forms may be thickened at one end only, or at the centre 
 of the rod, the extremities being pointed. They may also be lance-, 
 spindle-, or club-shaped, or even pear-shaped. One characteristic is 
 always present, namely, segmentation. 
 
 The Klebs-Loeffler bacilli stain readily with alkaline methylene blue 
 and many other aniline dyes. 
 
 Northrup gives the following directions for the preparation of Neisser's 
 stain and its application to the differentiation of the diphtheritic germ : 
 
 "No. I. — 1 gm. methylene blue dissolved, 20 c.c. of 96 per cent, alcohol, 
 90 c.c. distilled water, 50 c.c. glacial acetic acid. 
 
 "No. 2. — 2 gm. vesuvin to 1 liter of boiling distilled water. 
 
 "The culture is stained in No. 1 for one to three seconds, or even 
 somewhat longer; washed off in water and stained with No. 2 for three 
 to five seconds or longer; washed off and mounted. Colored in this 
 way, a twenty-four-hour-old culture on blood serum or bouillon will 
 show the body of the bacilli stained brownish yellow, while at one or both 
 ends may be frequently seen the so-called polar granules (Neisser-Ernst 
 bodies) as deeply colored blue, oval-shaped areas, the diameter of which 
 is greater than that of the bacillus in which they are found. The out- 
 lines of these bodies are sharply defined, and they are not peculiar to 
 true diphtheria bacilli, but are found occasionally in a slightly atypical 
 form in certain forms of pseudodiphtheria bacilli, especially in older 
 cultures." 
 
 The diphtheria bacilli may be grown upon blood serum, agar-agar, 
 bouillon, milk, etc., and they are pathogenic for pigeons, rabbits, guinea- 
 pigs, chickens, certain small birds, cattle, goats, and horses. 
 
 Bacteriological Diagnosis. — A portion of the pseudomembrane should 
 be removed from the throat of the patient with an aseptic cotton-wound 
 probe, wire loop, or other instrument, and smeared over a clean cover- 
 glass, dried and stained with Roux's double stain of dahlia violet and 
 methyl green, or with Loeffler's blue-staining solution. 
 
 The coverglass thus prepared should be mounted and examined with a 
 microscope. The diphtheritic bacilli, if present, will be readily recognized 
 by their typical appearance. If not found, a culture in blood serum 
 should be made, which, in from twelve to twenty-four hours, in a tempera- 
 ture of 37° C, will develop grayish colonies, the size of a pinhead, with 
 regular outline, the surface being dry. Held to the light, the periphery 
 is translucent, the centre being somewhat opaque, on account of its 
 greater thickness. 
 
456 DISEASES OF THE LARYNX 
 
 Upon the above appearances and reactions a fairly positive diagnosis 
 of diphtheria may be made. 
 
 The development of the streptococcus is much slower (twenty-four to 
 seventy-six hours), the colonies are white, and pinpoint in size. 
 
 The development of the staphylococcus is slower than that of the 
 diphtheritic bacillus, but faster than that of the streptococcus. It presents 
 the appearance of a flocculent or white colony much larger than a pin- 
 head, and has a halo-like border. The areas are darker in the centre. 
 
 A negative result with the microscopic examination, or with the cul- 
 tures, does not justify a positive statement that the case is not one of true 
 diphtheria. The author knows of an instance in which seven different 
 examinations were made by an expert bacteriologist and pathologist, 
 before the Klebs-Loeffler bacilli were found. 
 
 Mixed infection generally occurs, hence a case of simple diphtheria is 
 not commonly seen in practice. The Klebs-Loeffler bacilli are usually 
 associated with streptococci, staphylococci, and diplococci, and the symp- 
 toms and the progress of the disease are modified accordingly. Again, 
 virulent diphtheria bacilli may be present in a healthy throat without 
 giving rise to any symptoms. Should, however, these same bacilli be 
 lodged in a throat with enlarged, ragged tonsils, there is every prob- 
 ability that the person would be affected by true diphtheria. Mixed 
 infections are more serious than simple ones, as the accessory germs may 
 produce severe pathological changes, independent of the diphtheritic 
 process. 
 
 The Systematic Distribution of the Bacilli. — Many investigators report 
 the presence of Klebs-Loeffler bacilli in pneumonic areas and lymphatic 
 glands, but they are generally associated with other germs. They have 
 been found in the lungs, the spleen, the bone-marrow, the liver, the 
 nasal accessory sinuses, the heart's blood, and they are probably in 
 other tissues of the body. 
 
 Pseudodiphtheria Bacilli. — There are two schools of thought regarding 
 the so-called pseudobacilli of diphtheria: (a) The larger school holds 
 that the pseudodiphtheria bacillus is under no circumstances convertible 
 into the true diphtheria bacillus, (b) The smaller school holds that 
 the two germs are identical. The scope of this work will not permit of 
 a presentation of the data upon which these two schools of thought rest 
 their claims. Suffice it to say that the two germs are differentiated, 
 according to the first or larger school, by their mode of development on 
 various culture media, their morphology, and their pathogenicity. 
 
 Histopathology. — The distribution of the false membrane may involve 
 the mucous membrane of the nose, pharynx, tonsils, hard and soft 
 palate, mouth and lips, larynx, trachea, the bronchi from the largest 
 to the smallest, the ear, and abraded surfaces of the skin. The vagina, 
 the duodenum, the conjunctiva?, and other mucous membranes may 
 also be involved. 
 
 In about 75 per cent, of the cases the membrane is above the larynx. 
 In 15 per cent, of the cases the larynx is involved. Previous to the use 
 of antitoxin, autopsies often showed the pseudomembrane extending 
 
DIPHTHERIA 457 
 
 from the tip of the nose to the smallest bronchi; since the use of antitoxin 
 it is rarely found so extensively distributed. 
 
 The appearance of the pseudomembrane varies from a pale yellow 
 through a dirty brown to a black color. Its consistency is usually tough 
 and leathery, although if may be friable. It is firmly attached to the 
 underlying tissues when found on the uvula or the pharyngeal wall, 
 and loosely attached in the trachea. 
 
 The formation of the pseudomembrane begins with an exudation of 
 lymphatic cells, which rapidly undergo coagulative necrosis, leaving a 
 reticulated substance composed of fibrin from the broken-down cells. 
 
 If the fibrin penetrates the deeper layers of the mucosa, it is difficult 
 to remove it, as the line of demarcation is not easily established between 
 the living and the dead tissue. If, on the other hand, the fibrin remains 
 superficially attached, it is easily removed, for obvious reasons. When 
 the pseudomembrane is deeply attached, its removal is attended by some 
 bleeding; if superficially attached, there is no bleeding. 
 
 Sloughing of the mucous membrane may occur when the bloodvessels 
 supplying it become degenerated, thrombosed, or otherwise injured, so 
 that the nutrition supplied to the parts is shut off. This is often spoken 
 of as "gangrenous diphtheria." 
 
 It is seen by the foregoing statement of the varying appearances and 
 conditions of the pseudomembrane of diphtheria that the picture pre- 
 sented is kaleidoscopic in character. Its appearance in the early stage 
 is usually as a whitish or yellowish, circumscribed film, and, at a still 
 later period, it may become yellowish or dirty brown in color. If hemor- 
 rhage takes place beneath or within the false membrane, it may become 
 black. 
 
 According to Northrup, the pathological changes in various parts of 
 the body have been shown by numerous writers, and only a brief men- 
 tion of them can be made here. 
 
 The nervous system is involved in some cases with degeneration of 
 the posterior roots (Bikeles and Kalisko) where they enter the gray 
 matter of the posterior cornua, thus accounting for the ataxic symptoms 
 which occur in diphtheritic paralysis. Manicatide reports his findings 
 as follows: 
 
 (a) Purely muscular changes with no nerve involvement. 
 
 (6) Polyneuritis. 
 
 (c) Lesions of the spinal cord, which were either localized in the gray 
 matter, leading to atrophy of muscles, or involving the white matter of 
 the cord, in a similar way to that seen in locomotor ataxia or multiple 
 sclerosis. 
 
 (d) Cerebral paralysis, chiefly due to circulatory changes. 
 
 The heart undergoes degeneration, chiefly fatty. This simple type 
 of degeneration precedes the more destructive hyaline changes, which 
 lead to the loss of the sarcous elements. The changes are due to 
 toxins. 
 
 The lungs are, in about 60 per cent, of cases, affected by broncho- 
 pneumonia. True lobar pneumonia has not been found. 
 
458 DISEASES OF THE LARYNX 
 
 The spleen is affected by cell infiltration in the splenic follicles. In the 
 centres of the follicles masses of epithelial cells are sometimes found. 
 There is local edema of the centre or the periphery of the follicles. 
 Necrotic areas and hyaline changes are also present. No bacteria have 
 been found in sections of the spleen. 
 
 The lympatic glands first undergo congestion and hemorrhage and 
 there is dilatation of the lymphatic sinuses. Later, foci very similar 
 to miliary tubercles form, by a process of proliferation, phagocytosis, 
 and degeneration. These changes are due to the toxins formed by the 
 lymphatics and not to bacteria. The same changes, with minor modi- 
 fications, take place in the tonsils. 
 
 The thymus gland undergoes the same changes as described under 
 lymphatic glands. 
 
 The skeletal muscles undergo fatty degeneration. 
 
 The bone marrow undergoes hyperplastic changes. 
 
 The pancreas has not been found involved in autopsies following true 
 diphtheria. Hibbard and Morrissy found glycosuria in 25 per cent, 
 of 230 patients. Others have failed to find it so commonly present. 
 Examinations for sugar should be made in every case of diphtheria. 
 
 The alimentary canal may be affected by true diphtheria of the stomach. 
 The pseudomembrane has not been found in the intestine. 
 
 The liver undergoes degenerative changes, ranging from simple fatty 
 to hyaline degeneration. Focal necrosis is the most characteristic change 
 in this organ in diphtheria. 
 
 The kidneys undergo fatty and hyaline degeneration. Casts are pres- 
 ent. There are also interstitial changes in about 25 per cent, of cases 
 examined. There is an increase in the cells of the glomeruli, and some- 
 times necrosis with hemorrhage into the capsular space is present. 
 
 Types of Diphtheria. — Before considering the symptomatology, it 
 will be well to consider briefly the various types of diphtheritic mani- 
 festations. It is often described, according to the seat of local manifesta- 
 tion as angina, local or general; nasal diphtheria; bronchial diphtheria; 
 broncholaryngeal (ascending) diphtheria; conjunctival diphtheria; aural 
 diphtheria; vaginal and rectal diphtheria, etc. 
 
 Monti's classification, according to Northrup, in Nothnagel's Encyclo- 
 pedia of Practical Medicine, is as follows : 
 
 Catarrhal Diphtheria (Bacteriological Diphtheria; Diphtheria Fruste). — 
 This type is characterized by simple redness and swelling of the tonsils 
 and the pharynx, with no false membrane. Microscopic examination 
 shows the Klebs-Loeffler bacilli present. Spontaneous recovery occurs 
 in a few days. The germs, transplanted into another throat, might give 
 rise to a more severe type. Careful quarantine should be maintained 
 to prevent the spread of the disease. 
 
 Fibrinous Diphtheria. — This type is due to the action of the Klebs- 
 Loeffler bacilli uncomplicated by any other germ. It may be purely 
 local in its character, the membrane and the slight redness surrounding 
 it being the only symptoms; or it may be general, with a tendency for 
 the false membrane to spread to other parts, with great toxemia and 
 
DIPHTHERIA 459 
 
 severe complications. It is more often local in its manifestations. Micro- 
 scopic findings : the Klebs-Loeffler bacilli. 
 
 Mixed, Phlegmonous, or Streptodiphtheria. — This type is characterized 
 by great inflammatory reaction in the neighborhood of the pseudomem- 
 brane, and by the presence of the Klebs-Loeffler bacilli with some other 
 pathogenic organism, usually the streptococcus, and their toxins. Mixed 
 infections are more dangerous, and experiments on animals (Roux and 
 Martin) show that antitoxin has little or no effect in checking the ravages 
 of this type of infection. 
 
 Septic or Gangrenous Diphtheria (Septicemia). — In dealing with this 
 type, we are essentially treating septicemia of diphtheritic or of mixed 
 infectious origin. It is usually of mixed infection (Klebs-Loeffler, strepto- 
 cocci, and staphylococci) origin, although in rarer cases it seems to 
 originate from the simple Klebs-Loeffler bacillus infection, which has 
 assumed the so-called gangrenous diphtheria type. In other words, 
 what started out as a simple diphtheria later became complicated by 
 other germs and their toxins, a true septicemia resulting. It is doubtful 
 if true septicemia ever results from pure Klebs-Loeffler bacillus in- 
 fection. 
 
 General Symptomatology. — The disease is ushered in by a feeling of 
 discomfort, lassitude, loss of appetite, constipation, slight sore throat, 
 difficulty in swallowing, and more or less hoarseness. 
 
 The temperature varies with the type, but has certain characteristics 
 which may be recognized. For instance, even in the fibrinous type, 
 which is the least febrile, there is a rise of temperature with the beginning 
 of the formation of the membrane. It is commonly said that this type is 
 not attended with fever. Notwithstanding, it will be found, and there will 
 be a recurrence of elevated temperature with each extension of the pseudo- 
 membrane to a new part. In all types of diphtheria there is an increase 
 of temperature with each extension of the local field of infection. There 
 is a greater fluctuation of the temperature curve in the mixed infec- 
 tion and the septic type than there is in the catarrhal and the fibrinous 
 varieties. 
 
 The pulse rate is invariably increased in uncomplicated cases in the 
 beginning, in proportion to the toxic products eliminated. The pulse 
 rate in infants is especially high. 
 
 Brachycardia (slowing of the pulse rate), if persistent, is a grave 
 symptom. 
 
 Tachycardia (increased pulse rate), when reaching a rate of 140 or 
 more, is a grave symptom. At 140 the death rate is about 20 per cent., 
 increasing to 90 per cent, at a pulse rate of 180. Nasal diphtheria is 
 usually the cause of the tachycardia, hence the occurrence of a rapid 
 pulse should at once lead to a critical examination of the nasal fossae. 
 The nose is very richly supplied with lymphatic tissue, hence the rapid 
 absorption and the toxic symptoms. 
 
 Reduced blood pressure, as shown by sphygmographic tracings, indicates 
 an increased absorption of diphtheria toxins, and warrants a grave 
 prognosis. The same is true of an intermittent pulse. 
 
460 DISEASES OF THE LARYNX 
 
 Partial angina is the most common anatomical form of the disease". 
 Early there is a general redness of the pharynx and the pillars of the 
 fauces. At the site of pseudomembrane formation, which is usually 
 the tonsil, there is increased redness. It may form, however, on the 
 posterior pillars, the uvula, or the walls of the pharynx. First one tonsil 
 is involved, then the other. The cervical glands are somewhat swollen 
 and tender. The temperature is elevated 1° to 2° with frequent oscilla- 
 tions. The general health is good. There is transient albuminuria. The 
 course is from six to eight days. 
 
 General or toxic angina is characterized by a thicker and more exten- 
 sive pseudomembrane, gray or dirty yellow in color, or even brown or 
 black. The whole, or nearly the whole, of the tonsils, the pillars (arch), 
 the uvula, and the pharynx are covered by the membrane in from three 
 to six days. Grave symptoms appear early, and are usually ushered in by 
 a chill followed by fever. Delirium, restlessness, apathy, and vomiting- 
 are often present. Swallowing becomes difficult on account of the 
 swollen and stiffened condition of the fauces and the pharynx. The 
 epipharynx (nasopharynx) is filled with tenacious mucus. The cervical 
 glands are swollen and tender. Albuminuria is severe. Without treat- 
 ment the pseudomembrane may be cast off and be reformed, continu- 
 ing thus for three to six weeks. Under proper treatment the disease 
 may be brought under control in from three to six days. 
 
 Phlegmonous or streptodiphtheritic angina involves the entire throat 
 from the beginning. The mucous membrane is dark red, and the uvula 
 swollen. Within a few hours a dirty gray or blackish membrane forms, 
 and rapidly spreads. The cervical glands are much swollen and very 
 tender. While the membrane is forming and spreading, the temperature 
 is elevated. Toxic symptoms, as rapid pulse, delirium, restlessness, 
 apathy, etc., set in after the membrane has reached its limit. The tem- 
 perature usually drops at this time. Albuminuria often appears within 
 forty-eight hours. Under antitoxin treatment the disease may be con- 
 trolled in from five to six days. In obstinate cases the kidneys and the 
 heart may become involved and thus complicate the case. 
 
 Septic angina is characteristic of certain epidemics, although it usually 
 develops from the phlegmonous variety. The symptoms are most grave 
 from the beginning. Vomiting is violent and attended with extreme 
 prostration. The temperature curve rises very suddenly. The pulse 
 is small, soft, and rapid. Respiration is increased proportionately. 
 The tonsils and the fauces are swollen. They are a livid bluish white, 
 with discolored spots. Bloody matter is mixed with the exudate. The 
 cervical glands are very much swollen and tender on both sides. Death 
 occurs usually on the second to the fourth day, from collapse and general 
 sepsis. 
 
 Diphtheria of the nose may assume any one of the foregoing types, 
 although it is probably more often of the simple fibrinous type. It 
 may be primary or secondary. The upper lip is excoriated by the nasal 
 discharge. The child " snuffles, " sleeps a great deal, and takes food 
 poorly on account of the nasal occlusion, and he may become cyanotic 
 
DIPHTHERIA 461 
 
 in attempting to nurse the breast. The glands of the neck are swollen. 
 Nasal hemorrhages occasionally take place. Many cases run a benign 
 course, while others are malignant from the beginning, death occurring 
 within a few days. In older children the disease runs a more favorable 
 course. In scrofulous children it may be more chronic, often extending 
 over many weeks. 
 
 The nasal occlusion is at first thought by the parent to be due to 
 a foreign body in the nose. The membrane is usually situated on the 
 septum, although it frequently involves the whole Schneiderian membrane, 
 and may be removed with the forceps or the syringe, as a cast of the 
 interior of the nose. 
 
 In phlegmonous, mixed, or streptodiphtheria of the nose the symptoms 
 are more severe from the beginning, the membrane is mixed with blood 
 and appears black (black diphtheria). Toxic symptoms are marked, 
 and the glands of the neck much swollen and tender. The patients 
 are little inclined to take food. Early and vigorous treatment is often 
 followed by recovery. The disease is, however, to be regarded as very 
 grave in its nature. On account of the rich lymphatic supply of the nose, 
 the septic form of nasal diphtheria is especially serious. 
 
 Laryngeal Diphtheria (True Croup; Membranous Croup; Diphtheritic 
 Croup, Etc.). — Laryngeal diphtheria may be primary, although it is 
 usually secondary to diphtheria of the nose, the pharynx and tonsils, 
 the trachea and the bronchi. On account of the great danger, and at 
 the same time a possibility of a favorable issue under proper treatment, 
 we will, according to Northrup, enter into a brief but careful analysis of 
 this type of diphtheria. It should be studied under three headings, 
 namely: (1) stage of invasion; (2) stage of spasm — exudation; (3) 
 stage of asphyxia. 
 
 Stage of Invasion. — This is characterized by a simple angina becoming 
 suddenly complicated with hoarseness, and a cough characteristic of 
 laryngeal irritation. The Klebs-Loeffler bacillus may or may not be 
 found. A negative finding is not conclusive, however, as heretofore stated . 
 
 Stage of Spasm (Exudation). — The pseudomembrane may develop so 
 rapidly that within twenty-four hours there is laryngeal stenosis. The 
 cough is dry, short, and hoarse, becoming paroxysmal in character and 
 often lasting for several minutes. It is attended with cyanosis, full veins, 
 and a perspiring forehead. Aphonia, more or less complete, soon 
 develops. The respiration is wheezing and noisy. As the stenosis 
 becomes more advanced, the inspiratory act is prolonged and is attended 
 with a whistling noise. There is pronounced depression of the supra- 
 clavicular region, the neck, and the epigastrium. The severe symptoms 
 come in waves; extreme cyanosis, and harsh, difficult respiration, which 
 gives way, temporarily, thus affording the sufferer a brief respite from 
 the aggravated symptoms. The natural duration of this stage is from 
 one-half to seven days. 
 
 Stage of Asphyxia. — This stage is characterized by greatly impeded 
 respiration and toxic symptoms. The respiration becomes more rapid 
 and irregular, the child sits up suddenly, and falls back again exhausted. 
 
462 DISEASES OF THE LARYNX 
 
 The cyanosis and the retraction of the supraclavicular, the jugular, and 
 the epigastric regions is more pronounced. The suffocative attacks occur 
 more frequently. The head is thrown back, and all the accessory muscles 
 of respiration are called into action. Even the abdominal muscles 
 are retracted. The larynx rises with each respiratory effort. During 
 one of the suffocative attacks, complicated with convulsions, death 
 comes. According to Monti, in untreated cases the death rate is from 
 95 per cent, to 98 per cent. Under modern methods of treatment the 
 death rate is small in cases taken early. 
 
 Phlegmonous or Mixed Infection of the Larynx. — It is usually secondary 
 to a similar process in the nose or the throat, and is characterized by 
 great redness of the mucosa of the larynx and the trachea, with some 
 grayish pseudomembrane scattered here and there in the larynx and the 
 trachea. The stenosis of the larynx is not so marked as in the preceding 
 type, nevertheless, death may occur suddenly from it. The toxic symp- 
 toms are also marked in this type, and no doubt contribute toward 
 a fatal result. 
 
 Septic Diphtheria of the Larynx. — This is also secondary to a similar 
 process in the nose or the throat, or both, and begins with fever, apathy, 
 and marked weakness. The mucous membrane of the larynx and the 
 nose is swollen, and covered with a grayish-yellow exudate. Toxic 
 symptoms, as vomiting, delirium, suppression of urine, heavily coated 
 tongue, rapid pulse, etc., are marked. The prognosis is quite grave. 
 
 Causes of Asphyxia in Diphtheria. — Four theories have been advanced : 
 (a) spasm of the glottis; (b) obstruction by pseudomembrane; (c) 
 paralysis of the dilators of the glottis; (d) excitation of the respiratory 
 centres by carbonic acid poisoning, and reflex action of the pneumo- 
 gastric nerve. 
 
 Autopsies have shown many instances of death from asphyxia when 
 there was little or no false membrane to account for it. This leaves spasm 
 of the glottis, paralysis of the dilators, and the irritation from carbonic 
 acid as possible theoretical explanations. The latter two have but few 
 supporters; hence, the probable explanation of the majority of cases is 
 to be found in the first theory, namely, spasm of the muscles of the 
 larynx. 
 
 Diphtheria of the Trachea and the Bronchi. — This is usually second- 
 ary to laryngeal diphtheria, although it may occur primarily in the bronchi 
 or the trachea. Where it thus forms, and the larynx is secondarily 
 involved, it is known as "ascending croup." If a cast of the bronchi is 
 coughed up, it is a positive sign of bronchial involvement. Other signs, 
 as respirations 50 to 60 per minute, continuous dyspnea (as contrasted 
 with intermittent when the pseudomembrane is in the larynx and upper 
 trachea), supraclavicular and epigastric depressions not so well marked, 
 pale face, blue lips, and great physical depression, may aid in reaching 
 a diagnosis of bronchial diphtheria. The prognosis is very grave. 
 
 Diphtheria of the Ear. — This is usually carried to the external ear 
 by scratching (abrasion) with the infected fingers of the patient. Infec- 
 tion of the external auditory meatus is seen in rare instances in which 
 
DIPHTHERIA 463 
 
 there is diphtheritic otitis media with extension through the tympanic 
 membrane. 
 
 Otitis media as a complication of diphtheria, occurs in only about 4 to 
 6 per cent, of the cases. When present it is characterized by deafness 
 and pain in the ear upon swallowing and coughing; these are followed 
 by aural discharge, after which the pain subsides. 
 
 Diagnosis. — The differential diagnosis of diphtheria should be made 
 between (a) peritonsillar abscess; (b) follicular tonsillitis; (c) pseudo- 
 diphtheria; (d) pseudocroup; and (e) catarrhal rhinitis; the chief diag- 
 nostic point in each case are the microscopic and the culture findings. 
 
 Prognosis. — This may be summarized under the following headings: 
 
 (a) The Age of the Patient. — The mortality is the lowest in the first 
 year and the tenth year, and the highest in the second to the sixth year 
 of life. 
 
 (b) The Site of the Local Lesion. — Involvement of the larynx results 
 in the highest mortality. Nasal diphtheria in infants is very fatal. 
 
 Treatment. — The administration of antitoxin has reduced the cases 
 coming to operation one-half. The death rate in laryngeal cases under 
 antitoxin has been reduced from 70 per cent, to 16 per cent. Intubation 
 is attended with a lower rate of mortality than tracheotomy. 
 
 Time of Beginning Treatment. — Briggs and Guerard have compiled 
 the following table: 
 
 Mortality. 
 
 Cases. Deaths Percent. 
 
 First day of disease 1415 5 3.5 
 
 Second day of disease 2640 213 8.0 
 
 Third day of disease 2340 300 12.8 
 
 Fourth day of disease 1458 346 23.6 
 
 Fifth day of disease 1912 671 35.0 
 
 It will be seen bv the foregoing table that earlv treatment influences 
 the prognosis very favorably. 
 
 Complications and Sequelae of Diphtheria. — Adenopathy. — Swelling 
 of the lymphatic glands in the region of the local diphtheritic lesion 
 usually occurs. The cervical glands and the tonsils are accordingly most 
 commonly affected. After these come the bronchial, the intestinal, and 
 the mesenteric glands. 
 
 In the pare diphtheria, ?". e., the simple fibrinous type, the glands are 
 swollen, slightly tender, and freely movable in the surrounding tissue. 
 
 In the mixed forms of infection there is greater swelling and tenderness, 
 the glands being lost to the touch in the surrounding swollen and infil- 
 trated tissue. In some cases the swelling is enormous, constituting the 
 symptom known as "le con proconsulair." Suppuration occurs only 
 occasionally, and then only in the mixed type. In the septic type gan- 
 grenous sloughing may occur. Treatment often results in recovery 
 from even severe diphtheritic adenopathy. 
 
 Gastro-intestinal. — Vomiting, loss of appetite, diarrhea, and diphtheria 
 of the esophagus and the stomach sometimes occur. 
 
 Urine. — The urine is variable in quantity and chemical proportions. 
 Albuminuria is present in about one-half of all cases of diphtheria 
 
464 DISEASES OF THE LARYNX 
 
 and in nearly all cases of the toxic varieties. It is generally due to de- 
 generative changes in the kidneys. Hyaline, granular, and epithelial 
 casts may be found. 
 
 According to Simon, in diphtheria a well-marked increase of urine is 
 the rule, and with the exception of very mild or extremely severe cases, 
 of constant occurrence. It is interesting to note that, barring a tempo- 
 rary diminution immediately after the injection, the leukocytosis is 
 nowise influenced by the antitoxin treatment. 
 
 Hyperleukocytosis. — This exists in nearly all cases, and varies accord- 
 ing to the toxemia and the sepsis. It may be so severe as to constitute 
 a true leukemia. 
 
 Heart Lesions. — Endocarditis, myocarditis, waxy degeneration, nerve 
 degeneration, heart clots, and dilatation have been found in certain 
 cases which were examined post mortem. 
 
 Nervous Affections. — Degeneration of nerve tissue, paralysis, lessened 
 functional activity, etc., sometimes attend, but more often follow, an 
 attack of diphtheria. 
 
 Postdiphtheritic Paralysis. — Postdiphtheritic paralysis usually affects 
 the velum palati (benign and discrete form) and the pharynx. The 
 chief symptom is difficulty in swallowing and the return of liquids through 
 the nose. Each act of swallowing is accompanied by a laryngeal cough. 
 The voice is nasal, articulation is very much interfered with, and the 
 patient snores during sleep. The paralysis disappears in from one to 
 three weeks. 
 
 In the general or diffused postdiphtheritic paralysis the palatal and the 
 neighboring muscles are involved. The muscles of the eye are most 
 frequently affected. Unequal pupils, diplopia, strabismus, or ptosis 
 may be present. Complete recovery eventually takes place. The patellar 
 reflex is impaired, or lost, and the muscles of the feet may be paralyzed. 
 The patients shuffle their feet on the floor in walking. " Diphtheritic 
 pseudotabes," or even complete paralysis of the lower extremities, may 
 complicate some cases. The muscles of the upper extremities are less 
 often affected. The muscles of the neck and the head are rarely involved. 
 If they are, the child's head falls over on his shoulder. The facial expres- 
 sion may be lost, giving an idiotic cast to the countenance. 
 
 Diaphragmatic paralysis occurs in about 7 per cent, of cases, and may 
 lead to a fatal termination. The chief sign of diaphragmatic paralysis 
 is a sinking in of the abdomen during inspiration, and distention during 
 expiration. Respiration is rapid and panting. Bronchitis or other 
 slight lesion of the lower respiratory tubes may lead to asphyxiation and 
 death. 
 
 Cardiac or vagus paralysis complicates about 1 per cent, of the cases. 
 
 Skin. — Erythema, papular eruption, brownish discolorations, and 
 eruptions of the skin, like those of measles and scarlet fever, may com- 
 plicate the disease. 
 
 Bronchopneumonia. — This is a serious complication, and often causes 
 death after tracheotomy and intubation. It is ushered in by a rise of 
 temperature, increased cyanosis (in laryngeal cases), change of the 
 
DIPHTHERIA 465 
 
 respiration-pulse ratio from normal 1.4 to 1.3. At first the physical 
 signs are those of diffuse bronchitis, later of consolidation over several 
 areas. 
 
 Prophylaxis. — The following rules should be observed in preventing 
 the spread of diphtheria. (Abstracted from the Rules of the Health 
 Department, City of New York.) 
 
 1. No one but the attendant and the physician should be permitted 
 to enter the sick-chamber. 
 
 2. The discharge from the nose and mouth should be received on 
 cloths provided for the purpose, and immersed for two or three hours in 
 a solution composed of six ounces of carbolic acid dissolved in one to 
 two gallons of hot water, and then boiled in soap-suds for one hour. 
 All bed and personal clothing used about the patient should be similarly 
 treated inside the sick-room. 
 
 3. The hands of the attendant and the physician should be washed 
 in the same carbolic acid solution, and washed in soap-suds after making 
 applications or handling the patient, and before eating. 
 
 4. Surfaces soiled by discharges should at once be flooded with carbolic 
 acid solution. 
 
 5. Table utensils used by the patient should be kept in the sick-room, 
 for his especial use, and should be washed in carbolic acid solution and 
 then in hot soap-suds. The vessel containing the soap-suds should then 
 be washed in the carbolic acid solution. 
 
 6. The sick-room should be aired two or three times daily, and swept 
 frequently after scattering sawdust, wet tea-leaves, etc., on the floor 
 to prevent the dust from rising. The furniture and the woodwork should 
 be wiped with damp cloths. The sweepings should be burned, and the 
 cloths soaked in the carbolic acid solution. 
 
 7. All unnecessary articles of furniture, pictures, draperies, clothing, 
 etc., should be removed from the room as soon as the nature of the malady 
 is recognized. 
 
 8. When the patient has recovered, he should receive a hot soap-suds 
 bath, including his hair; clean clothes should be put on, and he should 
 be removed from the sick-room. He should be kept in quarantine 
 as long as cultures of the diphtheria germ can be obtained from his 
 throat. 
 
 In addition to the rules given in regard to the patient and the sick- 
 room, the physician and the nurses should protect their clothing by 
 wearing long gowns, which should be kept just outside the patient's 
 room. 
 
 9. They should also be given immunizing doses of antitoxin. 
 
 10. The room should be scrubbed with bichloride of mercury solution, 
 1 to 1000, all over, the woodwork repainted or varnished, the walls cleaned 
 and repapered, and the furniture sterilized with formaldehyde vapor. 
 In the case of upholstered furniture, disinfection can be more thoroughly 
 done by steam. 
 
 11. The periodical inspection of public schools by a corps of physicians 
 will do much toward limiting the spread of the disease. 
 
 30 
 
466 DISEASES OF THE LARYNX 
 
 Immunization by Antitoxin. — An immunizing dose of antitoxin ranges 
 from 100 to 500 units, according to the age of the patient and the length 
 of time immunity is desired. In an average case 100 units will be effec- 
 tive for ten days, while 500 units will be so for twenty-eight days. 
 
 Treatment of Diphtheria. — The treatment may be divided into (1) 
 local, (2) general, and (3) measures for the relief of the suffocation. 
 
 Local Treatment. — This consists in the use of an antiseptic solution, 
 such as boracic acid, chloride of sodium, etc., at a temperature of 110°, 
 with a fountain syringe. The patient should be wrapped tightly in a 
 sheet fixed with safety pins. He should be placed upon his side and the 
 glass or hard-rubber nozzle of the syringe applied to one nostril, the fluid 
 flowing out at the other, until it comes forth clean. The patient's mouth 
 should be held open with a spool or a mouth gag, to prevent swallowing, 
 as this act might force the solution into the middle ear and cause infec- 
 tion and mastoiditis. The pharynx should be treated in a similar man- 
 ner. If it is desirable to combat pain and swelling, the temperature of 
 the solution should be about 130°. The irrigations may be repeated at 
 intervals of six hours. 
 
 General Treatment. — The general treatment of diphtheria consists in 
 the administration of stimulants to overcome the depression, the weak 
 action of the heart, the irregular pulse, and the septic condition. Alcohol, 
 in the form of whisky or brandy, is the best for this purpose, and should 
 be given to an infant in 10 to 15 drop doses, well diluted with water, 
 three or four times a day. A child of three or four years may be given 
 an ounce in twenty-four hours. In septic cases much more can and 
 should be given. Strychnine is the second best stimulant. Dose, child 
 one year old, T l^ grain every two or three hours. Child three to four 
 years old, fa grain every two or three hours. 
 
 Sedatives should be given to relieve restlessness, cough, and spasm 
 (second stage) in laryngeal cases. Morphine may be given in fa to fa gr. 
 doses. Emetics may be given to overcome spasms and to remove mucus 
 in laryngeal cases. 
 
 Antitoxin in Diphtheria. — The value of antitoxin is shown by a compari- 
 son of the following tables : 
 
 Table I. — By Briggs and Guerard. 
 
 Treated with antitoxin. Mortality. 
 
 Ages. Cases. Deaths. Per cent. 
 
 0-2 years 1494 469 31.4 
 
 2-5 years 3678 762 20.7 
 
 5-10 years 3184 473 14.8 
 
 Over 10 years 1444 99 6.0 
 
 Table II. — By Babinsky. 
 
 Not treated with antitoxin. Mortality. 
 
 Ages Per cent. 
 
 0-2 years 63.3 
 
 2-4 years 52.8 
 
 4-6 years ; 37.9 
 
 6-10 years . . . 24.6 
 
 10-15 years 14.6 
 
DIPHTHERIA 467 
 
 The advantages of the antitoxin over the other methods of treatment 
 at the various ages is strikingly shown by a comparison of the foregoing 
 tables, and needs no further comment. 
 
 Antitoxin in laryngeal cases is valuable in two ways, namely: (a) It 
 prevents many cases coming to the operative stage, and (b) it affects 
 favorably the intubated and tracheotomized cases. Statistics show 
 that it affects the intubated cases more favorably than it does those upon 
 which tracheotomy has been performed. 
 
 Antitoxin seems to increase paralysis rather than to decrease it. This 
 is perhaps explained by the fact that cases treated with antitoxin live 
 longer, and thus give more time for it to develop. Many more severe 
 cases survive. 
 
 Injections of antitoxin often produce a transient albuminuria. 
 
 Dosage and Clinical Administration of Antitoxin. — The following 
 dosage is recommended : (a) 2000 to 3000 units in ordinary diphtheria to 
 a child over one year old; (b) 3000 to 5000 units in severe laryngeal cases 
 of any age; (c) 1500 to 2000 units to an ordinary case in a child under 
 one year old. 
 
 Repeat the dose in twelve hours, or less, if the symptoms are increasing, 
 and in eighteen to twenty-four hours if there is no decided improve- 
 ment. 
 
 A third dose may be given, if needed, in twenty-four hours. 
 
 An ordinary sterilized hypodermic syringe holding 5 c.c. is suitable 
 for making the injections. The skin should be cleansed with an anti- 
 septic solution. 
 
 Place of Injection. — The skin of the thigh, the posterior axillary line of 
 the chest, or the abdomen are favorable locations. 
 
 Effects of Antitoxin on the Pscudomcmbrane. — In a few hours after the 
 injection the pseudomembrane becomes blanched, the dirty color less 
 marked, and the membrane more granular and swollen. Later it becomes 
 loosened around its edges, rolls up, and detaches itself spontaneously 
 or after irrigation. If the membrane returns repeat the dose of antitoxin 
 at once. 
 
 Effects on the Temperature. — In pure or simple diphtheria the tempera- 
 ture rapidly returns to the normal, whereas in the mixed cases it comes 
 down more slowly. If the temperature does not fall in the regular way, 
 a second injection is indicated, provided the temperature cannot be 
 accounted for by some complication. 
 
 Indications for Antitoxin. — 1. If it is suspected that the child has a 
 mild pharyngeal, nasal, buccal, conjunctival, or cutaneous case, give 
 antitoxin if he is over one year of age and there is a distinct history of 
 exposure. 
 
 2. If a laryngeal case is suspected, give antitoxin at once, and make 
 microscopic and cultural examinations afterward. 
 
 3. In all catarrhal cases antitoxin must be given. 
 
 4. In pseudodiphtheria, with repeated negative findings as regards 
 the Klebs-Loeffler bacilli, antitoxin need not be given. If in doubt, 
 however, give it. 
 
468 
 
 DISEASES OF THE LARYNX 
 
 Surgical Treatment. — Tracheotomy. — This operation is not now in 
 vogue, relatively, as it was in former years. Intubation is usually elected 
 in its stead, as it is a safer and surer means of tiding the patient over 
 the suffocative period. Nevertheless, there are still cases in which 
 tracheotomy is indicated. 
 
 The indications for tracheotomy are: (a) When intubation tubes are 
 not available, or if, for any reason, their use is not understood (Northrup) : 
 
 Fig. 291 
 
 Fig. 292 
 
 Tracheotomy tube. 
 
 (b) in excessive edema of the larynx, 
 where the intubation tube does not 
 give relief; (c) when the membrane 
 is in the lower tracheal tract, though 
 these cases are favorable for tra- 
 cheotomy. 
 
 The method of performing trache- 
 otomy now in use is known as the 
 high operation, in contradistinction 
 to tracheotome inferieure, as first 
 practised by Trousseau. In the low 
 position of Trousseau, the blood- 
 vessels passing over the field of 
 operation render the operation 
 difficult. 
 
 High tracheotomy is preferable. 
 It should be done under antiseptic 
 
 precautions, although this is not always practicable, on account of the 
 
 urgency for immediate relief. 
 
 Steps. — (a) The cricoid cartilage should be located with the index 
 
 finger of the left hand, while the larynx is held firmly but lightly between 
 
 the thumb and the second finger. 
 
 (b) The skin and the subcutaneous tissue should now be incised, 
 beginning with the location of the tip of the index finger, carrying it 
 downward in the median line \ inch to 1 inch (Fig. 291). 
 
 (c) With the tip of the index finger in the superior angle of the wound, 
 the bistoury should be passed under it into the trachea and the incision 
 
 The line of incision in upper tracheotomy 
 preparatory to laryngeal fissure or laryngec- 
 tomy. 
 
TRACHEOTOMY 
 
 469 
 
 carried downward in the median line far enough to admit the finger into 
 the wound. With the finger thus placed blood cannot enter the trachea. 
 A still better practice is first to check all bleeding with artery forceps or 
 ligatures, and then open the trachea. If suffocation is imminent, the 
 first method may be adopted. 
 
 (d) The cannula (Fig. 292) should be next introduced as the finger is 
 gradually withdrawn. If necessary, the dilator and the retractors may 
 be used. 
 
 (V) The cannula should now be secured in its position by pieces of tape 
 passed around the neck. 
 
 (f) If the suffocation is not relieved at once, there is either pseudo- 
 membrane still lower down in the trachea — perhaps a detached piece 
 over the orifice of the cannula — or the cannula has become filled with 
 mucus and shreds of pseudomembrane. In this event the inner cannula 
 should be removed and cleared of mucus, etc. 
 
 (g) If the removal of the inner cannula does not relieve the suffocation, 
 there is probably membrane low down in the trachea. 
 
 Fig. 293 
 
 Dwyer's intubation instruments. 
 
 The mishaps or accidents which may attend the operation are: (a) 
 failure to open into the trachea, especially in very fat children; (6) 
 hemorrhage where the incision is carried to either side or too far down- 
 ward; (c) an irregular or too small incision, making the introduction 
 of the cannula difficult; (d) secondary hemorrhage; (e) asphyxiation 
 from dislodged membrane ; (/) a too greatly retracted head, thus flatten- 
 ing the trachea and causing stenosis. 
 
 The after-effects of tracheotomy may be summarized as follows: (a) 
 disappearance of the cyanosis and suffocation; (b) sleep; (c) coughing 
 with expulsion of pieces of membrane and mucus through the cannula; 
 (d) slight fever of two to three days' duration. 
 
 The complications which may arise are: (a) infection of the tracheal 
 wound, the bronchi, and the lungs; (b) ulceration of the trachea at the 
 tip of the cannula; (c) erysipelas of the wound; (d) and most important 
 of all, bronchopneumonia from the second to the seventh day after the 
 operation. When this occurs the prognosis is very grave. 
 
470 
 
 DISEASES OF THE LARYNX 
 
 The after-treatment consists in: (a) the removal of the inner cannula 
 every two or three hours for cleansing; (b) the external cannula should 
 be removed and cleaned every twenty-four hours, the child being placed 
 flat on his back as in the operation — the wound should be cleansed 
 each time the external cannula is removed; (c) under antitoxin it is not 
 probable that the cannula will need to be worn after the third day, 
 whereas under the older methods of treatment it was usually worn a 
 week or more. 
 
 Fig. 294 
 
 The index finger of the left hand holding the epiglottis against the base of the tongue 
 preparatory to intubation. (After Shurley.) 
 
 The author recently removed the cannula from a child who had worn 
 it for four years. It was necessary first to dilate the glottis with curved 
 Heryng bougies introduced through the tracheal opening. After a few 
 treatments laryngeal respiration was sufficiently restored, and the tube 
 was removed. An attempt was afterward made to close the tracheal 
 wound, but the anterior wall of the cartilaginous rings of the trachea 
 had disappeared from pressure necrosis. The skin, when brought over 
 the wound, acted as a valve closing the trachea, and asphyxia resulted. 
 
 Intubation. — To O'Dwyer is due the credit of first practising intuba- 
 tion upon his patients. The tubes used at first were straight and easily 
 expelled. The tubes were gradually improved and their retention more 
 sure. At about this time Dr. F. E. Waxam successfully intubated a 
 
INTUBATION 471 
 
 patient in private practice. Dr. O'Dwyer was greatly encouraged by 
 Dr. Waxham's success, and improvement in the tubes and instruments 
 for their introduction and removal rapidly followed, and, though there 
 was much opposition, intubation became one of the recognized thera- 
 peutic measures in stenosis from laryngeal diphtheria and immortalized 
 O'Dwyer's name. 
 
 Fig. 295 
 
 The tube passing through the chink of the glottis, the index finger still holding the epiglottis 
 against the base of the tongue. A stout loop of thread is attached to the tube to provide for its 
 speedy removal in case suffocative symptoms follow its introduction, and in case it is accidentally 
 engaged in the esophagus. 
 
 The introduction of antitoxin has very greatly reduced the necessity 
 for intubation, though there are still many cases in which it is indicated. 
 
 Indications for Intubation. — (a) Great tracheal stenosis, as shown 
 by much retracted supraclavicular and epigastric areas, necessitates 
 the immediate resort to intubation, even though antitoxin has been 
 given and sufficient time has not elapsed for its favorable influence. If 
 milder suffocative symptoms are present, and antitoxin has been given, 
 intubation may be delayed pending the results of the antitoxin. Since 
 the use of antitoxin not one-half as many cases come to operation as 
 formerly, (b) If not within easy call, the physician may intubate without 
 waiting for marked suffocative symptoms. 
 
 Technique of Intubation. — The child is prepared for intubation by 
 wrapping it in a sheet or a blanket from the shoulders downward. The 
 
4?2 
 
 DISEASES OF THE LARYNX 
 
 sheet should be secured with strong safety pins, so as to bind the arms 
 and legs of the child. This being done, the nurse should sit upright in a 
 chair with the child upon her lap, his head resting against her left breast. 
 His legs should be secured between hers, and her right hand should grasp 
 his left, and her left hand his right. The assistant should stand behind 
 the nurse and hold the child's head between his hands, as though 
 suspending the child from the parietal walls of his cranium. A tube 
 (Fig. 296) of proper size, threaded with silk through its eyelet, should be 
 in readiness. The operator should stand or sit in front of the child, 
 
 Fig. 296 
 
 The tube in position in the larynx. The loop of thread is still attached, as the tube may hav< 
 to be removed by the nurse to relieve impending suffocative symptoms. 
 
 introduce the mouth gag, turn it over to the assistant, who holds it between 
 his hand and the patient's left cheek while the operator introduces 
 the index finger of his left hand and hooks it over the epiglottis (Figs. 
 294 and 295). Then, after crowding his finger as far to the left as possible, 
 the intubation tube, or the introducer, is carried into the mouth, imme- 
 diately over the centre of the posterior portion of the tongue, the handle 
 of the introducer being on the chest of the child. As the tip of the tube 
 passes back of the epiglottis under the finger of the operator, the handle 
 should be gradually elevated, until the tip of the tube is directly over 
 the chink of the glottis, when it should be suddenly lowered, thus pass- 
 
INTUBATION 
 
 473 
 
 ing the tube into the box of the larynx, and on downward into the 
 glottis and the trachea. The tip of the finger then engages the rim 
 at the head of the tube (Fig. 297), the introducer is loosened and removed, 
 and with a gentle pressure the tube is firmly pushed deep into the larynx 
 and the trachea. If, after waiting twenty to thirty minutes, the child 
 tolerates the tube, the loop of string should be cut (Figs. 296, 297, and 298), 
 the index finger reintroduced against the head of the tube, and the string 
 removed. For obvious reasons the child should be kept wrapped until 
 the string is removed. Fig. 299 shows a false entry of the tube into the 
 esophagus because the handle of the introducer was not sufficiently 
 elevated before the tube was dropped into the laryngeal box. 
 
 Fig. 297 
 
 The removal of the loop of thread, the index finger of the left hand being placed against the 
 head of the tube to prevent its displacement. 
 
 Intubation may also be performed in the dorsal position, the same 
 relative positions and steps being observed as in the upright position. 
 
 Extubation or the Removal of the Tube. — The removal of the tube 
 may be done by observing the same precautions as are used in intubation, 
 the index finger of the left hand guiding the extractor to the opening 
 in the tube (Fig. 300). Another method now occasionally used is to 
 leave the silk string attached, looping it over the left ear and securing it 
 to the cheek with adhesive plaster. The removal of the tube is thereby 
 
4?4 
 
 DISEASES OF THE LARYNX 
 
 rendered quite easy. It is also easy for the child to remove it, hence this 
 is a serious objection to the method. One grain of Dover's powder, or 
 A" t° iV g r - °f morphine, may be given a few minutes before extubation, 
 to prevent spasm and reintubation for its relief. 
 
 When to Remove the Tube. — Under antitoxin treatment the tube may 
 ordinarily, in a child over two years of age, be removed in from three to 
 five days. Should the tube become obstructed, it should be immediately 
 removed. 
 
 Fig. 298 
 
 The tube in position after the withdrawal of the thread. 
 
 Complications and Difficulties. — (a) If the finger of the operator is 
 short and stubby, it may be difficult to introduce the tube beside and 
 beneath it. (b) The tube may make a false passage through the ventricles 
 of the larynx, (c) The prolonged efforts of an awkward or inexperienced 
 operator may cause suffocative symptoms, (d) Transient spasm of the 
 glottis may cause temporary delay in introducing the tube, (e) The 
 narrowest point through which the tube must pass is the cricoid ring, and 
 edema or swelling at this point may give rise to some difficulty in intro- 
 ducing it. A smaller one may be passed with slight force. The action 
 of the tube in being expelled in this condition has been aptly said to 
 "creep back like an oiled cork in a bottle." (/) Prolonged retention of 
 the tube may be necessary on account of the persistence of the pseudo- 
 membrane, ulcerations about the cricoid cartilages, traumatisms, cica- 
 
INTUBATION 
 
 475 
 
 tricial contractions, edema, abductor paralysis, or exuberant granulations. 
 (g) More rarely, the tube may be swallowed (no danger from it), (h) 
 The tube may become obstructed by the thread or catgut being aspirated 
 into it and swollen by the secretions; even food may obstruct it. 
 
 The Feeding of Intubated Children. — Most cases take liquid food 
 very well when in the upright position, although some take it with pain 
 and cough. If the upright position is not practical, Casselberry's position 
 may be resorted to. It consists in placing the patient on his back with a 
 
 Fig 299 
 
 Making a false passage into the esophagus on account of lowering the handle of the obturator. 
 The tip of the tube should be introduced by the side of the finger tip, and the handle of the obturator 
 elevated until the tube stands perpendicularly, and then passed directly downward through the 
 chink of the glottis. 
 
 pillow beneath the shoulders, his head bent downward and backward at 
 an angle of 45 degrees, the legs being elevated (Fig. 301). Liquid or semi- 
 solid food may be given in this position. The child should be allowed to 
 swallow several times before assuming the upright position, to remove 
 the food from the epipharynx. Hillis places the patient upon his stomach, 
 as shown in Fig. 302. Gavage may be resorted to if the pharynx and 
 the larynx are not too swollen and painful. The tube should be intro- 
 duced through the nose and rapidly passed into the esophagus. Food 
 being poured into the funnel passes into the esophagus and the stomach. 
 
Fig. 300 
 
 The introduction of the obturator for the removal of the tube. The finger is first introduced 
 to lift the epiglottis and to guide the tip of the obturator into the intubation tube. 
 
 Fig. 301 
 
 
 Feeding an intubated child with a nursing bottle. Casselberry's position. The shoulders are 
 raised to allow the head to assume a lower position than the shoulders. 
 
INTUBATION 
 
 477 
 
 When removing the tube, pinch it to prevent the liquid passing into the 
 larynx as it comes out. 
 
 Feeding an intubated child through a rubber tube by suction. 
 
 Rectal alimentation may be resorted to if feeding by either of the 
 foregoing methods is not practicable. 
 
CHAPTEK XXVI. 
 
 PACHYDERMIA LARYNGIS. MALFORMATIONS AND DEFORMITIES. 
 
 PROLAPSE OF THE VENTRICLES. STENOSIS. 
 
 SUBGLOTTIC STENOSIS. 
 
 According to Chiari, the verrucous form of pachydermia is identical 
 with the papilloma of the laryngologist, and has no relation to the diffuse 
 form. Diffuse pachydermia may be primary, or it may be secondary 
 to some other affection of the larynx, such as tubercle or syphilis. In 
 Chiari's experience typical pachydermia is a very rare disease. He 
 describes the following forms: 
 
 1. The most frequent and mildest form is a thickening and loosening 
 of the epithelium of the interarytenoid fold and the vocal cords, such as 
 frequently occurs in chronic catarrh. The treatment is the same as 
 for chronic catarrhal laryngitis, and consists of inhalations, insufflations, 
 applications by means of a brush, and cauterization. The best applica- 
 tions are lactic acid and iodine. The nitrate of silver is apt to cause 
 increased thickening. Small singer's nodules may disappear under the 
 influence of rest and the application of the nitrate of silver in solution 
 or in the solid stick. If they are of considerable size, forceps should be 
 used to remove them. 
 
 2. The typical form of pachydermia laryngis (chorditis nodosa), as it 
 affects chiefly the vocal processes, calls for a plan of treatment varying 
 according to the circumstances of the case, authors differing greatly 
 in their opinions. Some recommend purely expectant treatment and 
 avoidance of tobacco, strong drinks, and the abuse of the voice; others 
 recommend the internal administration of the iodide of potassium, 
 which, though occasionally of some benefit, may also at times produce 
 general impairment of health. Chiari recommends the use of elec- 
 trolysis, as employed by Moll, of Arheim, a current of from 10 to 12 
 milliamperes being used for from three to five minutes at a time. He 
 considers it the best means of preventing recurrence, though good 
 results have also followed operative procedures. 
 
 3. Large genuine pachydermia growths in the interarytenoid space 
 interfere very materially with the voice. Unfortunately, treatment by 
 means of cutting forceps, hot or cold snares, etc., do not guarantee free- 
 dom from recurrence. 
 
 4. The last group includes those circumscribed thickenings, out- 
 growths, or nodules which accompany tuberculosis, syphilis, chronic 
 perichondritis, and perhaps also lupus, which have been referred to as 
 secondary or "accessory" pachydermia. The prognosis depends on their 
 etiology, as also does the treatment, the latter varying according to the 
 
MALFORMATIONS AND DEFORMITIES OF THE LARYNX 479 
 
 nature of the most distressing symptoms. Naturally the syphilitic form 
 is much more favorable than the tuberculous, though not infrequently 
 it resists specific remedies. Operative treatment of the same kind as 
 for the typical primary form is called for in suitable cases; that is, if the 
 general health is good and the respiration or voice is not seriously inter- 
 fered with by the local disease. The method of treatment which is most 
 highly recommended is the use of electrolysis by means of a bipolar 
 instrument with a current of from 10 to 15 ma. This causes no reaction, 
 and seems to protect against recurrence better than any other treatment. 
 There is no doubt that pachydermia laryngis, whether in the simplest 
 form in the interarytenoid space or in the typical form on the processus 
 vocalis, is only a symptom of chronic catarrh, and is not to be looked 
 upon as a disease itself. 
 
 MALFORMATIONS AND DEFORMITIES OF THE LARYNX. 
 
 Malformations of the larynx may be either congenital or acquired. 
 But little is known concerning the true cause of congenital malformations, 
 only that some paternal disease or taint acts as a predisposing factor. 
 Acquired deformities are the result of postnatal disease. 
 
 Malformations of congenital origin are often associated with arrested 
 development of the genitalia. The lungs, the bronchi, and the trachea 
 have the same embryological origin (the foregut) as the larynx, hence 
 in malformations of the larynx there is also a similar defect in these 
 organs. In monstrosities having no larynx the lungs are also absent. 
 If the larynx is diminutive the lungs are likewise affected. Of the other 
 congenital deformities, webs or bands across the glottis are a common 
 form. The webs usually connect the vocal cords at the anterior commis- 
 sure, though they are sometimes between the ventricular bands. They 
 are of a pale color, but may be differentiated from the vocal cords by 
 their position. They may be either fragile or resilient. The perforated 
 diaphragm variety is rare, and is associated with poorly developed 
 lungs. Another form of congenital malformation consists of clefts in 
 the interarytenoid space extending to the palate and the cricoid cartilage. 
 The epiglottis is often deformed by arrested development, the small 
 V-shaped epiglottis of childhood being a common variety. A very small 
 larynx, and total absence of this organ have been reported. 
 
 Hypertrophy or hyperplasia at the anterior commissure has been 
 mentioned as being of congenital origin. 
 
 Laryngocele (dilatation of pouches) is due to congenital malformation 
 and failure of union in portions of the thyroid cartilage. It is rare in 
 man, though common in the lower animals. 
 
 In acquired malformations, erosions from syphilis, tuberculosis, etc., 
 may result in the partial destruction of the framework of the larynx, and 
 the epiglottis is also often thus partially destroyed. 
 
 Acquired stenosis (see also Stenosis of the Larynx) may follow trau- 
 matism or constitutional causes such as syphilis. These cases are serious 
 
480 DISEASES OF THE LARYNX 
 
 on account of the edema and the dyspnea. Tracheotomy or intubation 
 may become necessary. Redundant granulations following the pro- 
 longed use of the tracheotomy tube caused laryngeal stenosis in one of 
 my cases. The child had been tracheotomized four years before he 
 came under my care, and upon examination I found him unable to breathe 
 through his larynx. The larynx was opened by bougies passed upward 
 through the tracheal wound and through the glottis. This procedure 
 was performed under general anesthesia. 
 
 Hypertrophies or growths, usually of a papillomatous nature, form at 
 the anterior commissure in either the single or the multiple variety. 
 Microscopically they appear as local hypertrophies of the mucous mem- 
 brane, having a stratified epithelial covering, enclosing a core of connec- 
 tive tissue with some bloodvessels and a glandular substance near the 
 base. Indeed, they are but elevations of the normal tissue. This seems 
 to distinguish them from true papilloma. Though these papillomatous 
 elevations of the mucous membrane are congenital, mouth-breathing, 
 according to Lennox Browne, tends to perpetuate them. 
 
 PROLAPSE OF THE VENTRICLE OF MORGAGNI. 
 
 Watson Williams claims that there can be no prolapse of the ventricles, 
 but that which appears to be a prolapse is, in fact, an infiltration of the 
 tissues. This is apparently supported by the fact that nearly all reported 
 cases have been either syphilitic or tuberculous. On the other hand, the 
 tumor-like mass is quite soft to probe pressure, and a number of observers 
 have reported successful, though fugitive, replacement of the pouching 
 membrane. 
 
 The presence of this condition should arouse suspicion of either syphilis 
 or tuberculosis. The treatment by local applications is useless. Re- 
 placement, followed by cauterizations to excite inflammatory reaction, 
 offers some hope of permanent cure. The extirpation of the mass with 
 cutting forceps, or by thyrotomy, may be resorted to if simpler measures 
 fail. Antisyphilitic remedies should first be tried, however, before 
 surgical interference is attempted, unless it becomes necessary to perform 
 tracheotomy to relieve suffocative symptoms. 
 
 STENOSIS OF THE LARYNX (MALFORMATION OF THE LARYNX). 
 
 Stenosis of the larynx properly comes under malformations, but its 
 importance merits separate treatment ; hence, the various types of stenosis 
 are included in this section, regardless of their relationship to malforma- 
 tions. Stenosis arising from constitutional disorders, as syphilis, tuber- 
 culosis, and leprosy, each have their peculiarities. 
 
 Syphilitic Stenosis. — There are three prominent conditions arising 
 in the course of syphilitic laryngitis which may cause laryngeal stenosis, 
 namely : 
 
STENOSIS OF THE LARYXX 
 
 4S1 
 
 Fig. 303 
 
 (a) Chronic edema. 
 
 (b) Cicatricial contraction or webs. 
 
 (c) Hyperplastic or papillary growths. 
 
 (a) Chronic Edema, — Chronic edema is commonly present in syphilitic 
 laryngitis, though it does not always seriously occlude the glottis. Never- 
 theless, it presents favorable conditions for the supervention of an acute 
 process, which may produce serious stenosis. This is especially true 
 in children who inherit a syphilitic taint. Such children are predisposed 
 to acute edema, which gives rise to symptoms quite like those found 
 in croup. Fortunately the infantile cases respond quickly to antisyphilitic 
 remedies. In adults, as well as in 
 
 children, the treatment consists in 
 the administration of the iodide of 
 potash or iodonucleoid, which often 
 reduces the local edema in a short 
 time. 
 
 It should be stated that it is the 
 tertiary stage of syphilis that results 
 in stenosis, hence the treatment should 
 be conducted accordingly. 
 
 (b) Webs and Cicatricial Contraction. 
 — Webs and cicatricial contraction 
 are the most common manifestations 
 of syphilitic laryngitis. The webs 
 vary in color and thickness. They 
 are usually pale, and may be indis- 
 tinguishable from the cords over which 
 they extend. The vocal cords and 
 the ventricular bands are usually 
 bound together, and the web often 
 extends across the chink of the glot- 
 tis, especially at the anterior portion (Fig. 303). Lennox Browne cites 
 a case in which the epiglottis was bound down by cicatricial adhe- 
 sions. 
 
 The voice is hoarse or restricted in its register, while the breathing is 
 dyspneic. The degree of the dyspnea depends upon the amount of 
 edema and fixation of the cartilages, as well as upon the overlying web 
 or cicatricial tissue. When a patient gives a history of recurrent attacks 
 of dyspnea extending over several years, it is presumptive evidence 
 that he is suffering from syphilis of the larynx. A spasmodic cough, 
 not unlike that in pertussis, is usually present. Pain is not uncommon. 
 There may be an admixture of syphilis and tuberculosis, which may 
 somewhat obscure the diagnosis. 
 
 (c) Hyperplastic or Papillary Growths. — These usually form near the 
 anterior commissure of the o-lottis, and thev mav be either sino-le or 
 multiple. The treatment should be antisyphilitic and expectant. If 
 they produce stenosis, they should be removed with laryngeal forceps, 
 the snare, or by laryngofissure. 
 
 31 
 
 cicatricial web across the anterior com- 
 missure of the vocal cords. 
 
482 DISEASES OF THE LARYNX 
 
 Tuberculous Stenosis.— Tuberculosis of the larynx does not often 
 close the glottis by cicatricial contraction, as in syphilis. This is explained 
 by the slight reparative effort following tuberculous ulceration. It 
 may produce stenosis by the excessive infiltration of the arytenoid carti- 
 lages, which may overhang the glottis and occlude the respiratory passage. 
 Tuberculous perichondritis and chondritis may result in fixation of the 
 arytenoids, and thus prevent abduction of the vocal cords. The lumen 
 of the glottis is thereby rendered very narrow, and distressing dyspnea 
 results. 
 
 Lupous Stenosis of the Larynx. — Lupus of the larynx is characterized 
 by a cicatricial contraction and matting together of the parts. Lupus 
 runs a much more chronic course than active tuberculosis of the larynx, 
 hence the greater changes. Virchow says that the arytenoids are occa- 
 sionally surrounded by hard papillary growths in the active stage of 
 lupus. The scar tissue in lupus is very unyielding and not readily 
 absorbed, even under the pressure of laryngeal tubes. 
 
 Leprous Stenosis. — The stenosis rarely occurs until the patient is in 
 the last stages of the disease. In this stage it often becomes so great 
 as to necessitate tracheotomy to relieve the distressing dyspnea. 
 
 Ventricular Eversion and Stenosis. — The eversion of the sacculus 
 laryngis is scarcely possible as a primary condition. (See Prolapse of 
 the Ventricle of Morgagni.) Anatomically it appears to be too firmly 
 adherent to the adjacent tissues to permit of its prolapse. There may 
 be a disease of the underlying perichondrium of the laryngeal carti- 
 lages which predisposes to the eversion and the consequent stenosis. 
 Tumors and glandular enlargement may also push the sacculus toward 
 the median line and cause stenosis. 
 
 Traumatic Stenosis.— Stenosis of the larynx may be due to the inhala- 
 tion of hot vapors or to ingestion of corrosive fluids, as carbolic acid. 
 It may also be due to a penetrating wound. In a case recently under 
 my care the stenosis was due to the use of a 60 per cent, solution of 
 carbolic acid as a gargle. The acute edema rendered it necessary to 
 perform tracheotomy. The tube had been worn for seventeen months 
 when I first saw him, and had excited a hyperplastic nodule just below 
 the posterior portion of the cords. The stenosis seemed to be due more 
 to the hyperplastic nodule than to cicatricial contraction caused by the 
 carbolic acid. We may therefore include the prolonged use of the 
 tracheotomy tube as a cause of laryngeal stenosis. 
 
 Treatment. — The treatment of laryngeal stenosis is both medical 
 and surgical. 
 
 Medical Treatment. — (a) In syphilitic edema and infiltration without 
 cicatricial contraction the iodides are indicated. Saline laxatives may 
 be given with good results. 
 
 (b) Acute edema supervening upon a preexisting fibrous stenosis 
 should be treated by the local application of adrenalin and by free saline 
 catharsis. 
 
 (c) The edema of tuberculous laryngitis may be relieved by tonic 
 remedies and the cautious administration of mild cathartics. 
 
STENOSIS OF THE LARYNX 483 
 
 Surgical Treatment. — (a) Webs of syphilitic origin should be broken 
 down by systemic dilatation by means of Schroetter's laryngeal tubes 
 (Fig. 304). The larynx should be cocainized, the index finger of the 
 left hand introduced through the narrowed chink of the glottis. The web 
 will thus be stretched and torn. A larger tube should be introduced 
 after leaving the first one in place a few minutes. This process should 
 be continued three times a week until the stenosis is completely over- 
 come. Even then the tubes should be introduced at intervals of a few 
 weeks to prevent the reformation of the webs. 
 
 (6) Cicatricial contraction due to syphilis should be overcome in the 
 same manner as described in the preceding paragraph, though the dilata- 
 tions will have to be performed more persistently. 
 
 (c) Hyperplastic or papillary growths of syphilitic origin do not always 
 yield to the iodides, and should, therefore, be removed with laryngeal 
 forceps under general or cocaine anesthesia, by either direct or indirect 
 method. Occasionally the papillary growths become wedged in the 
 chink of the glottis and cause sudden and alarming dyspnea, and necessi- 
 tate an emergency tracheotomy. (See Tracheotomy.) 
 
 (d) Tuberculous chondritis and abscess of the larynx, when causing 
 stenosis, should be relieved by the removal of the diseased and dislocated 
 cartilage with a laryngeal curette or biting forceps. 
 
 Fig. 304 
 
 Schroetter's laryngeal dilator. 
 
 Tuberculous ankylosis of the arytenoid cartilages, attended by fixation 
 of the cords in adduction with severe dyspnea, necessitates tracheotomy 
 for the immediate relief of the symptoms, or laryngofissure may be 
 necessary at a later time to overcome the ankylosis, or to remove the 
 arytenoid cartilages. The abduction of the cords during respiration is 
 thus made possible and the distressing dyspnea relieved. 
 
 (e) The cicatricial stenosis of lupus should be treated by dilatation 
 with Schroetter's tubes, as described in a preceding paragraph, excepting 
 that it may require greater persistence. 
 
 (/) Leprous stenosis should be relieved by tracheotomy if the gravity 
 of the suffocative fits warrant it. 
 
 (g) Ventricular eversion with stenosis, while secondary to some 
 diseased process of the underlying perichondrium, should be overcome 
 by removing the prolapsed sacculus membrane with a snare under cocaine 
 anesthesia. Failing in this, tracheotomy may be performed, and the 
 everted mass removed subsequently by laryngofissure. (See Laryngo- 
 fissure.) 
 
 Traumatic stenosis, whether of chemical or mechanical origin, may 
 
484 
 
 DISEASES OF THE LARYNX 
 
 often be successfully treated by first performing laryngofissure (see 
 Laryngofissure), and then introducing a tracheotomy tube with a rubber 
 
 Fig. 305 
 
 Tracheotomy tube with rubber tube extension for stenosis of the larynx. 
 Fig. 306 
 
 Tracheotomy tube with rubber tube extension for stenosis of the larynx. 
 
 tube extending upward from it through the chink of the glottis (Figs. 
 305 and 306). The rubber tube exerts constant pressure and gradually 
 
STENOSIS OF THE LARYNX 485 
 
 removes the hyperplastic tissue causing the stenosis, by pressure atrophy- 
 Chevalier Jackson recently reported seven cases successfully treated by 
 this method. My own case is progressing favorably and promises to be 
 entirely successful. The tube should be worn for from four to sixteen 
 weeks, and should be removed every two or three days. 
 
 Subglottic Stenosis. — Sajous pointed out that the subglottic space has 
 not received the attention which its importance as an inherent portion 
 of the larynx warrants. He urges systemic examination of this space 
 in all laryngeal cases. The forms of stenosis peculiar to the lower sub- 
 glottic region present features of unusual danger and symptoms likely 
 to be ascribed to syphilitic disease. Inasmuch as the iodide of potassium 
 greatly increases the danger in subglottic stenosis, it should not be 
 administered in a case presenting dyspnea as a symptom, unless the 
 non-existence of this condition is determined by infralaryngoscopical 
 examination, or the causative disease is clearly recognized as being 
 independent of the respiratory tract. He advised that preliminary 
 tracheotomy be performed when the iodide of potassium is to be admin- 
 istered during the existence of advanced subglottic stenosis. 
 
 Massei states that the subglottic space is the most frequent seat of 
 syphilis, tuberculosis, tumors, rhinoscleroma, and foreign bodies. Slight 
 syphilitic stenosis is frequently curable without local treatment by 
 the administration of sublimate injections with or without the iodides. 
 In simple inflammatory and neoplastic stenosis, intubation offers the 
 best results. He agrees with Sajous that too great dependence is placed 
 in general antisyphilitic treatment in severe stenosis, and that such a 
 course may be fatal. 
 
CHAPTER XXVII. 
 
 NEUROSES OF THE LARYNX. 
 
 NEUROSES OF MOTION. 
 
 The classification of J. Solis-Cohen is as follows : 
 Neurosis of the Motor Nerves of the Larynx. — The motor neuroses 
 are divided into two groups: 
 
 1. Spasms of the larynx, or hyperkinesis, i. e., excessive motion. 
 
 2. Paralysis of the larynx, or akiriesis, i. e., absence of motion. 
 Spasms of the Larynx.— Spasms of the larynx may be due to irrita- 
 tion of the central brain cells in which all the intrinsic muscles are thrown 
 into violent action, or to irregular nervous impulses sent out from the 
 motor centres of the brain, causing incoordination of the laryngeal 
 muscles. 
 
 Paralysis of the intrinsic laryngeal muscles may be limited to one 
 muscle or to a group of muscles, or it may affect all of them. 
 
 The spasms may be either tonic or clonic. 
 
 Tonic spasms are (a) of central origin ; (6) from irritation of the trunk 
 of the recurrent laryngeal; and (c) from reflex irritation. 
 
 (a) Tonic Spasms of Central Origin. — In tabes dorsalis spasm of the 
 adductors of the larynx occurs. The clinical picture shows sudden 
 dyspnea with loud inspirations, the cords remaining in adduction for a 
 variable time. It also occurs in tetanus and hydrophobia. 
 
 (b) Tonic Spasm from Irritation to the Trunk of the Recurrent Laryngeal 
 Nerve. — When the injury is transient and slight, the laryngeal spasm is a 
 forerunner of paralysis. Aneurysm of the arch of the aorta, cancer of the 
 esophagus, pleuritic adhesion of the apex of the right lung, and tumors 
 of the mediastinal glands may cause the irritation. A slight lesion may 
 also occur in tabes. 
 
 (c) Tonic Spasms from Reflex Irritation. — These may occur from irrita- 
 tion of the larynx, the fauces, and the neighboring parts. In highly sensi- 
 tive children irritation in a remote part of the body may cause adduction 
 spasms. The latter condition has been described as laryngospasm 
 infantum, and is usually due to intestinal irritation, tapeworm, a tight 
 prepuce, or constipation. 
 
 Clonic spasms of the laryngeal muscles are always of central origin, 
 and they consist of rhythmical inward movements of the cords. The 
 condition may last but a few minutes, or it may persist for many months. 
 The pillars of the fauces are also often affected in a like manner. 
 
 Both tonic and clonic spasms may be present in the same case, 
 especially in the depressors of the epiglottis. The disease most often 
 
NEUROSES OF MOTION 487 
 
 causing clonic spasms of the larynx are syphilis, meningitis, and intra- 
 cranial tumors. 
 
 Clinically, spasm of the larynx may be classified as follows: 
 
 (a) Spasm of the adductor muscles (laryngismus stridulus). 
 
 (b) Spasm of the tensor muscles. 
 
 (c) Spasmodic laryngeal cough or laryngeal chorea. 
 
 (a) Laryngismus Stridulus (Adductor Spasm). — Synonyms.- — Spasm of 
 the larynx; laryngeal spasm; spasm of the abductors of the vocal cords; 
 spasm of the glottis; spasmus glottidis; false croup; child-crowing; 
 thymic asthma; asthma rachiticum; Miller's asthma. 
 
 Laryngismus stridulus is a spasmodic act of the intrinsic muscles of 
 the larynx accompanied by stridor. It is a neurosis, and is not necessarily 
 associated with laryngeal disease. It is not a disease, but a symptom. 
 While it is not a disease, it is a symptom causing great alarm. It is often 
 associated with laryngeal or tracheal diseases, though it mav be a reflex 
 phenomenon from irritation in either contiguous or remote organs. It is 
 sometimes a symptom of acute laryngitis, pseudomembranous croup, and 
 diphtheritic croup, especially in children. It may also occur in non- 
 inflammatory diseases of the larynx. It is common in children, but 
 rather rare in adults. It is sometimes associated with intestinal disorders, 
 as indigestion, worms, and constipation. Uterine disorders and sexual 
 excesses have been known to produce it. Disorders of the contiguous 
 organs, as the lingual tonsils, the teeth (dentition), elongated uvula, and 
 inflamed tonsils, sometimes excite the spasm. The irritation of the 
 fauces with a brush, or a foreign body in the pharynx, sometimes causes 
 the symptom. Cases have been reported in which the pressure from 
 an enlarged thymus gland caused laryngismus stridulus. Cerebral irri- 
 tation, caries of the vertebra?, and rickets are known causes. Laryn- 
 gismus stridulus appears in the laryngeal crises of tabes. 
 
 Treatment. — The treatment consists in relieving the source of the 
 irritation rather than in applications to the larynx. For the immediate 
 relief from the suffocative spasm the application of cold water to the chest 
 or hot water to the nape of the neck should be made. If suffocation 
 seems imminent and the lower jaw is relaxed, seize the tongue between 
 the thumb and the forefinger and exert traction about every three seconds, 
 to excite the respiratory centre through the reflex action of the phrenic 
 nerve. If the jaw is set, the same result can be accomplished by exerting 
 pressure with the fingers under the angles of the jaw. Should these 
 measures fail, resort to intubation or tracheotomy. 
 
 (b) Spasm of the Tensor Muscles of the Vocal Cords; Aphonia Spastica; 
 Phonatory Spasms. — Spasm of the tensor muscles is essentially a neurosis 
 from overuse of the voice. The muscles are fatigued and fail to respond 
 to the nervous stimulus sent out from the motor centres of the brain; 
 they are tired and irritated by a local accumulation of the toxins from 
 faulty metabolism. Writer's and telegrapher's cramp are similar affec- 
 tions. 
 
 Symptoms. — Spasm of the tensor muscles is characterized by sudden 
 onset at any moment during speech. It may come on at the beginning 
 
488 DISEASES OF THE LARYNX 
 
 or in the midst of a sentence. I have seen cases in which the speech was 
 suddenly almost or entirely lost for some minutes, after which it would 
 quickly clear up and remain so for an indefinite period. The patient 
 complains of a rough, harsh feeling in the larynx, accompanied by 
 the spontaneous flow of a few tears and slight congestion of the con- 
 junctivae. A drink of water hastens the cessation of the spasms. The 
 cords are tense and approximated in the median line. 
 
 Treatment. — The cases seen by the author have been mild, and occurred 
 only at long intervals. They required no special treatment other than 
 a few minutes' rest of the voice and a drink of cold water. 
 
 In severe and oft-recurring spastic aphonia prolonged rest of the 
 voice is necessary. Such cases are usually overtaxed, or are affected 
 by a slight general debility, and they should, in addition to prolonged 
 rest away from the persons with whom they are daily associated, be given 
 tonic or specific remedies to correct the debility or the specific diseases 
 with which each is affected. To this end iron, strychnine, arsenic, 
 cathartics, iodide of potash, eggs, milk, etc., should be given. 
 
 (c) Spasmodic Laryngeal Cough or Laryngeal Chorea. — This condition 
 is quite similar to chorea in other parts of the body, though it is not 
 usually associated with it. There are, however, synchronous contractions 
 of other respiratory muscles which furnish the blast of air back of the 
 cough. The choreic cough occurs at frequent intervals, and is a dry, 
 noisy, respiratory explosion resembling the yelp or bark of a dog. It 
 occurs most often in females at about the age of puberty, or at the age of 
 greatest instability of the nervous system. It rarely occurs during sleep. 
 Between the intervals the voice is clear. The vocal cords appear normal 
 and are closely approximated during the attacks. 
 
 Treatment. — The cough is due to an hysterical temperament or to a lack 
 of balance of the nervous system at or about the age of puberty, and little 
 can be done to improve it. A sea voyage or an outdoor life will add 
 tone to the system, and thus tend to check the recurrence of the attacks. 
 Tonics and sedatives may also be administered. The child should be 
 taken from school and sent to the country, or in some way kept outdoors. 
 Fresh air and sunshine will do more for these cases than any other mode 
 of treatment. 
 
 NEURALGIA OF THE LARYNX. 
 
 True neuralgia is rare, and is characterized by pain without a visible 
 cause. Similar pain may be caused by malaria, gout, rheumatism, 
 pressure from some tumor or swelling, epipharyngitis, and angina of 
 the pharynx. It is obvious, therefore, that the foregoing diseases should 
 be excluded before making a diagnosis of neuralgia. 
 
 Treatment. — The treatment of a true neuralgia is successfully accom- 
 plished with phenacetin, gr. v to x, every three hours, also with cannabis 
 indica, aconite, and morphine, which should be administered until they 
 produce their physiological effects. Though cocaine, if sprayed into the 
 throat, affords immediate relief, it is not to be recommended, because 
 
LARYNGEAL APOPLEXY 489 
 
 neuralgic patients easily acquire the cocaine habit. Menthol affords 
 relief. Cold or hot applications to the neck also prove grateful to these 
 patients. 
 
 If the pain is due to gout, rheumatism, malaria, or pressure of a tumor 
 or a gland, treatment appropriate to these conditions should be instituted. 
 
 MOGIPHONIA. 
 
 Mogiphonia is characterized by a difficulty in maintaining the tension 
 of the vocal cords while singing, or during forced accentuated speaking. 
 In ordinary conversation no difficulty is experienced. 
 
 Treatment. — The treatment is rest. Overtaxation being the cause, 
 other forms of treatment are not indicated, unless the condition has 
 recurred often and at frequent intervals. When this is the case, tonics, 
 massage, cathartics, and eliminative treatment should also be used. 
 
 NERVOUS COUGH. 
 
 This is a spasmodic, croupy, or even musical laryngeal cough, for which 
 no physical cause can usually be assigned. It is peculiar to neurotic 
 individuals who present other stigmata of a neurosis. It is a ''daytime" 
 cough, which subsides entirely during sleep, but returns the following 
 morning, often with increased severity. It may be a reflex disturbance 
 from a hypersensitive area in the nose, the epipharynx, or the chest, 
 hence a careful examination of these parts should be made. The sensi- 
 tive areas in the nose and the epipharynx may be located by gentle 
 probe pressure without the use of cocaine. In the nose Jacobson's 
 tubercle near the anterior end of the middle turbinated body may be 
 the seat of the sensitive area. When this is touched with the probe 
 it will give rise to the peculiar nervous cough, provided, of course, that 
 it is the source of the reflex. Impacted cerumen in the external auditory 
 meatus may cause it. The reflex may also have its origin in the gastro- 
 intestinal tract. 
 
 Treatment. — As most cases are due to a true neurosis rather than to 
 some physical lesion, the treatment must be of a tonic and sedative 
 character. Sprays of iced lime-water, or menthol in combination with 
 camphor, gr. ij to an ounce of liquid petrolatum, etc., may be used to 
 relieve the laryngeal irritations. Antispasmodics and sedatives, as 
 aconite, cannabis indica, and the bromides, may be given internally to 
 allay the spasms and the local irritation. 
 
 LARYNGEAL APOPLEXY. 
 
 Synonyms. — Laryngeal vertigo; laryngeal syncope; bronchial syn- 
 cope; complete glottic spasm in the adult. 
 
490 DISEASES OF THE LARYNX 
 
 Laryngeal apoplexy is characterized by a transient irritation and 
 burning sensation in the lower part of the throat, followed by a fit of 
 coughing, dimness of vision, dizziness, and unconsciousness, the patient 
 falling to the floor. The face may be either congested or pale. 
 
 The disease is a neurosis affecting the coordination of the respiratory 
 centres and the nerves of the larynx. It is rare. The attacks may last 
 but a few seconds, when the spasms cease and the mind becomes clear 
 again. They may recur at intervals of a few weeks. 
 
 Etiology. — The disease is chiefly found among the well-to-do and those 
 leading sedentary lives, though one case is reported as occurring in a sailor 
 ( Whalan). Getchell reported 77 cases ranging in age from seventeen to 
 seventy-seven years. All but four were males. Rheumatism and gout 
 are occasionally associated with it. Neurasthenia is a rather constant 
 factor. Local inflammatory disease of the bronchi, the pharynx, and 
 the larynx is commonly present, and may be an important causative 
 agent. Lennox Browne reported 3 cases in which there was varix at the 
 base of the tongue. 
 
 Among the exciting causes may be named worry from strenuous 
 business or social conditions, and either physical or mental overwork. 
 A pinch of snuff or other irritating substance inhaled into the larynx and 
 the bronchi may bring on an attack. 
 
 Symptoms. — The face is usually flushed, though it may be pale. 
 A deep breath is taken, followed by laryngeal spasm. There may be 
 epileptiform convulsions, and the sequence ends in a few moments by 
 a return to consciousness. After the attack all signs of the disease dis- 
 appear. The disease is clinically like apoplexy with a laryngeal aura 
 and laryngeal spasm, the latter being continued long enough to produce 
 unconsciousness. Such spasms are likely to occur in neurasthenia 
 and in tabes. Other signs of neurasthenia, epilepsy, and tabes should 
 be sought for before pronouncing the case one of laryngeal apoplexy. 
 
 Treatment. — The treatment should be addressed to the correction of 
 alimentary and hepatic disorders, and to the regulation of the excretory 
 organs of the body. Tonics and antispasmodics may be given to tone 
 and tranquillize the nervous system. Local lesions, if present, should 
 receive appropriate treatment. For instance, bronchitis is the most 
 common concomitant disease, and possibly has something to do with 
 its causation. It should, therefore, be treated by the administration of 
 4 grains of iodide of potassium in a glass of water after each meal for 
 several weeks or months. By relieving the associated diseases of the 
 upper respiratory tract the laryngeal spasms and the syncope are some- 
 times entirely relieved. 
 
 PARALYSES OF THE INTRINSIC MUSCLES OF THE LARYNX. 
 
 It is difficult to make a classification of the paralyses of the laryngeal 
 muscles in such a way as to have it coincide with clinical observation. 
 The intrinsic muscles are supplied by branches of the right and the left 
 
PARALYSIS OF THE INTRINSIC MUSCLES OF THE LARYNX 491 
 
 pneumogastric or vagus nerves. It will be remembered that these nerves 
 have their origin near the median furrow beneath the floor of the fourth 
 ventricle. Two motor branches, the superior laryngeal and the re- 
 current or inferior laryngeal, are given off from each vagus to the larynx. 
 The superior laryngeal also supplies sensation to the whole laryngeal 
 mucous membrane. 
 
 By reference to Fig. 307 it will be seen that the superior laryngeal 
 supplies only one pair of the intrinsic muscles of the larynx, the crico- 
 thyroidei. These muscles are tensors of the vocal cords, hence the wavy 
 outline of the cords (Fig. 308) in superior laryngeal paralysis. 
 
 Fig. 307 
 
 Schema of the nerve supply of the intrinsic muscles of the larynx. P, the pneumogastric nerve; 
 R, recurrent laryngeal nerve; S.L., superior laryngeal nerve; A.C., arytenoid cartilages; T, thyroid 
 cartilage; C, cricoid cartilage; A, interarytenoideus muscle; C.A.P., crico-arytenoideus posticus 
 muscle; C.A.L., crico-arytenoideus lateralis muscle; T.A.I., cricothyroidei interni muscles. 
 
 The recurrent or inferior laryngeal nerves supply all the other intrinsic 
 muscles of the larynx, namely, the arytenoideus, the crico-arytenoidei 
 postici, the crico-arytenoidei laterales, and the internal tensors of the 
 vocal cords. 
 
 If the lesion involves all the fibers of the left recurrent laryngeal nerve, 
 there is total paralysis of all the muscles of the left side of the larynx 
 
492 
 
 DISEASES OF THE LARYNX 
 
 Fig. 308 
 
 except the cricothyroideus (external tensor). The same is true of the 
 right side (Fig. 308). If the lesion involves only a small branch of the 
 left recurrent, one muscle alone may be involved, say the crico-arytenoi- 
 deus posticus. This muscle is an adductor, hence there would be in- 
 complete adduction of the anterior two-thirds of the vocal cord on the 
 left side, while the opposite cord would slightly encroach beyond the 
 median line. The adduction of the posterior third is controlled by 
 the arytenoideus, hence, this muscle being unaffected, closure in that 
 region is complete. Single muscles are rarely affected except in diph- 
 theria and other local inflammations of the larynx, and in hysteria. 
 It is always a question when a single muscle is affected, excepting one of 
 the cricothyroidei, as to whether the lesion is in a nerve twig or in the 
 muscle itself. Inflammatory infiltration may inhibit the nerve twig 
 
 supplying a certain muscle, or the infiltra- 
 tion may cause a mechanical barrier to the 
 proper motion of the muscle. Hysterical 
 paralysis is, of course, not a true paralysis. 
 Paralysis of involuntary muscles usually 
 has its origin in a lesion of the medulla 
 oblongata or the spinal cord. Lesions of 
 the cerebral cortex, on the other hand, 
 cause central paralysis of voluntary motion. 
 In making a diagnosis in this class of cases, 
 aphasia must be distinctly separated from 
 aphonia; the same is true in considering 
 the etiology. Kraus, in 1884, demonstrated 
 that stimulation of the gyrus prefrontalis 
 in the lower animals produced a contrac- 
 tion, or muscular movements, of the larynx, 
 the pharynx, and the palate. Semon and 
 Horsley fully substantiated the findings of Kraus by a long series of 
 experiments on the lower animals. 
 
 Irritation of one of the external borders of the restiform bodies pro- 
 duces unilateral adduction of the vocal cords. Bulbar lesions usually 
 produce unilateral paralysis, but many cases of unilateral paralysis are 
 also caused by lesions in the medulla. 
 
 Laryngeal paralyses are seldom brought about by tumors of the 
 medulla or the pons. Gottstein thoroughly reviewed this aspect of the 
 question, and refers to several cases of glioma and one of aneurysm of the 
 basilar artery. A bulbar lesion causing laryngeal paralysis usually 
 involves the dorsal motor nucleus of the pneumogastric, which lies near 
 the median furrow, and is beneath the floor of the fourth ventricle. 1 In 
 
 Paralysis of the cricothyroidei. 
 The only muscles of the larynx sup- 
 plied by the superior laryngeal. All 
 the other intrinsic muscles of the 
 larynx are supplied by the recur- 
 rent laryngeal nerves. 
 
 * Edinger, Anatomy of Central Nervous System of Man, English translation from fifth German 
 edition, p. 375, says: 
 
 ' 'We have learned, then, two nuclei for the vagus, a ventral one, which from its position (in the 
 prolongation of the ventral horn) and from the appearance of its cells (multipolar with axis cylinders 
 passing directly into the nerve) is motor; and a dorsal one, which, lying in the prolongation of the 
 gray matter of the base of the posterior horn, is also by its structure characterized as sensory." 
 
PARALYSIS OF THE SUPERIOR LARYNGEAL NERVE 493 
 
 laryngeal paraylsis the abductors are usually the first, perhaps the only, 
 muscles affected as a result of a central or a peripheral lesion, while in 
 hysterical aphonia the adductors are affected. 
 
 Tumors, traumatisms, and other lesions at the base of the skull give 
 rise to laryngeal paralysis by implicating the trunks of the pneumo- 
 gastrics. It is often difficult to differentiate these conditions from bulbar 
 lesions, as they frequently involve the facial, the glossopharyngeal, the 
 acusticus, the spinal accessory, also other branches of the pneumogastrics 
 besides the laryngeals, depending upon the extent of the lesion. The 
 portion of the pneumogastric which lies in the neck (usually the trunk 
 and the recurrent laryngeal after it winds around the large vessels in the 
 thorax, travelling back along the esophagus to the larynx) is very often 
 the seat of the lesion causing the laryngeal paralysis. Among the lesions 
 in this locality causing paralysis of the nerves just mentioned are en- 
 larged glands, traumatisms due to wounds in operating, goitres, aneu- 
 rysms, mediastinal tumors, tumors of the esophagus and the pharynx, 
 pleurisy, scoliosis of the cervical vertebrae, tuberculosis of the apices of 
 the lungs, and even pericarditis. 
 
 Laryngeal paralysis may be the very first, and for a long time the only 
 significant indication of an aneurysm of the arch of the aorta. Often 
 no palpable reason for the paralysis can be ascertained, and then recourse 
 must be had to a tentative diagnosis of a simple neuritis. The rare 
 cases of paralysis of individual muscles must be ascribed to lesions of 
 their respective nerve twigs, or to an involvement of the muscular struc- 
 ture itself. Paralysis of the abductors is now and then due to traumatism 
 by the passage of a bolus of food or cold drinks through the lower pharynx 
 into the esophagus, as the location of the muscles is very superficial. 
 In paralysis of the pneumogastric nerve due to a bulbar lesion the in- 
 volvement of the other nerves readily establishes the diagnosis. How- 
 ever, an injury to the base of the skull may simulate a bulbar lesion by 
 implicating several nerve trunks in addition to the pneumogastric. 
 Jackson, Proust, Senator, and Eisenlohr have reported cases of bilateral 
 paralysis as being due to bulbar lesions, though they are comparatively 
 rare. There is no authenticated case of paralysis of the adductors 
 alone from an essential lesion. Occasionally a bulbar lesion produces 
 bilateral paralysis, in which instance the abductors alone are usually 
 involved; more often the paralysis is unilateral, though not so often as 
 when due to other lesions. 
 
 PARALYSIS FROM DISEASE OR INJURY OF THE SUPERIOR 
 
 LARYNGEAL NERVE; PARALYSIS OF THE EXTERNAL 
 
 TENSORS OF THE VOCAL CORDS. 
 
 So far the only lesions which have been noted as causing paralysis 
 of the cricothyroid muscles are diphtheria, enlarged glands, and in- 
 flammation of the areolar tissue beneath the angle of the jaw. Typhoid 
 fever may cause it. Paralysis of these muscles is extremely rare. 
 
494 DISEASES OF THE LARYNX 
 
 Symptoms. — Anesthesia of the larynx, the phenomenon which was 
 described under neurosis of the larynx, is a prominent and significant 
 symptom. The anesthesia is explained by the fact that it is the superior 
 laryngeal nerve, a branch of the pneumogastric, which is affected. This 
 branch supplies the cricothyroid muscles with motor stimulus, and 
 the whole of the mucosa with sensation. Whenever, therefore, there is 
 anesthesia of the whole mucosa of the larynx, the lesion involves the 
 superior laryngeal nerve fibers, either after they leave the pneumogastric 
 or higher up in the pneumogastric itself. A low-pitched voice and 
 inability to sing high tones is characteristic of this affliction. When the 
 thyro-epiglottic and the aryteno-epiglottic muscles are paralyzed the 
 epiglottis stands upright, hence the larynx cannot be closed. Because 
 of this and the attending anesthesia, food often finds its way into the 
 larynx and upper respiratory tract. No warning is given the patient 
 until the food reaches an area below the vocal cords. Hence, pneumonia 
 is frequently a serious sequence. Complete bilateral paralysis of the 
 cricothyroid muscles is manifested by the peculiar wavy outlines of the 
 vocal cords (Fig. 308). According to E. MacKenzie, when this paralysis 
 is unilateral the laryngoscope shows one vocal cord on a higher plane 
 than the other. 
 
 Diagnosis. — The peculiar wavy outline of the vocal cords and the 
 local anesthesia clear up the diagnosis as to the hoarseness and aphonia, 
 and distinguish it as a true motor paralysis rather than a neurosis or an 
 inflammatory disease. 
 
 Prognosis. — It is very bad if there is complete bilateral paralysis, 
 but not so very grave when only one cord is implicated. The patient 
 may succumb to inanition or pneumonia. Lobar pneumonia is the 
 usual type, and cases have been recorded where death from this disease 
 could only be ascribed to the passage of food or other foreign substance 
 into the trachea because of the anesthesia. The prognosis is very bad 
 if the recurrent laryngeal nerve is involved at the same time. 
 
 Treatment. — Nourishment by the esophageal tube, galvanism, strych- 
 nine, and general tonics are indicated. 
 
 PARALYSES OF THE RECURRENT OR INFERIOR LARYNGEAL 
 BRANCH OF THE PNEUMOGASTRIC NERVE. 
 
 All the intrinsic muscles of the larynx except the cricothyroidei are 
 supplied with motor stimulus by the recurrent laryngeal nerves. The 
 crico-arytenoidei postici are abductors of the vocal cords and therefore 
 muscles of respiration, in a sense, also, of phonation, as their action is 
 necessary to maintain the required equilibrium of the other muscles in 
 this act and in modulating the voice. 
 
 The recurrent laryngeal nerve supplies motor stimulus to the following 
 muscles ; 
 
PARALYSIS OF BOTH RECURRENT LARYNGEAL NERVES 495 
 
 Fig. 309 
 
 „ . . f Crico-arytenoidei laterales (abductor). 
 
 Recurrent laryngeal A ten J deus (ad ductor). 
 (uifenor laryngeal { Crico . arytenoidei postici (adductor). 
 '" (^ Thyro-ary tenoidei (internal tensor). 
 
 The superior laryngeal nerve supplies the cricothyroidei (external 
 tensors). 
 
 It is clear, from the above analysis, that the recurrent laryngeal nerve 
 is the chief motor supply to the larynx, and that it presides over both 
 adduction and abduction of the vocal cords. 
 It is obvious, therefore, that when all the fibers 
 of the main trunks of the recurrents are 
 affected there is total paralysis of both the 
 adductor and the abductor muscles of the 
 larynx. The only intrinsic muscles of the 
 larynx not affected are the external tensors, 
 the cricothyroidei, which are supplied by the 
 superior laryngeal nerves. These play so 
 small a part in the general movements of the 
 cords that their action under these circum- 
 stances is practically nil. The cords, there- 
 fore, assume the so-called cadaveric position 
 
 (Fig. 309). In studying the various paralyses of the recurrent laryn- 
 geal I shall first speak of total paralysis, and follow with the partial 
 paralyses. I mean by the term partial paralysis, the paralysis of cer- 
 tain groups of muscles rather than an incomplete paralysis of part or all 
 of the muscles of the larynx. 
 
 Larynx in quiet breathing and 
 the cadaveric position. 
 
 COMPLETE PARALYSIS OF BOTH RECURRENT LARYNGEAL 
 
 NERVES. 
 
 Etiology. — By reference to Fig. 310 the course and distribution of 
 the right and the left recurrent laryngeal branches from the pneumo- 
 gastrics is illustrated in diagrammatic form. The left recurrent is given 
 off at the level of the transverse portion of the arch of the aorta, and 
 passes under it, thence upward in the groove between the trachea and 
 the esophagus to the muscles of the larynx. As it reaches the larynx it 
 breaks into several twigs, thus supplying motor stimulus to all the in- 
 trinsic muscles of the left half of the larynx except the cricothyroid, 
 which is supplied by the superior laryngeal. The left recurrent nerve is 
 the one most often affected, on account of its relationship to the arch of 
 the aorta and the left subclavian artery. Aneurysm of the transverse 
 portion of the arch of the aorta causes compression and neuritis of the 
 left recurrent laryngeal, and thus inhibits the motor impulses reaching 
 the left half of the larynx. Unilateral paralysis results. Occasionally 
 the aneurysm is so large as to encroach upon the structures on the right 
 side of the chest, and may thus also cause compression and neuritis of the 
 right recurrent, in which event the paralysis would be bilateral. 
 
 While the right recurrent laryngeal is not so often involved, it is, 
 
496 
 
 DISEASES OF THE LARYNX 
 
 nevertheless, so situated with reference to the subclavian artery and the 
 apex of the right lung as to be somewhat frequently the source of laryn- 
 geal paralysis. The right recurrent nerve is given off on the level with 
 the subclavian artery, and curves around the latter as it starts upward 
 to the larynx. Aneurysm of the subclavian may therefore compress it 
 and cause neuritis and consequent laryngeal paralysis of the intrinsic 
 muscles of the right half of the larynx. The right recurrent nerve is in 
 
 close proximity to the apex of the 
 Fig. 310 right lung, and may become in- 
 
 volved in pleuritic exudates and 
 adhesions in this region, and thus 
 cause paralysis of the right half of 
 the larynx. 
 
 The mediastinum is frequently 
 the seat of malignant or other 
 growths which press upon one or 
 both of the recurrent nerves. En- 
 larged glands of the neck, malig- 
 nant tumors of the esophagus, and 
 other growths in the neck may 
 cause pressure and degeneration of 
 one or both pneumogastric nerves, 
 and produce unilateral or bilateral 
 paralysis of the larynx. Scoliosis, 
 goitre, and pericarditis may also 
 injure the recurrent nerves. Gum- 
 mata are frequently the source of 
 the nerve lesion. 
 
 The central lesions which cause 
 laryngeal paralysis are in the 
 medulla oblongata or the spinal 
 cord. The exact location of the 
 pneumogastric nuclei seems to be, 
 according to Kraus, Semon, and 
 Horsley, in the gyrus prefrontalis. Tumors of the medulla and the 
 pons rarely cause laryngeal paralysis. Aneurysm of the basilar artery 
 is a known cause. Bulbar lesions causing laryngeal paralysis usually 
 involve the dorsal motor nucleus of the pneumogastric nerve which 
 lies near the median furrow beneath the floor of the fourth ventricle. 
 
 Tumors, traumatisms, and other lesions at the base of the skull give 
 rise to laryngeal paralysis by implicating the trunks of the pneumo- 
 gastric nerves. It is often difficult to differentiate these from bulbar 
 paralysis, as these conditions often involve the facial, the glossopharyn- 
 geal, the acusticus, the spinal accessory, or other branches of the pneumo- 
 gastric nerve. 
 
 The nerves and their filaments may be completely atrophied. The 
 remains of the neurilemma have been found, but fatty degeneration is 
 the most frequent degenerative change. 
 
 Schema showing the relations of the pneu- 
 mogastric nerve to the trachea, esophagus, 
 vessels of the thorax. Also the recurrent 
 laryngeal and superior laryngeal branches and 
 their distribution to the intrinsic muscles of the 
 larynx. (See Fig. 307.) 
 
PARALYSIS OF BOTH RECURRENT LARYNGEAL NERVES 497 
 
 Symptoms. — The symptoms, whether due to lesion of the pneumo- 
 gastric trunk or to the recurrent laryngeal nerve, are very much alike. 
 The voice is usually weak and husky. The sensibility of the mucous 
 membrane is usually unimpaired, unless the lesion of the pneumogastric 
 trunk is above the point where the superior laryngeal nerve is given off. 
 If both pneumogastric trunks or both recurrent nerves are injured, the 
 voice is aphonic, as the cords stand in the cadaveric position. If the 
 recurrent nerve on one side only is affected, the vocal cord on that side 
 rests in the cadaveric position, while the opposite cord has its normal 
 movements. Indeed, it encroaches beyond the median line upon at- 
 tempted phonation, while during deep inspiration it is widely separated 
 from the opposite cord. In one-sided paralysis the position of the aryte- 
 noid cartilages is characteristic ; the arytenoid cartilage on the unaffected 
 side overlaps the opposite arytenoid, and is either anterior or posterior 
 to it. Cough is usually absent, and when present is usually due to an 
 irritation of the trachea by the pressure of a tumor in the neck or upper 
 mediastinum. The cough is like that in aneurysm of the arch of the aorta. 
 I have seen a few cases of aneurysmal cough, and they were dry and 
 slightly harsh or brassy. One case in particular was free from cough 
 except in public gatherings or other places likely to excite the heart's 
 action. Coughing and expectorating are performed with great difficulty 
 in bilateral paralysis. 
 
 Dyspnea is absent in unilateral paralysis, but may be present in bilat- 
 eral paralysis in spite of the fact that the cords are separated in the 
 "cadaveric" position. In the " cadaveric" position the cords stand mid- 
 way between adduction and complete abduction. They are not as widely 
 separated as is usual in inspiration, hence the dyspnea. 
 
 In some cases the paralysis is partial, and the symptoms are, therefore, 
 correspondingly modified. 
 
 Sir Felix Semon and Rosenback have shown that the abductor nerve 
 fibers degenerate earlier than the adductor nerve fibers, hence the abduc- 
 tor muscle (crico-arytenoideus posticus) is paralyzed earlier than the 
 adductor (crico-arytenoideus lateralis). This phenomenon is usually 
 referred to as "Semon's law." If, therefore, the case is seen early the 
 abductors may be paralyzed. If, however, the case is examined at a 
 later period, the degeneration will have extended to both the abductor 
 and the adductor nerve fibers, and the paralysis will affect both the 
 abductor and the adductor muscles. This causes the so-called "cadav- 
 eric" position of the vocal cords. 
 
 Diagnosis. — Bilateral paralysis of the abductor nerves during quiet 
 respiration bears a slight resemblance to complete paralysis. The act 
 of phonation, however, is attended by the adduction or approximation 
 of the cords, which readily distinguishes it from the passivity of the 
 cadaveric position. 
 
 Prognosis. — In view of the serious nature of the causes which produce 
 complete paralysis of one or both recurrent laryngeal nerves, the progno- 
 sis is grave. In case it is due to syphilitic gummata or to the pressure 
 of enlarged glands, the prognosis under appropriate treatment is good. 
 32 
 
498 DISEASES OF THE LARYNX 
 
 If due to the toxemia of diphtheria or to an acute inflammation, complete 
 recovery may occur in a few weeks. 
 
 Treatment. — The treatment depends upon the cause of the paralysis 
 and the duration of the symptoms. If enlargement of the thyroid gland 
 is the cause, the administration of thyroid extract may diminish the size 
 of the tumor and thus relieve the pressure upon the nerve. An operable 
 tumor causing pressure upon the trunk of the pneumogastric or the 
 recurrent laryngeal nerve should be removed in order to relieve the 
 pressure. If the nerve has undergone degenerative changes, improve- 
 ment may be slight or may not result; if, however, the nerve is still healthy, 
 the paralysis may disappear after the operation. In aneurysm of the arch 
 of the aorta or of the right subclavian, dependence should be placed in 
 the use of iodonucleoid in from 5 to 15 grain doses three times a day. 
 Syphilitic gummata may be treated with mercurial inunctions and the 
 internal administration of iodonucleoid in doses ranging from 10 to 25 
 grains three times a day; or the iodide of potash 10 to 60 grains three 
 times a day. The iodonucleoid is as reliable a drug as the iodide of 
 potash, and has the advantage of being tolerated by the most sensitive 
 stomach. It is free from potash, having a nucleoid base. It is absorbed 
 more readily by the blood and rapidly saturates the system with 
 iodine, which is the active agent in both the iodide of potash and the 
 iodonucleoid. 
 
 Galvanism and faradism combined with external massage over the 
 laryngeal region may increase the circulation and nutrition of the atro- 
 phied muscles. Strychnine is also a valuable remedy, because it increases 
 the nerve energy and tone of the muscles. 
 
 If the paralysis is due to diphtheria or one of the exanthemata, consti- 
 tutional remedies, as strychnine, iron, and the bitter tonics, should be 
 given to build up the waning and depleted cell energy. Eliminative 
 remedies, to stimulate the excretory powers of the intestines, the kidneys, 
 the liver, and the skin, should be given to clear the toxins from the blood 
 and the lymph. 
 
 Tracheotomy may become necessary in a case of severe dyspnea. 
 
 UNILATERAL PARALYSIS OF THE RECURRENT LARYNGEAL 
 
 NERVE. 
 
 Etiology. — Unilateral paralysis of one-half of the intrinsic muscles 
 of the larynx is quite common, as each nerve traverses a long and un- 
 interrupted course before it gives off the terminal twigs to the muscles 
 of the larynx. The left recurrent is given off from the pneumogastric 
 nerve on a level with the transverse portion of the arch of the aorta around 
 which it curves (Fig. 310) and passes upward in the groove between 
 the trachea and the esophagus to the larynx. Aneurysm of the trans- 
 verse portion of the arch of the aorta compresses it and causes degenera- 
 tive changes and consequent laryngeal paralysis. Tumors of the medias- 
 tinum and of the neck or enlarged glands of the neck may compress 
 and injure it. The right recurrent nerve is given off from the right 
 
LARYNGEAL PARALYSIS 499 
 
 pneumogastric on a level with the right subclavian artery, around which 
 it curves in close contact with the apex of the right lung. Aneurysm 
 of the right subclavian causes compression and degeneration of the 
 right recurrent laryngeal nerve, and paralysis results. Pleuritic inflamma- 
 tion and adhesions at the apex of the lung may involve the right recurrent 
 and cause laryngeal paralysis upon that side. Malignancy of the esopha- 
 gus or other growth, or inflammatory swelling, may involve either the 
 right or the left recurrent laryngeal nerve and produce unilateral paralysis. 
 
 Symptoms. — The symptoms include hoarseness or even aphonia at 
 the beginning of the paralysis. Later the unaffected cord compensates 
 for the loss of motion on the effected side, and the aphonia or hoarseness 
 is improved. Dyspnea is absent. The laryngeal image shows the vocal 
 cord on the affected side in the "cadaveric" position, i. e., half-way 
 between adduction and abduction, while the unaffected cord performs 
 both adduction and abduction without restraint. The epiglottis may 
 deviate from the median line. 
 
 Prognosis. — The prognosis depends upon the cause. If due to a 
 transient inflammation or exudate, it is good under appropriate treat- 
 ment. If due to syphilis, the prognosis is good if the case is properly 
 treated. If due to some incurable disease, the prognosis is correspond- 
 ingly grave. If dyspnea is present, the prognosis is more grave. 
 
 Treatment. — When practicable, treat the disease causing the para- 
 lysis as in postdiphtheritic or postexanthematic and syphilitic affections. 
 If an incurable disease, as carcinoma or sarcoma of the mediastinum, the 
 esophagus, or the larynx, is the cause of the paralysis, treat the distressing 
 symptoms as they arise. If the thyroid gland is enlarged, give thyroid 
 extract, or perforin thyroidectomy if the extract fails. 
 
 LARYNGEAL PARALYSIS FROM LESIONS OF THE MEDULLA AND 
 THE NUCLEI OF THE SPINAL ACCESSORY NERVE. 
 
 Laryngeal paralysis from disease or injury of the medulla oblongata 
 and the nuclei of the accessory portion of the spinal accessory is character- 
 ized by paralysis of all the intrinsic muscles of the larynx on the side 
 involved, or if only a few filaments are involved there will be paralysis 
 of only one or at most two muscles of the larynx. It is still further char- 
 acterized by the paralysis of certain muscles, extrinsic to the larynx, 
 which are supplied by nerves having their origin in the immediate vicinity 
 of the motor nucleus of the pneumogastric. Thus there may be para- 
 lysis of the facial, the acusticus, or of the nerves leading to the extremities. 
 
 Pathology. — Laryngeal paralysis due to a central lesion is dependent 
 upon the involvement of the spinal accessory roots, from which some of 
 the fibers of the pneumogastric nerves arise in the floor of the fourth 
 ventricle. There must be a lesion in the medullary or nerve roots supply- 
 ing the larynx. Syphilis, locomotor ataxia, progressive bulbar paralysis, 
 multiple sclerosis, and tumors of the neck and the brain comprise the 
 chief morbid anatomy of central paralysis of the larynx. 
 
500 
 
 DISEASES OF THE LARYNX 
 
 Diagnosis. — The diagnosis depends on the symptom complex of all 
 the nerves involved. There is usually an associated paralysis of the 
 nerves supplying the tongue, the palate, and the facial muscles, or of the 
 nerves of audition, or of the extremities. Other regions supplied by the 
 accessory root may be paralyzed. All the intrinsic muscles of the larynx 
 may be paralyzed, or only a part of them, depending on whether all or 
 only a few of the fibers from the motor pneumogastric nucleus are dis- 
 eased. 
 
 Prognosis. — The prognosis is nearly always very grave, and even 
 when the disease is due to syphilis it should be guarded, though under 
 antisyphilitic treatment improvement may be expected. 
 
 Treatment. — The treatment should be varied to meet the symptomatic 
 indications. If syphilis is present, the iodonucleoid or the iodide of 
 potash should be given in large doses. If a malignant growth is the cause 
 treat the unfavorable symptoms as they arise. If marked dyspnea is 
 present from paralysis of the abductors on both sides, either intubation 
 or tracheotomy should be performed. 
 
 BILATERAL ABDUCTOR PARALYSIS. 
 
 Etiology. — The causes of bilateral abductor paralysis of the vocal 
 muscles are syphilis, mediastinal tumors, aneurysm, and enlarged medias- 
 tinal lymphatic glands. Neurasthenia is also a cause of the paralysis. 
 
 Fig. 311 
 
 Fig. 312 
 
 Bilateral paralysis of the thyro-arytenoidei 
 interni and of the arytenoideus. 
 
 Position of the cords when emitting a high 
 pitched tone and in abductor paralysis. 
 
 Symptoms. — The symptoms have been so admirably given by N. L. 
 Wilson in an article read before the American Laryngological, Rhino- 
 logical, and Otological Society, in 1900, that I will quote him: 
 
 "The patient gave a remote history of syphilis, and was somewhat 
 addicted to alcohol; has had a few attacks of dyspnea, especially at night, 
 for the past eight months. Voice only slightly husky, inspiration a little 
 noisy, and expiration soundless. Occasionally had headaches. Oph- 
 thalmoscope showed nothing abnormal. Heart and lungs normal; 
 
BILATERAL ABDUCTOR PARALYSIS 
 
 501 
 
 urine, acid and clear, specific gravity 1020. There was no albumin or 
 sugar. The laryngoscopic examination showed the epiglottis to be 
 normal, mucous membrane of the larynx normal, the vocal cords white, 
 with a small slit between them during inspiration. The left vocal band 
 was immovable in the median line; the right moved slightly." (Fig. 312.) 
 The patient was warned of the danger of sudden death from dyspnea, 
 but refused to be tracheotomized. Three months later he died suddenly 
 from dyspnea. 
 
 Fig. 313 
 
 Fig. 314 
 
 Fig. 315 
 
 Unilateral paralysis of the 
 thyro - arytenoidei interni 
 and of the arytenoideus. 
 
 Paralysis of the thyro ary- 
 tenoidei interni. 
 
 Bilateral paralysis of the 
 arytenoidei. 
 
 Fig. 31G 
 
 Fig. 31' 
 
 Fig. 318 
 
 Unilateral paralysis of the 
 right arytenoideus. 
 
 Paralysis of the adductor 
 muscles of the larynx. It 
 also shows the position of 
 the cords in deep inspiration. 
 
 Paralysis of the adductors 
 and arytenoideus. 
 
 Pathology. — When due to syphilis the disease may affect the abductor 
 muscles, the peripheral nerve filaments of the recurrent nerves, the nerve 
 trunk, or the medulla. When due to mediastinal tumors, aneurysm, or 
 enlarged glands, the recurrent trunk is pressed upon, causing atrophy 
 or other degenerative changes in its nerve fibers. When due to neuras- 
 thenia, the flow of the nervous impulses through the recurrent nerve 
 are inhibited. 
 
 Prognosis. — The cases of paralysis due to neurasthenia generally 
 recover, though death may occur. When the paralysis is due to other 
 
502 DISEASES OF THE LARYNX 
 
 causes, more than half of the patients die. When operated upon, more 
 than two-thirds recover. In the syphilitic cases the administration of 
 the iodides and mercury sometimes effects a cure. When due to medi- 
 astinal tumors, aneurysm, and enlarged glands, it may be necessary to 
 remove a portion of the vocal cords pending the consideration of the 
 operation or other treatment of the mediastinal disease. 
 
 Treatment. — The faradic and galvanic currents have been used, and 
 in but few cases with success. Antisyphilitic treatment has proved of 
 value in a number of cases. Surgical treatment should be early recom- 
 mended, as procrastination may lead to a fatal issue. 
 
 Surgical Treatment.— Three methods of procedure are available, namely : 
 (a) tracheotomy, (b) intubation, and (c) laryngofissure and the removal 
 of a part or all of the vocal bands. 
 
 Tracheotomy is usually preferable, as it affords the least inconvenience 
 to the patient and is ordinarily easily performed. The cyanosis, conges- 
 tion, and edema of the tissues which sometimes complicates the case 
 (A. G. Root) may, however, render this procedure difficult to perform. 
 (See Tracheotomy.) 
 
 Intubation may be performed for the temporary relief of the dyspnea. 
 It is not suitable for permanent relief, as the tube may be coughed up, 
 and its use is uncomfortable to the patient. 
 
 . Laryngofissure and the removal of a portion or all of the vocal cords 
 may be practised if the tracheotomy tube is objected to. After this 
 operation the vocal functions are sometimes gradually resumed. (See 
 Laryngofissure.) 
 
CHAPTEE XXVIII. 
 
 THE SINGING VOICE. 
 
 The range of the average voice is from two to two and one-half octaves, 
 although many singers embrace three to four octaves. 
 
 The singing voice begins from the third to the sixth year, and changes 
 but little until puberty. At this time there is a great change, especially 
 in boys, in whom it becomes deeper or lower in pitch, assuming more 
 the quality of the voice of an adult male. There is some change in girls' 
 voices, although it is not so noticeable as in boys. The larynx becomes 
 larger, the cartilages consolidated, and the cords longer and thicker. 
 
 The vocal organs should not have special stress put on them during 
 this transition period, as coordination is distributed by the rapid changes 
 in the shape, the size, and the position of the parts of the larynx. 
 
 Voice production is dependent upon three functions of the vocal 
 apparatus. By "vocal apparatus" is meant the larynx (primary source 
 of tone), the chest (source of motive power), and the resonant chambers 
 of the chest and the head. 
 
 Without the motive power of the outgoing current of air through the 
 larynx there could be no vibration of the cords, and without the vibration 
 of the vocal cords and the outgoing current of air through the upper 
 respiratory tract there could be no vibration or secondary tones or har- 
 monics to enrich the laryngeal or primary tone. In other words, a 
 voice, to be pleasing or "sympathetic," must have all the qualities which 
 can be imparted to it by a proper respiratory act, a normal placement of 
 the larynx, and unimpeded vibration of the vocal cords; also the richness 
 or quality imparted to it by the resonance chambers of the chest and the 
 head. 
 
 Defects of the singing voice are, therefore, largely due to the following 
 causes : 
 
 (a) Improper methods of breathing. 
 
 (b) Improper action of the extrinsic and the intrinsic muscles of the 
 larynx. 
 
 (c) Local disease of the larynx. 
 
 (d) Faulty or imperfect use of the resonance chambers of the head 
 and the chest. 
 
 The nose is one of the most important resonant chambers, hence 
 diseases or abnormalities in this region are especially productive of 
 harm to the singing voice. The epipharynx, the soft palate, the uvula, 
 and the tongue are also largely concerned in voice production. Growths 
 or diseased conditions of the epipharynx, the soft palate, and the tongue 
 are therefore potent factors in defects of the singing voice. Enlarged 
 
504 DISEASES OF THE LARYNX 
 
 tonsils, especially if cicatrices interfere with the movements of the pillars 
 of the fauces, mar the purity of the tone and interfere with its placement. 
 The same is true of postnasal adenoids. In both instances the mobility 
 and the normal action of the uvula form a curtain or valve which regulates 
 the volume and the direction of the vibrating air current from the larynx 
 in its passage through the epipharynx and the nasal chambers. It is 
 important that their action should be free and untrammelled. Postnasal 
 adenoids push the soft palate forward and downward, while enlarged 
 and adherent tonsils interfere with its free movement in an upward and 
 backward direction toward the posterior wall of the pharynx. A voice 
 thus modified loses its charm. Not only is the quality or timbre impaired, 
 but the range is also curtailed. I could cite instances in which the quality 
 has been improved and the range increased one to three intervals by the 
 removal of the tonsils. As adenoids are more obstructive in children, 
 they do not greatly affect the adult voice. On account of an associated 
 postnasal catarrh with adenoids, the singing voice is often thereby in- 
 directly affected. Postnasal catarrh involves the postsuperior surface 
 of the soft palate and produces a laxity of the tissues composing it, 
 including the palatine muscles. There is an increase in the fibrous 
 tissue, together with an edema (slight), and boggy condition of the 
 muscle fibers. The uvula is relaxed and often hangs down until it touches 
 the base of the tongue or the posterior wall of the pharynx. This gives 
 rise to a tickling sensation, and is often a source of annoyance to singers 
 and speakers. 
 
 The presence of enlarged and diseased tonsils not only interferes with 
 the muscular activity of the soft palate, but causes a chronic enlargement 
 of the mucous membrane of the epipharynx and the mesopharynx, thus 
 augmenting the catarrhal condition already mentioned. A very common 
 symptom of tonsillar disease is a sensation of a splinter of wood lodged 
 in the throat. This is a symptom which, so far as I know, has not here- 
 tofore been attributed to this condition. I have often noted it, and 
 regard it as significant of cryptic infection. 
 
 Defects of the singing voice due to nasal diseases are chiefly due to 
 an interference with the production of the harmonics or overtones which 
 give quality and character to the voice. The bones of the face are so 
 constructed that there are numerous cavities communicating with the 
 nasal chambers. The lightness of the bones makes them admirable 
 sounding boards for the primary tones of the vocal cords. It becomes 
 apparent at once that any condition of the nose which interferes with 
 the proper entrance of the column of air into the nasal and the accessory 
 cavities will prevent the voice taking on the rich qualities of tone which 
 make it pleasing to the human ear. 
 
 Deflection of the septum, thickening of the nasal mucosa from chronic 
 catarrhal inflammation, polypi, and other morbid processes interfere 
 with the resonant chambers of the head. The mucosa of the nose is 
 reflected through the normal openings into the accessory sinuses, and is 
 here affected by catarrhal or other thickening simultaneously with the 
 invasion of the nasal membrane. The openings into the sinuses are more 
 
THE SINGING VOICE 505 
 
 or less closed by the thickening, and the resonant quality of the cavities 
 is thereby diminished. More often the middle turbinal or a high devia- 
 tion of the septum blocks the nose and affects the resonance of the voice. 
 
 Jean de Reszke has well said that the more he studies the voice the 
 more he is convinced it is a question of the nose. I have for many years 
 been impressed that the chief charm in a public speaker's voice is im- 
 parted to it by the nasal resonance. If this were lacking it failed to hold 
 the attention of his auditors. I only speak of this to emphasize the fact 
 that there is something very attractive to the average person in the reso- 
 nance of nasal origin. There seems to be no other quality that can take 
 its place. What is true in this regard of the speaking voice is doubly 
 true of the singing voice. 
 
 The mouth influences the singing voice to a marked degree, not only 
 in modifying the resonance, but more particularly, in enunciation and 
 articulation. The placement of the tongue, its concave-convex shape, 
 with the tip elevated against the roof of the mouth, etc., modify the mu- 
 sical quality of the voice. Hence all abnormal conditions of the tongue 
 which interfere with its movements affect the voice. If it is "tongue-tied," 
 adherent to the anterior faucial pillars, or the geniohvoglossus muscle is 
 too short, the musical value of the voice is impaired. Hypertrophy of 
 the tongue is occasionally an impediment to the acquirement of vocal 
 excellence. 
 
 The larynx being the primary source of tone, it is natural to presume 
 that most defects of the singing voice are due to some lesion or faulty 
 method of using it. This is probably true, although it should be re- 
 membered that many of the laryngeal inflammations are indirectly the 
 result of nasal disease. Chronic laryngitis and, in many instances, acute 
 laryngitis are secondary effects of chronic nasal obstruction and catar- 
 rhal sinuitis. Recurrent or persistent hoarseness should, therefore, lead 
 to a thorough inspection of the nasal chambers for obstruction or diseases 
 of the sinuses. Hoarseness is not necessarily a sign of an antecedent 
 nasal disease, as it is also a prominent symptom of laryngeal tubercu- 
 losis, cancer, etc. 
 
 Papillomata or other laryngeal neoplasms interfere with the motility 
 and the adjustment of the vocal cords, and thus produce hoarseness, 
 aphonia, or spasm of the muscles of the larynx. Morbid growths in this 
 region should be removed with great care and with due regard to the 
 functional integrity of the vocal apparatus. Awkward or aggressive 
 surgery might forever banish the possibility of a musical career, or 
 even a voice for ordinary social purposes. 
 
 Any of the various forms of laryngeal paralysis described in the previous 
 chapter will, of course, impair or entirely destroy the singing voice. 
 
 Methods of Breathing. — Defects of the Singing Voice Due to Improper 
 Methods of Breathing. — To obtain the purest and richest singing voice 
 the method of breathing should be carefully cultivated. The natural 
 method of breathing is not suitable for the singing voice (H. Curtis). 
 It is adapted to the ordinary function of oxygenating the blood, but is 
 poorly suited for singing. For this purpose the respiratory acts should 
 
506 DISEASES OF THE LARYNX 
 
 be done in such a way as to give the most perfect control over the expira- 
 tory current, and at the same time maintain the same quality or tone 
 of the voice during the varying stages of the act. 
 
 In order to obtain the most perfect control of the expiratory current of 
 air for artistic purposes, the respiratory method should be such as will 
 give the greatest chest capacity, as well as full control over the emission 
 of the air for phonatory purposes. 
 
 The quality or timbre is best maintained throughout all the registers 
 by such a method as will keep the upper portion of the thorax in a fixed 
 position. 
 
 The control of the expiratory current for artistic purposes is a complex 
 coordination of the muscles of the chest walls (scaleni and intercostals), 
 the diaphragm, the abdominal walls, and the larynx. The singer should 
 not, however, be made conscious of the part the larynx plays in this 
 capacity, as this would lead to an undue tension of the laryngeal muscles. 
 Nothing could be more damaging to the quality of the voice than this. 
 In fact, the larynx has but an infinitesimal muscular function in voice 
 production. The singer should be made to understand clearly that 
 only when the laryngeal muscles are at "ease" can the voice charm 
 the listener. The auditory nerve should only be conscious of quality, 
 richness, sweetness, fulness, splendor, unlimited reserve, and all the 
 emotions that make the inner self a free spirit, travelling through the 
 world of ennobled thought and imagination. The most beautiful song, 
 when coming from an overtense larynx, calls attention to the material, 
 the singer, as opposed to the ethereal, the song, thus defeating the pur- 
 poses of artistic singing. 
 
 I have thus digressed at this point in order to emphasize the impor- 
 tance, indeed, the absolute necessity, of maintaining a proper poise of the 
 laryngeal muscles during the artistic activity of the expiratory current 
 of air with which the singing voice is produced. 
 
 The Inferior Costal Type. — The chest cavity is conical in shape, with 
 the apex at the top. It may be increased in all its diameters during the 
 inspiratory act by the action of the scaleni, the intercostals, and the 
 diaphragmatic muscles. All these muscles should, therefore, be used to 
 fill the lungs to their greatest capacity. The inferior intercostals and 
 the diaphragm are especially important for this purpose, hence it is 
 usually spoken of as the inferior costal type. The upward and out- 
 ward movement is chiefly confined to the ribs and the sternum below 
 the sixth rib. The downward movement of the diaphragm pushes the 
 abdominal viscera with it, and thus tends to increase the abdominal 
 convexity. The experience of the great artists has shown that the lower 
 portion of the abdominal walls should not be allowed to participate in 
 this distention, as the perfect control of the expiratory current is thereby 
 hindered. The lower portion of the abdominal wall should, therefore, 
 be retracted, while the upper portion is allowed to distend. 
 
 The upper chest wall should be maintained in the position it assumes 
 during deep inspiration. That is, during expiration it should remain 
 fixed in the position assumed during deep inspiration. In this way the 
 
THE SINGING VOICE 507 
 
 resonance imparted to the voice by the thoracic cavity is increased and 
 maintained of the same quality throughout all the registers of the voice. 
 Failure thus to fix the upper chest wall will result in the voice taking 
 varying tonal qualities as it passes from one register to another. I have 
 heard singers whose voices were rich in quality in the middle register, 
 but in passing into the upper or the lower register assumed an entirely 
 different quality. This change is not always due to a failure to fix the 
 upper chest wall as described, as it may also arise from improper place- 
 ment of the soft palate. Nevertheless, it is important that the upper 
 wall of the thorax should be maintained in the position assumed during 
 deep inspiration. 
 
 The inferior costal or artistic type of breathing may be analyzed as 
 follows : 
 
 (a) It is chiefly performed by the inferior portion of the chest walls and 
 the diaphragm. 
 
 (b) The upper abdominal walls also participate in the outward expan- 
 sion. 
 
 (c) The inferior abdominal walls are maintained in a retracted position 
 during inspiration and expiration. 
 
 (d) The upper chest walls are maintained throughout inspiration 
 and expiration in the position assumed during deep inspiration. 
 
 The effects sought for are: 
 
 (e) The greatest chest capacity. 
 
 (/) Perfect control of the expiratory air current. 
 
 (g) A maintenance of the same resonant quality throughout all the 
 registers. 
 
 Factors Which Influence the Voice. — Deviation from the foregoing- 
 type of breathing during the act of singing are detrimental to the artistic 
 qualities of the voice. It is true that some of the greatest artists do not 
 use this method of respiration. What their voices would have been 
 had they used this method can only be conjectured. There are so many 
 elements entering into the composition of a great artist, that a fault in 
 one direction may be obscured or compensated for in other ways. For 
 instance, an artist may use superior costal breathing and overcome 
 in a large measure any defect of the voice resulting therefrom by the 
 brilliancy of vocal execution or by the transcendent spiritual or mental 
 conception which dominates the mind and the body during the singing. 
 There is no shadow of doubt as to the transforming power of an exalted 
 or overmastering conception of the part being rendered. This alone does 
 not make one a great artist. The physical mechanism whereby this con- 
 ception is expressed should be so coordinated and adjusted as to not 
 detract from its full expression. 
 
 The Vocal Resonators. — The voice, like musical instruments, has its 
 sounding board. The sounding board of the piano and the violin are 
 familiar to all. If the string of a violin were stretched upon a heavy slab 
 of marble the tone given off would be weak and disagreeable. It would 
 lack the overtones or harmonics which make it rich and grateful to the 
 ear. The same string when adjusted on a violin gives forth a tone of 
 
508 DISEASES OF THE LARYNX 
 
 great sweetness and power, as the sounding board adds numerous over- 
 tones to the fundamental tone of the string. The fundamental tone 
 predominates while the harmonics coordinate in such a way as to give it 
 " color" or timbre. 
 
 What is true of the violin string is also true of the vocal cords. The 
 fundamental tone is weak and thin, but it is enriched by the harmonics 
 of the resonance chambers of the chest and the head. 
 
 The resonance chambers (sounding board) of the head are: (a) The 
 ventricular pouches; (b) the pharynx; (c) the epipharynx; (d) the nares; 
 (e) the accessory nasal cavities; and (/) the mouth. 
 
 The resonance from the chest has been referred to under Methods of 
 Respiration. 
 
 The ventricular pouches do not, perhaps, play an important role in 
 the production of overtones. The pharynx (including the epipharynx) 
 communicates with the mouth and the posterior nares. The soft palate 
 acts as a valve or curtain which regulates the amount of the vibrating 
 current of air going to the nose and mouth. In this way the quality 
 of the resonance is regulated to suit the musical expression of the singer. 
 The soft palate is, therefore, an important part of the vocal apparatus. 
 If it is elevated against the posterior wall of the pharynx, the voice 
 assumes a peculiar and objectionable quality known as throatiness, a 
 condition also assisted by the elevation of the posterior portion of the 
 tongue (H. Curtis). 
 
 The soft palate is prolonged downward in two pairs of folds known 
 as the pillars (palatine arches) of the fauces. 
 
 The anterior pillar contains the palatoglossus (glossopalatine) muscle, 
 while the posterior pillar embraces the palatopharyngeus (pharyngo- 
 palatine). They assist in the modulation of the voice by coordinating 
 with the movements of the soft palate. The function of the uvula is 
 not well understood. 
 
 The faucial tonsils lie between the pillars, and when enlarged or dis- 
 eased, affect their motility and impair the voice. They often become 
 adherent to the sinus tonsillaris and thus very materially interfere with 
 their action. I have no hesitancy in indorsing the opinion of Sir Morrell 
 Mackenzie, H. Curtis, and others- who advocate their removal in adults 
 when they give rise to the slightest trouble. Curtis says their existence in 
 the adult is unnecessary, as they serve no good purpose. When we 
 remember that in childhood they are composed of lymphatic tissue, 
 to meet the exigencies of the infectious fevers to which childhood is so 
 susceptible, and that in adulthood they are usually fibrous from repeated 
 and long-continued inflammation or irritation, it is easy to understand 
 why they no longer serve any useful purpose. 
 
 If the pillars are adherent to the tonsils, they should be freed, and in 
 most instances this should be followed by complete ablation of the 
 tonsils. (See Operations of the Tonsils.) The immediate effect of their 
 removal is sometimes detrimental to the voice. After a few weeks this 
 passes away and the voice begins to show the value of the procedure. 
 At first the loosened pillars may relax and fail to perform their muscular 
 
THE SINGING VOICE 509 
 
 function. After a few weeks they become attached to the fibrous tissue 
 formed in the sinus tonsillaris, and perform their functions in a much 
 better manner than before the tonsillectomy. Sir Morrell Mackenzie 
 says he has never seen any other than beneficial effects to the voice 
 follow their removal. 
 
 The pharynx is supplied with numerous lymphatic masses, especially 
 near its vault and along the lateral walls. The enlargement of the 
 lymphatic tissue in the vault is commonly known as postnasal adenoids, 
 while that along the lateral walls of the pharynx is called pharyngeus 
 hypertrophica lateralis. When the scattered masses over the posterior 
 wall of the pharynx are diseased and enlarged, the condition is known 
 under various names as follicular pharyngitis, granular pharyngitis, or 
 " clergymen's sore throat." 
 
 Adenoids are not commonly present in adults, although they may be. 
 Many children, however, have marked defects of the voice from their 
 presence. The resonance is interfered with by the obstruction in the 
 epipharyngeal space and the entrance to the nares. The soft palate is 
 crowded forward and downward by them. The voice has a dead or so- 
 called " nasal" quality, which in reality is an absence of nasal resonance. 
 In other words, the nasal chambers are the chief resonators of the voice. 
 It is obvious, then, that adenoids are an absolute hindrance to the singing 
 voice. The treatment is their complete removal (see Adenoids). 
 
 Hypertrophica lateralis impairs the voice by perpetuating a chronic 
 irritation and congestion of the parts, including the larynx. The voice 
 becomes husky and the muscles of the larynx tire upon slight or moderate 
 singing. The hypertrophic glandular masses should be removed. 
 
 "Clergymen's sore throat" or chronic pharyngitis, is, according to Sir 
 Morrell Mackenize, the most common cause of trouble to singers, the 
 voice becoming husky and tiring upon slight use. Just behind the soft 
 palate the muscles of the posterior pharyngeal wall contract in coordina- 
 tion with those of the soft palate, and aid in closing or constricting the 
 pharynx at this point. Resonance is, therefore, modified by the existence 
 of inflammatory disease of the pharynx, as the muscles of the pharynx 
 and the soft palate are edematous and somewhat restricted in their 
 movements. 
 
 Chronic pharyngitis is accompanied by a similar affection of the 
 posterior wall of the soft palate and the uvula. A relaxed or elongated 
 uvida is nearly always a sign of chronic epipharyngitis. The practice 
 of amputating the uvula under such circumstances should not be done 
 without first attempting to cure the preexisting pharyngitis. 
 
 The tongue performs an important function in regulating the reso- 
 nance chamber of the mouth. If there is a shortening of the geniohyo- 
 glossus muscle, or an hypertrophy of the entire tongue, this function 
 is impaired. I have frequently seen the tongue adherent quite high 
 on the anterior pillars of the fauces. This not only interferes with the 
 correct movements of the tongue, but with those of the anterior pillars 
 also. In one case of this kind, where the tonsils had been completely 
 removed by cautery dissection, hoarseness became a troublesome factor. 
 
510 DISEASES OF THE LARYNX 
 
 Lingual tonsils and varicosities sometimes give rise to hoarseness and 
 a web-like feeling in the larynx. 
 
 "Tongue- tie" interferes with the proper performance of the glossal 
 function, especially in articulation. 
 
 The absence of some of the front teeth, or even marked irregularity of 
 the same, might also interfere with resonance and articulation in singing. 
 
 Cleft palate (either hard or soft) would for obvious reasons interfere 
 with both resonance and articulation. 
 
 The Nasal Chambers. — As these are the chief resonators or sounding 
 boards of the voice, special attention should be directed to their condi- 
 tion in searching for defects of the singing voice. This is of special 
 importance in view of the fact that many pharyngeal and laryngeal 
 affections are caused by preexisting disorders of the nose. 
 
 The nose is divided into two cavities by the nasal septum, and these 
 cavities are still further partially divided by the turbinated bodies. 
 The lateral walls of the nares are in communication with numerous 
 air cells or sinuses which communicate with the nasal chambers. Above 
 the nose they open into the frontal sinuses, while posteriorly they open 
 into the sphenoidal sinuses. Thus the bones of the face form numerous 
 bony chambers which make up the chief sounding board of the vocal 
 apparatus. At least it is this portion of the resonance apparatus that 
 gives the voice its sympathetic and attractive quality. I would not mini- 
 mize the importance of the chest and other resonance chambers, but 
 I would emphasize the importance of the resonance chambers of the nose. 
 
 Defects of the Singing Voice from Improper Methods of Respiration. — 
 While there can be no well-defined analysis of the defects due to improper 
 methods of breathing, there can, nevertheless, be a classification which 
 will emphasize the underlying principles. The following is given for 
 this purpose rather than to catalogue a series of defects : 
 
 (a) Superior costal breathing does not use the entire thoracic capacity, 
 hence the voice does not possess the reserve force and the evenly sus- 
 tained quality afforded by the inferior costal type of breathing. 
 
 (b) The same may be said of the abdominal type of breathing with 
 even greater emphasis. The resonance is less pronounced than in either 
 the superior or the inferior costal type, while the control of the expiratory 
 breath is jerky. The voice is thereby rendered uneven and less sym- 
 pathetic in quality. 
 
 .(c) On account of the greater difficulty in controlling the expiratory 
 breath, the extrinsic and the intrinsic muscles of the larynx are put upon 
 a tension in an involuntary attempt to compensate for the lessened control 
 of the thoracic and the abdominal muscles. This at once impairs the 
 artistic qualities of the voice and in some cases almost destroys its sing- 
 ing qualities. The voice becomes rough, metallic, unsympathetic, and 
 forced. The laryngeal muscles tire easily, and prolonged singing is an 
 impossibility. There is a feeling as of a web across the cords. Frequent 
 ineffectual attempts are made to clear the throat. 
 
 The foregoing symptoms may be present in so slight a degree as to 
 escape notice, or they may be so severe as to ruin the voice. 
 
THE SINGING VOICE 511 
 
 The superior costal or artistic type of breathing, if intelligently and 
 faithfully practised, will avoid these difficulties and add materially to the 
 power and attractive qualities of the singing voice. 
 
 Defects of the Singing Voice Due to Tone Blindness. — J. Mount-Bleyer 
 has called attention to a condition of the hearing centres of the brain 
 which is neither a disease nor a defect, but is the result of inattention 
 or lack of training. For instance, some hear an orchestra as a whole, 
 while others distinguish the tone of each instrument; still others dis- 
 tinguish the exact musical quality of each instrument. The difference 
 is not so much in the mechanism of hearing as it is in the training which 
 the brain centres have received. One, through a love of music, seeks 
 for the finer qualities and variations, while another casually receives 
 only the most general impressions from music. In the first place, there 
 is eager, expectant attention, while in the latter there is an indifferent, 
 passive attention. It cannot be said that one has a good ear and the 
 other a poor ear. Each may have equally good ears, or the one hearing 
 the less may have the better. One, however, has a cultivated brain 
 centre, which enables him to distinguish tones and qualities unnoticed 
 by the other. Suitable training of mechanically perfect "ears which 
 hear not," and "ears that hear and hear not," would rapidly convert 
 them into highly discriminating organs of hearing. 
 
 We often hear the remark, "I do not sing because I have no ear for 
 music." In other words, he sings poorly because he has not educated 
 the so-called ear to a full appreciation of musical intervals, rhythm, and 
 the other qualities which make music so attractive. His belief is that 
 his ears are defective as to musical matters, while the opposite may 
 be true. The whole matter may be summed up in the statement that 
 his "ears" have not been educated. 
 
 J. Mount-Bleyer refers to Mr. Evans' work as superintendent of 
 singing in the London schools, where he has 300,000 pupils under his 
 direction. In no instance of obstinate inability to distinguish one sound 
 from another has he failed to educate them to appreciate such distinc- 
 tions. This fact is significant and should encourage those interested in 
 the cultivation of the voice to give more attention to the exact education 
 of the "ear." 
 
 Treatment. — I will here briefly outline the method of procedure used 
 by M. Duchemin, director of music in the asylums of Paris: 
 
 "M. Duchemin, setting aside all ideas of notations, commences by 
 demonstrating to the pupil, by means of any musical instrument whatever, 
 the interval of a note and that of a half-note. When the pupil has been 
 sufficiently instructed in the distinction of these intervals, he makes him 
 listen to the interval of a note and to that of a major third. He next 
 makes him compare the major third with the fourth, and thus successively 
 all the major intervals of the same octave. He then returns to the point 
 from which he started, and makes him compare the major with the minor 
 intervals. When the pupil is acquainted with all the ascending intervals, 
 he then repeats all the intervals, but in the descending scales. Finallv, 
 when the pupil has compared all the intervals by twos and twos, M. 
 
512 DISEASES OF THE LARYNX 
 
 Duchemin makes him listen to isolated intervals, either ascending or 
 descending, at first to those comprised within a single octave, afterward 
 to those within two octaves, and so on." (J. Mount-Bleyer.) 
 
 I have recently tried this method in a few cases where the claim was 
 made that they "had no ear for music," with gratifying results. The 
 quickness with which they learned to differentiate between the various 
 intervals was surprising to me. Both vocal and instrumental music, 
 including the orchestra, assumed a new and delightful place in their 
 lives. I would, therefore, urge that further attention be given to this 
 part of the subject. 
 
 It is not within the province of this work to speak of methods of teach- 
 ing, except in so far as they may apply to the defects of the singing voice. 
 I cannot refrain, however, from the remark that, in my judgment, M. 
 Duchemin's method of procedure might be used with great advantage 
 in both vocal and instrumental instruction as a preliminary training in 
 musical education. Public schools, conservatories of music, and private 
 teachers might, with great advantage to their students, follow this method. 
 As music is made up of these intervals arranged in varying rhythm, 
 periods, and sequence, it is of primary importance that the ear be trained 
 to recognize them readily. This is all the more apparent when we re- 
 member that only when sensory impressions become intimate parts of 
 one's experience can they be reexpressed with power and beauty. An 
 " ear" trained in this way will not only hear the music of others more 
 accurately, but its possessor will be able to render music more accurately 
 himself. 
 
 I wish here to consider a few of the more common conditions which 
 impair the singing voice. 
 
 Laryngitis of a subacute or chronic type is one of the most frequent 
 derangements of the vocal apparatus to be found among singers. It 
 renders the voice slightly rough or hoarse, and in extreme cases aphonic. 
 The impairment is not constant, but comes and goes with the changes of 
 the weather or with fatigue and use of the voice. Its tendency is to 
 become more and more fixed with each recurrence. The etiology may 
 be embraced in an antecedent nasal disease, an improper use of the 
 laryngeal apparatus, or in some general condition which lowers the vital 
 energy. If it is due to the first, the nose and the epipharynx should 
 receive appropriate attention, with a view to restoring their respiratory 
 functions. Nasal obstruction, chronic sinuitis, etc., should be treated 
 according to the descriptions given elsewhere in this work. The hoarse- 
 ness may be due to an improper use of the vocal apparatus; the faulty 
 method should be detected and corrected if possible. Six years ago a 
 lady consulted me concerning her throat, stating that she was a student 
 of vocal music, and that after moderate use of the voice she became 
 slightly husky, there being the sensation of a web over the cords. Upon 
 examination of the nose and throat I could detect no apparent cause for 
 the condition. I found her, however, to be quite "high-strung," and 
 asked her to go through some of her exercises in my presence. It was 
 quite apparent that the whole muscular system, including the larynx, 
 
THE SINGING VOICE 513 
 
 was of a "high tension." As she was a woman of culture and intelligence, 
 I explained to her the necessity of overcoming this overtension, and 
 offered her some suggestions as to how to do it. She was told to assume 
 a natural and comfortable position in the chair, and to allow her arms, 
 including the hands, to drop at her sides in extreme relaxation. She 
 was then to allow the whole body, including the tongue and the lower 
 jaw, to participate in the relaxation. Next she was to hum very softly 
 the note that came naturally to her throat. After she had gone through 
 with this exercise for a few minutes the vocal exercise was varied by 
 singing the tones within a range of one-half octave, cautioning her all 
 the time to maintain extreme relaxation of the whole body. The exer- 
 cises were gradually broadened to those she was in the habit of singing, 
 the difference being in her physical condition during their production. In 
 a surprisingly short time she thus trained the extrinsic and the intrinsic 
 muscles of the larynx to a normal tension, which not only caused the 
 hoarseness to disappear, but resulted in a placement of the larynx which 
 gave added richness to her voice. There were poise and dignity in it, 
 which were hitherto undeveloped. 
 
 I do not mean to imply that all persons suffering from "high tension" 
 can be made to sing beautifully, but I do want to say that many singers 
 who become hoarse from overtension of the laryngeal muscles may be 
 speedily and effectually relieved of the hoarseness and other tension 
 anomalies of the voice by suitable advice and vocal exercises. The 
 maimer of going through with the exercises should be emphasized. 
 
 If the hoarseness is due to some general systemic disturbance which 
 results in laxity of the cords or the laryngeal mucosa, remedies suited to 
 the case should be given. 
 
 33 
 
CHAPTEE XXIX. 
 
 DEFECTS OF SPEECH. 
 
 Defects of speech are due to a great variety of causes, most of which 
 are extralaryngeal. The larynx is the primary source of spoken tones, 
 but it is not the complete vocal apparatus. It has been customary, in 
 times past, to speak of it as the vocal organ, but this can no longer be 
 done in strict conformity to well-known facts concerning voice produc- 
 tion. While the vibrations of the vocal cords produce the primary tone, 
 it is much modified by the chest, pharynx, epipharynx, nasal and acces- 
 sory chambers, tongue, and the mouth. The character of the tone 
 is also somewhat dependent upon the respiratory movements of the chest, 
 abdominal muscles, and diaphragm. The voice changes when there is 
 a marked increase in the physiological activity of other parts of the body, 
 as at puberty. This is especially noticeable in boys. Mental states 
 exert a marked influence on the quality of the voice, as may be noted in 
 anger, joy, hatred, and love. 
 
 It is, therefore, apparent that defects of speech may have their origin 
 in parts remote from the laryngeal apparatus. The demands of domestic 
 and social life often make it important that one possess a voice that is 
 pleasing in timbre, range, pitch, and modulation, as well as in articulation. 
 Hence, attention should be directed to some of the more important lesions 
 which impair the quality and integrity of speech. 
 
 Speech and Brain Development. — That there is an intimate connec- 
 tion between the development of the organs of speech and the cerebral 
 centres of intelligence is, I think, scarcely open to question. This is 
 especially true in children. I have seen them four years of age, apparently 
 as bright and intelligent, with the exception of speech, as other children 
 of the same age. They had reached the age at which spoken language 
 should be used to communicate their wants and express their ideas. If 
 it is not acquired within a reasonable length of time, they are in danger 
 of becoming mentally inferior to other children of the same age. That 
 this inferiority is not altogether due to their inability to acquire knowledge 
 through the senses, and through the natural inquisitiveness of childhood, 
 has been shown by various writers who have reported remarkable in- 
 crease in the mental development in children who were only trained 
 to use the muscles of articulation, not yet having been led into the realm 
 of thought in which information concerning things and affairs is incul- 
 cated. Makuen, of Philadelphia, reports cases in which the simple 
 training of the muscles of the mouth, tongue, and fauces aroused the 
 dormant faculties of the brain. The use of the motor tracts, of the 
 muscles of speech, stimulated the centres of speech and thought, and 
 
DEFECTS OF SPEECH 515 
 
 the patient passed rapidly from a "backward child" to one of ordinary 
 intelligence. 
 
 I will not at this time consider fully the interdependence of the organs 
 of speech and mental development, but will only thus briefly refer to it 
 in order to emphasize the importance of slight impediments of speech 
 in children who are of the age at which language is most naturally 
 acquired. It is obvious that an impediment at this time is a much more 
 serious hindrance than it is after speech has been acquired. It is very 
 much easier for him to cover up or compensate for a defect in the organs 
 of speech, if the faculty of speech has been already acquired, than it is 
 if that faculty is not developed. Hence, abnormalities of the organs of 
 speech, which develop after speech has been acquired, result in but 
 slight defects of speech; whereas abnormalities of a similar nature, in a 
 child who has not yet acquired the faculty of speech, will in some cases 
 prevent the acquisition of spoken language, while in others it will only 
 interfere with it to such an extent as to make it defective. If this were the 
 extent of the damage done, it might be passed over with comparative in- 
 difference; but, as I have already suggested, mental development is also 
 hindered. I have no doubt that a considerable number of the so-called 
 " backward children" coining under this category are so chiefly on 
 account of a slight physical imperfection of some part of the organs of 
 speech. I do not mean to say that all "backward children" come under 
 this classification, as no doubt many of them are defective in cerebral 
 development from quite different causes. I only wish to call attention 
 to the fact that each case should be carefully studied, the physical im- 
 pediments to spoken language corrected, and suitable training of the 
 organs of speech instituted, in order to give the child the best possible 
 chance of taking the position in society to which he was born. 
 
 An analysis of the peripheral causes of the' defects of speech is inter- 
 esting as well as instructive, especially to those who meet them in practice, 
 or at least to those who attempt to treat them. Defects of speech are 
 subdivided into six varieties by 11. Cohen, of Vienna, as follows: 
 
 1. Stammering. 
 
 2. Stuttering. 
 
 3. Nasal twang. 
 
 4. Defects due to malformations of the hard and soft palates. 
 
 5. Deaf-mutism. 
 
 6. Defects of speech due to diseases of the central nervous system. 
 Instead of following the classification given by Cohen, the author will 
 
 treat the subject under the following heads : 
 
 1. Defects of speech of nasal origin. 
 
 2. Defects of speech of epipharyngeal and faucial origin. 
 
 3. Defects of speech of lingual origin. 
 
 4. Defects of speech of laryngeal origin. 
 
 5. Defects of speech of thoracic and abdominal origin. 
 
 6. Defects of speech due to deaf-mutism. 
 
 7. Defects of speech due to malformations of the palate. 
 
 8. Defects of speech of central origin, 
 
516 DISEASES OF THE LARYNX 
 
 1. Defects of Speech of Nasal Origin.— The etiology may be: (a) 
 Deflection of the septum, (b) Spurs or ridges on the septum, (c) Split 
 or double convexity of the septum from an old traumatic lesion or abscess. 
 (d) Nasal polypi or other neoplasms, (e) Chronic turgescence of the 
 inferior nasal conchse. (/) Hypertrophy of the inferior nasal conchse. 
 (g) Hypertrophy (mulberry) of the posterior ends of the inferior and 
 middle conchse. (h) Congenital occlusion of the posterior nares. ({) 
 Displacement of the columnar cartilage, (y) Enlargement of the middle 
 conchse from hyperplasia or cystic degeneration. (k) Obstruction 
 to the olfactory fissure. 
 
 The foregoing conditions do not cause great defects of speech, as 
 they only interfere with the resonant quality of the voice. Nor do they 
 materially interfere with the muscular mechanism of speech pro- 
 duction. 
 
 In a general way they may be said to produce those changes in the 
 voice which make it "dead," "muffled," "thick," "flat," or lacking in 
 resonance. The speech is still further modified by diffidence, which so 
 often accompanies nasal obstruction. The diffidence, backwardness, 
 or timidity is due to a self-consciousness, to which the defect gives rise, 
 and to a direct effect upon the brain and general system, through the 
 lymphatic and venous stasis attending nasal and postnasal obstruction. 
 Guye, of Amsterdam, has called attention to a condition which he calls 
 "aprosexia," or difficult attention. 
 
 Inability to fix the attention is often attended with diffidence and 
 timidity, and not only is articulation impaired thereby, but fluency 
 and coherency is also somewhat affected. 
 
 The elementary sounds of spoken language which depend largely 
 on the resonance of the nasal chambers are not so markedly impaired 
 as those but slightly depending upon it. For instance, the letters m, n, b, 
 and d derive their peculiarity from the initial sound, while the final vowel 
 and nasal tones are secondary. Notwithstanding the fact that they are 
 secondary, their absence or suppression makes a noticeable change in the 
 speech, and amounts to a defect. If the final vowel-nasal sound in the 
 above examples were more prominent, the nasal obstruction would not 
 interfere with speech nearly so much, as the speaker could "force" them, 
 and thereby somewhat overcome the apparent effects of the stenosis. 
 The letters m and n end in a kind of "hum" which is very difficult to 
 produce when nasal obstruction is present, especially when the hum is 
 somewhat suppressed. 
 
 The letters b and d seem to begin with the sound thrown forward 
 against the lips (b) and against the tip of the tongue and roof of the 
 mouth (d) respectively. The initial sound is, however, made in the 
 larynx and rendered resonant in the chest and nasal chambers. Nasal 
 obstruction modifies the resonance, thus causing a "dead" or "flat" 
 tone to explode at the lips or the tip of the tongue. Thus the speech 
 is rendered defective. We might continue the analysis of the various 
 sounds in speech, showing how nasal obstruction from one or more of 
 the foregoing conditions affects the beauty, music, rhythm, and coherency 
 
DEFECTS OF SPEECH 517 
 
 of speech. We might go still farther and show that coherency of thought 
 is impaired also. 
 
 2. Defects of Speech of Epipharyngeal and Faucial Origin. — These 
 may be caused by the following : (a) Postnasal adenoids, {b) Fibroma 
 or other neoplasms of the nasopharynx (epipharynx). (c) Chronic 
 catarrhal thickening of the mucosa of the epipharynx. {d) Hyper- 
 trophied or hyperplastic faucial tonsils, (e) Adhesions of the anterior 
 and posterior pillars of the fauces to the tonsils. (/) Depression of the 
 soft palate against the root of the tongue by the postnasal adenoids. 
 (g) Paralysis of the palatine muscles, especially those of the membranous 
 curtain which control the current of air passing to the nares. (h) Par- 
 alysis of the soft palate and uvula, (i) Adhesion of the anterior faucial 
 pillars to the base of the tongue, (y) Cleft soft palate and uvula, (k) 
 A shortened soft palate, as is sometimes found after operation for cleft 
 palate. 
 
 In the above table the muscular mechanism of speech is affected, and 
 the defects of speech are correspondingly more pronounced. The explana- 
 tion of the more marked defects which seem to have their origin in this 
 classification is not as easy as may appear on first thought. We cannot 
 say that the speech is defective because the muscular action of the parts 
 is interfered with, because many cases come under our observation 
 in which there is great muscular impairment but little impediment of 
 speech, while others can scarcely be said to have articulate speech at all; 
 and in still others they cannot be said to have coherent thought. The 
 explanation in some cases is that the muscular impairment existed 
 quite early — before articulate speech was acquired. The impediment 
 thus interfered with the acquirement of articulate speech. The presence 
 of postnasal growths produced mental hebetude (aprosexia), heretofore 
 referred to, and the mental ability to acquire articulate speech and 
 consecutive thought was thus impaired. In a few years the growing 
 child becomes more vigorous in mind and body, and makes renewed 
 and voluntary efforts at articulate speech. His failures humiliate and 
 irritate him. He avoids the necessity of speech as much as possible. 
 The speech centres and motor vocal tracts are little used, and lie dormant. 
 His mental growth is thereby retarded. The sensitive, reticent child 
 loses the mental growth to be gained by spoken language. He becomes 
 and is regarded as a "backward child." 
 
 It becomes the duty and privilege of the rhinologist and laryngologist 
 to loosen the bonds which fetter his imprisoned mind, thus enabling him 
 to enjoy the common pleasures of life, even though he may never become 
 a brilliant member of society. 
 
 3. Defects of Speech of Lingual Origin. — The causes may be: 
 (a) Inflammatory adhesions binding the tongue to the anterior faucial 
 pillars and epiglottis. (6) A congenital shortness of the geniohyoglossus 
 muscle, (c) Tongue-tie. (d) Enlargement of the tongue, (e) Excessive 
 enlargement of the lingual tonsils. 
 
 Of the foregoing, the most important are adhesions of the tongue to 
 the anterior faucial pillars, tongue-tie, and shortening of the genio- 
 
518 DISEASES OF THE LARYNX 
 
 hyoglossus muscle. Either condition materially interferes with the 
 articulatory function of the tongue, thus impairing speech. Lisping 
 is a common sign in these conditions. If these lesions exist prior to the 
 acquirement of speech, they may give rise to the clinical picture hereto- 
 fore referred to under "backward children." The early correction of 
 these physical imperfections may place the child on an equal footing 
 with his fellows, and save society the disagreeable presence of a crippled 
 mind in its midst. 
 
 4. Defects of Speech of Laryngeal Origin. — The etiology may 
 be: (a) Too great strength in the uplifting muscles of the larynx, (b) 
 A weakness of the down pulling muscles of the larynx, (c) Laryngitis. 
 (d) Singer's nodules, (e) Chorditis nodosum. (/) Tuberculous inflam- 
 mation and infiltration, (g) Perichondritis. (h) Laryngeal rheuma- 
 tism, (i) Catarrhal accumulations, (j) Neoplasms, (k) Paralysis of 
 the intrinsic laryngeal muscles. 
 
 If the acute affections of the larynx, as laryngitis, and the chronic 
 conditions, such as chronic laryngitis, laryngeal tuberculosis, perichon- 
 dritis, paralysis, rheumatism, and neoplasms which cause hoarseness 
 or aphonia, are omitted, there is little to catalogue as causes of defects of 
 speech. This is the more surprising when we recall the fact that the 
 larynx is the primary source of the voice. 
 
 Makuen has referred to a condition of the extrinsic muscles of the 
 larynx which rendered the voice sibilant and falsetto. It is given in the 
 table above in a and b, and is interesting because it illustrates one of 
 the fundamental problems in voice culture, namely, voice placement. 
 If the larynx is allowed to rise too high, the voice becomes falsetto and 
 unnatural in quality. If, on the other hand, the laryngeal box is held 
 down in its proper position, the voice assumes its natural register, the 
 tone being pure and pleasing to the ear — that is, it is natural. 
 
 The natural and simple things of life appeal most strongly to normal 
 minds. The simple rural scenery, the grandeur of the mountains, the 
 simple melodies of the negroes, the rugged vitality of the Wagnerian 
 opera, and the eloquence of the orator stir the imagination, quicken 
 and fascinate the mind, as the unnatural, the complex, and the artificial 
 cannot do. 
 
 Hence, the aim should be to give those having defective speech a 
 speech that is simple and natural. It should be natural in quality, 
 tone, pitch, timbre, and rhythm, as well as in modulation and articu- 
 lation. 
 
 5. Defects of Speech of Thoracic and Abdominal Origin. — The 
 causes may be: (a) Pulmonary tuberculosis in its relation to stammer- 
 ing, (b) Irregularity of the respiratory rhythm. 
 
 Irregularity of the respiratory movements is an almost constant factor 
 in stammerers. Whether this is due to some fault of the respiratory 
 centre, or to some peripheral lesion, has not yet been determined. 
 Makuen has called attention to the fact that all, or nearly all, stammerers 
 are either tuberculous, or come from families with this disease well 
 marked in its history. He thinks the peripheral tuberculous lesion 
 
DEFECTS OF SPEECH 519 
 
 accounts for the irregularity of the respiratory rhythm, which in turn 
 causes the stammering. 
 
 His conclusion is not necessarily correct, as the lack of rhythm may 
 be due to developmental causes within the medulla, or along the motor 
 nerve tracts leading to the diaphragm, lungs, and intercostal muscles. 
 It is a well-recognized fact that those having a tuberculous tendency, 
 especially those inheriting it, have a lowered cellular vitality, and that 
 nutrition, or the processes of metabolism, are imperfectly performed. It 
 is therefore possible to explain the lack of respiratory rhythm as being 
 the result of the malnutrition and faulty development of the respiratory 
 centre and the motor respiratory tracts. 
 
 Whatever the explanation may be, the clinical fact remains, that 
 nearly all persons who stammer are of tuberculous parentage and com- 
 plain of ill health. Another fact, however, which makes it seem probable 
 that the lesion is peripheral (in the lungs and diaphragm) is that under 
 suitable treatment and training they may be freed from the defect. 
 
 La Fayette Page calls attention to intoxications arising from diseased 
 conditions of the upper respiratory tract. He cites the work of Schwalbe 
 and Retzius, who demonstrated the connection of the lymphatic vessels 
 of the nasal mucous membrane and those of the cranial cavity. Through 
 the lymphatic and venous stasis of the nasal mucous membrane, the 
 effects extend to the cranial cavity, thus giving rise to mental dulness. 
 
 He also cites the intimate nervous connections between the nasal 
 mucous membrane and the cortical centres of the brain as a possible 
 source of mental dulness and irritability. 
 
 Makuen in his writings seems to lay greatest stress on impairment of 
 the organs of speech, as the larynx, fauces, nose, or tongue, as the chief 
 hindrance of mental growth and development. 
 
 In the opinion of the author, defects of speech and mental acumen are 
 due to complex conditions which it would be difficult to define. It appears, 
 nevertheless, that children who are defective in speech are improved 
 by correcting, either surgically or by training, the physical impediments 
 to speech. We also know, from clinical observation, that upon the 
 removal of postnasal adenoids or section of the geniohyoglossus muscle, 
 etc., the mechanism of speech and the mental activity of the child are 
 often much improved. Those who hold, as Guye and Page, that the 
 mental quickening is due to the removal of the cause of the venous and 
 lymphatic stasis, overlook the fact that the mechanism of speech is at the 
 same time improved. The soft palate which was crowded down against 
 the base of the tongue is freed, or the tongue is loosened, and resumes 
 its normal function in articulate speech. Again, those who hold the views 
 of Makuen to the exclusion of all others overlook the fact that the veno- 
 lymphatic stasis, with its attendant toxemia and brain hebetude and 
 irritability, is overcome and allows the brain to resume its normal activity. 
 
 It should not be forgotten that the toxemia referred to by Page affects 
 the system much deeper than the brain. The whole system is poisoned, 
 as has been shown by the author in various articles on mouth breathing. 
 
 There may be great imperfection of speech without impairment of 
 
520 DISEASES OF THE LARYNX 
 
 the mental faculties. Nevertheless, it must be said that in nearly all 
 cases "the speech belieth the man." 
 
 Elegance of speech is an index of a finished mind. Training the 
 organs of speech improves not only the expression of thought, but the 
 thought itself is more elevated, more finished. The quality of mind 
 is improved by a better mode of expression. 
 
 6. Defects of Speech Due to Deaf-mutism. — This subject is quite 
 fully considered under deaf-mutism, and will only be briefly analyzed 
 here. It may be caused by: 
 
 (a) Congenital defect of the auditory apparatus. 
 
 (b) Acquired defect of the auditory apparatus. 
 
 (c) Nasal and epipharyngeal diseases. 
 
 (d) Improper and untimely training. 
 
 (e) Lack of training. 
 
 Congenital defects of the auditory apparatus are probably present in 
 about one-half of the cases of deaf-mutism, whereas in the balance the 
 defect is due to the ravages of some disease, usually one of the exan- 
 thematous fevers. In either instance the child is partially or totally deaf, 
 and cannot, therefore, readily acquire the faculty of speech. He is not 
 mute because the organs of speech are defective, nor because the centres 
 of speech are impaired. Both the peripheral organs of speech and the 
 central mechanism of the brain may be in perfect condition. The child 
 is mute because he cannot hear others speak, and is thereby deprived 
 of the most useful aid in learning, namely, imitation. If he learns to 
 speak he must be taught by other and more difficult methods. He 
 must be given timely and proper special training. If he has acquired 
 deaf-mutism after having some ability to speak, he may not be a mute 
 in the full sense of the word, but may need some special training to 
 prevent his losing the little speech he already possesses. If the deaf- 
 ness comes before the seventh year of age, there is a strong tendency 
 to lose the faculty of speech; hence, special training is necessary to 
 maintain that already acquired, as well as to broaden it. If the deafness 
 comes on after the seventh year, the patient rarely loses the faculty of 
 speech, hence his training can be more simple than that of a child losing 
 his hearing before that age. 
 
 Reference has been made under Deaf-mutism to the interdependence 
 of the brain development and the use of the organs of speech. Brain 
 development and intellectual growth depend largely upon the voluntary 
 use of the organs of speech. It is a common observation with most of us 
 that an idea or train of thought is much clearer after having been ex- 
 pressed in words. The growth of the brain seems to depend upon the 
 cooperation of the various senses and peripheral organs. The intelli- 
 gence of the child will, therefore, largely depend upon the use of its vocal 
 apparatus, as well as all the other peripheral organs of the body. 
 
 At certain ages the various faculties of the brain develop most naturally, 
 and these periods should be taken advantage of by his instructors. At 
 one time the imagination, which later in life finds expression in so many 
 practical ways, has the ascendancy. The training at this period should 
 
DEFECTS OF SPEECH 521 
 
 be of such a character as to lead the imagination along wholesome lines. 
 It should be bridled, but not suppressed. When adulthood is reached, 
 and the practical affairs of life must be faced, the faculty once known 
 as imagination is utilized in foreseeing the outcome of a given series 
 of events. Cause and effect, and the sequence of events, will be cor- 
 rectly interpreted, somewhat in proportion to the character of the training 
 received during the imaginative period in childhood. 
 
 The other faculties of the mind should also receive due consideration 
 in the training of the child. The child that is deaf needs this training 
 tenfold more than the one with normal hearing. It becomes obvious, 
 therefore, that the deaf-mute needs a teacher well schooled in the knowl- 
 edge of the child mind, that he may facilitate its unfolding in the most 
 wholesome and natural manner. Not one mother in ten thousand is 
 fitted for this task, and even if she were, her love for the child would 
 probably make her its worst enemy, in so far as its proper training and 
 restraint are concerned. The proper thing to do, therefore, is to place 
 the child who is a deaf-mute under the care of the most competent 
 teacher available for the purpose, at the earliest possible time, certainly 
 before the sixth year of age. 
 
 The child that has no training will remain a deaf-mute. He may 
 go through the manual sign language, learn to communicate with his 
 fellows, but he will always be much handicapped in the race of life, as 
 his communication with his fellows must be limited to the few who have 
 likewise learned the sign language. Then, too, he is forever debarred 
 from the pleasure and developmental power derived from the mechanical 
 action of the vocal apparatus, and the pleasurable sensation experienced 
 in ventilating the blood and stimulating articulation, which accompany 
 voice production (Makuen). 
 
CHAPTEB^XXX. 
 
 NEOPLASMS OF THE LARYNX. 
 
 Benign tumors of the larynx and the trachea are characterized by 
 the absence of pain and by non-recurrence. Malignant neoplasms, on 
 the contrary, are characterized by pain, recurrence, and destructive 
 processes. 
 
 Varieties. — Almost all types of benign tumors which occur in other 
 parts of the body are found also in the larynx. The following are more 
 or less frequently reported in the literature : papilloma, fibroma, myxo- 
 fibroma, polypus, cystoma, lipoma, telangiectases, chorditis nodosa, and 
 pachydermia laryngis. 
 
 Location. — In looking over the literature for a period of ten years, I 
 found lipoma and cystoma on the epiglottis; cystoma on the ventricular 
 pouches; lipoma, cystoma, and papilloma in the arytenoid region; polypus, 
 telangiectasis, fibromyxoma, papilloma, fibroma, singers' nodules (chor- 
 ditis nodosa), and myxocystoma on the upper surface of the vocal cords 
 and in the subglottic region. These and doubtless other benign neo- 
 plasms occur in the locations indicated. 
 
 Etiology. — Much has been written, while but little is known, concern- 
 ing the exciting causes of these growths in the larynx. 
 
 Jonathan Wright says: " There is a strong likelihood that if these 
 tumors are not the result of chronic inflammatory changes, the chronic 
 inflammations play an important role in their etiology, and that this 
 should be borne in mind in the treatment." They occur at all ages, but 
 most frequently in middle adult life. Papilloma, however, occurs more 
 frequently in children, and measles is apparently a prolific exciting cause. 
 Both men and women are affected, but the tumors are found more fre- 
 quently in men. Sir Felix Semon has called attention to the fact that 
 they are thought to occur more frequently in Germany and France than 
 in the United States or England. 
 
 Benign neoplasms are relatively common among street vendors, singers, 
 and speakers. Congenital tumors are rare. Papilloma is the most 
 common variety. The anterior commissure is the most frequent site 
 for laryngeal tumors. Lipoma rarely occurs within the cavity of the 
 larynx, but is located extrinsically on the anterior surface of the epi- 
 glottis. Syphilis and tuberculosis, though they produce growths of 
 their own kind, have little influence in causing innocent neoplasms. 
 Papilloma, fibroma, and singer's nodules are more frequent than lipoma, 
 myxoma, and cysts. Gerhardt says he has never seen an adenoma, 
 a chondroma, angioma, or a neuroma. Others, however, have reported 
 adenoma in the larynx. Moritz Schmidt, in his work on Newgrowths 
 
78 
 
 256 
 
 15 
 
 46 
 
 53 
 
 109 
 
 
 
 1 
 
 
 
 3 
 
 
 
 1 
 
 22 
 
 36 
 
 6 
 
 8 
 
 
 
 3 
 
 15 
 
 76 
 
 1 
 
 2 
 
 NEOPLASMS OF THE LARYNX 523 
 
 of the Upper Air Passages, gives the following table of laryngeal tumors 
 seen in his clinic of 32,997 cases in ten years : 
 
 Men. Women. Cases. 
 
 Fibroma 178 
 
 Papilloma 31 
 
 Singers' nodules 56 
 
 Lipoma 1 
 
 Mxoma 3 
 
 Fibromyxoma 1 
 
 Tuberculous tumors 14 
 
 Cysts 2 
 
 Sarcoma 3 
 
 Carcinoma 61 
 
 Tracheal carcinoma 1 
 
 This table is significant, and is contrary in some respects to the accepted 
 opinion. For instance, in the above table fibroma occurs more frequently 
 than papilloma. He found 256 fibromata and only 46 papillomata. 
 Singers' nodules occurred in 109 cases, hence both the fibromata and 
 the singers' nodules (chorditis nodosa) were found more frequently than 
 papillomata. The apparent discrepancy is, no doubt, in the differential 
 diagnosis, which is often carelessly made. It is too often made without 
 a microscopic examination, and is, therefore, often incorrect. 
 
 The discussion concerning the exciting causes of benign neoplasms 
 may be summarized as follows: 
 
 The causes are (a) local and (6) constitutional. 
 
 (a) Prominent among local causes is irritation. This produces hyper- 
 emia and cell activity, hence the persistence and the exaggeration of 
 these two conditions may endanger life by allowing the tumor to grow 
 so large as to interfere with respiration, or they may assume malignant 
 tendencies. Mouth breathing is an important factor in producing irrita- 
 tion of the larynx. The required amount of moisture and warmth is 
 not carried to the larynx, and the mucous membrane is overtaxed by 
 the burden thrown upon it. The imperfectly prepared air causes a 
 dryness as well as a hyperemia incident to the increased physiological 
 activity of the mucosa, and the resultant irritation leads to an increased 
 cellular activity. Under these conditions, the cellular arrangement 
 is disturbed and neoplastic growths result. 
 
 (6) Constitutional influences play an insignificant part in the etiology 
 of innocent neoplasms. This does not take into consideration the specific 
 constitutional dyscrasias, as syphilis and tuberculosis, which produce 
 peculiar local laryngeal redundancies. 
 
 In an adult, laryngeal papilloma is often associated with a warty skin, 
 so much so that we can almost speak of a "warty diathesis." This 
 theory was advanced by Fauvel, but it may be said, on the contrary, 
 that the skin and the larynx have a totally different developmental origin. 
 Sir Morrell Mackenzie maintained that syphilis and tuberculosis exer- 
 cised a decidedly antagonistic influence to the development of new forma- 
 tions. Lennox Browne did not share this view, his experience rather 
 proving the reverse. Moritz Schmidt thinks that they favor new forma- 
 
524 DISEASES OF THE LARYNX 
 
 tions, because they always induce a low state of resistance or a local 
 vulnerability. 
 
 The Tendency to Malignancy. — It has been held that operative 
 interference has a tendency to convert benign growths into malignant. 
 
 This belief grew out of the fact that tumors which were operated upon 
 and thought to be benign, were shown to be malignant in the recurrent 
 state. Sir Felix Semon has shown that unoperated cases show even a 
 greater percentage of converted malignancy than the ones which were 
 operated upon. The following are his figures: 
 
 In a total of 10,747 benign cases reported in the literature, 45 after- 
 ward became malignant. They were divided as follows: 
 
 In 8216 operated cases, 33, or 1 in 249, became malignant. 
 
 In 2531 non-operated cases, 12, or 1 in 211, became malignant. 
 
 It is thus shown that a greater percentage of the non-operated cases 
 become malignant. These figures should disprove the old theory that 
 operative interference is an active factor in converting non-malignant 
 neoplasms into the malignant variety. At the same time we must reckon 
 the immense benefits which result from operations upon cases which 
 do not become malignant, but continue to be troubled by the benign 
 neoplasms. 
 
 Neoplasms of the Subglottic Space. — Ferreri states, with reason, 
 that subglottic polypi often cause greater obstruction to respiration 
 than polypi of the supraglottic space. They do not, however, cause a 
 change in the voice until they come in contact with the vocal cords, 
 whereas, tumors of the supraglottic region cause it from the beginning. 
 
 The development of subglottic polypi is insidious, hence they are not 
 usually diagnosticated until well advanced, a fact which explains why 
 they are usually larger than supraglottic polypi. 
 
 The most common form of benign subglottic tumor is the fibroma. 
 Myxoma does not occur quite so frequently, but it is not uncommon to 
 find it associated with fibroma in the form of a myxofibroma. Ferreri 
 also says that, exceptionally, cysts, chondromata, and circumscribed 
 keratosis have been observed in the subglottic space. Papilloma is rarely 
 found in the subglottic region. When present they are difficult to remove 
 by the intralaryngeal route, except by direct laryngoscopy. Thyrotomy 
 (laryngofissure) may therefore become necessary, or infrathyroid laryn- 
 gotomy may be the chosen method of operation. 
 
 The endolaryngeal methods of operating are with forceps, the snare, or 
 the galvanocautery, either by direct or indirect laryngoscopy. Attacks 
 of suffocation may render tracheotomy imperative, in which case the 
 growth may be removed through the tracheal wound. 
 
 Papilloma. — Etiology. — According to Jonathan Wright, this type of 
 neoplasm occurs more frequently in the larynx than any other variety. 
 According to the table of Moritz Schmidt, fibroma occurs more fre- 
 quently. They are closely related to various inflammatory growths 
 which accompany syphilis, tuberculosis, and pachydermia. In view 
 of this fact, many laryngologists regard chronic inflammation as an 
 etiological factor. As already stated under General Etiology, this is 
 
NEOPLASMS OF THE LARYNX 525 
 
 still a mooted question. According to Jonathan Wright, they are usually 
 classified as papillary fibromata. This may account in part for the 
 discrepancy between Schmidt and other writers. Schmidt may have 
 classified as fibromata what others call papillary fibromata. Schmidt 
 observed papilloma in about 9 per cent, of his cases, Schrotter in about 
 18 per cent., and Moure in about 50 per cent. Schnitzler and Killian 
 say they occur more frequently in children, and that fibromata occur 
 more frequently in adults. Harmon Smith, J. Payson, C. Clark, Faurd, 
 and Sir Morrell Mackenzie found them much less frequently in 
 children. 
 
 Symptoms. — Papillomata are usually attached to the anterior third 
 of vocal cords, or at the anterior commissure, though they may spring 
 from any portion of the larynx. Tuberculous papillomata often grow 
 at the posterior commissure. 
 
 Microscopically they have a stratified epithelial covering over a core of 
 more or less vascular connective tissue. The outward growth of the 
 epithelium is in contrast to the involuted growth of carcinoma. True 
 nests or pearls of epithelial tissue have been found. 
 
 Papilloma may appear upon inspection to be either pedunculated or 
 sessile, though upon microscopic examination all varieties have the 
 same structure. It is probable that those having a sessile or diffused base 
 are in reality only numerous sessile pedunculated growths closely crowded 
 together and fused in the process of development. When single, the 
 growths may present a distinct pedicle with a warty growth at its ex- 
 tremity. When multiple, it may appear to be sessile, or it may have 
 the appearance of a cauliflower-like growth. 
 
 Papillomata may be pale or congested. When congested they are more 
 active in their growth, and when pale less active. These appearances 
 may be used for prognostic purposes. For example, when pale their 
 activity is diminished and their removal is not so likely to be followed 
 by recurrence, and vice versa. In one of the cases reported by Harmon 
 Smith, there was a fibrosis at the anterior commissure of the cords, which 
 Jonathan Wright thinks might disappear when the papillomata cease 
 to recur. 
 
 Like warts on the skin, papillomata of the larynx come and go without 
 any apparent reason. J. Payson Clark emphasizes the importance of 
 a physiological change which marks the limit of their growth. When 
 this period occurs their removal may be accomplished with a reasonable 
 hope of non-recurrence. He also emphasizes the futility of operating 
 when they regrow immediately after operation; tracheotomy is then the 
 rational mode of treatment. 
 
 Hoarseness or aphonia are characteristic symptoms, though Logan 
 Turner exhibited the larynx of a child crowded with papillomata, which 
 died, without previous symptoms, during a choking fit at dinner. The 
 hoarseness and aphonia may be transitory or constant. Dyspnea and 
 cyanosis are sometimes severe, and when present, necessitate immediate 
 tracheotomy. If the dyspnea is great, the supraclavicular region will 
 be depressed. 
 
526 DISEASES OF THE LARYNX 
 
 The general health is often impaired and the weight diminished by 
 several pounds. 
 
 Pathology. — Papillomata may be either hypertrophied normal papillae 
 or they may be newgrowths. 
 
 Prognosis. — According to J. Payson Clark, the prognosis during the 
 retrogression stage, or stage of physiological limit, is quite favorable. 
 This stage is also favorable for the removal of the growths. Conversely, 
 during the stage of active growth, or before the stage of physiological 
 limit, the prognosis is much less favorable either as to life or hope of cure 
 by operation. Some cases get well without operative interference. 
 According to Clark, the prognosis is influenced by the technique with 
 which tracheotomy is performed. A preliminary tracheotomy per- 
 formed at leisure and with exactness is more favorable than an emer- 
 gency tracheotomy done in haste with poor technique. He therefore 
 urges that a preliminary tracheotomy be performed when dyspnea 
 first develops, and that the removal of the growths be delayed for several 
 weeks, or until the growths begin to diminish in size. 
 
 The prognosis is bad when the patient develops a cold or contracts 
 measles or other infectious sequela, especially if a tracheotomy tube is 
 being worn. 
 
 According to Harmon Smith, B. V. Burns collected statistics of 127 
 children with laryngeal papillomata, of which 48 were not operated 
 upon, and of these, 32 died, 28 by suffocation. Three were cured spon- 
 taneously; 26 were tracheotomized, 7 died after operation. Twenty- 
 one were subjected to laryngofissure, 8 being permanently cured. Forty 
 were operated upon by the intralaryngeal route, and 13 were permanently 
 cured. In Rosenberg's statistics of 109 children with papillomata 
 subjected to laryngofissure, 20 died from suffocation due to recurrence 
 of the growths. In 43 there was recurrence after repeated operations, 
 though 40 were finally cured. 
 
 The prognosis is much more favorable in adults. 
 
 Treatment. — Local. — Delevan reports good results from the local 
 application of alcohol in adults; Shurly from the use of thuja occiden- 
 talis. Zinc chloride, nitrate of silver, adrenalin, and lactic acid have been 
 tried with slight success. 
 
 Internal. — Of the internal remedies, arsenic has produced the best 
 results. Bostoc favors the use of potassium iodide. The value of these 
 remedies seems to depend upon their regenerating effect upon the general 
 system. 
 
 Surgical. — The trend of opinion is away from laryngofissure (thy- 
 rotomy) and the indirect laryngeal method, and toward tracheotomy 
 and the direct laryngeal method. 
 
 Laryngofissure is not favored on account of the frequent recurrence 
 of the growths. The operation is attended with shock, possibly by death, 
 and is somewhat disfiguring. It is often attended with stenosis of the 
 larynx and an impairment of the voice. The chief argument against 
 this operation for laryngeal papilloma is that other methods afford a 
 better means of relief, 
 
OPERATION BY INDIRECT LARYNGOSCOPY 527 
 
 Operation by direct laryngoscopy (Chapter XXXI) with Jackson's 
 self-illuminated tube spatula is much superior to indirect laryngoscopy. 
 The growths are brought into clearer vision and greater accessibility. 
 Removal by direct laryngoscopy may be attempted when dyspnea and 
 cyanosis are not present. If these symptoms are present, the instruments 
 for tracheotomy should be in readiness should suffocation occur. The 
 growths may be removed through Jackson's self-illuminated tube spatula 
 with straight forceps. 
 
 Operation by indirect laryngoscopy may be practised when symptoms 
 of suffocation are absent and Jackson's or Killian's tube spatula are not 
 at hand. The surgeon should, however, be prepared to perform trache- 
 otomy if suffocation threatens during the operation. 
 
 Tracheotomy should be performed in all cases in which dyspnea and 
 cyanosis are present. This procedure should not be postponed until 
 it becomes an imperative measure, but should be done while the patient 
 is still in a condition to permit the operator to do it with deliberation 
 and good technique, as suggested by J. Payson Clark. According to 
 G. Hunter Mackenzie, tracheotomy is sometimes followed by a cure of 
 the papillomata. While this is true of some cases, it is not true of all, 
 nor of the majority of cases. Tracheotomy should be done to avoid 
 the dangers of suffocation, aside from its curative influence. It should 
 rarely be followed by the immediate removal of the growths. Weeks 
 or months should usually intervene. Indeed, it is useless to remove the 
 growths while they are in the active stage, as they will recur, often in 
 greater abundance, than before their removal. Indeed, if the healthy 
 tissue is injured during the operation the growth will often promptly 
 appear at this point (H. L. Swain). 
 
 When the growths show a state of quiescence or of retrogression, 
 they may be removed by indirect or direct laryngoscopy or through 
 the tracheal wound. 
 
 OPERATION BY INDIRECT LARYNGOSCOPY. 
 
 In describing this operation for the removal of papilloma, it must be 
 taken as a type of surgical procedure used in the removal of nearly all 
 varieties of benign laryngeal neoplasms. Each case will, of course, 
 require some modification of the various steps in the operation. 
 
 Technique.— The Preparation of the Patient.— (a) The throat should 
 be gently sprayed with Seiler's or Dobel's solution. The fauces and the 
 larynx should then be sprayed with a 2 per cent, solution of cocaine to 
 reduce the reflex irritability. 
 
 (b) The larynx is then swabbed with a 10 per cent, solution of cocaine. 
 This should be repeated at intervals of five minutes until anesthesia is 
 induced. If this does not produce anesthesia after several applications, 
 one or two applications of a 20 per cent, solution should be made. This 
 strength of solution should be used sparingly and with caution, although 
 in my experience the larynx has been quite tolerant of cocaine, 
 
528 
 
 DISEASES OF THE LARYNX 
 
 (c) The laryngoscopic mirror is introduced into the oropharynx with 
 its reflecting surface directed downward and forward so as to reflect the 
 rays of light from the head mirror to the growth, the tongue being gently 
 
 Fig. 319 
 
 Krause-Heryng laryngeal forceps. 
 
 Fig. 320 
 
 rolled forward on the forefinger of the 
 left hand. The epiglottis is thereby 
 lifted, exposing the larynx to view. 
 
 (d) Next introduce the curved 
 laryngeal pincette or double cutting 
 forceps (Fig. 319) into the upper 
 space of the larynx until its cutting 
 extremity touches the growth (Fig. 
 320). It must be borne in mind that 
 the image in the mirror is reversed, 
 hence the movements of the instru- 
 ment should be directed in an exactly 
 opposite direction from what appears 
 to be necessary according to the image 
 in the mirror. For example, if the tip 
 of the instrument seems to need a 
 more forward position, so manipulate 
 the handle as to move the tip back- 
 ward, i. e. } lower the handle. If the 
 tip of the instrument seems to be too 
 near the posterior portion of the 
 image, it is in reality too near the 
 anterior portion. A little practice 
 upon a model or upon a patient will 
 familiarize the student with this 
 procedure. The surgeon soon learns 
 intuitively to move the instrument 
 in the proper direction. 
 It is of great aid first to fix firmly in the mind the anatomical relations 
 of the various parts of the larynx. For example, it must be remembered 
 
 Detailed drawing showing the laryngeal 
 forceps placed to remove the neoplasm. 
 
MALIGNANT NEOPLASMS OF THE LARYNX 529 
 
 that the epiglottis stands at the anterior commissure of the larynx, and 
 the arytenoid prominences at the posterior commissure. These simple 
 anatomical guides, if impressed upon the memory of the operator, will 
 lead him unconsciously to guide the laryngeal instrument in the proper 
 direction. 
 
 (e) Having located the growth with the laryngeal forceps or pincette, 
 so manipulate the handle of the instrument as to separate the tips, and 
 then with a slight downward movement of the instrument close the 
 forceps upon the neoplasm and remove it en masse or in part. If the 
 growth is large or multiple, several repetitions of the foregoing pro- 
 cedure may be required. The growth should be removed with as little 
 trauma to the surrounding tissues as possible. 
 
 OPERATION BY DIRECT LARYNGOSCOPY. 
 
 (See Direct Laryngoscopy, Chapter XXXI.) 
 
 MALIGNANT NEOPLASMS OF THE LARYNX. 
 
 The Lymphatic Drainage of the Larynx. — The lymphatics of the 
 larynx are of clinical importance in malignant neoplasms and infectious 
 diseases of the larynx. According to Most, Cunes, Boubland, and 
 Green, the following summary gives the essential facts: 
 
 The lymphatic trunks which take their source from the larynx are 
 derived from a network of radicles which extend throughout the larynx 
 beneath the mucous membrane. This network is divided by a hori- 
 zontal plane at the level of the vocal cords into a supraglottic and an 
 infraglottic portion. The supraglottic portion includes the lymphatics 
 of the epiglottis, arytenoids, ventricular bands, ventricles, and vocal cords. 
 The network of vessels is continuous throughout these areas. Over 
 the upper portion and posterior surface of the epiglottis the network is 
 fine and the meshes are far apart. In front and lower down, especially 
 at the sides, the meshwork is denser and the strands thicker. Over the 
 arytenoids, ventricular bands, and throughout the ventricular pouches 
 the lymph channels are thick and closely woven. In the vocal cords, 
 however, the network is very fine and more sparse than in any other part 
 of the larynx. The infraglottic network is finer than that above the 
 vocal cords, but by no means as fine as that of the cords themselves. 
 The lymph from these radicles is collected into trunks which leave the 
 laryngeal cavity at certain definite places. 
 
 In the upper part of the larynx the only place of egress is through the 
 thyrohyoid membrane. The lymph vessels of the upper network as- 
 semble in the vicinity of the aryepiglottic folds into several trunks, three 
 to six in number, which leave the larynx through the above-mentioned 
 membrane near the superior thyroid artery, a corresponding group 
 being on either side of the larynx. 
 
 These trunks course outward and backward, more or less in relation 
 to the superior thyroid artery, to the carotid region, and terminate in 
 34 
 
530 
 
 DISEASES OF THE LARYNX 
 
 Fig. 321 
 
 nodes which lie along the surface of the internal jugular vein at the level 
 of the bifurcation of the carotid. The upper trunk of this group often 
 runs backward, after emerging from the thyrohyoid membrane, along the 
 hyoid bone to the tip of the lesser, and thence outward to a node lying on 
 the inferior aspect of the posterior belly of the digastric muscle. The 
 lower trunks of this group may run by a lower course, outward and down- 
 ward, into glands in the chain lying on the surface of the internal jugular 
 vein, below the lower border of the lateral lobe of the thyroid gland 
 (Fig. 321). 
 
 The collecting trunks of the infraglottic network are divided into an 
 anterior and a posterior division. The anterior division consists of three 
 or four small trunks, which pierce the cricothyroid membrane in the 
 
 median line and terminate in small 
 glands which lie in the median line 
 at uncertain locations. The up- 
 permost of these is fairly constant 
 and lies in the V-shaped space on 
 the cricothyroid membrane formed 
 by the inner borders of two thy- 
 roid isthmuses, and a third on the 
 anterior surface of the trachea. 
 These two are denominated re- 
 spectively the prethyroid and the 
 pretracheal glands. They may 
 receive trunks from the anterior 
 infraglottic group. Efferent trunks 
 from these glands run to the be- 
 forementioned chain of glands 
 lying on the anterior external sur- 
 face of the internal jugular vein. 
 
 In the posterior division are three 
 to five infraglottic collecting trunks, 
 which penetrate the cricotracheal 
 membrane at or near the line of 
 junction of the cartilaginous and 
 membranous portions of the trachea 
 and run into a chain of glands, two or five in number, which lie along the 
 course of the recurrent laryngeal nerve known as the recurrent chain. 
 From these glands run vessels communicating with the lowermost glands 
 of the internal jugular chain and a few to the supraclavicular group of 
 glands. 
 
 The lymphatic drainage from all parts of the larynx thus eventually 
 leads into the chain of glands lying under the sternomastoid muscle, 
 along the surface of the internal jugular vein, or into the supraclavicular 
 glands. The prelaryngeal, prethyroid, and pretracheal glands are 
 merely intercepters of the current on its way to the deeper glands. 
 
 The spread of infection or of malignant neoplasms from either the 
 supracordal (glottic) or infracordal region is to the deep lymphatic 
 
 Schema of the lymphatic flow from the supra- 
 glottic and the infraglottic regions of the larynx. 
 The glands of the supraglottic region flow into 
 the posterior chain, while the infraglottic glands 
 flow into the anterior cervical chain of glands. 
 This is of diagnostic significance in determining 
 if a cancer is supraglottic or infraglottic. 
 
MALIGNANT NEOPLASMS OF THE LARYNX 531 
 
 nodes along the internal jugular vein beneath the sternomastoid muscle, 
 or, in other words, to the same lymphatic system into which the tonsils 
 drain. In infectious and advanced malignant processes of the larynx 
 the deep cervical glands along the internal jugular vein and beneath the 
 sternomastoid muscles are enlarged. In malignant tumors of the larynx 
 such enlargement of the glands constitutes a contra-indication to opera- 
 tive interference. 
 
 Varieties. — Epithelioma, adenocarcinoma, and sarcoma. Of these 
 the epithelioma occurs the most frequently. Ziemssen reported 57 
 epitheliomata in 68 malignant cases, while 9 were sarcomata. Bos- 
 worth collected 344 cases, of which 204 were carcinomata and 130 sar- 
 comata. Sir Felix Semon, in 1899, gathered the statistics of all laryngeal 
 growths, amounting, all told, to 10,747 non-malignant cases and 1550 
 malignant cases, 1 in 7 being malignant. 
 
 General Facts. — It may be stated, with some confidence, that malig- 
 nant neoplasms may be cured if operated upon sufficiently early. This 
 is not done as often as it should be, hence the mortality rate is still 
 extremely high. The crying need of the hour is "an early diagnosis." 
 How sad the comment upon medical attainments is the "fact" that but 
 few practitioners are able to diagnosticate laryngeal cancer until the 
 patient is in extremis. Yet how easy it is to learn one or two simple 
 indications that should at least put them on their guard, and save their 
 self-respect, their reputation, and the lives of their patients. 
 
 What, then, are the early indications of laryngeal cancer? The early 
 signs of cancer of the larynx are: 
 
 (a) Continued hoarseness without cough, and without other known 
 cause. 
 
 (b) Sharp, sudden pains in the larynx, the ear, or the pharynx. 
 
 (c) Age, the fortieth year and upward; though cancer, especially 
 sarcoma, may occur at a much younger age. 
 
 (d) A laryngoscopic examination may show loss of movement of one 
 of the vocal cords. 
 
 The above symptoms are not conclusive, but they should arouse 
 suspicion of malignancy. The practitioner may, upon the foregoing- 
 data, make a tentative diagnosis of a malignant growth in the larynx; 
 and he will be correct in nearly every instance. 
 
 To sum up: If a patient, forty or more years old, complains of con- 
 tinued hoarseness without cough, and of sharp, sudden pains through 
 the larynx, pharynx, or ear, he should be suspected of having a malignant 
 growth in the larynx. 
 
 What other diseases cause this symptom-complex? Perhaps laryngeal 
 tuberculosis, syphilis, perichondritis, or rheumatic laryngitis may approx- 
 imately duplicate it. There are other peculiar symptoms of these dis- 
 eases, however, which readily distinguish them from malignant neoplasms. 
 In rheumatism there may be sharp pains and hoarseness, but the symp- 
 toms are fugitive; they do not persist as in malignant neoplasms. In 
 tuberculosis and syphilis a casual examination should readily enable 
 the practitioner to make the differentiation. 
 
532 DISEASES OF THE LARYNX 
 
 The extreme simplicity of the symptom complex of the early stage of 
 malignant growth of the larynx encourages me to emphasize the symp- 
 toms, as I have in the preceding paragraphs. I wish to urge every practi- 
 tioner of medicine and surgery to impress indelibly upon his mind the 
 few facts just given. Cancer of the larynx is not a rare disease, but, on 
 the contrary, is quite common; more than 1500 cases were on record in 
 1889, and since then as many more have been diagnosticated and treated, 
 though many have not been published. Inasmuch, therefore, as the dis- 
 ease is comparatively common, I desire to make plain the tentative 
 diagnosis, and divest it all of complex considerations. It may be reduced 
 to (a) age, forty years or more; (6) continued hoarseness without cough; 
 and (c) sudden, sharp pains in the larynx, pharynx, or ears. 
 
 Etiology. — The exciting cause of malignant neoplasms of the larynx 
 is not clearly understood. Chronic inflammation of the larynx seems 
 to be a factor, as the statistics show that families having a history of 
 malignant growths are more often attacked in the larynx when subject 
 to chronic inflammations. The use of tobacco also seems to be an 
 exciting cause. 
 
 Virchow tersely says that healthy tissues, if continually subjected to 
 irritations, may be the seat of heteroplastic growths, and that the larynx, 
 more than any other organ, where no trace of heredity or predisposition 
 exists, is likely to be the site of malignant growths. 
 
 Age. — The age at which malignant growths of the larynx appear 
 varies somewhat with the variety of the cancer. Sarcoma often occurs 
 in the very young. The author saw a case of melanosarcoma in a child 
 eighteen months old, which pursued a very rapid course with a fatal 
 termination. • It is, however, more frequent in young adult life. Epi- 
 thelioma occurs in middle adult life and in old age; carcinoma, chiefly 
 between the ages of forty and sixty. 
 
 Malignant growths of the larynx, without reference to their variety, 
 according to the following table from Gerhardt, occur with greatest 
 frequency between the fiftieth and sixtieth years : 
 
 Cases. 
 
 20 to 30 ... 4 
 
 30 to 40 18 
 
 40 to 50 49 
 
 50 to 60 76 
 
 60 to 70 30 
 
 70 to 80 10 
 
 Total 187 
 
 Schrotter observed carcinoma in a child aged three and one-half years, 
 and in a girl aged ten and one-half years. 
 
 Sex. — Sex influences the formation of malignant growths to a marked 
 degree. Gerhardt found carcinoma three times as prevalent in males 
 as in females, while Semon found them in males four times as frequently. 
 
 Social Standing. — The conditions in life seem to influence the occur- 
 rence of malignant growths of the larynx, the well-to-do being more 
 often afflicted than the poor. 
 
MALIGNANT NEOPLASMS OF THE LARYNX 533 
 
 Pathology. — The pathological anatomy of laryngeal cancers is quite 
 similar to that of carcinoma and sarcoma elsewhere in the body, and 
 will not be described in detail. Under Symptoms will be found a brief 
 characterization of malignant epithelial neoplasms, to which the reader 
 is referred. 
 
 Symptoms. — The chief clinical symptoms are: (a) Continued hoarse- 
 ness without other known cause, (b) Sharp lancinating pains in the 
 ear and pharynx, (c) Loss of movement of the vocal cord on the affected 
 side, (d) The patient is forty years of age, or more, except in sarcoma, 
 which may occur at any age. 
 
 Continued hoarseness may be the only symptom for several months, 
 and the pain and the loss of movement of the cord may commence at a 
 later period; hence, continued hoarseness, without other known cause, 
 should, in a patient forty or more years of age, be sufficient to arouse 
 suspicions as to the presence of a malignant growth in the larynx. While 
 it may be said that a positive early diagnosis is difficult to make, it is, on 
 the other hand, easy to make a provisional diagnosis and place the patient 
 under observation so as to give him the advantage of the earliest possible 
 diagnosis. I make a plea, therefore, with Sir Felix Semon, von Bergmann, 
 Chevalier Jackson, Otto Stein, and others for an early diagnosis. This 
 alone offers a reasonable hope for the successful treatment of this 
 disease. 
 
 The hoarseness grows progressively worse, and the voice may finally 
 become aphonic. 
 
 As the edema develops, and the growth encroaches upon the lumen 
 of the glottis, dyspnea, of greater or less intensity, may embarrass the 
 patient. 
 
 Cough, increasing with the progress of the disease, is usually present. 
 The expectoration is at first similar to that in chronic laryngitis, and 
 later is admixed with purulent secretion, and with blood in the ulcerative 
 stage. 
 
 Dysphagia, or difficult deglutition, is a late symptom in the intrinsic 
 variety of the disease. If, however, the primary cancer is in the pharynx 
 or the esophagus, it may appear at a much earlier period. 
 
 The enlargement of the lymphatic glands of the neck is a late symp- 
 tom, only occurring after ulceration of the tumor has taken place. Epi- 
 thelioma is often attended with a very tardy enlargement of the glands. 
 In intrinsic tumors of the larynx two sets of glands are secondarily 
 affected, namely, the group at the angle of the jaw and those behind 
 the sternocleidomastoid muscle. The subglottic glands of the larynx 
 empty into those at the angle of the jaw, while the supraglottic glands 
 empty into those posterior to the sternocleidomastoid muscle. If, there- 
 fore, the glands at the angle of the jaw are enlarged, it should arouse 
 suspicion, at least, of a subglottic cancer. 
 
 The late involvement of the lymphatic glands in intrinsic laryngeal 
 cancer is another argument in favor of an early diagnosis, as the tumor 
 can then be easily removed in toto. Should the diagnosis be made only 
 after glandular enlargement has taken place, the operation is a much 
 
534 
 
 DISEASES OF THE LARYNX 
 
 more formidable one, as it necessitates the removal of the glands. Fur- 
 thermore, the probability of total resection of either tumor or glands is 
 greatly lessened in the advanced stage of the disease, for recurrence 
 generally takes place. 
 
 Laryngoscopy. — The laryngoscopic examination often presents a 
 picture so characteristic as to confirm at once the suspicion aroused by 
 the other symptoms present. When only one side is affected, the 
 abductors, and later the adductors, are paralyzed on the affected side. 
 Both sides are paralyzed when the entire larynx is involved. 
 
 According to Semon's law, the abductor muscles atrophy before the 
 adductor fibers, hence adductor paralysis appears first and is followed 
 by adductor paralysis. 
 
 By reference to Figs. 322 and 323, illustrating two of the author's 
 cases, the laryngeal image in unilateral cancer of the larynx is shown. 
 
 Fig. 322 
 
 Fig. 323 
 
 Carcinoma of the right ventricular band of 
 the larynx. It was removed by the intralaryn- 
 geal route by the author, returned in one year, 
 was reoperated upon by the same route with- 
 out relief, the patient dying two months later. 
 (Author's case.) 
 
 Paralysis of the thyro-arytenoidei externi 
 and the arytenoideus in attempted phonation, 
 more severe on the left side. Drawn from 
 author's case of subglottic carcinoma of the 
 larynx. 
 
 The microscopic diagnosis is not always reliable, especially if the 
 tissue is removed by the endolaryngeal route (W. J. Terry), as the can- 
 cerous growth may be deeply seated beneath the mucous membrane. 
 If, however, the specimen for examination is removed by laryngofissure, 
 it can be obtained from the deeper structures, and should, therefore, 
 afford an accurate means of diagnosis. B. Fraenkel maintains that the 
 microscopic diagnosis is of fundamental importance. Negative results 
 should not, however, be taken as final, especially if the specimen is 
 obtained by the endolaryngeal route. A positive finding, however, is 
 dependable if made by a competent pathologist. A globular collection 
 of epithelial cells is suspicious only. Epithelial cells must be found 
 where they do not belong. The irregular structure of the epithelium, 
 such as is found in typical epithelial nests, is characteristic of 
 cancer. 
 
 When the microscopic findings include the foregoing points, a positive 
 diagnosis of cancer of the epithelial variety may be made. 
 
MALIGNANT NEOPLASMS OF THE LARYNX 535 
 
 Diagnosis. — Cancer of the larynx should be differentiated from (a) 
 chronic laryngitis, (b) syphilitic laryngitis, (c) tuberculous laryngitis, 
 perichondritis, and (d) benign neoplasms of the larynx. 
 
 (a) Chronic laryngitis: hoarseness, while present in both chronic 
 laryngitis and carcinoma, is more persistent in carcinoma. In chronic 
 laryngitis the voice is husky upon arising, but becomes clear during the 
 day. In chronic laryngitis of ttu hypertrophic variety there are discrete 
 enlargements of the mucosa, but they do not have the distinct nodular 
 surface which is present in carcinoma. In chronic laryngitis the vocal 
 cords are freely movable in both abduction and adduction, whereas, in 
 carcinoma one or both cords are immovable. 
 
 (6) In syphilitic laryngitis the hoarseness is low-pitched, and brassy 
 or raucous in character. In carcinoma of the larynx it is higher pitched, 
 and softer in character; indeed, it may become aphonic in the later stages. 
 The cords are freely movable in syphilitic laryngitis, and the history of 
 the case usually clears the diagnosis. 
 
 (c) Tuberculous laryngitis is characterized by hoarseness and pain, 
 and when perichondritis is present, by fixation of one or both vocal 
 cords. The history and the examination of the sputum render the 
 diagnosis so clear that malignancy is practically excluded. 
 
 (d) Benign neoplasms of the vocal cords (the most frequent site of 
 intrinsic malignant neoplasm) are characterized by hoarseness, though 
 pain and paralysis of the laryngeal muscles are absent. 
 
 Prognosis. — The general prognosis of malignant growths of the larynx 
 is bad. This would not be so if an earlier diagnosis were made. In 
 other words, the prognosis depends in a large measure upon the early 
 recognition and surgical removal of the diseased tissue. Sir Felix Semon 
 claims that 90 per cent, of his cases have been cured by thyrotomy. All, 
 or nearly all, of his surgical cases were diagnosticated and operated upon 
 in the early stage, hence the high percentage of cures. Jackson, in a 
 total of 9 complete laryngectomies, including the epiglottis, had but 1 
 death immediately following the operations. The other cases lived eight 
 or more months after the operations. 
 
 Gluck in his first 10 cases reported 2 as cured (three years without 
 recurrence). In his last series of 22 cases 1 died, making a percentage 
 of recoveries higher than Semon's. Of a total of 23 complete laryn- 
 gectomies, he claims 3 good results. In 1903, out of 125 cases he claimed 
 he could show 38 living cases, the oldest still alive and in good condition 
 thirteen years after the operation. 
 
 Of those dead, some lived eleven, eight, six and one-half, five and 
 one-half, four and one-half, and three and one-half years. Some died 
 of illness other than recurrence. 
 
 Kocher in 12 cases had 6 recurrences. White and Powers, after 
 reviewing a large number of cases, conclude that in complete laryngec- 
 tomies the death rate is 35 per cent., while in partial laryngectomies it 
 is about 27 per cent. 
 
 Werckmeister collected 297 cases of complete laryngectomy, of which 
 36 were fatal, by which he probably means that 36 died during or soon 
 
536 DISEASES OF THE LARYNX 
 
 after the operations. How many died later from recurrence is probably 
 not shown in these figures. 
 
 In a collection of 105 cases operated on by laryngofissure, 4 died of 
 pneumonia within eight days. The low death rate from this cause stamps 
 the procedure as safe from a surgical standpoint. The voice after laryn- 
 gofissure varied with the extent of the operation. In benign tumors 
 it usually remains fair or good. In malignant neoplasms, as they generally 
 affect the integrity of one or both cords, it is not so good. If only one 
 cord is involved, a useful voice is retained in simple laryngofissure and 
 in hemilaryngectomy. 
 
 In summing up the prognosis under operative treatment, it may be 
 said : (a) That in those cases diagnosticated and operated on in the early 
 stage, before ulceration and extension to the neighboring parts, the 
 prognosis is good, (b) In those cases operated on in the late stages the 
 prognosis is bad. (c) The personality of the operator and the fortunate 
 opportunity of seeing the cases in an early stage favor a better prognosis. 
 (d) Laryngofissure gives a better chance of recovery when the disease has 
 not extended to the extrinsic parts of the larynx, (e) Total laryngectomy is 
 attended with greater shock and a higher mortality than the more limited 
 operations. It should be remembered, however, that this method of 
 operating is usually adopted in the more advanced and hopeless cases. 
 (/) Keishaber has divided cancer of the larynx into two clinical groups, 
 which, from the standpoint of prognosis and treatment, is important, 
 namely: (1) intrinsic cancer of the larynx, and (2) extrinsic cancer of 
 the larynx. Intrinsic cancer has its origin in the vocal cords, the 
 ventricular bands, and the ventricular pouches. Extrinsic cancer of the 
 larynx arises from the arytenoid cartilages, the epiglottis, and other parts 
 contiguous to the larynx. In intrinsic cancer the growth develops slowly 
 and extends with extreme reluctance by metastasis to the lymph glands 
 behind the sternocleidomastoid and to the neighboring tissues surround- 
 ing the larynx. 
 
 In the extrinsic variety the reverse of the above facts is true. In 
 other words, the prognosis in intrinsic cancer of the larynx is naturally 
 much more favorable than it is in the extrinsic variety. To make 
 accurate deductions from the statistics of cancer of the larynx it is neces- 
 sary to know whether it is intrinsic or extrinsic, sarcomatous (for it is 
 much more favorable in this variety) or carcinomatous ; whether operated 
 in the early, middle, or late stage; whether by laryngofissure, partial 
 laryngectomy, hemilaryngectomy, complete laryngectomy, or by ligation 
 and resection of the external carotid arteries and their branches, as advo- 
 cated by Dawbarn. 
 
 The foregoing data fairly represents the prognosis under existing 
 methods and conditions, though I fear that it presents it in a too favor- 
 able light. 
 
 Frank Hartly, in 1902, reviewed the literature from 1833, when Brauers 
 performed the first thyrotomy, and the first laryngectomy by Watson 
 in 1878, down to the more improved methods of operating in 1900. The 
 death rate within the first days after the operation, up to 1889, for laryn- 
 
MALIGNANT NEOPLASMS OF THE LARYNX 537 
 
 gectomies was 44 per cent., and of those remaining cured for three 
 years prior to 1889 it was 7 per cent. Since 1889 the death rate within 
 the first ten days has been 8.5 per cent.; in those remaining cured, 15 
 per cent. The following tabulation shows the improvement in the 
 immediate and the remote death rate and the net gain in the mortality: 
 Death rate in laryngectomies for every one hundred operations. 
 
 Immediate deaths. Remote deaths. Total deaths. Living. 
 
 Per cent. Per cent. Per cent. Per cent. 
 
 Prior to 1889 44.0 52.0 96.0 4.0 
 
 1889 to 1900 8.5 47.5 56.5 44.0 
 
 The present total death rate before the end of the third year is 56 
 per cent., as against 96 per cent, prior to 1889. The tremendous im- 
 provement in the mortality rate is encouraging, and stands as the strongest 
 argument in favor of still further improving the surgical technique for 
 the cure of this dread disease. It should be remembered, however, 
 that the improved mortality rate following the surgical treatment is 
 largely due to the more intelligent selection of cases, as well as to the 
 improved technique and asepsis now in vogue. In the period prior to 
 1889 the failure to elect the proper method of operating probably largely 
 contributed to the high death rate. There is still room for improve- 
 ment in this regard, and it is to be hoped that in the near future a still 
 lessened mortuary report will be given. 
 
 Pean reports a case of extirpation of the larynx and part of the esopha- 
 gus for a cancerous tumor diagnosticated by laryngoscopic examination. 
 Although apparently limited to the left side, it was found to extend to 
 the right side, and to the upper portion of the esophagus, the hyoid bone, 
 and the base of the tongue. The whole mass was removed, and, to com- 
 pensate for the extensive loss of substance, the esophagus was drawn up 
 and stitched to the skin in the upper angle of the wound. The trachea 
 with a cannula inserted in it was also secured by suture to the skin. An 
 artificial larynx was supplied, which not only enabled the patient to 
 swallow, but also allowed him to inhale air physiologically prepared in 
 passing through the nose. 
 
 Pean draws the following conclusions from the case: 
 
 1. That it is impossible, prior to operation, to be certain of the extent 
 of the disease when no subjective symptoms are present. 
 
 2. That the surgeon must never promise beforehand to limit the opera- 
 tion to the removal of only a part of the larynx. 
 
 3. That an extensive operation, including the removal of the hyoid bone 
 and the base of the tongue, may be undertaken with safety and success. 
 
 4. That after such operations, important modifications of the anatomy 
 of the parts operated on always follow, the abnormal openings of the 
 trachea and the esophagus being raised, and the epiglottis and the root 
 of the tongue being lowered. 
 
 5. That, thanks to suitable mechanical appliances, the functions of 
 the parts can be, to a large extent, restored, even after the most extensive 
 operations. 
 
538 DISEASES OF THE LARYNX 
 
 Treatment. — The various methods of treating laryngeal cancer may 
 be appropriately studied under the following heads : 
 
 1. The endolaryngeal operation. 
 
 2. Laryngofissure or thyrotomy. 
 
 3. Subhyoid pharyngotomy. 
 
 4. Partial laryngectomy or hemilaryngectomy. 
 
 5. Complete laryngectomy. 
 
 6. Ligation or injection of the external carotids and their branches. 
 
 7. Tracheotomy. 
 
 Each of the foregoing methods of treatment has its advocates, and, in 
 selected cases, its advantages. I shall endeavor to point out the most 
 prominent indications for each in such a way as to enable the surgeon 
 to elect the one most suitable for the case in hand. 
 
 1. The Endolaryngeal Operation. — The endolaryngeal operation for 
 cancer of the larynx is not unlike that described for papilloma of the 
 larynx. The responsibility attending it is, of course, much greater on 
 account of the gravity of the disease. The most distinguished advocate 
 of this method of operating is B. Fraenkel, who cured three cases by 
 operating on them by the endolaryngeal route at intervals covering a 
 period of five years. At the time of his published report there had 
 been no recurrence after two years of quiescence. I have operated on 
 a few cases by this method, in one of which there was recurrence in ten 
 months, with pronounced hoarseness, dyspnea, pain, and cachexia. 
 The second operation did not relieve the patient as did the first. He 
 gradually grew worse, and died two months after the second operation, 
 which was performed twelve months after the first. The case (Fig. 
 322) should have been subjected to hemilaryngectomy or complete 
 laryngectomy at the time of the first operation, notwithstanding the fact 
 that the tumor was apparently accessible to the double cutting forceps 
 via the mouth. It is quite probable that I did not succeed in removing 
 all the cancerous tissue, which I could have done had I resorted to an 
 operation by the external route. Notwithstanding the brilliant results 
 reported by B. Fraenkel, I think the endolaryngeal operation should 
 rarely be the operation of choice. It may be chosen when other methods 
 are refused. Direct laryngoscopy promises better results than are 
 obtained by the indirect method. Laryngofissure may be performed, if 
 a pathologist be present in order to make an examination of the specimen 
 by the freezing method, which only requires a few minutes. In Figs. 324 
 and 325 are shown the author's cases of pedunculated carcinoma of the 
 larynx. This is a rare condition, and I know of only two similar cases 
 on record (B. Fraenkel). The glands of the neck were large and firm. 
 A gland was first removed and submitted to microscopic examination 
 and carcinoma was found. The laryngeal neoplasm was then removed 
 with a snare. As the patient swallowed the growth, warm salted water 
 was given and the tumor ejected. The patient, aged forty-five years, 
 died eighteen months later, metastatic carcinomata being found post 
 mortem in the liver, spleen, and stomach. 
 
 The operation may be completed by the method which appears to be 
 
MALIGNANT NEOPLASMS OF THE LARYNX 
 
 539 
 
 best in view of the macroscopic and microscopic findings. The precise 
 location and extent of the growth, whether intrinsic or extrinsic, should 
 also be determined after the larynx is opened by laryngofissure. 
 
 In order to render the thorough examination of the parts through the 
 laryngofissure possible, the interior of the larynx should be brushed or 
 sprayed with a 10 per cent, solution of cocaine to abolish the reflexes. 
 Adrenalin, 1 to 1000, may be used to shrink the mucous membrane, and 
 thus bring the limitations of the growth into greater prominence. 
 
 Ftg. 324 
 
 Fig. 325 
 
 The author's case of pedunculated carci- 
 noma of the larynx growing from the left 
 ventricular band. The tumor was distinctly 
 movable. It was removed with a cold-wire 
 snare through the mouth. The patient swal- 
 lowed it, was given warm salt solution, after 
 which he ejected it, and the rare specimen was 
 thus preserved. A gland was previously re- 
 moved from the corresponding side of the 
 neck, and upon microscopic examination by 
 the Columbus laboratories it was pronounced 
 carcinoma. The laryngeal tumor was likewise 
 submitted and pronounced carcinoma. Peculiar 
 interest attends the case on account of the 
 distinct segregation of the tumor from the 
 surrounding tissues and its pedicled attachment. 
 
 View of the inferior surface of the author's 
 case of pedunculated carcinoma of the larynx 
 in a man aged forty-five years. The peduncle 
 was tubular and composed of mucous mem- 
 brane, and was attached to the ventricular 
 band of the left side. The tumor was freely 
 movable in the larynx, occasionally obstruct- 
 ing the breathing. The tumor presented the 
 appearance of a gland dislocated beneath the 
 mucous membrane. 
 
 2. Laryngofissure or Thyrotomy. — This operation is one that should 
 be chosen for the purpose of obtaining a specimen for examination and 
 for the removal of cancerous and benign growths. 
 
 The indications : (a) For the removal of foreign bodies lodged in the 
 ventricular pouch which cannot be removed by either the direct or 
 indirect endolaryngeal route. 
 
 (6) For the removal of benign neoplasms which cannot be reached 
 successfully by the endolaryngeal route. 
 
 (c) To obtain a specimen from a suspected malignant neoplasm of 
 the larynx, for microscopic examination, especially when the one re- 
 moved by the endolaryngeal route gives a negative result. 
 
540 DISEASES OF THE LARYNX 
 
 (d) To expose the interior of the larynx to view in order to determine 
 the gross appearance, site, and extent of a laryngeal neoplasm, pre- 
 liminary to the election of the method of removal. 
 
 (e) As a method of election for the removal of an intrinsic malignant 
 growth of the larynx. 
 
 When should laryngofissure be the method of choice or election in malig- 
 nant neoplasms f 
 
 (/) When, upon laryngoscopic examination, the growth is found to be 
 limited to the soft parts or to a small area, and can be removed through 
 the laryngofissure, with the sacrifice of but little or none of the carti- 
 laginous framework of the larynx. 
 
 (g) When, upon laryngoscopic examination, the growth, while some- 
 what extensive, does not appear to involve the deeper tissues, and can in 
 all probability be entirely removed by laryngofissure. 
 
 (h) When the growth is somewhat more extensive than in (/) and 
 (g), but is still circumscribed within a fractional part or one-half of the 
 larynx, having its origin from one cord, or the ventricular pouch or band, 
 is not ulcerated, and there is no enlargement of the glands posterior to the 
 sternocleidomastoid muscle. 
 
 (i) When the growth is intrinsic, the vocal cord, the ventricular pouch, 
 or the ventricular band, even though it is quite large, and the lymphatic 
 glands posterior to the sternocleidomastoid muscle are not enlarged, it 
 is barely possible that operation by laryngofissure may be successfully 
 done. If the growth has involved the cartilaginous framework of the 
 larynx to such an extent as to necessitate the removal of a considerable 
 portion of it on one side, laryngofissure should not be the method of 
 choice. Hemilaryngectomy or incomplete laryngectomy should be 
 chosen after a preliminary laryngofissure. 
 
 Axiom: Laryngofissure should be the operation of choice when the 
 malignant neoplasm is intrinsic, and when diagnosticated in the early 
 stage. 
 
 Laryngofissure or thyrotomy has been frequently referred to as a 
 method of removing growths, foreign bodies, and stenosis of the larynx. 
 It will be described as such, and cross-reference will be made to it 
 wherever the author thinks it the proper procedure for other affections. 
 
 Technique. — The operation consists in splitting the larynx in the 
 anterior median line and removing the growth through the fissure thus 
 made. It is not a formidable procedure, and should be done much 
 oftener than it is. 
 
 (a) The preparation of the patient: In this, as in all cases where a 
 general anesthetic is to be administered, the patient should be placed in 
 a hospital twenty-four to forty-eight hours before the time of operation. 
 Broken doses of calomel, followed by a saline cathartic the following 
 morning, should be administered in time to produce a free evacuation of 
 the bowels a few hours before the operation. The patient should be 
 given no food within nine hours of the operation. 
 
 (b) The preparation of the field of operation: The neck should be 
 cleansed and shaved twelve hours prior to the operation, and a moist 
 
MALIGNANT NEOPLASMS OF THE LARYNX 
 
 541 
 
 carbolic dressing placed over the laryngeal region and held in position 
 with a bandage. The cleansing should be repeated after the patient is 
 under the influence of the anesthetic. 
 
 (c) Anesthesia: Rectal anesthesia, as practised by Cunningham, of 
 Boston, and Stucky, of Lexington, is performed by the administration of 
 the vapor of ether with Cunning- 
 ham's apparatus. It combines sim- Fig. 326 
 plicity and safety; a small amount 
 of ether is used; and its administra- 
 tion is not followed by nausea or 
 vomiting, though prolonged diar- 
 rhea may be produced. The 
 method is especially useful in 
 operations about the head, as the 
 anesthetist is removed from the 
 field of operation. In throat opera- 
 tions it is especially recommended, 
 as the anesthesia may be admin- 
 istered throughout the operation 
 and the secretions are not stimu- 
 lated thereby. 
 
 (d) The cutaneous incision : The 
 incision should be made in the 
 anterior median line, and should 
 extend from the os hyoides above 
 to the sternoclavicular notch below 
 (Fig. 326). There are but few structures of importance which are en- 
 countered in this region, excepting a small amount of areolar tissue 
 and the anastomosis of the inferior laryngeal arteries in the median 
 line. These arteries are encountered at either the inferior border of the 
 thyroid cartilage or the superior border of the cricoid cartilage, hence 
 it may not be necessary to cut them, as they can be pushed aside. 
 There are no serious objections to severing them, but if this is done it is 
 better to locate them and tie them off with absorbable catgut on either 
 side of the median line before dividing them. The venous oozing 
 may be controlled by pressure, or, if too profuse, the venous trunks 
 may be ligated. 
 
 (d) The incision of the thyroid cartilage: This should be done in the 
 median line with knife or scissors (Fig. 327). The knife is preferable 
 unless the cartilage has become ossified, as the dissection can be carried 
 to the mucous membrane without cutting it. This is important, as the 
 incision through the membrane at the anterior commissure of the glottis 
 should be exactly in the median line, as otherwise one of the cords will 
 be injured. 
 
 (e) The incision through the mucous membrane: First locate the 
 median line at the anterior commissure. If in doubt, begin the incision 
 at the upper limit of the wound, and cut downward to the anterior 
 commissure. The knife should then be inserted through the incision and 
 
 I* 
 
 The line of incision for the complete or partial 
 removal of the larynx. , ___ 
 
542 
 
 DISEASES OF THE LARYNX 
 
 between the cords, and the incision at the commissure made from within 
 outward. In this way the cords will not be injured. The incision is 
 then extended to the lower limit of the thyroid cartilage. 
 
 Fig. 327 
 
 Fig. 328 
 
 Laryngofissure. Tracheotomy has been per- 
 formed, a cross-puncture at the lower border 
 of the thyroid made, and the scissors blade 
 introduced through it preparatory to making 
 the incision through the anterior commissure 
 of the thyroid cartilages. (After Moure.) 
 
 Laryngofissure (thyrotomy) completed, the 
 tumor exposed ready tor removal. (After 
 Moure.) 
 
 (/) The larynx should then be opened by retracting the two thyroid 
 cartilages from the median line (Fig. 328). This is done by the assistants 
 with retractors. 
 
 (g) The removal of the growth : Having completed the laryngofissure, 
 and having separated the incised thyroid cartilages, the location and 
 character of the growth should be studied. The growth may be re- 
 moved through the laryngofissure with a snare, scissors, or knife. The 
 
MALIGNANT NEOPLASMS OF THE LARYNX 543 
 
 better surgical procedure is with the knife or scissors, as with either of 
 these instruments the scope of the operation is entirely under the control 
 of the operator, whereas with the snare the depth of the cut cannot be 
 accurately estimated. 
 
 Qi) Hemorrhage: The hemorrhage in the preliminary part of the 
 operation, i. e., the laryngofissure, is comparatively slight, as it is con- 
 trolled by pressure and ligatures as the bleeding points appear. In the 
 removal of the growth, however, there may be considerable hemorrhage 
 both during and after the operation. This is easily controlled with 
 artery forceps or with the actual cautery applied to the bleeding areas. 
 The hemorrhage which occurs after the patient becomes conscious is 
 expectorated, and causes little or no trouble. During the operation the 
 patient's head should hang over one end of the table, which should 
 be lowered to prevent aspiration of blood into the lungs. 
 
 (i) The closure of the laryngofissure: Having removed the neoplasm 
 (or foreign body), the thyroid cartilages are reunited with an absorbable 
 ligature. The coaptation of the cut edges of the cartilages should be 
 carefully done. If, for instance, one side is higher than the other the 
 vocal cords at the anterior commissure will not approximate on the same 
 level, and vocalization will be somewhat modified. 
 
 (j) The closure of the cutaneous wound: This should be done with 
 simple sutures about one-fourth of an inch apart, and the whole covered 
 with plain sterile gauze. The tracheotomy tube may be removed in 
 twenty-four hours or at the end of the operation, and the wound entirely 
 closed. At the end of from three to six days the stitches should be 
 removed. At this time the wound should be thoroughly healed, little 
 additional attention being required. 
 
 Laryngofissure is the preliminary step for stenosis of the larynx. 
 The tracheotomy tube with the upward extending rubber tube in the 
 chink of the glottis. (See Stenosis of the Larynx.) 
 
 3. Subhyoid Pharyngotomy. — Subhyoid pharyngotomy for the removal 
 of malignant neoplasms of the larynx is rarely used. There are cases, 
 however, when it should be elected for this purpose in preference to any 
 other method. 
 
 The indications: The indications for subhyoid pharyngotomy are 
 few, and it is used chiefly in cases of extrinsic malignant neoplasms 
 of the larynx, and in cases complicated by extension to or by origin in 
 the pharynx. They are as follows : 
 
 (a) When the growth is situated in the epiglottis or other of the higher 
 portions of the larynx. 
 
 (b) When the growth is situated in the upper portion of the larynx 
 and involves the pharyngeal wall. 
 
 (c) When the malignant growth begins in the pharynx and extends to 
 the supraglottic (extrinsic) portion of the larynx. 
 
 Technique. — (a) Place the patient under chloroform or ether anesthesia 
 per the rectum or mouth after the usual preliminary preparations. 
 (6) Prepare the neck and face by cleansing, etc. 
 
544 DISEASES OF THE LARYNX 
 
 (c) Elevate the shoulders of the patient by placing a sand pillow under 
 them, and draw the head well backward to bring the hyoid region into 
 easy access. Also elevate the foot of the operating table to prevent blood 
 and secretions entering the trachea while the reflexes are abolished by 
 the anesthetic. 
 
 (d) Make a transverse incision through the skin after Kocher's method, 
 beginning about \ inch below the inferior border of the hyoid bone, and 
 extend it from the anterior border of the sternocleidomastoid muscle 
 to the corresponding point on the opposite side of the neck. The incision 
 should be from 2\ to 3 inches in length. Then make a perpendicular 
 incision in the median line, beginning above at the transverse incision, 
 and extending downward to the prominence of the thyroid cartilage. 
 
 (e) Divide the superficial fascia, in which the anterior jugular vein 
 is found. The jugular vein should be ligated in two places on each 
 side of the neck and severed between the ligatures. 
 
 (/) Sever all the muscles, including the sternohyoid, on either side of 
 the median line, and just beneath them the thyrohyoid muscles, thus 
 exposing the thyrohyoid membrane to view. 
 
 (g) With the finger applied to the membrane explore for the epiglottis, 
 so as to avoid injuring it in the next step of the operation. 
 
 (h) Incise the thyrohyoid membrane, thus exposing the diseased area 
 to inspection. 
 
 (i) Carefully inspect the deeper field, beginning at the anterior surface 
 of the epiglottis, for evidences of a malignant growth. 
 
 (j) Seize the epiglottis with toothed forceps, and gently draw it out^ 
 ward through the wound, securing it with either a suture through its 
 tip or with locked forceps. 
 
 (k) Traction upon the epiglottis opens the wound and exposes the 
 deeper parts to view. 
 
 (I) Through the opening all diseased tissue is removed with scissors, 
 knives, and double cutting forceps, some of the surrounding healthy 
 tissue being also included. 
 
 (m) The wound is now closed by suturing the thyrohyoid membrane, 
 the muscles, and the superficial fascia with absorbable catgut, and the 
 skin with non-absorbable ligatures. 
 
 (n) The external wound should be dusted with iodoform 1 part and 
 boric acid 4 parts, and a gauze dressing applied. 
 
 (o) The dressing should be removed in three to five days and renewed. 
 The stitches in the skin should be removed on about the fifth or sixth day. 
 
 (p) At the end of ten or twelve days the patient should be able to 
 leave the hospital. 
 
 4. Partial Laryngectomy. — This operation is often spoken of in the 
 literature as synonymous with laryngofissure, which is but the preliminary 
 step in partial and hemilaryngectomy. Partial laryngectomy is a more 
 extensive operation than simple laryngofissure. In laryngofissure only 
 the soft parts and the growth are removed, whereas in partial laryn- 
 gectomy a portion of the cartilaginous framework is removed with the 
 growth. 
 
MALIGNANT NEOPLASMS OF THE LARYNX 545 
 
 Indications. — The indications for partial laryngectomy are some- 
 what different from those for laryngofissure. For example, it is not 
 indicated for the removal of foreign bodies in the larynx, benign 
 neoplasms, or of cancerous growths which only involve the soft 
 structures. 
 
 The following are the chief indications: 
 
 (a) When malignant growths are limited to the soft parts on one side 
 of the larynx, and when it is suspected that the cartilage is also involved, 
 a partial laryngectomy may be done. 
 
 (6) When malignant growth is limited to one side, and involves a 
 portion of the cartilaginous framework of the larynx. The removal of 
 the growth and the portion of the cartilage involved is regarded as 
 sufficient to obliterate all traces of the growth. If partial laryngec- 
 tomy will not obliterate the growth, complete laryngectomy should 
 be performed. 
 
 (c) If, for any reason, there is a suspicion of involvement of the deeper 
 structures, partial laryngectomy is indicated. 
 
 Technique. — The technique is so little different from that given in 
 laryngofissure that a detailed description is unnecessary. The chief 
 difference consists in the removal of the affected portion of the carti- 
 laginous framework in addition to the procedures practised in laryngo- 
 fissure, in which only soft tissues are removed. The additional fact that 
 partial laryngectomy is usually indicated in extrinsic cancers also implies 
 a more serious condition, with earlier glandular involvement. Hence, the 
 anxiety and desire to be certain to include all the diseased tissue, even 
 at the expense of some healthy tissue. 
 
 5. Complete Laryngectomy. — The removal of the larynx is a formidable 
 and sad procedure. The death rate in the hands of the average operator 
 is high. The condition of the patient, should he recover from the opera- 
 tion, is often pitiable, indeed, though this fact does not always appear in 
 the published reports. However, from the patient's point of view he 
 would rather be alive without his larynx than dead with it. Complete 
 laryngectomy may, therefore, be done when simple and less radical 
 measures hold out little or no hope of success. 
 
 Indications. — In a general way it may be said that the total removal 
 of the larynx is indicated in those cases in which the disease involves 
 a large portion of the soft and cartilaginous structures in both lateral 
 halves of the larynx. It may also \)e indicated when one side is involved 
 in its entirety and there is a strong suspicion that it has also invaded 
 the opposite side. 
 
 The following fairly represents the chief indications for complete 
 laryngectomy : 
 
 (a) The involvement of one-half of the larynx, with a strong suspicion 
 that it has invaded the opposite side, the glands of the neck not being- 
 involved. 
 
 (b) The involvement of both sides of the larynx, especially if the carti- 
 laginous framework is included in the process, the glands of the neck not 
 being involved. 
 
 35 
 
546 
 
 DISEASES OF THE LARYNX 
 
 (c) The involvement of the extrinsic areas of the larynx on both sides. 
 If the intrinsic portions only, as the vocal cords, are invaded by the 
 cancerous growth, it may be successfully operated on by laryngofissure. 
 
 (d) The involvement of the extrinsic portions of the larynx on both 
 sides, together with the contiguous tissues, as the pharynx, necessitates 
 the total extirpation of the larynx together with the other structures that 
 are cancerous. 
 
 Fig. 329 
 
 The superficial soft tissues dissected from the larynx preparatory to the complete removal of 
 the carcinomatous larynx. The remaining soft tissues should be dissected from the larynx before 
 separating the posterior wall of the larynx from the esophagus. 
 
 (e) When both sides are extrinsically more or less involved, together 
 with the glands of the neck, total laryngectomy and the ablation of all 
 the lymphatic glands on both sides of the neck are indicated, though a 
 fatal result will probably follow. 
 
 Technique. — The method of W. W. Keen is probably the simplest, 
 safest, and most thorough which has yet been devised, and is the one 
 used by me. It is given in the following description: 
 
 (a) The preparation of the patient for the operation bears an impor- 
 tant relation to the success or failure of the surgical procedure. If the 
 patient's general health is bad the prognosis is correspondingly bad. 
 It is essential, therefore, that the general condition of the patient be 
 improved by a short course of forced feeding and tonic remedies. The 
 operation should be performed in the morning, when the vital forces 
 are at their best. On the evening prior to the operation a cathartic 
 
MALIGNANT NEOPLASMS OF THE LARYNX 
 
 547 
 
 should be given, and a saline given early the following morning. The 
 face (adult male) and neck should be shaved and cleansed the day before 
 the operation, and a moist carbolic acid dressing applied. 
 
 (6) On the following morning the patient should be placed upon the 
 operating table in the Trendelenburg position, with the foot of the table 
 raised to prevent the aspiration of blood into the trachea. The patient 
 should have his head lowered throughout the operation, and for three 
 days after it. 
 
 (c) Ether vapor, per rectum, as recommended by Cunningham and 
 Stucky, is, perhaps, the best method of inducing anesthesia, as the anes- 
 thetist and his apparatus (Cunningham's) are removed from the field 
 of operation. 
 
 Fig. 330 
 
 Fig. 331 
 
 Carcinoma of the larynx removed by complete 
 laryngectomy. Posterior view. (Author's case.) 
 
 Carcinoma involving all of one and part of 
 the other half of the larynx. Complete laryn- 
 gectomy was performed by the author by 
 Keen's method without tracheotomy. Anterior 
 view. (Author's case.) 
 
 The anesthetic may be administered by the mouth or the tracheotomy 
 tube (in case a preliminary tracheotomy has been performed), or, if 
 tracheotomy is performed during the operation, it may be given by the 
 mouth until tracheotomy is performed, and then through the tracheotomy 
 tube. 
 
 If tracheotomy is not done either before or during the operation, the 
 anesthetic may be given by mouth until the trachea is severed from the 
 cricoid cartilage, and then through the stump of the trachea. 
 
 (d) The incision should be made in the median line, beginning at the 
 hyoid and extending downward to the sternal notch (Fig. 326). The 
 only vessels of any consequence encountered are the superior and 
 inferior laryngeal arteries and their branches. The arteries and veins 
 should be ligated as they are exposed (Plate IX). The venous hemor- 
 rhage may be controlled by pressure, or the larger trunks may be tied. 
 
548 
 
 DISEASES OF THE LARYNX 
 
 (e) Separate the soft structures (Fig. 329), including the muscles in 
 the median line, and dissect them from the larynx down to the esophagus 
 on the posterior wall of the larynx. 
 
 Fig. 332 
 
 Complete laryngectomy. The larynx has been severed from the trachea at the junction of the 
 first ring and the cricoid cartilage. The larynx is being separated from the anterior wall of the 
 esophagus by blunt dissection. 
 
 (/) Introduce a heavy anchor suture between the first and second 
 cartilaginous rings of the trachea on either side, and pass one end of the 
 suture through the adjacent skin, as shown in Fig. 332. This is done to 
 prevent the trachea dropping into the mediastinum when it is severed 
 from the larynx. 
 
 (g) Tie the anchor sutures described in the preceding paragraph, and 
 sever the trachea from the cricoid ring of the larynx with a sharp scalpel. 
 If the anesthetic has been given by the mouth, it should be transferred to 
 the trachea. 1 
 
 (h) Dissect the posterior wall of the larynx from the esophagus with 
 the finger or blunt instrument, as shown in Fig. 332. This is often a 
 
 1 In this description it is presumed that the removal of the larynx is done without tracheotomy 
 either prior to or during the operation, as suggested by Dr. W. W. Keen. I performed the opera- 
 tion in this manner in August, 1905, with satisfaction. The larynx and carcinoma thus removed 
 are shown in Figs. 330 and 331. The patient died six days after the operation from exhaustion. He 
 rallied after the operation, progressed very favorably for five days, took food per rectum for four 
 days, and by mouth for one. He was then unable to retain food on his stomach. Rectal feeding 
 was again tried, but was not retained. Death occurred the following day. The patient was fifty 
 years old, and had been a heavy whisky drinker for twenty-five years. The carcinoma was extrinsic 
 and large, and while chiefly limited to the right half of the larynx, it had extended to the left side 
 of the epiglottis. There was no enlargement of the glands of the neck. Only one enlarged lymphatic 
 gland was found, and that was in the glosso-epiglottic space. 
 
PLATE IX 
 
 Arteries of the Larynx. The superior laryngeal and the 
 inferior laryngeal arteries, branches of the superior and inferior 
 thyroid arteries, respectively, supply the walls, glands, muscles, 
 and mucous membrane of the larynx. 
 
MALIGNANT NEOPLASMS OF THE LARYNX 
 
 549 
 
 difficult task, as the adhesions are firm. Every effort should be made to 
 avoid tearing the wall of the esophagus, as it is difficult to repair it by 
 suture. 
 
 (i) Having separated the esophagus from the larynx as high as the 
 arytenoid cartilages, it should be severed from the larynx by transverse 
 incision (Fig. 334). 
 
 (j) The only attachment remaining is the thyrohyoid membrane in 
 front. This should also be severed by a transverse incision (Fig. 334). 
 The larynx and the neoplasm are thus extirpated, leaving the pharynx 
 open in front. 
 
 Fig. 333 
 
 Complete laryngectomy. The thyroid glands turned aside with ligatures through them. The 
 trachea severed below the cricoid cartilage preparatory to dissecting the larynx from the esophagus 
 and other deep soft tissues. Anchor sutures passed through the upper ring of the trachea to 
 prevent the trachea dropping into the mediastinum, a, thyrohyoid membrane. 
 
 (k) The lower pharyngeal membrane should now be sutured to the 
 thyrohyoid membrane below the hyoid bone, as shown in Fig. 326, thus 
 closing the wound in the anterior wall of the pharynx. 
 
 (/) The soft tissues should be brought together in the median line 
 by buried absorbable catgut sutures. 
 
 (m) The stump of the trachea should be securely sutured to the skin, 
 as the breathing must in future be carried on through it. 
 
 (?i) The skin should be closed by sutures except around the stump 
 of the trachea, as shown in Fig. 335. 
 
 (o) A dressing should be applied over the line of skin sutures. A 
 thin dressing of gauze should be placed over the tracheal stump to filter 
 the air inspired through it. This portion of the dressing should be 
 frequently changed, as it becomes soiled by the secretions coughed out 
 through the trachea. 
 
550 
 
 DISEASES OF THE LARYNX 
 
 After-treatment. — Keep the foot of the bed elevated a foot or more 
 for three days, to promote drainage of the trachea, or until the patient 
 can take food by the mouth. Sustain the patient by rectal feeding at 
 intervals of three or four hours for four days. At the end of this time 
 the pharyngeal wound is usually united, and food may be given by mouth. 
 In from twelve to fourteen days the patient should be able to leave the 
 hospital, if he is not dead. 
 
 Fig. 334 
 
 Complete laryngectomy. The larynx has been removed, leaving an opening in the anterior wall 
 of the pharynx. The sutures are in position ready to close the wound. 
 
 Axioms. — 1. Early diagnosis and an early operation in laryngeal 
 cancer means a probable cure. 
 
 2. An early provisional diagnosis of cancer may be made if three 
 clinical facts are borne in mind, namely, a patient forty or more years old, 
 complaining of continued hoarseness without cough, with sudden sharp 
 pains in the larynx, pharynx, or ears. 
 
 3. The operation of choice should be the one that will insure the com- 
 plete removal of malignant tumor with the least destruction of normal 
 healthy tissue and the least damage to the function of the larynx. 
 
 4. Intrinsic cancer of the larynx is successfully treated by laryngo- 
 fissure, a simple and comparatively safe method. 
 
 5. Complete removal of the larynx is a formidable and dangerous 
 operation, only suited to extensive involvement of the soft and the carti- 
 laginous portions of the larynx in both lateral halves. 
 
MALIGNANT NEOPLASMS OF THE LARYNX 
 
 551 
 
 6. Extensive involvement of the larynx and of the adjacent structures 
 means certain death without an operation, and probable death with an 
 operation. 
 
 7. If the diagnosis of cancer of the larynx is only made at an advanced 
 stage, the physician is guilty of "ignorance," when it is easy to be "wise." 
 
 Postoperative Considerations. — The surgeon's responsibilities are by no 
 means ended when the operation is completed. There are several con- 
 ditions which are either present or likely to arise that demand his thought- 
 ful attention. Among them are the following: 
 
 The incision after complete laryngectomy. The end oi the trachea is sutured to the skin. 
 
 1. Shock arid Sudden Death. — Stoerk attributes death by shock to the 
 severing of the fibers of the inhibitory cardiac branches of the pneumo- 
 gastric nerve. They are given off, and pass forward to the larynx, thence 
 downward back of the trachea, where they may be injured in separating 
 the esophagus from the larynx and the trachea. It is, therefore, well 
 to keep close to the posterior wall of the trachea, and to avoid undue 
 manipulation and traumatism in making the separation. 
 
 Crile, by experimentation upon lower animals, arrives at the con- 
 clusion that sudden death in laryngectomy and intubation is due to an 
 irritation of the middle and the upper portion of the larynx, the irritation 
 exciting a reflex inhibition of the cardiac branches of the pneumogastric 
 nerve. He therefore recommends a preliminary incision through the 
 cricoid membrane, through which the interior of the larynx may be 
 brushed with a 5 per cent, solution of cocaine. After that is done the 
 operation of election is continued. He also suggests that an injection 
 of atropine helps to prevent the reflex influence upon the heart. He 
 
552 DISEASES OF THE LARYNX 
 
 makes the following distinctions between asphyxia and reflex action on 
 the respiratory organs and the heart: 
 
 (a) In asphyxia there are more or less violent efforts to breathe, the 
 heart momentarily beating stronger; whereas, 
 
 (b) In reflex disturbances the breathing stops suddenly and the heart 
 immediately becomes weak. 
 
 The above distinctions are peculiarly applicable to impending death 
 during intubation in diphtheria and pseudomembranous croup. During 
 intubation the patient is suddenly asphyxiated, or is thrown into a state 
 of shock, the characteristics of each being given in the above paragraph. 
 
 Treatment of Cardiac Reflexes. — (a) Instantly lower the head without 
 further manipulation of the larynx. 
 
 (b) Slap the chest with a cold wet towel, then immediately dry the 
 surface and repeat the cold applications. 
 
 (c) Artificial respiration should, in the meantime, be kept up. 
 Treatment of Asphyxia. — (a) Remove the intubation tube or the 
 
 obstruction to the larynx and clear it of membrane. 
 
 (b) The patient will then, in all probability, cough out more membrane 
 or obstructing secretions, thus clearing the lumen of the trachea. 
 
 (c) Reintroduce the cannula (in diphtheria), and no further trouble 
 will be likely to occur. 
 
 While the foregoing remarks upon shock and sudden death do not, in 
 all respects, have a direct bearing upon the operation for cancer of the 
 larynx, they nevertheless have an indirect relationship, and may prove of 
 value in the study of this subject. 
 
 2. Inspiration pneumonia is a common sequel of the operative treat- 
 ment of laryngeal cancer, and is a frequent cause of death. In laryngo- 
 fissure, one of the simplest external laryngeal operations, the death rate 
 is about 4 per cent. In complete laryngectomy the mortality from 
 pneumonia alone i much greater. 
 
 3. Recial Alimentation. — After complete laryngectomy the patient 
 should be sustained by rectal alimentation for three or four days, after 
 which he may be given food by the mouth. In the simple operations the 
 rectal feeding may be discontinued somewhat earlier, proportionate to 
 the extent of the operation. Indeed, in simple laryngofissure it may be 
 dispensed with altogether. 
 
 4. The Voice. — After laryngeal operations the voice may be good, 
 if the cords are not greatly damaged in the removal of the growth or 
 the larynx is not removed in its entirety. If the tumor arises from the 
 cords, and has penetrated deeply into their substance, they must be 
 removed, and the voice is consequently weak and otherwise impaired. 
 After laryngofissure for laryngeal cancer the voice is usually more or 
 less impaired, while in benign growths it is usually very good. After 
 hemilaryngectomy and partial laryngectomy, one cord remains, and 
 gives a husky though useful voice. After complete laryngectomy, when 
 the trachea is stitched to the skin, there is no voice except in rare cases, 
 where the tissues around the tracheal opening are thrown into vibration. 
 When the trachea is stitched to the pharyngeal wound there may be 
 
MALIGNANT NEOPLASMS OF THE LARYNX 553 
 
 more or less voice. This is obtained by the peculiar conformation of the 
 parts after the healing process is complete. The larynx being removed, 
 the base of the tongue drops backward and downward, approximating 
 the posterior wall of the pharynx. The cavity below the base of the 
 tongue forms an air chamber, which is utilized to force air through 
 the constriction formed by the base of the tongue and the pharyngeal 
 walls, thus throwing the tissues at this point into vibration. The union 
 of the trachea to the pharyngeal wound is not often practised, as the 
 tension is so great that the tissues tear apart, slough away, or undergo 
 gangrenous degeneration. 
 
 5. Recurrence. — Recurrence of the cancerous growth is common on 
 account of failure to make an early diagnosis. Intrinsic growths are 
 less malignant than the extrinsic, hence recurrence in this variety is not 
 so common. 
 
 It may be said, then, that recurrence of laryngeal cancer is largely 
 dependent upon the following factors : 
 
 (a) Intrinsic cancers of the larynx do not recur as frequently as the 
 extrinsic. 
 
 (b) Conversely, extrinsic cancers more often recur than the intrinsic. 
 
 (c) Extralaryngeal cancers, involving the larynx, have a still greater 
 tendency to recurrence. 
 
 (d) An early diagnosis and operation by laryngofissure, in intrinsic 
 cancer of the larynx, should result in a death rate of only 10 per cent., 
 and 5 of the 10 die of pneumonia rather than of recurrence. 
 
 (e) Complete laryngectomy in cancer of the larynx was, up to 1889, 
 attended with a death rate of 44 per cent., but since antiseptic surgery 
 and an improved technique have been attained, it is reduced to about 
 15 per cent. When I speak of a death rate of 15 per cent., I mean death 
 within three years after the operation. Quite a number die within a 
 few months from pneumonia, septicemia, gangrene, exhaustion, or other 
 sequelae. In still others recurrence brings on a fatal issue. 
 
 (/) The ligation or injection of the external carotids and their branches 
 should only be done when the cancer is inoperable, as it does not cure, 
 but only hold out the hope of retarding the growth of the tumor by 
 diminishing its nourishment. 
 
 (g) Tracheotomy should be reserved for inoperable cases in which 
 the cancerous tumor obstructs the breathing and threatens the life by 
 suffocation. 
 
CHAPTEE XXXI. 
 
 FOREIGN BODIES IN THE LARYNX, TRACHEA, BRONCHI, AND 
 
 ESOPHAGUS. 
 
 Etiology. — The lodgement of foreign bodies in the air passages is 
 most common in infants and young children, as they have an instinctive 
 desire to test all substances with their mouths. Coughing, laughing, 
 crying, and ineffectual attempts to swallow draw the foreign bodies into 
 the lower air tract. The small caliber of the larynx and air tubes in 
 infants and young children increases the chance of lodgement of foreign 
 bodies. The smaller size of the larynx and air tubes in infants and 
 young children renders the obstruction greater than in older subjects 
 from the same foreign bodies, hence the danger is correspondingly 
 greater in young subjects. 
 
 The nature of the foreign bodies ranges anywhere from particles of 
 food to marbles, coins, safety pins, burrs, and false teeth. 
 
 Symptoms. — The symptoms of a foreign body in the respiratory 
 passages are those of obstructed breathing, laryngeal, tracheal, bronchial, 
 or pulmonary irritation, and inflammation. The patient is suddenly 
 seized with a violent choking and suffocative attack, characterized by 
 cyanosis, aphonia, beads of perspiration on the forehead, and a weak 
 pulse. These symptoms usually subside within a few minutes, but return 
 again in a few hours or days. After the foreign body remains in the 
 larynx for several weeks the spasmodic symptoms cease and the cough, 
 etc., become more constant, often leading to a diagnosis of tuberculosis. 
 A negative finding upon examination of the sputum removes the suspicion 
 of tuberculosis. A positive finding does not, however, exclude a foreign 
 body. A history of spasmodic cough and dyspnea and hoarseness fol- 
 lowed by a persistent cough should excite suspicion of a foreign body 
 in the respiratory tract if the patient is a small child. If the foreign 
 body lodges in the ventricle of the larynx or in the subglottic space, 
 hoarseness or aphonia is usually present. When the foreign substance 
 changes its position, or a fresh irritation arises, new suffocative attacks 
 are excited. If the foreign body lodges in the trachea, bronchus, or 
 one of the bronchioles, the voice remains clear. Bronchial rales or 
 pneumonia may subsequently develop. In some instances the move- 
 ments of the foreign body when in the bronchus may be detected by 
 auscultation (Halstead). Dyspnea, attended with an elevation of tem- 
 perature, often leads to an erroneous diagnosis of tracheal diphtheria. 
 A laryngoscopic examination may not reveal the foreign body, even 
 though it is lodged in the ventricle of the larynx. By direct laryngoscopy 
 (Fig. 337), a better view of the larynx may be obtained. To Gustav 
 
FOREIGN BODIES IN THE LARYNX 555 
 
 Killian belongs the credit of devising instruments whereby almost all 
 of the respiratory tract may be clearly inspected for foreign bodies. 
 This alone is enough to immortalize him in the scientific annals of medi- 
 cine and surgery, though he has in many other ways made his name 
 equally famed in rhinology and laryngology. 
 
 Indications. — The indications are to remove the foreign body as 
 soon as possible, as it may become dislodged and migrate to a new and 
 more dangerous location. The continued presence of the foreign body 
 may also give rise to considerable local irritation and subsequent edema 
 or septic inflammation. Pneumonia is a rather frequent complication. 
 In prolonged cases serious septic absorption may occur. Cases are re- 
 corded wherein the foreign body remained in the air passages for years 
 without causing death. It should not be deduced from this fact that 
 the early removal of the foreign body is not desirable, as the risks attend- 
 ing its continued presence in the air passages are infinitely greater than 
 those incident to its early removal. 
 
 The indications are, therefore, to institute proceedings for its removal, 
 either by (a) holding the child's head downward and thumping it on the 
 back (a dangerous procedure), the surgeon being prepared to perform 
 a tracheotomy should suffocative symptoms supervene; (6) the titilla- 
 tion of the larynx with the finger, in the hope of dislodging the foreign 
 body or of exciting a coughing spasm, during which it may be expelled 
 (a dangerous procedure) ; (c) the direct removal with instruments by the 
 aid of a laryngoscopic mirror; (d) the removal of the foreign body 
 by the indirect method with the Killian or the Jackson tubes; (e) trache- 
 otomy to relieve the suffocative dyspnea; if cyanosis is marked, trache- 
 otomy may also be done to establish a new avenue of inspection and 
 for the instrumental removal of the foreign body; (/) and, finally, the 
 indications are to have a skiagraph made to accurately locate the foreign 
 body. If it is a metallic or bony substance, its location is easily shown, 
 whereas if of vegetable matter it is less easily shown on the skiagraphic 
 plate. 
 
 Having located the foreign body, practise bronchoscopy or tracheos- 
 copy and remove it with suitable instruments, by either upper or lower 
 bronchoscopy, upper bronchoscopy being preferable when practicable. 
 Treatment. — It is generally understood among the laity that pound- 
 ing a child on the back, especially when held head downward, will often 
 dislodge a foreign body from the respiratory tract. These procedures 
 have, therefore, usually been performed before a physician is called, 
 provided it is known that a foreign body has been inhaled. Even though 
 the foreign body is not thus removed, the suffocative symptoms often sub- 
 side within a few minutes and the incident is often forgotten. This 
 method of procedure is dangerous, as the foreign body may be inspired 
 deeper into the air passages instead of being expelled. If the physician 
 is present he should prepare to do a tracheotomy if the suffocative 
 symptoms demand it. If the child is in a fairly comfortable condition, 
 he should be removed to a hospital and all arrangements for any emer- 
 gency be made, before an attempt is made to remove the foreign body. 
 
556 DISEASES OF THE LARYNX 
 
 When the symptoms recur a few hours or days later, without the marked 
 strangulation and coughing which characterized the initial attack, the 
 family often sees no connection between the two, and fails to report the 
 occurrence of the first one to the attending physician. If the foreign 
 body assumes a new location, the violent spasmodic seizures are repeated. 
 If suffocation is imminent, tracheotomy should be performed at once, 
 for, as Chevalier Jackson says, if this is not done the child may never 
 breathe again. When this is done the breathing is immediately relieved, 
 provided the foreign body is in the larynx. If it is in the trachea or 
 bronchus, it may not relieve the distress unless the foreign body is expelled 
 through the tracheal wound. As a matter of fact, it is frequently thus 
 expelled the moment the edges of the severed tracheal rings are retracted. 
 If it is not voluntarily expelled, the lining mucous membrane of the 
 trachea should be titillated, a procedure that sometimes causes its expul- 
 
 Fig. 336 
 
 Kierstein's lamp. 
 
 sion. Having performed tracheotomy, which is not attended with volun- 
 tary expulsion of the foreign body, proceed to pass a probe upward 
 through the tracheal wound into the larynx, to locate it if it is there. If 
 lodged in the ventricular pouch or in the subglottic space, its removal is 
 not difficult. Having located it, introduce slender forceps, seize it, and 
 remove it through the tracheal wound. 
 
 If the foreign body is lodged in the trachea at its bifurcation, it may be 
 easily seen through a tracheoscopic tube introduced through the trache- 
 otomy wound (Plate X). For illumination a Kierstein head lamp 
 (Fig. 336) or a small electric lamp at the distal end of the tube, as devised 
 by Jackson (Fig. 337), may be used. If a Killian or Jackson tube is 
 not available, the foreign body may be detected with a probe intro- 
 duced through the wound, after which slender forceps may be introduced 
 through the wound without a tracheoscope and the foreign body removed. 
 This method is inexact and crude, and should only be used as an emer- 
 gency measure. 
 
PLATE X 
 
 Lower Bronchoscopy, a, the electric wire supplying the lamp 
 at the distal end of the bronchoscope tube; b, the conduit for 
 aspirating the secretions and blood from the distal end of the 
 tube; c, the tracheotomy wound; d. the distal end of the tube • 
 e, the larynx; /, the foreign body; it, the lungs 
 
FOREIGN BODIES IN THE LARYNX 
 
 557 
 
 If the foreign body is in one of the bronchi, its removal is more difficult. 
 Indeed, if it is not voluntarily expelled upon making the tracheal opening, 
 or upon titillating the tracheal mucosa, a bronchoscope should be intro- 
 duced through the mouth or the tracheotomy wound. 
 
 I am greatly indebted to Dr. Chevalier Jackson for personal instruc- 
 tion and for the description of the technique of tracheobronchoscopy 
 given in his classical treatise upon this subject. In describing the 
 technique of the various procedures for the removal of foreign bodies 
 from the upper respiratory tract, I have adhered to his methods and 
 largely to the instruments devised by him. In so doing I am not un- 
 mindful of the fact that the greatest credit is due to Prof. Gustav Killian, 
 of Freiburg, who was the first to remove a foreign body from the bronchus 
 by upper bronchoscopy, and who has, through his writings and demon- 
 
 Fig. 337 
 
 rx 
 
 \ 
 ^ 
 
 -l\y^" 
 
 Jackson's split-tube spatula for direct laryngoscopy. The handle B gives great leverage and 
 greatly aids in overcoming the resistance of the muscles at the base of the tongue when the epi- 
 glottis and tongue are lifted forward. 
 
 strations, made bronchoscopy available to every specialist throughout 
 the world. Jackson's illuminated bronchoscopic tubes are, however, 
 easier for the inexperienced surgeon to use, and for this reason I recom- 
 mend them in this work, though the latest apparatus, devised by 
 Killian's assistant, are most ingenious and admirable, and in many 
 instances are better adapted for the work than Jackson's tubes. 
 
 Much credit is also due to Dr. Ingals, one of the first Americans 
 to adopt bronchoscopy, for his writings, wherein he reports thirteen 
 foreign bodies searched for or removed by bronchoscopy. Two deaths 
 have followed the removal of foreign bodies in his practice, the cause 
 of death being attributed to reflex irritation of the vagus nerve. 
 
 Tracheoscopy and Bronchoscopy. — The Preparation of the Patient. — If a 
 general anesthetic, preferably ether, is used, the patient should be pre- 
 pared as for a surgical operation. The morning hour before the patient 
 
558 
 
 DISEASES OF THE LARYNX 
 
 has had breakfast is, therefore, the most favorable time, though in 
 many cases the imminent danger in which the patient is placed leaves 
 no choice in this respect. If time permits, the bowels should be emptied. 
 If the tracheobronchoscope is to be used through a tracheal wound, the 
 neck should be shaved and cleansed. This route, as suggested by Jack- 
 son, is less septic than the mouth, as the instruments may be introduced 
 through a sterile wound; whereas if they are passed through the mouth, 
 the danger of septic infection of the deeper air passages is more likely 
 to occur. In spite of this fact, upper bronchoscopy should be practised 
 when feasible. 
 
 Fig. 338 
 
 The position of the patient and assistant in upper tracheobronchoscopy. (After Jackson.) 
 
 The Anesthetic. — Stolid adults tolerate the introduction of the tubes 
 under cocaine anesthesia, whereas more excitable ones, and children, 
 require a general anesthetic. The larynx, trachea, and right bronchus 
 may be cocainized by cotton-wound applicators before the introduction 
 of the tubes, whereas the left bronchus and secondary and tertiary 
 bronchioles can only be reached after the tube is introduced (Jackson). 
 Ether is the best anesthetic. Ethyl chloride and chloroform should not 
 be used, as they are not well tolerated by the lower respiratory tract. 
 Profound anesthesia may be induced, though it is an advantage to retain 
 enough of the reflexes for the patient to aid in disposing of the secretions, 
 thus preventing the occurrence of aspiration pneumonia. 
 
FOREIGN BODIES IN THE LARYNX 559 
 
 Position of the Patient. — Killian usually passes the tubes with the 
 patient in the upright position under local anesthesia. Jackson prefers 
 general anesthesia, with the patient in the recumbent posture (Fig. 
 338), as it is less tiresome for the operator to sit than to stand during 
 what is often a prolonged ordeal. The head of the patient is also steadied 
 more readily in this position. Jackson prefers the recumbent posture, 
 also because the patient is in position for tracheotomy should suffocation 
 occur during the attempted upper bronchoscopy. The head should 
 hang over the end of the table, in Rose's position, and should be firmly 
 grasped by an assistant, as shown in Fig. 338. The head should be 
 slightly turned to one side, so as to bring the angle of the mouth parallel 
 with the trachea. The tube when introduced will then rest in the angle 
 of the mouth. If the tube is to be introduced through the tracheal wound, 
 the head should also be turned to one side to remove the chin from 
 the axis of the tube. 
 
 Fig. 339 
 
 Battery for illuminating Jackson's tubes. 
 
 Introduction of the Tube. — A tube should be selected of the proper 
 length and size to reach the required depth and to correspond with the 
 caliber of the respiratory t" act to be explored. The length of the tube 
 will depend somewhat upon whether it is to be introduced through the 
 mouth or through the tracheal wound. The shorter the tube, the clearer 
 will be the field of inspection, though with Jackson's illuminated tubes 
 the length of the tube makes but little difference. The size of the tube 
 will depend upon the age of the patient and whether the trachea, bronchus, 
 or one of the bronchioles is to be explored. The secondary and tertiary 
 bronchi may only be explored with small tubes. Having selected a tube 
 of the proper size and length, an assistant should smear it with sterile 
 vaseline and hand it to the operator. The moment the tube is engaged in 
 either the larynx or the tracheal wound the assistant should remove the 
 obturator to allow free respiration. The tube should then be passed 
 
560 
 
 DISEASES OF THE LARYNX 
 
 to the desired depth. Another assistant should have entire charge 
 of the chloride of silver battery (Fig. 339) which furnishes the energy 
 for the electric light at the distal end of the tube. He should now turn 
 on the light while the operator inspects the field at the bottom of the 
 tube. A third assistant should have sole charge of the pump or suction 
 
 Fig. 340 
 
 Jackson's exhaust pump for removing secretions in tracheobronchoscopy. 
 
 apparatus (Fig. 340) with which the secretions are withdrawn from 
 the tube, and should apply the suction at the suggestion of the operator. 
 There is a suction tube in the wall of the bronchoscope through which 
 the secretions are removed. The use of a cotton-wound applicator 
 will often clear the field better than the suction apparatus. The fourth 
 
 Fig. 341 
 
 Long forceps for the removal of foreign bodies by bronchoscopy. 
 
 assistant should hold the patient's head in position. The anesthetist 
 should closely observe the pulse and respiration, as they may stop through 
 reflex irritation excited by the presence of the bronchoscope in the trachea. 
 Inspection. — The tumor or foreign body should be sought for at the 
 depth of the tube by direct inspection through it. The illumination 
 
FOREIGN BODIES IN THE LARYNX 561 
 
 is brilliant, and a clear view may be obtained in most subjects if the 
 secretions are removed by the pump and cotton-wound applicators. 
 
 The Removal of a Foreign Body or Growth. — Long shanked hooks and 
 forceps (Fig. 341) are introduced through the tube, the growth or foreign 
 body seized and withdrawn. It often requires patience and perseverance 
 to accomplish the purpose in hand. If the tube has been either carelessly 
 or roughly introduced, the mucosa may be injured, and the blood will be 
 a worse obstacle to the view than the secretions. It is sometimes necessary 
 to spend an hour or more in exploring the deeper air tract for a foreign 
 body. Even then it may not be located. 
 
 Having completed the exploration successfully, the tracheotomy wound, 
 if one has been made, may be allowed to close at once, even though the 
 obstruction to breathing is not completely relieved. The embarrassment 
 which still remains is usually due to the congestion of the respiratory 
 tract in the region formerly occupied by the foreign body, and will disap- 
 pear in from three to seven days. If the foreign body is not found, or, 
 if found, is not removed, the tracheotomy tube may be left in place 
 indefinitely, or until such time as the foreign body is found or is expelled 
 voluntarily. 
 
 Complications and Sequelae. — When tracheoscopy and bronchoscopy 
 are performed through the mouth under a general anesthetic, pneumonia 
 is occasionally a serious sequela. If performed through the mouth under 
 partial general anesthesia, or under cocaine anesthesia, such a sequela 
 does not so often occur. When performed through a tracheotomy 
 wound under strict aseptic precautions, pneumonia rarely follows except 
 as a result of a septic condition established by the presence of the foreign 
 body. That is, bronchoscopy per se, when performed under good surgical 
 conditions, does not often cause pneumonia. 
 
 General Considerations. — According to Killian, foreign bodies in 
 the larynx, trachea, and bronchi may be divided into (1) hard and (2) 
 soft varieties. He still further subdivides them for clinical purposes into 
 (a) slender, (b) flat, (c) round, (d) cubical, (e) irregular, (f) metallic, (g) 
 non-metallic, (h) friable, and (i) those likely to swell. These subdivisions 
 are of clinical significance, because the size, shape, consistency, and 
 chemical composition have much to do with the location and the tech- 
 nique of removing the foreign bodies. 
 
 (a) Slender objects, as needles, pins, nails, splinters, etc., usually 
 lodge with the point turned upward, and they lie diagonally across the 
 lumen of the tube. Needles and pins usually cause little inflammation, 
 hence mucus and large granulations are not present to obstruct the 
 view. Slender foreign bodies should be grasped with forceps (Fig. 341) 
 near the point buried in the tube wall, pushed downward to disengage the 
 buried point, and then removed through the bronchoscopic tube. Small 
 nails may be removed with a rod-magnet introduced through the broncho- 
 scopic tube. 
 
 (b) Flat objects, as coins, buttons, pebbles (flat), usually lodge in the 
 trachea, though small buttons may enter the bronchi. Coins are usually 
 found in adults, as they are too large to enter the lower air tubes in infants 
 
 36 
 
562 DISEASES OF THE LARYNX 
 
 and children. Children from three to six years old have a fascination 
 for small flat pebbles. These usually lodge in the trachea near the bifur- 
 cation. Flat objects usually stand diagonally across the lumen of the 
 trachea or bronchus, and are easily grasped with forceps. They may be 
 removed by upper bronchoscopy in nearly all cases. 
 
 (c) Round objects, as glass beads, cherry stones, coffee beans, etc., are 
 frequently coughed up before assistance is called. They remain movable 
 for quite a while, changing position from time to time. As Killian says, 
 they are difficult to grasp with the forceps on account of their shape and 
 the ease with which they elude the forceps, as it pushes the foreign body 
 before it. A bead or other round object is, therefore, more easily re- 
 moved if it is first pushed down to the bifurcation of the trachea, where 
 it may be grasped with the forceps. Oval seeds, as prune stones, are 
 rough, and are easily grasped with the forceps. When present in chil- 
 dren, prune stones are usually near the bifurcation of the trachea, as they 
 are too large to enter the bronchi. 
 
 (d) Cubical foreign bodies are difficult to grasp with forceps on account 
 of their width. Killian recommends the use of his hook or hook forceps 
 for this purpose. He also recommends lower bronchoscopy (through a 
 tracheotomy wound) after failure by upper bronchoscopy. 
 
 (e) Irregular objects, as bone fragments, are usually found in adults. 
 When present in children they lodge in the trachea. If small, the frag- 
 ments may enter the right bronchus. As the bone fragment is usually 
 rendered sterile by cooking, infection attending its presence is some- 
 what delayed. If allowed to remain in the bronchus or trachea too long, 
 bronchitis, bronchiectasis, pulmonary abscess, or gangrene may develop. 
 The bone fragments are irregularly flat, and vary in size from 14 to 16 mm. 
 long by 8 to 9 mm, wide. 
 
 Carious teeth are occasionally aspirated into the trachea or bronchi, 
 and when present quickly excite infective reaction. They should, there- 
 fore, be removed as quickly as possible. 
 
 Collar buttons are difficult to remove, especially when the larger flat 
 end is turned upward. When the button lies crosswise of the air tube 
 it may be grasped by its neck with forceps or a hook and removed. 
 
 False teeth are usually too large to pass below the vocal cords, though 
 Wild reports a case in which a plate with two false teeth entered the 
 left bronchus. It was removed eleven days after the accident by lower 
 bronchoscopy, after being observed by upper bronchoscopy. 
 . (/) Metallic substances may be clearly demonstrated by skiagraphy, 
 whereas (g) non-metallic substances are less clearly defined. The skia- 
 graph may, therefore, be used to locate the foreign body in many subjects 
 
 (h) Friable substances, as a fragment of an apple or a swollen and 
 partially disintegrated bean, are difficult to remove, as they break into 
 smaller fragments when seized with forceps. When thus broken the 
 smaller particles are often coughed up, though it is sometimes dangerous 
 to depend upon this mode of ejection, as the particles may be aspirated 
 into one of the secondary or tertiary divisions of the bronchus. Should 
 this accident occur, one lobe of the lung may be deprived of air and 
 
FOREIGN BODIES IN THE LARYNX 563 
 
 rapidly undero retrograde changes, and become the seat of infection and 
 inflammation. Furthermore, the foreign body is less accessible and 
 more difficult to remove when in one of the smaller bronchi. Killian 
 has constructed forceps, modelled somewhat after an obstetric forceps, 
 with which friable substances, as a swollen bean, fragments of apple, etc., 
 may be grasped and removed without leaving fragments in the air tube. 
 
 Barbed cereal spikes of wheat, rye, etc., are often difficult to remove, 
 as the barbs usually point upward and engage in the mucous membrane 
 when attempts are made to remove them. They have a tendency to 
 descend gradually to the deeper tubes. A forceps that will grasp the 
 entire length of the spike should be used, to prevent fragmentation. 
 
 (i) A swollen bean, or other substance likely to swell from the ab- 
 sorption of the moisture of the lower respiratory tract, may gradually 
 close the lumen of the bronchial tube (secondary) and thus shut off the 
 air supply to a portion of the lung. The secretions are retained and 
 undergo decomposition, and finally cause serious inflammatory reaction, 
 as violent fever, pneumonia, and atelectasis. According to Killian, 39 
 per cent, of these cases have died. 
 
 Killian has collected 164 reported cases of foreign bodies in the lower 
 respiratory tract which were treated by bronchoscopy. Of these, 8 
 coughed the foreign body up. The result is unknown in 5, leaving 159 
 cases in which the results are known. 
 
 Twenty-one (13 per cent.) died, 2 from cocaine poisoning, 2 from 
 stenosis, 16 from pulmonary complications, 5 with the foreign body in 
 situ, and 11 in spite of removal. 
 
 Upper bronchoscopy was fully successful in 54 cases. 
 
 Lower bronchoscopy was fully successful in 63 cases. 
 
 Of the first 18 cases occurring in Prof. Killian's practice, one died six 
 months after the removal of the foreign body from severe pulmonary 
 complications. 
 
 In two he failed to find the foreign body. 
 
 Upper bronchoscopy was performed in 12 cases. 
 
 Upper and lower bronchoscopy in 5 cases. 
 
 Lower bronchoscopy in 1 case. 
 
 Direct Laryngoscopy. — Direct laryngoscopy should be done as a routine 
 procedure in the examination of the larynx, as by it a better view of the 
 parts is obtained. It may be done in the office under cocaine anesthesia, 
 though it is a very disagreeable procedure. Foreign bodies and neo- 
 plasms may also be removed by direct laryngoscopy; indeed, this should 
 be the method of choice, especially in papilloma of the larynx, as repeated 
 operations are often necessary to eradicate the disease. 
 
 Anesthesia. — Cocaine anesthesia is usually sufficient for office examina- 
 tions and for the removal of growths and foreign bodies from the supra- 
 glottic portion of the larynx. First brush the larynx with a 4 per cent, 
 solution of cocaine to lessen the reflex irritability, and after waiting 
 a minute swab the larynx with a 20 per cent, solution of cocaine, under 
 the guidance of a laryngeal mirror. One to three such applications at 
 intervals of from three to five minutes generally induce local anesthesia 
 
564 
 
 DISEASES OF THE LARYNX 
 
 profound enough to permit of an operation. Cocaine is not well toler- 
 ated by children, and should be used with caution. 
 
 Posture of the Patient. — The sitting posture is generally used. The 
 patient should be seated upon a stool 8 inches high; an assistant, sitting 
 behind the patient, should hold his head retracted backward to bring 
 the mouth in line with the axis of the trachea. The assistant should also 
 steady the mouth gag in the patient's mouth and retract the upper lip 
 with the index finger to prevent its being injured between the upper teeth 
 and the tube spatula. The surgeon should stand in front of and over 
 the patient, with his eye in line with the tube spatula and the larynx 
 (Fig. 343). 
 
 Fig. 342 
 
 The non-illuminated separable tube spatula. 
 
 Introduction of the Tube Spatula. — Pass the instrument into the throat 
 until the distal end of the instrument is behind the tip of the epiglottis. 
 Then draw the epiglottis forward against the base of the tongue, as shown 
 in Fig. 343. If the spatula is placed too low, against the cricoid ring, 
 the patient has a pronounced sense of suffocation; whereas if the instru- 
 ment is withdrawn a little higher the dyspnea is relieved and the patient 
 breathes with a "brassy" tubular sound. 
 
 Examination through the Tube Spatula. — Forcibly draw the epiglottis 
 forward against the base of the tongue to bring the anterior portion of 
 the larynx into view. This is very difficult to do in some patients and 
 comparatively easy in others. If the illuminated instrument is used, the 
 light should be turned on before introducing it into the mouth. If a 
 non-illuminated tube is used, a Kierstein head lamp should be utilized 
 to illuminate the larynx. 
 
 Upper Tracheobronchoscopy. — Upper tracheobronchoscopy is used for 
 diagnostic and therapeutic purposes. By it the condition of the trachea, 
 
FOREIGN BODIES IN THE LARYNX 
 
 565 
 
 bronchi, and bronchioles may be observed, and treated by cotton-wound 
 applicators moistened with the medicine. Jackson has observed and 
 successfully treated ulcers of the trachea by upper tracheobronchoscopy. 
 Persistent cough that resisted all other methods of treatment was quickly 
 cured when the diseased tracheal mucous membrane was brushed with 
 a mild solution of the nitrate of silver via the tracheobronchoscope. 
 Foreign bodies in the trachea, bronchus, or one of the smaller bronchioles 
 may be diagnosticated and removed through the tracheobronchoscope. 
 
 Fig. 343 
 
 Direct laryngoscopy with Jackson's self-illuminated tube spatula, a, electric cord supplying the 
 lamp at the distal end of the spatula; b, the conduit for the electric cord; c, the tip of the tube 
 spatula holding the epiglottis forward against the base of the tongue; d, the conduit for the 
 removal of the secretions and blood from the larynx during examinations and operations by direct 
 laryngoscopy. 
 
 Preparation of the Patient. — If a general anesthetic is to be given, the 
 patient should be prepared as for a major surgical operation if time 
 permits. 
 
 Anesthesia. — A general anesthetic, preferably ether, should be admin- 
 istered. The larynx, trachea, and bronchi should also be brushed with 
 a 20 per cent, solution of cocaine. The larynx may be brushed with 
 cocaine before the introduction of the bronchoscope, and the trachea 
 
566 
 
 DISEASES OF THE LARYNX 
 
 and bronchi as the tube is passed downward. The anesthetic should 
 not be administered until it has attained its full effect, as it is safer to 
 preserve the reflexes, so that the patient will aid in disposing of the secre- 
 tions. Otherwise, aspiration pneumonia may result. The use of cocaine 
 in the larynx and trachea prevents the reflex phenomena due to irritation 
 of the vagus nerve. After the bronchoscope is introduced the anesthetic 
 should be given through the tube or by rectum after Cunningham's 
 method. 
 
 The Position of the Patient's Head. — After fixing the mouth open with 
 a Furguson or Furguson-Pynchon mouth gag, have an assistant seated 
 on a stool at the right side of the head of the patient, with his left foot on 
 a low stool. The patient's head and neck are drawn beyond the end of 
 the table, and are supported and controlled by the assistant. His right 
 arm is passed beneath the neck of the patient, the hand grasping the 
 mouth gag and side of the face. The assistant's left arm rests upon his 
 left knee, and his hand supports the patient's head. The head and neck 
 are thus under the complete control of the assistant (Fig. 343). By 
 raising his right arm the neck is raised, and by raising the left hand the 
 head is raised, and by reversing the movements of the arm and hand the 
 opposite effects are produced. With the right and left hands the head 
 may be rotated on its vertebral axis. The foot of the table should be 
 fifteen inches lower than the head. 
 
 Fig. 344 
 
 Jackson's self-illuminated tracheobronchoscope. 
 
 Introducing the Split-tube Spatula. — The split-tube spatula should 
 be introduced to expose the chink of the glottis while the tracheobron- 
 choscope (Fig. 344) is being introduced. This procedure is identical 
 with that described in the section on Direct Laryngoscopy, the only 
 difference being the recumbent posture of the patient and the use of the 
 split-tube spatula. Jackson's split-tube spatula (Fig. 337) is so con- 
 structed that it may be easily removed after the tracheobronchoscope 
 has entered the trachea. 
 
 Introducing the Tracheobronchoscope. — Having properly introduced 
 the split-tube spatula and exposed the cords of the larynx to view through 
 it, the tracheobronchoscope is introduced through the tube spatula to 
 
FOREIGN BODIES IN THE LARYNX 567 
 
 the larynx. The light is turned on by an assistant, and the operator's 
 eye is placed at the proximal end of the tracheobronchoscope to watch 
 the respiratory movements of the vocal cords. The tracheobroncho- 
 scope should be passed through the glottis during an inspiratory move- 
 ment of the vocal cords, as they are separated at this time. 
 
 Fig. 345 
 
 <?\ 
 
 Jackson's safety-pin closer. 
 
 Having passed the vocal cords and a short distance into the trachea, 
 the split-tube spatula should be separated and removed from the mouth. 
 
 The tracheobronchoscope resting in the angle of the mouth and trachea 
 should be pushed downward (cocaine being applied to the mucous mem- 
 brane with a long cotton-wound probe) until it reaches the foreign body, 
 morbid process, or the bifurcation of the trachea. The tracheobroncho- 
 scope should rest in the left angle of the mouth if the right bronchus is 
 
 Fig. 346 
 
 Mosher's safety-pin holder. 
 
 to be entered; if the left bronchus, the right angle of the mouth. The 
 assistant should constantly guard the upper lip of the patient with his 
 index finger to prevent it being pinched between the upper teeth and the 
 bronchoscope. 
 
 Having entered the right or left bronchus, the tube is passed down- 
 ward, the operator watching for the secondary bronchi, morbid lesion, or 
 the foreign body. By using the smallest-sized bronchoscope the terminal 
 bronchioles may be explored for abscess or other morbid lesion, and if 
 
568 DISEASES OF THE LARYNX 
 
 the diseased area is not accessible to bronchoscopic treatment it may be 
 accurately diagnosticated and located and operated through the chest 
 wall by a general surgeon. 
 
 The Removal of the Secretions and Blood. — The secretions and blood 
 may be removed with Jackson's pump or aspirator (Fig. 340), which is 
 attached to the conduit for this purpose. An assistant should have 
 entire charge of the aspirator, and use it as directed by the operator. 
 Long cotton-wound applicators may also be used to remove the secretions. 
 According to Ingals, the preliminary use of atropine prevents excessive 
 secretions. It also guards against reflex shock. 
 
 The Removal of Foreign Bodies. — Variously shaped forceps, hooks, 
 screws, etc., are used to remove foreign bodies (Figs. 345, 346, 347, and 
 348). 
 
 Topical Applications. — Ulcers and other local morbid lesions of the 
 mucous membrane of the trachea and bronchi may be brushed with a 
 weak solution of the nitrate of silver through the tracheobronchoscope. 
 
 Remarks. — The trachea and bronchi are elastic and expansile, and 
 tolerate the straightening and dilatation with the bronchoscope. 
 
 The illuminated tubes should not be boiled unless the electric light 
 is removed. They should be immersed in alcohol. Likewise the un- 
 illuminated tubes should not be boiled, as the lustre of the interior of 
 the tube is thus destroyed and its capacity to carry the reflected rays 
 from the head lamp is diminished. 
 
 Fig. 347 Fig. 348 
 
 Jackson's forceps, curved jaws. Jackson's forceps, cupped jaws. 
 
 Do not use instruments in lower bronchoscopy that have just been 
 used in upper bronchoscopy. Have freshly sterilized instruments ready 
 for the purpose. Have sterile lamps in a sterile tube ready for use should 
 a lamp burn out. 
 
 The patient's head and face should be prepared as for a major opera- 
 tion about the head. The teeth and mouth should be cleansed with 
 soap and alcohol. The operator and assistants should be dressed in sterile 
 gowns and caps, a precaution especially necessary in handling the long 
 instruments. 
 
 The patient should be allowed to sit up as soon as possible, to prevent 
 the occurrence of pneumonia. 
 
 Lower Tracheobronchoscopy. — Lower tracheobronchoscopy consists in 
 introducing the tracheobronchoscope through a tracheotomy wound, as 
 shown in Plate X. 
 
 Indications. — Lower tracheobronchoscopy is indicated when direct 
 laryngoscopy or upper tracheobronchoscopy fails. A larger tube may 
 
FOREIGN BODIES IN THE LARYNX 569 
 
 be used in lower bronchoscopy, an advantage in removing large foreign 
 bodies. 
 
 Position of the Patient. — Primary lower bronchoscopy should always 
 be done in the dorsal position, as tracheotomy is to be performed. The 
 patient should be placed in Rose's position, with the head extended 
 beyond the end of the table. 
 
 Low Tracheotomy. — Low tracheotomy should be performed, as the chin 
 is thus farther removed from the operative field and is not so much in the 
 way of the long instruments. The tracheobronchoscope may, however, 
 be introduced through a high tracheotomy wound. 
 
 Stop all bleeding before introducing the tracheobronchoscope. 
 
 The trachea should be swabbed with a 20 per cent, solution of cocaine 
 through Trousseau's dilator (Fig. 349). 
 
 If the right bronchus is to be entered, have the patient's head turned to 
 the left, and vice versa. 
 
 Fig. 349 
 
 Trosseau's dilator. 
 
 Introduction of the Tracheobronchoscope. — Jackson's illuminated short 
 tracheobronchoscope should be introduced through the tracheotomy 
 wound, the operator's eye being at the proximal end of the tube watching 
 for the bifurcation of the trachea (Plate X). The end of the broncho- 
 scope usually lodges against the bifurcation, so that both bronchi are 
 visible. Lateral pressure in either direction will allow the tube to pass 
 into one of the bronchi. The moment the tube enters the bronchus, 
 cough is excited. A cotton-wound applicator moistened with a 10 per 
 cent, solution of cocaine should be applied through the tube and the tube 
 passed to the secondary bifurcation (Fig. 350, SL). When a secondary 
 bronchus is entered cough is again excited, and cocaine should be applied 
 as before. It is impossible to maintain anesthesia deep enough to abolish 
 entirely the cough reflex for any length of time, unless rectal anesthesia 
 is used, and even then it is not advisable to abolish all the reflexes, as 
 the patient is thereby subjected to the danger of aspiration pneumonia. 
 
 Having introduced the tracheobronchoscope, the foreign body and 
 morbid lesions should be studied, treated, or removed. 
 
 After-treatment. — The tracheotomy wound should not be sutured 
 except at its upper and lower angles. The tracheotomy tube should be 
 worn for a few days, but should be abandoned before the patient leaves 
 the hospital. The tracheotomy wound should be cleansed every three 
 hours with a warm 1 to 5000 bichloride solution. The wound should 
 
570 
 
 DISEASES OF THE LARYNX 
 
 heal from the bottom, beginning with the severed tracheal rings. If 
 the fleshy portion of the wound tends to heal first, it should be prevented. 
 Diverticulum or Pouch of the Hypopharynx.— The inferior constrictor 
 muscle of the pharynx forms the posterior and lateral walls of the hypo- 
 pharynx, and it is in the median or posterior wall of this muscle that the 
 pouching occurs. The lower fibers are attached to the cricoid cartilage 
 and extend in a horizontal direction. The remainder of the muscle 
 fibers radiate in an upward and median direction (Fig. 351), and it is in 
 the central and lower portion of this part of the muscle that the pouching 
 occurs. Various theories have been advanced to explain the pouching 
 in this region, but the one advanced by Wilson is probably correct, 
 namely, the occasional congenital absence of muscle fibers in this region. 
 
 Fig. 350 
 
 Fig. 351 
 
 Tracheobronchial tree. LM, left main bron- 
 chus; SL, superior lobe bronchus; ML, middle 
 lobe bronchus; IL, inferior lobe bronchus. 
 (Jackson.) 
 
 Pouch of the posterior wall of the hypopharynx. 
 
 He has found the muscle fibers absent in a considerable percentage of the 
 cadavers examined by him. When the pouch is present it may be the 
 seat of lodgement for a bolus of food or a foreign body. When such a 
 condition is present it may be examined by direct pharyngoscopy with 
 the Killian or Jackson tube spatula and the food or foreign body removed 
 through the same instrument. 
 
 Spasm of the inferior constrictor muscle, especially the circular portion 
 which forms the mouth of the esophagus, may occur and prevent the 
 swallowing of food for a few hours or days 
 
 In attempting esophagoscopy in a patient in whom the pouch is present 
 the esophagoscope may enter the pouch and lead to the erroneous im- 
 pression that the esophagus is closed by stricture. A careful observation 
 and manipulation should lead to a correct diagnosis. 
 
ESOPHAGOSCOPY 571 
 
 ESOPHAGOSCOPY; FOREIGN BODIES IN AND STRICTURES OF 
 
 THE ESOPHAGUS. 
 
 The examination of the esophagus through the mouth is now an 
 established procedure, and should be considered in connection with 
 bronchoscopy, as foreign bodies may lodge in either tube. The differen- 
 tial diagnosis between a foreign body in the trachea or bronchi and the 
 esophagus must, therefore, be made. Not only this, but the foreign body 
 should be removed, whether it is in the bronchi, the trachea, or the 
 esophagus. A brief description of esophagoscopy will, therefore, be 
 given in this work. 
 
 The sizes of tubes required, according to Chevalier Jackson, are, for 
 infants, 7 mm., and for adults 10 mm. in diameter. 
 
 The normal appearance of the esophageal lumen with the Jackson 
 self-illuminated tubes is a whitish grayish pink, in strong contrast to the 
 red color of the tracheal membrane. 
 
 Examination of the Upper End of the Esophagus. — This is the 
 easiest of all the examinations with the straight tubes, and is accom- 
 plished by the same technique as described under Direct Laryngoscopy. 
 According to Jackson, the split tubular speculum (Fig. 337) should 
 be passed back of the base of the tongue until the epiglottis appears, 
 after having cocainized the introitus esophagi with a 10 per cent, 
 solution. Having engaged the tip of the epiglottis, a straight cotton- 
 wound applicator, dipped in a 10 per cent, solution of cocaine, should 
 be passed through the tubular speculum and applied to the epiglottis, 
 the laryngeal and the esophageal orifices; a few minutes should be 
 allowed for anesthesia to supervene. The tubular speculum is then 
 passed down back of the epiglottis and the cricoid cartilage, and lifted 
 forward against the base of the tongue. The larynx and the esophageal 
 depression are thus brought into view. The spatular end of the tubular 
 speculum is inserted into the esophageal depression to a point below 
 the arytenoid cartilages, and far enough to engage the posterior portion 
 of the cricoid cartilage. The cartilage should then be lifted forward, 
 thus exposing the pyriform fossae and the esophageal lumen. 
 
 ESOPHAGOSCOPY. 
 
 According to Dr. Chevalier Jackson, preliminary to passing a tube 
 into the lumen of the esophagus the upper end of the esophagus should 
 be examined, as described in the preceding paragraph, to learn the 
 pathological conditions present in this region. This procedure will 
 prevent the making of a false passage through an ulcerated surface and 
 will locate a foreign body if present at the entrance of the esophagus. 
 In passing the long tube extreme gentleness should be practised. If the 
 tube does not readily pass, it is either not correctly placed or it is 
 improperly directed. The tube should be lubricated with sterile vase- 
 
572 
 
 DISEASES OF THE LARYNX 
 
 line. The proximal end should be held lightly with the right hand, the 
 handle directed horizontally to the right. The forefinger of the left 
 hand is passed into the right glosso-epiglottic fossa, posteriorly to the 
 lateral glosso-epiglottic fold and posteriorly to the tense pharyngo- 
 epiglottic fold, and, if possible, into the right pyriform sinus. 
 
 The tube should then be made to follow the same route, while the 
 finger slides toward the median line and lifts the tongue and anterior 
 pharyngeal tissues upward (dorsal decubitus). When the cricoid carti- 
 lage can be reached, which is possible only in children, it is better to 
 lift upon it directly rather than upon the soft tissues. When possible, 
 as it usually is in adults, the cartilage should be lifted indirectly by 
 traction upon the tissues at the extreme point reachable with the finger, 
 often the right glosso-epiglottic fossa. 
 
 Fig. 352 
 
 Fig. 353 
 
 The probable position assumed by a penny 
 when lodged in the subglottic space. 
 
 The position assumed by a penny, as shown 
 by skiagraphy, when lodged in the mouth of 
 the esophagus of a child, aged three years. 
 (Author's case.) 
 
 The head of the patient should be held in extreme extension with the 
 mouth widely open, as shown in Fig. 343. 
 
 After the introitus is passed the obturator is removed, and the cord 
 is attached to the light carrier by the bayonet fitting. The tube must be 
 guided by the eye so as to follow the esophageal lumen by sight. After 
 passing the introitus the head of the patient should be raised slightly 
 to prevent he tube pressing on the trachea. 
 
 The entire lumen of the esophagus may be examined for stricture 
 or other pathological lesion, and for foreign bodies. When a foreign body 
 is found it may be removed as by bronchoscopy. By using a longer tube 
 almost the entire surface of the stomach may also be inspected with 
 
ESOPHAGOSCOPY 573 
 
 great clearness of illumination with Jackson's self-illuminated gastro- 
 scope. 
 
 In one of my cases the skiagrapher reported the foreign body, a penny, 
 to be located at the bifurcation of the trachea. As it was impossible for 
 me to get to the studio to examine the plate, I acted upon his diagnosis 
 and attempted to locate the foreign body in the trachea. At one time I 
 passed the tube into the esophagus and heard a slight metallic click. 
 Further search failed to elicit the metallic sound. When I viewed the 
 skiagraphic plate a few days later I found the shadow of the penny on a 
 level with the cricoid cartilage, instead of at the bifurcation of the trachea, 
 as reported by the skiagrapher. Nine days after the attempted removal 
 by bronchoscopy the penny was passed per rectum, thus showing the 
 penny to have been in the upper portion of the esophagus, from which 
 place it was probably dislodged at the time I heard the metallic click. 
 Another point of diagnostic interest in this case was the position of the 
 penny. Its flat surface stood at right angles to the vocal cords, a fact 
 which immediately attracted my attention when I saw the plate a few 
 days later. Had the penny been in the subglottic space, its edge would 
 probably have presented anteriorly. The location and position of the 
 penny led me to inform the parents that it was not in the trachea, but 
 was in the upper part of the esophagus at the time the skiagraphic plate 
 was made. This diagnosis was later verified by the passage of the 
 penny (Figs. 352 and 353). 
 
PART IV 
 
 THE EAR. 
 
 CHAPTER XXXII. 
 
 THE CLINICAL ANATOMY AND PHYSIOLOGY OF THE EAR. 
 
 The organ of hearing is divisible into (a) the external ear, (b) the 
 middle ear, and (c) the internal ear. 
 
 THE EXTERNAL EAR. 
 
 From a clinical point of view the auricle is of interest on account of the 
 destructive inflammatory processes which attack its cartilaginous frame- 
 work and the perichondrium covering it. Perichondritis and chondritis 
 of the auricle occurring in the insane from traumatism has been fre- 
 quently observed and reported (Fig. 375). Perichondritis following the 
 mastoid operation occasionally occurs. I have seen but one case in my 
 practice, and it developed several weeks after the mastoid operation; the 
 exciting cause was undoubtedly the influenza bacillus, as it followed an 
 attack of la grippe. In performing the plastic operation upon the meatus, 
 that is, in making the Koerner, Panse, Siebenmann, or the Ballance 
 incisions, the cartilage of the auricle is included; hence it is necessary to 
 exercise great care as to surgical cleanliness, otherwise infection of the 
 perichondrium and cartilage may occur. 
 
 The external auditory meatus is divisible into a cartilaginous and an 
 osseous portion. The cartilaginous portion of the meatus (the auricular 
 extension) is attached to the osseous or deeper portion by bands of 
 fibrous tissue. The superior and posterior walls of the cartilaginous 
 meatus are thinner than the anterior and inferior walls. The inferior 
 wall extends deeper along the floor of the meatus than the other walls, 
 and is known as the processus triangularis. The anterior wall of the 
 cartilaginous meatus is crossed by two or three fissures, which are filled 
 with connective tissue and a few muscle fibers. These fissures are 
 called the fissures of Santorini, and they render the auricle more movable. 
 They are of clinical importance, first, because they afford an outlet for 
 the discharge of pus into the meatus in deep abscess of the parotid gland, 
 and secondly, because they render the auricle more elastic and thus 
 permit it to be turned on the cheek during the mastoid operation. 
 
576 THE EAR 
 
 In the newborn the meatus is fibrous throughout its entire length, 
 and its walls are collapsed and in apposition. Bone salts are gradually 
 deposited and the canal assumes its open condition. 
 
 The sebaceous glands are limited to the cartilaginous portion of the 
 meatus, hence furunculosis of the meatus is confined to this area. The 
 beginner in otology is sometimes confused in making a differential diag- 
 nosis between acute suppurative mastoiditis with bulging of the post- 
 superior wall, and furunculosis of the cartilaginous meatus. In the 
 first instance the bulging is in the bony meatus close to the drumhead, 
 and the auricle is not tender or sensitive upon manipulation. In the 
 second instance the bulging is more external in the cartilaginous meatus, 
 and the auricle is extremely sensitive upon manipulation. The sensi- 
 tiveness of the auricle in furunculosis is due to the fact that the inflamma- 
 tory reaction attending the furuncle or boil has extended by continuity 
 of tissue from the cartilage of the meatus to the cartilage of the auricle, 
 and thereby renders the nerve fibers of the auricle exquisitely sensitive. 
 
 THE MIDDLE EAR. 
 
 The membrana tympani forms the outer wall of the middle ear. It is 
 a composite membrane of three layers : the outer one being a reflection 
 of the skin of the meatus, the middle one being fibrous tissue, and the 
 inner a reflection of the mucous membrane of the middle ear. The 
 handle of the malleus is embedded within these structures, hence the 
 sound waves impinging upon the eardrum are transmitted to the handle 
 of the malleus, and thence to the incus and stapes, where the foot plate 
 transmits them to the sound-perception apparatus. 
 
 The membrana tympani is of clinical importance chiefly on account of 
 the various changes in its appearance in diseased conditions of the middle 
 ear. These changes are, therefore, of diagnostic value. In order to 
 appreciate fully the abnormal appearances of the eardrum, it is first 
 necessary to know the normal characteristics. A normal drumhead is 
 characterized by the presence of the handle of the malleus, the short 
 process of the malleus, the triangular cone of light, the anterior and 
 posterior folds, and a faint view of the long process of the incus seen 
 through the semitransparent pearly gray eardrum. 
 
 When the Eustachian tube is closed the air within the middle ear 
 cavity becomes rarefied by the gradual absorption of the oxygen into the 
 blood of the surrounding tissues. As a result of the negative pressure 
 thus brought about, the eardrum is pushed inward — that is, the eardrum 
 is retracted. This changes the contour of the eardrum as viewed through 
 the external auditory meatus. The cone of light is broken or altogether 
 lost, the handle of the malleus is drawn inward and is foreshortened, 
 the short process of the malleus projects more prominently toward the 
 observer's eye, and the anterior and posterior folds which arise from the 
 short process are accentuated. 
 
 In retraction due to obstruction of the Eustachian tube the membrana 
 
THE EUSTACHIAN TUBE 577 
 
 tympani is regular or uniform throughout its entire area, with the excep- 
 tion of the part containing the malleus. If the retraction is due to an 
 adhesion to the inner wall of the tympanic cavity the membrane is 
 irregularly retracted. The membrana tympani, upon suction with 
 Siegle's otoscope, remains fixed at the point of adhesion, and is dis- 
 tended in other areas, giving a blistered appearance. 
 
 PERFORATION OF THE MEMBRANA TYMPANI. 
 
 The clinical significance of perforation of the membrana tympani when 
 due to middle ear disease is somewhat dependent upon whether it is 
 marginal or central in location. When marginal it usually signifies 
 bone necrosis, and when central (away from the margin) it signifies a 
 simple middle ear suppuration without bone necrosis. 
 
 Its significance is still further differentiated by its exact location; 
 that is, if it is marginal the bone necrosis is in the immediate vicinity of 
 the marginal perforation. If, for instance, the perforation is in the margin 
 of Shrapnell's membrane (membrana flaccida), immediately above the 
 short process of the malleus, the tegmen antri is necrotic; if it is in the 
 post-superior margin of the eardrum (the part nearest to the antrum) 
 the mastoid antrum is necrosed. 
 
 The point to be borne in mind is that the perforation is secondary to 
 the bone necrosis, the necrotic process extending from the ear cavities 
 to the eardrum. Its clinical significance is, therefore, an index to a 
 preexisting morbid process in the tympanic cavities, the focal point of 
 which is in the neighborhood of the perforation. Leutert, Zaufal, the 
 author, and others have called attention to the significance of the fore- 
 going facts. 
 
 The further elaboration of the clinical significance of perforations of 
 the eardrum is given in Fig. 404. 
 
 THE EUSTACHIAN TUBE. 
 
 The second and most common avenue of approach to the middle ear 
 cavity is through the Eustachian tube. It is through this channel that 
 nearly all middle ear diseases invade the middle ear cavity. The tube 
 is about 36 mm. long, the pharyngeal opening being about 25 mm. 
 lower than the tympanic opening. The tympanic opening corresponds 
 to the anterosuperior quadrant of the eardrum, hence it is not in the 
 most dependent portion of the cavity. This does not interfere with 
 drainage under normal conditions, as the cilise of the epithelium of the 
 tympanic cavity sweep the secretions to the opening of the tube and 
 through it to its pharyngeal opening. If, however, the cilise are impaired 
 in their functional activity by an inflammatory or other morbid process, 
 the elevated position of the tympanic orifice of the tube materially 
 interferes with the drainage. Under these conditions the secretions are 
 37 
 
578 THE EAR 
 
 retained, decomposition follows, and further irritation of the mucous 
 membrane results. 
 
 The tympanic end of the tube has an osseous framework, and is about 
 8 mm. long. The pharyngeal end of the tube has a cartilaginous and 
 membranous framework, and is about 15 mm. long. The tube is trumpet- 
 shaped at both extremities, and is narrowest at the junction of the osseous 
 and cartilaginous portions. This is known as the isthmus. The frame- 
 work is lined with mucous membrane which is covered with ciliated 
 epithelium, which carries the secretions toward the pharyngeal orifice. 
 
 Under ordinary conditions the membranous walls of the tube are in a 
 state of collapse, and only open when certain palatal muscles are con- 
 tracted. Yawning and swallowing cause these muscles to contract, and 
 air is thus admitted into the tympanic cavity. 
 
 The muscles regulating the patency of the pharyngeal orifice of the 
 tube are the tensor veli palati and the levator palati; they also elevate the 
 soft palate and assist in approximating it against the posterior wall of 
 the pharynx in the act of swallowing. As the superior ends of the muscles 
 are attached to the cartilaginous lip and to the membranous portion of 
 the tube, and the inferior end to the soft palate, it is obvious that the 
 contraction of the muscles will produce a twofold result, namely, the 
 pharyngeal orifice of the tube is opened and the soft palate is elevated. 
 
 When, for any reason, the act of swallowing does not open the tube 
 sufficiently to admit air into the tympanic cavity, the oxygen is absorbed 
 from the contained air by the blood in the surrounding tissues, and a 
 partial vacuum, or negative pressure, results. The blood in the sur- 
 rounding tissues is drawn to the parts by the negative pressure, and 
 congestion results. The retained secretions undergo decomposition 
 and irritate the lining mucous membrane. The hyperemia induces 
 overnutrition. As a result of the combined irritation and increased 
 nutrition the mucous membrane becomes thickened, either by hyper- 
 trophy or hyperplasia. The secretions are not only retained in excessive 
 quantity, but are changed in character. This condition is known as 
 middle ear and tubal catarrh. 
 
 Anything that obstructs the flow of secretions of the Eustachian tube 
 predisposes the mucous membrane of the tube and middle ear to infec- 
 tion and inflammation. The two great underlying principles relating 
 to the etiology of inflammation of mucous membrane-lined cavities are: 
 (a) The exciting cause of inflammation is almost always a pathogenic 
 microorganism. The microorganism is powerless to grow upon healthy 
 tissue, hence the second great underlying principle relates to the con- 
 ditions which favor their growth, (b) The predisposing cause is usually 
 an obstructive lesion interfering with the drainage and ventilation of 
 the cavity, thereby lowering the resistance of the tissues. The patho- 
 genic microorganisms then flourish, and with their toxins excite the 
 reaction of inflammation. 
 
 The action of the tensor and levator veli palati muscles is so intimately 
 associated with that of the muscles of the palate and pharynx that it is 
 somewhat difficult to estimate the influence of the other muscles on the 
 
THE EUSTACHIAN TUBE 
 
 579 
 
 patency of the tubes. The pharyngopalatinus (posterior pillar of the 
 fauces) has its upper attachment in the soft palate, and it contracts 
 during deglutition, and thus indirectly exerts a tensive action upon 
 the tubal muscles. In inflammatory processes involving the tonsils and 
 the faucial pillars the swollen condition of the palatopharyngeus muscle 
 indirectly interferes with the action of the tubal muscles. In this way 
 disease of the tonsil causes tubal and middle ear disease; that is, drainage 
 and ventilation are interfered with. The microorganisms causing the 
 tonsillar disease find a lowered resistance of the tubal membrane, grow 
 there, and cause catarrhal or suppurative inflammation. 
 
 The anterior wall of the pharyngeal end of the tube is membranous, 
 while the upper and posterior walls are cartilaginous. The tensor and 
 levator veli palati muscles are attached to the membranous portion of the 
 tube, hence when they contract the tube is opened to its isthmus. 
 
 Fig. 354 
 
 Showing a method of catheterization, a, the ring indicating the direction of the tip of the 
 catheter; b, the posterior wall of the pharynx; c, c, the ridge forming the posterior lip of the 
 mouth of the Eustachian tube; f, f, Rosenmiiller's fossa; b, d, e, the route traversed by the tip 
 of the catheter to enter the mouth of the Eustachian tube. 
 
 Much has been written concerning the normal patency of the Eusta- 
 chian tube, and the preponderance of the evidence is in favor of the 
 view that it is closed except during the act of deglutition. Politzer's 
 experiment, consisting of a vibrating tuning fork held in front of the nose, 
 shows that it is but faintly heard except during deglutition, thereby 
 proving that the tube is closed under ordinary conditions and is open 
 during deglutition. This permits of the interchange of air between the 
 pharynx and the middle ear, and maintains an equilibrium of pressure 
 on the inner and outer surfaces of the membrana tympani. 
 
 The pharyngeal end of the tubal cartilage (posterior and superior 
 walls) forms a projecting lip or tubal prominence on the lateral wall of 
 
580 THE EAR 
 
 the epipharynx. Just behind this is a groove known as Rosenmuller's 
 fossa. The fossa and tubal prominence are the landmarks used in the 
 introduction of the Eustachian cacheter. The tip of the catheter is first 
 lodged in the fossa of Rosenmuller, then drawn forward, gliding down- 
 ward and inward over the prominence, and thence upward and outward 
 into the tubal orifice (Fig. 354). 
 
 To inflate the tube and middle ear, the compressed air should be 
 applied at the beginning of the act of deglutition, as the tubal muscles are 
 then contracted and the tube open. The Eustachian tube of an infant 
 is shorter, straighter, and more easily inflated than that of an adult. 
 In an adult the tube is sharply bent at the isthmus, whereas in an infant 
 the tube is nearly straight. A lower degree of air pressure should, there- 
 fore, be used for infants than for adults. Earache in infants and young 
 children is often quickly relieved by inflation, as it is due to tubal con- 
 gestion and obstruction, or to a plug of tenacious mucus in the lumen 
 of the tube. 
 
 THE TYMPANIC CAVITY; TYMPANUM; CAVUM TYMPANI. 
 
 The tympanic cavity is the space between the tympanic orifice of 
 the Eustachian tube and the mastoid antrum. Its lining mucous mem- 
 brane is continuous with that of the Eustachian tube, and extends to the 
 antrum and mastoid cells. It is covered with ciliated epithelium, the 
 wave-like motion of which carries the secretion to the Eustachian tube. 
 
 The upper wall (tegmen tympani) of the tympanic cavity forms a 
 portion of the floor of the middle fossa of the cranial cavity; the outer 
 wall is composed of the eardrum, and in its upper portion (outer wall 
 of the attic) of bone. The wedge of bone forming the outer wall of the 
 attic should be removed in the radical mastoid operation to fully expose 
 this space to inspection and treatment during and after the operation. 
 The inner wall of the tympanic cavity is contiguous to the outer wall 
 of the cochlea and vestibule; the posterior wall separates the tympanic 
 cavity from the antrum and mastoid cells; the anterior wall is very thin 
 and covers the internal carotid artery; and the lower wall separates the 
 tympanic cavity from the jugular bulb. The facial nerve runs across 
 the upper and posterior wall and is usually enclosed in a bony covering, 
 though numerous instances are on record in which the bony covering 
 was absent. 
 
 The foregoing description of the relations of the walls of the tympanic 
 cavity to the contiguous vital organs is of great clinical significance 
 in middle ear and mastoid infections and inflammations. 
 
 The Contents of the Tympanic Cavity. — The tympanic cavity 
 contains the chain of ossicles, the tympanic muscles, and the chorda 
 tympani nerve. The handle of the malleus is attached to the membrana 
 tympani, and the foot plate of the stapes is attached to the membrane 
 of the oval window. The incus is suspended between the malleus and 
 stapes, and completes the anatomical connection between the membrana 
 
THE TYMPANIC CAVITY 581 
 
 tympani and the labyrinth. The chain of ossicles transmits the sound 
 waves from the membrana tympani to the labyrinth, though there is little 
 doubt that some waves are transmitted through the air in the tympanum 
 to the round or oval window without the intervention of the ossicles. 
 I recall one patient on whom I did a radical mastoid operation, removing 
 the malleus and incus, who heard whispered speech at ten feet, showing 
 that good hearing is possible though all the ossicles were removed except 
 the stapes. 
 
 The Chain of Ossicles and the Membrane of the Oval Window. — It is 
 shown by the case just cited that all the receiving apparatus may be 
 removed except the contents of the oval window without greatly im- 
 pairing the hearing, though this is exceptional. Orientation of hearing 
 is greatly diminished, as is also the faculty of keying the perception 
 apparatus to catch sounds accurately. The tensor tympani and the 
 stapedius muscles are rendered ineffective by the removal of the malleus 
 and incus, hence the ear has lost its focussing apparatus. The mem- 
 brana tympani receives a larger number of sound waves than the foot 
 plate of the stapes, hence the hearing is more acute with the eardrum 
 and the ossicles intact than it is without them. 
 
 A Physiological Law. — It may be laid down as a physiological law 
 that anything that interferes with the normal tension existing between 
 the membrana tympani, ossicles, and the contents of the oval window tcill 
 cause tinnitus and deafness. Hence, pathological changes in the eardrum, 
 thickening or other change in the mucous membrane which covers the 
 ossicles, ankylosis of the ossicles, especially of the foot plate of the stapes, 
 as in spongifying of the bony capsule of the labyrinth, etc., result in 
 tinnitus and deafness. Catarrhal inflammation of the mucous membrane 
 of the middle ear and Eustachian tube induces a negative pressure in 
 the tympanic cavity, and disturbs the normal tension between the ear- 
 drum and the oval window; the mucous membrane of the walls of the 
 tympanic cavity and ossicles is thickened, and tinnitus and deafness 
 follow. The inflation of the tympanic cavity in tubal and middle ear 
 catarrh restores (in a degree) the normal tension and decreases the 
 congestion of the mucous membrane, and thereby lessens the tinnitus 
 and deafness. 
 
 The heads of the malleus and incus and their ligamentous attachments 
 to the walls of the tympanic cavity divide the cavity into two compart- 
 ments, namely, the atrium, or middle ear proper, and the attic. When 
 there is a suppurative process in the attic or the antrum and mastoid 
 cells for a considerable time, adhesive bands form and still further 
 increase the barrier between the atrium and the attic. The drainage of 
 the secretions is blocked, and gives rise to retention and decomposition 
 of the secretions and to pressure symptoms, as pain and tenderness. 
 Necrosis is also augmented by the increased pressure from the retained 
 secretions. Suppuration in the attic, and in the antrum and mastoid 
 cells in old chronic cases, is, therefore, a more serious condition than 
 suppuration with its focal centre in the atrium. 
 
 The chorda tympani nerve passes through the upper portion of the 
 
582 THE EAR 
 
 atrium between the handle of the malleus and the long process of the 
 incus, and is usually severed or destroyed in the radical mastoid operation. 
 As a consequence, the sense of taste at the base of the tongue and the 
 neighboring parts of the fauces is impaired; indeed, it is perhaps best 
 to destroy the nerve, as the irritation during the application of post- 
 operative dressings would otherwise excite a disagreeable sense of taste. 
 
 The Walls of the Tympanum. — The superior wall, the tegmen 
 tympani, is a thin plate of bone forming a portion of the middle fossa 
 of the skull, and it is frequently the seat of necrosis in suppurative in- 
 flammation of the middle ear. The necrotic process often extends through 
 it, and thus exposes the dura to infective bacteria which may be present. 
 Ordinarily a wall of granulation tissue is formed in Nature's effort toward 
 repair and protection. Such a perforation may, therefore, exist for years 
 without involving the cranial contents. On the other hand, if the secre- 
 tion is blocked by the ossicles, their ligaments, and the adhesive bands 
 at the floor of the attic, the infective bacteria may be forced through 
 the granulation tissue into the cranial cavity and excite meningitis or 
 brain abscess. 
 
 One of the strongest arguments against curettage of the attic through 
 the external auditory meatus is, that the granulation tissue may be 
 removed and the dura exposed to the pathogenic bacteria. The same 
 objection does not hold to its removal during the radical mastoid opera- 
 tion, as perfect drainage is thereby established. 
 
 The inferior wall or floor of the tympanic cavity is of clinical interest, 
 on account of its proximity to the jugular bulb. It is only in exceptional 
 cases, however, that the floor is thin, hence the jugular bulb is ordinarily 
 in no danger in the curettage of the floor. Occasionally the floor is so 
 thin that in curetting granulations from it there is danger of injuring 
 the jugular bulb and causing serious or even fatal hemorrhage. When 
 the jugular bulb is thrombosed, necrosis of the floor of the tympanic 
 cavity may occur, and granulations spring from this point. Granula- 
 tions of the floor of the tympanum in cases of lateral sinus thrombosis 
 are significant of the involvement of the jugular bulb. 
 
 The outer wall of the tympanum is chiefly composed of the membrana 
 tympani, though at its upper and lower portions it is composed of bone. 
 The bony wall at its upper portion forms the outer wall of the attic, 
 or the recessus epitympanicus (Fig. 355). The handle of the malleus 
 is embedded in the membrana tympani, as is also the short process, 
 located at the upper extremity of the handle. 
 
 The inner wall of the tympanum is of interest because it also forms 
 the outer wall of the labyrinth, and because of the presence of impor- 
 tant structures concerned in the function of sound conduction (Fig. 
 357). The most important of the structures concerned in sound con- 
 duction are the oval window (fenestra vestibuli), the stapedius muscle, 
 the tensor tympani muscle, and the round window (fenestra cochlea). 
 The other important structures are the promontorium, a projection due 
 to the beginning of the basil turn of the cochlea; the prominentia canalis 
 facialis, which forms the upper and posterior border of the fossula 
 
THE TYMPANIC CAVITY 583 
 
 fenestra? cochleae; and the prominentia canalis semicircularis lateralis. 
 The prominences of the facial nerve canal and of the lateral semicircular 
 canal form the median boundary of the attic (recessus epitympanicus), 
 and they lie in close relation to the deep portion of the postsuperior wall 
 of the external auditory meatus. The removal of this wall in the radical 
 mastoid operation is likely to result in injury to these two structures. 
 The Stacke protector is sometimes used to protect these structures by 
 passing it from the middle ear upward and backward into the aditus 
 ad antrum. 
 
 The facial nerve is usually covered by bony tissue, though in excep- 
 tional cases it is not. In necrotic processes it is frequently exposed, 
 hence extreme caution is necessary in removing the postsuperior wall 
 of the meatus, lest the nerve be injured. The nerve comes sharply 
 outward from the cranium and then turns downward, forming a rather 
 sharp knee, without coming near the mastoid surface. Hence, the 
 outer portion of the posterior wall of the meatus may be removed without 
 danger of injuring the facial nerve. T. Passmore Berens reported a 
 case in which the facial nerve came near the surface, and in which it 
 would have been injured if the posterior wall of the meatus had been 
 removed as completely as usual. The bone of the postsuperior wall 
 of the meatus is often spoken of as a "wedge of bone," from the fact that 
 it is triangular in shape. The point of the wedge is at its deepest portion, 
 while the pole is the external portion. The point of the wedge forms the 
 outer wall of the aditus ad antrum, the constriction which marks the 
 boundary between the attic and the antrum. 
 
 The malleus and incus are also removed in the radical mastoid opera- 
 tion, and the obstruction to the drainage of the mastoid cells and the 
 antrum is thus completely removed. The chief objection to the ossicu- 
 lectomy alone for the cure of chronic suppurative ear disease is that 
 neither is free drainage thereby established, nor is all the morbid material 
 removed; that is, the necrosis and granulations are usually present in 
 the antrum and cells as well as in the attic, hence the removal of the 
 malleus and incus does not give relief except in the attic. If the disease 
 is limited, or focalized in the attic, ossiculectomy may be all that is 
 necessary to do. 
 
 The Antrum. — The antrum is embryologically a part of the middle 
 ear, while the mastoid cells are not. It communicates with the attic 
 through the aditus ad antrum. The mastoid cells drain into it. The 
 ciliated epithelium lining the cells, antrum, tympanum, and the Eusta- 
 chian tube propels the secretions successively through these parts to 
 the pharyngeal orifice of the tube. In severe acute inflammation, and 
 in prolonged chronic inflammation, the epithelium is denuded in certain 
 areas of its cilise, and the drainage of the secretions is interfered with. 
 The superficial destruction of tissue thus started may extend to the deeper 
 tissues, as the epithelium, mucous membrane, periosteum, and the bone. 
 Necrosis may be thus established. When such extensive destruction 
 has become established there is little probability of a cure except by the 
 radical, or the meatomastoid operation. 
 
584 THE EAR 
 
 The Mastoid and Temporal Bone Cells. — A knowledge of the possible 
 distribution of the mastoid and temporal bone cells is sometimes a matter 
 of extreme importance in the successful treatment of mastoiditis. In 
 many chronic cases it is absolutely necessary for the surgeon to remove 
 all morbid tissue, and to establish free drainage of the remotest air spaces 
 in the temporal bone. The pneumatic cells are not always confined 
 to the mastoid process, but may be in the posterior root of the zygoma, 
 the squamous plate of the temporal, in front of the external auditory 
 meatus and in the posterior wall of the pyramid of the petrous portion 
 of the temporal bone. When in the latter position they are not easily 
 reached, though as Jansen has shown, they may be exenterated. I have 
 seen cases in which pus-discharging cells were in front of the meatus 
 with a canal of communication leading to the antrum. Had they not 
 been opened and exenterated in the course of the radical operation, 
 the operation would have been a failure. Hence it is necessary in all 
 chronic cases to make careful search for pneumatic cells in other regions 
 than the mastoid process. In one of Dr. Wale's bony specimens the 
 mastoid cells communicated with the sphenoid sinus. 
 
 The Arteries of the Middle Ear. — The middle ear receives its chief 
 blood supply from branches of the internal carotid artery. The 
 branches pass backward through the canaliculus carototympanici to the 
 mucous membrane of the middle portion of the tympanic cavity. The 
 middle meningeal artery sends a branch to the upper portion of the middle 
 ear, while the A. stylomastoidea sends a branch to the postinferior portion 
 and to the mastoid cells. As all these branches are quite small, they 
 have no special clinical significance. 
 
 THE PHYSIOLOGY OF THE EAR. 
 
 I. Membrana Tympani. — The eardrum is stretched across the inner 
 end of the external meatus, and is elastic enough to undergo considerable 
 movement when the air in the meatus is alternately condensed and rare- 
 fied with Siegle's otoscope. The membrane is attached to a groove in 
 the annulus, the sulcus tympanicus, by an extension of the periosteum, of 
 which the middle or fibrous layer is composed. The annulus tympanicus 
 does not extend completely around the meatal opening, but is absent at 
 the upper portion, the Rivinian segment. The part of the membrane 
 attached to the annulus is known as the pars tensa or the membrana 
 tensa. 
 
 The part attached to the Rivinian segment is not stretched, but is 
 loosely drawn, and is known as Shrapnell's membrane, the pars flaccida 
 or the membrana flaccida. This portion of the membrane forms the outer 
 wall of Prussak's space, while the pars tensa forms the lower portion of 
 the outer wall of the tympanic or middle ear cavity (Fig. 355). 
 
 The membrana tympanum is not placed perpendicularly across the 
 opening of the meatus, but forms an angle of about 140 degrees with the 
 postsuperior wall, and one of 45 degrees with the anteroinferior wall. 
 
THE PHYSIOLOGY OF THE EAR 585 
 
 This is of clinical importance in the removal of foreign bodies from the 
 meatus. 
 
 The function of the membrana tympani is to receive and convey sound- 
 waves to the chain of ossicles, and thence to the labyrinth. That it is 
 not absolutely essential to fair hearing is shown by the fact that good 
 hearing is often present when the membrane is perforated or entirely 
 absent. The ear-drum also protects the tympanic mucous membrane 
 from the deleterious effects of the air and from the entrance of morbific 
 germs and foreign bodies. 
 
 When the normal tension of the drumhead is disturbed there is an 
 impairment of hearing, hence, any morbid condition of the Eustachian 
 tube which interferes with the ventilation of the tympanic cavity, or any 
 inflammatory disease of the mucous membrane which interferes with the 
 mobility of the ossicular chain, or any morbid condition of the drumhead 
 which interferes with its elasticity or motility, will cause more or less 
 deafness. 
 
 II. The Eustachian Tube.— The function of the Eustachian tube 
 is twofold, namely: (a) to ventilate, and (b) to drain the tympanic and 
 mastoid cavities. When these spaces are healthy, the Eustachian tube 
 is adequate for the purpose. When, however, the spaces are inflamed, 
 and the secretions are greatly increased in quantity, it is not large enough 
 to accommodate the passage of the secretions into the epipharynx. 
 WTien its capacity is thus overtaxed, the retention of the secretions 
 causes pressure necrosis in the direction of least resistance, namely, 
 the membrana tympani. Perforations thus arise in the course of infec- 
 tive inflammations of the tympanic cavity, the antrum, and mastoid 
 cells. The Eustachian tube is generally large enough to carry off the 
 secretions from the tympanic cavity, even when in a diseased state, but 
 when in addition the antrum and mastoid cells are involved it is not 
 capable of disposing of the secretions, retention occurs, and the pressure 
 symptoms (pain, tenderness, and swelling) of mastoid inflammation ensue. 
 If the excess of secretions from the antrum and the mastoid cells are 
 diverted from the tympanic cavity, the morbid process tends to subside 
 because the tube is large enough to drain the secretions from the tym- 
 panic cavity. In other words, the retention of the secretions in any 
 cavity tends to foster inflammatory processes in the mucous membrane, 
 which may, in time, extend to the periosteum and the bone to which 
 it is attached. (See Diseases of the Nasal Accessory Sinuses, the Clin- 
 ical Anatomy of the Tonsils, and Meatomastoid Operation.) 
 
 The Tympanic Cavity. — The function of the tympanic cavity and its 
 contents is to transmit sound waves to the labyrinth. It also forms a 
 channel of communication between the Eustachian tube and the epi- 
 pharynx, on the one hand, and the antrum and mastoid cells on the 
 other. The cavity is divided into two spaces by the interlocking heads 
 of the malleus and incus. The lower space is called the atrium, or 
 the middle ear proper, while the upper is called the attic. The attic 
 is still further subdivided by the heads of these bones into an inner 
 and an outer attic. The outer space is divided into an upper and 
 
586 
 
 THE EAR 
 
 Fig. 355 
 
 a lower space by the external ligament of the malleus (Fig. 355). The 
 lower space is called Prussak's space, suppurative inflammation of which 
 is difficult to cure. (See Suppuration of Prussak's Space.) 
 
 The inner wall of the tympanic cavity presents two anatomical features 
 of physiological and clinical interest, namely, the oval and round windows. 
 The oval window, the fenestra vestibuli, receives the foot plate of the 
 stapes, which is surrounded by the annular ligament, and communicates 
 with the vestibule of the labyrinth. The round window opens into the 
 cochlea, and the membrane closing it forms an elastic valve to relieve 
 the shock to the cochlea in the presence of excessive sound waves. 
 
 The Intrinsic Muscles of the Ear. — 
 The tensor tympani muscle pulls 
 the handle of the malleus inward, 
 thus increasing the tension of the 
 drumhead. This movement of the 
 malleus is communicated to the 
 long process of the incus, which in 
 turn acts upon the stapes and com- 
 presses it into the oval window. 
 Prolonged retraction of the mem- 
 brana tympani is attended with a 
 shortening of the tendon of the 
 muscle, a condition which materi- 
 ally interferes with the cure of the 
 deafness resulting from these con- 
 ditions. The stapedius muscle 
 acts in antagonism to the tensor 
 tympani, and counterbalances the 
 compression of the foot plate of the 
 stapes in the oval window. The 
 membrana tympani, the circular 
 ligament of the oval window, and 
 the interposed chain of ossicles are 
 thus poised to receive the sound 
 waves and transmit them to the 
 cochlea, where the impression is 
 received by the delicately attuned 
 organ of Corti, which in turn transmits the impression through the 
 auditory nerve to the auditory centre of the brain, where it is perceived 
 as sound. 
 
 It is apparent from the foregoing physiological data that it is of great 
 therapeutic value to maintain free drainage and ventilation of the middle 
 ear and its accessory cavities, and to prevent the morbid changes incident 
 to the inflammatory processes of the middle ear. 
 
 The Physiology of the Sound-perceiving Apparatus. — The sound- 
 perceiving apparatus is composed of the terminal nerve filaments of 
 the labyrinth, the acoustic (auditory) nerve, and the auditory centre in 
 the brain. 
 
 Coronal section through the tympanum, a, 
 extremity of the upper; b, extremity of the 
 lower bony wall of the meatus; d, tegmen tym- 
 pani; e e, attic, external portion, internal por- 
 tion; f, malleus and superior ligamentum mallei; 
 2, incus; h, stapes within the fenestra vesti- 
 buli; i, promontory; k, Prussak's space; m, 
 hypotympanic recess (cellar); I, scar in the 
 lower half of the drumhead in apposition with 
 the promontory; 2, incudostapedial junction. 
 (After Bruhl-Politzer.) 
 

THE PHYSIOLOGY OF THE EAR 587 
 
 The Auditory Nerve. — The auditory nerve arises between the facial 
 and glossopharyngeal nerves in the medulla oblongata, and passes into 
 the internal auditory canal, in the fundus of which it divides into two 
 branches; the vestibular branch (nerve) enters the vestibule, where it 
 sends twigs to the utricle and the superior ampullar of the semicircular 
 canals ; the cochlear branch (nerve) passes into the cochlea and gives off 
 twigs to the saccule and to the ampulla of the superior semicircular canal. 
 
 The' distribution of the auditory nerve in the cochlea forms a spiral 
 ganglionic ribbon, the ganglionic cells being connected by medullated 
 nerve fibers, the whole being supported on the membranous cochlea, 
 which is attached to the osseous cochlea by fibrous bands. The mem- 
 branous labyrinth is filled with a fluid called endolymph, and is surrounded 
 by a fluid called the perilymph. The cochlear distribution of the auditory 
 nerve is called the organ of Corti. 
 
 The Function of the Vestibular Apparatus. — Within the vestibule (saccule 
 and utricle) the otoliths, acting upon the delicate hair-like prolongations 
 within the ampulla, preside over the sense of the position of the head 
 (body) in space. The angle of the impact of the otoliths upon the hair- 
 like processes (the relative bending) creates a sensation which, being 
 interpreted by the brain centres, gives conscious knowledge of the relative 
 position of the head (body) to the line of gravity and consequently to the 
 plane of the earth. In other words, they aid in the maintenance of 
 equilibrium. (See Functional Tests of the Vestibular Apparatus.) 
 
 The Function of the Semicircular Canals. — These canals are the organs of 
 coordinated movements, or statical sense, hence they are also a part of 
 the apparatus presiding over the sense of equilibrium. (See Functional 
 Tests.) 
 
 The Function of the Cochlea. — Corti's cells constitute the true terminal 
 acoustic (auditory) nerve apparatus. They are about 2000 in number 
 and are ciliated. The function of the cochlear apparatus is to perceive 
 and differentiate sound waves, and convey them to the auditory nerve 
 trunk, thence to the acoustic centres of the brain, where they are perceived 
 as sound. 
 
 Shambaugh controverts the theory of Helmholtz that the basilar mem- 
 brane is the resonator of the internal ear. According to Helmholtz, 
 the fibers of this membrane vibrate in sympathy with the sound waves 
 as they react upon the labyrinth and thus stimulate the hair cells of 
 the organ of Corti. Shambaugh's conclusions are ingenious, and are 
 as follows (Plate XI): 
 
 1. * 'The hair cells of the organ of Corti are the real end organs wherein 
 the physical impulses of sound waves are transformed into the nerve 
 impulses, which result in tone perception. 
 
 2. "The perception for the various tones takes place in different parts 
 of the cochlea, those of higher pitch being taken up by the hair cells 
 located near the beginning of the basal coil, those of lower pitch by the 
 cells near the apex of the cochlea. 
 
 3. "The stimulation of the hair cells is effected only through the 
 medium of their projecting hair. 
 
588 
 
 THE EAR 
 
 4. "The hypothesis that each hair cell acts as its own agent in selecting 
 its stimulus from the impulses passing the endolymph is shown to be 
 untenable for a number of reasons, chiefly, however, because the relation 
 existing normally between the hair cells and membrana tectoria will not 
 permit of these impulses in direct contact with the hair cells. I have 
 shown conclusively that the hairs of the hair cells project normally into 
 the under surface of the membrana tectoria. 
 
 Fig. 356 
 
 &1&H+*- 
 
 
 *:>.' 
 
 r?:.Z2- 
 
 
 Mt 
 
 
 Lv, labium vestibularis; Mt, membrana tectoria; Lt, labium tympana?; Mb, membrana basilaris; 
 LS, ligamentum spirale; SH, streifen of Hensen. (Shambaugh.) 
 
 5. "The stimulation of the hair cells is accomplished only through 
 an interaction between the hairs of the hair cells and the membrana 
 tectoria. 
 
 6. "The hypothesis of Helmholtz that this stimulation is brought about 
 through the vibration of the fibers of the membrana basilaris is untenable, 
 especially for the following reasons : In tracing the membrana basilaris 
 toward the beginning of the basal coil in the vestibule this structure is 
 found at a considerable distance from the lower end of the coil, and where 
 a perfectly formed organ of Corti is still present to become so stiff and rigid 
 as to render it incapable of vibrating. Even a complete absence of a 
 
THE PHYSIOLOGY OF THE EAR 589 
 
 basilar membrane in this locality is sometimes noted. The logical 
 conclusion is that since the stimulation of the hair cells in this locality 
 is accomplished without the intervention of a vibrating membrana 
 basilaris, therefore the stimulation of the hair cells throughout the cochlea 
 is not dependent on the vibration of this membrane. 
 
 7. "The logical conclusion is that the stimulation of the hair cells is 
 accomplished through vibrations of the membrana tectoria transmitted 
 to it by impulses passing through the endolymph. 
 
 8. "The membrana tectoria is shown to be so constituted anatomically 
 as to be capable of responding to the most delicate impulses passing 
 through the endolymph. Furthermore, the great variation in size of 
 this membrane from one end of the cochlea to the other, together with its 
 lamellar structure, suggests the probable physical basis which renders it 
 capable of acting the part of resonator by responding in one part to im- 
 pulses of a certain pitch, and in another part to impulses of another 
 pitch (Fig. 356). 
 
 9. "Finally, the pathological phenomena of 'tone islands/ 'diplakousis 
 binauralis of dysharmonica/ and of 'tinnitus aurium' are all plausibly 
 accounted for in this conception of the physiology of tone perception. 
 
 10. "To restate briefly the process by which the phenomenon of tone 
 perception is accomplished: The sound waves conducted from the f air 
 impinge upon the membrana tympani, producing vibrations in it. These 
 vibrations conducted along the chain of ossicles transmit impulses 
 to the intralabyrinthine fluid through the medium of the foot plate of 
 the stapes. The impulses originating in the fluid in the vestibule pass 
 directly into the scala vestibuli and through the membrane of Reissner 
 to the endolymph, where sympathetic vibrations are imparted to the sev- 
 eral parts of the membrana tectoria, depending on the pitch of the tone. 
 The vibrations in turn stimulate the hairs of the hair cells which normally 
 project into its under surface. The nerve impulses originating from all 
 the hair cells thus stimulated by a particular tone come together in the 
 brain centre in the cortex when the tone picture forms the final step in 
 the process of tone perception." 
 
CHAPTEE XXXIII. 
 
 THE FUNCTIONAL TESTS OF THE EAR. 
 
 Physiological Facts. — (a) Range of Hearing. — The normal range of 
 hearing, in man, for musical tones is from 16 to about 48,000 double 
 vibrations per second. After the fiftieth year the upper limit of hearing 
 is somewhat lowered. Persons seventy or more years old do not usually 
 hear tones of more than 37,000 vibrations per second. 
 
 (b) Paths through Which the Sound Waves Reach the Labyrinth. — 
 1. Sound waves reach the labyrinth chiefly through the tympanic mem- 
 brane, the ossicles and the oval window into which the foot plate of the 
 stapes is inserted. The foot plate does not form a bony union with the 
 oval window, but is attached to it by a fibrous membrane or ring. This 
 allows it to vibrate in the window. Politzer demonstrated that the 
 malleus performed the greatest excursions, the incus less, and the stapes 
 least of all. Helmholtz found the greatest excursions of the stapes to be 
 tV to TT mm - I* * s obvious that slight interference with the movements 
 of the foot plate either by adhesive bands or ankylosis at the window 
 will materially interfere with the transmission of sound waves to the 
 labyrinth, and thus impair the function of hearing. 
 
 2. Sound waves also reach the labyrinth through the fenestra cochlea 
 (round window), hence the function of the ear is not altogether destroyed 
 when the foot plate is fixed, as in spongifying of the bony capsule of the 
 labyrinth. 
 
 3. Sound waves are also carried to the labyrinth to a considerable 
 extent through the bones of the skull (Fig. 357). This explains the 
 somewhat startling fact that deaf persons hear tolerably well if the 
 speaker places the tips of his fingers against the forehead of the listener. 
 Weber's well-known experiment demonstrates that when a tuning fork 
 of 512 vibrations is placed upon the skull and the external meatus is 
 artificially closed with the finger, the vibrating fork is heard much better on 
 that side. In other words, bone conduction is thus increased. Though 
 it is thus increased in intensity, its duration is less than by air conduction. 
 
 In the normal ear, hearing by bone conduction for tuning forks is 
 a little more than one-half of that by air conduction. The relative 
 duration of hearing by bone and air conduction varies greatly with differ- 
 ent forks of the same number of vibrations. It also varies with the 
 point of contact made with the fork. It is heard a little longer when 
 the fork is placed over the mastoid antrum than when placed on the tip. 
 It is customary with most otologists to place it between these two points, 
 just posterior to the external meatus. Politzer, Bezold and Andrews 
 have called attention to the varying results obtained by forks of the same 
 
THE FUNCTIONAL TESTS OF THE EAR 
 
 591 
 
 number of vibrations. Each set of forks should therefore be carefully 
 and repeatedly tested upon normal persons, to establish their normal 
 register. By normal register is meant the length of time the fork is heard 
 by normal ears by bone conduction when placed over the mastoid just 
 back of the external auditory meatus, and the time it is heard by air 
 conduction when held as near as possible to the auditory meatus. Grade- 
 nigo, at the London International Congress of Otologists, gave a scheme 
 for the uniform record of the functional tests, in which he gives the 
 registers of the forks used. This should be done by all observers. In this 
 way the records will be of uniform standard and value. 
 
 Fig. 357 
 
 Air and bone conduction (schematic). 1, cranium; 2, cerebrum; 3, auditory nerve going to tem- 
 poral lobe; 4, labyrinth; 5, tympanum and auricles; 6, auditory meatus; 7, pinnae; a, tuning fork 
 placed on the vertex; a b, osteal bone conduction; a c, craniotympanal bone conduction; d, tuning 
 fork held in front of the ear; d c, air conduction. (After Briihl-Politzer.) 
 
 The Bezold-Edelmann set of forks and whistles has become standard. 
 It is constructed upon scientific principles, and should be used by all 
 otologists. With it every musical tone recognizable by the human ear 
 may be produced. The forks are weighted and are free from overtones. 
 With them deaf mutes may be tested for "islands of hearing," and when 
 found the island or areas of the organ of Corti which are functionating 
 may be utilized to teach the deaf mute speech if it is within the range 
 of tones used in articulate speech. The forks and whistles are also 
 superior to any other set of instruments for testing the auditory appa- 
 ratus because they are constructed on scientific principles and are adapted 
 to the requirements for which they were constructed. No other set of 
 forks and whistles meets all these demands. 
 
 (c) Tone. — The tensor tympani and the stapedius muscles have long 
 been regarded as the tension regulators of the ossicular chain, the sta- 
 
592 THE EAR 
 
 pedius counterbalancing the tensor tympani. A few years ago the late 
 Dr. T. F. Rumbold wrote an article stating that they were the tone- 
 selecting muscles of the ear, just as the ciliary muscles are the viewpoint 
 selectors of the eye. In other words, that they are the focussing muscles 
 of the ear. He says that through their action the ear is enabled to select 
 a particular voice from a multitude of voices; and that they attune the 
 drumhead to catch and transmit to the labyrinth the sound waves selected 
 at will by the listener. 
 
 (d) Perception. — The normal ears of a given subject perceive sound in 
 its actual pitch. Both ears perceive it exactly alike. They perceive 
 sound coordinate in pitch, timbre, and intensity. In certain pathological 
 states one or both ears may be "out of tune." 
 
 Principles Underlying the Tests of Hearing. — 1. The normal range 
 of hearing is from 16 to 48,000 double vibrations per second. 
 
 2. When the conduction apparatus is diseased or obstructed, the hear- 
 ing for the lower tones of the scale is impaired or lost. 
 
 3. When the perception apparatus is diseased, the hearing for high 
 tones is lost. 
 
 4. The normal ear hears about twice as long by air conduction as by 
 bone conduction. That is, a fork heard by bone conduction for twenty 
 seconds will be heard about forty seconds when held close to the auricle. 
 
 5. When the conduction apparatus is diseased or obstructed, bone 
 conduction is increased and the time left in which the fork should be 
 heard by air conduction is diminished; or bone conduction may be so 
 much increased that the fork is heard longer than by air conduction. 
 
 6. When the perception apparatus is diseased, bone conduction is 
 diminished or shortened and the relative time of hearing by air con- 
 duction is exaggerated. 
 
 The Functional Tests of the Auditory Apparatus. — We are 
 now ready to discuss the application of some of the most approved 
 physiological experiments pertaining to the cochlea, with the hope of 
 arriving at some conclusion as to their value as aids in diagnosis and 
 prognosis. It is not assumed by the writer that a correct diagnosis 
 cannot usually be made, or at least fairly accurately guessed at, without 
 the use of the functional tests. We grant as much. The only question 
 herein discussed is as to the reliability of the tests in those cases in which 
 there is some doubt as to the diagnosis. The otologist should, however, 
 make constant use of the tests, in order that he may become skilled in 
 their application and in his deductions therefrom. It is necessary, there- 
 fore, to make a routine practice of applying them to all or nearly all cases 
 coming under observation. The writer has for many years made this 
 his practice in both private and clinical work, and he feels that he has 
 been well rewarded for his trouble. The convictions herein expressed 
 are based upon this experience. 
 
 The Watch Tests. — This instrument has long been used to test the 
 acuteness of hearing, and is of more or less value. The patient may be 
 able to hear the watch distinctly at about the normal distance, and yet not 
 understand conversation, or vice versa. While it may not afford an 
 
THE FUNCTIONAL TESTS OF THE EAR 593 
 
 accurate means of diagnosis, it is often the means by which comparisons 
 may be readily made from time to time during the progress of treatment. 
 In catarrhal inflammation of the middle ear, and especially of the Eusta- 
 chian tube, the watch may be heard distinctly one day, and indistinctly, 
 or not at all, another day. This variation is rather diagnostic of this type 
 of disease, and is accounted for by the intermittent stoppage of the 
 lumen of the tube and the subsequent rarefaction of the air in the middle 
 ear. When the tube becomes clear, air is restored to the tympanic cavity, 
 and the normal tension of the drumhead and the ossicular chain is 
 restored. I use two watches, one of which gives a high-pitched and 
 the other a low-pitched tick. The low-pitched one is the Ingersoll dollar 
 watch, which can be heard at a distance of one hundred and twenty 
 inches, while the high-pitched one (a Paillard's non-magnetic Swiss) 
 can be heard at sixty inches. 
 
 Prout's method of recording the result of the test is used, i. e., the num- 
 ber of inches the watch is heard by the normal ear is used as the denomi- 
 nator, and the distance at which it is actually heard as the numerator. 
 Thus, if the Paillard, or high-pitched watch, is used, and is heard at ten 
 inches, the fraction ^ expresses the result. If the loud-ticking watch is 
 used, and is heard at thirty inches, the fraction T V°o expresses the result. 
 There are five ways of using the watch, namely: (a) Finding the distance 
 at which it is heard upon approaching the ear; (b) placing it in firm con- 
 tact with the auricle ; (c) placing it against the mastoid process ; (d) placing 
 it between the teeth and noting in which ear it is heard more plainly, as in 
 the Weber experiment; and, finally, (e) first finding the distance at which 
 the watch is heard upon approach, and then noting how much farther 
 it can be heard upon withdrawing it from the ear. As before stated, 
 Rumbold uses the latter test to ascertain the tonicity of the middle ear 
 muscles. The writer has also used it for the same purpose for the last 
 ten years and finds improvement in atonic cases following the admin- 
 istration of strychnine and iron, and rest and outdoor exercise. Whether 
 this is due to increased tonicity of the muscles or other causes I will not 
 attempt to state. 
 
 The Voice Test. — In 1871 Oscar Wolf published his conclusions as to 
 the voice as a means of testing the organ of hearing. He found the 
 letter R the lowest in the scale, having 128 vibrations per second, while 
 the highest number of vibrations was produced by S, which gave from 
 5400 to 10,840 vibrations per second. Hence, by the use of these conso- 
 nants we may test the hearing for the lower and within two octaves of 
 the higher range of hearing. With marked limitations this experiment 
 may be used to differentiate between disease of the middle ear and of the 
 cochlea. In other words, he found speech to be confined within about 
 6^ octaves. The greatest strength and timbre belong to the vowel a, 
 which can be heard 252 m., and the smallest to the consonant h, which 
 can be heard 8.4 m. distance. He classifies the various sounds and letters 
 so that they may be used for testing purposes. There are several objec- 
 tions to this method of testing, in spite of the great amount of scientific 
 investigation bestowed upon it by Wolf, Clarence Blake, and others. If 
 38 
 
594 THE EAR 
 
 words are used, the patient often hears the vowel sounds distinctly, and 
 if numerals, he experiences the same difficulty, with the additional one 
 of attempting to infer the number by sequence. Then, too, there is the 
 difference in quality, timbre, pitch, and carrying quality of the voice of the 
 different observers. This difference is less pronounced in the whispered 
 voice, especially if it is given with the residual air. In fact, when the 
 whispered voice is used it should be given only with the residual air, 
 thus rendering all voices more nearly alike. An intelligent application of 
 this method will aid in diagnosis, and in noting the progress made under 
 treatment. 
 
 Technique. — (a) Place the patient in a chair at one end of the room 
 with the ear to be tested toward the other end of the room. 
 
 (b) Instruct him to moisten the tip of the index finger and insert it 
 firmly into the meatus of the other ear. 
 
 (c) The physician should then approach within a few feet of the patient 
 and pronounce words or phrases, and ask the patient to repeat what he 
 
 hears. The physician should grad- 
 Fig. 358 ually recede from the patient until 
 
 he ceases to repeat correctly what 
 is spoken to him, and the distance 
 should be entered in the record of 
 the case. 
 
 (d) If the room is not long enough, 
 
 the examining surgeon when at the 
 
 ^^^^^^^Jjf^ extremity of the room should turn 
 
 B L^-—-— I his back to the patient and continue 
 
 the test. This lengthens the dis- 
 ^ tance by one-third. If the distance 
 
 Poiitzer's acoumeter. is still too short it may be increased 
 
 by two-thirds by turning the patient 
 with his open ear to the opposite wall. This is the method pursued in 
 Poiitzer's clinic (Harry Kahn). 
 
 The above technique may be carried out with either the conversational 
 loud or the whispered voice according to the degree of deafness of the 
 patient, and the record should state which style of speech is used. 
 (e) Inflate the tested ear. 
 
 (/) Make the same tests again, and record the difference following 
 inflation. 
 
 The Politzer Acoumeter. — This instrument (Fig. 358) was designed 
 to take the place of the watch, or at least to supplement it, and can be 
 heard at about 40 feet. All of the instruments are supposed to be of the 
 same pitch and timbre, but in the mad rush of American dealers I fear 
 little attention has been given to their exact construction. It is, however, 
 a valuable adjunct to the watch tests, and may be applied in the same 
 way, 40 feet being taken for the denominator, and the actual number of 
 feet at which it is heard as the numerator. Politzer and Lucae claim that 
 it more nearly corresponds with the voice tests than either the watch or 
 the distance test with the tuning forks. 
 
THE FUNCTIONAL TESTS OF THE EAR 
 
 595 
 
 The Range of Hearing. — As already stated, the normal range of 
 hearing for adults under fifty years of age is from 16 to 48,000 double 
 vibrations per second. After the fiftieth year this may be greatly reduced. 
 In other words, the upper register is lowered by the changes incident 
 to senility. The range of hearing varies in different individuals ac- 
 cording to the age and the pathological condition of the auditory appara- 
 tus. The lowest tones which are perceived are between 16 and 23 vibra- 
 tions per second (Pyer), while the highest audible tone is e 8 , with 40,960 
 vibrations (Landois and Stirling). In youth the upper limit is about one 
 octave lower, or e 7 , with 20,480 vibrations per second. In the beginning 
 of senility it is about a 6 , or 13,653 vibrations, while in very old persons it 
 is near g 6 , or 12,288 vibrations per second (Zwaardemaker). 
 
 The foregoing data should be borne in mind in estimating the probable 
 significance of tests of the range of hearing, as it is apparent that there 
 is no fixed upper limit of hearing, since it varies in the same individual 
 at different periods in his life. There is also quite a distinct variation in 
 different individuals of the same age. Any marked variation, however, 
 from the above figures would in most instances indicate the presence of 
 some pathological process within the auditory apparatus. 
 
 Fig. 359 
 
 Testing the hearing with the Galton-Edlemann whistle at eighteen inches 
 
 By referring to the third principle we find that high tones are 
 diminished or lost when the cochlear apparatus or apparatus of per- 
 ception is diseased; hence, in applying this principle, the age of the patient 
 should be taken into account. The upper limit of hearing is also lost in 
 certain conditions of the middle ear, notably in marked retraction of the 
 membrana tympani, whereby the foot plate of the stapes is forced inward 
 against the labyrinthine fluid. This increased pressure so affects the 
 terminal endings of the auditory nerve as to interfere with the perception 
 of high tones. This condition can usually be differentiated from true 
 labyrinthine or nerve deafness by inflating the middle ear. This pro- 
 cedure usually restores the normal tension to the membrana tympani 
 and the ossicles, and thereby relieves the increased labyrinthine tension. 
 
596 THE EAR 
 
 The upper limit of hearing being restored, the diagnosis of tubal obstruc- 
 tion is made. 
 
 The best equipment for making a complete test of the range of hearing 
 is the Bezold-Edelmann set of forks and whistles. With these every 
 musical tone from 16 to 48,000 vibrations can be tested. 
 
 By referring to the second principle, we find that in disease of the 
 apparatus of conduction the power to hear tones of the lower register 
 is impaired or lost. Loss of hearing for low tones is, therefore, usually 
 a sign of tubal catarrh, disease of the middle ear, or obstruction of the 
 external meatus. It must not be forgotten, however, that the portion of 
 the cochlea which perceives low tones may be diseased, while the other 
 parts are not affected. In this case the loss of low tones would not signify 
 disease of the middle ear. These cases are exceedingly rare, and may be 
 differentiated by testing the vestibular (static) apparatus by the methods 
 described in a subsequent portion of this chapter. 
 
 The Weber Experiment. — This is one of the best-known and most 
 reliable tests made with the forks. Weber's experiment consists in 
 placing the tuning fork c 2 , 512 v., on the median line of the skull, fore- 
 head, teeth, or chin, and then closing the external meatus of one ear with 
 the moistened finger, under which condition he found that the sound 
 lateralized toward that ear. Clinically it has been shown that when the 
 middle ear is diseased, or the external meatus is obstructed by cerumen 
 or other morbid conditions, the sound for the vibrating tuning fork 
 (when on the median line of the skull as the vertex, forehead, teeth, or chin) 
 is lateralized to the affected ear; and that when the labyrinth is affected 
 the sound is lateralized toward the unaffected ear. This rule, like all 
 rules, has exceptions. If the middle ear and the labyrinth are both 
 affected, there are manifestly two opposing conditions, one of which 
 increases and the other of which decreases bone conduction (Figs. 360 
 and 361). 
 
 In such cases dependence must be placed upon a much more extended 
 examination. Indeed, dependence should rarely, if ever, be placed upon 
 a single test. 
 
 Another exception to the rule, which has been noted by several ob- 
 servers, is often found in cases in which both middle ears are affected, 
 but unequally. Ordinarily the fork is lateralized toward the side most 
 affected, but the opposite is often true. Hence, in bilateral deafness 
 the Weber experiment is not reliable. 
 
 In simple or uncomplicated labyrinthine disease, however, the vibra- 
 tions from the fork are almost universally lateralized toward the good ear. 
 Jacobson and Politzer have never seen an exception to this rule in un- 
 doubted cases. The test seems, therefore, to be a reliable one in this 
 class of cases. 
 
 The accuracy of the Weber test will depend very much upon the fork 
 used. In nearly all cases the best results are obtained with fork c 2 , 512 v. 
 Occasionally better results may be had with lower ones. Forks of more 
 frequent vibrations should not be used, as they often give exactly the 
 opposite result. They are, therefore, useless for making this test. In 
 
THE FUNCTIONAL TESTS OF THE EAR 
 
 597 
 
 exceptional cases a c 2 , 512 v., fork may not be at all adapted for this 
 test. When we remember that a fork of higher pitch should never be 
 used, we can readily understand why a c 2 fork with marked overtones 
 should not be used. The high overtones might so counterbalance the 
 true tone of the fork that it would be a question as to which was referred 
 to by the patient in response to the test To avoid the overtones the 
 Edelmann-Bezold weighted forks should be used. 
 
 Fig. 360 
 
 Fig. 361 
 
 The Weber experiment with the e 2 tuning 
 fork. The patient is deaf in the left ear and 
 the sound lateralizes to the left ear, thus indi- 
 cating disease of the sound-conduction (middle 
 ear) apparatus of the left ear. 
 
 The Weber experiment with the c 2 tuning 
 
 fork. The patient is deaf in the left ear and 
 the sound lateralizes to the right or good ear, 
 thus indicating disease of the perception appa- 
 ratus (labyrinth) of the left ear. 
 
 According to Politzer, w T hen the patient is in doubt as to which ear 
 perceives the sound, the sound will become distinctly lateralized if ear 
 specula are inserted in both external meatuses. He also calls attention to 
 the fact that in double chronic disease of the middle ear the sound of the 
 fork may be lateralized to one side when placed on the vertex, and to the 
 other when placed on the maxilla or the bridge of the nose. 
 
 The Weber test is, therefore, found to be the more reliable in uni- 
 
598 THE EAR 
 
 lateral disease of the middle ear, somewhat less reliable in labyrinthine 
 disease, and still less reliable in double chronic affections of the middle 
 ear. 
 
 The Schwabach Test. — The Schwabach test is made with a vibrating 
 A fork, by first placing it upon the vertex Of the examining surgeon 
 until it ceases to be heard, and then transferring it to the vertex of the 
 patient, note being made of the relative length of time the fork is heard 
 by the surgeon and the patient. It has been shown by Siebenmann, 
 Bezold, Hollinger, and others that in hyperostosis of the bony capsule 
 of the labyrinth (spongifying), bone conduction for this fork is greatly 
 prolonged, i. e., ten to sixty seconds. In view of this fact, the Schwa- 
 bach test is often of great assistance in diagnosticating this disease. 
 
 If, however, the fork is heard longer by the examining surgeon than 
 by the patient it may be inferred that the patient has labyrinthine disease. 
 This conclusion should not be definitely recorded until all other tests 
 have been applied. 
 
 The Rhine Test. — In this test only the difference between bone and air 
 conduction is recorded. For example, if bone conduction lasts twenty-five 
 seconds and air conduction fifteen seconds, the Rinne test shows a 
 negative record, or Rinne — 10". If air conduction lasts ten seconds 
 longer than bone conduction, it is recorded positively by the Rinne test, 
 or Rinne +10". If hearing by air conduction exceeds that by bone 
 when applied to the deaf ear, there is nerve deafness; and when bone 
 conduction exceeds that by air when the fork is applied to the deaf ear, 
 there is middle ear deafness. This test is not as reliable as the Weber, 
 but is nevertheless one that should always be used in conjunction with 
 the other tests (Figs. 362 and 363). The Rinne test may be recorded 
 in successive degrees as follows: 
 
 (a) Normal. Normal Rinne is always positive, that is, the c 2 fork 
 is heard by bone conduction for about twenty seconds, and by air con- 
 duction for about forty seconds. 
 
 (b) Positive, or slightly shortened normal. 
 
 (c) Shortened positive, or greatly shortened normal (a few seconds 
 longer air conduction than normal bone conduction). 
 
 (d) Negative, or greatly prolonged hearing by bone conduction. 
 
 (e) Shortened negative, or only a few seconds of longer hearing by 
 bone conduction than by air conduction. 
 
 (J) Indifferent, or conduction of equal duration by both bone and air. 
 
 According to Lucae the Rinne test is only reliable when hearing for 
 whispered conversation is reduced to 1 m. 
 
 If there is increase of bone conduction to such an extent that a shortened 
 negative Rinne test is obtained, the test is reliable. If, however, bone 
 conduction is only increased to a moderate extent and a shortened plus 
 Rinne test is obtained, it does not afford much information. The more 
 profound the deafness from the middle ear disease the more reliable is 
 the test. 
 
 If the results of the range of hearing, the Weber and the Rinne' tests, 
 correspond, the latter is additional proof of a pathological condition. 
 
THE FUNCTIONAL TESTS OF THE EAR 
 
 599 
 
 Thus, if a patient complains of deafness in the right ear, and the Weber 
 test lateralizes the sound to the right side, and the Rinne is — 10", the 
 Rinne* corroborates the other tests and confirms the other signs pointing 
 to disease of the middle ear. There are many cases in which the diagnosis 
 is in doubt when the information afforded by the various physiological 
 tests renders the diagnosis clear. When, however, the Rinne test is 
 negative, and duration of bone conduction also shortened, there may be 
 some doubt as to the significance of the negative Rinne test. In such 
 cases there may be present both middle and labyrinthine disease. This 
 apparently anomalous result is often very significant, and should lead to 
 most careful investigation and to a very guarded prognosis as to the 
 hearing. It is often the case that, through the very contradictions arising 
 from the tests, we are enabled to arrive at a correct idea as to the location 
 and extent of the pathological process. 
 
 Fig. 362 
 
 Fig. 363 
 
 Showing the Rinne - a' fork in position on the 
 mastoid process in the Rinne" test. 
 
 Showing the Rinne a' fork held close to the 
 ear in Rhine's test; indeed, the prong tips 
 should be within the concha 
 
 In middle ear disease affecting one side only and of moderate degree, 
 the Weber is the more reliable test. 
 
 In the aged the Rhine* test is not so reliable, on account of the dimin- 
 ished bone conduction incident to senility. 
 
 When there is great deafness, and the Rinne test gives a positive result 
 (plus Rinne), it is a fairly reliable sign of involvement of the nerve. 
 
 The timing fork best suited for making this experiment is a 1 , although 
 it may be made with higher pitched forks. With higher forks than a 1 it 
 is, however, difficult to eliminate hearing by air conduction. Unlike the 
 Weber test, the lower forks are not suited for this test, as upon the mastoid 
 the patient cannot so easily distinguish between the mechanical vibra- 
 tions and the tone of the fork. 
 
 The fork used should have its register established by numerous experi- 
 
600 THE EAR 
 
 ments upon normal ears, and in publishing reports of cases this register 
 should be named unless the Bezold-Edelmann forks are used. 
 
 The Gelle Test. — This test is based upon the physiological experiment 
 of compressing the air in the external auditory meatus with a Politzer 
 bag, while the vibrating fork is upon the vertex or the bag. At the time 
 of compression the perception for the tone of the fork is greatly diminished 
 in a normal ear. This is due to the increased pressure within the labyrinth. 
 According to Gelle, if there is ankylosis of the foot plate there will be no 
 increased pressure within the labyrinth, hence no change in the intensity 
 of the tone; he therefore claims that it is of value in diagnosticating this 
 condition. On the other hand, if there is marked deafness and the tone 
 is greatly diminished with each compression of the air in the meatus, 
 it signifies that the foot plate is freely movable and that deafness is due 
 to labyrinthine disease. The compression should not be made with the 
 finger inserted into the meatus, but should be done with a Delstanche 
 masseur and Siegle's otoscope, or the Politzer bag, which will drive the 
 drumhead and the ossicles inward, compressing the labyrinthine fluid, 
 and even then it often fails to afford information. (See Functional Tests 
 of the Vestibular Apparatus.) 
 
 Bing Test, No. 1. — This test is also used to differentiate between middle 
 ear and labyrinthine affections. The experiment is based upon the fact 
 that when the tuning fork upon the mastoid ceases to be heard, it is 
 heard anew when the external meatus is closed with the finger. In cases 
 of great deafness, if closing the meatus does not develop the tone anew, 
 it is, according to Bing, a sign of middle ear disease, whereas if it is 
 heard again (in cases of great deafness) it is a sign of labyrinthine dis- 
 ease. 
 
 Bing Test, No. 2. — This test is usually referred to as the "entotic" use 
 of the speaking tube. The purpose of the test is to differentiate between 
 ankylosis of the foot plate of the stapes and adhesive bands or other 
 pathological conditions which hinder the malleus and the incus in trans- 
 mitting sound waves. The test is made by comparing the hearing of 
 a patient through a speaking tube applied to the external meatus and 
 one applied to the Eustachian catheter. If the patient hears the fork 
 better through the speaking tube by way of the catheter than he does 
 through the external meatus, the inference is that the foot plate is freely 
 movable, while the malleus and the incus are fixed or hindered in their 
 vibrations. If such is the case, a rational treatment is at once suggested, 
 i. e., either the freeing of the malleus and the incus from the adhesions or 
 other hindrances, or the removal of one or both ossicles, preferably only 
 the incus. 
 
 Functional Tests of the Vestibular Apparatus.— A thorough 
 knowledge of the vestibular reactions under normal and pathological 
 conditions is absolutely essential to the differential diagnosis of several 
 labyrinthine and intracranial pathological processes. A description of 
 the application of the tests will be followed by a discussion of the rationale 
 of physiological and pathological nystagmus (the visible reaction). 
 The substance of this section is taken, chiefly, from the writings of 
 
THE FUNCTIONAL TESTS OF THE EAR 
 
 601 
 
 Barany and Neumann. Dr. John R. Fletcher, who has worked with 
 these investigators, has rendered invaluable assistance in translating 
 and abstracting their monographs upon the subject, and he has, in addi- 
 tion, greatly aided me by many valuable suggestions and by a critical 
 review of this section. 
 
 The Caloric Tests. — Two tests, each attended with different reactions, 
 are described under this caption. 
 
 Fig. 364 
 
 WATER 
 120-FAR. 
 
 Fig. 365 
 
 Showing (a) the caloric test (warm water), right ear, 
 producing nystagmus, the quick component of which is 
 to the affected or tested side; (b) the negative galvanic 
 urrent ( — ) applied in front of the right ear, produc- 
 ing nystagmus to the same side; (c) turning the patient 
 to the right with the quick component of the primary 
 nystagmus (during turning) to the right. 
 
 NEUTRAL J 
 POSIT/ON^ 
 
 HOT 
 WATER 
 
 Schematic drawing showing the influ- 
 ence of hot water applied to the right 
 middle ear. u, the utriculus. As the 
 endolymph in the utriculus is warmed it 
 rises through the anterior vertical semi- 
 circular canal, and thus stimulates the 
 crista ampullaris of this canal upon the 
 ( + ) side of greatest physiological activ- 
 ity. As the horizontal canal is on a 
 lower level than the utriculus, the endo- 
 lymph remains stationary. The result 
 of warm irrigations is therefore limited 
 to rotary nystagmus to the right. 
 
 1. The Cold Water (or Air) Test. — Water of a lower temperature 
 than that of the body is used, 78° F. being the temperature usually 
 employed. This may be injected into the external meatus against the 
 membrana tympani, or inner wall of the tympanic cavity. A fountain 
 syringe may be used for this purpose. The force of the stream should 
 not be great. If the labyrinth is diseased a horizontal nystagmus with 
 the quick component directed to the opposite side will occur as the endo- 
 
602 
 
 THE EAR 
 
 lymph flows from the utriculus to the ampulla, thus irritating the hair 
 cells of the crista ampullaris upon the side of least physiological activity. 
 2. The Warm Water (or Air) Test. — Inject water of a higher tempera- 
 ture than the body into the meatus of the suspected ear, and if the 
 
 Fig. 366 
 
 Fig. 367 
 
 Showing (a) caloric test (cold water), right ear, with 
 nystagmus to the left; (b) the positive galvanic electrode 
 ( + ) in front of the right ear, causing nystagmus to the 
 left; (c) turning the patient to the left, causing primary 
 nystagmus to the left. The total result is a combined hori- 
 zontal and rotary nystagmus to the left. 
 
 COLD 
 WATER 
 
 Schematic drawing showing the 
 influence of cold water applied to 
 the right middle ear. u, the utric- 
 ulus. As the endolymp'i in the 
 anterior vertical and horizontal 
 canals and the utriculus is cooled 
 it seeks the lowest level, hence the 
 movement of the endolymph in the 
 anterior vertical canal is from the 
 ampulla to the utriculus. The crista 
 ampullaris is thus stimulated upon 
 the side of least physiological activ- 
 ity and causes rotary nystagmus to 
 the left. The endolymph also flows 
 downward from the utriculus 
 through the ampulla of the hori- 
 zontal canal, and stimulates the 
 crista ampullaris upon its side of 
 least physiological irritability and 
 produces horizontal nystagmus to 
 the left. The total result of cold 
 water irrigation is, therefore, a com- 
 bined horizontal and rotary nystag- 
 mus to the left or opposite side. 
 
 labyrinth is affected a combined horizontal and rotary nystagmus, will 
 occur. The quick component of each type will be to the affected side, 
 as the hair cells of the crista ampullaris of the horizontal and anterior 
 vertical canals are stimulated upon the sides of greatest physiological 
 activity (Figs. 364, 365, 366, and 367). 
 
NYSTAGMUS 603 
 
 The Turning Test. — In making this test the patient should be seated 
 upon a revolving chair, head erect, and turned either to the right or 
 the left — to the right when the right ear is being examined, and to the 
 left when the left ear is being examined. Each turn should occupy 
 two seconds. The patient should wear opaque spectacles to prevent 
 fixation of vision. Two turns should be made, the surgeon meanwhile 
 observing the eyes over the rims of the spectacles. If the labyrinth is 
 affected a primary nystagmus (during the turning) will occur toward 
 the affected ear. If the labyrinth is normal ten turnings will be required 
 to produce this reaction. The after-nystagmus (that which follows the 
 sudden cessation of the turnings) will be of less amplitude, and the 
 quick component will be in the opposite direction. 
 
 The Galvanic Test. — Alexander, Neumann, Frey, Hammerschlag, and 
 Barany have done the most recent exhaustive work in nystagmus by 
 galvanization. At present there exists quite a difference of opinion 
 regarding the clinical value of the reaction thus produced. The test is 
 made as follows: 
 
 (a) To stimulate both sides at the same time, place one electrode 
 in front of either tragus or behind either mastoid, and use a current of 
 2 to 6 ma. 
 
 (6) To stimulate one side, place one electrode before the tragus and 
 the other in the hand of the same side. Use 20 to 24 ma. current. The 
 direction of the nystagmus is away from the anode ( + ) and toward 
 the kathode ( — ) ; hence, if the positive pole or anode is placed before the 
 tragus of the left ear of a sound person and the negative or kathode is 
 held in the hand of the same side, the direction of the nystagmus will 
 be toward the right side of the person examined, or away from the anode. 
 The opposite is true when the electrodes are reversed, the quick com- 
 ponent of the nystagmus will then be toward the ear before which the 
 kathode is placed, or toward the kathode. The nystagmus is of the 
 combined character, strong rotary and weak horizontal, both to the same 
 side. It is increased by directing the eyes to the side of the quick com- 
 ponent and lessened or completely suppressed by looking toward the side 
 of the slow component. There is no difference in the degree of nystagmus 
 produced by the anode and kathode. The law governing the reaction 
 movements being dependent upon the position of the head, covers this 
 case, as in nystagmus by turning, etc. When the head is inclined 90 
 degrees to the right and the kathode placed on the right ear the patient 
 will fall forward. 
 
 NYSTAGMUS. 
 
 Nystagmus may be divided into two special types, namely: 
 (a) Ocular nystagmus. 
 (6) Vestibular nystagmus. 
 Ocular Nystagmus. — Ocular nystagmus is of an undulating char- 
 acter, in which both movements of the eyes occur with equal rapidity and 
 amplitude of excursion, and it has therefore no quick component, as is 
 the case in vestibular nystagmus. It is never rotary. 
 
604 THE EAR 
 
 According to Barany, ocular nystagmus is designated as the undu- 
 lating nystagmus produced in following moving objects with the eyes. 
 This type is best seen by observing a person looking out of a moving 
 car. When one attempts to fix the vision upon passing objects there 
 appears an ocular nystagmus in the direction of the motion of the train. 
 Upon turning in a revolving chair, ocular nystagmus may be observed, 
 and this must be reckoned with in examinations of deaf-mutes in whom 
 both labyrinths have been destroyed, since they too show a typical ocular 
 nystagmus. One can observe ocular as well as vestibular nystagmus 
 upon one's own eyes, by closing one eye and feeling it through the lids 
 with the fingers. Ocular nystagmus can also be produced by the use of a 
 revolving cylinder upon which alternate black and white stripes have been 
 painted. By this method ocular nystagmus may be produced in any 
 direction except rotary, according to the change in the direction of vision. 
 
 Vestibular Nystagmus. — Vestibular nystagmus is distinguished by 
 rhythmical movements of the eyes of unequal velocity, and is, therefore, 
 said to have two components, the quick in one direction, and the slow in 
 the other. The direction of the nystagmus is designated by the direction 
 of the quick component, as this movement is most easily seen, though in 
 reality the slow component is produced by the vestibular irritation. The 
 hair cells of the ampulla are pulled upon by the flow of the endolymph 
 against the cupola which caps the crista ampullaris (Fig. 368), and this 
 impulse is transmitted through the vestibular nerve to Deiters' nucleus, 
 thence to the oculomotor centre (both of which are in the floor of the 
 fourth ventricle), and thence to the extrinsic muscles of the eyes. 
 
 Physiological Experimental Vestibular Nystagmus. — Vestibular 
 Nystagmus Due to Turning. — Physiological experimental vestibular 
 nystagmus may be produced by turning the person examined in a re- 
 volving chair. Barany has found ten turnings to be the number best 
 suited for experimental work, as the nystagmus reaches its maximum of 
 intensity at this number (during turning), the eyes coming to a state of 
 rest if turning is continued. The time required for the ten turnings 
 is from twenty to twenty-two seconds. The turning may be to the right 
 or to the left. Turning to the right means turning in the direction of the 
 movement of the hands of a watch, face upward, or from the tip of the 
 nose toward the right ear (Fig. 369). Turning to the left is, of course, 
 in the opposite direction, or from the tip of the nose toward the left 
 ear (Fig. 369). The nystagmus which occurs during turning is called 
 primary, and is of shorter duration and of longer excursions than the after- 
 nystagmus, which follows the sudden cessation of the turning. The 
 primary nystagmus is always in the direction of turning; for example, the 
 quick component is directed to the right while turning to the right, and 
 vice versa. The after-nystagmus is in the opposite direction to the turning. 
 Another characteristic of vestibular nystagmus is that it increases in 
 intensity when the eyes are voluntarily directed toward the quick com- 
 ponent, and diminishes or ceases completely when the eyes are directed 
 toward the slow component. Fixation of vision diminishes the duration of 
 the horizontal after-nystagmus, but it can be again elicited by directing 
 
NYSTAGMUS 
 
 605 
 
 the eyes toward the side of the quick component. On this account, 
 Barany advises the use of opaque spectacles in the investigation of hori- 
 zontal nystagmus, as suggested by Dr. Hans Abels. When the person 
 examined looks straight into the spectacles, fixation of the vision is 
 impossible, and the complete duration of the nystagmus can be measured 
 in seconds by the use of a stop watch. When the spectacles are used the 
 nystagmus cannot be again produced, by looking in the direction of the 
 quick component, if the nystagmus has ceased. The average duration of 
 horizontal nystagmus is forty seconds, though the variation below and 
 above this is considerable. 
 
 Fig. 368 
 
 Fig. 369 
 
 The fistula test, causing irregular nystagmatic 
 movements of the eyes. 
 
 Turning to the right is from the tip of the nose 
 toward the right ear. Turning to the left is from 
 the tip of the nose toward the left ear. 
 
 Flourens discovered the law that each semicircular canal produces 
 nystagmus in its own plane. If one be turned with the head erect, the 
 horizontal pair of canals functionate; if turned while the head is inclined 
 90 degrees to the shoulder, the posterior vertical pair are stimulated and 
 the nystagmus will be vertical (with relation to the head) ; if turned while 
 
608 
 
 THE EAR 
 
 the head is inclined 90 degrees forward, or backward, the anterior vertical 
 pair of canals functionate, causing a rotary nystagmus, as when the crista 
 ampullarii of these canals are stimulated, rotary nystagmus is always pro- 
 duced. In an intermediate position of the head (45 degrees forward) the 
 
 Fig. 370 
 TO THE RIGHT 
 
 Schematic drawing showing the effects upon the vestibular apparatuses of turning the patient 
 to the right. P, the pivotal point; +, the side of greatest physiological activity of the crista 
 ampullaris of the horizontal semicircular canals; — , the side of least physiological activity of the 
 crista ampullaris of the horizontal canals, (c) The cupola of the crista ampullaris; b, b, b, the 
 direction of movement of the endolymph in the right horizontal canal during turning (head erect) 
 to the right, i. e., from the ampulla to the utriculus, or in the direction of greatest physiological 
 activity; e, e, e, the direction of movement of the endolymph in the left horizontal canal (head 
 erect), during turning to the right, i. e., from the utriculus to the ampulla, or direction of least 
 physiological activity. The right crista ampullaris being stimulated upon its side of greatest physio- 
 logical activity has the greater pull, and it, therefore, determines the direction of the quick com- 
 ponent toward the right; a, right stapes. 
 
 result is a combined nystagmus, that is, horizontal and rotary, as both the 
 horizontal and the anterior vertical canals are stimulated. This is accord- 
 ing to the second part of Flouren's law, namely, when two or more semi- 
 circular canals are simultaneously stimulated, the resulting nystagmus 
 is in the planes of the canals, i. e., there is a combined nystagmus. In 
 
NYSTAGMUS 607 
 
 physiological nystagmus in normal persons, the symptoms accompanying 
 spontaneous nystagmus (vertigo, nausea, vomiting) are rarely present, 
 though they may be in neurasthenics. 
 
 Physiological Rotary Nystagmus. — The direction of rotary nystagmus 
 is designated according to the direction of the quick movement of the 
 upper Iambus of the cornea; thus Fig. 364 signifies rotary nystagmus 
 directed to the patient's right. It is increased or diminished in the same 
 manner as the horizontal nystagmus, by looking in the direction of 
 the quick or slow component, respectively. Rotary experimental physio- 
 logical nystagmus is, contrary to the rule in the case of horizontal nystag- 
 mus, seldom accompanied by vertigo, nausea, and vomiting. Those who 
 experience it are of the unstable nervous type, namely, neurasthenics. 
 
 Physiological Caloric Nystagmus. — Schmiedkam and Hensen, while 
 experimenting in 1868 to determine the pressure resistance of the mem- 
 brana tympani, noticed that vertigo, nausea, and vomiting occurred when 
 the external auditory canal was filled with cold water, while water of the 
 body temperature caused no such effect. Many otologists have observed 
 vertigo and nystagmus when using quite warm or cold water in the ear, 
 notably Urbantschitsch, Colin, and Babinsky. To Robert Baranv, 
 however, belongs the honor of having so thoroughly investigated this 
 phenomenon as to place it upon a perfectly reliable clinical basis for the 
 determination of vestibular reaction. He has published the following 
 results : 
 
 If the right ear of one with an intact vestibular apparatus is irrigated 
 with water of a lower temperature than the body, while the head is 
 erect, a horizontal and rotary nystagmus directed to the left will occur. 
 If water of a temperature higher than that of the body is employed, the 
 resulting nystagmus will be rotary toward the right; that is, away from 
 the irrigated side when cold is used, and toward it when warm water 
 is employed. Barany's theory is that the endolymph is subject to the 
 same physical disturbance which is observed when water in a vessel is 
 either cooled or warmed; namely, if cold is applied to the side of the 
 vessel the cooled water within it sinks, and if heat is applied the water 
 rises; thus, in either instance a circulation is established. When the 
 endolymph in a semicircular canal is caused to circulate the cupola of the 
 crista ampullaris bends in the direction of the current (Fig. 370). As the 
 water in the vessel, when cooled, moves downward, so the endolymph 
 when cooled moves from the highest to the lowest part. It is plain, there- 
 fore, that when cold water is used, the rotary nystagmus comes from the 
 anterior vertical canal, as the summit of its arch is the highest exposed 
 point of the vestibular apparatus when the head is erect. The combination 
 of the rotary with the horizontal nystagmus is due to the simultaneous 
 stimulation of the crista ampullaris of the horizontal semicircular canal 
 in the direction of the least physiological activity, i. e., from the utriculus 
 to the ampulla, and of the anterior vertical canal in the direction of the 
 least physiological activity, i. e., from the ampullaris to the utriculus 
 (Fig. 367). When the head is erect the arch of the horizontal canal 
 lies on a somewhat lower plane than its ampulla, thus by gravity causing 
 
608 THE EAR 
 
 the endolymph when cooled to flow from the utriculus through the 
 ampulla backward to the lowest part of the canal. If we remember that 
 the direction of greatest physiological activity in the horizontal and the 
 anterior vertical canals is reversed, the full explanation can be easily 
 arrived at. The highest point of the horizontal canal, with the head erect, 
 is at the junction of its smooth end with the utriculus. Its lowest point 
 is between this and the ampulla, and this causes the flow of the endolymph 
 to be interfered with when warm water is used, thus causing the anterior 
 vertical canal to functionate alone. The result is a rotary nystagmus to 
 the irrigated side. As the flow of endolymph is in the direction of greatest 
 physiological activity (Fig. 365) in the irrigated ear the cupola and 
 hair cells are stimulated upon the positive side, hence the vestibular 
 apparatus of the irrigated ear exerts the greater pull and overbalances 
 the influence of the vestibular apparatus of the opposite ear. 
 
 Fletcher's Law. — According to J. R. Fletcher, the greatest pull or 
 physiological activity is always on the side of the quick component. In 
 caloric nystagmus we have to deal almost exclusively with the horizontal 
 and anterior vertical canals, as their ampullae lie close together, just 
 behind the median tympanic wall, and are exposed to thermic influences 
 applied in the tympanic cavity, while the position of the posterior vertical 
 canal is medial or internal to them, and its ampulla is on its inferior end. 
 The canal is consequently well protected from heat and cold throughout 
 its whole course. 
 
 Barany noted changes in the direction of the caloric nystagmus when 
 the position of the head was varied, as he also demonstrated in nystagmus 
 produced by turning. The irrigation of the right ear with cold water, 
 with the head inclined to the left shoulder, produced horizontal nystagmus 
 to the right. This he explained on the theory of balance of the coordinate 
 action of the semicircular canals of the two ears through the two centres 
 in Dieter's nucleus, in the same manner as the coordinate movements 
 of the eyes is accounted for. When the head is turned to the left shoulder 
 the horizontal canal becomes vertical, and its prominence the highest 
 point. Its ampulla rests against the inner tympanic wall. When cold 
 water is injected the endolymph flows toward the ampulla from the 
 prominence, or, as before expressed, from the ampulla to the utriculus, 
 the direction of greatest physiological activity, and horizontal nystagmus 
 occurs toward the right. When the head is turned to the left shoulder, 
 the prominence is on a lower plane than the ampulla, and being exposed 
 in the antrum, the endolymph flows toward it, or from the utriculus 
 to the ampulla, causing the greatest pull on the hairs of the crista ampul- 
 laris in the direction of the least physiological activity, thus allowing 
 the left apparatus to overbalance it, with the result of a horizontal nystag- 
 mus to the left. It will be observed that these movements of endolymph 
 are the same as in primary nystagmus by turning with the head erect. 
 These reactions are always produced whether the tympanic membrane 
 has or has not been perforated or destroyed. 
 
 Pathological Experimental Vestibular Nystagmus. — If in turning 
 in one direction the nystagmus lasts only half as long as that produced 
 
NYSTAGMUS 609 
 
 by turning in the opposite direction, the vestibular apparatus on the 
 opposite side to the quick component of the half-enduring after-nystag- 
 mus is disabled, and such a condition is certainly pathological. 
 
 Spontaneous horizontal nystagmus, when not due to alcohol, tobacco, 
 or intestinal intoxication, or to seasickness, is probably of intracranial 
 origin (brain abscess, tumor, meningitis), and should lead the examining 
 surgeon to search thoroughly for the intracranial disease. In abscess, 
 if extradural and in the period of latency, the difficulty is great because 
 of the absence of other symptoms. A single symptom, even when so 
 important as nystagmus, is far from being sufficient to warrant a diagnosis. 
 
 In spontaneous nystagmus (which is always pathological) the rotary 
 element is usually present in combination with a nystagmus in another 
 plane. In these cases the accompanying symptoms, vertigo, nausea, and 
 vomiting, are frequently of the severest type. In pathological vestibular 
 nystagmus the quick component is toward the diseased ear so long as 
 the labyrinth is not completely destroyed. When it is destroyed the 
 nystagmus suddenly and violently swings to the other side and remains 
 there three or four days, after which it gradually diminishes and 
 finally ceases altogether, unless in the meantime some complication 
 occurs in the brain, when it will again move toward the diseased ear. 
 When a labyrinth is completely destroyed it cannot functionate, and 
 cannot, therefore, show signs of irritation. In such a case, the nystagmus 
 must, therefore, emanate from the sound side through the loss of co- 
 ordination, which causes tension of the cilia of the crista ampullaris of the 
 side which does functionate. The reversed nystagmus continues to this 
 side for a few days, because of the loss of balance which previously 
 existed. The excursions are wide. This form of nystagmus is of the 
 utmost interest to otologists. Only when experimental nystagmus in the 
 healthy is thoroughly understood is the great value of the spontaneous 
 nystagmus as a clinical symptom fully appreciated. Let us take, for 
 example, a case of suppurative labyrinthitis, in which it is thought 
 necessary to do a labyrinthine operation, in which the labyrinth is to be 
 completely opened. The vestibular function will be destroyed by the 
 operation if the disease has not already done so, and the nystagmus will 
 be directed to the sound side immediately after the operation. If, on 
 the following day, the quick component is directed toward the diseased 
 side, meningitis should be diagnosticated at once, as this is a sure sign 
 of meningitis upon the affected side. When this condition arises, the 
 dressings should be removed and better drainage provided. 
 
 Any obstruction to the thermal conduction to the median tympanic 
 wall will cause a slow response, hence the water used must be of a 
 temperature greatly different from that of the body. If water of the body 
 temperature is used, no matter how long, even when no obstructive 
 lesion is present, the result is negative. If the vestibular apparatus has 
 been destroyed, or the vestibular nerve paralyzed, irrigation with either 
 hot or cold water will not produce nystagmus. 
 
 By the aid of the caloric test unilateral destruction of the vestibular appa- 
 ratus, or paralysis of the vestibular nerve, can be promptly diagnosticated, 
 39 
 
610 THE EAR 
 
 When atresia of the external auditory canal is present, or cholesteato- 
 matous masses are in the tympanic cavity, and interfere with thermal 
 conduction to the lateral wall of the labyrinth, this test will fail. A 
 relatively longer continued flow and lower temperature of water must be 
 used in cases of very acute suppurative otitis media on account of local 
 congestion and elevation of temperature. When the caloric test fails, 
 the rotation test may be used. If the diseased side shows a nystagmus, 
 lasting but half as long as that of the sound side, it is a sign that the disease 
 has extended to the vestibule. 
 
 The average duration of physiological rotary nystagmus is twenty-four 
 seconds to the right and twenty-two seconds to the left. That of the 
 horizontal nystagmus is forty-one seconds to the right and thirty seconds 
 to the left. In those cases in which the duration of the horizontal nystag- 
 mus is above the average it lasts two and one-half times as long as the 
 rotary nystagmus. A mere change of relation between the two sides is of 
 no significance. The difference must be at least as two to one 
 
 Contra-indications to the Caloric Test.- — The use of the caloric test is 
 contra-indicated in traumatic and dry perforations of the membrana 
 tympani. If water is introduced through the external auditory canal 
 into the tympanic cavity, which is not suppurative, it will often cause or 
 reexcite a suppurative process. Irrigation is not contra-indicated if there 
 is suppuration, as it is impossible to create that which already exists. 
 
 Barany's Fixation Apparatus. — When spontaneous nystagmus exists the 
 degree of involvement may be accurately estimated by the responsive- 
 ness of the vestibular apparatus to an added external irritation. Before 
 irrigating, a fixation point must be found where the nystagmus ceases, 
 or is nominal. For this purpose Barany has devised an instrument 
 which is made fast to the head of the patient by a head band. A metal 
 plate with a dial from which a metal rod extends at right angles, bearing 
 a shorter pendent rod which can be moved back and forth from side to 
 side, form the essential parts of this instrument. The patient fixes his 
 eyes upon the pendent rod, and it is moved to the point at which the 
 nystagmus is least or altogether disappears. When this point is deter- 
 mined, irrigate the affected ear gently with cold water. If this induces 
 an additional reaction, the nystagmus will reappear while the patient 
 looks at the fixation point. 
 
 In grave cases with spontaneous nystagmus this method of examina- 
 tion must be very exact, as the correct diagnosis depends largely on 
 the caloric test in conjunction with Barany's fixation apparatus. 
 
 Nystagmus in Circumscribed Labyrinthitis. Differential Diag- 
 nosis and Some Surgical Suggestions. — In circumscribed labyrinth- 
 itis the following classification must be observed: 
 
 1. Erosion with fistula. 
 
 (a) Erosion with normal irritability. 
 
 (b) Erosion with diminished irritability. 
 
 2. Traumatic with traumatic neurosis. 
 
 1. Erosion with Fistula. — Circumscribed disease of the labyrinth is 
 characterized by attacks of vertigo and nystagmus, and always by some 
 
NYSTAGMUS 611 
 
 impairment of hearing. Erosion with fistula is always secondary to 
 disease of the tympanic cavity, which not only involves the drum and 
 ossicles, but often also the bony promontory. The form of circum- 
 scribed labyrinthitis of greatest interest for the study of nystagmus is 
 erosion with fistula. This form may remain circumscribed for a long 
 time, or become diffused, or it may heal with the formation of con- 
 nective tissue over the fistulous opening gradually ossifying and closing 
 the fistula. 
 
 Barany describes vertigo as being of two kinds: 
 
 1. That which occurs without any external cause. 
 
 2. That which occurs with an external cause. 
 
 1. This type comes on at any time and under all circumstances, 
 while the patient quietly sits at a desk, during a meal, while walking, 
 and even during sleep. Such attacks are, as a rule, quite severe and 
 of long duration. They may last from one-half to several hours. The 
 nystagmus is of the spontaneous rotary type, the quick component of 
 which is directed to the diseased side. There may also be a weaker 
 nystagmus, the quick component of which is directed toward the sound 
 side. The accompanying phenomena, nausea, vomiting, and the sensa- 
 tion of movements of objects, are quite severe. In the interval between 
 the attacks the patients frequently feel perfectly well, and often show no 
 signs of nystagmus or disturbances of equilibrium. 
 
 2. The external causes of the second form of vertigo are rapid move- 
 ments of the head, stooping forward, rising, inclining the head backward, 
 and especially toward the shoulder of the diseased side, and going from 
 a hot to a cold room, or vice versa. These attacks are not usually severe 
 and their duration is short, lasting only from a few seconds to a few 
 minutes. Nystagmus is present, but vomiting, as a rule, is not. 
 
 Symptoms of cochlear disease are very often associated with either 
 form of these attacks. Both forms occur in cases of erosion of the laby- 
 rinth in the course of acute or chronic suppurative otitis media. Fistula 
 is a consequence of erosion of the labyrinthine wall. Movements of the 
 eye, of a nystagmatic character, produced by compression and aspira- 
 tion of air in the external auditory canal and in the tympanic cavity, 
 are significant signs of fistula and aid in differentiating this condition 
 from brain abscess. 
 
 When the vestibular apparatus responds normally to the caloric 
 test, compression and aspiration of the membranous canal through the 
 fistula in the bone causes long, slow movements of the eyes and an active 
 nystagmus of some seconds' duration. Very slight movements of the eye 
 may be observed when the test for fistula is made, and the response to the 
 caloric test is partly or completely lost. It is also true that exceedingly 
 small movements of the eyes by compression and aspiration have been 
 observed by Barany, Hennebert, and many others, in the absence of 
 fistula. In such cases the response of the vestibular apparatus to heat 
 and cold is normal. This fact excludes fistula, as in such cases (see 
 above) the movements of the eye must be very long and slow. The direc- 
 tion of the movements differ in different cases. The movements which 
 
612 THE EAR 
 
 result from compression are, however, always in the opposite direction 
 to those which result from aspiration. 
 
 Test for Fistula. — An olive-shaped tip, to which is attached a rubber 
 tube with a valveless bulb on the other end, is placed tightly in the 
 external auditory meatus. While the patient looks at the forehead of 
 the examiner, pressure must be made on the bulb. The amount of 
 pressure has never been determined in pounds. It must not be too 
 little nor very great, and should be done rather suddenly, but not so 
 much so as to startle the patient, otherwise the movement of the head 
 may deceive the examiner into the belief that he has seen the eyes move. 
 When a retro-auricular fistula is present a soft rubber bell, which encloses 
 both the fistula and the ear, may be used instead of the olive-shaped tip. 
 Direct pressure with a cotton-tipped probe will give the same results, 
 but the first is to be preferred as the more gentle method. 
 
 The reaction of the diseased side to irrigation with cold water is greater 
 than that of the sound side; this is due either to the absence of the tym- 
 panic membrane and the bony covering, or to greater vestibular irri- 
 tability. 
 
 Between attacks it may be possible to observe a very weak rotary 
 and horizontal nystagmus to both the caloric tests. Occasionally rotary 
 nystagmus by turning will last longer than the normal horizontal 
 nystagmus. This is always a pathological condition. 
 
 In case of diminished irritability there is a moderate degree of rotary 
 and horizontal nystagmus (a combined spontaneous nystagmus), to 
 both right and left, which is usually strongest to the diseased side, but 
 sometimes to the sound side. Upon inclining the head backward, that 
 is, placing the anterior vertical canal in the horizontal plane, vertigo 
 and rotary nystagmus take place in about 50 per cent, of the cases. The 
 quick component of the nystagmus is directed to the diseased side. Its 
 duration is about fifteen seconds. After waiting ten minutes the same 
 procedure will give a like result. Compression and aspiration produce no 
 nystagmus and the eye movements are minimal. The response to cold 
 water is quite typical as to the direction and character of the nystagmus, 
 but it is very weak. Turning ten times in the direction of the diseased 
 side produces an after-nystagmus to the opposite side, of about thirty 
 seconds' duration, a reduction of one-fourth of the normal average. 
 
 2. Traumatic Circumscribed Labyrinthitis with Traumatic Neu- 
 rosis. — Such cases suffer attacks of vertigo with or without the external 
 causes mentioned above. In these attacks the quick component of the 
 nystagmus is directed to the diseased side, The consciousness of an 
 injury to the head followed by impairment of hearing, of vertigo, Rom- 
 berger phenomenon, hemiparesthesia, sensitive spots, trembling of the 
 eyelids, unsteady gait, with closed eyes causing great apprehension on 
 the part of the patient, finally develops into neurasthenia. 
 
 For the purpose of diagnosis the history of the case must be carefully 
 studied. The patient may or may not have been unconscious after 
 the accident. If so, how long ? Inquire if there was nausea and vomiting, 
 bleeding from the ears, nose, and mouth. Was he able to walk? If not, 
 
NYSTAGMUS 613 
 
 was it necessary for him to go to bed, and did vertigo come on while 
 in bed? Did movements of the head or turning in bed cause vertigo or 
 nystagmus ? Did the vertigo come on first upon arising from bed, or after 
 he returned to work. Has the vertigo increased or diminished? A 
 complete history is quite necessary as these cases are of medicolegal 
 interest. 
 
 Vertigo, and in consequence incapacity for work, is the common 
 complaint of those who receive injuries to the head, whether malingerers 
 or not. Inclining the head backward causes vertigo, slight nausea, and 
 weak rotary nystagmus to the injured side. This nystagmus cannot be 
 immediately reproduced, though the patient experiences a strong vertigo 
 and slight nausea. 
 
 Syringing the injured ear with water of 77° F. produces typical strong 
 nystagmus to the sound side. The same procedure on the sound side 
 gives the same result. Severe vertigo, nausea and vomiting, pallor, free 
 perspiration, and trembling of the whole body form the usual clinical 
 picture. The nystagmus which is accompanied by vertigo is quite the 
 same as the spontaneous type, only stronger. With the head erect the 
 after-nystagmus by turning to the side opposite the injury is quite like 
 the normal. Objects seem to turn around the patient. There is no 
 nausea, and, therefore, it is unlike the spontaneous type. About three 
 turnings with the head inclined 90 degrees forward produces rotary 
 nystagmus with vertigo and nausea, which the patient identifies as 
 being similar to the spontaneous attacks. If the patient, with or without 
 suggestion from the examiner, identifies the horizontal primary or after- 
 nystagmus with the spontaneous attacks, he is malingering and his story 
 is untrue. Those who have the real trouble make no mistakes. 
 
 Nystagmus from Intoxication. — Smokers, drinkers, and those who 
 suffer from auto-intoxication have spontaneous attacks of vertigo and 
 nystagmus, which may or may not be accompanied by vomiting. In 
 much the greater number of such patients the membrana tympani is 
 intact, the vestibular apparatus responds to all tests, and perception of 
 sound is normal. The nystagmus is vestibular in character, arising 
 from toxic influences acting upon the centres in the fourth ventricle. 
 Slight attacks of vertigo are also found in those who consider themselves, 
 and who, upon examination, seem to be perfectly healthy. They have 
 such attacks upon arising in the morning and when stooping quickly. 
 Temporary congestion of the head probably causes them. 
 
 Nystagmus in Neurasthenics. — Spontaneous attacks of vertigo of 
 cerebral origin occur specifically in neurasthenics. The vertigo comes 
 on when the vision is fixed on an object for some time, and causes dis- 
 turbances of equilibrium. The movements of the eye are not of the 
 vestibular type, though they are constant. They may fall, but in no 
 definite direction. Apparent movement of surrounding objects is noticed 
 by them. They also have attacks of vertigo of the true vestibular char- 
 acter when bending forward, arising in the morning, or upon movement 
 of the head. The vertigo produced by turning ten times is stronger 
 than the spontaneous attacks. They become pale, tremble, perspire, and 
 
614 THE EAR 
 
 lose consciousness completely or partly. Any or all of these symptoms 
 may be present. One or two turnings with the head inclined 90 degrees 
 forward produces vertigo and rotary nystagmus, which they identify with 
 their spontaneous attacks. They occur without disease of the ear, and 
 stamp the neurasthenic, as do also the following symptoms in disease of 
 the ear: 
 
 In neurasthenics with circumscribed labyrinthitis rapid movements 
 of the head produce a stronger vertigo than in neurasthenia alone. In 
 about 50 per cent, of these cases such attacks can be produced upon the 
 first examination by quickly inclining the head backward while the 
 patient is in a sitting posture. Vertigo and rotary nystagmus to the dis- 
 eased side occur, and cannot be reproduced by the same manipulation 
 for ten or fifteen minutes. It is probable that the rapid movement of the 
 head causes an expenditure of energy the regeneration of which requires 
 this time (Barany). Vestibular disease tends to shorten the duration 
 of horizontal after-nystagmus; neurasthenia tends to prolong it. In 
 neurasthenics who have vestibular disease, the duration of the after- 
 nystagmus is normal, because the two tendencies counteract each 
 other. 
 
 Acute Destruction of the Labyrinth of One Side. — The symptoms 
 of destruction of the labyrinth are always the same whatever the 
 cause may be. These are, immediately after the destruction, strong 
 rotary and horizontal nystagmus, the quick component of which is 
 directed to the sound side. Severe vertigo, nausea and vomiting, apparent 
 movement of surrounding objects, sensation of turning of the body, and 
 inability to walk are often complained of. The patient must lie down, 
 and quickly finds lying on the sound side to be more comfortable, because 
 in looking at surrounding objects the eyes are directed away from the 
 nystagmus, that is, toward the destroyed labyrinth. It will be remem- 
 bered that one of the characteristics of vestibular nystagmus is that it is 
 diminished by looking toward the slow component and increased by 
 looking toward the quick component. From the position assumed the 
 eyes are directed toward the slow component, and all annoying symptoms 
 are quickly relieved. The position voluntarily assumed while in bed is 
 quite suggestive. 
 
 The caloric and pressure tests are negative. After two or three days 
 the symptoms begin to disappear, the nausea and vomiting being the 
 first to subside in persons of a stable nervous system. On the third day 
 there is no vertigo while the patient keeps quiet, though the nystagmus 
 persists. With the quick movements of the head the nystagmus in- 
 creases and the vertigo again comes on. When the complete operation 
 on the labyrinth is done, the nystagmus and accompanying symptoms 
 subside much more quickly, and this suggests that the stimulation of 
 Defers' nucleus through the trunk of the vestibular nerve is so great 
 that coordination is delayed. As these conditions are the same whether 
 the destruction is traumatic or toxic, the impression is conveyed through 
 the nerve trunk. The crista ampullaris, being destroyed, cannot take the 
 position of greatest physiological activity as it does in circumscribed 
 
NYSTAGMUS 615 
 
 labyrinthitis and the nystagmus is, therefore, directed to the sound side. 
 The removal of the restraint upon the other side allows the sound side 
 to functionate violently, causing the compound nystagmus and accom- 
 panying symptoms to be severe. It must be remembered that a hori- 
 zontal nystagmus frequently appears toward the diseased side when the 
 nystagmus to the sound side is diminished. Barany does not attempt 
 to explain this phenomenon, as to do so would be pure speculation. 
 
 In two or three weeks after destruction of the labyrinth all symptoms 
 disappear except a little nystagmus to the sound side, and occasionally 
 slight horizontal nystagmus to the diseased side. These are symptoms 
 of latent labyrinthitis. In the period of latency the sound side loses 
 some of its responsiveness to both the caloric and the turning tests, 
 probably on account of the changes which take place in the centres in the 
 readjustment of the equilibrium. 
 
 Nystagmus in Latent Destruction of the Labyrinth of One Side. — 
 Weak rotary nystagmus exists to both sides when the eyes are in 
 the extreme lateral position, though it is somewhat stronger to the 
 sound side. There is no nystagmus when the patient looks straight 
 ahead, unless opaque spectacles are used, in which case very slight 
 nystagmus occurs to the sound side. The caloric test of the diseased 
 side is negative. Cold water in the sound ear usually produces a strong 
 rotary nystagmus to the opposite side. In some cases this reaction is 
 weaker than normal. Evidently the readjustment both in the centres 
 and the vestibular end organ differs in individuals. It is probable that 
 the sound end-organ takes up the function previously performed by 
 both, and in one case transmits a strong impression and in another a 
 weak impression to Deiters' nucleus. 
 
 The galvanic tests for both the anode (positive pole) and the kathode 
 (negative pole) are negative or nearly so. Aspiration and compression 
 tests are negative. Ten turnings to the diseased side, with the head erect, 
 produce horizontal after-nystagmus to the sound side of about thirty 
 seconds duration when the opaque spectacles are used. Ten turnings 
 to the sound side with the head erect, produces horizontal after-nystag- 
 mus, when opaque spectacles are worn, of fifteen seconds' duration. 
 The same turning to diseased side with the head inclined 90 degrees for- 
 ward produces rotary after-nystagmus to the sound side of twenty seconds' 
 duration if the spectacles are worn. Ten turnings to the sound side 
 with head inclined forward 90 degrees produces rotary after-nystagmus, if 
 the spectacles are worn, of ten seconds' duration. These turning reac- 
 tions are typical of latent uncomplicated labyrinth destruction of one side, 
 and may be used clinically and relied upon when the caloric test is made 
 uncertain by atresia or stricture of the external auditory canal, the 
 presence of a cholesteatomatous mass, or acute suppurative otitis media. 
 If the duration of the after-nystagmus to the sound side is below the 
 averages given above, that to the destroyed side will not be more than 
 half as long. If the duration to the sound side is greater than the average, 
 the same relation will persist. 
 
 Nystagmus by turning in both pathological and normal cases should 
 
616 THE EAR 
 
 be frequently made by the surgeon if he means to become thoroughly 
 acquainted with this valuable aid to diagnosis. 
 
 Nystagmus in Meningitis. Differential Diagnosis. — In the early 
 stage the differential diagnosis between meningitis and cerebellar abscess 
 is very difficult. The condition of temperature marks the greatest 
 difference. The nystagmus in both cases is the same. In meningitis 
 the temperature is, as a rule, high, though abscess may also begin with 
 this symptom. All the pressure symptoms in the posterior fossa may 
 accompany circumscribed meningitis in this situation. Hemiataxia has 
 however, never been observed in Politzer's clinic. Nystagmus of the 
 same vestibular character, as in cerebellar abscess, is produced by in- 
 volvement of the vestibular nerve in the internal auditory canal. Sudden 
 diminution of sound perception in the ear is more indicative of meningitis. 
 Severe stiff neck and hyperesthesia of the skin are symptoms more fre- 
 quently encountered in meningitis than in cerebellar abscess. If the 
 meningitis extends to the convexity, general convulsions, sunken abdomen, 
 small, quick pulse, Cheyne-Stokes respiration, and total unconsciousness 
 occur, and these make the diagnosis simple and, it may be added, opera- 
 tive interference less effective. In meningitis serosa there are also symp- 
 toms. The changes of temperature are slight. Sinus thrombosis, espe- 
 cially of the cavernous and transverse sinuses, and middle ear suppura- 
 tion complicated by mastoiditis (or when simple) may cause meningitis. 
 In these cases the symptoms are nystagmus, vertigo, vomiting, headache, 
 and facial paralysis. 
 
 Optic neuritis, choked disk, unconsciousness, and convulsions form 
 a symptom complex which never characterizes an uncomplicated otitis 
 media. Such symptoms may be present in very young children. In these 
 cases a simple paracentesis, or an operation for acute mastoiditis, may 
 often cause the symptoms to disappear. With hysteria we often find 
 otitis media with hemianesthesia, hemiparesis, vertigo, nausea and 
 disturbances of vision, though in hysteria the hemiparesis and anesthesia 
 are on the diseased instead of the opposite side. 
 
 Nystagmus of Intracranial Origin.— Intracranial nystagmus is of 
 the vestibular type, with the difference that instead of becoming con- 
 tinually weaker and ceasing altogether in from twenty (rotary) to forty 
 (horizontal) seconds, on the average (physiological vestibular nystagmus), 
 or in from a few minutes to three days (pathological vestibular nystag- 
 mus), it grows constantly stronger without the tendency to cease. The 
 early differential diagnosis between vestibular and intracranial nystagmus 
 depends largely upon the responsiveness of the vestibular apparatus 
 to the caloric and turning tests. In cases in which the vestibular irrita- 
 bility is lost a positive diagnosis can be made from the character of the 
 spontaneous nystagmus (Barany, Neumann). When a labyrinth is non- 
 responsive and a strong rotary nystagmus to the same side is present, 
 the nystagmus must arise from some intracranial disease. When the 
 vestibular end-organ is completely destroyed it cannot produce nystagmus. 
 The nystagmus which occurs to the diseased side cannot emanate from 
 the sound side, because by the loss of coordination it would overbalance 
 
NYSTAGMUS 617 
 
 and produce a nystagmus to the side opposite to the destroyed labyrinth. 
 The presence, however, of a stronger irritation through the course of the 
 vestibular nerve, or from Deiters' nucleus of the diseased side, will pro- 
 duce nystagmus to the diseased side. The accompanying vertigo is very 
 marked. These cases are always of intracranial origin. If a labyrinth 
 is destroyed, and there is a strong rotary nystagmus with the quick com- 
 ponent directed to the opposite side, it is natural to suppose that it is 
 caused by the sound vestibular apparatus. This is, however, not neces- 
 sarily true. If the nystagmus increases instead of diminishing in intensity, 
 as in labyrinth destruction, then it is of intracranial origin, probably due 
 to a cerebellar abscess irritating the opposite half of Deiters' nucleus. 
 
 When the tympanic membrane is intact, and deafness with nystagmus 
 of the intracranial type, tumor along the course of the vestibular nerve 
 is most probable. 
 
 In labyrinth suppuration, in which the vestibular apparatus of the 
 affected side does not respond to the physiological tests, and in which 
 the nystagmus is toward the diseased side, circumscribed meningitis 
 of the posterior fossa may be present. This nystagmus is of the same 
 character as that emanating from the vestibular apparatus, or that caused 
 by cerebellar abscess. The differential diagnosis is made chiefly from 
 the peculiarities of the pulse and temperature. 
 
 Neumann says that in cerebellar abscess the nystagmus is always of 
 the rhythmic character, so thoroughly described by Barany. The differ- 
 entiation between the vestibular nystagmus of cerebellar origin and 
 that from the semicircular canals is made, on the one hand, through the 
 exact examination of function of the vestibular apparatus, and on the 
 other, the course of the disease. The nystagmus induced by circum- 
 scribed labyrinthitis is directed to the diseased side. Should the disease 
 progress to the destruction of the irritability of the vestibular apparatus 
 the direction of the nystagmus changes. It moves toward the sound side, 
 and remains there until the entire labyrinth is destroyed. It then grad- 
 ually diminishes in intensity, and in a short time ceases. If the labyrin- 
 thine operation (Neumann) is performed (the whole labyrinth is re- 
 moved) while the nystagmus is directed to the sound side, it remains 
 unchanged for the first day, and then decreases noticeably for two or 
 three days, and in a short time ceases altogether. During the time the 
 nystagmus is directed to the diseased side, the response to irritation is 
 the same as in a normal ear. By irrigating with cold and warm water 
 the typical nystagmus as described by Barany appears. When the 
 direction of the nystagmus changes to the sound side, the irritability 
 of the labyrinth is usually lost, but if the labyrinth responds to irrigation , 
 the nystagmus is very weak or of short duration. As the disease pro- 
 gresses, the irritability of the labyrinth fails completely, and the nystag- 
 mus remains directed to the sound side. The nystagmus of cerebellar 
 origin is, however, directed to both the diseased and the sound sides, 
 though that directed to the diseased side overbalances the other. In the 
 cases of otitic cerebellar abscess examined by Neumann in the last year, 
 in which an exact examination of nystagmus was made, the cerebellar 
 
618 THE EAR 
 
 abscess was always a complication of labyrinthine suppuration. In 
 these cases the differentiation of cerebellar from labyrinthine nystagmus 
 was as follows: 
 
 1. When the nystagmus is directed toward the diseased side, either 
 a circumscribed labyrinthitis or a cerebellar abscess may be present. 
 In circumscribed labyrinthine disease, irritability from irrigation is 
 normal; but, at the same time, the symptoms of a labyrinthine fistula 
 exist, that is, compression and aspiration of air or pressure on the wall 
 of the labyrinth causes nystagmatic eye movements. When irritability 
 for irrigation is lost, direct pressure with a probe or galvanization will 
 produce nystagmus. 
 
 Under these circumstances the diagnosis of cerebellar abscess cannot 
 be made before the labyrinthine operation is performed. These indica- 
 tions worked out by Neumann in his clinic should in such cases justify 
 adding the labyrinthine operation to the radical mastoid operation. 
 After the operation on the labyrinth, the nystagmus, when induced 
 from the labyrinth, must change its direction to the sound side. Neu- 
 mann has not observed a single case of cerebellar abscess associated 
 with circumscribed labyrinthine suppuration. If after the labyrinthine 
 operation rotary nystagmus remains directed to the diseased side, the 
 diagnosis of cerebellar abscess or some other disease in the posterior 
 fossa of the same side is immediately made, because a destroyed labyrinth 
 never causes nystagmus to the same side. Barany and Neumann are of 
 the opinion that the nystagmus toward the sound side emanates from the 
 sound side. If, in spite of the operative destruction of the labyrinth, 
 the nystagmus remains directed to the diseased side, it must be intra- 
 cranial, through irritation of Deiters' nucleus or the vestibular nerve at 
 the base of the brain. 
 
 2. If the labyrinth does not respond to irritation, and the spontaneous 
 rotary nystagmus is toward the affected side, and when the pulse and 
 temperature are characteristic, a diagnosis of cerebellar abscess may be 
 made. 
 
 3. If spontaneous nystagmus toward the sound side is present (the 
 opposite side being diseased) and the corresponding labyrinth is not 
 irritable, it may be of either labyrinthine or cerebellar origin. In such a 
 case it is impossible to differentiate before the labyrinthine operation. 
 If the nystagmus disappears in two or three days after the operation, 
 it is of vestibular origin. If, however, it does not cease after the opera- 
 tion, but increases in intensity and changes its direction to the diseased 
 side, it is of intracranial origin. 
 
CHAPTER XXXIV. 
 
 THE GENERAL ETIOLOGY OF DEFECTIVE HEARING. 
 
 Defects of hearing may arise from any condition that affects the func- 
 tional integrity of the conduction or the perception apparatus of the 
 organ of hearing. It may be stated as a general law that the deeper 
 (nearer the acoustic centre) the lesion, the more profound is the dis- 
 turbance of hearing. 
 
 A. Defects of Hearing Due to Lesions of the Auricle. — This 
 division of the subject may be passed by without analysis, as there is but 
 slight impairment of hearing, even from the total loss of the auricle. 
 
 B. Defects of Hearing Due to Affections of the External 
 Meatus. — (a) Inspissated cerumen, (b) Furunculosis. (c) Derma- 
 titis, (d) Eczema, (e) Foreign bodies, animate and inanimate. (/) 
 Exostosis of the meatus, (g) Collapse of the cartilaginous meatus. 
 (h) Congenital atresia of the meatus, (i) Congenital absence of the 
 meatus, (y) Cholesteatoma. 
 
 A glance at the foregoing analysis makes it apparent that hearing is 
 diminished on account of the obstruction to the transmission of sound 
 waves through the external auditory meatus and by the congenital 
 absence of this canal. Congenital absence of the external auditory 
 meatus is nearly always attended with absence of the middle and the 
 internal ears, hence the deafness may be attributed more to the latter 
 than to the former. 
 
 Cholesteatoma within the meatus is usually coincident with the same 
 process in the middle ear and the pneumatic cells of the mastoid, hence 
 the defect of hearing is largely due to the condition of the middle ear 
 and the mastoid spaces. 
 
 With these exceptions the obstructions in the meatus account for 
 deafness. It should be said, however, that inspissated cerumen in the 
 meatus is often a sign of middle ear catarrh, and the deafness may be 
 partially due to this condition. 
 
 Collapse of the cartilaginous meatus is usually found only in the 
 aged. The deafness in such cases may be due in part to senile changes 
 in the middle ear and labyrinth. 
 
 C. Defects of Hearing Due to Affections of the Drumhead.— (a) 
 Perforation, (b) Thickening, (c) Calcareous deposits, (d) Cicatricial 
 tissue, (e) Cicatricial bands extending to the ossicles and the wall of 
 the middle ear. (/) Retraction, (g) Bulging or pouching, (h) Inflam- 
 mation (myringitis). ({) Herpes, (y) Traumatic rupture, (k) Frac- 
 ture of the handle of the malleus. (/) Atrophy (lack of normal tension). 
 
 It may be stated as a general acoustic law that anything which dis- 
 
620 THE EAR 
 
 turbs the normal tension existing between the drumhead, the ossicles, 
 and the labyrinthine fluid will result in an impairment of hearing. It 
 should be noted that in nearly all of the foregoing conditions the normal 
 tension is disturbed, hence the deafness. 
 
 In a number of lesions of the drumhead there are, of necessity, patho- 
 logical changes in the middle ear which in part account for the deafness. 
 For example, perforation of the drumhead is nearly always attended 
 with either chronic suppuration or cholesteatoma of the middle ear, and 
 possibly of the attic, the antrum, and the mastoid cells. In thickening, 
 scars, cicatricial bands, calcareous deposits, retraction, and atrophy, 
 middle ear disease, usually of a chronic inflammatory nature, is present, 
 and in a large measure accounts for the defective hearing. 
 
 In simple myringitis, herpes, traumatic rupture, and fracture of the 
 handle of the malleus, the middle ear may not be involved and the deaf- 
 ness is transitory. 
 
 D. Defects of Hearing Due to Affections of the Middle Ear. — (a) 
 Simple catarrhal otitis media, (b) Catarrh with adhesions, (c) Sclerosis 
 of the mucous membrane, (d) Cholesteatoma, (e) Acute suppuration. 
 (/) Chronic suppuration, (g) Ankylosis of the ossicles, (h) Ankylosis 
 of the foot plate of the stapes to the oval window (fenestra of the vesti- 
 bule), (i) Adhesive bands uniting the ossicles to each other, to the 
 walls of the tympanum, and to the drumhead, (j) Atrophic otitis media. 
 (k) Anemia of the mucosa occurring with general anemia and debility. 
 (/) Loss of tonicity of the stapedius and the tensor tympani muscles. 
 (m) Congenital defect or absence of the middle ear. (??) Granulations 
 in the middle ear. (o) Serous and mucous accumulations, (p) Caries 
 of the ossicles, (q) Caries of the walls of the tympanum, (r) Polypus. 
 (s) Rarefying osteitis or spongifying of the bony capsule around the 
 oval window. 
 
 In the foregoing conditions we find the more common causes of deaf- 
 ness. The acoustic law given in the preceding section (C), namely, that 
 the condition which disturbs the normal tension between the drumhead, 
 the ossicles, and the labyrinthine fluid will cause deafness, applies with 
 special force to the affections mentioned in this section. All or nearly all 
 the pathological lesions named materially interfere with this tension, and 
 thereby interfere with the transmission of the sound waves to the laby- 
 rinth. A study of these lesions will verify the general law enunciated at 
 the beginning of this chapter, that as a general thing the deeper the lesion 
 the more profound the deafness. For instance, a lesion affecting only 
 the drumhead does not produce as profound deafness as does ankylosis 
 of the foot plate of the stapes. 
 
 Sclerosis of the mucosa of the middle ear is often complicated with the 
 same process in the bone beneath it. Chronic suppuration of the middle 
 ear is also often attended with sclerosis (eburnation) of the bone. 
 
 This process may extend to the mastoid or to the bony capsule of the 
 labyrinth, and thus augment the deafness. 
 
 The author has often seen cases in which the deafness was improved 
 only after the administration of iron and arsenic. These patients were 
 
THE GENERAL ETIOLOGY OF DEFECTIVE HEARING 621 
 
 anemic and suffered from general debility of a chronic type. Whether the 
 improvement was due to an increased tone of the stapedius and the 
 tensor tympani muscles, or to an increased tone and vital energy of the 
 whole organ of hearing, would be difficult to determine. T. M. Rumbold 
 believed that the trouble was in the muscles. This may be true, as there 
 may be a lack of muscular tonicity here as well as elsewhere in the body. 
 It may be said with equal certainty that all the tissues of the body, in- 
 cluding those of all parts of the auditory apparatus, are lowered in tone 
 and vital energy. We therefore think that the deafness due to or existing 
 with general anemia, accompanied by seeming loss of muscular tone of 
 the tension muscles of the middle ear, is probably due to a lowered 
 vitality of all the parts concerned in audition. 
 
 Granulations and polypi in the middle ear not only interfere with the 
 transmission of sound waves through the middle ear, but they often 
 also obstruct the external meatus. They usually signify necrosis of the 
 bony walls of the tympanum and an involvement of either the cranial 
 cavity, the mastoid cells, the sigmoid sinus, the jugular vein, or the 
 labyrinth. 
 
 Ankylosis of the foot plate of the stapes is a serious condition, inas- 
 much as it is usually impossible to permanently overcome it. The deaf- 
 ness and the tinnitus are great and exert a depressing influence upon the 
 patient. Great care should be exercised by the otologist in giving the 
 prognosis in this class of cases. He should not hold out false hope of 
 ultimate recovery, but he should so couch his language that the patient 
 will not entirely abandon hope. It is the physician's office to cheer as 
 well as to treat his patients. This is doubly true in hopeless cases, as 
 they are often despondent to the point of suicidal mania. Fixed atten- 
 tion arouses the benumbed organs, and even though a course of office 
 treatment is not advisable, the patient should be told to observe under 
 what conditions he hears most clearly and to seek to adapt himself 
 to his environment. Expectant attention is thus aroused, and the use- 
 fulness of the auditory apparatus is maintained at as high efficiency as 
 is possible. In addition to the above, rest is beneficial and the organic 
 salts of iron should be administered. 
 
 E. Defects o£ Hearing Due to Affections of the Eustachian Tube. 
 — (a) Catarrh, (b) Fibrous thickening of the mucosa, (c) Fibrous 
 bands across the lumen of the tube, (d) Fibrous rings or stricture of 
 the tube, (e) Lymphoid hypertrophy within the tube. (/) Hypertrophy 
 of the mucosa, (g) General sclerosis of the mucosa, (h) Paralysis of 
 the palatine muscles which regulate the patency of the mouth of the tube. 
 
 The chief function of the Eustachian tube being to maintain the 
 equilibrium of air pressure between the air in the middle ear and that 
 external to it, an obstruction to the normal passage of air destroys the 
 equilibrium. The normal tension of the drumhead, the ossicles, and 
 the labyrinthine fluid is disturbed, and deafness and tinnitus result. 
 
 It is not usually recognized that lymphoid hypertrophy plays a prom- 
 inent part in Eustachian obstruction. This must be true, however, 
 as there is a considerable quantity of such tissue in the mucosa of the 
 
622 THE EAR 
 
 tube, especially near its pharyngeal end. The same pathological processes 
 which cause hypertrophy of the pharyngeal and the faucial tonsils will 
 also cause hypertrophy of the tubal lymphoid tissue. We may, then, 
 speak of a tubal or " Eustachian tonsil" as a cause of Eustachian obstruc- 
 tion. 
 
 In long-continued catarrhal or suppurative inflammation of the middle 
 ear, fibrous thickening or fibrous bands may form in the Eustachian 
 tube and give rise to persistent deafness and tinnitus unless relieved by 
 suitable treatment. If air is not admitted to the middle ear in sufficient 
 quantity, the drumhead becomes retracted on account of rarefaction 
 of the air within the middle ear, the handle of the malleus is drawn 
 inward and rotated on its axis, and the chain of ossicles is forced inward 
 and compresses the labyrinthine fluids. Perhaps a more correct state- 
 ment would be to say that the normal tension between the drumhead and 
 the labyrinth is lost, and deafness and tinnitus result. 
 
 Tubal catarrh (salpingitis) is much more common than is generally 
 supposed, and no doubt many of the so-called cases of middle ear catarrh 
 are in reality of this type. 
 
 Since the normal patency of the tubes is controlled by the palatine 
 muscles, any condition which affects their innervation or motility will 
 cause defective hearing. These conditions will be considered in the 
 next section. 
 
 F. Defects of Hearing Due to Affections of the Epipharynx and 
 the Fauces. — (a) Adenoids, (b) Epipharyngeal catarrh, (c) Polypi 
 or other neoplasms, (d) Disease of the faucial tonsils, (e) Adhesions 
 of the anterior and the posterior pillars of the fauces to the tonsils. (/) 
 Suppurative inflammation of the epipharynx. (g) Paralysis of the 
 palatine muscles (e. g., postdiphtheritic), (h) Infections occurring 
 during the course of exanthematous fevers. 
 
 In this category are conditions which are sources of diseases of the ear 
 which are attended with impairment of hearing. All inflammatory con- 
 ditions which involve the mucosa about the pharyngeal orifices of the 
 tubes sooner or later extend within their lumens and cause more or less 
 obstruction. If the inflammation is of a suppurative type, the germs enter 
 the tube and the middle ear, and may cause an acute suppurative otitis 
 media. This may become chronic, and permanent damage to the entire 
 middle ear apparatus result. 
 
 Postnasal adenoids are recognized as frequent antecedents of tubal 
 and middle ear catarrh and deafness. 
 
 There has been much discussion as to whether adenoids extended over 
 the mouths of the Eustachian tubes. The free extremities of the lateral 
 adenoid masses do, no doubt, often occlude them. Perhaps a more 
 important pathological factor is that postnasal adenoids are usually 
 attended with severe postnasal catarrh, which in many cases becomes 
 purulent in character. This often causes obstruction of the tubes and 
 thus gives rise to disturbances of hearing as well as to structural changes 
 in the middle ear and its appendages. 
 
 The etiological relationship existing between hypertrophy of the faucial 
 
THE GENERAL ETIOLOGY OF DEFECTIVE HEARING 623 
 
 tonsils and disease of the Eustachian tube and the middle ear has long 
 been recognized, although not as fully as it should be. Their relationship 
 cannot be considered apart from that of the postnasal space, however, 
 as the same conditions which affect one affect the other also. Thus the 
 presence of enlarged faucial tonsils is usually attended with adenoids. 
 Both being lymphoid tissue, they respond to the same irritation and enlarge 
 simultaneously. Notwithstanding this fact, there are some conditions 
 of the faucial tonsils which cause tubal obstruction independently of 
 any effects due to the adenoids (C. R. Holmes). 
 
 The presence of diseased or enlarged tonsils produces chronic hypere- 
 mia of the mucosa of the epipharynx, and oftentimes a chronic catarrhal 
 or suppurative inflammation is present. Enlarged and diseased tonsils 
 do not always stand out beyond the pillars of the fauces. A normal 
 tonsil can neither be seen nor felt. Many of the pathological tonsils are 
 flat and lie hidden behind the anterior pillar. Pynchon has called them 
 "submerged tonsils." He has also suggested that if they are examined 
 "on the gag," they will bulge forward and inward and come into full 
 view. When thus examined they appear broad and flat with an irregular 
 surface. In some cases the lacunae are filled with debris, epithelium, 
 bacteria, and pus, while in others no such accumulations are to be seen. 
 This does not prove that they are not present in the pockets or lacuna?, 
 as upon introducing a tonsil hook into them, yellowish, round masses 
 may be removed. In others the masses are encysted, probably from 
 inflammatory closure of the mouths of the crypts. The point I wish to 
 make is that even though the tonsils do not project beyond the pillars 
 and are not apparently much diseased, they may be the seat of foci of 
 infection, irritation, and septic material, which gives rise to chronic 
 catarrh of the epipharynx and the Eustachian tubes. The material 
 in the lacuna? affords a good medium for the growth of bacteria, the 
 toxins of which enter the lymphatic and the blood-vascular systems 
 and cause disturbances in remote parts of the body. 
 
 G. Defects of Hearing Due to Mastoid Affections. — As these 
 conditions are secondary to and associated with pathological changes 
 within the middle ear, they will not be discussed here. 
 
 H. Defects of Hearing Due to Labyrinthine Affections. — (a) 
 Increased tension of the labyrinthine fluid from great retraction of the 
 drumhead. (6) Inflammation of the labyrinth, (c) Congenital defects. 
 (d) Hemorrhage, (e) Drugs. (/) Necrosis, (g) Tuberculous or syph- 
 ilitic disease, (h) Hyperostosis or spongifying of the bony capsule of 
 the labyrinth, (i) Certain neuroses cause more or less deafness or other 
 disturbances of hearing. 
 
 Increased tension of the labyrinthine fluid produces deafness. The 
 increased tension is usually due to extreme retraction of the drumhead, 
 whereby the foot plate of the stapes is forcibly driven inward against 
 the fluid within the bony labyrinth. If there are no firm adhesions 
 binding the drumhead and the ossicles in this position, it may be readily 
 overcome by inflating the middle ear. This at once relieves the deafness 
 and the tinnitus. 
 
624 THE EAR 
 
 Congenital defect of the labyrinth is quite commonly found in deaf- 
 mutes. It has been learned from careful functional examinations that 
 while they are deaf to most tones, they will hear other tones very well. 
 (See Deaf-mutism.) 
 
 Meniere's disease is thought to be due to an apoplectiform hemorrhage 
 in the labyrinth. Few post mortems have been made to corroborate this 
 belief. The clinical history of the cases, however, is in accordance with 
 this idea. 
 
 Syphilitic and tuberculous inflammations of the labyrinth are destruc- 
 tive, not alone to the hearing, but to the tissues as well. 
 
 The excessive administration of quinine is sometimes attended with 
 pronounced deafness which may continue for several months, or even 
 permanently. It is probably due to an anemia or a congestion of the 
 labyrinthine membrane and the auditory nerve endings. 
 
 Rarefying osteitis of the bony capsule of the labyrinth causes pro- 
 nounced deafness, which is usually gradually progressive. It is commonly 
 found in early adult life and does not yield to treatment. (See Hyper- 
 ostosis of the Bony Capsule of the Labyrinth.) 
 
CHAPTER XXXV. 
 
 FOREIGN BODIES IN THE EAR. CERUMINOUS PLUGS IN 
 THE MEATUS. 
 
 Children often introduce foreign bodies into the ear for very different 
 reasons from those which may be ascribed to adults. For example, 
 children in their play and in the spirit of imitation will do what they 
 conceive is being done by others. Their elders, in order to excite wonder- 
 ment and admiration, will do sleight-of-hand performances, pretending 
 to remove a knife or other object from the nose, mouth, or ears. Children 
 are thus led to introduce various objects into their ears. Peas, beans, 
 beads, gravel, buttons, bits of sealing wax, chewing gum, cherry pits, 
 etc., are commonly found in the ears of children. Burnet relates a 
 case of a woman from whom a bead was removed that had been intro- 
 duced sixty years previously. Children are fond of the sensation of a 
 smooth body, as a bead or bean, rubbed over the skin, and in this way 
 they sometimes accidentally introduce them into the external meatus. 
 
 These may remain in place for a long time without causing any serious 
 svmptoms, and be overlooked bv their parents and unnoticed by the 
 child. 
 
 In adults the introduction of foreign bodies into the external meatus 
 is more apt to be accidental, or the result of some treatment, as the 
 introduction of a bit of cotton which is allowed to remain long after 
 it has served its original purpose. Bits of pencil, toothpicks, twigs, and 
 straw may be introduced into the meatus during efforts to remove cerumen 
 or moisture, and remain in the meatus until symptoms arise which 
 cause them to seek relief from their physicians. 
 
 Animate objects, such as roaches, fleas, flies, rosebugs, bedbugs, 
 ixodix honimos, house-fly maggots, Texas screw-worms, and other living 
 parasites are the source of great agony and discomfort when they enter 
 the external meatus, on account of the clawing and twisting motion 
 incident to their efforts to get food or gain egress from the cavity. The 
 mode and place of sleeping influences the introduction of such objects 
 into the meatus, as sleeping outdoors in a hammock or upon the ground, 
 thereby inviting living insects to make their abode in this cavity. 
 
 J. F. Church narrates a case in which a sheeptick had been in a stock- 
 man's ear for two years. It was embedded beneath a mass of ceru- 
 men and blood, and was still living when removed. The sensation was 
 that of an intolerable scratching, accompanied by excruciating pain and 
 deafness, which would suddenly pass away. There would be intervals 
 of a month or more in which there would be no pain or discomfort in 
 the ear. At times blood clots admixed with cerumen were removed. 
 40 
 
626 THE EAR 
 
 When he came under the observation of Dr. Church the pain was, and 
 had been, severe for about four days, and extended to the mastoid region. 
 There was a feeling of numbness over the corresponding side of the 
 face. The meatus was filled with cerumen and epithelium, which was 
 removed with a spud and a syringe. This being done, the deeper portion 
 of the meatus was exposed to view, and a moving body was seen. It 
 presented the appearance of a perforation in the drumhead, with slender 
 maggots protruding through it. 
 
 The Texas screw-worm fly, or Compsomyia Lucilla macellaria, has 
 been thought to be of Mexican or South American origin, although Dr. 
 Williston, of Yale College, writes that "It grows especially from Canada 
 to Patagonia." Its chief habitat in the United States, however, has been 
 in Texas, hence its name. 
 
 Its ravages among cattle are common, and often occasion heavy finan- 
 cial loss by the destruction of its victims. It more rarely invades the 
 human family, but has been known to cause death in a number of 
 instances. Its favorite point of attack in man is the ear or the nose. 
 This is easily understood when it is known that the insect is attracted 
 by foul-smelling odors. Those, therefore, affected with ozena or chronic 
 otorrhcea are especially likely to be invaded. The worm in the act of 
 invading the tissues performs a sawing motion, and can penetrate bone. 
 Mackenzie reports cases in which the cranial cavity was penetrated by 
 them, and death from meningitis resulted. 
 
 FOREIGN BODIES IN THE EAR. 
 
 Treatment. — It is important that caution be given as to the great 
 harm that may be done by unwarranted, unskilful, or untimely efforts 
 to remove foreign bodies from the external meatus. It should be remem- 
 bered that foreign bodies, especially inanimate ones, can do little or 
 no harm so long as they are left undisturbed in the meatus. This, of 
 course, is not true for an indefinite period of time, but it is true in the 
 sense that there is no need of haste on the part of the attending surgeon. 
 More harm has been done to patients by the efforts to remove foreign 
 bodies than has ever been produced by the presence of bodies in the 
 meatus. If a foreign body is smooth and causes no pain or discomfort, 
 there is certainly no occasion for its hasty removal; if it is rough, and 
 causes considerable pain and discomfort, there is more excuse for its 
 immediate removal; but even then it may be much wiser to allay first 
 the irritation and swelling, after which it may be removed with compara- 
 tive ease with either the syringe, snare, or forceps. 
 
 I have seen cases in which the meatus was swollen and red from the 
 unskilled attempts of members of the family to remove a foreign body. 
 While thus swollen it was impossible for me to remove it immediately 
 without a general anesthetic. In such instances I have first used anti- 
 phlogistic remedies and soothing applications for a 'few days, after which 
 it was comparatively easy to remove the foreign body without any great 
 difficulty or pain to the patient. If an insect or other live body gains^ 
 
FOREIGN BODIES IN THE EAR 627 
 
 entrance to the meatus, the first step to be taken is to render it lifeless, 
 after which its removal can usually be effected with a syringe. 
 
 Having thrown out this warning against meddlesome or unintelligent 
 attempts to remove inanimate foreign bodies, we will discuss the best 
 methods of procedure for their removal. 
 
 1. First inspect the meatus in order to determine whether or not a 
 foreign body is present, and if present, its probable nature. This is 
 important, as the method of procedure for its removal will depend largely 
 upon the character of the body present. 
 
 2. Notice whether irritation or inflammation of the parts is present, 
 and whether it is probable that the foreign body will do harm by remain- 
 ing a few hours or days longer; and also as to whether it is probable that if 
 immediate steps for its removal are taken, the effort would be rewarded 
 by success. If the parts are swollen and inflamed to such an extent 
 as to make it impracticable to remove it at once, it is better to wait until 
 the swelling and inflammation are reduced by the use of hot, soothing 
 lotions, and the application of leeches to the tragus. After a few hours, 
 or at the most a few days, the swelling and painful condition will have 
 subsided, thereby rendering the removal of the offending object a matter 
 of comparative ease with little discomfort to the patient. 
 
 3. Syringing should first be tried, as the stream of water may be 
 forced into the meatus beyond the foreign body, and thus dislodge it from 
 the external auditory meatus. The position of the head should be con- 
 sidered in this and other methods of procedure, as the force of gravity 
 will oftentimes materially aid in the removal of the object. The head 
 should, therefore, be inclined toward the affected ear. Zaufal found, in 
 109 cases of foreign bodies in the external meatus, that he could remove 
 92 of them with the syringe, thereby demonstrating that nearly 90 per 
 cent, of foreign bodies may be removed by this method. I fear that in 
 the average practitioner's experience 90 per cent, of the removals have 
 been attempted with either forceps or the so-called "ear hook;" whereas 
 the 90 per cent, of successful efforts should have been accomplished 
 with a syringe, while in the other 10 per cent, it may have been proper 
 to resort to the forceps and ear hook. 
 
 4. The agglutination method was recommended by Riverias in 1674, 
 by Celsus in 1806, and was revived by Lowenberg in 1872. It con- 
 sists in placing heavy glue on the end of a piece of tape or a camel's- 
 hair brush, applying this to the foreign body in the external meatus and 
 leaving it in position until the glue becomes firmly enough fixed to bring 
 the foreign body with it when traction is exerted upon it. This is probably 
 one of the best methods, for most of the cases, after syringing has failed. 
 It is to be recommended on account of the absence of instrumentation, 
 whereby the meatus is so often seriously injured. 
 
 A strip of adhesive plaster may be introduced into the meatus, applied 
 to the foreign body and heated by focusing the rays of light upon it 
 with a convex lens. This softens the adhesive material and allows 
 to become fastened to the foreign body, after which it may be removed 
 by traction upon the adhesive strip. 
 
628 THE EAR 
 
 The agglutination method is not used as often as it should be, as most 
 physicians mistakenly think that a pair of forceps or the foreign body 
 hook, usually present in the pocket case purchased upon graduation, 
 are the instruments par excellence for this purpose. 
 
 5. The foreign body hook is, perhaps, less harmful in the hands of 
 an inexperienced operator than the forceps, and is, therefore, to be re- 
 commended as a better instrument for the removal of foreign bodies 
 from the external meatus. It should be so introduced as to allow the short 
 hook to pass inward with its side against the wall of the meatus until it 
 passes beyond the foreign body, when it should be rotated to bring 
 the hook back of the foreign body. Slight traction should then be made 
 upon it, with the view of dislodging the foreign body from its position in 
 the meatus. If it fails to do this, it should be withdrawn and re-intro- 
 duced in another position, thereby to find a point at which the body may 
 be loosened. If the foreign body has passed beyond the isthmus of the 
 meatus and is lodged in the recess formed by the membrana tympani and 
 the floor of the meatus, the hook should be introduced above the foreign 
 body, as there is greater space at this point for the outward movement 
 of the impacted mass. The convexity of the floor of the external meatus 
 forms a favorable fulcrum upon which the lower portion of the foreign 
 body rests, while the upper portion makes the outward excursion. It 
 will be necessary, however, in some cases to introduce the hook either 
 posteriorly or anteriorly in order to slowly dislodge the mass from its 
 fixed position. After this has been done the hook should be introduced 
 above the mass, completely dislodging it from its point of impaction. 
 Its removal through the cartilaginous meatus may then be accomplished 
 with ease and little discomfort to the patient. 
 
 6. Various forceps, designed for the removal of foreign bodies from 
 the ear, have been devised and placed upon the market, none of which 
 serve a very useful purpose. Young practitioners have great satisfaction 
 in the thought that they have a full equipment at their command for the 
 removal of foreign bodies from the ear. Beyond the satisfaction they 
 thus afford, the instruments are of little value. It is with such instru- 
 ments that untold harm and irreparable damage have been done, and 
 not a few lives have been sacrificed to the enthusiasm of their owners. 
 The foreign body has, in many instances, been forced through the 
 drumhead into the middle ear, where the physician has left it, and it 
 was only discovered at a later period during a mastoid operation. 
 
 After a time its presence in the middle ear ^ives rise to necrosis and 
 serious infection, followed by intracranial complications, such as abscess, 
 meningitis, or sinus thrombosis, thrombosis of the jugular vein, laby- 
 rinthine necrosis, or transmission of infective thrombi to the lungs, the 
 spleen, or the kidneys. 
 
 Having thus briefly, but pointedly, suggested the dangers attending 
 the use of foreign-body forceps, it may be said that they have a useful 
 place, limited though it be, in the armamentarium of the physician. 
 
 The cautions given above are not for the purpose of discouraging the 
 practitioner from using the foreign-body forceps, but are intended to lead 
 
FOREIGN BODIES IN THE EAR 629 
 
 him to use them with great circumspection after having tried all other 
 means for the removal of the foreign body. Those devised by Dr. Samuel 
 Sexton are, perhaps, the best upon the market (Fig. 371). They are so 
 constructed that the toothed tips may be introduced at the sides of the 
 body, while the blades remain practically parallel with the walls of the 
 external meatus; this is a point of no small importance when we remem- 
 ber that most forceps for this purpose are so constructed that when the 
 blades are spread apart the tips are at such an angle as to be easily forced 
 into the meatal wall as they are pushed inward beyond the foreign body. 
 Whatever instrument may be used, great care and delicacy of manipu- 
 lation should be exercised, to avoid laceration of the meatus. If the 
 foreign body is removed the laceration will be of small moment, as 
 it can be properly treated and quickly healed; if, however, the efforts 
 to remove the foreign body are unsuccessful, the laceration may become 
 a very serious complication, as the parts cannot, for obvious reasons, 
 be properly treated. Swelling, infection, and inflammation may take 
 
 Fig. 371 
 
 Sexton's foreign-body forceps. 
 
 place, which will still further interfere with the removal of the foreign 
 body. Great discomfort results, and the condition is a serious menace 
 to the well-being of the patient. 
 
 7. Postauricular incision for the removal of foreign bodies is a very 
 ancient method of procedure, as Paul of Aegina suggested its use. 
 Von Troltsch, in his text-book on Surgical Diseases of the Ear, sug- 
 gested that in infants the incision is most effective when made above 
 the auricle in the squamous region, as this area is depressed at that 
 age, thus admitting of easy access to the meatus without injuring the 
 postauricular artery. He thinks the injury to the artery should not be 
 done needlessly, as it is an important source of nutrition to the auricle. 
 With our improved methods of surgery and asepsis, we do not now 
 fear an injury to this artery, and would not, therefore, make the incision 
 above the auricle with this object in view. The incision in this posi- 
 tion is, however, undoubtedly best adapted for the removal of foreign 
 bodies which cannot otherwise be removed from the meatus of an infant 
 on account of the oblique angle it forms with the squamous plate. 
 The roof of the osseous meatus is gradually formed by the development 
 
630 THE EAR 
 
 of the squamous bone, and extends inward at an obtuse angle, thus 
 affording a favorable field for the introduction of instruments for the 
 removal of foreign bodies. In adults, von Troltsch suggests that the 
 incision should be made posterior to the meatus, as its roof is now at right 
 angles to the squamous plate. 
 
 With the antiseptic and aseptic methods now in vogue there should be 
 little hesitancy in making a free incision in much the same manner as 
 described for mastoid operations. The wound may be closed at once, 
 union by first intention taking place. The skin of the cartilaginous 
 meatus should be elevated as in the mastoid operation and lifted from 
 its position. The foreign body is thus fully exposed to view, the meatus 
 is shortened and enlarged, and instrumentation for its removal becomes 
 comparatively easy. The patient should be under the influence of 
 a general anesthetic. A portion of the osseous meatus should be 
 chiselled away, if necessary, in order to facilitate the removal of the 
 foreign body. 
 
 Urbantschitsch reports a case of an oat husk which entered the 
 Eustachian tube while the patient was chewing an ear of grain. It 
 passed through the tube into the middle ear, and thence into the external 
 meatus. 
 
 ANIMATED FOREIGN BODIES IN THE EAR. 
 
 Treatment. — Great concern is usually occasioned by the entrance 
 of an insect or other animate body in the external meatus, on account 
 of the clawing and scratching and penetrating movements attending its 
 presence. Great noises of the most distressing and horrifying character 
 are sometimes present, due no doubt to the clawing and scratching 
 against the drumhead. On account of the great mental disturbance 
 of the patient, the physician should have well-formulated ideas as 
 to the proper methods of procedure for the removal of the insect, as 
 he will otherwise be led to resort to methods in his haste and anxiety 
 which will probably be unsuccessful and will only add to the pain and 
 discomfort of the patient. I would, therefore, make the following 
 suggestions : 
 
 (a) Avoid the use of instruments. It has been found by experience 
 that animate objects are not readily removed by the use of forceps or 
 other instruments. They have the power of clinging tenaciously to the 
 skin of the meatus with little hooklets in the case of maggots, and with 
 the feet in the case of fully developed insects. 
 
 (b) Drown the insect. This can usually be done with oil; if oil is not 
 at your command, water may be used instead. If maggots are within 
 the meatus, a 50 per cent, solution of chloroform should be used for 
 this purpose, as oil or water seems to have little power to cause their 
 death. 
 
 (c) If for any reason it is desired to remove them immediately without 
 waiting to render them lifeless, the syringe should be used, as in this 
 way they may sometimes be removed with great ease. On the other 
 
FOREIGN BODIES IN EUSTACHIAN TUBE AND MIDDLE EAR 631 
 
 hand, the method is oftentimes not successful until they have been ren- 
 dered lifeless by drowning in the water. If maggots are present, the 
 fumes of chloroform blown into the ear from the bowl of a pipe will 
 almost instantly render them lifeless. Chloroform may also be dropped 
 into the ear for this purpose with more certain results. After they are 
 rendered lifeless the insects or larvae are easily removed with the syringe, 
 and it will rarely be necessary to resort to the use of forceps. Should 
 it become necessary, however, to resort to them, they should be used 
 with great caution, as otherwise the meatus and drumhead may be 
 injured. The use of chlorinated water is of value in rendering them 
 lifeless, especially the Larvae. It is not, however, as efficacious as 
 chloroform. 
 
 (d) The agglutinative method may be used for the removal of dead 
 insects from the ear, as described under Foreign Bodies in the Ear. 
 
 FOREIGN BODIES IN THE EUSTACHIAN TUBE AND MIDDLE EAR. 
 
 Mayer 1 reports three cases of foreign bodies in the Eustachian tube: 
 one, a grain of corn, was in the bony portion of the tube, while the others 
 were in the cartilaginous end. They may enter the tube either through 
 the middle ear or the epipharynx. If there is a perforation in the drum- 
 head, a small grain or other substance may enter the middle ear through 
 it, and thence pass to the Eustachian tube. Foreign bodies which are 
 unskilfully or roughly handled in the effort to remove them from the 
 external auditory meatus may thus be driven into the middle ear, whence 
 they may gain entrance into the Eustachian tube. 
 
 The use of Eustachian bougies has, in the past, been a fruitful source 
 of foreign bodies in the tubes from accidental breaking while being used. 
 Formerly the bougies were armed with feathers, cotton, or hair, for the 
 introduction of medicaments, and were, consequently, more likely to be 
 broken in the tube. Better and smoother instruments are now used, 
 hence the accident occurs less frequently. 
 
 Voltolini has recommended the galvanocautery for the removal of 
 firmly embedded organic substances, as beans, etc., from the meatus and 
 the middle ear. At various sittings small portions are thus destroyed, 
 until the whole is finallv disintegrated and removed. This method of 
 procedure should be attempted with great caution, as there is considerable 
 danger of exciting inflammation of the contiguous parts. 
 
 If the foreign body is so deeply and firmly embedded in the middle 
 ear as to render it impossible to remove it by simple and direct methods, 
 the postauricular incision, such as described under mastoid opera- 
 tions, should be made, and, if necessary, a portion of the bone of the 
 meatus may be chiselled aw r ay. When it is thus exposed, an attempt 
 should be made to remove it with a stream of water. Should this fail, 
 forceps may be used. 
 
 1 Monatsschrift f. Ohrenheilkunde, Jahrg. iv, Nr. 1. 
 
632 THE EAR 
 
 Foreign bodies in the cartilaginous end of the Eustachian tube may 
 sometimes be seen with a postrhinoscopic mirror as they protrude 
 from the mouth of the tube. In such cases it is often possible to seize 
 the protruding end with a pair of curved forceps through the mouth 
 and thus remove it. If this cannot be done > the drumhead may be 
 perforated by means of a V-shaped incision, if a perforation does not 
 already exist, and air forced into the middle ear by means of a Politzer 
 bag or other compressed air apparatus with a suitable tip, applied 
 at the external meatus. In this way the current of air may be made to 
 enter the Eustachian tube and force the foreign body from its pharyngeal 
 orifice. 
 
 CERUMINOUS PLUGS. 
 
 Cerumen is the product of the ceruminous glands which are located 
 chiefly in the cartilaginous portion of the external auditory canal. A 
 few glands are also present at the commencement of the osseous portion 
 of the canal. The cerumen is normally thrown off by the movements of 
 the mandible (inferior maxilla) and by the exfoliation of the epidermis 
 which lines the canal. When, however, from any cause the secretion 
 becomes excessive in quantity, more tenacious in quality, or its discharge 
 is mechanically obstructed, ceruminous plugs form in the canal and 
 give rise to more or less disturbance of hearing. 
 
 Etiology. — The etiology may be studied under (a) diseases of the 
 canal and middle ear; (b) obstructive lesions of the canal; (c) modifica- 
 tions in the character of the ceruminous secretion; (d) foreign bodies in 
 the canal; and (e) improper methods of washing the ear. 
 
 (a) The diseases of the canal and middle ear which cause ceruminous 
 plugs may be subdivided into hyperemia of the skin of the canal, diffuse 
 and circumscribed eczema, and otitis media catarrhalis. 
 
 (b) Modifications in the character of the cerumen, as in increased 
 adhesiveness and the admixture of epithelium and hairs, cause the re- 
 tention of the cerumen. 
 
 (c) Foreign bodies in the external canal form the nuclei of ceruminous 
 plugs. They may be solid substances, as beads, small stones, etc., or 
 they may consist of dust, sand, or other finely divided particles. 
 
 (d) Improper methods of washing the ears are often responsible for 
 the presence of ceruminous accumulations in the canal. Irritating 
 soap-suds are introduced, the epidermis macerated in it, and the glands 
 overstimulated. A mild dermatitis results. The corner of a towel or a 
 washcloth is often twisted and screwed into the meatus, causing still 
 further irritation, and oftentimes pushing the cerumen into the osseous 
 portion of the meatus, where it remains, forming a nucleus for still more 
 extensive accumulations. 
 
 Symptoms. — The symptoms vary according to the degree of occlu- 
 sion, the position of the plug, the amount of secondary irritation and 
 inflammation, and the preexisting or associated lesions in the middle ear 
 and labyrinth. 
 
CERUMINOUS PLUGS 633 
 
 If the occlusion of the canal is incomplete in an ear which is otherwise 
 normal, there will be but little impairment of hearing; if, on the other 
 hand, the canal is entirely closed, there is marked diminution of hearing. 
 If the plug is dislodged into the fundus of the canal against the drum 
 membrane, the disturbance of hearing and the discomfort are much 
 greater. In some cases the plug causes severe inflammatory reaction 
 of the tissue immediately contiguous to it, which adds to the discomfort 
 and the impairment of hearing. Reflex pains in the mastoid region 
 are not uncommon in this condition. 
 
 If suppurative inflammation of the middle ear and the mastoid cells 
 is present with the ceruminous plug, the symptoms are modified accord- 
 ingly; that is, there is a mixture of the symptoms of the two conditions. 
 
 Pain is a symptom which is present only when the cerumen is hard 
 and exerts pressure on the inflamed walls of the canal. 
 
 In general, it may be said that the patient complains of a feeling of 
 fulness in the ears and the head, and occasionally of dizziness, vomiting, 
 headache, stupor, facial paralysis, trigeminal neuralgia, brain irritation, 
 eclampsia, blepharospasm, pain, etc. 
 
 The hearing may suddenly change from good to bad, or vice versa. 
 When the drumhead is perforated the plug may improve the hearing by 
 acting as an artificial membrane. 
 
 Diagnosis. — The diagnosis is made by inspecting the canal, either 
 with a speculum or by lifting the auricle upward and backward. The 
 plug appears as a yellow or brownish mass of greasy or granular 
 material, which, upon probing, proves to be either soft, semisolid, waxy, 
 solid, or hard as stone. 
 
 It may be mistaken for cholesteatoma, dried blood, a foreign body, 
 cotton stained with secretion, etc. In some cases there is an excessive 
 exfoliation of epidermis, which, becoming admixed with hairs and 
 cerumen, lodges in the canal, thereby causing its occlusion. In these 
 cases we have to deal with a pathological desquamation of epidermis 
 rather than with a hypersecretion of cerumen. 
 
 Prognosis. — When sudden loss or diminution of hearing follows 
 the introduction of water or other liquids into the meatus, the prognosis 
 as to the hearing is good, as the disturbance is probably due to the 
 swelling of the plug, which obstructs the canal. Cases complicated by 
 either adhesive otitis or labyrinthine affections are not greatly relieved 
 by the removal of the cerumen. 
 
 If we apply the tuning fork to the vertex, as in Weber's test, and the 
 sound lateralizes to the obstructed ear, we gain no information, as the 
 lateralization might be due to either middle ear disease or to the plug. 
 If, however, it lateralizes to the unobstructed ear, we may suspect laby- 
 rinthine involvement on the obstructed side. 
 
 Treatment. — The only form of treatment to be recommended is the 
 removal of the cerumen by forcible injections of warm water with a 
 syringe. If the plug has a moist appearance, or is soft to the probe, the 
 injections may be made at once; whereas, if it is hard and lustreless, 
 it should first be moistened by instilling a few drops of a solution of 
 
634 THE EAR 
 
 bicarbonate of soda and glycerin in water; this should be repeated 
 three or four times daily for about three days. The addition of the 
 glycerin is advantageous on account of its hygroscopic property, which 
 maintains the plug in a moist state between the instillations. When 
 softened it may be removed with a syringe or with a cotton-wound probe. 
 
 In rare instances the use of a round-ended probe may become neces- 
 sary on account of the firm adhesion of the cerumen to the meatus. 
 Persistent injections will ordinarily remove all secretions. Dizziness, 
 or even vomiting, is sometimes induced by the force of the stream, the 
 intralabyrinthine pressure being disturbed by the inward movement of 
 the foot plate of the stapes. 
 
 Keratosis Obturans, or Epithelial Plugs in the External Meatus. — In 1874 
 Wreden described this condition, calling it " keratosis obturans." It is 
 caused by a chronic desquamative dermatitis, in which the epithelium 
 is gradually thrown off and accumulated layer by layer in the fundus of 
 the canal. More or less deafness results, according to the degree of 
 occlusion and the proximity of the plug to the drumhead. It is often 
 mistaken for cerumen, as its layers may be admixed with and its surface 
 covered by it. A careful macroscopic or microscopic examination will 
 clear the diagnosis. Mr. Richard Lake advances the theory that it is 
 caused by a dry, scaly eczema, which is excited by a ceruminous plug, 
 while Burnett suggests that it is due to an excoriation and slow exudation 
 of dermoid cells, brought on by rough and clumsy attempts to clean the 
 ear. 
 
 Pain in the meatus is the most constant symptom. In rare cases ■ it 
 radiates around the ear and over the temporal region. 
 
 After syringing the ear the plug becomes whitish or grayish in color, 
 on account of the removal of the outer layer of cerumen, which is readily 
 soluble in water. It is firm and dense and more or less adherent to the 
 walls of the meatus. After its removal, if placed in water, it does not 
 soften and break up as cerumen does under like conditions. Its layers 
 resemble sodden white parchment. 
 
 Treatment. — Before proceeding to remove the plug with the syringe, 
 it should first be gently separated from the walls of the meatus with a flat 
 applicator. This allows the stream of water to pass around and behind 
 it, and facilitates its expulsion. If, however, it does not readily come 
 away, it should be removed piece by piece with a probe or forceps, 
 one hour often being required for its accomplishment. Children do 
 not calmly submit to the procedure, as it is somewhat painful; an anes- 
 thetic should, therefore, be given. Recurrences may be expected; 
 hence, frequent examination and treatments may be necessary. 
 
CHAPTER XXXVI. 
 
 MALFORMATIONS AND NEOPLASMS OF THE AURICLE. 
 MALFORMATIONS. 
 
 Malformations of the auricle are of importance chiefly from a cos- 
 metic point of view. The auricle plays such a small part in the function 
 of audition that its entire absence does not materially influence the 
 acuity of hearing. If, however, the auricle is so shaped as to occlude 
 the meatus, it may materially interfere with the transmission of the sound 
 waves and thus impair hearing. In most cases, however, when there 
 is a very marked defect there is also defective formation of the external 
 auditory meatus, the middle ear, and the labyrinth; hence, diminution in 
 hearing is usually due to other conditions than the changes in the auricle. 
 
 The malformations may be of a great variety of forms, ranging 
 from a plurality of the auricle to its entire absence. Between these two 
 extremes the auricle may be deformed to a slight degree, or it may be 
 overdeveloped or misshapen in almost every conceivable way. It may 
 be either arrested or overdeveloped. One part may be overdeveloped, 
 while in another the development is arrested. It is not uncommon to 
 see in a large company of people ears which project very markedly 
 from the head, and which often give rise, especially among school- 
 children, to their possessors being called "yellow kids." The term 
 "lop ear" is often applied to the same condition. 
 
 The defect may be either congenital or acquired. If congenital, it is 
 due to a lack of closure of the branchial clefts and to a disproportionate 
 development of one or more of the six tubercles or centres of develop- 
 ment of the auricle. It may be unilateral or bilateral, usually the former. 
 The bones of the face upon the side affected are usually also arrested in 
 their development. 
 
 Stahl, in 1859, called attention to the fact that deformity of the auric- 
 ular cartilage might be regarded as an indication of arrest of develop- 
 ment of the skull, and that it bore a relationship to the development of 
 the skull. Defective formation may consist of the entire absence of the 
 auricular cartilage, although it is probable that in nearly every instance, 
 a careful examination will reveal a small cartilaginous growth beneath 
 the skin. The arrest may take on the form of a simple shrivelling of 
 the whole auricle, or a portion of it. On the other hand, it may consist 
 of an excessive development of one part and a diminished development 
 of another; or it may assume any irregular type of development, as a 
 twisted shell, or it may be hooked, cone-shaped, fissured, or cauliflower- 
 like in form. 
 
636 THE EAR 
 
 Sometimes the upper portion of the auricle is turned downward 
 from above and compressed against the middle portion, as is seen in 
 the old statues of Pan (Politzer); or it may have deep indentations or 
 horizontal fissures, and in rare instances it may be spindle-shaped. 
 The tragus may be twisted inward, so as to close the meatus, or there may 
 be an absence of the auricle with the exception of the lobule, which 
 may be free or adherent to the adjacent skin. The meatus was present 
 in a case of this kind reported by Schwartze. It opened beneath the 
 lobule and led upward and inward to the drumhead. 
 
 The auricular appendages or supernumerary auricles, according to 
 Virchow, consist of reticular cartilage, subcutaneous cellular tissue, and 
 skin. They are usually located in front of the tragus, although they 
 may be on the lobule, the side of the neck, or the shoulders. Saissy, in 
 1829, advanced the theory that malposition of the auricle from an im- 
 properly placed head-dress invariably led to arrest of development. He 
 says: "Boys often wear their hats so low upon the head as either to push 
 the ear outward and cause it to project from the head, or to compress it 
 against the head and cause it to assume too close a position. "The latter 
 often occurs in females from confining the ears too closely with the head- 
 dress. To remove the deformity, it is only necessary to correct the habit." 
 
 Maschziker, in 1864, in his text-book on The Ear and its Diseases 
 and their Treatment, states that ears are placed in malposition by too 
 tightly drawn caps on children. 
 
 I have known mothers to bandage the ears of their little ones to bring 
 them more closely to the head, even when their fathers had widely pro- 
 truding auricles, and the children had evidently inherited the physical 
 trait. Thus the scientific tradition still holds popular credence, and 
 many a little child is made to suffer in consequence. 
 
 Saissy's views on the subject of imperforation of the external meatus 
 were more nearly correct, as he regarded it as usually associated with a 
 congenital and irremediable defect of the middle and the internal ears. 
 The etiology of auricular deformity is to be found in the disordered 
 development of the organ of hearing. There is insufficient closure of 
 the upper two branchial clefts, which arrests or accelerates develop- 
 ment of one or more of the six tubercles or centres of development, as 
 shown by Minot, Talbot, and others. 
 
 Classification. — Auricular deformities may be classed as follows: 
 
 (a) Entire absence of the auricle. 
 
 (b) Overdevelopment of the auricle (macrotia). 
 
 (c) Plurality of the auricle (polyotia, supernumerary). 
 
 (d) Arrested development of the auricle (microtia, shrivelled). 
 
 (e) Distortions of the auricle (cat-ears — as in the statues of Pan — 
 shell-, scroll-, hook-, spindle-, cone-, fissure-, and cauliflower-like for- 
 mations) 
 
 (/) Fistula in auris congenita is a remnant of the first branchial cleft, 
 and was first described by Heysinger in 1870. It opens in front of the 
 ear, either above or below the tragus, and is a blind canal filled with 
 creamy secretion mixed with pus. When its mouth becomes closed 
 
MALFORMA TIONS 
 
 637 
 
 the secretion accumulates within the canal, which may be felt as hard 
 nodules beneath the skin. Fistula auris congenita is of slight impor- 
 tance, and may be healed by laying it open with a knife and remov- 
 ing the epithelial lining and bringing the parts together again, after 
 which they unite by first intention, and thus obliterate the canal. Mild 
 caustic applications may be applied within the canal to excite inflam- 
 mation and adhesions for the purpose of closing the canal. 
 
 Fig. 372 illustrates one of my cases of microtia. The drawing is 
 from a plaster cast of the ear. The young man is healthy and has a 
 normal ear upon the opposite side. The cartilages of the fragmentary 
 auricle are not attached to the skull in any way except by the skin. 
 There is an entire absence of the external auditory meatus, and bone 
 conduction is nil upon this side. He came to 
 me to have the ear "opened up," if I thought fig. 372 
 
 it advisable. As there was no bony meatus, 
 and the autopsies on similar cases have 
 shown the middle-ear apparatus and laby- 
 rinth to be absent or quite rudimentary, I 
 advised him to leave the ear as it was. 
 
 Treatment. — Macrotia. — Figs. 373 and 374 
 illustrate one of my cases of macrotia. The 
 case was referred to me by G. F. Suker, 
 for the reduction of the lop-ear. The boy 
 was eleven years old, and presented numerous 
 stigmata of degeneracy. His schoolmates 
 called him the "yellow kid." It was, there- 
 fore, decided to overcome the defect by 
 operating upon the auricles. This was done 
 under general anesthesia. 
 
 The skin on the posterior surface of each 
 auricle was incised with a knife, the line of 
 incision extending in a curve from within one- 
 fourth inch of the superior attachment of the 
 auricle to within one-half inch of its inferior 
 attachment. A second incision was begun at 
 
 the upper point and extended backward and downward over the mastoid 
 process one-half inch posterior to the attachment of the auricle, and made 
 to join the inferior end of the auricular incision (Fig. 373). An ellipse or 
 segment of skin not unlike a segment of orange peel was thus outlined. 
 This was dissected from the auricle and the mastoid process. The second 
 step of the operation consisted in cutting through the cartilage of the 
 auricle, following the line of the auricular skin incision. The cartilage 
 was then severed at the auriculomastoid junction, care being exercised 
 to avoid cutting through the skin on the anterior surface of the auricle. 
 The cartilage was next carefully separated from the anterior skin of the 
 auricle (a). 
 
 The third step of the operation consisted in closing the wound (Fig. 
 374). This was done in such a way as to bring the auricle close to the 
 
 -J&X-- 
 
 Author's case of microtia. The 
 
 external auditory meatus, middle 
 ear, and labyrinth are absent. 
 
638 
 
 THE EAR 
 
 head, as the operation was done principally for this purpose. In order 
 to do this four deep stitches with silkworm gut were taken, so as to in- 
 clude the auricular skin, the auricular cartilage, the fibrous tissue over 
 the mastoid, and the mastoid skin. These were drawn firmly together 
 and secured. Ochsner's continuous horsehair suture was then used to 
 bring the edges of the skin together. 
 
 Fig. 373 
 
 Fig. 374 
 
 A, operation for macrotia, or lop-ear. An 
 elliptical piece of skin (a, 6) has been re- 
 moved from the posterior wall of the auricle 
 and mastoid process, a, the area of cartilage 
 to be removed from the concha of the auricle. 
 
 The operation for macrotia, or large project- 
 ing auricle. B, the sutured incision at the 
 close of the operation; C, the cartilage removed 
 from the concha of the auricle; D, the skin 
 removed from the posterior aspect of the auri- 
 cle and the mastoid process. 
 
 The superficial sutures were removed on the sixth day and the deep 
 stitches on the ninth day. 
 
 The results of the operation were excellent. Before the operation 
 the auricles at Darwin's tubercle were 3.5 cm. from the side of the head, 
 and after the operation they were 1.5 cm. distant. Three months after 
 the operation they were 1.25 cm. from the head. 
 
 NEOPLASMS OF THE EXTERNAL EAR. 
 
 Othematoma. — Definition. — This is a disease of the auricle charac- 
 terized by an effusion of blood between the perichondrium and the 
 cartilage. It may occur spontaneously or from direct violence. When 
 it occurs spontaneously it is probably due to degenerative changes in 
 
NEOPLASMS OF THE EXTERNAL EAR 639 
 
 the bloodvessels of the fibrous bands which traverse the cartilage of 
 the auricle. It is also probable that degenerative changes occur in the 
 fibrous tissue. 
 
 Etiology. — Dementia seems to have a close relationship to the disease, 
 as it is commonly found in the insane. Inhumane treatment of this 
 class of patients has been so often charged, and it is more than probable 
 that traumatism accounts for it among them to a large measure. This 
 is rendered more than probable by the fact that most of the cases have 
 involvement of the left ear, because the blow from the right hand of 
 the attendant would strike this ear. It must not be presumed, however, 
 that this is the only cause, as the degenerative changes above referred to 
 would be expected in this class of patients. The champion prizefighter, 
 "Battling" Nelson, has othematoma, which was caused by numerous 
 blows upon the ear in a series of boxing matches in remote places where 
 he did not have the opportnity of applying hot water. 
 
 The condition is common among the wrestlers of Japan, traumatism 
 being the probable cause. 
 
 Symptoms. — The tumor forms quickly, and this distinguishes it from 
 perichondritis, angioma, and other neoplasms. The rapid development 
 after an injury is quite characteristic. Its color is bluish, and it is rounded 
 and soft to the touch. It does not have the distinct fluctuation com- 
 mon to fluid sacs beneath the skin, but offers a doughy resistance. If 
 it is due to traumatism it is usually quite large, and often involves the 
 whole or the upper portion of the auricle; whereas if it is idiopathic it is 
 often quite circumscribed, being limited to a nodule in the concha or 
 other depression of the auricle. It is most common on the anterior or 
 concave surface of the auricle (Fig. 375). 
 
 Pain is present in the traumatic variety, but is absent in the idiopathic. 
 The tumor is opaque by transmitted light, whereas that of perichon- 
 dritis is transparent. If the auditory meatus is occluded by the swelling, 
 deafness and tinnitis are present. It should be borne in mind that the 
 deafness may be due to the rupture of the eardrum from concussion. 
 In the case of "Battling" Nelson, the hematoma became organized and 
 caused permanent deformity. 
 
 Diagnosis. — The diagnosis is based upon the rapid development of the 
 growth after an injury, the opaqueness by transmitted light, and the 
 absence of febrile symptoms. In the spontaneous variety the rapid 
 development of the tumor is quite characteristic. 
 
 Prognosis. — The traumatic variety ends by resolution more readily 
 than the idiopathic variety, except when there is extensive damage to the 
 cartilage. If there are no reactive symptoms and the swelling dimin- 
 ishes in size, the prognosis is favorable. Violent inflammatory symp- 
 toms, on the other hand, necessitate opening the tumor, thus rendering 
 the prognosis more unfavorable. In some cases there is recovery without 
 visible deformity, while in others recovery occurs with great shrinkage 
 or other deformity of the cartilage. N 
 
 Treatment. — The treatment should be symptomatic and modified to 
 correspond with the peculiar pathology of the case. If, for example, the 
 
640 
 
 THE EAR 
 
 othematoma is due to degenerative changes in the bloodvessels and the 
 connective tissue or the cartilage of the auricle, it would be wrong to apply 
 massage to promote absorption, as such manipulation would probably 
 provoke more hemorrhage. Such a procedure, if tried at all, should be 
 deferred until regeneration has closed the interior wounds. Pressure 
 bandages are also contra-indicated for the same reason. The applica- 
 tion of ice-bags or a Leiter coil may exert a favorable influence in pre- 
 venting passive inflammatory swelling; and if it is already present, 
 the cold reduces it somewhat. The application of heat is better treat- 
 ment, as it promotes regeneration. Cooling lotions locally, and cathartics 
 may also be tried with some advantage. The inflammatory type should 
 be incised and antiseptic dressings applied. 
 
 Fig. 375 
 
 Othematoma with ossification following a history of dementia and traumatism. 
 (Dr. G. McAuliff's case.) 
 
 Politzer recommends the puncture of the tumor in the early stage of 
 its development. If this is not followed by relief it is better to open it 
 thoroughly by free incision, after which the contents are removed and 
 the cavity packed with iodoform gauze. 
 
 Angioma. — Symptoms. — The bright red or lurid patches which are 
 not elevated above the surface of the skin are not included in this group 
 of tumors. The term "angioma," as used here, refers to the cavernous 
 tumors, which are bluish red in color and are made up of a series of 
 venous sinuses or cavities of various sizes and shapes. They are often 
 separated from each other by perforated fibrous septa, which afford 
 free intercommunication of their blood contents. 
 
 They may appear in the auricle, in the meatus, or in both. They 
 may be either primary or secondary extensions from adjacent struc- 
 tures. They vary in size but rarely grow larger than a small hen's egg. 
 
NEOPLASMS OF THE EXTERNAL EAR 641 
 
 They are irregular in shape. Pulsation is occasionally present. Angi- 
 oma is sometimes congenital, while in other cases it develops after trauma 
 or after the gradual dilatation of the bloodvessels of the simple angi- 
 oma, the bright red or lurid patches referred to in the preceding para- 
 graph. Cases are on record of angiomata which appeared after the 
 auricle had been frozen. 
 
 The presence of pain depends chiefly upon the rapidity with which 
 they grow. If of rapid development and large size, the pain is consider- 
 able. Troublesome pulsation is another characteristic of angioma of 
 rapid growth. 
 
 Deafness is present in those cases in which the meatus is occluded. 
 Reflex cough may also be present when the meatus is involved. 
 
 Diagnosis. — Othematoma is the only tumor which might be con- 
 founded with cavernous angioma. The former is of rapid growth, 
 smooth in outline, and opaque by transmitted light; whereas angioma 
 usually develops more slowly, is irregular in outline, and is transparent by 
 transmitted light. 
 
 Treatment. — The treatment should be addressed to the reduction of 
 the blood contents of the tumor, which interfere with its circulation. 
 This may be accomplished in several ways. Electrolysis is, perhaps, the 
 best method in growths of small or medium size. The needles con- 
 nected with the positive pole of the battery should be thrust through the 
 growth, while the negative (sponge electrode) pole is placed on some 
 remote portion of the body. The positive pole liberates oxygen and 
 acids, which coagulate the blood and soft tissues, thus contracting and 
 obstructing the cavernous sinuses of the tumor. Should the negative 
 pole be applied as .e commended by Ho veil, the results would be less 
 certain, as the negative pole liberates hydrogen gas, which tends to 
 liquefy the solid tissues. The negative pole is better adapted to use in 
 fibrous tumors, on account of its liquefying properties. 
 
 Multiple puncture of the surface with needle points and brushing the 
 surface with nitric acid has been recommended in small growths. Both 
 measures produce scar tissue, and thus cause contraction. 
 
 Politzer recommends the passage of several silk sutures through the 
 tumor. He first renders them aseptic and then saturates them in a solu- 
 tion of the perchloride of iron. The iron coagulates the blood and the 
 threads act as nuclei for the clot formations. 
 
 The Paquelin cautery has been used in larger growths. Such treat- 
 ment is necessarily limited to exceptional cases. 
 
 Injections of styptic remedies, as carbolglycerin, iodine, and the 
 perchloride of iron, are not safe procedures, as they may cause extensive 
 sloughing and subsequent disfigurement from cicatricial contraction. 
 Suppuration and perichondritis may also follow the injections, the 
 auricle becoming shrivelled and reduced in size. 
 
 Fibroma. — Fibroma of the external ear consists of spindle cells and 
 
 connective tissue. It is usually the result of local irritation, as from the 
 
 wearing of ear-rings, and is often found in negresses, who are peculiarly 
 
 subject to fibromata, not alone in the external ear, but in other parts of 
 
 41 
 
642 
 
 THE EAR 
 
 the body. They vary in size up to that of a large walnut, are rounded 
 in form, and may be pedunculated or sessile. They are usually located 
 in the lobule, as this is the portion in which ear-rings are worn. They 
 may appear elsewhere on the auricle or even at the entrance to the 
 auditory canal (Fig. 376). 
 
 Treatment. — A small V-shaped incision, including the growth, may 
 be made, and the cut surfaces brought together by skin stitches, thus 
 causing very little disfigurement. If the growth is pedunculated it 
 is easily removed with scissors, and the base cauterized and dressed 
 antiseptically. Large growths may be removed by excision, the parts 
 being brought together as well as possible to avoid disfigurement. If 
 necessary, a subsequent plastic operation may be performed to over- 
 come the deformity. 
 
 Fig. 376 
 
 Fig. 377 
 
 Fibrous tumor (keloid) of right auricle. 
 (Brtihl-Politzer.) 
 
 Carcinoma of the auricle. 
 (Bruhl-Politzer.) 
 
 Cysts. — Like cyst formations in other parts of the body, those of the ear 
 are the result of the plastic union of parts which are normally open or 
 separated, i. e., the sebaceous glands of the auricle may become infected, 
 their orifices closed, and the secretions retained in the dilated and inflamed 
 glandular sacs. They are variable in size, are soft, and may remain 
 stationary in their development for several years. 
 
 Treatment. — The treatment of cysts of the auricle consists in a free 
 incision into the tumor, the evacuation of its contents, curettement, and 
 the application of the tincture of iodine to the surface of the cavity. A 
 suitable surgical dressing should then be applied, and repeated daily 
 while repair is taking place. 
 
 Epithelioma. — The growth begins as a hard nodule situated in the 
 skin or the subcutaneous connective tissue; it grows slowly for a time, but 
 later develops quite rapidly. It is in this stage that ulceration is likely 
 to occur. The growth may be an extension from contiguous structures, 
 
NEOPLASMS OF THE EXTERNAL EAR 643 
 
 or it may be primary in the auricle or the meatus. Of the sixty cases 
 reported, nearly all occurred in patients more than forty years of age. 
 Dr. J. S. Brown reports a case in a man, aged seventy-eight years. Epithe- 
 lioma may begin as warty or fissured surfaces, which finally ulcerate and 
 continue to spread by the formation of new tissue at the edge of the ulcer. 
 This tissue rapidly undergoes disintegration, and the ulcerous process 
 may spread until the entire auricle and meatus or even the neighboring 
 structures are destroyed. 
 
 The nodular enlargements on the auricle may be present several 
 months before enlargement of the glands in the neck appears. Pain 
 may not be a symptom until ulceration takes place; hence, in the early 
 stage, epithelioma may be mistaken for fibroma. As the ulceration 
 and the deeper extension of the growth progress, the pain increases, 
 often becoming excruciating in character. The facial nerve may be- 
 come involved, and facial paralysis develop. The auditory nerve may 
 be affected, or hemorrhages may occur, and glandular enlargements 
 develop, which may result fatally. Death may be due to septicemia, 
 exhaustion, meningitis, thrombosis of the lateral sinus, or cerebral 
 abscess. 
 
 Treatment. — The treatment of epithelioma here, as elsewhere in the 
 body, consists in the complete removal of the growth by excision. To 
 accomplish this it may be necessary to remove the auricle in part or 
 entirely. The resulting disfigurement may be corrected by a subse- 
 quent plastic operation or the adjustment of an artificial auricle. While 
 the wound is healing a vulcanized or a silver tube should be worn in 
 the meatus to prevent cicatricial contraction. 
 
 Sarcoma. — Sarcoma of the auricle is rare. When present, it may 
 be of the round-cell variety, which develops rapidly and leads to an 
 early fatal issue, or it may be of the fibrosarcomatous type, which grows 
 slowly. This type may exist for many years without giving rise to 
 marked symptoms. The round-cell variety is painful, as its rapid 
 growth stretches the sensory nerves, and it is also often attended with 
 inflammation in the parotid and the mastoid regions. 
 
 The appearance of the tumor varies according to the variety and the 
 rapidity of development. If it is of the fibrosarcoma type, it is smooth 
 and covered with normal skin. If it is of the round-cell variety, the 
 rapid growth causes the skin to become eroded and the seat of fungous 
 granulations. The eroded surface secretes an unsightly suppurating 
 material composed of debris, pus, epithelium, leukocytes, and blood 
 corpuscles. The ulcerating surface often bleeds profusely. 
 
 The external meatus may be the seat of round-cell sarcoma and, in 
 extremely rare instances, of osteosarcoma. 
 
 Diagnosis. — A portion of the growth should be subjected to micro- 
 scopic examination. The round-cell sarcoma is pale on cross-section 
 and exudes a milky juice; it is composed almost entirely of round cells 
 and thin-walled bloodvessels. The fibrosarcoma has a considerable 
 quantity of intercellular cement substance, and the macroscopic appear- 
 ance of the tumor is coarse-grained and firm. 
 
644 THE EAR 
 
 Prognosis. — It is obvious that this will depend upon the type of the 
 growth, the round-cell variety being comparatively more speedy and 
 destructive. In this type death may result from intracranial extension, 
 hemorrhage, or exhaustion. 
 
 Treatment. — Early and complete removal of the growth is the best 
 treatment. This may be done with the knife or the galvanocautery. 
 If the growth cannot be completely removed, the parts continue to dis- 
 charge offensive material. 
 
 The Rontgen-rays have been used with some apparent success in 
 superficial sarcomata, but we are not ready to recommend this method 
 of treatment until further trial has demonstrated its real value. It is 
 unsafe to try it in the round-cell variety, as the early surgical removal 
 offers the only hope in this type of sarcoma. While using the Rontgen- 
 ray treatment extensions may occur, thereby rendering operative treat- 
 ment hopeless. The rays are of special value, however, after opera- 
 tion, as recurrences are less frequent or are delayed by their use. 
 
CHAPTER XXXVII. 
 
 DISEASES OF THE AURICLE AND EXTERNAL MEATUS. 
 PERICHONDRITIS OF THE AURICLE. 
 
 This is a rare affection and resembles othematoma. The upper 
 portion of the auricle is usually involved, as the cartilage is chiefly 
 found there. The lobule escapes, as it is free from cartilage. 
 
 Symptoms. — If the inflammation occurs as a complication of furun- 
 culosis of the meatus, the pain characteristic of that condition is present; 
 whereas, if it begins in the auricle, the first symptom may be circum- 
 scribed redness and swelling, which gradually spreads and becomes 
 more severe, until it finally involves the whole of the cartilaginous 
 portion, including the concha, or it may include the meatus. If the 
 meatus is wholly occluded by the swelling, the hearing is impaired. 
 Fluctuation soon occurs, and is due to the inflammatory exudate of 
 viscid serum beneath the perichondrium. The natural contour of 
 the auricle is modified by the swollen tissue, and its surface is reddened. 
 The perichondrium of the entire auricle may become detached and 
 thus interfere with the nutrition of the cartilage. This is a serious 
 complication, especially if the secretion becomes purulent. Under 
 such circumstances the cartilaginous auricle is apt to shrink or slough, 
 and leave marked deformity. 
 
 The greatest care should be exercised to prevent additional infec- 
 tion when there is an abrasion of the skin and when an incision is made 
 to evacuate the fluid beneath the perichondrium. 
 Should active infection be present, many weeks 
 or months may be required to check the progress 
 of the disease, and even then the auricle will be 
 greatly deformed. Perichondritis occasionally fol- 
 lows the mastoid operation, especially when the 
 plastic meatal flap includes the concha of the 
 auricle. 
 
 The deformity following perichondritis may be 
 so slight as to attract no attention, or it may be so 
 marked as to disguise completely the anatomical 
 characteristics of the auricle. 
 
 Treatment. — The early treatment should be 
 antiphlogistic in nature, heat being the best 
 agent. The Leiter coil (Fig. 378) should be 
 
 applied over the auricle and hot water passed through it. A hot-water 
 bag may also be used. A saline cathartic should be administered 
 
 Fig. 378 
 
 Leiter's coil. 
 
646 THE EAR 
 
 and leeches used around the auricle in conjunction with the heat. 
 If fluctuation is present, an incision should be made to evacuate the 
 fluid. The auricle should be cleansed before making the incision, to 
 prevent the possibility of additional infection. The cavity should be 
 carefully but thoroughly scraped with a dull curette, and then cleansed 
 with an antiseptic solution. If the infection is severe and granulations 
 are present, the cavity should be swabbed with the tincture of iodine 
 or the compound tincture of benzoin. Free drainage should be main- 
 tained by the insertion of a gauze wick, over which the usual dressing 
 of gauze pads should be placed and held in position with a bandage. 
 The dressings should be changed every twelve hours. 
 
 Subsequent operative measures may be undertaken to correct the 
 deformity if it is sufficient to produce disfigurement. 
 
 HERPES OF THE AURICLE. 
 
 The etiology is not always clear, although herpes is apparently caused 
 by middle ear disease. It is thought by some to be caused by malaria, 
 and by others to be a neurosis. It is most common in adults. 
 
 Symptoms. — The vesicular eruption is sometimes preceded by a 
 stinging or burning pain, especially if the meatus is involved. The 
 eruption is generally on the outer or concave surface of the auricle, 
 which is supplied by the auriculotemporal branch of the fifth nerve. 
 This is of interest, as the distribution of the eruption usually follows 
 the terminal branches of this nerve. It is more rarely on the posterior 
 or convex surface of the auricle, as the auriculotemporal branch of the 
 fifth nerve does not extend to this region. 
 
 The course and appearance of the eruption is about as follows: 
 
 At first there is a reddened area, which becomes papular, then vesic- 
 ular. The vesicles may become confluent and form bullae. The vesicles 
 at first contain clear serum, which later becomes cloudy and purulent. 
 The duration of the vesicular stage is limited to a few days, after which 
 the vesicles dry up, leaving crusts and an occasional superficial ulcer. 
 
 If the meatus becomes involved, more or less deafness and tinnitus 
 is present. 
 
 Treatment. — Tonics, purgatives, and outdoor exercise are indi- 
 cated to improve the general health of the patient. Cool or cold morn- 
 ing baths, or at least sponging of the neck and chest, are indicated to 
 improve the tone of the vasomotor nervous system. 
 
 The blisters should be protected by starch or boric acid powder and 
 cotton-wool dressings. The fluid contents of the vesicles should be 
 emptied, care being taken to avoid removing the elevated dermis, and 
 exposing the underlying parts to the air. This accident is attended with 
 considerable pain. Boric acid powder may be applied in suppurative 
 cases. If the meatus is involved, boric acid should be blown into it. 
 
DERMATITIS OF THE AURICLE 647 
 
 HERPES ZOSTER OF THE AURICLE. 
 
 This is a vesicular eruption which appears on a reddened surface, 
 although the area of redness does not extend much beyond the base of 
 the blisters. The vesicles are arranged in groups and are quite painful. 
 
 They most often appear upon the posterior surface of the auricle and 
 the lobule, and more rarely upon the anterior or superior surface of the 
 meatus. They still more rarely develop upon the anterior surface of the 
 auricle. 
 
 It is an affection of either the trigeminus or the great auricular nerve. 
 In some cases it seems to be of ganglionic origin. 
 
 The location of the eruption is determined by the distribution of the 
 affected nerve. 
 
 In rare instances the drumhead is involved, although the hearing 
 may be but slightly affected thereby. Within a few days after the for- 
 mation of the vesicles they burst, emptying their contents, after which 
 crusts form at the site of the eruption. 
 
 A few days later new epidermis forms, and unless there is a recurrence 
 of the disease, complete recovery takes place. 
 
 Treatment. — Although herpes has been recognized as a distinct 
 disease for a long time, the treatment of it has not developed beyond an 
 attempt to relieve pain and to prevent excoriations after the bursting 
 of the vesicles. The internal administration of arsenic is often recom- 
 mended with the idea of correcting the nervous disorder which is the 
 chief cause of the trouble. It is doubtful, however, if it has any specific 
 effect as a remedy. Anodyne remedies, such as the 5 per cent, ointment 
 of the hydrochlorate of cocaine, may be applied locally with a fair 
 degree of confidence that it will afford relief. Calomel dusted over 
 the eruptions, especially after they have discharged their contents, in- 
 duces healthy and speedy epidermization of the denuded surfaces. 
 
 DERMATITIS OF THE AURICLE. 
 
 Dermatitis may be due to traumatism, exposure to heat or cold, and 
 to a parasitic infection (Politzer). The treatment should consist of the 
 application of solutions of lead. 
 
 It occasionally happens that when there is an abrasion of the skin of 
 the auricle or a loss of the integrity of the epidermis due to eczema, 
 etc., erysipelatous infection may occur and lead to a much more severe 
 type of inflammation. 
 
 Treatment. — The treatment should be antiphlogistic, and weak 
 solutions of ichthyol (1 to 5 per cent.) should be applied locally. 
 
 Should the deeper tissues become involved and pus accumulate 
 therein, free incision should be made and the parts treated according 
 to aseptic surgical principles. 
 
648 THE EAR 
 
 Dermatitis from Exposure to Cold. — Synonyms. — Frostbite; chil- 
 blain; dermatitis congelationis auricula. 
 
 Etiology. — Exposure to extreme cold or prolonged exposure to moder- 
 ate temperature, as in the autumn of northern latitudes, also the ex- 
 treme thinness of the skin and slight amount of subcutaneous tissue 
 separating it from the cartilage of the auricle, predisposes to dermatitis. 
 
 The disease is characterized by the formation of nodules and excoria- 
 tions, especially on the elevated portions of the auricle. 
 
 In the extreme north the dermatitis is usually acute in character, and 
 is attended with simultaneous freezing of the nose. More or less necrosis 
 and gangrene, and partial loss of the auricle follows. 
 
 The affection is most common in young chlorotic girls of northern 
 climates, and always appears at the beginning of cold weather. It is 
 more than probable that insufficient and improper food predisposes to 
 its occurrence. These conditions, together with the unstable vasomotor 
 system at the age of puberty, may be considered the chief etiological 
 factors. 
 
 Symptoms. — Ordinary frostbite is characterized by moderate swelling, 
 redness, and circumscribed dermatitis. 
 
 The nodules heal slowly or not at all, and become covered by bloody 
 crusts. Even after the crusts disappear the skin continues to exfoliate 
 epidermis for a long time. In addition to these symptoms, which are 
 apparent to the eye, there are lancinating pains, sense of heat, itching, 
 etc., which cause the patient to scratch or rub the parts, thereby increas- 
 ing the inflammation. 
 
 Treatment. — In those cases which are due to extreme cold, snow or 
 ice-bags should be applied. In the subacute varieties, Goulard's extract 
 is serviceable. The auricle may be painted with iodine collodion, or 
 camphor ointments. For the relief of the intolerable itching the following 
 mixture is of value: 
 
 1$ — Collodion 3J 
 
 01. ricini TT\xx 
 
 01. terebinth §j — M. 
 
 Sig. — Apply locally to relieve itching. 
 
 The frequent application of camphor ointment will relieve the itching. 
 
 FURUNCULOSIS OF THE EXTERNAL MEATUS. 
 
 Synonyms. — Follicular inflammation of the external auditory canal; 
 otitis externa; follicularis s. circumscripta. 
 
 Etiology. — Furunculosis of the external auditory canal is a circum- 
 scribed inflammation involving either the hair follicles or the sudo- 
 riferous glands. As these organs are limited to the cartilaginous or 
 eternal portion of the canal, the furuncles are not found in the deeper or 
 osseous portion. The boils may occur without known cause, or they may 
 be a part of a general furunculosis. They may occur in the course of 
 
FURUXCULOSIS OF THE EXTERXAL MEATUS 649 
 
 suppurative otitis media and chronic eczema. Traumatism from 
 attempts at cleaning the ears often causes them. Furunculosis most often 
 appears in the spring and autumn, and is chiefly a disease of adult life, 
 though I have seen cases in infants. General debilitating diseases or 
 their sequelae predispose to it. 
 
 Symptoms. — The hearing is but slightly affected in most cases, as 
 the lumen of the canal is not completely obstructed. The pain is more 
 or less intense according to the depth of the inflammatory process. The 
 furuncle does not always present the appearance of a boil, as the skin is 
 tense and closely adherent to the cartilaginous meatus, thus preventing 
 the usual elevated appearance. 
 
 The auricle is extremely sensitive to the touch, and the movements of 
 the inferior maxilla in mastication cause pain. The tension of the skin 
 becomes so great that the patient is often unable to sleep. The swelling 
 in the external meatus is more or less diffused on account of the close 
 adhesion of the skin to the cartilaginous meatus, and with the inexperi- 
 enced may be mistaken for the redness and swelling in the postsuperior 
 portion of the meatus in njastoid inflammation. It is easily differen- 
 tiated from it, however, by remembering that the swelling due to mas- 
 toid disease is limited to the postsuperior wall of the osseous or deeper 
 portion of the meatus, while that due to furunculosis is in the posterior 
 and inferior wall of the outer or cartilaginous portion. The pain is 
 often greater in furunculosis. In infants the differentiation is more 
 difficult, as the meatus is very shallow and the swelling is near the mem- 
 brana tympani, which it may obscure. 
 
 The temperature is irregularly elevated during the first few days. 
 Deafness and tinnitus are present if the meatus is occluded, though 
 they may be present without occlusion. When this is the case the in- 
 flammation has probably extended to the drumhead and the tympanum. 
 
 The more superficial the furuncle the greater the redness and the 
 more circumscribed its area. Pain may or may not be present. If the 
 deep tissues are involved the redness and swelling are more diffused, 
 while the pain is greater. In some cases the surrounding tissues become 
 more or less swollen, as, for instance, when the anterior portion of 
 the meatus is involved, the skin in front of the tragus is swollen and 
 purple in color; whereas if the posterior portion is involved, the mastoid 
 skin may be swollen and simulate mastoiditis. Glandular enlargement 
 in the lateral region of the neck is not commonly present. 
 
 Course. — Furunculosis of the meatus is likely to go on to suppuration, 
 which usually takes place in from six to eight days. The deeper the 
 inflammation the more delayed the voluntary escape of pus. The 
 pain and swelling subside immediately after the pus is liberated, especially 
 if it is done by incision. Incision should be made early, as the progress 
 of the disease is often thereby checked. The meatus should then be 
 irrigated with warm boric acid solution, thoroughly dried and dusted 
 with bismuth, and a gauze wick inserted for drainage. The dressing 
 should be changed daily until the swelling and discharge have materially 
 subsided. If the boil is allowed to rupture spontaneously granulations 
 
650 THE EAR 
 
 may spring from its crater, and be mistaken for middle ear polypus. 
 Recurrences are to be expected in many cases. 
 
 Treatment. — Abortive treatment may be used before the forma- 
 tion of pus has taken place. The best remedy is a 12 per cent, solution 
 of carbolic acid in glycerin. This should be instilled into the meatus, 
 or applied with a cotton-wound applicator if the canal is open. Its 
 early use is often followed by a complete disappearance of the process. 
 The Leiter ice coil gives relief to the pain. Mixtures containing opium, 
 morphine, cocaine, etc., are recommended, but the carbol-glycerin 
 mixture is not only curative, but analgesic as well. Poultices have 
 been recommended, but their use is irrational and obsolete. Antiseptic 
 solutions are valuable adjuncts in the treatment of furunculosis, and 
 the carbol-glycerin solution answers this purpose admirably, in addi- 
 tion to its anodyne and curative properties. Should it fail to give the 
 desired relief, the meatus is at least prepared for operative measures. 
 
 In a large majority of cases the process has gone on to the suppurative 
 stage before the physician is called in. When pus is present the furuncu- 
 lous area should be freely incised with a narrow bistoury. Pus may not 
 appear at once, but this should not deter the physician from incising 
 each swollen and reddened area. If voluntary rupture has occurred 
 and the flow of pus is obstructed by granulations, the area should be 
 opened more freely. 
 
 After-treatment. — Immediately after incision the exposed cavities 
 should be cleansed with a 5 per cent, solution of carbolic acid to check 
 the growth of the pus cocci. Frequent instillations of the peroxide of 
 hydrogen should be used to keep the wound and the meatus free of 
 pus. 
 
 The ceruminous secretion is often absent after an attack of furuncu- 
 losis, or, if present, is of a dry, crumbling quality. Intolerable itching 
 usually complicates furunculosis. 
 
 Various remedies for the relief of the itching have been recommended. 
 The white precipitate ointment, boric acid 5 per cent, in lanolin, and 
 the glycerin-carbolic acid solution are valuable for this purpose. 
 
 The entrance of plain water into the meatus often leads to a relapse, 
 hence care should be exercised to prevent it. 
 
 DIFFUSED INFLAMMATION OF THE EXTERNAL MEATUS. 
 
 Synonym. — Otitis externa diffusa. 
 
 Etiology. — The causes are (a) infections from without and from 
 within the middle ear; (b) traumatism; (c) excoriation of the cutis of the 
 meatus; and (d) the injection of irritating fluids into the meatus. 
 
 Symptoms. — Unlike the furunculous type, the symptoms are chiefly 
 limited to the osseous meatus and the drumhead. The cutis is swollen 
 and congested, and after a few days throws off a serogelatinous secre- 
 tion, which is often so tenacious that it can be removed en masse (Politzer). 
 It is charged with pathogenic organisms, thus showing its bacteriological 
 origin. 
 
HEMORRHAGIC INFLAMMATION OF THE MEATUS 651 
 
 Great pain in the region of the ear is usually present, and movements of 
 the inferior maxilla aggravate it. Tinnitus and dizziness are occa- 
 sionally present. The hearing may be impaired, especially if the drum- 
 head is much swollen, or if there is a large accumulation of thick secre- 
 tion. 
 
 The duration of the disease is three or more days. If it runs an un- 
 interrupted course, an acute case may terminate on the third day. The 
 hearing is usually normal after the inflammation ceases. In rare cases 
 an excoriated or ulcerous surface is left, and becomes the seat of a granu- 
 lation tumor, which, when removed, checks further secretion of pus. 
 
 Periostitis and hyperostosis may remain as sequelae in rare cases. 
 
 Prognosis. — In the simple forms complete recovery usually occurs, 
 while in those cases which are complicated by excoriations, constriction 
 of the meatus from periostitis, hyperostosis, and dermoid thickening 
 are likely to affect the function of the ear. 
 
 Treatment. — It should be borne in mind that the disease is usually 
 of bacteriological origin, and remedies should be applied accordingly. 
 The carbol-glycerin mixture (12 per cent.) is, perhaps, one of the most 
 reliable remedies. It should be instilled into the meatus two to three 
 times daily and cotton-wool introduced into the cartilaginous canal. The 
 Leiter coil, and leeches to the tragus and the mastoid region are of great 
 value when there is swelling and pain. Antiseptic solutions of all kinds 
 have been recommended, but it is doubtful if any of them are of special 
 value. It may be said of aqueous solutions in general that their utility 
 is questionable. Remove the secretions from the meatus with the 
 peroxide of hydrogen and a cotton-wound applicator and then apply the 
 carbol-glycerin mixture. 
 
 If ulcers form and show no tendency to heal, they should be cauterized 
 with a 90 per cent, solution of the nitrate of silver. 
 
 HEMORRHAGIC INFLAMMATION OF THE MEATUS. 
 
 Synonym. — Otitis externa hemorrhagica. 
 
 This is a form of hemorrhage beneath the superficial layer of the skin 
 of the osseous meatus, and in most cases is probably a complication of 
 influenza otitis media. The hemorrhagic areas appear as bluish swell- 
 ings on the inferior or the posterior wall of the meatus. To the probe 
 they are soft and often rupture upon very slight pressure. The vesicles 
 may remain for several days, and when they disappear others may come 
 to take their place. In from one to two weeks they disappear altogether, 
 and complete recovery takes place. The hearing, if affected, returns to 
 normal. 
 
 Treatment. — The hemorrhagic vesicles should be opened with a 
 probe and gauze drainage applied to the meatus. The dressing should 
 be removed daily. Politzer recommends dusting the meatus with boric 
 acid powder in addition to the gauze drainage. 
 
652 THE EAR 
 
 CROUPOUS INFLAMMATION OF THE MEATUS. 
 
 Synonym. — Otitis externa crouposa. 
 
 This is a very rare condition, and usually occurs together with in- 
 fluenza otitis media or furunculosis of the meatus. The false mem- 
 brane is limited to the osseous portion of the meatus and to the outer 
 surface of the drumhead, and in this is similar to the diffuse inflamma- 
 tion of the meatus. It sometimes appears with a similar process on 
 the tonsils (Gottstein). The membrane forms in from one to two 
 days and is firmly attached; it may, however, be removed by forcible 
 syringing. It may form a cast of the osseous meatus and the drumhead. 
 The microscope shows it to be composed of a fibrous network infiltrated 
 with round cells, nuclei, epithelium, Staphylococcus pyocyaneus, and 
 Streptococcus pyogenes (Politzer). 
 
 The formation of the membrane is attended with some pain, which 
 is relieved when it is cast off. Recurrences are common. 
 
 Prognosis. — The prognosis is favorable. In rare cases the cartilage 
 of the meatus becomes necrotic or gangrenous. 
 
 Treatment. — The treatment consists in removing the false mem- 
 brane with forceps or by antiseptic solutions applied with a syringe, 
 and drying the meatus and dusting it with an antiseptic powder. 
 
 EXOSTOSIS AND HYPEROSTOSIS OF THE MEATUS. 
 
 These two terms are often used synonymously, although, according 
 to strict pathological interpretation, they should be used to describe differ- 
 ent lesions of the bony tissue. 
 
 An exostosis is a bony tumor growing from the wall of the meatus, 
 which may be either sessile or pedunculated. Hyperostosis is a diffuse 
 thickening of the bony tissue, or a true hyperplasia. 
 
 Etiology. — The cause of these pathological changes is often unknown, 
 but in many instances they are due to conditions which may be easily 
 recognized. Among them may be mentioned: 
 
 (a) Traumatic fracture of the walls of the meatus, whereby a cir- 
 cumscribed periostitis is excited, which finally results in the formation of 
 a bony mass or tumor. 
 
 (b) They may be due to developmental causes, particularly in those 
 cases wherein the middle and the inner section of the osseous meatus on 
 each side is the seat of the growth. When due to faulty development 
 the growths are usually small. They may be either sessile or peduncu- 
 lated. 
 
 (c) Chronic suppuration of the middle ear may excite a secondary 
 inflammation of the membranous canal, and cause a fibrous or con- 
 nective-tissue thickening, which, after a long period of time, may be 
 metamorphosed into osseous tissue. 
 
EXOSTOSIS AND HYPEROSTOSIS OF THE MEATUS 653 
 
 (d) There are some cases in which heredity seems to be a factor in the 
 production of the growths, as the same condition may be traced through 
 a few generations. 
 
 (e) Syphilis is undoubtedly a cause of the growths, although not in 
 a very large number of cases. 
 
 (/) Gout has been thought to be another cause, but it is doubtful if 
 this condition leads directly to their formation. 
 
 It is more probable that the gouty diathesis causes an inflammatory 
 process of the skin and the periosteum, which finally undergoes a retro- 
 grade change and becomes the seat of lime deposit. 
 
 Symptoms. — The symptoms are chiefly those recognizable by the 
 aid of the eye and the probe, although in some cases in which the lumen 
 of the ear is completely occluded the function of hearing may be affected. 
 If the growth is an exostosis, it appears as a rounded, elevated mass, 
 with a tense, whitish covering of skin. The lumen of the meatus is 
 reduced to a crescentic or slit-like opening. The swelling or growth is 
 composed of very dense tissue. If it is sessile, it will be difficult to dif- 
 ferentiate between it and a hyperostosis, but if it is pedunculated the 
 differential diagnosis may be more easily made, as this type of growth 
 is more often an exostosis. A favorite seat for the growths is at the 
 junction of the osseous and the cartilaginous portions of the meatus. 
 They may, however, form in any portion of the canal. Deafness may 
 be present, although it is not marked, unless there is concurrent disease 
 of the middle ear or the labyrinth, except in those cases in which the 
 growth completely obstructs the lumen of the canal. Secondary inflam- 
 mation of the cutaneous meatus may be caused by the pressure of the 
 growth against the opposing walls. In such cases there will be more or 
 less secretion from the dermatitis thus excited. Cases have been re- 
 ported in which the pressure of the growth was so great that necrosis of 
 the surrounding bone tissue resulted, thereby complicating the case. 
 
 Treatment. — The treatment is necessarily limited chiefly to surgical 
 procedures, except for the relief of those symptoms which are due to 
 secondary inflammatory processes. If the growth is large enough to 
 interfere in any way with the function of audition, it should be removed. 
 In some cases this can be done through the external auditory meatus 
 without lifting the auricle forward, as is done in the mastoid operation. 
 The skin and periosteum over the growth should be excised and elevated, 
 and the bony mass removed or reduced with a small chisel or gouge 
 or with a trephine. If the growth is sessile or diffused, and involves 
 the entire length of one wall of the meatus, it would, perhaps, be futile 
 to attempt to remove it through the external auditory meatus. A better 
 and much simpler procedure would be first to lift the auricle forward, 
 as in the mastoid operation, thus exposing the entire canal to view and 
 affording easy access with instruments. When this is done the skin of the 
 osseous portion of the meatus should be carefully elevated with a small 
 periosteum elevator, so that the healing process may be more certain 
 and rapid after the operation. The exposed tumor should then be re- 
 moved with a very sharp gouge, or, perhaps better still, by the use of a 
 
654 THE EAR 
 
 trephine. This method of procedure is also productive of better results 
 in many of the pedunculated growths, as the base can thus be completely 
 removed. 
 
 The indications for operative interference should be based upon the 
 amount of deafness present and upon the concurrent middle ear disease, 
 if present. If, for example, there is chronic suppurative ear disease, 
 with impairment of hearing, it is quite essential to the proper treat- 
 ment of the case that the external auditory meatus be completely freed 
 from the obstructive lesion, so as to afford better drainage and opportuni- 
 ties for treatment of the middle ear cavity. 
 
 Another indication is the presence of dermatitis with secretions, while 
 a still more urgent indication is secondary pressure necrosis of the con- 
 tiguous tissue. 
 
 It seems irrational, in view of the present status of surgery, to resort to 
 the use of laminaria tents for the dilatation of the canal, as the process 
 must necessarily be a long and painful one. This method was formerly 
 in vogue and is still recommended in some of the modern text-books on 
 otology. 
 
 STRICTURE OF THE EXTERNAL MEATUS. 
 
 Etiology. — Obstructive lesions of the external auditory canal are 
 due to the inflammatory swelling of the skin which lines its walls, as 
 described under dermatitis, furunculosis, perichondritis, eczema, etc. 
 It may also be due to new-growths, exostosis, and fibrous thickening of 
 the deeper dermal tissue. It is to the last-named condition that perma- 
 nent obstruction of the lumen of the canal is usually due. 
 
 Cicatricial rings or bands are produced by prolonged inflammation 
 of the meatus in the course of chronic otorrhea. In rare instances they 
 are due to syphilis, diphtheria, etc., or to the use of the cautery and acids 
 in the meatus. Partial closure of the canal sometimes follows the mas- 
 toid operation, especially if the plastic meatal skin flap is not properly 
 sutured and the wound is tightly packed with gauze. (See Mastoid 
 Operation.) In the aged the cartilage which supports the skin of the 
 meatus undergoes atrophic changes, which allows the walls to collapse 
 and obstruct the meatus. 
 
 In some cases the obstructive lesion is ring-like, while in others it may 
 be limited to one wall of the meatus. If it is due to an exostosis, there 
 is a tumefaction on one side of the canal. The tumor is hard to the 
 touch of the probe, and may either partially or wholly obstruct the meatus. 
 Exostosis sometimes follows the exfoliation of necrosed bone, while in 
 other cases it develops from the periosteum or from the bone beneath, 
 as true hyperostosis. 
 
 Treatment. — As the origin of the obstruction is various, so should 
 the treatment be varied. If inflammatory, suitable treatment should be 
 instituted. If it is cicatricial in character, laminaria tents and the sub- 
 sequent introduction of hard-rubber tubes may be used. In this way 
 the stricture is dilated, and maintained in this condition by the rubber 
 
MYCOSIS OF THE EXTERNAL MEATUS 655 
 
 tubes. Electrolysis may also be used with advantage; from five to 
 six sittings are required to reduce the fibrous constriction. The needles 
 connected with the negative pole of the galvanic battery should be 
 inserted into the fibrous ring, while a large sponge electrode connected 
 with the positive pole should be placed in contact with the body. The 
 amount of current necessary to soften the tissue varies from 25 to 50 
 ma., and each seance should last from five to twenty minutes, according 
 to the amount and density of the fibrous tissue. 
 
 Another method of treating fibrous strictures is to split the canal 
 longitudinally in several parallel lines and introduce sponge tents. 
 After thorough dilatation the hard-rubber tubes should be used to 
 maintain the patency of the meatus. 
 
 Jansen resorts to a surgical procedure which is probably the most 
 successful mode of treatment, whether the stenosis is cicatricial or 
 osseous in character. He detaches the auricle as in the mastoid opera- 
 tion, and then dissects away the fibrous ring, osteoma, or hyperostosis. 
 To cover the bony wound, he makes a pedunculated flap from the skin 
 over the mastoid process and inserts it through the line of incision made 
 in detaching the auricle. 
 
 Should the stricture be of long standing and accompanied by sup- 
 puration of the middle ear, a radical mastoid operation should be done, 
 during which the canal may be enlarged. 
 
 MYCOSIS OF THE EXTERNAL MEATUS. 
 
 Synonyms. — Parasitic inflammation of the external auditory canal; 
 otomycosis. 
 
 Etiology. — The source of the mycotic infection is often unknown. 
 Living in damp surroundings or in the presence of yeast spores seems 
 to favor it; hence, it is rather common among bakers. The habit of 
 instilling warm oil into the ears to relieve earache favors the growth 
 of the spores, as the oil is a good soil for their development. The spores 
 which most commonly cause the disease are the Aspergillus niger, flavus, 
 and fumigatus. Several other varieties are occasionally found. 
 
 It usually occurs in adults, and rarely in children or in the old. As the 
 sanitary and hygienic conditions surrounding the poor are bad, it is com- 
 mon among them. The fungus growth may, in rare cases, extend to the 
 middle ear cavity or even to the mastoid cells. 
 
 Symptoms. — The manifestations of the infection depend largely 
 upon whether the spores have attacked only the epidermis or also the 
 deeper living structures of the skin or the drumhead. If only the epi- 
 dermis is affected, there may be no symptoms, even when the drumhead 
 is covered with the false membrane; on the contrary, if the true skin is 
 involved, deafness and tinnitus are more or less severe as a result of 
 the swelling and inflammation which has been excited. This type of 
 inflammation is known as otitis externa parasitica, and is characterized by 
 shooting pains, itching, tinnitus, and deafness. 
 
 The appearance of the mycotic membrane is black or grayish in color, 
 
656 THE EAR 
 
 velvety in texture, and distributed chiefly over the osseous portion of the 
 canal, although the drumhead and the cartilaginous portion of the 
 canal may also be covered by it. It can be removed by syringing. The 
 underlying skin is red, slightly swollen, and largely denuded of epidermis. 
 
 The course of this type of inflammation, if not properly treated, may 
 extend over several weeks. Under treatment its duration may be much 
 shortened. 
 
 The pains and other subjective symptoms are usually greatly relieved 
 immediately after the removal of the membrane. 
 
 Treatment. — Almost the entire list of antiseptic mixtures and powders 
 have been used for the relief of this disease, but the remedy par excel- 
 lence is alcohol, which should be instilled into the meatus once or twice 
 daily; two to four days are usually sufficient time to effect a cure. The 
 alcohol should be used at intervals every two weeks for a few months 
 to prevent a recurrence. 
 
 ACUTE ECZEMA OF THE EXTERNAL EAR. 
 
 The superficial layers of skin are involved, and, in the beginning, 
 there is marked redness and swelling of the skin; nests or colonies of 
 fluid-filled vesicles soon make their appearance. 
 
 Etiology. — It is not always possible to ascribe a cause for the erup- 
 tion, although it is usually due to one or more of the following factors: 
 viz., neurosis, scrofula, rickets, discharge of pus from the middle ear, 
 irritating remedies, cold douches, and exposure to heat. Other causes 
 exist in selected cases. It may be a primary affection or it may be second- 
 ary to a similar process on some other part of the body. 
 
 Symptoms. — The onset of the disease is characterized by burning 
 and itching, which is soon followed by pain. Deafness and tinnitus are 
 present in those cases in which the meatus and the drumhead are in- 
 volved, especially when the exfoliated epidermis and secretions obstruct 
 the lumen of the canal. If the disease is limited to the auricle, the hear- 
 ing is not affected. There is some elevation of the temperature, especially 
 in children. The pain and the pyrexia give rise to restlessness and in- 
 ability to sleep. 
 
 The disease may terminate in one of three ways, namely: (a) In the 
 mild form the vesicles dry up and the epidermis peels off on the second or 
 third day, leaving the natural cuticle, (b) In a large number of cases 
 the blisters discharge their contents and after a few days the surface 
 becomes covered with yellow crusts. In time these disappear and 
 recovery takes place, (c) The third and most disagreeable mode of 
 termination is the persistence of serous or purulent secretion for several 
 weeks, after which the parts become covered with epidermis. 
 
 In some cases the eczema may persist in isolated areas for many weeks 
 and leave more or less scar tissue and contraction, or it persists and 
 beromes typically chronic in character. 
 
 The treatment will be considered under Chronic Eczema. 
 
CHRONIC ECZEMA OF THE EXTERNAL EAR 657 
 
 CHRONIC ECZEMA OF THE EXTERNAL EAR. 
 
 Symptoms. — Owing to the involvement of the deeper structures of 
 the skin there is greater thickening and rigidity of the auricle than in the 
 acute type. The crusts usually form in the hollows of the auricle and in 
 the posterior groove, while beneath them is secreted a serous or purulent 
 matter. The meatus may be obstructed by the thickening of its integu- 
 ment The whole auricle, and in some cases the meatus, is the seat of a 
 desquamative process. The process of desquamation and crust forma- 
 tion varies in different cases, although the desquamation is usually 
 predominant. 
 
 Exclusive of the appearance of the skin, the itching is the most severe 
 symptom. The patient is overcome with an irresistible desire to rub 
 or scratch the parts, and thus produce deeper lesions of the skin. 
 
 Tinnitus and deafness may result from desquamative plugs in the 
 meatus and from secondary hyperemia of the mucous membrane of 
 the middle ear. It is barely possible that in rare cases hyperemia of the 
 labyrinth may be induced. 
 
 The course of chronic eczema is quite different in individual cases, 
 some are cured under treatment in a few weeks, while others obsti- 
 nately persist under any form of treatment. Boils in the meatus may 
 complicate the condition. 
 
 Treatment. — The general treatment should be addressed to the 
 correction of constitutional dyscrasias and neuropathic states which so 
 often underlie the condition. Iron, arsenic, strychnine, iodine, and the 
 bitter tonics should be given in suitable combination for this purpose. 
 The administration of saline cathartics and an occasional dose of calomel 
 will often aid in overcoming the eczema. 
 
 Perhaps one of the best measures for its relief is negative in character, 
 namely, the avoidance of the local application of water, which greatly 
 aggravates the eczema. If it is desirable to use water for toilet pur- 
 poses, the patient should be instructed to add boric acid or a teaspoonful 
 of common table salt to the quart of water. The irritating qualities 
 of the water are thus reduced. 
 
 The local treatment is somewhat different in the acute and the chronic 
 forms, hence they will be considered separately. 
 
 Local Treatment of Acute or Subacute Eczema. — The remarks concerning 
 the avoidance of plain water are especially applicable to this type of 
 eczema. If proper care is exercised, some cases will be cured with no 
 local or constitutional treatment whatever. Others will persist in spite 
 of any mode of treatment, and gradually pass into the chronic form. A 
 soothing ointment composed of one dram of the oxide of zinc to the ounce 
 of lanolin or vaseline is very sedative, especially if the disease is due to an 
 irritating discharge from the middle ear. The addition of one grain of 
 the acetate of morphine will increase the sedative action of the ointment. 
 Calomel dusted on the excoriated or fissured surfaces acts well in some 
 cases. Lotions of liquor plumbi subacetatis and resorcin are indicated 
 42 
 
658 THE EAR 
 
 when there are large vesicated surfaces. As their application excites 
 pain, the parts should previously be painted with a 5 per cent, solution 
 of cocaine. Ichthyol in aqueous solution (2 to 50 per cent.) has proved 
 a valuable remedy. The parts should be painted once or twice daily. 
 Cotton pads may be applied over the painted surface to prolong the 
 therapeutic effect of the remedy and protect the diseased area from 
 the air. 
 
 When the case is in the crust-forming stage proceed as follows: 
 (a) Remove the crusts by first softening them for twenty-four or 
 forty-eight hours by local applications of oil, vaseline, lanolin, balsam of 
 Peru, or a 10 per cent, solution of Burow's mixture. If the oily prepara- 
 tions are used, cotton should be saturated with them and applied over 
 the scabs, and protected by another pad of gauze lightly held in position 
 by a bandage. If Burow's mixture is used, the pads of cotton saturated 
 with it should be covered with oiled silk or rubber cloth to prevent evapo- 
 ration. Change every two hours. 
 
 (6) At the end of twenty-four hours the crusts may be removed with 
 a probe or forceps. Great care should be exercised to avoid inflicting 
 injury to the underlying surface, as to do so causes a larger crust to 
 form. 
 
 (c) The parts are now ready for the medicated ointments referred to 
 above. They should be changed every day. The parts should be care- 
 fully cleansed each time by wiping them with cotton pads, water being 
 carefully avoided. If the crust formation is obstinate, the parts should be 
 painted with a 1 to 3 per cent, solution of the nitrate of silver before 
 reapplying the salve. 
 
 (d) When epidermization is established the new skin should be pro- 
 tected from mechanical or chemical (water) irritants by the use of 
 simple ointments for several weeks. If this is not done recurrences 
 are likely to take place and the hyperemia which is present in this stage 
 may be exaggerated. 
 
 Local Treatment of Chronic Eczema. — It is rather difficult to outline a 
 definite procedure for the treatment of chronic squamous eczema, as so 
 many remedies are recommended, none of which may be depended upon 
 except in selected cases. 
 
 Those remedies which soften the scaly epidermis and reduce the hyper- 
 emia of the skin afford the best results. 
 
 To soften the scaly epidermis, vaseline, lanolin, or olive oil should be 
 rubbed in once or twice daily; or a 10 per cent, solution of Burow's 
 mixture may be applied as described above. 
 
 After thus softening and removing the horny layer, the parts should 
 be painted with a 10 to 20 per cent, solution of the nitrate of silver. The 
 author has used this method after the suggestion of Politzer, with the 
 greatest satisfaction. An immediate cure should not be expected, as 
 several weeks are often necessary to effect it. 
 
 Fissures or cracks at the external auditory orifice are best treated with 
 solid nitrate of silver or salicylic acid ointment. 
 
CHRONIC ECZEMA OF THE EXTERNAL EAR 659 
 
 Nearly all the ointments in the Pharmacopoeia have been used in 
 eczema, but further mention of them need not be made here. If the 
 treatment according to the above principles fails, the case is probably 
 one which will resist all treatment. In the event of failure, special care 
 should be observed to soften thoroughly the scaly epidermis and to 
 remove it, and then the silver solution should again be used. Many of 
 the failures are due to the non-observance of this procedure. 
 
CHAPTER XXXVIII. 
 
 MALFORMATIONS AND DISEASES OF THE MEMBRANA TYMPANI. 
 
 In early life the upper portion of the membrana tympani may be absent 
 with no history of previous suppuration. This is explained by the fact 
 that in the embryo this is the last portion of the membrane to form, and, 
 the process not being complete, a perforation or opening persists. Von 
 Troltsch suggested that some of the perforations just above or behind the 
 processus brevis mallei, such as are seen in otorrhea, are congenital, 
 but have become enlarged by a subsequent suppuration within the 
 tympanum. This observation may be questioned in certain particulars 
 in view of the fact that the location of the perforation is usually indicative 
 of the character and seat of the middle-ear involvement. For instance, a 
 perforation in the region of the processus brevis mallei usually indicates a 
 necrosis of the malleus, and possibly, also, of the tegmen tympani. We 
 find that the perforation appears as readily in other portions of the mem- 
 brana tympani if the focus of the middle-ear lesion is in other locations. 
 Nevertheless, it may be said that a certain number of perforations in the 
 region of the short process of the malleus may be of congenital origin, 
 and that this portion of the membrana tympani is thereby rendered more 
 vulnerable. 
 
 INJURIES OF THE MEMBRANA TYMPANI. 
 
 While injuries to the membrana tympani are comparatively rare, 
 nevertheless, when they do occur it is important to know the proper 
 method of procedure. They may be due to either direct or indirect 
 violence. 
 
 Etiology. — Injuries by direct violence may be due to (a) attempts to 
 remove the cerumen from the meatus with a pin, a hairpin, a toothpick, 
 an earspoon, etc. ; (b) the accidental thrust of any long slender instru- 
 ment, tool, or splinter of wood; (c) the introduction of a caustic or a hot 
 fluid into the meatus; (d) the fracture of the bone which supports the 
 membrana tympani; (e) and finally, sneezing, inflation of the ear, etc., 
 may also rupture the membrana tympani. 
 
 Injuries by indirect violence may be due to (a) the violent and sudden 
 compression of air in the meatus by a blow on the ear with the palm of the 
 hand, or it may be due to (6) the concussion of the atmosphere during a 
 violent explosion or discharge from a large cannon. In view of the more 
 or less familiar occurrence of windows being blown inward at the time 
 of an explosion, it may be readily appreciated how the membrana 
 tympani may be ruptured by such an atmospheric disturbance. 
 
INJURIES OF THE MEM BRAN A TYMPANI 661 
 
 Symptoms. — Pain is a prominent symptom in those cases in which 
 there is severe reactionary inflammation, while it may be absent if 
 little or no inflammation follows the injury. In some cases the pain is 
 only present at the time of injury. Hemorrhage, more or less severe, 
 may immediately follow the injury, or in rare cases it may continue for 
 an indefinite period. Faintness, giddiness, nystagmus, staggering gait, 
 convulsions, and nausea characterize those cases in which the foot plate 
 of the stirrup is forced inward, and in which the trauma irritates or 
 otherwise injures the labyrinth. The loss of hearing may be partial or 
 complete and temporary or permanent. The tinnitus at first comes on 
 as a loud noise, and then subsides until it is only moderate in severity 
 or entirely ceases. The effects upon the hearing are various. Deafness 
 may be so great that the watch can only be heard by contact, or, on the 
 contrary, the patient may suffer from hyperesthesia acoustica. When 
 the labyrinth is injured the deafness may be great or absolute. If the 
 injury involves the semicircular canals, the equilibrium may be dis- 
 turbed for a few days or weeks. 
 
 If the injury occurs in an ear in which the drumhead is adherent to 
 the promontory, it may overcome the adhesions and thus affect the 
 hearing favorably. In some cases the orientation for sounds is lost, 
 while in others there is simply a sense of fulness in the ears. 
 
 The rupture is usually located in the postinferior quadrant of the 
 membrana tympani, the periphery not usually being involved, as the 
 membrane is thicker and firmer near its border. The appearance of the 
 rupture is usually a mere slit (dark line), which varies in extent and shape. 
 In other cases it may appear as a round perforation with ecchymotic 
 spots scattered over the membrane. If the injury is inflicted by a blunt 
 instrument, the perforation is irregular or ragged in outline. 
 
 Cases have been reported in which there was an escape of cerebro- 
 spinal fluid from the ear, a foreign body having entered the labyrinth. 
 The fluid may also escape into the middle ear when there is a fracture 
 through the petrous portion of the temporal bone. 
 
 The ossicles of the middle ear, more particularly the malleus, are 
 sometimes fractured. While the fractured parts reunite, they do not 
 usually do so in their normal position. The author once saw a case 
 in which the handle of the malleus was fractured about 1 mm. below 
 the short process and the parts reunited in nearly or quite their normal 
 position. 
 
 Prognosis. — The prognosis is usually good, as the injury ordinarily 
 consists of a simple laceration or perforation of the membrane. In those 
 cases in which the labyrinth is involved the prognosis should be guarded. 
 If the injury to the labyrinth consists of a perforation of its outer wall, a 
 good result may be expected after the lapse of a few weeks. The giddiness 
 and nausea may persist for one or more weeks. If the osseous walls of 
 the middle ear are fractured, or if the ossicles are injured, the hearing may 
 be permanently impaired. Should purulent inflammation complicate 
 the case, the prognosis becomes more grave. The functional tests of 
 hearing should be used in all cases of fracture or injury, as by them the 
 
662 THE EAR 
 
 surgeon is enabled to draw conclusions as to the extent and location 
 of the injury and as to the probable outcome of the case. 
 
 Treatment. — In nearly all cases no treatment should be used other 
 than the introduction of a cotton or gauze tampon into the meatus to 
 prevent the entrance of infectious matter through the wound. If, in 
 spite of this simple precaution, marked inflammatory symptoms develop, 
 leeches should be freely applied over the mastoid region and in front of 
 the tragus, to promote the reaction of inflammation and thus aid in des- 
 troying the bacteria. Great care should be exercised in the treatment of 
 these cases lest infection be carried into the wound and the case become 
 complicated by suppurative inflammation of the middle ear and mastoid 
 cells, hence meddlesome treatment is to be condemned. 
 
 MYRINGITIS; INFLAMMATION OF THE MEMBRANA TYMPANI. 
 
 Etiology. — Myringitis may be primary or secondary. The primary 
 form is rare, and when present it is usually due to an injury by a foreign 
 body, instrumentation, or the introduction of caustic fluids into the 
 meatus. Secondary inflammation of the membrana tympani is more 
 common, and is due to an extension of an inflammatory process from the 
 auditory meatus or the cavum tympani. Thus, in the various forms of 
 dermatitis and acute otitis media catarrhalis it is often present. 
 
 Symptoms. — The chief symptoms are pain, more or less severe in 
 character, with a slight rise in temperature. Deafness and tinnitus are 
 present in proportion to the local injury, the swelling of the membrana 
 tympani, and the nature of the associated middle ear disease. 
 
 Objective Symptoms. — The membrana tympani is usually most affected 
 in its upper portion and especially along the line of the handle of the 
 malleus. In this region it is yellowish red in color, from the congestion 
 present. In a few days or hours the handle is lost to view, owing 
 to the intense congestion and infiltration of the membrane, the upper 
 portion of which bulges outward into the canal. The epidermic layer 
 may become separated from the fibrous or middle layer of the ear drum 
 by the serous or seropurulent fluid which accumulates between them. 
 Blisters or blebs sometimes form. The inflammatory process may involve 
 the osseous portion of the canal and thus obliterate the line of demar- 
 cation between the eardrum and the canal. 
 
 The mode of termination is by slow resolution, and the signs of inflam- 
 mation often persist for many weeks. In some cases fatty degeneration 
 or even calcareous deposits may remain after the disease is cured. 
 
 Abscess of the membrana tympani may occur in the course of acute 
 otitis media. The process is confined chiefly to the fibrous and the 
 mucous membrane layers, in contradistinction to the blisters which 
 form under the dermic or outer layer. 
 
 Vesicular or herpetic eruptions sometimes complicate myringitis, as 
 referred to above. 
 
 Hemorrhagic eruptions similar to those described under Otitis Externa 
 Hemorrhagica are occasionally present. 
 
INFLAMMATION OF THE MEMBRANA TYMPANI 663 
 
 Diagnosis. — The chief diagnostic point to be found in the slight 
 disturbance of hearing. The ear appears to be extensively and seriously 
 involved, while the hearing is but slightly impaired. The appearance 
 is much like that of acute suppurative otitis media, but the loss of hear- 
 ing is slight as compared with that which occurs in the latter disease. 
 
 Prognosis. — The prognosis must be based upon a knowledge of the 
 etiology of each case and upon the destructive or degenerative changes 
 which occur in the membrana tympani. If the myringitis is due to a 
 severe injury, or if fatty degeneration and calcareous deposits are in the 
 substances of the membrana tympani, the prognosis is less favorable than 
 when the case is simple in origin and of slight severity. On the other 
 hand, if perforation takes place and chronic suppurative otitis media 
 supervenes, the prognosis is still more unfavorable. 
 
 Treatment. — The treatment is (a) general, (b) local, and (c) surgical. 
 The general treatment should consist in the administration of tonics, 
 the iodides, and cod-liver oil if the patient is subject to any dyscrasia; 
 saline cathartics should also be administered. The local treatment 
 should consist of the application of natural or artificial leeches to the 
 mastoid process, to increase the hyperemia and leukocytosis, i. e., promote 
 the reaction of inflammation. The instillation of solutions of cocaine 
 are advised, but are of doubtful utility unless used in the following 
 combination : 
 
 1$ — Cocaine hydrochloratis, 
 Menthol crystals, 
 
 Carbolic acid crystals aa 5J — M. 
 
 Sig. — One or two drops in the fundus of the auditory meatus will relieve the pain in from five 
 to fifteen minutes. 
 
 The parts are at the same time anesthetized and prepared for the 
 opening of the abscess in the membrana tympani if it is present. The 
 remedy should be used with some caution, as it is likely to be absorbed 
 in sufficient quantity to cause toxic symptoms. The instillation of alcohol 
 into the meatus dilutes the solution and faciliates its removal if it should 
 become necessary. 
 
 The surgical treatment should consist in the incision of the outer or 
 dermic layer of the membrana tympani. In cases which are complicated 
 by abscess care should be exercised to avoid perforating the inner layer, 
 as infection might thus be carried to the middle ear. Gruber recom- 
 mends making incisions in the osseous portions of the auditory meatus 
 near the membrana tympani. The incisions should be about -J- inch long 
 and parallel with the circumference of the drumhead, so as to incise the 
 arterial branches at its circumference. The incisions promote the 
 reaction of inflammation and favor resolution. 
 
 After the abatement of the acute stage a serous discharge is given 
 off from the membrana tympani and the painful symptoms subside. 
 The ear should now be irrigated with a warm boric acid solution, dried, 
 and the meatus closed with absorbent cotton. 
 
 The cavum tympani (middle ear) may be inflated by the Politzer 
 
664 THE EAR 
 
 method; the diagnostic tube should be used to determine if a perforation 
 is present. The membrana tympani should also be inspected for the 
 same purpose. If a perforation is present the diagnostic tube conveys 
 to the examiner's ear the whistling sound characteristic of a perforation. 
 The membrana tympani may be so swollen that the perforation can- 
 not be seen. The discharge of pus into the meatus is another indication 
 of the presence of a perforation. This is rendered all the more prob- 
 able if the discharge contains strings of mucus. The presence of a per- 
 foration and chronic otitis media render the prognosis more serious. 
 
 PERFORATION OF THE MEMBRANA TYMPANI; ULCERATION OF 
 
 THE DERMIC LAYER; CHRONIC MYRINGITIS; CHRONIC 
 
 INFLAMMATION OF THE DRUMHEAD. 
 
 Etiology. — The causes leading to perforation of the membrana tympani 
 may be either external or internal. One of the external causes is acute 
 myringitis, with local fatty degeneration and subsequent sloughing of the 
 substance of the drumhead, the degenerative process beginning with the 
 outer layer and extending inward. Another external source is acute 
 dermatitis of the external meatus. This may extend to the drumhead and 
 result in the same degenerative and perforative processes. In many 
 instances the fatty degeneration is not followed by perforation, but 
 calcareous changes occur instead. 
 
 In some cases the destructive process is limited to a simple ulceration 
 of the dermic layer, which may appear as a simple circumscribed rough- 
 ness of the surface or as a reddened area where the epidermis is removed. 
 
 The internal causes of perforation or chronic inflammation are either 
 the acute catarrhal or the acute suppurative forms of otitis media. The 
 mucous layer of the drumhead first undergoes the ulcerative process, 
 and the fibrous and dermic layers are involved at subsequent periods. 
 The membrana tympani may long remain the seat of chronic inflamma- 
 tion, because the bloodvessels are injected and radiate from the margins 
 of the ulceration or perforation. 
 
 Symptoms. — If the lesion is simple — a superficial dermic ulcer — the 
 symptoms are slight, and tinnitus and a moderate disturbance of hearing 
 are present. If the ulcer is phlegmonous in type, pain and increased 
 deafness result. The secretions and the exfoliation of epidermis form 
 crusts on the surface of the membrana tympani, which obscure the 
 real lesion. Granulations may spring from the bottom of the ulcer. 
 
 In those cases in which there is perforation the tinnitus and the deaf- 
 ness are great. If the middle ear cavity is not primarily infected, it 
 becomes so through the perforation. Pus is discharged through the 
 opening into the external auditory meatus. If the ear is inflated by 
 the Valsalva, the Politzer, or the catheter method, a whistling noise 
 may be heard through the diagnostic tube. Inspection, after removal 
 of the debris from the auditory meatus, usually reveals the perforation. 
 It is often oval, though it may be round, pear- or kidney-shaped. Its 
 
IXCISIOX OF THE MEM BR AN A TYMPANI 665 
 
 location generally indicates the focal centre involved within the middle 
 ear or the accessory mastoid cavities. 
 
 Course. — The duration of chronic inflammation of the membrana 
 tympani, with or without perforation, is usually quite prolonged. The 
 dermic layer often undergoes repeated or continuous desquamation, 
 or there may be foci of fatty degeneration with calcareous deposits. In 
 some cases there is an atrophic process which renders the membrane 
 thin and parchment-like, and its function is thereby impaired. In still 
 other cases of external origin perforation occurs, and is followed by infec- 
 tion and suppuration within the middle ear. This may continue indefi- 
 nitely, or until ulceration and necrosis of the bony walls of the middle 
 ear and the pneumatic spaces of the mastoid process occur. 
 
 Treatment. — In those cases in which there is an active desquamation 
 or dermic ulceration, the crusts should be softened with a warm solution 
 of bicarbonate of soda, and then removed by syringing with a warm 
 solution of boric acid. The author's experience has justified the local 
 application of a 10 gr. solution of the nitrate of silver or of the compound 
 tincture of benzoin. The nitrate of silver stimulates healthy granulation 
 and regeneration, and the compound tincture of benzoin is astringent and 
 stimulates the process of repair. 
 
 If perforation has taken place and the cavum tympani is not yet 
 infected, an endeavor should be made to bring about regeneration of the 
 membrana tympani, and thus close the perforation. This may be done 
 by maintaining the external auditory meatus and the membrana tympani 
 in an aseptic condition, and by making stimulating applications to the 
 margins of the perforations, with the view of promoting granulation 
 until the opening is completely filled in. Various drugs and procedures 
 have been employed for this purpose, the best one being the local appli- 
 cation of a 20 per cent, solution of trichloracetic acid. 
 
 For the treatment of the middle ear complications see Suppurative 
 Diseases of the Middle Ear. 
 
 INCISION OF THE MEMBRANA TYMPANI 
 
 This method of treatment is coming into vogue more than formerly, as 
 clinical experience has demonstrated that when it is done at the proper 
 time an acute inflammation of the middle ear is aborted. Its effects 
 are due to the promotion of the reaction of inflammation and the facility 
 with which the drainage of the tympanic cavity is accomplished. The 
 presence of the inflammatory exudate within the cavum tympani is a 
 source of irritation because of its chemical composition and on account 
 of the pressure it exerts upon the swollen and inflamed mucous membrane. 
 It is, therefore, important that free drainage be established at a very 
 early period in the course of the disease. Formerly, it was recommended 
 that simple puncture of the drumhead be made for this purpose. Hovell 
 advocates this procedure. The author's experience, however, has shown 
 that such an incision is too small and that a free incision is attended bv 
 
666 
 
 THE EAR 
 
 Fig. 379 
 
 immediate and better results. No harm comes from free incision of the 
 membrana tympani, as union often takes place before it is desirable.' 
 Even when union does not occur early, only a very slight amount of scar 
 tissue is left behind. 
 
 The operation should not be delayed until there is bulging of the 
 membrana tympani, but should be undertaken as soon as there is marked 
 redness and thickening. If the incision is delayed 
 the membrana tympani may be so swollen and 
 red that the outline of the malleus cannot be 
 distinguished, and bulging of the drumhead 
 may occur, resulting in serious and extensive 
 pathological changes. If it is done early the 
 progress of the disease is checked and the pro- 
 cess of resolution is established. The incision 
 increases the hyperemia and leukocytosis, and 
 thus raises the resistance of the tissue and de- 
 stroys the microorganisms. 
 
 The most suitable place for the incision is 
 
 in the posterior inferior quadrant (Fig. 379), 
 
 as this is generally the most accessible, owing to 
 
 the curvature of the anterior wall of the external 
 
 auditory meatus, which obstructs the view of the 
 
 anterior portion of the membrana tympani. 
 
 The best instrument for the purpose is a curved bistoury (Fig. 380). 
 
 The lance-shaped or the pear-shaped knives are not well adapted, as 
 
 they are made for simple paracentesis. The point of the knife should 
 
 be introduced only far enough to penetrate the thickness of the membrana 
 
 Right membrana tympani, 
 showing the division into A, 
 postsuperior quadrant; B, 
 anterosuperior quadrant; C, 
 antero-inferior quadrant; D, 
 postinferior quadrant. 
 
 Fig. 380 
 
 Ear instruments. 
 
 tympani, as to pass it deeper might subject the inner wall of the cavum 
 tympani to injury. It should be remembered that the distance from the 
 outer to the inner wall is only about y ^ to 6 inch. The incision should be 
 curved or V-shaped (Fig. 381), to allow a wider opening between the 
 lips of the incision, and should be from J to f inch in length. In this 
 way free drainage is established. 
 
 Immediately after the incision a bead of viscid mucus may be seen 
 
INCISION OF THE MEMBRANA TYMPANI 
 
 667 
 
 protruding through it. The contents of the tympanic cavity are not 
 discharged at once unless they are of a fluid nature, and to hasten this 
 discharge a solution of boric acid or bicarbonate of soda may be dropped 
 into the meatus to liquefy it. 
 
 Previous to the incision the external auditory meatus should be cleansed 
 with a 1 to 4000 solution of bichloride of mercury to render the mem- 
 brana tympani and the auditory meatus sterile. Anesthesia of the 
 membrana tympani may be obtained by dropping a small quantity of a 
 solution composed of equal parts of hydrochlorate of cocaine, menthol, 
 and carbolic acid into the auditory meatus. In from five to fifteen 
 minutes complete anesthesia is produced, and the incision may be made 
 with comparatively little or no pain. Complete absence of pain is not 
 always obtained, however, as it should be re- 
 membered that the parts contiguous to the FlG - 381 
 are often inflamed and 
 
 tympani 
 
 membrana 
 sensitive. 
 
 Immediately after the incision the auditory 
 meatus should be dried with a cotton-wound 
 applicator and then loosely packed with steril- 
 ized gauze. The end of the strip of gauze 
 should be made to touch the incised portion of 
 the drumhead, while the rest is placed loosely 
 in the meatus. It should be left in place until 
 it becomes saturated with the secretions, when 
 it should be removed and a fresh one intro- 
 duced. During the first two or three days it 
 may be necessary to pack the meatus two or 
 more times a day. The patient should be 
 kept in bed during this time, as much more 
 favorable and rapid progress may be made 
 under such conditions. After the first few days 
 it is not necessary to dress the meatus so often, 
 once a day being quite sufficient. A little 
 later every other day will be all that is neces- 
 sary. The dressings should be discontinued when the discharge through 
 the incision ceases. 
 
 After the incision is made all applications of solutions by means of 
 the syringe are to be stopped, as infection may thereby be conveyed 
 through the opening into the tympanic cavity. When the acute inflam- 
 mation has somewhat subsided, inflation by the Politzer method through 
 the Eustachian catheter should be performed to facilitate drainage. 
 
 Spontaneous perforation of the drumhead may take place in the course 
 of the disease from softening of the tissues by maceration or from press- 
 ure necrosis. As already stated, this should be anticipated if possible, 
 either by instrumental perforation of the drumhead or by one or more of 
 the remedies which have been recommended. Should spontaneous per- 
 foration occur the treatment should be similar to that recommended 
 after incision of the membrana tympani. 
 
 Showing a long, curved in- 
 cision through the membrana 
 tympani for the evacuation of 
 inflammatory secretions. With 
 such an incision the anterior 
 flap is forced aside by the 
 secretions as indicated by the 
 dotted line, thus providing 
 free space for drainage. A 
 simple puncture or paracen- 
 tesis as shown by the short 
 line is inadequate and should 
 not be practised. 
 
668 THE EAR 
 
 Paracentesis is an almost obsolete form of incision, and is not given as 
 synonymous with incision. The latter means a larger and more extensive 
 opening in the drumhead than is implied by the former. By paracentesis 
 is meant a mere puncture through the membrane with a double edged 
 or spear-pointed knife. What follows, therefore, refers to some form 
 of incision and not to a mere puncture of the drumhead. 
 
 The general purposes of incision of the membrana tympani are : (a) to 
 relieve pain; (6) to establish drainage for excessive secretions (catarrhal 
 and suppurative); (c) to open the middle ear for certain operations; 
 (d) to relieve intralabyrinthine pressure; (e) to allow sound waves to 
 reach the oval and round windows; and (f) to promote the reaction of 
 inflammation. 
 
 The indications for incision, as briefly outlined in the preceding para- 
 graphs, may be amplified as follows : 
 
 1. In otitis media with excessive secretion it may become necessary 
 to make a free incision to prevent pressure necrosis of the drumhead and 
 the tympanic mucosa. The secretion is often so thick and tenacious that 
 it will not discharge through the Eustachian tube. Retention also causes 
 pain and there is danger of decomposition and infection. The incision 
 also promotes the reaction of inflammation, and thus favors speedy 
 resolution. 
 
 The operation should not be delayed until pronounced pain develops, 
 bulging of the membrane being ample justification for the procedure. 
 Should pain persist without bulging, the incision should be made, as it 
 promotes the reaction of inflammation and thus favors resolution. 
 
 2. In acute myringitis abscess formations may occur between the 
 layers of the membrana tympani. They should be opened, care being 
 taken not to cut the inner or mucous layer which would expose the 
 middle ear to the dangers of infection from the abscess. 
 
 Pearly gray blisters sometimes appear on the membrana tympani. 
 These should be pricked, for if left to discharge spontaneously they 
 prolong the danger of infection. 
 
 Inflammation of the deeper layers with bulging and purplish swelling 
 should be scarified to relieve the pain and tension. Incisions through the 
 entire thickness should not be attempted, for the reasons already stated. 
 
 3. Tenotomy of the tensor tympani muscle is sometimes performed 
 to relieve deafness and tinnitus. (See Tenotomy of the Tensor Tympani 
 Muscle.) The preliminary step in the operation is an incision of the 
 membrana tympani. 
 
 4. In chronic catarrhal otitis media, a thickened membrana tympani 
 from hyperplasia with obstruction of the Eustachian tube is often present. 
 The rarefaction of the air within the tympanum causes the retraction 
 of the membrana tympani and pressure upon the labyrinthine fluid 
 by the foot plate of the stapes. The drumhead may be incised as a 
 temporary measure, or a portion of the drumhead may be removed with 
 a knife or cautery to admit air into the middle ear when the Eustachian 
 tube is obstructed. All such measures have met with but partial or 
 temporary success, the opening usually closing within a few days. 
 
INCISION OF THE MEMBRANA TYMPANI 669 
 
 The relief is often pronounced while the perforation remains open, 
 but quickly disappears after it closes. 
 
 Malherbe has written extensively upon what he terms "Evidement of 
 the Mastoid/' whereby a channel of communication between the tym- 
 panic antrum and the external acoustic meatus is established, as in the 
 meatomastoid operation, which permanently overcomes the disturbance 
 due to the closure of the Eustachian tube. 
 
 5. In acute catarrhal otitis media attended with pain, bulging, and 
 marked inflammatory infiltration, incision or scarification is often indi- 
 cated to promote the reaction of inflammation and to establish drainage. 
 If there is persistent pain with or without bulging of the membrana 
 tympani, incision is indicated. The relief which follows may be due 
 to the hemorrhage, for in many cases there is no discharge of secretions 
 for several hours, though it is more probably due to the promotion of 
 the reaction of inflammation. 
 
 When there is a livid, boggy appearance of the membrane it should be 
 freely scarified, limiting the incisions to the outer layer. Circumscribed 
 red spots sometimes appear in the course of the disease, which should be 
 opened to hasten the process of resolution. 
 
 The most bulging portion of the membrana tympani may appear 
 yellowish green in color, even though there is little pus in the secretion. 
 Free incision should be made to establish drainage and to relieve the 
 pressure necrosis which is beginning on the inner surface of the mem- 
 brana tympani. 
 
 6. Acute suppurative otitis media affords the most common opportu- 
 nity for incision of the membrana tympani, although it is often postponed 
 until voluntary rupture occurs. The presence of pus within the middle 
 ear cavity when the drumhead is still intact is an imperative indication 
 for incision. It is not necessary to wait for pain and bulging of the mem- 
 brana tympani; in fact, it is culpable negligence to do so, as every hour 
 adds to the destruction of tissue. Incise the membrana tympani at once 
 when the presence of pus is suspected in the middle ear, as it is of the great- 
 est importance to promote the reaction of inflammation to combat the 
 bacteria and their toxins. 
 
 The perforation in acute suppuration is usually small, hence it should 
 often be enlarged by radiating incisions toward the periphery (Fig. 382). 
 
 Persistent pain without bulging or profuse discharge of pus is an indi- 
 cation of retained pus within the antrum and mastoid cells. The incision 
 in these cases should include the pars flaccida (Shrapnell's membrane), 
 to afford a direct outlet from the attic and to increase the reaction of 
 inflammation. 
 
 7. Adhesive processes in the middle ear sometimes gives rise to condi- 
 tions which can be more or less relieved by incising the membrana tym- 
 pani. The adhesive process may interfere with the vibratory action of the 
 ossicles without the foot plate of the stapes being ankylosed. The open- 
 ing in the drumhead admits sound waves into the tympanum where 
 they strike the foot plate of the stapes, and fairly good hearing results. 
 The tinnitus which is associated with the deafness is also relieved to some 
 
670 THE EAR 
 
 extent. As it is not practicable to maintain the opening for any con- 
 siderable length of time, the procedure has almost fallen into disuse. 
 
 Calcareous deposits in the membrana tympani are often found associ- 
 ated with adhesive processes. They act as foreign bodies and impair 
 the vibratory function of the membrana tympani, and an opening, as 
 above stated, admits sound waves directly to the oval window. More- 
 over, the equilibrium of air pressure is thereby established and the press- 
 ure on the labyrinth by the ossicles is somewhat lessened. 
 
 Through the opening it is sometimes possible to sever adhesive bands 
 which extend from the malleus and incus to the walls of the tympanum. 
 While the beneficial effects thus obtained are not permanent, tem- 
 porary relief is marked and extremely gratifying to the patient. They 
 are much depressed in spirits, and the temporary respite adds to their 
 happiness. It should be frankly explained that the beneficial result will 
 in all probability not be permanent. 
 
 Fig. 382 
 
 Showing two perforations of the membrana tympani and the incisions for facilitating drainage 
 through them. The incisions should extend at an angle to the axis of the perforation so as to form 
 movable flaps which may be pushed aside by the secretions. 
 
 .8. Atrophy and relaxation of the membrana tympani from too fre- 
 quent inflation or other causes may be improved by light scarification 
 with a sharp-pointed bistoury. Only the outer and the middle layer 
 should be cut through. In this way the scar tissue and blood supply will 
 be increased, and the tension and tone of the membrane raised, with 
 benefit to the hearing. 
 
 9. Exploration of the middle ear and the attic sometimes becomes 
 necessary in chronic suppuration. This is best done when the opening 
 in the membrana tympani is high, as the roof or tegmen is usually 
 necrosed. If, therefore, the perforation is small or in the lower portion 
 of the drumhead, it may be necessary to extend it by incision in an 
 upward direction. This operation allows a small curved earprobe to be 
 introduced into the attic for exploratory purposes. 
 
 Preliminary examination of the function of hearing should be made 
 before incising or removing a portion of the drumhead to improve hearing 
 in adhesive processes of the middle ear. Unless bone conduction for 
 the watch and the c 2 , 512 v., fork is good, but slight improvement will 
 follow the operation. Lowered bone conduction is usually significant of 
 
INCISION OF THE MEMBRANA TYMPANI 671 
 
 labyrinthine disease, hence incision of the membrana tympani will be 
 of no value. 
 
 The middle and the lower portion of the posterior half of the membrana 
 tympani is less sensitive than the upper portion, the sensitiveness gradu- 
 ally increasing as the upper limit is approached. Blake takes advantage 
 of this fact and punctures the membrane in its least sensitive area, then 
 applies cocaine to the cut surfaces, waits a few minutes, and extends the 
 incision slightly upward, applies more cocaine, and so continues until 
 the incision is extended the desired length. 
 
 He also recommends the injection of a 2 per cent, solution of cocaine 
 through the Eustachian catheter into the middle ear, as a means of pro- 
 ducing anesthesia of the membrana tympani in middle ear operations. 
 
 Dupuy recommends the following mixture as a reliable local anesthetic 
 in eardrum and middle ear operations: 
 
 1$ — Aniline oil, 
 
 Alcohol aa 5J 
 
 Cocaine hydrochlorate gr. vj — M. 
 
 Sig. — Drop into the meatus and middle ear 
 
 This mixture does not always produce local anesthesia. In a number 
 of the author's cases it has failed, notably in aural polypi. 
 
 More or less cyanosis occasionally attends its use, hence it should be 
 applied with caution. 
 
 The following mixture is more reliable and less dangerous: 
 
 1$ — Cocaine hydrochlorate, 
 
 Menthol crystals, 
 
 Carbolic acid crystals aa 5J — M 
 
 Sig. — Drop into the meatus or middle ear, and in twenty minutes anesthesia is complete. 
 
 The absorption is greatly facilitated by first macerating the drum- 
 head with the peroxide of hydrogen. 
 
 Methods of Operating. — The electrocautery may be used in adhesive 
 non-inflammatory cases. The opening thus made remains longer than 
 one made with a knife. The points to be observed are the following: 
 
 (a) Preliminary local anesthesia should be produced by the injection 
 of the above formula or a 2 per cent, solution of cocaine into the middle 
 ear through a Eustachian catheter. 
 
 (b) The electrode should be a simple straight, pointed one with the 
 shank so bent that the electrode handle and the hand of the operator 
 do not obstruct the view. 
 
 (c) The current should be sufficient to instantly raise the point to 
 a bright-red heat. If the platinum point heats too slowly the adjacent 
 parts may be injured by the radiation of heat. The pressure exerted by 
 the electrode should be slight to avoid the danger of injuring the mucous 
 membrane of the inner tympanic wall. 
 
 '(d) Contact should be made with the drumhead before the electric 
 current is turned on. 
 
 (e) Usual time of heat contact, one second. 
 
672 
 
 THE EAR 
 
 Incision with a Lancet. — Preference should be given to Hartman's 
 curved lancet (Fig. 379), the spear-pointed instruments formerly used 
 being of little value except for simple puncture. 
 
 The most favorable or available location for incision in adults is the 
 posterior half of the drumhead. In children the external meatus is 
 shallow and straight, so that all portions of the drumhead are accessible. 
 
 Fig. 383 
 
 Fig. 384 
 
 Showing a long, curved incision of the mem- 
 brana tympani extending into the superior wall 
 of the meatus (white line). As there is a 
 plexus of bloodvessels around the margin of 
 the membrana tympani, greater reaction of 
 inflammation is produced by extending the 
 incision through it, hence the improvement of 
 the inflammation is more prompt than in simple 
 incision of the membrane. (See Reaction of 
 Inflammation.) 
 
 Incision for stapedectomy, showing the incu- 
 dostapedial articulation. The stapedius muscle 
 should be severed to prevent the dislocation of 
 the stapes, the incudostapedial articulation 
 broken, and the stapes removed from the oval 
 window. This operation is rarely justifiable. 
 
 Fig. 385 
 
 Showing an incision through the posterior fold of the membrana tympani to relieve the 
 tension of the membrane in adhesive processes. 
 
 Other things being equal, the most bulging portion (fluid being present) 
 should be incised, because it is the point of least resistance and because 
 the parts are not so sensitive in this area. If the bulging is pronounced, 
 the incision can often be made without the use of a local anesthetic. 
 
 The length, direction, and character of the incision should depend upon 
 the purpose for which it is made. If it is done to establish free drainage, 
 it should be long and curved, or angular (Fig. 383). If it is to expose the 
 contents of the middle ear, as for operations upon adhesive bands and 
 upon the stapes, the V-incision recommended by Blake (Fig, 384) should 
 
INCISION OF THE MEM BR AN A TYMPANI 673 
 
 be made. If it is for the purpose of admitting air to the middle ear, a 
 round or triangular opening may be made. The cautery is well adapted 
 for this purpose. If it is done preliminary of tenotomy to the tendon of 
 the tensor tympani, or for plicotomy, a short straight incision (Fig. 385) 
 is all that is necessary. 
 
 Postoperative Considerations. — (a) When the incision is made to 
 evacuate mucus or mucopus, a pulsation synchronous with swallowing 
 and articulation will occur at the point of incision. Pus and mucus 
 rarely appear immediately after the incision. This is quite disconcerting 
 to the inexperienced aurist, as he may have unwittingly promised an 
 immediate evacuation of the secretions. A little experience, however, will 
 teach him that on account of the thick and adhesive character of the 
 secretions they will usually require several hours to appear. The ex- 
 pulsion of the secretions can be hastened by instilling a warm solution 
 of bicarbonate of soda into the middle ear. The soda overcomes the 
 adhesive property of the mucus and facilitates its discharge. Some- 
 times the mucus is so thick and tenacious that it can be seized with 
 forceps and removed. It may also be removed by suction with the 
 Delstanche masseur. 
 
 (b) Closure of the incision in non-suppurative cases usually occurs in 
 from one to three days. In suppurative cases it may remain open a few 
 days or indefinitely. 
 
 (c) The dressing should consist of a strip of sterilized gauze placed 
 loosely in the meatus but touching the drumhead. If the discharge is 
 profuse a pad of gauze may be placed over the auricle and held in 
 position by a bandage. The meatus and the auricle should first be 
 cleansed with a 1 to 3000 bichloride solution before introducing the 
 gauze dressings. 
 
 43 
 
CHAPTER XXXIX. 
 
 DISEASES OF THE EUSTACHIAN TUBES 
 
 THE RELATIONSHIP OF THE EUSTACHIAN TUBES TO HEARING 
 AND MIDDLE EAR DISEASES. 
 
 The Eustachian tube is the chief source of communication between 
 the epipharynx and the middle ear. Through it the tympanic cavity 
 is ventilated and the normal tension of the drumhead and the ossicular 
 chain is maintained, thereby facilitating the transmission of sound 
 waves to the internal ear. The pharyngeal end of the tube is supported 
 by cartilage, while the tympanic end has an osseous framework. At 
 the union of the cartilaginous and the osseous portions the tube becomes 
 narrow, forming what is known as the isthmus. The throat end is 
 subject to the diseased processes peculiar to the epipharynx, while the 
 tympanic end is affected by the changes peculiar to the tympanic cavity. 
 In other words, the throat end is subject to pronounced catarrhal and 
 suppurative inflammations and to hypertrophy of the lymphoid tissue 
 in its mucous membrane, and the tympanic end to catarrhal and 
 adhesive changes in addition to the suppurative process. The adhesive 
 process is, therefore, chiefly found in the less accessible portion of the 
 tube — namely, beyond the isthmus, and consequently difficult to reach 
 with electrolytic bougies, or those used for the purposes of simple 
 dilatation. 
 
 The relationship of the Eustachian tube to the diseases of the tympanic 
 cavity is twofold, namely: (a) obstruction of its lumen by catarrhal 
 congestion, hypertrophy, cicatricial contraction, and mucous plugs; and 
 (b) as an avenue through which infective material may gain entrance 
 to the middle ear. The obstructive lesions or accumulations prevent the 
 proper ventilation of the tympanic cavity, and the contained air becomes 
 rarefied through the gradual absorption of the oxygen, thus causing 
 retraction of the drum membrane and engorgement of the bloodvessels 
 of the mucous membrane. 
 
 The retraction of the drumhead increases the tension of the ossicular 
 chain, and interferes with the normal transmission of sound waves 
 to the labyrinth. Tinnitus and deafness thus result. The obstruction 
 to drainage lowers the resistance of the tissues and predisposes to infec- 
 tion and inflammation. 
 
 Infectious material may gain entrance into the middle ear during 
 acts of yawning, coughing, sneezing, or swallowing. The tube is lined 
 with ciliated columnar epithelium, having a wave-like motion toward 
 the pharyngeal orifice. In the healthy state bacteria rarely travel toward 
 
TUBAL CATARRH 675 
 
 the middle ear on the mucosa. If, however, the catarrhal inflammation 
 of the lining membrane of the tube is severe or prolonged, the epithelium 
 may lose its cilia, and allow germs to reach the middle ear without the 
 tube being opened by the acts of coughing and sneezing. 
 
 Tubal tonsils, or hypertrophy of the lymphoid tissue in the mucous 
 membrane of the cartilaginous portion of the tube, is another possible 
 source of obstruction. A study of the histology of this structure shows 
 lymphoid tissue to be present in considerable quantity, and it is more 
 than probable that hypertrophy of this tissue is often responsible for 
 tubal and middle ear disturbances heretofore ascribed to catarrhal or 
 other diseases. 
 
 TUBAL CATARRH; CATARRHAL INFLAMMATION OF THE 
 EUSTACHIAN TUBE; SALPINGITIS. 
 
 Etiology. — Owing to the intimate anatomical connection of the 
 mucous membrane of the Eustachian tubes with that of the epipharynx, 
 it is easy to understand why they are usually involved in the course 
 of an attack of epipharyngeal inflammation. If the epipharvngitis is 
 chronic in character, the tubal disease is likewise chronic. While tubal 
 catarrh is usually secondary to a like process in the epipharynx, it is 
 not always so, especially in children. In young children the pharyngeal 
 orifice is narrow and is easily obstructed by the secretion and foreign 
 matter. For this reason local inflammation may occur in the tubes 
 independent of the epipharynx. 
 
 Adenoid growths are often associated with a chronic epipharvngitis, 
 which extends by continuity to tissue of the tubes. The adenoids do 
 not often afford a mechanical obstruction to the patency of the tubes, 
 as they grow from the posterior and superior walls of the epipharynx, 
 and, therefore, do not involve the regions of the Eustachian orifices on 
 the lateral walls. In some instances, however, they overlap the mouths 
 of the tubes and thus obstruct them. Tuberculosis may be associated 
 with adenoid growths and predispose to tubal inflammation. 
 
 Thomas H. Brunk first, and later W. S. Bryant, called attention to 
 the presence of granulation tissue and adhesive bands in Rosenmiiller's 
 fossae, claiming that their removal with the finger introduced through 
 the mouth, or with a straight curette through the nose, relieved tubal 
 catarrh and deafness. Indeed, this opinion is attracting considerable 
 attention, as the removal of these bands have in numerous cases been 
 followed by great improvement. The adhesive bands are frequentlv 
 present and should be searched for more frequently than has been 
 customary. 
 
 Pathology. — Congestion and round-cell infiltration characterize the 
 early and acute stages of the disease. At a later period the epithelial 
 covering becomes thickened, and fibrous tissue is deposited in the 
 subepithelial layers. Hypertrophy of the mucous membrane occurs 
 when the inflammation continues for a long time. If the inflammation 
 
676 THE EAR 
 
 is severe or prolonged the cilia are exfoliated, leaving the membrane 
 denuded in places. The catarrhal inflammation may extend to the 
 middle ear, although it has a tendency to limit itself to the pharyngeal 
 or cartilaginous portion of the tube. 
 
 Symptoms. — The subjective symptoms are a feeling of fulness in 
 the ears, which may be constant or intermittent, accompanied by sub- 
 jective noises and deafness. Pain is not usually severe, although it 
 may be if the inflammation is pronounced. If there is marked retraction 
 of the drumhead, giddiness and nausea may be complained of. The 
 sense of deafness is often out of proportion to the actual deafness. The 
 patients apply for relief with the statement that the external canal is 
 filled with cerumen. During mastication and swallowing they often 
 experience marked, though brief, relief from the symptoms. This is 
 explained by the incidental, but incomplete, ventilation of the tympanum 
 during the act of swallowing. Upon posterior rhinoscopy the mucous 
 membrane of the epipharynx and the Eustachian orifices appears red- 
 dened, swollen, and covered with a thick mucous secretion. The mouths 
 of the tubes are contracted by the swollen membrane, and may contain 
 a thick, tenacious mass of mucus. If adenoids are present, the furrows 
 between the lobules are more or less filled with a slimy secretion admixed 
 with pus. The ethmoidal and sphenoidal sinuses may also be the seat 
 of inflammation. With good illumination it is possible to see the enlarged 
 and tortuous bloodvessels in the inflamed area. 
 
 The drumhead is more or less changed in its position and appearance 
 by the rarefaction of the air in the tympanic cavity. It is more cupped, 
 the handle of the malleus is foreshortened, and the short process and the 
 posterior fold extending from it are more prominent. The angle formed 
 by the handle of the malleus and the posterior fold becomes more acute 
 with the increased retraction. The cone of light is diminished, broken, 
 or altogether wanting. If the drumhead is extremely retracted, the 
 promontory and the long process of the incus become visible through it. 
 
 Prognosis. — The prognosis is good in those cases in which adenoid 
 growths are removed, especially in children. It is also good in the early, 
 or congested stage of the simple catarrhal type in adults. In the hyper- 
 trophic stage it is not good, as the obstruction is more permanent in 
 character. If the obstruction is due to lymphoid hypertrophy in the 
 pharyngeal end of the tube, the prognosis is not good, although the 
 removal of the adenoids reduces the congestion and improves the deaf- 
 ness. If the obstruction is due to adhesive bands in Rosenmiiller's 
 fossa the prognosis is good if the bands are removed. 
 
 Treatment. — The treatment of tubal catarrh should be largely 
 addressed to the antecedent nasal and epipharyngeal conditions. If 
 there is pronounced nasal catarrh, sinuitis, nasal obstruction, or epi- 
 pharyngitis, appropriate treatment should be undertaken, and the aden- 
 oids should be removed. Removal of the adenoids is usually followed by 
 pronounced and immediate relief. Having corrected the nasal and 
 the epipharyngeal disorders, the tubal inflammation often subsides 
 without further treatment. Such a favorable result does not always 
 
TUBAL CATARRH 677 
 
 follow, however, especially if the mucosa has become hypertrophic or 
 hyperplastic in character. In many cases there is a mixture of tumes- 
 cence and hypertrophy, when local medical applications are only capable 
 of removing the congestion and limiting the further development of 
 the hypertrophic process. 
 
 Perhaps the most useful method of applying remedies to the vault of 
 the pharynx and the Eustachian orifices is by gargling after the von 
 Troltsch method. The patient should lie on his back while gargling, to 
 allow the fluid to enter the epipharynx. This is not difficult, as the head 
 can be turned to one side in taking the fluid into and in ejecting it from 
 the mouth. By following this method the whole of the epipharynx, 
 including the Eustachian orifices and the nasal chambers, may be 
 reached by astringent and antiseptic remedies, with very favorable 
 results. The deafness and tinnitus are often thereby relieved. 
 
 Fig. 386 
 
 Buttles-Pynchon inhaler. 
 
 The injection of from 1 to 4 minims of weak astringent solutions 
 into each of the Eustachian tubes through a catheter is recommended. 
 Care should be taken to avoid injecting it into the middle ear, as reaction- 
 ary inflammation might follow. The syringe should be so gauged as to 
 fill the catheter and leave a surplus of from five to ten minims. The extra 
 solution is to allow for the inevitable escape of fluid into the epipharynx. 
 The nose and the epipharynx should be sprayed with a 2 per cent, solu- 
 tion of cocaine to reduce the sensibility of the parts before introducing 
 the catheter. The solutions most often used are : (a) the iodide of potas- 
 sium, 10 gr. to the ounce; (b) the bicarbonate of soda, 3 to 5 gr. to the 
 ounce; (c) the sulphate of zinc, 1 gr. to the ounce; and (d) the nitrate 
 of silver, 2 to 5 gr. to the ounce. 
 
 Various vapors of iodine, ammonia, menthol, camphor, eucalyptol, 
 etc., have been recommended. Iodine and ammonia are readily vola- 
 tile, and the fumes therefrom may be sufficiently generated in a Buttles- 
 Pynchon inhaler, shown in Fig. 386. A piece of sponge or cotton should 
 be moistened with the desired solution and placed in the chamber of the 
 inhaler. The inhaler should be connected with the catheter and air 
 forced through it into the Eustachian tube. Another way of using the 
 vapors of the foregoing drugs, either singly or in combination, is with 
 a nebulizer. Either the nebulizer mav be attached to the Eustachian 
 
678 THE EAR 
 
 catheter, or the vapors may be driven into the middle ear by the modified 
 Politzer method, in which the nebulizing device takes the place of the 
 rubber bag used by Politzer. In other respects proceed according to the 
 directions given under the Politzer method. The author has often put 
 a few drops of the desired volatile solution into the Politzer bag and 
 then practised inflation in the usual manner. 
 
 The value of the foregoing topical remedies does not consist alone in 
 the medicinal properties of the drugs, but includes also the mechanical 
 effects of inflation. The current of compressed air directed into the 
 orifice of the Eustachian tube removes the secretions and temporarily 
 unloads the congested vessels and establishes normal glandular activity. 
 
 If adhesive bands are present in Rosenmuller's fossa, the index finger 
 of the right hand should be introduced through the mouth and the right 
 fossa thoroughly curetted with the nail. The left index finger should be 
 used to curette the left fossa. 
 
 The principles to be observed in the treatment of tubal catarrh may be 
 summarized as follows: 
 
 (a) The correction of obstructive nasal lesions, and of inflammatory 
 diseases of the nose and accessory sinuses. 
 
 (b) The removal of neoplasms, adhesive bands, and other inflam- 
 matory conditions in the epipharynx. 
 
 (c) The topical application of antiseptic, astringent, and stimulating 
 remedies to the mucosa of the Eustachian tubes. 
 
 (d) The mechanical effects of inflation. 
 
 (e) The administration of remedies to give tone and vigor to the 
 general system. 
 
 It should be said, in reference to the latter principle, that in many 
 cases of deafness from tubal catarrh the administration of tonics and 
 other constructive remedies is often followed by an improvement in 
 hearing. This is especially true in those cases in which there is no pro- 
 nounced nasal or epipharyngeal disease. It is usually best to begin the 
 treatment with a 2 to 3 gr. dose of calomel at bedtime, followed by a 
 saline cathartic the following morning. After this, laxative doses of 
 cascara may be given twice daily. The patient's alimentary tract is 
 thus kept in a condition to care for and distribute the constructive 
 remedies. These remarks are equally applicable to all catarrhal affec- 
 tions of the upper respiratory tract. 
 
 The Relation of the Eustachian Tube to Mastoiditis. — The 
 Eustachian tube is adequate to drain all secretions from the middle 
 ear, but it is often inadequate to drain the combined secretions of the 
 middle mastoid antrum and cells, resulting in retention, pressure necrosis, 
 and all the phenomena peculiar to mastoiditis. If the secretions from 
 the antrum and mastoid cells are diverted from the middle ear, the 
 Eustachian tube effectually drains it, and the diseased process rapidly 
 improves. (See Meatomastoid Operation.) 
 
OBSTRUCTION OF THE EUSTACHIAN TUBE 679 
 
 OBSTRUCTION OF THE EUSTACHIAN TUBE. 
 
 Partial Obstruction. — Etiology. — Obstruction of the Eustachian tube 
 may be due to a variety of conditions, namely: (a) Hypertrophy of 
 the mucous membrane, especially in the pharyngeal or cartilaginous 
 portion, the hypertrophy being an extension of the same process from 
 the nose and the epipharynx. (b) Repeated inflammations, giving 
 rise to a hyperplastic thickening and consequent obstruction, (c) 
 Adhesive bands or constrictions forming in either the tympanic or the 
 pharyngeal end of the tube, especially if the same pathological pro- 
 cess is going on in the tympanic cavity, (d) Syphilis, tuberculosis, 
 and diphtheria at the pharyngeal orifice, causing cicatricial contractions 
 which more or less obstruct the opening, (e) Adenoids, while they do 
 not grow from the Eustachian orifice, may be so large as to overlap 
 and thus close it. (/) Paralysis of the palatal muscles from diphtheria 
 and mixed infection, or from degenerative changes of the muscular 
 fibers from repeated inflammations coincident with tonsillar inflamma- 
 tion, giving rise to collapse of the muscular and other soft tissue at the 
 pharyngeal orifice and thus causing its occlusion, (g) Adhesions of 
 the posterior pillars to the tonsils interfere with the muscular move- 
 ments and contribute to the collapse of the Eustachian orifices, (h) 
 Degeneration of the palatal muscles as a result of severe or repeated 
 inflammation of the tonsils and contiguous structures, (i) Certain 
 anatomical features, as exostoses and hyperostoses of the walls of the 
 tubes, give rise to obstruction; there may be a sudden bend in the direc- 
 tion of the tube, or the carotid canal may encroach upon it and thus 
 obstruct it. (y) Adhesive bands in Rosenmuller's fossa as described 
 by Brunk. 
 
 Diagnosis. — The diagnosis may be made by observing the charac- 
 teristic retraction of the drumhead, foreshortening of the handle of 
 the malleus, and the prominence of the short process and the posterior 
 fold of the tympanic membrane. Postrhinoscopic examination may 
 show either cicatricial contraction, overlapping adenoids, or collapse of 
 the Eustachian orifice. The pillars (glossopalatine and pharyngo- 
 palatine arches) of the fauces may be adherent to the tonsils, and cause 
 more or less atony of the palatal muscles. The diagnostic tube used 
 during inflation gives the strident or rough murmur characteristic of 
 tubal obstruction. If the Eustachian tube is normally patent the tubal 
 sound is soft and blowing in character. 
 
 Complete Obstruction. — This condition may be due to one or more 
 of the causes given under Partial Obstruction, although it is usually 
 due to syphilitic, tuberculous, or diphtheritic cicatricial contraction at 
 the mouth of the tube. The symptoms are the same as in partial ob- 
 struction, excepting that tympanic inflation gives no rale or murmur 
 through the diagnostic tube. 
 
 Undue Patency of the Eustachian Tubes. — This condition is nearly 
 always associated with atrophic changes in the entire mucosa of the 
 
680 THE EAR 
 
 upper respiratory tract, especially of the nose, epipharynx, and oro- 
 pharynx. The process may not involve the entire Eustachian tube, 
 but may be limited to the pharyngeal orifice. Urbantschitsch reports 
 a case of this kind in which the end of the little finger could be inserted 
 into the orifice. 
 
 The characteristic symptoms are the inward and outward movements 
 of the drumhead synchronous with the respiratory movements, and the 
 soft, blowing murmur heard through the diagnostic tube, even without 
 inflation. There may be autophony or the ringing of the patient's 
 voice in his own ears. The voices of others sometimes give rise to the 
 same disagreeable sensation. The symptom is somewhat different from 
 hyperesthesia acoustica, in which there is a painful distinctness of hear- 
 ing; whereas in autophony the patient's own voice seems to ring or roar 
 in his head. 
 
 Treatment of Obstruction and Undue Patency. — The treat- 
 ment of partial obstruction varies with the lesion causing it. If there 
 is catarrhal congestion of the mucous membrane at the pharyngeal 
 orifice, relief may be afforded by the judicious use of antiseptic and astrin- 
 gent sprays in the nose and epipharynx. If, however, the hyperemia 
 is due to anterior nasal obstruction, this should be corrected. The 
 removal of adenoids is indicated to relieve the epipharyngitis and the 
 resulting tubal catarrh, as well as to overcome the mechanical obstruc- 
 tion they may form at the mouth of the tube. 
 
 It is difficult to overcome cicatricial contractions, especially if it is due 
 to syphilis. If due to diphtheria and tuberculosis, electrolysis may be 
 of value. An olive-tipped electrode, with the curvature of a Eustachian 
 catheter, should be introduced through a catheter. The tip should 
 enter the Eustachian orifice to the isthmus of the tube. The shaft of 
 the electrode should be covered with some insulating substance and 
 the strength of the current should vary from 5 to 30 ma., according 
 to the density and resistance of the tissue. Seances should last for 
 from five to twenty minutes. The negative pole of the battery should 
 be connected with the Eustachian electrode, as the tissue to be reduced 
 is dense and fibrous. If it is a simple hypertrophy, the positive pole 
 should be used. If the lumen of the tube is constricted higher up by 
 adhesive bands, a small, gold-tipped electrode should be introduced 
 through the Eustachian catheter until it comes in contact with the con- 
 striction, as recommended by A. B. Duel. It is claimed for electrolysis 
 in these cases that the obstruction disappears and the hearing and 
 tinnitus are improved. Others have found it of no practical value. The 
 status of electrolysis at best is open to criticism. The benefits derived 
 from it within the Eustachian tube may well be attributed to the dilata- 
 tion and inflation which are incidental to the procedure. Theoretically 
 electrolysis is an ideal treatment for fibrous constriction, while practically 
 it has been disappointing in the hands of most otologists. In obstinate 
 cases it should, however, be given a trial, and will in some cases be 
 attended with astonishingly good results. 
 
 The use of bougies in reducing tubal stenosis has long been recognized 
 
OBSTRUCTION OF THE EUSTACHIAN TUBE 
 
 681 
 
 as of considerable value in those cases in which the stricture is not com- 
 posed of connective tissue. If it is due to turgescence or simple hyper- 
 trophy, the results are often good. The bougies may be made of silk- 
 worm gut, whalebone, or celluloid. Those made of silkworm gut may 
 be impregnated with astringent remedies, as silver nitrate, sulphate of 
 zinc, etc., which often adds to the therapeutic effect. The whalebone 
 bougie is easier to introduce on account of its polished surface. Cellu- 
 loid bougies are also smooth and easy to introduce, but are more liable 
 to break. 
 
 Suarez di Mendoza has devised a metal catheter which maybe removed, 
 leaving the bougie in the Eustachian tube. The catheter is divided 
 longitudinally into two parts, and it can be separated and removed, 
 leaving the bougie in position. It is then cut off even with the nose 
 and left in position for twenty-four hours. By this method speedy 
 dilatation is obtained. 
 
 Fig. 387 
 
 Weaver'? intratympanic masseur. 
 
 Caution. — The introduction of bougies into the Eustachian tube may 
 injure the mucosa, hence emphysema of the submucous tissue may occur 
 if inflation is practised immediately afterward. It should rather be done 
 when the patient returns two days later for another treatment. The 
 introduction of bougies may be practised two or three times a week. 
 In favorable cases the rough strident murmur heard through the diag- 
 nostic tube during inflation will have been replaced, after a few treat- 
 ments, by a soft, full, blowing murmur. 
 
 In some cases great difficulty is experienced in passing the bougie 
 beyond the pharyngeal orifice, as it bends and returns with a sharp 
 tingling or smarting sensation in the lateral walls of the pharynx. The 
 Eustachian catheter should be given a larger and sharper curve, so 
 as to direct the tip of the bougie more in the direction of the lumen of 
 the tube. 
 
 The bougie should be made to persistently press against the con- 
 striction until it passes it, or until the hope of doing so is abandoned. 
 When it is found impossible to pass the bougie, electrolysis should be 
 tried. Larger bougies may be successively introduced until inflation 
 
682 THE EAR 
 
 gives a free, full, blowing murmur. After this they should be passed at 
 longer intervals for several weeks or months. 
 
 Massage of the Eustachian tube may be accomplished by the Weaver 
 masseur (Fig. 386). The masseur is attached to the catheter and the 
 current of air from the compressed-air tank turned on, the turbine wheel 
 interrupting the current of air. The mucous membrane of the tube 
 and middle ear is thus rapidly and intermittently compressed. The 
 bloodvessels and lymphatics are unloaded, and the glandular elements 
 are stimulated to greater activity. The tympanic cavity is inflated and 
 the air tension restored. In turgescence and hyperemia of the tubal 
 membrane this method of treatment is highly commended. 
 
 It should be said in conclusion that no one method of treatment is 
 applicable to all cases. Each should be carefully studied and all the 
 facts considered before determining the line of treatment. The nasal 
 and epipharyngeal condition, as well as the general health, should be 
 regarded as essential factors in determining the course of treatment in 
 each individual case. 
 
CHAPTEE XL. 
 
 THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION. 
 
 The data of an anatomical, physiological, and clinical character, 
 upon which the prinicples of tympanic inflation should rest, are as 
 follows : 
 
 (a) The Eustachian tube extends from the lateral wall of the epi- 
 pharynx to the cavity of the middle ear in an upward, outward, and back- 
 ward direction. If the head is rotated to the right and then inclined 
 forward, the right Eustachian tube will stand perpendicular to the plane 
 of the earth, thus favoring the drainage of the right middle ear. 
 
 (b) The pharyngeal orifice of the Eustachian tube is trumpet-shaped, 
 hence when a current of air is forcibly thrown into it the contained secre- 
 tions are " dished" out and carried into the epipharynx, while the re- 
 sidual air passes on through the tube into the middle ear. 
 
 (c) The walls of the Eustachian tube are covered with ciliated epi- 
 thelium, the cilia creating a current toward the pharyngeal orifice. If 
 the secretions are thick and become dried in the orifice, the sudden 
 impact of air during inflation dislodges the mass and clears the way for 
 the successful inflation of the middle ear. 
 
 (d) The walls of the tubes are approximated when in the normal state 
 of rest, and are only opened during inflation of physiological or artificial 
 origin. 
 
 (e) The drumhead, being the only yielding wall of the tympanic cavity, 
 is pushed outward toward the external meatus during inflation. 
 
 (/) The handle of the malleus is also carried outward, as it is in inti- 
 mate relationship with the drumhead. 
 
 (g) The incus and the stapes follow the outward movement of the 
 malleus only to a limited extent, as the articulations are such as to per- 
 mit the malleus to swing in this direction without marked movement of 
 the other ossicles. The inward movement of the handle of the malleus 
 is, however, accompanied by a corresponding, though more limited, 
 movement of the incus and the stapes in the same direction. 
 
 It is obvious, therefore, that in adhesive processes affecting the mo- 
 tion of the malleus inflation exerts more or less influence in breaking 
 them down; whereas if the adhesions affect the incus and the stapes, 
 but slight influence is exerted. 
 
 (h) The mucosa of the tympanic cavity is supplied by numerous 
 bloodvessels, capillaries, and lymph channels, which upon inflation (in 
 catarrhal inflammation) become less engorged and return to their 
 normal state of fulness. In other words, inflation is followed by an 
 active hyperemia and an approach toward normal physiological activity 
 
684 THE EAR 
 
 of the tissues composing the mucous membrane. The secretions become 
 thinner in character and approach the normal. They are, therefore, 
 more easily carried toward the Eustachian tube by the wave-like motions 
 of the ciliated epithelium. 
 
 (i) The oxygen is gradually absorbed from the air within the tym- 
 panic cavity, hence, after several hours, rarefaction takes place, thereby 
 again causing the drumhead to retract. This does not occur in normal 
 conditions, as air is admitted to the middle ear during each act of 
 deglutition and yawning. 
 
 (y) The palatal muscles have more or less control over the patency of 
 the tubes, hence it is important that they be free to act to their full 
 capacity. Repeated inflammations of the tonsils and fauces give rise to 
 adhesions to the pillars of the fauces (glosso- and pharyngopalatine arches) 
 and to degenerative changes in the muscular tissue. The action of the 
 palatal muscles is thereby interfered with and the regulation of the 
 patency of the tubes is impaired. The ventilation of the tympanic cavity 
 cannot be fully accomplished, hence more or less deafness and tinnitus 
 follow. 
 
 (k) Passive congestion of the mucosa also results from the rarefaction 
 of the air in the middle ear, and leads to abnormal activity of the mucous 
 glands, as well as to a change in the character of the secretion. A true 
 catarrhal state is thus induced. Repeated inflations, together with 
 other appropriate treatment of the nose and throat, will, in many cases, 
 be followed by a lessened congestion, a restoration of the glandular 
 activity, and a return to the physiological ventilation of the tympanum. 
 
 (/) Thick, tenacious secretion is not easily forced from the middle ear 
 through the Eustachian tube by inflation. The circulation and the 
 glandular elements of the mucous membrane become impaired. Never- 
 theless, the thick tenacious secretion is gradually absorbed or discharged. 
 
 (m) The transmission of sound waves through the ossicular chain to 
 the labyrinth is only perfectly performed when the tension existing 
 between the drumhead, the ossicles, and the intralabyrinthine fluid is 
 normal. If the tension is disturbed, more or less impairment of the 
 hearing results. Tympanic inflation restores the normal tension, unless 
 adhesive bands prevent the drumhead springing into position. 
 
 (?i) When the drumhead is perforated, the secretion flows from the 
 middle ear into the external auditory meatus. 
 
 The foregoing data show that the objects of intratympanic inflation 
 are as follows: 
 
 1. To restore the normal tension between the drumhead, the ossicles, 
 and the labyrinth. 
 
 2. To restore the normal circulation in the bloodvessels and the lymph 
 spaces. 
 
 3. To render the secretions more nearly normal. 
 
 4. To remove the morbid secretions from the Eustachian tube and the 
 tympanic cavity. 
 
 5. To break down newly formed adhesions. 
 
 By establishing the foregoing conditions tinnitus is relieved, hearing 
 
THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 685 
 
 improved, catarrhal inflammation checked, and the suppurative pro- 
 cesses ameliorated. 
 
 Methods of Inflation. — Valsalva's Method of Inflation. — While this 
 method is not of such general utility as either Politzerization or cathe- 
 terization, nevertheless it has a place in otological practice which is not 
 filled by either of the others. Although its therapeutic effects are rather 
 limited, it is of diagnostic value. 
 
 The method consists in forcing the air into the middle ear by a forcible 
 expiratory effort while the mouth and the nose are closed. The success 
 of the effort is in proportion to the dynamic power of the muscles of 
 the individual and the character and degree of the obstruction in the 
 Eustachian tube. The muscular power in children and women is less 
 than in adult males, hence it is proportionately less successful in the 
 former. 
 
 The hindrances to the successful performance of inflation are: (a) 
 Thick, tenacious secretions in the mouth and the lumen of the tube, as 
 well as in (6) the tympanic cavity, (c) When the tympanic cavity is in 
 a state of partial vacuum from the absorption of the oxygen from the 
 contained air, which causes the tympanic end of the tube to collapse 
 by the suction thus created, (d) Fibrous adhesive bands resulting from 
 chronic inflammation of the tubal membrane stretching across the lumen 
 of the tube and obstructing it. (e) When the mucous membrane in a 
 state of catarrhal inflammation is congested or even hypertrophied, thus 
 interfering with tympanic inflation. (/) When the mucous membrane of 
 the Eustachian tube is supplied with lymphoid tissue, which under favor- 
 able conditions undergoes an hypertrophy akin to the same process in 
 adenoids and tonsils, thereby diminishing the lumen of the tube, (g) 
 Thick, tenacious secretions in the middle-ear cavity offering resistance 
 to tympanic inflation, (h) The fact that there is no exit other than the 
 Eustachian canal for the air entering the middle ear, a factor of some 
 importance. It does not seem to the author, however, that it plays the 
 major role assigned to it by some authors, notably Politzer, who thinks 
 the drumhead offers considerable resistance. In such cases it is only 
 necessary to open the Eustachian tube, when the air will rush in from 
 the epipharynx to equalize the pressure on the two sides of the drum- 
 head. This is the result of physical laws, and requires no force or 
 artificial intervention other than a patent Eustachian tube. After 
 this is accomplished the air in the middle ear cavity may be compressed 
 even beyond the line of equilibrium, in order to stretch or break down 
 adhesive bands, or to expel the secretions. 
 
 The diagnostic value of this method is inferior to the others, inasmuch 
 as it is less sure of being successful. In normal cases, when the desired 
 result is obtained, a soft blowing sound is heard, which Politzer ascribes 
 to the outward bulging movement of the drumhead. The author is 
 inclined to take the view that it is due to the friction of the current 
 of air in its passage through the collapsed Eustachian tube. If the 
 tube is filled with secretions, as in moist tubal catarrh, the sound is 
 changed to a moist bubbling murmur. 
 
686 
 
 THE EAR 
 
 The prognostic value of the method is considerable, in view of the fact 
 that in those cases of catarrhal otitis media in which it can be successfully 
 performed the prospects of cure or relief are good. 
 
 Fig. 388 
 
 Bulbous-tipped silver Eustachian catheter. 
 
 Caution. — A word of caution should be given in regard to the evils 
 attending Valsalva's method of inflation as a therapeutic measure. If 
 the tinnitus and the "stuffed-up" feeling in the ears are relieved by this 
 method, the patient is tempted to resort to its use so frequently and for so 
 long a period of time that there is great danger of overstretching the mem- 
 brana tympani, thereby rendering it atrophic. The author never recom- 
 mends the method for therapeutic purposes, but, on the contrary, often 
 discourages its use by those who have already adopted it. 
 
 Fig. 389 
 
 Showing a method of catheterization, a, the ring indicating the direction of the tip of the 
 catheter; b, the posterior wall of the pharynx; c, c, the ridge forming the posterior lip of the 
 mouth of the Eustachian tube; /, f, Rosenintiller's fossa; b, d, e, the route traversed by the tip 
 of the catheter to enter the mouth of the Eustachian tube. 
 
 Catheterization. — Catheterization was first brought to the attention 
 of the Paris Academy in 1724 by a postmaster named Guyot, but its 
 therapeutic value was not clearly stated until a century later by Saissy, 
 in his treatise on the Diseases of the Internal Ear, 1819. 
 
 The Binnafont or Kramer method consists in introducing the catheter 
 (Fig. 388) through the inferior meatus of the nose into the epipharynx, 
 where it is turned outward and upward into the mouth of the Eustachian 
 
THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 687 
 
 tube. The curved tip of the catheter should be kept on the floor of 
 the nose at the junction of the floor and the septum. When the tip 
 touches the posterior wall of the pharynx it should be rotated outward 
 into Rosenmiiller's fossa, then rather quickly drawn forward over the 
 bulging posterior lip (plica salpingopharyngeus) of the Eustachian 
 orifice into the pharyngeal mouth of the tube. The eyelet of the catheter 
 indicates the direction of the curved tip, which, when in the mouth 
 of the tube, is generally turned in an upward and outward direction, 
 toward the outer canthus of the eye. In some cases, however, the tip 
 enters the orifice when directed horizontally outward (Fig. 389) . 
 
 It may be necessary to change the angle of the curvature of the tip to 
 suit individual cases. Saissy recommended an angle of 130 degrees, 
 while Politzer advises 145 degrees. 
 
 Fig. 390 
 
 Inflation of the middle ear through a catheter attached to a compressed air apparatus, the 
 American method. The catheter is held in position with the left hand, though not thus shown in 
 the illustration. 
 
 The best instruments are made of pure silver, as they can be easily 
 changed in shape and may be sterilized in boiling water, eliminating the 
 liability to infection. Before the days of sterile surgery, hard-rubber 
 catheters were largely used, and they are still recommended by some 
 authors. Saissy, however, nearly one hundred years ago, recommended 
 silver, which is today preeminently the best material for the purpose. 
 
 The Lowenberg Method. — The Lowenberg method consists in turning 
 the tip of the catheter, after it has entered the epipharynx, toward the 
 median line until the metal ring on the outer extremity assumes the 
 horizontal position, and then drawing it forward until it touches the pos- 
 terior extremity of the septum. In making the forward movement the 
 outer extremity should be slightly removed from the septum, so as to 
 bring the curved tip beyond the median line, thereby making sure that it 
 catches on the septum. The outer end of the catheter should then be 
 moved toward the nasal septum, and held near the tip with the fingers 
 of the left hand. The tip should then be rotated downward and outward 
 
688 THE EAR 
 
 more than 180 degrees, or through more than half a circle, into the 
 pharyngeal orifice of the Eustachian tube. If there is no malforma- 
 tion and the velum palati is not so tense as to displace the tip backward, 
 it will enter the orifice, where it should be held during inflation. 
 
 The fixation of the catheter, after it has been properly introduced into 
 the pharyngeal orifice of the Eustachian tube, is most easily accom- 
 plished by grasping the free end between the thumb and the forefinger, 
 while the other fingers rest across the bridge of the nose. 
 
 The auscultation or diagnostic tube (Fig. 390) should be used to deter- 
 mine whether the catheter is in place. The statements of the patient on 
 this point are not trustworthy, as the sensation produced by inflation 
 often gives rise to a feeling of fulness in the ears when the auscultation 
 tube does not confirm the patient's statement. The physician should 
 make a common practice of using the auscultation tube when inflating 
 the ears, not alone to judge whether the procedure is successful, but to 
 enable him to determine the condition of the Eustachian tube and the 
 middle ear. If there is a soft, blowing murmur, the tube is normally open, 
 although it may be normally inflated and the murmur not heard. This 
 is exceptional, however, and the fact of inflation can be demonstrated 
 by using the manometer tightly fitted into the external auditory meatus. 
 The U-shaped tube of the manometer should contain a few drops of 
 colored fluid, which will rise in the outer arm of the manometer tube 
 during inflation. If the Eustachian tube is obstructed by catarrhal 
 swelling or hypertrophy of the mucous membrane, the character of the 
 sound during inflation becomes sibilant and rough. The presence of 
 mucus in the tube is indicated by moist bubbling rales. It occasionally 
 happens that at the beginning of inflation there are signs of obstruction, 
 which after a few moments suddenly disappear. In these cases it is 
 probable that a thick plug of mucus obstructed the tube and was dis- 
 lodged by the operation. In atrophic otitis media the Eustachian tube 
 is correspondingly open, and inflation gives a very soft, blowing murmur. 
 
 Other Methods of Catheterization. — There are several other methods of 
 catheterizing the Eustachian tubes, not commonly used, that in excep- 
 tional cases may be resorted to. 
 
 (a) Catheterization from the opposite nasal cavity may be done with 
 the ordinary catheter in those cases in which there is a narrow pharyngeal 
 vault, by introducing the catheter along the floor of the nose in the usual 
 way until it reaches the posterior wall of the pharynx, then rotating the 
 curved tip toward the opposite Eustachian orifice until the ring on the 
 outer end of the catheter stands horizontally toward the median line. 
 The outer end of the catheter should then be removed from the septum, 
 thus bringing the tip in approximation with the pharyngeal opening of 
 the tube. Gentle pressure in a backward direction will bring it well 
 into the opening. Inflation should then be practised in the usual 
 manner. 
 
 This method may be used when there is an obstructive lesion in the 
 nose upon the side to be catheterized and in those cases in which there is 
 congenital occlusion of the posterior nares on that side. 
 
THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 689 
 
 (6) Catheterization through the mouth may be done by using an 
 instrument with a longer curve than is ordinarily used through the nose. 
 The postrhinoscopic mirror will be found very useful in placing the tip 
 in the mouth of the tube. When there is cleavage of the palate the 
 ordinary catheter may be used, as the soft palate is out of the way, thereby 
 enabling the operator to reach the mouth of the tube with the shorter 
 curved tip. In many of these cases the operation may be accomplished 
 without the use of the postrhinoscopic mirror, as the pharyngeal openings 
 may be seen with the unaided eye. 
 
 The Diagnostic and Therapeutic Value of Catheterization. — There are 
 various methods of forcing air through the catheter into the middle ear, 
 all of which are of value, the choice of method depending largely upon the 
 mechanism afforded by the local instrument dealers rather than upon 
 the peculiar merits of any individual method, (a) The Politzer bag, 
 shown in Fig. 391, is connected directly with the Eustachian catheter, 
 and is, perhaps, the most familiar apparatus for this purpose, owing to 
 the reputation of its distinguished inventor. It is admirably adapted 
 to the use of general practitioners on account of its simplicity and the 
 slight expense. 
 
 (6) The equipment of a modern American otologist, however, usually 
 affords appliances which are even more convenient, and perhaps more 
 scientific in their application in office practice than the Politzer bag. 
 Many offices in the large cities now have compressed air piped through 
 the building, and with a gauge the desired pressure can be obtained 
 for each individual case iVn equipment of this character is admirably 
 adapted to the purposes of the otologist, and renders the work of inflation 
 more exact and scientific in its application. The shut-off should be 
 applied to the expanded end of the catheter after it is properly adjusted, 
 and inflation accomplished by liberating the air by means of the lever, as is 
 done in spraying the nose and throat (Fig. 390). The exact amount of air 
 pressure can be accurately estimated by the pressure gauge. The author 
 uses the regulator attached to the compressed-air tank devised by Edwin 
 Pynchon. It is so arranged that the amount of air pressure can be quickly 
 adjusted to the needs of the case. A pressure of from seven to twenty- 
 five pounds is all that is ordinarily required for the inflation of the middle 
 ear. In some cases a pressure as low as five pounds is quite adequate 
 for the purpose. 
 
 (c) The nebulizing inflator is an instrument whereby inflation can be 
 performed through the catheter in a very simple and easy manner. The 
 tip of the nebulizer is made to fit into the expanded end of the catheter, 
 and the medicated nebula is driven through the catheter into the middle 
 ear. The impact of the medicated air thus released passes through 
 the tube and the catheter to the middle ear. This appliance affords 
 a convenient and simple means of applying medicated vapors. 
 
 The diagnostic tube should be used in connection with these methods, 
 and the character of the sounds transmitted through it noted for diagnos- 
 tic and prognostic purposes. 
 44 
 
690 
 
 THE EAR 
 
 Politzer's Method.— In 1863 Politzer 1 introduced a method of inflating 
 the middle ear cavities which still proves of the greatest utility in aural 
 practice. It is performed with a pyriform rubber bag (Fig. 391), of 
 about ten ounces' capacity, to which is attached a nozzle suitable for 
 introduction into the anterior nares. The patient is seated in front of the 
 operator, the nozzle inserted well into one nostril, while the opposite 
 nostril is firmly closed. The index and middle fingers of the operator's 
 left hand should engage the tip of the nose, while the thumb com- 
 pletes the closure of the nostrils. The patient is then instructed to 
 swallow, and as the laryngeal box is observed to rise, the bag is forcibly 
 compressed with the operator's right hand. The nozzle and the oper- 
 ator's fingers completely close the anterior nares, while the act of swallow- 
 ing brings the muscles of the soft palate and of the posterior wall of the 
 
 Fig. 391 
 
 Politzer's bag and tips. 
 
 pharynx into apposition, thus completely walling off the respiratory path 
 in that direction. The compressed air thus confined finds the point of 
 least resistance via the Eustachian tubes, and is conveyed to the middle 
 ear and inflation accomplished. The method is simple, the instru- 
 ments of simple construction and slight expense, and the procedure 
 is easily performed. The act of swallowing, if performed more than 
 once or twice, becomes quite difficult for the patient unless aided by 
 the use of a sip of water. 
 
 Miot introduced a simple expedient which in some respects is more 
 convenient than water. Sugar lozenges are kept on the treatment table, 
 and one given to the patient before performing inflation. As the lozenge 
 is dissolved in the mouth of the patient the act of swallowing is easily and 
 
 1 Wiener med. Wochenschrift, No. 6. 
 
THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 691 
 
 naturally performed as often as necessary without the inconvenience 
 attending the use of water. The tubes may also be rendered patulous 
 by uttering the sounds, och, k, king, kick, and by forcibly blowing out 
 the cheeks. 
 
 The author, in using the Politzer bag, places a piece of soft-rubber 
 tubing, one foot long, between the tip of the bag and the nozzle (Fig. 391). 
 By this measure the liability of mechanical injury to the mucous mem- 
 brane of the nose when forcibly compressing the bag is avoided, and 
 the hand of the operator has great freedom of movement within a circle 
 of twenty-four inches diameter. 
 
 Auscultation during the use of the Politzer method shows two sets of 
 sounds: one due to the entrance of air into the middle ear cavity, the 
 other to the escape of air in the epipharynx. The former is a soft, blow- 
 ing murmur when the drumhead is intact, while the latter is rough, 
 loud, and gurgling in character. After a little experience the tympanic 
 sounds may be readily distinguished from the rough pharyngeal noises, 
 and the latter are soon disregarded altogether. If for any reason the 
 
 Fig. 392 
 
 Politzer's bag and tube for use with a Eustachian catheter or nasal tip. 
 
 tympanic murmur is not heard, the use of the manometer tube should 
 be resorted to in order to determine whether the air is forced into the 
 middle ear. 
 
 It sometimes happens that inflation cannot be performed by Politzer's 
 method, in which event the use of the catheter is usually indicated. 
 
 A Modified Politzer Method. — The American Method. — The author 
 uses a modification of Politzer's method, in which the rubber bag is 
 discarded and the compressed-air apparatus substituted. It is not 
 only a more convenient, but also a more exact method of inflation. 
 A suitable nose-piece adapted to receive the tip of the shut-off of the air 
 tank tube, such as is used with spray bottles, comprises the outfit. The 
 Buttles-Pynchon inhaler is one of the best for the purpose, as it is con- 
 structed to be used with the ordinary shut-off of a compressed-air ap- 
 paratus. It is a Pynchon modification of the Buttles inhaler, in which 
 the acorn-shaped nose-piece unscrews at about its middle portion (Fig. 
 386), thus affording an easy means of introducing pieces of sponge, 
 gauze, felt, or cotton-wool upon which volatile medicaments may be 
 dropped and blown into the tympanic cavity. By means of the com- 
 
692 THE EAR 
 
 pressed-air tank with a pressure regulator the exact amount of air 
 pressure needed to inflate the ear may be established for each case 
 at the time of the primary examination. This should be made a part 
 of the record, and utilized in the future treatments. If it is found after 
 a few treatments that inflation is accomplished with less air pressure 
 than was at first required, a favorable prognosis may be given. The 
 great advantage of this method over Politzer's is the fact that the amount 
 of pressure used can be accurately estimated, regulated, and recorded. 
 This method should be adopted in all modern offices, but for bedside 
 practice and for home use the Politzer bag still holds a distinct and 
 useful place in otological practice. 
 
 Thomas Hubbard has also devised an ingenious compressed-air 
 apparatus for the graduated and scientific regulation of the air pressure 
 in tympanic inflation. His apparatus is also provided with an air filter. 
 
 External Mechanical Massage. — In the hands of the author external 
 mechanical vibration below the angle of the inferior maxilla has proved a 
 valuable adjunct to the inflation of the middle ear. In some cases which 
 resist successful inflation mechanical massage applied in this region 
 with the vibrator will bring about the desired result. The mechanical 
 vibration thus imparted probably lessens the passive congestion of the 
 mucosa of the pharynx, tonsils, and faucial pillars, and thus favorably 
 influences the mouth and the lumen of the Eustachian tube. 
 
 Comparative Value of the Methods. — It may be said that no one method 
 should be used to the exclusion of all others. Each will, under certain 
 circumstances, answer the purpose better than another. The condi- 
 tions favorable to the employment of any method cannot always be 
 foreseen, but can only be ascertained by trial. The author has often 
 found it impossible to inflate by catheterization when he could do it 
 readily by the Politzer method, or vice versa. He has also found the 
 Politzer method inadequate in some instances in which the modification 
 described by the author, using the compressed-air tank and a nose-piece, 
 did the work satisfactorily. 
 
 Valsalva's method is commended on account of its simplicity and the 
 absence of instruments of any kind in its performance. On the other 
 hand, it is to be strongly condemned on account of the ease with which 
 it may be abused. It is done entirely by the patient, and the relief it 
 affords may tempt him to resort to its use much oftener than is neces- 
 sary or safe. There are few cases requiring inflation oftener than once 
 on each alternate day for a period of six weeks. With Valsalva's method 
 the patient often inflates his ears several times daily for many weeks 
 or months, thus producing pressure atrophy of the drumhead. When 
 this condition arises the state of the patient's ears is_worse than before 
 treatments were given. 
 
 Catheterization is regarded by many as the most effective method of 
 inflation yet devised. In the author's experience, a louder tympanic 
 murmur is heard by this than by any other method. He believes, there- 
 fore, that where it can be used without great discomfort to the patient it 
 should be given preference. However, there are certain nasal deformi- 
 
THE PRINCIPLES AND METHODS OF TYMPANIC INFLATION 693 
 
 ties which may prevent, or at least greatly hinder, its successful use. 
 Some other method, preferably the tank and nose-piece, should then be 
 used. Politzer himself claims more for his method than for any other, 
 not excepting catheterization. 
 
 The Politzer method is extensively recommended and used on account 
 of its simplicity and the ease with which it is practised. In those cases 
 in which the catheter cannot be used, as in marked nasal obstruction, 
 hypersensitiveness of the mucosa, timid patients, and children, it should 
 be elected as preferable to catheterization. 
 
 Unless the diagnostic (auscultation) tube is used, the operator is 
 never certain of the results obtained by any method whatsoever, the 
 patient's statements often being untrustworthy. 
 
 The modified Politzer method, in which the compressed-air tank takes 
 the place of the rubber bulb, is ordinarily preferable to the Politzer 
 method, as the pressure can be accurately regulated to suit each case. 
 The tympanic murmur is louder and is heard much longer and more 
 continuously on account of the constant air pressure than with the 
 short puff obtainable with the Politzer bag. The author believes, how- 
 ever, that where catheterization can be done with little discomfort to 
 the patient it should be given preference. 
 
 Recapitulation. — 1. Catheterization is the most effectual method of 
 inflation in most subjects. 
 
 2. The compressed-air tank and nose-piece are preferable if, for any 
 reason, catheterization cannot be performed. 
 
 3. The Politzer method should be used in bedside practice and as a 
 "home treatment," and in all other instances in which the compressed- 
 air apparatus and nasal tip are not available. 
 
 4. Valsalva's method should only be recommended when the others 
 are not available, and then only with strict instructions as to its possible 
 evil results if the directions as to the frequency and period of use are not 
 strictly followed. 
 
CHAPTEE XLI. 
 
 INFLAMMATORY DISEASES OF THE TYMPANUM. 
 ACUTE CATARRHAL OTITIS MEDIA. 
 
 Acute catarrhal otitis media comprises about 13 per cent. (Hovell) of 
 all ear diseases; it is, therefore, a very important division of otology, and 
 should be considered in some detail, especially in view of the fact that 
 the general practitioner is so frequently called upon to treat it. 
 
 General Etiology. — The causes of simple catarrhal otitis media are 
 numerous, and may be considered under three different headings, 
 namely: 
 
 1. Exciting causes, or pathogenic microorganisms. 
 
 2. External influences, or those conditions external to the body which 
 act as predisposing causes. 
 
 3. Internal influences, or those conditions within the body which pre- 
 dispose to otitic inflammations. 
 
 1. Exciting Causes. — The exact relation of microorganisms to the inflam- 
 mation of the middle ear is not yet fully determined. That they are 
 found in healthy ears is probable, as the investigations by Zaufal have 
 shown them to be present in the ears and epipharynx of rabbits. We 
 know that the various infectious fevers, as scarlet fever, measles, diph- 
 theria, etc., are often accompanied by acute catarrhal otitis media, 
 although complications from these sources are very prone to take on the 
 suppurative type. There is no special bacteria which causes catarrhal 
 inflammation of the middle ear, but there is usually a combination of 
 two or more, such as the Diplococcus pneumoniae and the Streptococcus 
 pyogenes. The Staphylococcus pyogenes albus and aureus, and the 
 Bacillus pyocyaneus are next most frequently found in the middle ear. 
 Friedlander's bacillus is less frequently found in combination with the 
 Staphylococcus cereus albus, Bacillus pyocyaneus, and the Micrococcus 
 tetragenus. These and other microorganisms may be present in the 
 tympanic cavity without exciting inflammation. It is necessary that the 
 conditions of the secretions and the tissues be favorable for their rapid 
 propagation before they are able to excite an inflammatory process. It 
 has been found that the invasion of a new microorganism is sufficient, 
 under certain circumstances, to excite inflammation. After the inflam- 
 mation has subsided the invasion of another type of microorganism may 
 cause a recurrence of the inflammation. The question of microorgan- 
 isms in their relation to inflammatory processes is still involved in so 
 much speculation and doubt that it is impossible to give any definite 
 statement as to the exact influence they have as etiological agents in 
 
ACUTE CATARRHAL OTITIS MEDIA 695 
 
 catarrhal inflammations. It seems that after the primary irritation of 
 the tissues has subsided, the soil is prepared for other germs, so that 
 upon their entrance there is a recrudescence of the inflammatory process. 
 
 It is well known that pathogenic microorganisms are more virulent 
 at times than at others, hence the presence of microorganisms per se is 
 not sufficient to cause acute inflammation. They must be of the proper 
 virulency, the soil must be prepared to favor their activity, and the cellu- 
 lar structures must be so modified in their functional activity as to be 
 unable to resist their influence. Even the tubercle bacillus may be 
 found in the secretions of the middle ear without giving rise to patho- 
 logical changes. 
 
 Channels of Invasion.- — Microorganisms nearly always gain access to 
 the tympanum through the Eustachian tube. There are several other 
 routes, however, through which they may enter it. The bloodvessels 
 may carry them to the mucous membrane of the tympanum, where they 
 may be thrown out with the serum and mucus, and thus give rise to 
 inflammation. They may also gain access through the drumhead, 
 when it is perforated, either from congenital or pathological states. In 
 rare instances they may gain entrance from the cranial cavity through 
 the bony walls, or through the internal auditory canal and labyrinth. 
 
 As has been stated, they most frequently gain entrance through the 
 Eustachian tube. This may occur in spite of the fact that the tube is 
 lined with ciliate columnar epithelium, whose cilise create a current to- 
 ward the epipharynx. The Eustachian tube is patent as it momentarily 
 opens to admit air into the tympanum, and the microbes may be swept 
 inward with the current of air to the middle ear. This may also take 
 place during paroxysms of sneezing or vomiting. Hence there is no 
 absolute physiological barrier offered by the ciliated epithelium of the 
 tube to the entrance of microorganisms into the middle ear. 
 
 The microorganisms excite catarrhal inflammation which may assume 
 the suppurative type. They may also be present without exciting any 
 pathological reaction. 
 
 2. External Influences. — The external causes of otitis media cannot 
 be considered without also taking into account the internal conditions 
 which predispose to it. It is convenient, however, for purposes of study 
 to consider the external causes separately, and in so doing we shall have 
 to take into consideration the local conditions of the upper respiratory 
 tract, as well as certain constitutional states which will be considered 
 in detail under the second type of general causes. 
 
 Exposure to the weather is a fruitful predisposing cause of otitis media, 
 especially when the tone of the system is not up to the normal standard. 
 If the patient has chronic rhinitis or obstructive disease of the nasal 
 cavities, or has adenoids and epipharyngeal inflammation, exposure 
 to the inclemencies of the weather is especially liable to result in acute 
 catarrhal inflammation of the middle ear. Certain other factors enter 
 into this proposition, as clothing, climate, zone, age, sex, and the occu- 
 pation of the patient. 
 
 It seems appropriate, therefore, that these etiological factors should be 
 
696 THE EAR 
 
 considered under this heading, rather than under separate paragraphs. 
 It is evident that the effect of exposure to the weather will depend very 
 largely upon the amount and kind of clothing worn, and the climate and 
 latitude in which the patient lives, as well as upon his occupation. Age 
 and sex will, also, largely determine this effect. The character and amount 
 of clothing worn does not per se determine the influence that exposure 
 to the weather will have upon the patient, as the habits of the individual 
 and the character of the house in which he lives modify his susceptibility 
 to such exposure. If he lives in a house that is but partially heated, 
 and has been accustomed to sleeping in a bedroom which was never 
 heated, the exposure to the inclemencies of the weather will not effect 
 him as much as it will one who lives in a well-built house which is 
 uniformly heated. 
 
 Many of our country homes are so loosely constructed that they are 
 well ventilated through the crevices about the windows and doors. There 
 is not, therefore, the extreme difference between the conditions indoors 
 and outdoors found in the better portions of the large cities. 
 
 Those living in country houses are subjected to a more even tem- 
 perature and atmosphere, within and without the house, than those 
 who live in closely built and better heated houses. They are, there- 
 fore, not so susceptible to changes of the weather, and the amount of 
 clothing they wear, when exposed, need not differ so much in quantity 
 and character from that worn while indoors. 
 
 I have known patients accustomed to country life, who were exposed 
 to the inclemencies of the weather a hundred times more than they 
 were in after years when living in the city, to be entirely free from catar- 
 rhal conditions of the nose and ears while living in the country, and 
 rapidly develop them after removing to the city. 
 
 The catarrhal inflammation developed, in spite of the fact that they 
 were taking extraordinary precautions, in the way of additional clothing, 
 to protect themselves while outdoors. It seems, therefore, that the 
 habits of life which tend to lower cell vitality have more to do with 
 the predisposition of the upper respiratory tract to catarrhal inflam- 
 mation than the amount or character of clothing worn. Our modern 
 dwellings, with their superb heating plants, storm windows, etc., are, 
 perhaps, less of a boon to humanity than is generally supposed. The 
 more primitive style of living seems to accustom the system to the vari- 
 ations in the temperature and hygroscopic conditions of the atmosphere. 
 It is not reasonable, however, to expect that we will return to that mode 
 of living. We can only say in this connection that in the construction 
 of our houses more attention should be given to the question of ventila- 
 tion. It has been said that good ventilation and cheap heating do not 
 go hand in hand. Within certain limits this is undoubtedly true. Never- 
 theless, the architect can do much toward the proper ventilation of 
 dwelling houses without materially increasing the expense of heating. 
 
 The attention of the public should be frequently called to this fact 
 until they are educated up to the point that they will demand that this 
 problem receive appropriate attention at the hands of the architects. 
 
ACUTE CATARRHAL OTITIS MEDIA 697 
 
 The climate and latitude in which one lives influence, in a marked 
 degree, the character and amount of exposure to which he is subjected. 
 In the temperate zone the climate is usually variable and subject to 
 verv rapid changes in temperature and hygroscopic conditions of the 
 atmosphere, and is, therefore, one of the factors in the etiology of acute 
 inflammations of the upper respiratory tract and middle ear. Those 
 living in the more frigid and torrid zones are less exposed to sudden 
 changes in the temperature and atmosphere, and are, consequently, less 
 subject to catarrhal inflammations. Those living near large bodies of 
 water, as the ocean, or the chain of Great Lakes between Canada and 
 the United States, are especially affected by climatic conditions, as the 
 atmosphere is moist and penetrating. The skin is thereby chilled and the 
 vasomotor nervous centres are disturbed, and many of the functions of 
 nutrition and metabolism are modified in such a way as to excite inflam- 
 matory processes in the mucous membranes, especially those of the 
 respiratory tract. 
 
 Certain occupations give rise to greater exposure than others, conse- 
 quently sex, which largely determines the nature of one's occupation, 
 must have some influence in the etiology of this disease. A greater pro- 
 portion of males are exposed to the inclemencies of the weather, hence 
 catarrhal inflammation of the mucosa is more common with them than 
 females. 
 
 Age also determines, to some extent, the amount of exposure. Young 
 male adults in the vigor of life, full of ambition and enterprise, more 
 often subject themselves to the inclemencies of the weather in the pur- 
 suit of their vocations than those who are younger or older. Hence, 
 we find catarrhal inflammation of the middle ear and upper respiratory 
 tract more common in voung adulthood than at any other period of 
 life. 
 
 A careful study of the above facts will demonstrate that exposure to the 
 weather is a question of considerable complexity, as the effects of the 
 exposure are largely determined by the mode of life, clothing, zone, age, 
 sex, and occupation of the patient. It is not sufficient, therefore, for one 
 to say to the patient, "You should not expose yourself to the inclemencies 
 of the weather." All the facts pertaining to his mode of life should be 
 taken into consideration, and advice given accordingly. It has become 
 quite the fashion nowadays to tell patients that they should take a cold 
 plunge bath each morning, and that they should walk at least five miles 
 a day. This advice with certain limitations is sound, and is based upon 
 the data given above. The attempt is made by this procedure to bring 
 the patient for a brief time each day back to the primitive methods of 
 living. It is well known that life in the open air, and a certain amount 
 of exposure of the body to varying degrees of heat and cold, are favor- 
 able to the well-being of the system. 
 
 More attention should be given to this subject than is now done. 
 The influence of open air upon the cellular vitality is greater, perhaps, 
 than is generally appreciated. We know that many women work indoors 
 all day, are constantly making physical exertion, and are anemic and 
 
698 THE EAR 
 
 poorly nourished in spite of the fact that they have plenty of wholesome 
 food. The same amount of exercise taken in the open air would trans- 
 form them into robust, red-blooded women. Fresh air is the most 
 potent therapeutic agent for the upbuilding of the system. 
 
 3. Internal Influences. — The internal conditions which predispose to 
 catarrhal inflammation of the middle ear and upper respiratory tract 
 have a more intimate clinical relationship to acute catarrhal otitis media 
 than the external influences. It is well established that middle ear dis- 
 ease is almost invariably preceded by some form of nasal or epipharyn- 
 geal disease. Whatever causes the preexisting infection and inflamma- 
 tion of the nasal mucous membrane or the mucosa of the epipharynx 
 will also directly or indirectly lead to a similar condition within the 
 Eustachian tube and middle ear. This is easily accounted for when we 
 remember that the mucous membrane of the Eustachian tube and 
 middle ear is a continuation or reflection of that lining the nose and 
 epipharynx. It is quite similar in physiology and structure, and inflam- 
 mations therefore readily extend from one part of it to another. If there 
 is a difference in the structure of the mucous membrane, as in the meso- 
 pharynx, where the epithelium is squamous, the inflammatory process 
 does not readily extend to that part. The mucosa of the nose, epi- 
 pharynx, Eustachian tube, and middle ear are lined by columnar ciliated 
 epithelium, hence there is no bar to the extension of the inflammatory 
 process from one to the other. 
 
 In this connection it is of advantage to briefly refer to the diseases of 
 the nose, epipharynx, and fauces which cause inflammatory diseases 
 of the Eustachian tube and middle ear: 
 
 (a) Nasal diseases which cause pathological processes within the mid- 
 dle ear are either inflammatory or obstructive in character. The inflam- 
 matory diseases are acute rhinitis, acute fibrinous rhinitis, diphtheritic 
 rhinitis, syphilitic rhinitis, tuberculous rhinitis, and catarrhal and suppura- 
 tive sinuitis. The inflammation may extend to the middle ear through 
 the Eustachian tube by continuity of tissue, or the pathogenic bacteria 
 may invade the ear through the Eustachian tube or through the blood and 
 lymph channels. They also influence the inflammatory changes in the 
 middle ear by causing the closure of the Eustachian tube, thereby inter- 
 fering with the ventilation of the tympanum. The oxygen is gradually 
 absorbed from the middle ear, thus gradually rarefying the air. The 
 blood within the vessels of the mucosa of the middle ear rushes in 
 to fill the partial vacuum thus created, and congestion and engorge- 
 ment of the mucous membrane follows. This leads to changed nutrition 
 of the parts and to a disturbed relationship of the cellular structures, 
 which after a time predisposes to an inflammatory process. 
 
 Nasal obstruction is also a fruitful source of ear disease. The pres- 
 ence of spurs, ridges, thickening, and deflections of the septum, and 
 enlargement of the middle turbinate (see Vicious Circle of the Nose) 
 cause stenosis of one or both nares or obstructs the ostia of the sinuses. 
 As the nasal cavities are the natural channels for the respiratory and 
 expiratory currents of air, any interference with their patency results 
 
ACUTE CATARRHAL OTITIS MEDIA 699 
 
 in physiological disturbances of a very pronounced character. When 
 the diaphragm contracts, the thoracic cavity is enlarged and the air 
 from without rushes in to fill the increased space. If the nasal chambers 
 through which the air enters the respiratory tract are obstructed, the 
 contraction of the diaphragm acts as the valve in a syringe when it 
 is forcibly pulled out; the air is thus rarefied posterior to the point of 
 obstruction. The partial vacuum thus created is attended with the rush 
 of blood to the vessels of the mucosa. This condition after a time 
 leads to tissue changes and predisposes to inflammatory processes. The 
 patency of the Eustachian tubes is thereby diminished, which still further 
 affects the middle ear. Hence nasal and sinus obstruction is a constant 
 menace to the middle ear cavity. 
 
 All cases should be carefully examined for any diseased state of the 
 nose, as the subsequent treatment of the case will depend very largely 
 upon the successful treatment of the nasal conditions. 
 
 Ethmoiditis and sphenoiditis are a fruitful source of middle ear inflam- 
 mation. The morbid secretions from these cells flow into the epipharynx 
 and excite an inflammation which in time extends by continuity of 
 tissue to the Eustachian tube and middle ear. 
 
 (b) Epipharyngeal diseases predisposing to middle ear catarrh may be 
 studied under two headings, namely, postnasal adenoids, or neoplasms, 
 epipharyngitis and adhesive bands in Rosenmuller's fossae. The pres- 
 ence of postnasal adenoids in the vault of the pharynx gives rise to 
 epipharyngitis, either of the catarrhal or suppurative type. For reasons 
 already given, this inflammatory process may give rise to middle ear 
 inflammation. Postnasal adenoids may be so situated as to close the 
 mouths of the Eustachian tubes, a common cause of middle ear 
 catarrh. 
 
 (c) Enlarged or diseased faucial tonsils have for many years been 
 recognized as one of the principal etiological factors in the production of 
 middle ear disease. This relationship is readily understood when we 
 remember that the tonsils are situated between the anterior and posterior 
 pillars of the fauces (glosso- and pharyngopalatine arches). The pos- 
 terior pillar embraces the palatopharyngeus muscle, which has some 
 influence in controlling the patency of the Eustachian tube. It is appar- 
 ent that when the tonsils are diseased the pillars are congested or inflamed, 
 and in time their muscular fibers undergo more or less degeneration 
 and atrophy. 
 
 (d) Tubal disease, while intimately associated with middle ear disease 
 in nearly every case coming under observation, may be present without 
 a similar process in the middle ear. In other words, there is a time 
 when the inflammation extends from the epipharynx into the Eustachian 
 tube, and does not yet involve the middle ear. Reference has already 
 been made to the fact that congestion or obstruction of the Eustachian 
 tube is a fruitful source of inflammatory diseases in the middle ear, 
 and need not be dwelt upon at greater length in this place. 
 
 (e) Constitutional disorders, as anemia, scrofula, syphilis, and tuber- 
 culosis, lower the vitality and thus predispose the middle ear to inflam- 
 
700 THE EAR 
 
 matory attacks. This has already been referred to under the external 
 causes of otitis media. 
 
 After all that has been said as to the causes of otitis media, we may 
 go back to the primary statement that those influences external to the 
 body which, under varying circumstances, affect the vasomotor system, 
 and certain diseased states of the epipharynx, cause obstruction of 
 the Eustachian tube and subsequent infection and inflammation of the 
 middle ear. 
 
 Pathology. — The cavum tympani contains serum admixed with mucus 
 in varying proportions. Epithelial cells are also found in the secretion. 
 They show evidence of having undergone degenerative changes peculiar 
 to inflammatory processes. While the secretion cannot be said to be sup- 
 purative in character, it may contain a number of pus corpuscles. The 
 mucous membrane of the middle ear, unlike that of the nose, has very 
 few glands; hence, the mucus is formed from the chalice of goblet cells 
 of the mucosa. In the nose the mucus is chiefly formed by the cells 
 lining the glands, only a few goblet cells participating in its production. 
 There is, therefore, in the middle ear a very rapid degenerative process 
 (mucoid degeneration) going on during the acute inflammatory process. 
 The intercellular spaces are filled with fluid, while the bloodvessels are 
 very much congested, thus rendering the membrane very much swollen 
 and thickened. The surface of the mucous membrane is denuded of 
 epithelium in patches. Hovel calls attention to the fact that leukocytes 
 are found mingled with the secretion in the immediate region of these 
 patches. 
 
 Pronounced destructive processes are not commonly present in this 
 type of middle ear disease. In rare instances the drumhead is perforated, 
 while there is more or less maceration of the mucous membrane lining 
 the tympanic cavity. After a few days the morbid changes described 
 above rapidly disappear, the mucous membrane returning to its normal 
 condition. There remains, however, a peculiar susceptibility to recur- 
 rent inflammations. This may be due to the fact that microorganisms 
 of the proper virulency gain entrance to the cavity and, finding the soil 
 prepared by the primary inflammatory process, readily excite a recur- 
 rence of the inflammation. 
 
 General Symptoms and Diagnosis. — Acute otitis media is usually 
 due to a bacterial infection via the Eustachian tubes, though it occa- 
 sionally enters via the blood current. The exudate may be simple or 
 purulent. In simple catarrhal inflammation the drumhead rarely rup- 
 tures, no matter how intense the inflammation may be. If the exudate 
 is purulent there is a tendency to rupture at the point of greatest bulging. 
 Severe simple catarrhal cases begin with the same constitutional dis- 
 turbances present in severe purulent cases, namely, chills, fever, vomiting, 
 and prostration. It is often quite difficult to differentiate between acute 
 non-suppurative and acute suppurative otitis media, until the drum 
 membrane ruptures. Both types of inflammation are due to infection, 
 one undergoing resolution before suppuration, and the other passing 
 into the suppurative stage. 
 
ACUTE CATARRHAL OTITIS MEDIA 701 
 
 Intracranial complications never occur in acute non-suppurative 
 otitis media, and somewhat rarely in the acute suppurative variety. Such 
 complications occur more often in the chronic type, with acute exacer- 
 bations. 
 
 The exudate has a tendency to become organized into adhesive fibrous 
 bands, hence it is very important that their absorption should be has- 
 tened as much as possible. The air douche, by means of the Politzer 
 bag and the catheter, should be used to clear the middle-ear cavity of the 
 exudate, or at least to spread it over a larger surface, thereby reducing 
 the amount of exudate at any one point. The inflations should be 
 repeated from time to time until the ear is free from the exudate, as shown 
 by the auscultation tube. According to Edwin Pynchon, the use of the 
 continuous air douche through a Eustachian catheter will abort acute 
 otitis media. A pressure of about five pounds is required for this purpose. 
 The compressed-air tank should be adjusted to this pressure and the 
 current of air passed through the catheter into the tube and middle ear 
 cavity. 
 
 Infants often have acute otitis media of very short duration, probably 
 of pneumococcal origin. Intestinal disturbances in infants are often 
 accompanied by ear infection, and an examination of the ear should 
 always be made. The exanthematous fevers of childhood are common 
 causes of middle ear infections, which in later years result in many 
 deaths from meningitis, sinus thrombosis, brain abscess, etc. Great pains 
 should be taken in these diseases to keep the nose and epipharynx clean 
 during the fever. Scarlet fever and measles are especially destructive in 
 this way. Diphtheria more rarely invades the middle ear. 
 
 Acute tuberculous otitis media is seldom accompanied by pain. This 
 is in striking contrast to other types of acute infection. If an acute tuber- 
 culous otitis media begins with pain and other symptoms peculiar to the 
 ordinary acute suppurative otitis media, the prognosis is much more 
 favorable than in the non-painful variety. 
 
 Acute otitis media occuring during diabetes is not of diabetic origin. 
 The occurrence of the two diseases is accidental. The diabetic disease, 
 however, gives rise to constitutional disturbances which favor the long 
 continuance of the ear discharge. 
 
 Neglected cases of chronic catarrhal otitis media result in shrinking 
 and atrophy of the mucous membrane, or adhesions may form, thus 
 causing permanent loss of hearing. The deposit of lime salts or adhesive 
 processes may fix the ossicles or bind them to the contiguous walls of the 
 cavum tympani. 
 
 Symptoms. — The symptoms of this disease vary according to the 
 period of time which has elapsed since the onset. At the beginning 
 they are much more pronounced than they are after a few days, when 
 the more acute inflammatory process has begun to subside. 
 
 1. The onset of acute otitis media is usually signalized by a slight 
 chill, which is quickly followed by a temperature ranging from 99° to 
 102°. The fever is, however, of such slight character in most cases that 
 the attention of the patient is not usually attracted to it. The symptom 
 
702 THE EAR 
 
 which quickly develops, and which should demand the attention of the 
 attending physician, is the fain, which may be characterized as a dull, 
 boring, aching sensation, or it may assume a more acute type, and 
 become excruciating in its intensity. It is usually intermittent or throb- 
 bing in character, synchronous with the pulse beat at the wrist. It 
 is due to the great swelling of the drumhead and mucous membrane 
 uf the middle ear, whereby the sensitory nerve filaments are put "on 
 the stretch" with each arterial pulsation. It may also be due to the 
 bulging of the drumhead outward into the meatus. There is a great 
 amount of intercellular fluid thrown out at this stage of the disease, 
 which together with the congestion of the bloodvessels renders the mucous 
 membrane and drumhead very much thicker than normal. 
 
 In the first stage the drumhead is very red and thickened, and the 
 handle of the malleus obscured from view. Its surface may present 
 the appearance of a piece of raw beefsteak, except that it is more velvety 
 in its texture. The drumhead may or may not bulge into the external 
 meatus, depending upon the amount of secretion within the middle 
 ear. 
 
 If the middle ear is filled with exudate, the drumhead is of necessity 
 pushed outward. If, however, it is only partially filled, it may remain in 
 its normal position or even be retracted. 
 
 Auricular tenderness is sometimes present, especially over the tragus. 
 The mastoid process may or may not be tender upon percussion or press- 
 ure. Pressure over the mastoid antrum nearly always elicits tenderness, 
 though it may be slight. 
 
 Bone conduction is increased on the affected side. The lower tone 
 limit is lost, while the upper tone limit is not affected in those cases in 
 which the labyrinth is not involved. If the disease is unilateral, the Weber 
 experiment lateralizes to the affected side. The Rinne test is usually 
 negative in character. By the term negative I do not mean that it shows 
 nothing, but that bone conduction for the tuning fork over the mastoid 
 process is longer than by air conduction when the fork is held near the 
 external auditory meatus. If the labyrinth is involved, bone conduction 
 is diminished, and the Weber test shows the sound lateralized to the 
 unaffected ear, while the Rinne test gives a positive sign. Labyrinthine 
 involvement is, however, very rarely present in simple catarrhal otitis 
 media. 
 
 2. The second stage of this disease is characterized by the disappear- 
 ance of the pain, fever, and redness of the drumhead. The congestive 
 phenomena are lessened in intensity, hence the drumhead and mucous 
 membrane are less thickened and swollen. The drumhead, instead 
 of being beefy or purplish red in color, is yellowish or greenish in tint. 
 The change in color may be explained by the fact that there is less 
 blood in the drumhead, and the pale, slightly greenish secretion in the 
 middle ear is seen through it. The greenish-yellow color often gives 
 rise to the idea that there is pus in the middle ear. 
 
 Another symptom of considerable significance is the presence of a 
 dark wavy line (Fig. 393) extending in a nearly horizontal direction across 
 
ACUTE CATARRHAL OTITIS MEDIA 
 
 703 
 
 the drumhead. This line, which is 1 to 2 cm. in thickness, is due to the 
 peculiar refraction of light at the junction of the viscid secretion and the 
 air in the tympanic cavity. If it is below the umbo, it is usually concave 
 on its upper surface; whereas if it extends above the umbo, it is usually 
 composed of two concave surfaces. The line will be higher or lower on 
 the face of the drumhead according to the amount of secretion in the 
 middle ear. If the middle ear is completely filled, the line will not be 
 visible. 
 
 The position of the head determines the direction of the line, as the 
 fluid gradually seeks the level of the new position (Figs. 394). The viscid 
 nature of the secretion and the narrowness of the tympanic cavity inter- 
 feres with the rapid change in the position of the secretion. The line is 
 often not visible, on account of the great thickness and congestion of 
 the drumhead. 
 
 Fig. 393 
 
 Fig. 394 
 
 Right membrana tympani, showing mucus 
 secretion and air bubbles after tympanic in- 
 flation. 
 
 Right membrana tympani with mucus secre- 
 tions and air bubbles after tympanic inflation, 
 the patient having just arisen from the prone 
 position. 
 
 Another symptom is the presence of oval or round rings (Figs. 387 and 
 388), which are due to the air bubbles in the viscid mucus. They may 
 extend above the dark line, described above, or they may be within 
 the field of the mucus itself. They may be single or multiple. After 
 tympanic inflation the line disappears, while the entire field of the 
 drumhead is occupied by the air bubbles. After several hours they will, 
 in part, disappear, and the line will return. 
 
 Aural ausculation, if used during the process of tympanic inflation, 
 shows the presence of moist rales, due to the air passing through the 
 viscid mucus. They are very different in character from the soft, blow- 
 ing murmur heard during inflation of the normal ear. 
 
 The first inflation may not be successful, as the Eustachian tube is 
 filled with viscid mucus, hence it should be repeated several times. 
 The diagnostic tube should always be used in performing tympanic 
 inflation. 
 
 The membrana tympani may or may not bulge into the auditory 
 meatus, as this depends upon the amount of secretion within the middle 
 ear. When it bulges into the meatus it is a positive indication that 
 paracentesis, or incision of the eardrum, should be performed. To 
 
704 THE EAR 
 
 neglect this subjects the patient to unnecessary pain and to sponta- 
 neous perforation of the membrane. Spontaneous perforation should 
 not be allowed to occur, as the perforating process is due to necrosis. 
 Not only is irreparable damage thus done to the drumhead, but other 
 parts are subjected to pressure and to possible ulceration and necrosis. 
 
 Incision of the membrana tympani should, therefore, be done early, to 
 prevent great destruction of tissue and to promote the reaction of inflam- 
 mation. The incision does not result in scar tissue, which usually follows 
 spontaneous rupture of the drumhead. 
 
 It should be made at the most bulging portion, and should be crucial or 
 V-shaped in character and from J to f inch in length. Simple para- 
 centesis, while often recommended, is not sufficient for free drainage 
 of the tympanic cavity. If the incision is made straight and the drum- 
 head is tense, the aperture for the discharge of secretion is very small, 
 while the crucial or curved incision forms a slight flap which permits 
 a larger opening for the discharge of the tympanic contents. 
 
 Bone conduction is increased and the Weber and Rhine experiments give 
 the results described under the onset of the disease. 
 
 Prognosis. — This is favorable or unfavorable according to the period 
 at which treatment is instituted. If the case is seen early and appropriate 
 remedies are used, favorable results will follow in nearly all cases. If, 
 however, the case is allowed to run on for some time before treatment 
 is commenced, changes of considerable importance may have taken 
 place, such as adhesion of the contiguous parts, and ulceration in the 
 superficial portions of the mucous membrane, the prognosis is not so 
 favorable. 
 
 There are certain conditions which render the prognosis less favorable, 
 as syphilis, tuberculosis, anemia, etc. It is obvious that if the diseases 
 of the nose, epipharynx, and fauces, which predispose the patient to the 
 primary attack, are present, there will be greater difficulty in effecting 
 a favorable termination of the disease, and when it seems to have been 
 cured there may be recurrences. 
 
 The duration of the acute type varies from one to six weeks, although 
 in some cases it may be aborted in one or two days. The pain, which is 
 one of the first symptoms to appear, is also one of the first to subside. 
 Then the redness of the drumhead and the swelling of the mucosa, 
 after which the hearing power begins to return. Later the tinnitus 
 passes away. This symptom, however, often remains for several weeks, 
 and in those cases which merge into the chronic form it may become a 
 permanent symptom. 
 
 Treatment. — There are several influences to be considered in the 
 treatment of acute catarrhal middle ear inflammation, as the causes are 
 various and sometimes quite complicated. We are often called upon to 
 relieve the patient of the pain or even of the acute inflammatory process, 
 but we are not so frequently asked to treat the conditions which, if re- 
 moved, would prevent a recurrence of the disease. This cannot be done 
 without giving attention to the nasal, epipharyngeal, and faucial condi- 
 tions which are largely responsible for the middle ear inflammation. 
 
ACUTE CATARRHAL OTITIS MEDIA 705 
 
 The treatment should, therefore, be addressed to the relief of the acute 
 inflammatory process in the middle ear and the upper respiratory 
 tract in general, as well as to the complete removal of the morbid condi- 
 tions of the nose, epipharynx, and fauces. The first duty of the attend- 
 ing physician is to allay the pain as quickly as possible. 
 
 General or hygienic treatment should first of all be considered, as 
 the proper care of the patient will largely influence the progress of the 
 disease. He should be kept in the house during the acute stage, and if 
 fever is present he should remain in bed. The room should be well 
 ventilated and exposed to sunshine. His food should be simple and 
 nourishing, such as is usually given to bedridden patients. The bowels 
 should be regulated with calomel and saline cathartics, while alcoholic 
 beverages and tobacco should be forbidden. A light pledget of cotton 
 should be kept in the external meatus to protect the drumhead and the 
 middle ear from air currents. 
 
 Pain, being the most prominent subjective symptom, should receive 
 appropriate treatment at once. It is often so excruciating that the patient 
 is very restless. A mixture of equal parts of carbolic acid, glycerin, and 
 the hydrochlorate of cocaine may be dropped into the external meatus, 
 where it will, in most cases, afford relief within a few minutes. A mix- 
 ture of laudanum and oil in the external meatus is not of very much 
 value. The mixture is usually warmed in a teaspoon before use, and 
 if there is any virtue in it at all, it is due to the warmth or protection it 
 affords to the exposed and inflamed membrane. 
 
 Another remedy of value for the relief of pain as well as of the conges- 
 tion is a 12 per cent, solution of carbolic acid in glycerin (Andrews). 
 While this solution does not have as great anesthetic power as the one 
 above recommended, it nevertheless aids materially in allaying the pain. 
 
 The author has often used the fumes of chloroform as a relief. 
 There are a number of ways in which this may be applied, perhaps 
 most conveniently with a pipe, in the bowl of which there is a small 
 piece of cotton upon whfch a few minims of chloroform are dropped. 
 The stem of the pipe should be placed to the meatus, while the bowl 
 is placed to the mouth of the operator. 
 
 The fumes thus gently blown into the external auditory meatus 
 usually afford relief in a very few seconds or minutes. Leeches applied 
 to the tragus, or posterior to the auricle, also relieve the pain and promote 
 the reaction of inflammation. 
 
 Cold may be applied over the ear, although the effect is neither good 
 nor pronounced. Hovell recommends the use of blisters by means of 
 plasters over the mastoid process, though they are liable to produce 
 ugly sores. Their value is due to the fact that they promote the reaction 
 of inflammation, but there are other remedies which are more efficacious 
 and which do no harm, such as the leukodescent light from a 500 candle- 
 power lamp. 
 
 Tympanic Inflation. — During the past few years the literature has 
 shown a partiality for the use of glycerin and carbolic acid for the cure 
 of acute middle ear inflammations. The remedy is a valuable one, but 
 45 
 
706 THE EAR 
 
 it does not meet all the indications, especially those which arise from 
 the great tumefaction and adhesive processes. It is important that 
 tympanic inflation be performed at frequent intervals, as the increase 
 of the air pressure within the middle ear separates the inflamed surfaces. 
 In this way adhesions are prevented, or, if formed, are broken down 
 and a long train of symptoms and impairment of the auditory function, 
 so often seen in the dry or adhesive types of chronic ear disease, are 
 averted. The inflation also serves a very useful purpose in freeing the 
 tympanic cavity from secretions and in maintaining the patency of the 
 Eustachian tubes. 
 
 If the drumhead is very red and swollen, and there is great pain, the 
 air douche should be used with great caution, as there is danger of 
 perforation. Inflation should be chiefly limited to the second stage 
 of the disease, and should be performed at frequent intervals. The 
 
 Fig. 395 
 
 The application of the artificial leech to the mastoid process. The cord is drawn, thus rapidly 
 rotating the circular knife applied to the skin of the mastoid process. 
 
 patient should be provided with the Politzer air bag and instructed 
 in its use. The frequency with which it should be used depends upon 
 the rapidity with which the secretions are formed. In ordinary cases 
 it should be used at intervals of one to three hours. In this way the 
 tympanic cavity and Eustachian tubes are kept free from secretions. 
 The hyperemia is reduced by the increased air pressure, and the adhe- 
 sions between the ossicles and tympanic walls are prevented. 
 
 Inflation is most effective when performed through the Eustachian 
 catheter, but this, of course, can only be done by the attending physician. 
 If the case requires more frequent inflation than can be conveniently 
 given by the physician, dependence must be placed upon the use of the 
 Politzer air bag. 
 
 Leeching over the mastoid process and in front of the tragus is often 
 attended with prompt and marked improvement. There is no other 
 
ACUTE CATARRHAL OTITIS MEDIA 
 
 707 
 
 remedial measure that acts as promptly, and it would be a distinct ad- 
 vantage if leeches were used more frequently than they are at present. 
 The artificial leech, as shown in Figs. 395 and 398, may be used instead 
 of live leeches if desired. 
 
 Pneumomassage is a valuable adjunct to the treatment of the later 
 stages of acute inflammations of the middle ear. During the very acute 
 or first stage it cannot be used on account of the pain and great swelling 
 present, but later it is valuable, as it lessens the vascular and lymphatic 
 engorgement of the tissues and prevents ankylosis of the ossicles. The 
 form of pneumomassage best adapted for use in these cases, at least 
 in the secondary stage, is alternating compression and rarefaction of 
 the air in the external meatus. With the Victor massage apparatus and 
 the Pynchon modification of the pump (Fig. 15) any variety or character 
 of compression and rarefaction that may be desired can be produced. 
 
 Fig. 396 
 
 The exhaust pump withdrawing blood through the circular incision. 
 
 Care should be taken to adjust the piston to such a length of stroke 
 as will cause no pain, as otherwise it may increase the inflammatory 
 process or rupture the drumhead. The principle is the same as that 
 relating to the use of massage in any other part of the body — namely, 
 that it should be used with such force as not to produce contusion or 
 injury to the tissues. If such an instrument is not available, Siegle's 
 otoscope (Fig. 397) or the Delstanche masseur (Fig. 14) may be used. 
 If neither of these are at hand, a simple rubber tube with a suitable 
 meatal tip, through which alternating compression and rarefaction may 
 be produced with the mouth, will serve the purpose. These instruments 
 have the advantage of being under the perfect control of the operator, 
 while they have the disadvantage of imposing upon him the necessity 
 of administering the treatment from one to fifteen minutes, as the case 
 
708 THE EAR 
 
 may require. Some otologists regard the massage machines, which are 
 propelled by an electric motor, as being impressive pieces of machinery, 
 which have but little actual value as therapeutic agents. The author's 
 years of actual experience, however, with both kinds of apparatus has 
 proved that better results are obtained by the judicious use of the so- 
 
 Fig 397 
 
 Siegle's otoscope. 
 
 called ''machines" than is possible with the hand devices. However, 
 the hand instruments are especially well adapted for use in acute catar- 
 rhal cases, as pneumomassage is not usually applied for long periods 
 at any one time. Pneumomassage is of little value in well-advanced 
 adhesive processes, and in selected cases the only treatment is surgical. 
 
 ACUTE INFLAMMATION OF THE EXTERNAL ATTIC OF THE 
 TYMPANIC CAVITY (POLITZER). 
 
 The external attic' is sometimes the seat of a circumscribed acute 
 inflammation. The exudate is thrown out into Prussak's space (Fig. 
 355) and partly into the spaces formed by the folds of mucous membrane 
 between the malleo-incudal body and the external tympanic wall. 
 
 The disease is characterized by slight pain and deafness, with a tumor 
 or blister-like formation on the anterior portion of Shrapnell's mem- 
 brane (membrana flaccida); or if the posterior spaces are involved, the 
 projection forms upon the posterior portion of the flaccid membrane. 
 
 Etiology. — The exciting cause of this rather rare condition is the same 
 as in acute otitis media, namely, the specific bacteria of exanthematous 
 fevers, epipharyngitis, and influenza. The predisposing causes are 
 those conditions which give rise to obstructed drainage through the 
 Eustachian tube. Sea bathing and cold solutions in the external canal 
 also act as predisposing causes. It is probable that the infection usually 
 reaches Prussak's space through the Eustachian tube, although it is 
 possible for it to pass through the Rivinian foramen. 
 
 Symptoms. — In the mild form there is a feeling of fulness in the middle 
 ear, slight pain, deafness, and tinnitus. The membrana flaccida is red- 
 dened and bulging, or it may be yellow at its prominent portion. The 
 upper wall of the meatus near the drumhead is red and slightly swollen. 
 
CHRONIC MOIST CATARRHAL OTITIS MEDIA 709 
 
 The membrana tensa usually appears normal. The process may run its 
 course in a few days. 
 
 In the severe form the reactive symptoms are more pronounced, the 
 hearing being temporarily more disturbed, although there is usually no 
 permanent loss of hearing. The membrana flaccida is much more bulg- 
 ing, often completely covering the short process and handle of the malleus. 
 The course in the severe form is prolonged, though it may end in com- 
 plete recovery. 
 
 Treatment. — The treatment is the same as for acute otitis media and 
 acute suppurative otitis media, except there is no need for tympanic 
 inflation, as there is no deafness from swelling of the mucosa of the 
 middle ear and Eustachian tube, and the tension of the membrana 
 tensa and ossicles is not disturbed. 
 
 CHRONIC MOIST CATARRHAL OTITIS MEDIA. 
 
 This disease is characterized by intermittent or remittent deafness 
 and tinnitus aurium. It may follow acute catarrhal otitis media, or it 
 may come on without any previous history of acute disease. In some 
 cases deafness is progressive, while in others it extends by leaps and 
 bounds. The patient often makes the statement that he hears very well 
 until after exposure, after which he is much more deaf. The acuity of 
 his hearing is usually less during the damp, cool weather of late autumn 
 and early spring. 
 
 Etiology. — The etiology as given under Acute Catarrhal Otitis 
 Media in a large measure applies to this disease. Therefore a detailed 
 statement is not given in this connection. It is sufficient to state that 
 in most instances the chronic disease is an immediate result of the 
 acute inflammation. This is especially true in those cases which are 
 not treated early or in an appropriate manner. It is also especially 
 liable to follow the acute type in those cases in which there has been 
 previous chronic rhinitis, sinuitis, epipharyngitis, and obstruction of the 
 Eustachian tubes. The obstruction of the tubes by adenoids, epipharyn- 
 geal catarrh, nasal and accessory sinus disease, etc., undoubtedly forms 
 one of the chief factors in the production of the disease. (See Etiology, 
 Acute Catarrhal Otitis Media.) 
 
 Symptoms. — Subjective Symptoms. — The chief subjective symptoms 
 are deafness and tinnitus aurium. In addition to this, there is a feeling 
 of fulness in the ears. Giddiness is present in a certain number of cases, 
 but is by no means a constant symptom. 
 
 Deafness. — This is the chief symptom of the disease, and is usually 
 the one which leads the patient to seek relief. In quite a number of cases, 
 however, the tinnitus is so much more annoying than the deafness that 
 relief is sought on this account. The deafness may at first be so slight 
 and insidious in its progress that the patient is unconscious that his 
 hearing is defective. He explains his inability to understand what is said 
 to him by the slipshod way in which he is spoken to. It is not uncommon 
 
710 THE EAR 
 
 for such patients to feel offended when it is intimated that they do not 
 hear well. They are very apt to reply that they can hear when they 
 are spoken to in the proper manner. Later they notice slight subjective 
 noises, after which it is only a question of a few months until they be- 
 come conscious that their hearing is defective. In some subjects, how- 
 ever, the progress is not so insidious as that just described. On the con- 
 trary, it may be very rapid, then after a time seemingly remain stationary 
 for months or years. The deafness may again suddenly become worse, 
 and so continue throughout life. The rapid progress made is not indica- 
 tive of the severity of the inflammatory process, but rather points to 
 the fact that certain vital parts have become involved, thereby limiting the 
 sound-conducting function of the auditory apparatus. If the changes 
 which take place in the middle ear are limited to the mucosa of the tym- 
 panic cavity, the deafness is slighter and less rapid in its progress; 
 whereas, if the ossicular chain, and the round or the oval windows are 
 involved in a marked degree, the deafness comes on suddenly and is 
 more pronounced in character. It is important to bear this in mind, 
 as otherwise it is not possible to understand why in one case of simple 
 chronic catarrhal otitis media there is such slight deafness, while in 
 another there is marked and sudden increase in the deafness. 
 
 Tinnitus aurium is a symptom which is almost constantly present 
 in greater or less degree, causing the patients much annoyance. Their 
 sleep and rest at night are interfered with. They sometimes become 
 nervous and hysterical, and if relief cannot be afforded are apt to become 
 morose. The noises in the head assume almost any variety of sounds 
 or tones, ranging from simple pulsating murmurs to thundering noises, 
 or reports like the shot of a pistol or cannon. In many cases they are 
 of a whistling or singing character, while in others there is a buzzing, 
 or dripping sound. They may be musical or simply noise. They may 
 be mild or very intense. They may be constant, intermittent, or re- 
 current. It is doubtful if the noises in simple catarrhal otitis media 
 ever assume the form of spoken language. Those who seem to hear 
 voices and to receive messages and revelations probably have a central 
 lesion of the cortex. The brain may otherwise be practically normal, 
 so that the psychological phenomena referred to the organ of hearing 
 may be the only evidence that the patient has departed from the normal 
 mental state. The case of Joan of Arc, which has excited so much 
 historic and romantic interest, possibly belonged to this class. 
 
 In some cases the tinnitus is synchronous with the heart beats, while 
 in others it is very irregular in rhythm. Various explanations have been 
 given to account for those cases in which the noises are synchronous with 
 the cardiac pulsations, none of which seems to explain them satisfactorily. 
 The most probable explanation is that in some way or other the vibratory 
 thrill of the arteries of the tympanum is imparted to the membrana 
 tympani and the ossicular chain in such a way as to be transmitted to the 
 labyrinth, from whence the sensation is conveyed through the auditory 
 nerve to the brain centre, where it is appreciated as sound. The tin- 
 nitus may be very high or low in pitch, and in either case is indicative 
 
CHRONIC MOIST CATARRHAL OTITIS MEDIA 71 1 
 
 of an advanced stage of the disease. If, on the other hand, it is medium 
 in pitch a less advanced stage is indicated. The state of the general 
 health very materially influences the degree and the character of the 
 noises. When the patient is fatigued or is affected by some disease 
 which lowers his vitality they are worse. I have seen patients who were 
 the subjects of neurasthenia, in whom the pulsating noises were very 
 pronounced. Some of these patients did not have ear disease, the pul- 
 sating tinnitus being only one of the symptoms peculiar to their nervous 
 and anemic condition. In others, who were subject to catarrhal otitis 
 media, the tinnitus was very much aggravated by the neurasthenia. 
 The excessive use of alcohol and tobacco increases the intensity of the 
 noises, and may even cause pulsating tinnitus, synchronous with the 
 cardiac pulsations, even in persons who are not subject to otitis media. 
 
 Autophony consists of a vibration and echo-like reproduction of the 
 patient's own voice. This symptom is sometimes present in the moist, 
 but more particularly in the dry type of catarrh. It is most commonly 
 found in those cases in which there is an undue patency of the Eus- 
 tachian tube. 
 
 The paracusis of Willis, or "paracusis A^ illisii," is a symptom which 
 is present in well-advanced cases. When present it is an unfavorable 
 sign, and should lead to a very guarded prognosis, as a more careful 
 examination may reveal the presence of hyperostosis (spongifying) of 
 the bony capsule of the labyrinth in addition to the middle ear disease. 
 Paracusis Willisii consists of. an ability to hear better in the presence of 
 noises than in a quiet place. Thus patients will hear better in a street 
 car or train than they do in a quiet country home. It is a probable 
 indication that the mobility of the ossicles is interfered with by ankylosis 
 or adhesive processes, or the swelling of the mucous membrane of the 
 tympanic walls, or it may point to hyperostosis of the bony capsule of 
 the labyrinth. 
 
 Objective Symptoms. — The drumhead should be examined with refer- 
 ence to its position, color, lustre, and reflection of light. In infants its 
 position is normally at a very obtuse angle to the superior w^all of the 
 meatus, while in adults the obtuseness of the angle is much less pro- 
 nounced. In other words, in adults the drumhead is more nearly at right 
 angles to the axis of the external meatus than it is in very young children. 
 In infants it is so nearly parallel with the superior wall of the meatus 
 that it seems to be a continuation of it. As the tympanic ring develops 
 it rapidly assumes a more erect position, until it finally assumes that 
 which is maintained throughout adult life. Its position will, therefore, 
 depend upon the age of the patient and upon the completeness w r ith which 
 development has taken place. 
 
 If the Eustachian tube is closed for any reason, the drumhead will be 
 drawn inward or retracted. This gives rise to a change in the contour 
 of the drumhead, and consequently modifies the reflections from its 
 surface. The cone of light which is normally present with the apex 
 toward the lower end of the handle of the malleus, while its base is directed 
 downward and forward toward the periphery, will either diminish in 
 
712 
 
 THE EAR 
 
 size, break into one or two whitish spots, or entirely disappear. These 
 changes are, in most cases, indicative of retraction of the drumhead. 
 If there are adhesions binding the membrana tympani to the promontory 
 or other portions of the inner tympanic wall, its surface will present 
 an uneven appearance, especially after inflation. At the points of 
 adhesion it will appear whitish in color, whereas in the non-adherent 
 portions there may be a slight reddish color, due to the reflection of 
 light from the red mucous membrane of the inner tympanic wall. 
 
 The color of the drumhead has been variously described as of a pearl- 
 gray, pinkish-gray, bluish-gray, or yellowish-gray membrane. Some of 
 these observations have been made upon cadavers, in which the normal 
 colors were not present. By the use of such lights as are now at the com- 
 mand of most practitioners, the healthy 
 Fig. 398 membrane uniformly presents a pearl- 
 
 gray color, with here and there a slight 
 admixture of orange and purple. The 
 orange is due to the red reflex of the 
 inner tympanic wall, and is now regarded 
 as a sign of spongifying. 
 
 Calcareous spots are sometimes found 
 on the drumhead, even when there is no 
 history of a previous suppurative process, 
 and are undoubtedly the remnants of 
 former inflammatory processes. 
 
 In the normal drumhead there is a dis- 
 tinct luminous lustre (Fig. 398), which is 
 so modified in chronic catarrhal otitis 
 media as to materially lessen its smooth- 
 ness and brilliancy. The membrane ap- 
 pears whitish and velvety in texture in 
 proportion to the amount of thickening it 
 has undergone. The redness and the 
 pinkish-gray color disappear because the vascularity and transparency 
 of the drumhead are diminished. 
 
 The appearance of the drumhead may be modified by the presence of 
 tympanic secretion. The dark line spoken of under Symptoms of Acute 
 Otitis Media, which marks the upper limit of the secretion, may be present 
 in these cases. Unless the thickening of the drumhead is so pronounced 
 as to interfere with its transparency, the bubbles of air spoken of in the 
 same connection may also be seen. The presence of an appreciable 
 amount of mucus in the middle ear is usually a sign of a subacute attack, 
 but the drumhead may be so thickened that it is not easy to discern it. 
 The opacity of the mucus increases with its viscidity, hence some estimate 
 may be made by observing the character of the secretion present. In 
 those cases in which the drumhead is atrophied in circumscribed areas 
 the secretion may be clearly seen at these points, while at the more 
 opaque and thickened areas its presence cannot be detected. If there is 
 a large quantity of mucus in the middle ear, the drumhead may bulge 
 
 A normal membrana tympani of 
 the right ear as viewed through a 
 speculum. 
 
CHRONIC MOIST CATARRHAL OTITIS MEDIA 713 
 
 outward in its entirety if non-adherent, or in part if there are adhesions 
 (Fig. 399). 
 
 Prognosis. — The curability of chronic otitis media is somewhat in 
 proportion to its chronicity and the pathological changes in the essential 
 structures of the tympanic cavity. If the disease is of recent occurrence 
 and the morbid changes are slight, the prognosis is quite favorable. If 
 the disease is of long standing and pronounced degenerative changes 
 in the mucous membrane covering the ossicles or the membrana tym- 
 pani have occurred, the prognosis as to the restoration of hearing is not 
 good. 
 
 Fig. 399 Fig. 400 
 
 Adhesive retractions (a, a) of the Adhesive processes affecting the 
 
 membrana tympani. membrana tympani. 
 
 Treatment. — The treatment should take two general factors into 
 account, namely, the etiology and the pathological changes present. 
 If the chronic disease is the offspring of an acute catarrhal process, the 
 causes of the acute disease should be determined and eradicated if pos- 
 sible. If the patient has been subject to either of the forms of rhinitis or 
 sinuitis, he should be treated accordingly. Ethmoiditis and sphenoiditis 
 are particularly responsible for otitis media, and in a number of cases the 
 chief cause. Too little attention has been given to these cavities in the 
 treatment of ear disease. Appropriate treatment, surgical or otherwise, 
 addressed to the sinuses, if given early, speedily relieves the ear disease. 
 The symptoms of mild chronic ethmoiditis and sphenoiditis are not 
 so obvious as to attract the attention of the physician unless he has had 
 unusual opportunities for making such observations. The patient, 
 perhaps, only complains of a " dropping" into the throat. An examina- 
 tion of the epipharynx and posterior choanse may show a mucopuru- 
 lent secretion flowing over the posterior ends of the middle turbinate 
 on to the posterior wall of the epipharynx. Anterior rhinoscopy shows 
 the middle turbinal closely approximated to the septum. The divulsion 
 of the middle turbinal away from the septum, or its partial or complete 
 removal, will often exert a very favorable influence upon the course of the 
 aural disease. In some cases it may be necessary to make a total exen- 
 teration of the ethmoidal cells and to remove the anterior wall of the 
 sphenoidal sinus. 
 
 If the ear disease is due to tonsillar disease, total ablation of the tonsil 
 with its capsule intact is the best method of procedure. 
 
714 THE EAR 
 
 Adenoids and inflammatory processes of the epipharyngeal mucous 
 membrane, if present, should be treated. The presence of adenoids often 
 perpetuates a chronic epipharyngitis, hence their removal exerts a favor- 
 able effect. As the pharyngeal inflammation extends by continuity 
 of tissue to the Eustachian tube and middle ear, it is obvious that the 
 removal of the adenoids or their remnants will exert a very favorable 
 influence upon the course of the ear disease. McBride and Logan 
 Turner have shown that adenoids often persist in adults, undiminished 
 in size. In every case of chronic catarrhal otitis media the otologist 
 should examine the epipharynx, and if adenoids are present they should 
 be removed, even though they do not obstruct the nose. 
 
 When the structures adjacent to the Eustachian tube have been freed 
 from morbid processes, the ear may be treated for the removal of the 
 local morbid lesions and to restore the equilibrium of tension between 
 the drumhead ossicles and the labyrinthine fluid. 
 
 The tympanic cavity should be inflated for three purposes, namely: 
 (a) To force the secretions from the tympanic cavity and Eustachian 
 tube; (6) to restore the equilibrium of air pressure on the two surfaces 
 of the membrana tympani ; and (c) to improve the arterial and lymphatic 
 circulation of the lining mucous membrane. (See Principles of Tym- 
 panic Inflation, and Methods of Tympanic Inflation.) 
 
 The air should be rarefied in the external meatus with Delstanche's 
 rarefacteur after each inflation, as this increases the passive hyperemia 
 of the inflamed membrane and promotes the absorption of the inflam- 
 matory exudates. It also reduces the annoying tinnitus usually present 
 in this disease. 
 
 The mechanical removal of the secretions from the middle ear may be 
 accomplished by paracentesis (Schwartze) or incision of the drumhead 
 and by suction applied to the external meatus. This procedure is only 
 indicated when the secretions are so heavy and tenacious as to resist being 
 discharged through the Eustachian tube, or when the tube is obstructed 
 by disease. The incision should be long and curved (see Incision of 
 the Membrana Tympani), as in acute suppurative otitis media before 
 perforation. 
 
 Even then the secretions will not appear in the meatus for several 
 minutes or hours, unless the middle ear is forcibly inflated or suction is 
 applied to the meatus. The meatus should be lightly packed with a strip 
 of gauze for a few hours, at the end of which time it will be saturated 
 with the secretion. After thoroughly cleansing the meatus with a cotton- 
 wound applicator it should be refilled with gauze. The incision usually 
 closes in from one to three days, and should be repeated if marked 
 bulging of the membrana tympani reappears. 
 
 When the secretions are more serous in character, drainage is facili- 
 tated, as suggested by Politzer, by having the patient take a swallow of 
 water in his mouth, then inclining his head well forward and somewhat 
 toward the opposite side, thereby causing the axis of the Eustachian 
 tube to stand perpendicular to the plane of the earth. The patient's 
 head should be held in this position for two or three minutes, to allow 
 
ADHESIVE PROCESSES IN THE MIDDLE EAR 715 
 
 the secretions in the middle ear to gravitate to the tympanic end of the 
 Eustachian tube. At the end of this time he should swallow the water 
 held in his mouth, thus opening the pharyngeal end of the tube and 
 allowing the secretions to flow into the pharynx. As Politzer says, shortly 
 after this procedure the membrana tympani presents a grayish color, 
 whereas it was yellowish in color. 
 
 The passive hyperemia of the mucous membrane of the Eustachian 
 tube gradually subsides during the treatment by inflation, and the 
 patency of the tube is gradually restored. The secretions also diminish 
 in quantity and in consistency, and the tube becomes adequate to carry 
 on its drainage and ventilating functions. 
 
 In rare instances the swelling of the tube persists, and it may become 
 necessary to make local applications of weak zinc, silver, ammonium 
 chloride, ol. eucalyptus, and the vapors of menthol to the tube. Gener- 
 ally speaking, these remedies are of slight value, a better procedure 
 being the administration of hepatic and saline aperients. Mechanical 
 vibrations behind the angle of the inferior maxilla are very useful in 
 opening the Eustachian tube when it resists the usual methods. 
 
 A. H. Buck has recommended the introduction of medicated bougies. 
 Politzer uses a small violin string cut into suitable lengths for this purpose. 
 They are soaked in a saturated solution of the nitrate of silver, dried, 
 and introduced through a catheter as far as the isthmus tubse, and left 
 in position for from three to five minutes. Three to four applications 
 often open the tubes. 
 
 ADHESIVE PROCESSES IN THE MIDDLE EAR. 
 
 Synonyms. — Sclerosis of the middle ear; otitis media catarrhalis 
 chronica; dry catarrh of the middle ear; otitis media catarrhalis sicca; 
 otitis media sclerotica; proliferous inflammation of the middle ear. 
 
 Etiology. — The causes of adhesive processes in the middle ear are 
 not fully understood. It is probable that several conditions are included 
 under this title. Exudative catarrhs of the middle ear are often attended 
 by the formation of adhesive processes, and these sometimes appear 
 without being preceded by a secretive or exudative catarrhal inflamma- 
 tion. The trophic centres or tracts seem to be at fault, and the onset 
 and progress of the disease are insidious and result in pronounced 
 deafness. The membranous labyrinth is often involved, probably 
 from the same trophic influences. The mucous membrane around the 
 oval window is especially affected, and the cicatricial contraction of the 
 fibrous bands often fixes the stapes firmly in the window. Atrophy, 
 fatty and colloidal degeneration of the labyrinth often occur simul- 
 taneously or precede the sclerotic processes in the middle ear. The 
 adhesive processes resulting from exudative catarrh of the middle 
 ear are not attended with such pronounced deafness, and are marked 
 by decided symptoms even in the early stages. In the trophic or in- 
 sidious form, symptoms do not usually manifest themselves until the 
 disease is well advanced. 
 
716 THE EAR 
 
 The etiology may be summarized as follows : 
 
 (a) Exudative or moist catarrh of the middle ear. There is some 
 doubt as to the causative influence, as in children in whom it most 
 frequently occurs the adhesive processes are rarely found. 
 
 (b) Trophic disturbances affecting either the middle ear or labyrinth. 
 It appears in some cases to affect the labyrinth first and extend to the 
 middle ear. Probably both the middle ear and labyrinth are affected 
 at the same time, although the symptoms may become manifest in one 
 earlier than in the other. It is also quite probable that hyperostosis or 
 spongifying of the bony capsule of the labyrinth is mistaken for an ad- 
 hesive process, though the normal appearance of the drumhead should 
 obviate such a mistake in diagnosis 
 
 Pathology. — The adhesive processes maybe classified as either diffused 
 or circumscribed. The diffused type usually arises from an exudative 
 chronic catarrh; the circumscribed type from trophic disturbances. 
 
 According to Politzer, "the structural changes in the mucous mem- 
 brane consist in partial or total transformation of the new-formed round 
 cells into fibrous connective tissue, interstitial hypertrophy of the mucous 
 membrane with retrograde metamorphosis of the new-formed tissue, 
 shrinking, sclerosis, atrophy, and calcification." 
 
 In those cases in which the secretions are still abundant the mucous 
 membrane is hyperemic, spongy, or gelatinous, and yellow or bluish 
 red in color. The surface is uneven and ragged in appearance. 
 
 After the moist stage has subsided the membrane becomes smooth, very 
 thick, and firmly attached. 
 
 In the diffused or insidious type the changes seem to proceed from the 
 periosteum to the epithelial surface of the membrane. The favorite 
 location for the adhesive process in these cases is about the oval window 
 (spongifying?). The general appearance on inspection through an open- 
 ing in the drumhead shows very little evidence of the true condition. The 
 contraction and calcification take place in the deeper portions of the 
 mucosa and fix the foot plate of the stapes in the oval window. 
 
 In another class of cases numerous fibrous bands form in the middle 
 ear. They may extend from the ossicles to the walls of the tympanum or 
 from ossicle to ossicle; or they may extend from the walls to the drum- 
 head. The ossicles are thus bound together, and the drumhead is drawn 
 by contracting fibrous bands to the fixed walls of the middle ear (Fig. 400). 
 The normal tension of the ossicular chain and drumhead is thereby 
 unbalanced, and serious disturbance of hearing occurs. 
 
 In fetal life bands or folds of mucous membrane exist in the same places 
 often occupied by fibrous formations in the adhesive process. They may 
 be, therefore, only perversions of an earlier embryonal formation. Accord- 
 ing to Toynbee and von Troltsch the bands are sometimes transformed 
 by calcareous deposits into bone-like processes. 
 
 In addition to the foregoing changes, the articulations of the ossicles 
 may be ankylosed by fibrous formations or by the deposit of lime 
 salts. In either event the vibratory function of the chain of ossicles is 
 impaired. 
 
ADHESIVE PROCESSES IN THE MIDDLE EAR 717 
 
 The mucous membrane of the entire attic in rare cases undergoes 
 calcification, and a partial or complete obliteration of the attic results. 
 
 The changes in the Eustachian tubes are largely dependent upon 
 whether the middle ear disease is of the diffused or the circumscribed 
 variety. In the diffused type the tube is similarly affected, while in 
 the trophic type it is usually normal. The lumen is obstructed in the 
 diffused variety, while it is unaffected in the circumscribed type. 
 
 Both ears are affected except in rare cases. This, together with the fact 
 that it rarely occurs in children, in whom the moist or exudative catarrhs 
 are most common, rather discredits exudative catarrh as the cause. When 
 it occurs in children it is usually easy to trace it to disturbances of nutri- 
 tion, scrofula, etc. 
 
 Symptoms. — It is convenient to study the symptoms under the (a) 
 drumhead, (b) the Eustachian tubes, and (c) the subjective symptoms. 
 
 (a) The drumhead is thickened, lustreless, and opaque. Areas of 
 opacities more or less sharply defined may sometimes be seen. In some 
 cases they are sharply defined, and appear as chalky white deposits, 
 while in others they merge into the surrounding tissue with ill-defined 
 borders. The spaces between the whitish deposits appear dark or 
 bluish in color. 
 
 The handle of the malleus appears less distinct and wider than normal 
 on account of the thickened condition of the drumhead. The cone of 
 light is shortened, irregular, or broken. The handle of the malleus 
 is drawn inward and backward, and is, therefore, foreshortened. 
 
 The adhesive bands may be attached to the drumhead and cause cir- 
 cumscribed retractions (Fig. 399). The retracted areas may also be due 
 to atrophy or to direct adhesions of the drumhead to the inner tympanic 
 wall. They appear as rounded, oval, or irregular depressions (Fig. 401). 
 
 Schwartze called attention to a distinct reddish glimmer around the 
 umbo as indicating a circumscribed inflammation (insidious type) 
 around the oval window. In these cases the drumhead is usually normal, 
 although it is occasionally opaque or atrophic. Such cases are now 
 generally recognized as hyperostosis of the bony capsule of the laby- 
 rinth. 
 
 The external meatus is usually devoid of cerumen, although it may be 
 covered with a dense brown secretion. 
 
 (6) In the diffused variety the Eustachian tubes may be more or less 
 obstructed by fibrous formations in their lumens. In the circumscribed 
 variety they are usually normal. 
 
 (c) The subjective symptoms vary according to the degree of involve- 
 ment of the middle ear and labyrinth. They also vary with the location 
 and character of the lesion. 
 
 Perhaps the most common and pronounced subjective symptom is 
 tinnitus. If the disease is well advanced it is continuous, although its 
 intensity varies with the atmospheric conditions and constitutional vigor 
 of the patient. If tired, worried, or weakened from the excessive use of 
 alcoholic beverages, or illness, it becomes more pronounced. The noises 
 vary in character and intensity even in the same individual. 
 
718 THE EAR 
 
 Disturbances of hearing may appear simultaneously with the tinnitus, 
 although the subjective noises usually appear first. The noises some- 
 times increase with the deafness, although in many cases they gradually 
 diminish and cease altogether with complete deafness. 
 
 Pain is rarely present, although hyperesthesia acoustica is often a 
 prominent symptom in the early stage of the disease. It is especially 
 marked in the presence of shrill tones and loud speech. 
 
 More or less giddiness and fulness in the head are experienced in the 
 cases in which there is continuous tinnitus. In some cases the Meniere 
 group of symptoms is present, especially when there is a sudden increase 
 in the deafness. It is probably due to a rapid deposit of an exudate in 
 the labyrinth. The giddiness is sometimes persistent, while in others it 
 gradually disappears without apparent damage. Aprosexia or difficulty 
 in fixing the attention is sometimes complained of. 
 
 The hearing is disturbed in proportion to the interference with sound 
 waves passing through the drumhead and ossicles and the degree of patho- 
 logical changes in the labyrinth. The patient hears at a greater distance 
 at one time than another, although the variation is not as great as is 
 observed in ordinary catarrhal otitis media with secretion. The con- 
 dition of the patient influences the. hearing in a marked degree. He hears 
 better in the morning when vigorous than he does toward evening when 
 weary. Mastication of the food temporarily increases the deafness. 
 
 Hearing for speech may be yery poor, while the finest variations in 
 music may be distinguished, or the falling of a small instrument may be 
 distinctly heard (Pqlitzer). 
 
 Paracusis Willisii, or ability to hear better in a noisy place, as in a 
 street car, is quite characteristic of this affection. It is important to 
 ascertain in every case whether or not this symptom is present, as it gives 
 a fair indication as to the prognosis of the disease. It should not be 
 assumed, however, that the patient cannot be benefited by treatment 
 because this symptom is present. The ordinary treatment by inflations 
 and massage will usually fail to afford relief, but more radical measures, 
 to be described, will in rare instances prove effective. 
 
 The Course of the Disease. — The course of the disease is progressive, 
 although it is not steady in its advancement. It rarely progresses by 
 gradual increase in the deafness, but goes by leaps and bounds. It often 
 remains stationary for years and then suddenly becomes worse. It is 
 always progressive, as it is due to degenerative pathological changes in 
 tissues, as contraction, calcification, and ossification. These conditions 
 develop slowly, on account of the nature of the pathological process. 
 They progress by Jeaps because the changes may involve portions 
 of the tissue but little concerned in the function of hearing, until 
 finally it encroaches upon tissue intimately concerned in audition, 
 and hearing suddenly becomes impaired. This does not necessarily 
 mean that the pathological process has suddenly increased, but that it 
 has invaded functionating tissue. The disease rarely causes complete 
 deafness. 
 
 In the insidious or trophic type of the disease, persistent tinnitus, often 
 
ADHESIVE PROCESSES IN THE MIDDLE EAR 719 
 
 of a most aggravated character, may exist for years without deafness. 
 The trophic interstitial changes are chiefly about the fenestra of the vesti- 
 bule (oval window). Finally, the foot plate of the stapes is ankylosed, 
 and deafness becomes a pronounced symptom. These cases are often 
 mistaken for nervous tinnitus until the deafness sets in. 
 
 Politzer says that the greater number of cases in which ankylosis of 
 the stapes was observed post mortem, he found from the history of the 
 patient that the decrease of hearing occurred after the existence of 
 subjective noises for ten or fifteen years, and the progressive increase 
 of deafness was very gradual. In these cases there was generally a 
 marked negative Rinne, with sometimes lengthened and sometimes 
 diminished duration of perception through the cranial bones, the latter, 
 especially when the disease had existed for a long time, and in old 
 age. 
 
 When unilateral adhesive inflammation has existed for a long time and 
 the other ear subsequently becomes involved, the progress in this ear is 
 quite rapid, in contradistinction to the progress in bilateral involvement. 
 
 In rare cases a change for the better takes place spontaneously. This 
 may be permanent, or it may be followed by a sudden increase of the 
 deafness and tinnitus. 
 
 Diagnosis. — (a) Thickening, contractions, and chalky deposits in the 
 drumhead. 
 
 (6) The drumhead often presents a ground-glass appearance. 
 
 (c) Marked negative Rinne with loss of hearing for low tones shows 
 middle ear involvement. 
 
 (d) Adhesive bands may be present, and the Rinne test does not show 
 a marked negative result. Labyrinthine involvement probably present. 
 
 (e) High tones are heard better than low ones. In some cases, how- 
 ever, there is loss of hearing for high tones, thereby indicating labyrinthine 
 involvement. 
 
 (/) By the use of Siegle's otoscope (Fig. 397) the drumhead may be 
 made to move back and forth under alternate suction and pressure. If 
 adhesions are present, the drumhead remains fixed at these points. 
 
 (g) Inflation of the middle ear causes the thin portions of the drum- 
 head, when present, to bulge outward like bubbles. Improvement of 
 hearing usually lasts while the bubbles remain inflated. The adherent 
 parts remain unmoved under inflation. 
 
 (h) Marked movement of the handle of the malleus precludes anky- 
 losis of the malleus and incus. Ankylosis of the incus diminishes the 
 movement of the malleus. 
 
 Prognosis. — The prognosis will be studied . under two headings, 
 namely: (1) the more favorable signs, and (2) the unfavorable signs. 
 
 The More Favorable Signs. — (a) Fibrous bands following the secre- 
 tive form of catarrh are more favorable than those from the insidious 
 type which are more often associated with labyrinthine disease, (b) If 
 the case has not progressed to a high degree of deafness the prognosis 
 is more favorable, (c) If subjective noises have been but little mani- 
 fested, the prognosis is more favorable. (d) Good bone conduction is 
 
720 THE EAR 
 
 also a favorable sign, (e) Improvement in hearing and tinnitus after 
 inflation is a good sign. 
 
 The Unfavorable Signs.— (a) Early deafness, (b) Slight or no increase 
 in the hearing distance after inflation of the middle ear. (c) Diminished 
 bone conduction, (d) Advanced age. (e) Constitutional ailments. (J) 
 Heredity. 
 
 It should be said that complete restoration of hearing is not possible 
 in any of the cases, as the changes have been of long duration and are 
 retrograde in character. Indeed, few cases are benefited by treatment. 
 
 Treatment. — This is most conveniently divided into (a) non-surgical 
 and (b) surgical treatment. The purpose of treatment should be three- 
 fold, namely, to improve the hearing, mitigate the tormenting subjective 
 noises, and check the progress of the disease. 
 
 Non-surgical Treatment. — The form of treatment most in vogue among 
 physicians in America is inflation of the middle ear, by either the Politzer 
 method or through the Eustachian catheter. Politzer claims better 
 results by his method than by the use of the catheter. This is probably 
 due to the fact that the Eustachian tubes are usually quite patent and 
 easily inflated by the bag. Those cases which show improvement after 
 the use of the air bag are more favorable for treatment than those which 
 show no improvement. The longer the improved hearing continues 
 after each inflation the more hopeful is the prognosis. The object of 
 middle ear inflation is to restore the normal air pressure to the cavity of 
 the middle ear and to stretch or break down recent adhesions. It is quite 
 probable that but little effect of this kind is produced by this procedure, 
 except in the early stages while the adhesive bands are slight and fragile. 
 The chief use, therefore, of intratympanic inflation is to equalize the air 
 pressure, and thus overcome in some measure the pressure upon the 
 labyrinthine fluid and auditory nerve endings. 
 
 Local medical treatment has but little if any curative effect. The medi- 
 cated vapors and nebula?, so much extolled in the medical literature a few 
 years ago, have no appreciable effect whatever, except such as may be 
 explained by the inflation which usually accompanies their use. We may 
 say the same in regard to many of the medicines injected through the 
 Eustachian tubes, as their use is usually preceded by inflation. 
 
 Numerous injections have been recommended for adhesive processes in 
 the middle ear, some of which seem to be followed by good results. Only 
 those which have proved of special value will be referred to here. 
 
 The following formula has been used extensively by Politzer through 
 a catheter with favorable results : 
 
 I^ — Sodii bicarb gr. x 
 
 Glycerini . . ttl viiij 
 
 Aquae des q. s. 3J — M. 
 
 Ft. sol. 
 
 Sig. — Inject 5 to 8 drops into the middle ear through a catheter 2 to 3 times per week. 
 
 It acts mildly and does not cause irritation. 
 
 Pilocarpine is another popular remedy, and should be used in a 2 per 
 cent, solution, 5 to 6 drops being injected into the middle ear. Perspira- 
 
ADHESIVE PROCESSES IN THE MIDDLE EAR 721 
 
 tion and salivation usually occur while the patient is still in the office, 
 especially in those cases in which the membrane of the middle ear is still 
 boggy and well supplied with bloodvessels. In the dry or trophic type 
 these symptoms may not occur. It should not be used in patients with 
 weak hearts. 
 
 Delstanche recommended the injection of liquid vaseline into the 
 middle ear through a catheter. M. A. Goldstein has also reported 
 favorable results from its use. It is claimed that it lubricates and softens 
 the fibrous tissue, and that the force used in its introduction stretches 
 the fibrous bands and liberates the ossicles. Probably the only benefit 
 is from the simultaneous inflation of the middle ear. 
 
 Caution. — Whatever method of medication is used, extreme care 
 should be exercised lest too great an irritation be produced by the remedy. 
 Temporary improvement only follows excessive irritation. The case 
 then rapidly passes into a worse condition than before treatment. 
 
 Massage.— The alternate rarefaction and condensation of the air in the 
 external acoustic (auditory) meatus moves the drum membrane back and 
 forth. As the handle of the malleus is located between the layers of the 
 drum membrane, it is also propelled inward and outward with the move- 
 ments of the drumhead. If there are firm adhesions binding it to the 
 promontory, it will not perform these excursions. 
 
 Bing has recommended prolonged rarefaction of the air in the external 
 auditory meatus by the use of an olive-tipped instrument inserted into the 
 meatus. The tip is perforated and has a valve at its inner extremity. 
 The air is withdrawn from the meatus through the rubber tubing, where- 
 upon the air pressure closes the valve. In this way rarefaction can be 
 maintained for one-half to one hour. He thinks that in some cases this 
 is an advantage over simple alternating rarefaction and condensation of 
 the air in the meatus. 
 
 Lucae has devised a spring probe with a cup-shaped extremity to fit 
 over the short process of the malleus. Pressure is exerted upon the 
 short process, and then released, repeating the motion a number of 
 times. This motion is transmitted to the other ossicles, the ankylosis 
 and cicatricial adhesions being stretched or broken down. The treat- 
 ments are very painful, and are, therefore, not used to any great extent. 
 If this difficulty could be overcome, the use of the probe would prove 
 of greater value. It might be advisable to administer nitrous oxide gas 
 and use the probe during the brief anesthesia. There is little danger 
 or inconvenience connected with this anesthetic, and the exigencies of 
 the case often warrant its use. The injection of a 2 per cent, solution 
 of cocaine into the middle ear through a catheter may also be practised 
 to mitigate the pain. The use of Lucae's probe in suitable cases at 
 intervals of seven to ten days, inflation being practised on alternate days, 
 is sometimes helpful. If the element of pain can be eliminated, it is the 
 remedy par excellence in cases in which the adhesive processes are not 
 too far advanced. The hearing is sometimes improved to a remarkable 
 degree, and the subjective noises correspondingly diminished. The 
 improvement is not permanent in a majority of cases, nor is there any 
 method of treatment known which will make it so. 
 46 
 
722 THE EAR 
 
 The length of time during which any of the aforesaid treatments should 
 be continued varies. It should only be continued while the hearing dis- 
 tance continues to increase. This usually ranges between two and six 
 weeks. The greatest amount of improvement occurs during the first six 
 or eight days. To continue the treatments longer than improvement of the 
 hearing distance increases often leads to ill effects. 
 
 As the improvement in hearing is temporary, it becomes necessary 
 to give occasional treatments to maintain the beneficial effects realized. 
 Politzer thinks his method of inflation the best adapted for the after- 
 treatments. 
 
 Stenosis of the Eustachian tube may be overcome by inflation if due to 
 accumulated mucus, or by the use of bougies if due to fibrous bands 
 or rings within its lumen. If bougies are used, they should be intro- 
 duced through the Eustachian catheter. In the adult the tube is about 
 one and one-half inches long, and the bougie should be passed through 
 its entire length. Bougies may be made of whalebone, catgut, or celluloid. 
 If for any reason it is desirable to locate the stricture, an olive-tipped 
 bougie should be used, whereas to secure its therapeutic effect it should 
 be filiform in shape. Medicated bougies (silkworm gut) may be used 
 and left in place for twenty or thirty minutes. A solution of the nitrate 
 of silver is the astringent chiefly used for this purpose. 
 
 The introduction of the bougie should be done with extreme caution 
 and gentleness, as force may cause it to penetrate the mucosa of the 
 tube. This would be unfortunate, as subsequent inflation might cause 
 emphysema of the submucous tissues. This accident occasionally 
 happens in catheterization of the tubes through abrasions made during 
 the manipulation of the bougie. 
 
 Internal medication is of value in those cases suffering from consti- 
 tutional diseases. I have seen cases resist all treatment until iron and 
 arsenic were administered. Others will improve in hearing when the 
 iodide of potash or tonics are given. But even these cases do not entirely 
 recover; they only become somewhat improved in hearing and tinnitus. 
 
 I am indebted to Dr. Geo. F. Suker for the following analysis of the 
 conditions of the ear in which thiosinamin is indicated. In 1897-98 he 
 used it in a number of such cases, and bases his conclusions upon this 
 experience together with the literature concerning its use in other con- 
 ditions : 
 
 The class of cases in which thiosinamin has been found of value 
 come under the following heads : 
 
 1. So-called catarrhal deafness in which there is a diapedesis of 
 leukocytes into the meshes of the membrana tympani which ultimately 
 cause cicatricial-like thickening. 
 
 2. Subacute suppurative otitis media with a small perforation of the 
 drum. The latter is thickened by infiltrations, but there is no true 
 fibrous ankylosis of the ossicles. 
 
 3. Inflammation of the middle ear, suppurative or otherwise, leading 
 to a fibrous ankylosis of the ossicles and with very slight structural 
 changes of any kind in the membrana tympani. 
 
 4. Deafness, rather a loss in the acuity of hearing, due, as we have 
 
ADHESIVE PROCESSES IN THE MIDDLE EAR 723 
 
 reasons to suppose, to some fibrous changes in the auditory nerve or 
 its endings. 
 
 5. Cases in which two or more of the above-mentioned conditions are 
 present in the ear. 
 
 6. Suppurative otitis media with extensive loss of drum substance 
 and the formation of fibrous bands which impede the free action of the 
 ossicles. 
 
 7. Cases in which there is a transudation of the lymph into the 
 substance of the drum, which, instead of being absorbed, remains 
 and becomes partly organized, thus causing drum thickening, and, there- 
 fore, interferes with the transmission of sound waves. 
 
 All such cases, if the thiosinamin is persistently given in alternating 
 periods of time, will be markedly benefited. It may be administered by 
 the mouth or hypodermically. If by the mouth, the dose should be rapidlv 
 increased until 6 to 10 grains per day are taken. If employed hypo- 
 dermically, use a 10 per cent, solution in equal parts of glycerin and 
 water. Of this, give 12 to 18 mm. three times a week. 
 
 Thiosinamin acts as a glandular stimulant; at first it causes a breaking- 
 down of the exudate. Its powers of removing or absorbing an exudate 
 is not unlike that of potassium iodide and mercury, peptone, pepsin, 
 sodium urate, and allied bodies. 
 
 In employing the thiosinamin treatment, the hygienic and other 
 needed regime must not be overlooked. Give it for periods of six to 
 eight weeks, and then cease for a week or ten days, after which begin 
 again. 
 
 Whether or not larger experience will support the claims thus clearly 
 set forth remains to be demonstrated. Enough evidence is available, 
 however, to justify extended trials of it. Its favorable action on keloids 
 and lupus is well known. 
 
 Rest is another therapeutic measure of special value in neurasthenic 
 cases. I have seen cases make material improvement both in hearing 
 and in the severity of the subjective noises under this mode of treatment. 
 J. A. Stucky reports good results following rest in bed, with massage of 
 the body. 
 
 Surgical Treatment. — Operations on the drumhead for the relief of deaf- 
 ness have been performed for more than a century. Himly and Astley 
 Cooper, in 1795, removed portions of the drumhead and strongly recom- 
 mended the procedure as a means of admitting sound waves to the labv- 
 rinth and of relieving the increased tension of the ossicular chain. Others 
 soon followed in their wake, all to meet with ultimate disappointment, as 
 the relief was only temporary. It was found impossible to keep the wound 
 open for any length of time. Later vulcanite and metal eyelets were 
 used with unsatisfactory results. All efforts to maintain the opening in 
 the membrana tympani (drumhead) have failed. The difficulty has been 
 to secure the epidermization of the edges of the wounded membrane. 
 The author suggests the use of small skin grafts on the margin of the 
 perforation, after the Thiersch method. 
 
 Malherbe recommends lifting the auricle forward and the removal of 
 the posterior wall of the meatus external to the annulus tympanicus, as 
 
724 
 
 THE EAR 
 
 Fig. 401 
 
 in the meatomastoid operation. He then establishes communication 
 between the middle ear and the meatus via the antrum and the aditus 
 ad antrum. The opening is maintained by inserting a celluloid or gold 
 tube through the opening in the wall of the meatus. He only recom- 
 mends this procedure in cases of moderate severity. An improvement 
 over this method would be to form the Ballance plastic flaps and reflect 
 them through the opening in the meatus, as described under the meato- 
 mastoid operation. This would ob- 
 viate the necessity of wearing the 
 vulcanite tube recommended by Mal- 
 herbe. 
 
 Section of the posterior fold of 
 the drumhead (Fig. 404) was first 
 suggested by Politzer in 1871: "It 
 is advisable in all cases where the 
 objective signs of an abnormal in- 
 ward curvature of the membrana 
 tympani are present, where the 
 inferior extremity of the handle of 
 the malleus is, therefore, abnormally 
 inward, and the short process of 
 the malleus and the posterior fold 
 of the membrane extending from it 
 project strongly toward the external 
 meatus. If these changes are com- 
 bined with a disturbance of hearing 
 of a high degree and loud subjec- 
 tive noises, which cannot be materi- 
 ally improved by the local methods of 
 treatment, an experimental section 
 of the posterior fold is justifiable in 
 such cases. " 
 
 The operation is simple and con- 
 sists of a section of the fold just pos- 
 terior to the short process of the 
 malleus or midway between it and 
 the peripheral extremity of the fold. 
 The knife should not penetrate deep enough to sever the chorda 
 tympani nerve in its passage between the malleus and incus. 
 
 The handle of the malleus should immediately drop downward and 
 forward as the tension is relieved. The tinnitus is usually most relieved, 
 although in some cases there is also an improvement in hearing. The 
 benefit lasts only a few weeks or months in most cases. 
 
 Adhesion of the drumhead to the promontory may be overcome by 
 making a small triangular opening in the drumhead and introducing a 
 right-angle knife through it. The adhesion is then severed, as shown 
 in Fig. 401. 
 
 Severing an adhesion of the membrana 
 tympani to the promontory. A small tri- 
 angular flap is made in the drumhead and 
 the right-angle knife introduced through the 
 opening thus made and the adhesive band 
 severed. 
 
CHAPTER XLIL 
 
 HYPEROSTOSIS OF THE BOXY CAPSULE OF THE LABYRINTH. 1 
 
 Synonyms. — Spongifying of the bony capsule of the labyrinth; oto- 
 sclerosis; otitis media insidiosa; hyperplasia of the bony capsule of 
 the labyrinth; capsulitis labyrinthii. 
 
 Etiology. — The dense bone of the osseous capsule of the labyrinth 
 contains cartilaginous cells, hence it is the area of election for the trans- 
 formation of the cartilage into bone. The ossicles also have cartilage 
 cells in them, and may be the seat of this disease. The distribution of the 
 cartilage cells is most constant in the posterior half of the margin of the 
 oval window (fenestra of the vestibule), hence this is the most frequent 
 site of the morbid process. They are also found in the capsule of the 
 semicircular canals and the upper and lower walls of the cochlea. Any 
 or all of these points may be affected and give rise to symptoms peculiar 
 to the physiological bearings of the various structures. That is, the 
 hyperostosis may be limited to the ossicles, the oval window, the cochlea, 
 or to the semicircular canals, or it may involve two or more of them 
 at once. 
 
 In addition to the predisposition of the cartilaginous area to undergo 
 metaplastic changes, there are certain extraneous or constitutional 
 diatheses which act as exciting causes. Syphilis, scrofula, acute rheu- 
 matism, gout, tonsillitis, inflamed processes of the ears, and exposure to 
 the inclemencies of the weather have been ascribed as initiative influences 
 in the disease. It is difficult to understand how the inflammatory 
 diseases of the tonsils, adenoids, and middle ear can have any relation- 
 ship to the metaplastic changes in the capsule of the labyrinth. The 
 etiology is still obscure. 
 
 Age exerts a positive influence upon the development of the disease. 
 It usually begins between the eighteenth and the fortieth years of life. 
 Heredity has been noted as a rather common factor in the etiology, many 
 cases giving a history of other members of the family having had the 
 disease. In a noted American literary family several members were 
 affected by it. The majority of the cases occur in young women. Sexual 
 intercourse and parturition aggravate the symptoms, probably on account 
 of the increased hyperemia produced by these acts. The marriage of 
 women affected by this disease should, therefore, be carefully considered 
 before being consummated. 
 
 Pathology. — According to Denker, the osseous changes may be divided 
 into two stages, the first of which consists in an active proliferation of all 
 the cellular elements within the bone. Xew vascular and cellular tissue 
 
 1 I am greatly indebted to an article by Henry J. Hertz, wherein he reviewed the work of 
 Continental observers, for many of the ideas presented in this chapter. 
 
726 THE EAR 
 
 is formed in the narrow spaces and in the Haversian canals. Among 
 the newformed bone cells may be found giant cells, under the influence 
 of which the basement of the bone substance is principally absorbed. 
 Hollow spaces are formed, and areas of erosion gradually undermine 
 the originally compact bone, which becomes traversed by irregular 
 and abnormal channels. With the absorptive process there is the 
 formation and apposition of new bone, which is unlike the original, in 
 that it is more voluminous and porous. The second stage is ushered in 
 when the progressive changes cease and when the new bone assumes a 
 lamellar structure. Then the abnormally large and thick bone corpuscles 
 are found concentrically arranged, and the nuclei undergo atrophy. The 
 vascular system is likewise gradually altered by the formation of connec- 
 tive tissue, in which at times may be found fat cells. The Haversian 
 canals and spaces have been changed in structure by this resorptive and 
 appositional process, and all the cartilaginous elements have been meta- 
 morphosed into osseous tissue, as it cannot be found in the newgrowth. 
 Thus the process constitutes not only an hyperplasia and hyperostosis, 
 but also a metaplasia. 
 
 The new structure differs from the normal by its affinity and greater 
 absorptive power for carmine stains, which fact is utilized in the differ- 
 ential diagnosis. The microscopic evidence of this new formation is the 
 osteophytes, situated usually near the stapes articulation. Frequently 
 the stapes is partially absorbed by penetrating bloodvessels and replaced 
 by osseous formations, and sometimes a dislocation of the stapes is pro- 
 duced by an encroachment of the osteophytes. The functions of the oval 
 and round windows may also be seriously interfered with by the hyperos- 
 tosis producing partial or complete occlusion. When the process invades 
 the base of the cochlea, the patency of the Eustachian tube is threatened, 
 and the microscope shows its lumen to be narrowed by thickening of 
 the periosteum. Owing to the great vascularity attending the process, 
 especially in the first stage, it is probable that the distressing tinnitus of 
 progressive deafness may have its origin in the increased capillary 
 circulation. 
 
 The structural alteration consequent upon an invasion of this bone 
 into the cochlea and the semicircular canals may cause a change in the 
 pressure of the labyrinthine fluid. The mechanical and physical qualities 
 of the endolymph and perilymph may be so altered as to interfere with 
 the nutrition of the parts and induce disease. The detonating sounds 
 heard by some patients and the Meniere's symptom complex may be 
 ascribed to a perforation of the septum dividing the endolymph and 
 perilymph. 
 
 While the histological alterations are found to be identical by dif- 
 ferent authorities, yet their designation of the bone hyperplasia differs 
 and new terms are consequently introduced. Politzer defines it as cap- 
 sulitis labyrinthii or otosclerosis. Siebenmann, noting the resemblance 
 to sponge because of the rarefied spaces and porous structures, desig- 
 nated the new formation as spongification. Katz compares the process 
 to Volkmann's osteitis vascularis chronica. 
 
HYPEROSTOSIS OF THE BONY CAPSULE OF THE LABYRINTH 727 
 
 Symptoms and Diagnosis. — The symptoms, while more or less con- 
 stant, vary with the anatomical structures involved. If only the ossicles 
 are affected, the ankylosis of the stapes may be partial or complete; if the 
 posterior bony margin of the oval window is the seat of the changes, 
 the ankylosis may be complete and the stirrup pulled posteriorly by the 
 stapedius muscle; if the cochlea is involved, the signs of nervous deafness 
 are present, i. e., diminished bone conduction and the loss of hearing for 
 the upper tone limit; if the process is in the semicircular canals, giddiness 
 and nausea may be present. In mixed cases there may be a combination 
 of these symptoms. 
 
 In the cases commonly recognized in practice the disease is charac- 
 terized by the signs of middle ear disease without the objective appear- 
 ances of it. That is, there is (a) loss of the lower tone limit, (b) a nega- 
 tive Rinne, and (c) an increased duration of hearing by bone conduction, 
 all symptoms found in middle ear disease, but upon inspection of the 
 membrana tympani its appearance is normal, or is so slightly changed 
 that it cannot account for the marked degree of deafness present ; and the 
 Eustachian tube is normally patent. 
 
 When the hyperostosis is located exclusively in the ossicles, and the 
 ankylosis is partial or complete, the symptoms are those of ordinary 
 middle ear disease, except the membrana tympani is normal in appear- 
 ance and the Eustachian tube open. 
 
 When the hyperostosis is limited to the cochlea, the usual signs of ner- 
 vous deafness, loss of hearing for the upper tone limit, positive Rinne, and 
 shortened and diminished bone conduction are present. 
 
 When both the oval window and the cochlea are involved, it is prac- 
 tically impossible to make a diagnosis. This is also true when the oval 
 window is affected by hyperostosis (spongification) and the middle ear 
 is simultaneously diseased. Tinnitus is present in nearly all cases, 
 and is sometimes very pronounced. The paracusis Willisii is more pro- 
 nounced than in any other form of ear disease. 
 
 Summary of Symptoms. — As the spongifying or hyperostosis 
 affects various parts of the ear structures, the symptoms vary ac- 
 cordingly. 
 
 The following classification includes the chief clinical characteristics 
 of each subdivision: 
 
 Hyperostosis about the Oval Window (Fenestra of Vestibule). — 1. Loss 
 of hearing for one-half to one and a half octaves of the lower tone limit 
 in one or both ears. 
 
 2. Negative Rinne in varying degree. 
 
 3. Prolongation of hearing by bone conduction for fork A of the 
 Edlemann-Bezold set of forks (Schwaback test). 
 
 4. Hyperemia of the promontory, appearing as a yellowish-red glow 
 through a membrana tympani otherwise normal in appearance. The 
 handle of the malleus may be foreshortened, but is not rotated. 
 
 5. Patency of the Eustachian tubes. 
 
 Hyperostosis of the Stapes. — The same as the preceding except in a 
 less degree 
 
728 THE EAR 
 
 Hyperostosis of the Cochlea. — 1. Loss of hearing for the upper tone 
 limit, and slightly for the lower tone limit. Shambaugh reported a case 
 in which there were islands of deafness, thereby showing that the hyper- 
 ostosis may be limited to definite isolated areas in the cochlea. 
 
 2. Positive Rinne. 
 
 3. Shortened duration of hearing by bone conduction for fork A. 
 
 4. Hyperemia of promontory showing through an otherwise normal 
 membrana tympani. 
 
 5. Patency of Eustachian tubes. 
 
 Hyperostosis of the Semicircular Canals. — 1. Giddiness or dizziness 
 at times. 
 
 2. Nausea may or may not be present. 
 
 3. Perhaps slight deafness. 
 
 4. Membrana tympani and Eustachian tubes normal. 
 Hyperostosis around Oval Window Combined with Catarrhal Otitis Media 
 
 or Other Middle Ear Disease. — 1. Loss of hearing for one-half to two 
 octaves of the lower tone limit. 
 
 2. Negative Rinne in varying degree. 
 
 3. Prolonged hearing by bone conduction for fork A. 
 
 4. Retraction of the membrana tympani. 
 
 5. Foreshortening and rotation of the malleus. 
 
 6. Eustachian tubes obstructed. 
 
 A positive diagnosis of spongifying in a case with the above symptom 
 complex is impossible except at the postmortem examination, as it is 
 masked by the catarrhal otitis media which presents the same symptom 
 complex. 
 
 Prognosis. — The cure of the disease appears to be impossible. In a 
 few cases slight or temporary improvement follows treatment, and in the 
 early stage of the disease certain medicinal, mechanical, and surgical 
 procedures afford relief. In the later stages all remedial measures fail. 
 
 Treatment. — Medicinal. — Small doses of phosphorus, gr. 21^, three 
 times daily, for six months of the year, have given the best results. The 
 treatment acts best in the early stages during the active proliferation of 
 the cellular elements within the bone, when new vascular tissue is being 
 formed in the narrow spaces and Haversian canals, and the absorptive 
 processes and apposition of new bone is in progress. 
 
 Thyroid extract has likewise occasionally given good results under the 
 same conditions. 
 
 Iodine, in the form of the iodide of potash, and mercury has been given 
 by Politzer with good results when the diagnosis was made early on 
 account of other members of the family having had the disease. That 
 is, its appearance was carefully watched for, because of the known 
 hereditary influence present. When a father or mother is known to have 
 the disease, they should be warned that their children are liable to the 
 same trouble, and that they should be periodically examined after puberty 
 for its earliest expression. In this way there is some hope of modifying 
 its progress by the administration of phosphorus, iodide of potash, or 
 thyroid extract, and by the correction of inflammatory diseases of the 
 
HYPEROSTOSIS OF THE BONY CAPSULE OF THE LABYRINTH 729 
 
 tonsils and adenoids, and of rheumatic, gouty, and scrofulous diseases. 
 Thyroidectin in five-grain doses may be given three times a day. Deple- 
 tion of the vessels of the head may be produced by the administration 
 of cathartics and by hot foot and sitz baths. 
 
 To accomplish anything of importance an early diagnosis is positively 
 necessary, and heredity should give warning of the impending disorder. 
 
 Mechanical. — Pneumomassage with the Delstanche rarefactor (Fig. 
 14) may be used to mobilize the ossicles when they are not excessively 
 ankylosed (Hartz). 
 
 Clarence Blake calls attention to the fact that in practising pneumo- 
 massage gentleness should be observed in its application, as otherwise 
 the whole ossicular chain may be dislocated and irreparable damage 
 done. He also calls attention to the fact that the posterior segment 
 of the membrana tympani may become relaxed by excessive massage. 
 Indeed, great damage may be done by any treatment addressed to the 
 Eustachian tubes and middle ear. Aurophones are also damaging in 
 this disease. The massage should therefore be gently administered, 
 preferably with a hand pump, for one to two minutes, two or three times 
 a week, for two months. After a rest of two months the massage may be 
 tried again, provided improvement followed the first course of treatment. 
 Further massage may be given at the discretion of the aurist. As soon 
 as the nature of the disease is known, the patient should be advised to 
 begin a systematic course in lip reading. 
 
 Surgical. — Stapedectomy has been tried with almost universal failure. 
 Jack has performed the operation a number of times with but one or two 
 permanent improvements. In some cases stapedectomy is followed by 
 the formation of scar tissue over the oval window, thus rendering the 
 hearing worse than before the operation. 
 
CHAPTER XLIII. 
 
 ACUTE AND CHRONIC SUPPURATIVE OTITIS MEDIA. 
 CHOLESTEATOMA. 
 
 ACUTE SUPPURATIVE OTITIS MEDIA. 
 
 This type of inflammation of the middle ear is characterized by 
 marked hyperemia of the mucous membrane of the middle ear, includ- 
 ing the inner wall of the drumhead. This may be followed by pain and 
 perforation of the drumhead, through which the pus discharges into 
 the external auditory meatus. 
 
 Etiology. — The exciting cause of this disease is the presence of patho- 
 genic microorganisms in the middle ear, as already described under 
 Acute Catarrhal Otitis Media; indeed, the catarrhal inflammation often 
 assumes the suppurative type after a few days. In many cases the 
 inflammation remains catarrhal in type until the drumhead is per- 
 forated, the microorganisms thus receiving the required environment to 
 promote their rapid propagation, though spontaneous rupture some- 
 times promotes a rapid reparative process, due to good drainage and 
 the increased reaction of inflammation. (See Chapter VI.) The per- 
 foration may occur either spontaneously or by surgical intervention. 
 Incision of the membrana tympani is not contra-indicated, as, if it is done 
 under aseptic conditions, the danger of increased infection is reduced to 
 the minimum; indeed, the reaction of inflammation is promoted, and 
 the infection is thus overcome instead of being increased. Some cases 
 are undoubtedly suppurative in type from the beginning, the inflamma- 
 tion, temperature, and pain being more pronounced than in the simple 
 catarrhal inflammation. 
 
 Arthur B. Duel arrives at the following conclusions in reference to the 
 relation of the infectious fevers to acute suppurative otitis media, his 
 conclusions being based upon a study of 6000 cases of scarlet fever, 
 measles, and diphtheria in the Willard Parker Hospital : 
 
 Acute purulent otitis developed in about 20 per cent, of the scarlet 
 fever cases, in about 10 per cent, of the diphtheria cases, and in about 
 5 per cent, of the cases of measles. There were 26 mastoid cases, 2 in 
 measles, 2 in scarlet fever, and about 20 in combined scarlet fever and 
 diphtheria. Two were complicated with thrombosis of the lateral 
 sinus. 
 
 Time of appearance: In scarlet fever the ear complications occurred 
 the second or third week; in diphtheria, during the acute symptoms; in 
 measles, during the acute stage, fever still being present. 
 
 In scarlet fever cases there was usually much greater destruction of 
 
ACUTE SUPPURATIVE OTITIS MEDIA 731 
 
 tissue than in those due to diphtheria or measles. A combination of two 
 or more of the infectious diseases increased the danger, nearly one-half 
 of such cases developing acute suppurative otitis media, and mastoiditis 
 was a frequent sequela. 
 
 The Rivinian segment as an etiological factor: In children under 
 five years of age Duel found postauricular swelling present most fre- 
 quently, which, he thinks, was due to the escape of pus through the 
 unclosed Rivinian segment. Between the ages of five and ten the post- 
 auricular swelling was due to perforation of the thin mastoid cortex. 
 In older children mastoid swelling was rare, except in those cases in 
 which the external meatus was greatly inflamed. In all cases there was 
 sagging of the postsuperior wall of the meatus near the drumhead. 
 
 The "predisposing causes are colds, exposure, chronic rhinitis, chronic 
 and acute epipharyngitis, adenoids, enlarged or inflamed tonsils, syph- 
 ilis, tuberculosis, and other constitutional diseases. The acute exan- 
 thematous fevers, as scarlet fever, measles, diphtheria, whooping-cough, 
 and influenza, are also responsible for many cases. The use of the 
 nasal douche sometimes causes the disease. The author formerly used 
 the nasal douche quite frequently in office practice, but abandoned it 
 after seeing two or three cases of acute suppurative inflammation result- 
 ing directly from it. Cold injections into the meatus, bathing, diving, and 
 snuffing cold fluids into the nose also act as causes. 
 
 Age has a direct influence, a large majority of the cases being in chil- 
 dren. The damp, unsettled weather of the autumn and spring also 
 favor its occurrence. 
 
 Those cases occurring independently of any other disease are usually 
 unilateral, while those occurring in connection with scarlet fever, diph- 
 theria, measles, epipharyngitis, and adenoids are usually bilateral. 
 
 Finally, it may be stated that all conditions which lower the resistance 
 of the tissues of the middle ear predispose to infectious inflammation. 
 The exciting causes are the pathogenic microorganisms. The various 
 constitutional diseases and the local diseases of the fauces, nose, and 
 epipharynx produce lowered cell resistance, and predispose to the in- 
 fection. 
 
 The indications, in view of the foregoing facts, are to remove the pre- 
 disposing causes and increase the reaction of inflammation, in order to 
 increase the resistance of the tissues to the bacteria and their toxins. 
 (See Inflammation, and the Methods of Promoting the Reaction of 
 Inflammation, Chapters VI and VII.) 
 
 Symptoms. — The symptoms may be grouped under pain, tempera- 
 ture, the appearance of the membrana tympani, the character of the 
 secretions, the subjective noises, and the disturbances of hearing. 
 
 Pain. — The pain is sometimes preceded by a feeling of heaviness in 
 the ear, or by a severe headache. It may be piercing, tearing, boring, 
 or throbbing in character, and is more severe in children than in adults. 
 It is continuous, but becomes less severe toward morning, when the 
 patient falls into a sound sleep. Photophobia, edema of the eyelids, 
 and conjunctivitis occasionally complicate severe inflammations prior 
 
732 THE EAR 
 
 to the time of perforation of the drumhead. Facial paralysis and 
 trigeminal neuralgia occasionally complicate the disease. 
 
 Temperature. — The temperature at the onset is elevated from 1° to 3° F., 
 and is sometimes preceded by a slight chill, or creepy sensations, and, 
 occasionally, in very young children, by convulsions. After the sup- 
 purative process is well established, and drainage is taking place through 
 the perforation in the drumhead, the temperature subsides to about 
 1° above normal. 
 
 The Membrana Tympani. — In the early stages the membrana tympani 
 presents the appearances found in acute catarrhal otitis media. It is 
 scarlet red, ecchymotic, swollen, and more or less bulging. The handle 
 of the malleus is obscured by the swollen drumhead. In the post- 
 superior quadrant of the membrana tympani a blister is sometimes pres- 
 ent, giving a pearly lustre to this area. If the case is seen quite early, 
 the round spots due to the bubbles of air in the viscid mucus may be 
 seen through the still transparent drumhead. In the influenzal cases a 
 hemorrhagic bleb often completely covers the drumhead, ^iter a day 
 or two the posterior half of the drumhead becomes covered with dead, 
 cracked epithelium, beneath which there is a serous infiltration. Politzer 
 was the first to show that the light reflexes on the bulging portions of the 
 posterior segment of the drumhead sometimes pulsate. The yellow 
 purulent secretion behind the membrana tympani does not show as often 
 as one might expect, on account of the swollen and reddened condition 
 of the drumhead. Occasionally, however, a greenish-yellow bulging spot 
 may be seen, and when it appears, perforation is imminent. 
 
 In diabetic patients, and occasionally in others, small interlamellar 
 abscesses form in the posterior segment of the membrana tympani, or 
 near the umbo. They are of the size of a millet-seed, and rupture early 
 in the course of the disease. 
 
 The External Auditory Meatus. — The osseous portion of the meatus is 
 almost always hyperemic, and is sometimes infiltrated, and more or less 
 covered with blisters. The cartilaginous portion of the meatus is in- 
 jected and painful in severe inflammations, the infection taking place 
 through the numerous anastomoses of the capillary bloodvessels be- 
 tween the mucous membrane of the tympanic cavity and the skin of the 
 meatus. The swelling and redness, or the so-called "sagging" of the 
 postsuperior portion of the osseous meatus, near the membrana tym- 
 pani (Fig. 402), occurs in those cases in which there is a marked 
 suppurative process in the border mastoid cells (the cells along the 
 posterior border of the meatus). When it occurs it is usually a positive 
 indication for the mastoid operation. 
 
 Perforation. — Perforation takes place at the seat of one of the inter- 
 lamellar abscesses, or at the most bulging portion of the drumhead, 
 generally in the anterior half, although it may occur in the posterior 
 segment. The size and shape of the perforation varies, usually being 
 an ill-defined area with irregular edges, while in others it appears as a 
 small dark round spot, with a pulsating drop of mucus covering it. In 
 still other cases the opening cannot be located. Inflation sometimes 
 
ACUTE SUPPURATIVE OTITIS MEDIA 733 
 
 enables the observer to distinguish its edges. The same is true when 
 the air is rarefied in the external canal with Siegle's otoscope (Fig. 397). 
 The perforation is usually single, except in tuberculous patients, when it 
 is multiple and near the margin of the drumhead (Fig. 404). In influ- 
 enzal otitis the perforation often occurs on the apex of a nipple-shaped 
 elevation. Such a perforation is, therefore, significant of serious mastoid 
 disease. Even under favorable conditions, the nipple-shaped perfora- 
 tion persists for some time. In those cases occurring independent of 
 one of the infectious diseases the perforation rarely exceeds the size of 
 a millet-seed, whereas in cases secondary to the infectious fevers it may 
 be so large as to destroy the entire membrana tympani. The membrana 
 flaccida (Shrapnell's membrane) is rarely perforated in acute suppurative 
 otitis media. 
 
 Secretions. — The secretions may be serous, seromucous, serosan- 
 guineous, seropurulent, mucopurulent, or mucohemorrhagic. If it is 
 purulent, it often runs a more favorable course than the mucopurulent 
 type. The quantity of pus, serum, 
 
 and mucus varies greatly at differ- Fig. 402 
 
 ent times, and one form of secretion 
 may alternate with another. In neph- 
 ritic, cachectic, leukemic, hemophilic, 
 and traumatic cases the hemorrhagic 
 secretion is usually present. 
 
 Subjective Noises. — Pulsating 
 noises sometimes occur in acute sup- 
 purative otitis media, although they 
 are not always present. They are 
 due to the increased pressure within 
 the cavum tympani from the hyper- 
 emia and excess of secretion. The 
 labvrinth is also hvperemic and 
 somewhat infiltrated, the noises being Bu,ging „ or f s + agging f of the . poste + " or 
 
 ' P superior wall of the meatus; an imperative 
 
 thereby augmented. Autophony IS indication for the mastoid operation. 
 
 sometimes present. 
 
 The Hearing. — The hearing is impaired somewhat in proportion to the 
 amount of congestion and secretion present. As the disease progresses, 
 and the membrane becomes more congested, and the cavity filled with 
 the secretion, the deafness, which at first was slight, becomes quite pro- 
 nounced. In scarlatinal and diphtheritic infections involving the laby- 
 rinth the deafness may be profound. 
 
 Hearing by bone conduction for the watch, tuning-fork, and acou- 
 meter remains intact, except in those cases wherein the labyrinth is 
 involved. In the Weber test the sound is lateralized to the diseased ear, 
 except in the aforesaid labyrinth cases, in which it is lateralized to the 
 sound ear. 
 
 Course. — Taking the perforation of the drumhead as one of the 
 early milestones in the progress of the disease, we may subdivide it 
 into three classes, namely: (a) those cases running a very rapid and 
 
734 THE EAR 
 
 destructive course, wherein the drumhead is perforated within the first 
 one or two days; (b) those cases wherein perforation occurs on the 
 third or fourth day (primary suppurative otitis media) ; (c) and the 
 more chronic type, in which perforation occurs within the second or 
 third week of the disease. 
 
 Perforation usually ameliorates the symptoms, especially the pain 
 and temperature. Improvement does not always follow, however, as 
 the mastoid antrum and cells may also contain pent-up secretions, 
 and thus give rise to pain and elevation of temperature, in spite of the 
 lowered tension within the tympanic cavity. The fever, headache, and 
 subjective noises are also abated when perforation and drainage into the 
 meatus take place. 
 
 After a variable time the discharge ceases and the perforation closes. 
 In the cases occurring independently of the infectious fevers, this will 
 usually take place in from one to three weeks; sometimes, however, it may 
 take as many months. In those cases due to the infectious fevers and to 
 influenza (nipple-shaped perforation), the perforation only closes after a 
 protracted period. 
 
 I have seen a fatal type of mastoiditis develop seven years after an 
 attack of mild scarlet fever. In one case, seven years after the scar- 
 latinal infection, cavernous sinus thrombosis complicating mastoiditis 
 occurred, and was speedily followed by death. In another case, one 
 year after a very mild attack of measles, suppurative labyrinthitis de- 
 veloped very suddenly, deafness being almost complete. Pachymenin- 
 gitis, followed by death four days later, terminated the case. There is 
 great danger for the safety of those patients whose ears become infected 
 during the course of the exanthematous fevers. A latent or concealed 
 inflammation so often persists, which after a lapse of a few years becomes 
 very active and destructive. It is, therefore, always best to give a guarded 
 prognosis in otitis media secondary to the eruptive fevers. The prognosis 
 in those cases occurring independently of the exanthematous fevers 
 is much more favorable. 
 
 Another type of otitis having dangerous tendencies, is that running 
 an irregular or intermittent course. The discharge ceases, and then, 
 after a variable interval, reappears. Pain also occurs at irregular inter- 
 vals. In other words, the acute type becomes chronic and somewhat 
 latent in character. Necrosis of the bony tissue takes place, and mastoid- 
 itis, complicated withsinus thrombosis, brain abscess, or meningitis,occurs. 
 
 Terminations and Sequelae. — This phase of the subject is of great 
 importance, on account of the apparent harmlessness of the disease in 
 many cases, whereas it is in reality a most grave and destructive one. 
 It is not so much the disease that is to be feared as its sequelae. The 
 terminations and sequelae should engage the thoughtful consideration 
 of the attending physician quite as much as the primary otitis. For 
 convenience of discussion, Politzer's classification of the terminations 
 will be followed: 
 
 (a) Cure. — That many cases terminate in a positive cure, no vestige 
 of the disease remaining, cannot be questioned. That many are pro- 
 
ACUTE SUPPURATIVE OTITIS MEDIA 735 
 
 nounced "cured" when in reality a serious sequela is left as a heritage, 
 is also unquestioned. A careful analysis of the case, its etiology, course, 
 etc., should be considered in arriving at a correct conclusion as to whether 
 or not it is "cured." What, then, are the points that should be consid- 
 ered in arriving at such a conclusion? In the first place, if the case is 
 primary, or independent of a preceding infectious fever, and has run 
 a mild and rapid course, and if there are no demonstrable ear lesions, 
 it is safe to pronounce the case as probably cured. Such an opinion 
 should, however, be based upon accurate and intelligent observations. 
 I have seen many cases pronounced cured in which subsequent results 
 demonstrated the opinion to have been erroneous. 
 
 (6) Catarrhal. — A catarrhal termination is not attended with immediate 
 serious consequences, but it may in time produce pronounced im- 
 pairment of hearing. The perforation may become completely closed 
 by cicatricial tissue and a seromucous secretion, with slowly increasing 
 deafness and tinnitus as the chief symptoms. 
 
 (c) Adhesive Processes. — This form of termination is comparatively 
 common. The thick mucoid secretion or exudate becomes organized, 
 the adhesive bands binding the ossicles to each other or to the walls 
 of the tympanic cavity. The drumhead may also be involved by ad- 
 hesions to the inner tympanic wall, forming ridges and folds toward 
 the wall from which the adhesive bands spring. The deafness and 
 tinnitus are usually progressive, although they may increase by bounds. 
 In the earlier stages, bone conduction is increased, Rhine (see Func- 
 tional Tests of Hearing) being negative, while in the more advanced 
 stages Rinne is positive. The positive Rhine in the later stage is ac- 
 counted for by the extension of the sclerotic process to the labyrinth. 
 
 (d) Permanent Deafness. — Permanent deafness is usually a result of 
 the secondary infection from scarlet fever, measles, diphtheria, etc., the 
 membrana tympani and ossicles being partially or entirely destroyed. 
 I have seen cases, however, in which the drumhead and ossicles were 
 entirely destroyed and the inner wall (promontory) of the tympanic 
 cavity plainly visible, in which the hearing was remarkably acute. The 
 chief loss of function seemed to be an inability to locate the direction 
 of sound or speech. After once grasping the fact that they were being 
 addressed, these cases seemingly hear with almost normal acuteness. 
 Another cause of permanent, and often very pronounced, deafness is the 
 panotitis of Politzer, wherein the whole auditory apparatus is involved 
 in the infective process. In these cases there is caries of the bone sepa- 
 rating the tympanic cavity from the labyrinth (promontory), or there is 
 a perforation of the round window leading to the labyrinth. This con- 
 dition is usually secondary to the infectious fevers. 
 
 (e) Mastoiditis. — While mastoiditis nearly always complicates middle 
 ear infection, it is not always severe enough to cause serious symptoms. 
 In some cases, however, notably those due to the infectious fevers, in- 
 fluenza, and typhoid fever, the mastoid involvement often becomes the 
 chief problem in the management of the case. In mastoiditis having 
 its origin in influenza the abscess is usually circumscribed, and is located 
 
736 THE EAR 
 
 in the mastoid process, the tympanic cavity containing no pus. In 
 children the mastoid process is often perforated through the external 
 plate, thus giving rise to a subperiosteal abscess. 
 
 (/) Loss of Mucous Membrane, Ossicles, and Infection of the Labyrinth. 
 — Labyrinthitis, described under (d) Permanent Deafness, is found 
 following mild infectious fevers, typhoid fever, and tuberculosis. The 
 tympanic cavity is denuded of mucous membrane, and the ossicles are 
 necrosed. A probe introduced into the cavity through the external 
 meatus shows bare, comparatively smooth bony walls. The labyrinth 
 may be exposed by necrosis of the promontory or inner wall of the 
 middle ear, or the wall of the horizontal semicircular canal may be 
 perforated. The hearing in these cases may not be as profoundly affected 
 as in (d), except when the cochlea is involved. 
 
 (g) Chronic Suppuration. — This sequela is not so much to be dreaded 
 as the more latent form, in which there seems to be a cure, when in fact 
 necrosis may be steadily progressing. In the plainly manifested chronic 
 suppuration the physician and patient are not so readily deceived, but 
 recognize the possible danger still attending the further progress of the 
 disease. 
 
 (h) Death. — A fatal issue may result early in the disease from menin- 
 gitis, sinus thrombosis, septicemia, or brain abscess. The infection 
 may reach the meninges through the labyrinth, the tegmen antri or 
 tympani, or through one of the open sutures of the temporal bone in 
 infants and young children. 
 
 Diagnosis. — The diagnosis of acute suppurative otitis media in the 
 early stage is neither easy nor simple. The apparent difference between 
 it and acute catarrhal otitis media is often so slight that only a careful 
 and intelligent examination will enable the surgeon to make a correct 
 diagnosis. 
 
 (a) Pain. — In suppurative otitis media the pain previous to per- 
 foration is very intense and boring in character, especially in chil- 
 dren. 
 
 (b) Temperature. — The temperature ranges from 1° to 3°, or even 
 more, above normal in children, but may not run so high in adults. 
 In catarrhal otitis media the temperature does not usually exceed 1° or 2° 
 above normal. 
 
 (c) Appearance of the Drumhead. — In suppurative otitis media before 
 perforation the drumhead is quite similar in appearance to that in 
 catarrhal otitis media. The perforation may appear as a dark spot or 
 it may not be visible. A pulsating droplet of mucus or pus is, however, 
 significant of perforation. If the drumhead is destroyed the red pro- 
 montory may be seen when the pus is cleared away. 
 
 (d) The Probe. — The probe may be used to differentiate between a 
 reddened promontory wall and a reddened drumhead. The promon- 
 tory is firm and unyielding, while the drumhead is resilient. With the 
 probe a flake of mucus or pus may be brushed away, and thus show 
 whether a perforation is present. Necrosis of the promontory or cochlear 
 wall may also be demonstrated with the probe. In the acute stage 
 
ACUTE SUPPURATIVE OTITIS MEDIA 737 
 
 nystagmus, nausea, and vomiting may be present when the labyrinth is 
 involved. (See Tests of Vestibular Apparatus.) 
 
 (e) Inflation. — Inflation of the middle ear and the simultaneous use 
 of the diagnostic tube will produce a whistling tympanic murmur when 
 perforation is present, and a soft, blowing tympanic murmur when the 
 drumhead is intact. Inflation should be practised with caution in acute 
 cases, as the infectious material may be forced into the deeper recesses 
 of the tympanic and mastoid cavities. If during inflation the distal 
 end of the diagnostic tube is dropped into a basin of water, bubbles 
 of air will arise in the water if perforation is present. A manometric 
 tube partly filled with water and inserted into the external meatus 
 during inflation will cause the column of water to rise in the distal arm 
 of the U-shaped tube during inflation if a perforation is present. 
 
 (J) Compression of Air in the Meatus. — Compression of the air in the 
 external canal will force air through the perforation into the middle ear. 
 The sound may be heard by inserting one end of the diagnostic tube into 
 the nose of the patient (one nostril being closed), the other end being 
 placed in the external auditory meatus of the observer. 
 
 Prognosis. — The prognosis has already been quite fully considered 
 under Terminations and Sequelae. 
 
 Treatment. — The treatment will be considered in connection with 
 the subject of middle ear suppurations in general. A brief resume, 
 however, will be given in this connection. 
 
 (a) Complete asepsis or cleanliness and drainage should be striven 
 for, to prevent the otorrhea becoming chronic. To fail in this regard 
 subjects the patient's life to great hazard. If thorough asepsis is main- 
 tained, a secondary staphylococcus infection will be prevented. Staphylo- 
 coccus infection means chronicity. Do not allow it to occur. 
 
 (b) In the early stage, before perforation occurs, a 12 per cent, solu- 
 tion of carbolic acid in glycerin should be dropped into the meatus. 
 It is also a valuable remedy after perforation, as it is hygroscopic, reduces 
 the edema of the mucous membrane, and thus establishes a more rapid 
 flow of blood through the tissues. The resistance of the tissues is thus 
 raised and the infection checked. 
 
 (c) Early incision of the drumhead should be practised at its most 
 bulging portion. The incision should be free and curved to allow of 
 good drainage. Simple puncture, the so-called paracentesis, is never 
 indicated. It is an obsolete procedure. Drainage is the object sought 
 for, hence use the lance with a free hand. Incision also promotes the 
 reaction of inflammation, and thus favors a speedy resolution (Fig. 403). 
 
 (d) If the secretion is thick and tenacious, the syringe may be used to 
 remove it. A sterile alkaline solution should always be used for this 
 purpose, as it thins the secretion and facilitates its removal. 
 
 (e) An aqueous solution of the peroxide of hydrogen may also be 
 used to break down the secretion, after which it may be more readily 
 wiped away with a cotton-wound probe. 
 
 (/) The cotton-wound probe should be used gently, but repeatedly, at 
 each sitting. In the author's experience this is the most effectual method 
 47 
 
738 THE EAR 
 
 of removing the secretion in those cases in which the perforation is of 
 large size. 
 
 (g) Inflation of the middle ear may be practised with caution after 
 the pain and other acute symptoms have subsided. 
 
 (h) A safer procedure is to use suction with Siegle's otoscope in the 
 external auditory canal. 
 
 (i) Constitutional treatment : Calomel may be given in y 1 ^ grain doses 
 three to ten times a day. For the relief of the pain, 1 grain of codeine, 
 
 or 3 to 6 grains of phenacetin may be 
 FlG - 403 given. The epipharynx should be fre- 
 quently gargled after the von Troltsch- 
 Swain method, the patient lying upon his 
 back. 
 
 (/) Six weeks of daily inspection and 
 appropriate treatment will, in most cases, 
 result in a complete cure. Less faithful 
 and intelligent attention will result in many 
 cases becoming latent or chronic, with the 
 usual sequelae so unfortunate in their effects. 
 (k) In those cases in which there is 
 
 A long, curved incision extending » j • , i ii ,-i 
 
 across the drumhead and into the Sagging of the pOStSUpCTlOr Hieatal Wall the 
 
 meatus at the upper portion. simple mastoid operation should be per- 
 
 formed at once. Delay is dangerous. If 
 the infection is staphylococcal, the urgency for the operation is not 
 so great as in streptococcus infection. In the latter type, local treat- 
 ment is usually unavailing, surgical procedures being required to effect 
 a cure. 
 
 (/) The ice-bag may be used over the mastoid process for one-half to 
 two hours when great pain is present. If no improvement follows, it 
 should be discontinued and operative measures considered. Discon- 
 tinue the ice when pus flows freely and the pain subsides. If the infec- 
 tion is streptococcal, its use will be unavailing. If it is staphylococcal, 
 it may abate the infective process. 
 
 (m) Artificial or natural leeches, applied over the mastoid process and 
 in front of the tragus, afford the most effectual method of promoting the 
 reaction of inflammation and aborting the disease. (See Chapter VII.) 
 
 ACUTE SUPPURATIVE OTITIS MEDIA IN INFANTS AND 
 CHILDREN. 
 
 In view of the fact that in 50 per cent, of the cases of measles in infants 
 and young children there is an inflammatory affection of the middle ear, 
 and that with all infectious diseases in young patients there is more or 
 less inflammation of the ears, a brief consideration of these inflammations 
 is in order. 
 
 The pathological changes found vary all the way from a simple catar- 
 rhal inflammation, with swelling and cloudiness of the mucosa, to infil- 
 
ACUTE SUPPURATIVE OTITIS MEDIA IN CHILDREN 739 
 
 tration and purulent secretion. This secretion is usually serous or sero- 
 mucous, with some pus cells. 
 
 The embryological conditions influencing the occurrences of the process 
 in infants are: (a) The presence of an opening in the upper or Rivinian 
 segment of the drumhead, which does not always close before birth. In 
 bathing, water may thus gain entrance into the tympanic cavity and 
 excite an inflammation, (b) According to Weiss, the mucous membrane 
 of infants is embryonic in type, and is, therefore, more liable to become 
 infected. 
 
 The cachexia of infancy, bronchitis, the infectious fevers, and chronic 
 intestinal catarrh are also special causes. 
 
 Coughing, vomiting, sneezing, and other violent respiratory efforts 
 may force infected matter through the Eustachian tubes into the middle 
 ears and excite catarrhal and suppurative inflammations. 
 
 Otitis media is sometimes present in the newborn, and is probably due 
 to the forcible entrance of amniotic fluid into the middle ear during 
 delivery. 
 
 Adenoids, enlarged or diseased tonsils, epipharyngitis, and coryza are 
 common diseases of childhood, and contribute toward the causation of 
 otitis media. 
 
 Symptoms. — In infants with cachexia there are often no subjective 
 symptoms. Objectively, the drumhead may be a little reddened, espe- 
 cially about the short process and along the handle of the malleus. A 
 small amount of slimy secretion may be found in the canal. It may 
 be questioned whether the cachexia is the cause of the ear disease, 
 or the ear disease is the cause of the cachexia. It is quite certain, 
 however, that even a mild suppurative process in infants is quite suffi- 
 cient to cause pronounced disturbances of nutrition. Every case of 
 malnutrition, peevishness, twisting of the head, or dropping it to one 
 side should lead to the careful inspection of the ears of these young 
 patients. Boring the head, or occiput, into the pillow, hanging it to one 
 side (affected ear), placing the hand to the affected ear, going to sleep 
 when lying on the ear toward which the head is inclined, refusing to 
 take the breast except on the side which allows the patient to lie with 
 the affected ear against the bosom, all point to acute inflammation of 
 the middle ear. The infant cannot tell of its sufferings, but if the 
 physician carefully observes its actions, they will often speak louder 
 than words. 
 
 In older children the symptoms are more pronounced, and just prior 
 to perforation of the drumhead the pain is often excruciating. There 
 may be nystagmus, vomiting, unconsciousness, and convulsions. In other 
 words, signs of labyrinthine and meningeal irritation are often present. 
 
 When perforation takes place there is immediate relief, although the 
 patient is by no means necessarily out of danger, especially if labyrin- 
 thine and meningeal symptoms are present. 
 
 The tendency to frequent relapses is a prominent characteristic of 
 otitic inflammations in infancy and childhood. After the tenth to the 
 fifteenth year of age this tendency is not so marked. 
 
740 THE EAR 
 
 Treatment. — The treatment is almost the same as in adults, with 
 the exception that tympanic inflation is usually followed by great relief. 
 When the inflammation is suppurative in character, the external meatus 
 should be thoroughly cleansed with cotton-wound probes. The same 
 treatment described under Acute Suppurative Otitis Media and Acute 
 Mastoiditis is applicable to these cases. The removal of adenoids, when 
 present, is usually followed by great improvement or a cure of the 
 otorrhea. Many cases of chronic otorrhea in children cease after the 
 removal of the adenoids. If, however, the otorrhea is secondary to scarlet 
 fever, measles, or diphtheria, it is often necessary to perform a mastoid 
 operation to effect a cure. If nystagmus and meningeal symptoms were 
 present the case should be carefully watched and free drainage main- 
 tained, and, if necessary, suitable surgical procedures adopted. 
 
 CHRONIC SUPPURATIVE OTITIS MEDIA. 
 
 Owing to the faulty instruction, or, more properly speaking, to the 
 lack of systematic instruction in otology in most American medical col- 
 leges, false ideas are prevalent concerning the true importance of chronic 
 suppurative otitis media. The acute exacerbation is the only phase 
 that ordinarily attracts serious consideration. When we recall the fact that 
 none of the prominent life insurance companies will accept an applicant 
 who is affected with chronic or intermittent otorrhea, we are brought face 
 to face with the business man's view of the disease. He has found, after a 
 careful study of the mortality tables, that applicants thus affected do not 
 live to the full term of their natural lives. Both clinical observation and 
 pathological findings bear out this conclusion. Clinically, we find chronic 
 otorrhea attended with a sallow muddy complexion and acute exacer- 
 bations, during which there is pain and mastoid tenderness, and an 
 increased flow of pus, which subsides only to return again after many 
 weeks, months, or years. In other cases sinus thrombosis, septicemia, 
 labyrinthitis, meningitis, brain abscess, etc., which often lead to a fatal 
 termination, are associated. Bearing these facts in mind, and their 
 relation to what seems to be a simple and harmless chronic otorrhea, 
 it becomes apparent that chronic suppurative otitis media is not to be 
 thought of as a trivial or an unimportant disease. 
 
 Symptoms. — The symptoms vary with the nature and location of 
 the pathological process, as well as with its acuteness or chronicity. 
 In some cases the signs of the ear disease are so latent that but little 
 thought and less attention are given to them. In others, there is a 
 constant or intermittent flow of pus or mucopus into the external canal, 
 with occasional twinges of pain. In still others, there are acute exacer- 
 bations, characterized by profuse pus discharge, often admixed with 
 blood, and attended with pain, mastoid tenderness, and swelling. The 
 chief difference between the types is in the degree of obstruction to 
 free drainage and in the virulency of the microorganisms in the tympanic 
 cavity and mastoid cells. So long as there is free drainage, and there are 
 
CHRONIC SUPPURATIVE OTITIS MEDIA 741 
 
 no virulent microorganisms jeopardizing the middle ear and cranial 
 contents, the symptoms are not alarming in character. On the other 
 hand, when free drainage is interfered with, and virulent infection 
 supervenes upon the preexisting less virulent infection, the symptoms 
 assume a most aggravated and alarming character. In other words, 
 the so-called chronic suppurative otitis media assumes the proportions 
 of an acute mastoiditis, with threatened intracranial complications. 
 
 The Latent Form. — The symptoms in this type of middle ear suppura- 
 tion are scarcely appreciable to the patient, as there is little discharge 
 and no pain or tenderness over the mastoid process. The patient often 
 says there is no discharge, nor has there been for many months or years. 
 Ocular inspection, however, will often show a small amount of pus 
 in the middle ear and external auditory meatus. The amount is so 
 small that it does not reach the concha, but is evaporated in the meatus, 
 the dried remains being thrown off with the cerumen and epidermis. In 
 these cases there is a central perforation of the drumhead, the size 
 varying from a millet-seed to almost the entire membrane (pars tensa), 
 though frequently cases of latent otorrhea are observed in which the 
 perforation is marginal. 
 
 The Chronic Discharging Form. — There is a profuse but intermittent 
 purulent discharge, sometimes admixed with mucus and blood. Acute 
 coryza, epipharyngitis, and exposure to inclement weather increases 
 the amount of discharge and its purulency. Pain may be present, espe- 
 cially when aggravated by either of the foregoing conditions. There is, 
 at these times, a slight tenderness over the mastoid process, especially 
 over the antrum. Inspection of the fundus meati shows pus completely 
 filling it, or oozing through the perforation in the drumhead. If the 
 drumhead is largely destroyed, and the pus has its origin in the attic, it 
 may be seen to trickle down the long process of the incus into the atrium 
 of the middle ear. After removing all the pus from the middle ear, the 
 promontory appears as a yellowish-red reflex. Granulations or polypi 
 may be present, filling the middle ear cavity, or even protruding into 
 the external meatus. 
 
 I have seen cases in which the polypus protruded into the concha of 
 the auricle. When polypi are present, blood is often admixed with the 
 secretions. 
 
 There is more or less elevation of temperature during the subacute 
 exacerbations. The skin is yellow and muddy, the whites of the eyes 
 are slightly discolored, and a feeling of lassitude and mental inertia 
 possesses the patient. 
 
 Chronic Otorrhea with Acute Exacerbations. — This form of chronic sup- 
 purative otitis media attracts attention on account of the exacerbations 
 of pronounced pain, mastoid tenderness, and elevation of temperature. 
 The patient and attending physician become conscious of the danger, 
 which may have existed for some weeks, months, or even years pre- 
 viously. What was previously regarded as a simple harmless discharge 
 is now recognized as a threatened mastoiditis. There is a profuse 
 flow of pus, perhaps admixed with blood, the mastoid is tender to the 
 
742 
 
 THE EAR 
 
 touch, either at its tip or over the antrum, and the temperature ranges 
 from 1° to 4° above normal. There may be no distinct chill. 
 
 The patient complains of lassitude, and is disinclined to pursue his 
 vocation. He may be apprehensive of impending danger. 
 
 Having thus characterized the more obvious symptoms of the three 
 most common types of chronic suppurative otitis media, the further study, 
 of the signs of this disease, and their significance in estimating the nature 
 and location of the pathological changes, will be based upon the location 
 of the perforation in the drumhead. 
 
 Fig. 404 
 
 The significance of central and marginal perforations of the membrana tympani. 
 
 Perforations, their Location and Significance. — To Leutert, Zaufal, 
 and others we owe our knowledge of the pathological significance of the 
 location of the perforations in the drumhead. It may be said, in gen- 
 eral, that if the perforation is marginal, there is bone necrosis in the 
 region of the perforation; and if the perforation does not involve the 
 margin of the drumhead, but is near its centre, bone necrosis is absent, 
 the case being one of simple suppurative otitis media. The informa- 
 tion thus afforded, while not absolute, is nevertheless very valuable in 
 arriving at a full knowledge of the case. 
 
 The Clinical Significance of Chronic Perforations of the Mem- 
 brana Tympani. — A central perforation (Fig. 404, a, b, c) usually sig- 
 nifies inadequate drainage and ventilation through the Eustachian tube, 
 the perforation occurring at the point of least resistance. A central per- 
 
CHRONIC SUPPURATIVE OTITIS MEDIA 743 
 
 foration is rarely attended with necrosis of the bony walls of the cavum 
 tympani or of the ossicles, and may be successfully treated without 
 major surgical interference. According to Leutert, all central per- 
 forations indicate tubal infection. * 
 
 (c) This is a central perforation (Fig. 404), located over the tympanic 
 orifice of the Eustachian tube, and is the result of continual middle ear 
 infection from the tube. The Eustachian tube is probably infected from 
 the epipharyngitis, if present. The epipharyngitis may be due to the 
 presence of adenoids or their remnants, or to diseased tonsils, or to 
 ethmoiditis and sphenoiditis. A perforation of the membrana tym- 
 pani over the tympanic orifice of the Eustachian tube should, therefore, 
 direct the attention of the aural surgeon to the epipharynx and the contig- 
 uous structures, rather than to the tympanic cavity. A radical mas- 
 toid operation upon a case with a perforation at this point would, in 
 all probability, fail to check the otorrhea. An attempt to close the 
 tympanic orifice of the Eustachian tube at the time of the radical opera- 
 tion would, in all probability, meet with failure, as the continued infec- 
 tion from the epipharynx would prevent closure. The rational treatment 
 of such a case would be to cure the sinuitis, remove the adenoids and 
 tonsils, or to adopt such other remedial measures as will cure the epi- 
 pharyngitis. 
 
 A perforation of the inferior margin of the membrana tympani (Fig. 
 404, d) signifies necrosis of the inferior wall or floor of the tympanic 
 cavity. The only vital structure in this region is the jugular bulb. As 
 the bony wall separating the tympanic cavity and the jugular bulb is 
 usually quite thick, the perforation may signify nothing more than 
 necrosis of the floor of the tympanic cavity, a region which is accessible 
 to curettement through the external meatus. In rare instances, however, 
 the jugular bulb is separated from the tympanic cavity by only a thin bony 
 wall, or the wall may be entirely absent. A marginal perforation at this 
 point should, therefore, be regarded as suspicious of necrosis from jugular 
 bulb disease, especially if septic symptoms are present. The exploration 
 and curettement of the floor of the tympanum should in such cases be 
 prosecuted with caution. 
 
 A perforation of the membrana flaccida immediately above the 
 short process of the malleus (Fig. 404, e) usually signifies necrosis 
 of the head of the malleus, a structure in close apposition to the 
 perforation. 
 
 A marginal perforation immediately above the short process of the 
 malleus and extending to the superior wall of the meatus (Fig. 404,/) 
 usually signifies necrosis of the tegmen tympani (roof of the attic). 
 
 A perforation of the membrana tympani at the margin of the pos- 
 terior quadrant of the membrana tympani (Fig. 404, g) usually signifies 
 necrosis of the incus and of the walls of the antrum. 
 
 Numerous small perforations near the margin of the membrana 
 tympani (Fig. 404, h) are usually significant of a tuberculous otitis 
 media. 
 
 From the foregoing data it may be inferred that a central perfora- 
 
744 THE EAR 
 
 tion signifies a simple infectious process in the cavum tympani, probably 
 of tubal origin, whereas a marginal perforation usually signifies bone 
 necrosis. Marginal perforations are, therefore, indicative of a more 
 serious process in the middle ear (cavum tympani) than is indicated 
 by a central perforation. The entire absence of the membrana tympani 
 is equivalent to a marginal perforation, and is strongly suggestive of 
 bone necrosis. 
 
 While the significance of chronic perforations is generally to be inter- 
 preted as given in the foregoing paragraphs, it should not be inferred 
 that the location of the perforation is an infallible guide to the condi- 
 tion present in the middle ear and mastoid cavities. All other clinical 
 phenomena should be taken into consideration, and a conclusion be 
 drawn from the entire symptom complex. 
 
 Prognosis as to Hearing. — In simple or central perforations the hear- 
 ing may be but slightly affected after the suppurative process is re- 
 lieved. In the complex or marginal perforations, with bone necrosis, 
 the hearing is usually diminished after the radical operation, whereas it 
 is greatly improved after the meatomastoid operation. The patient 
 should be made to understand that, while every effort will be made to 
 maintain or improve the hearing, the chief concern is to check, or to 
 cure, the suppurative process, which, if allowed to run its course, may 
 jeopardize both the health and life of the patient. 
 
 According to Clarence Heath, of London, many of the cases hereto- 
 fore operated by the radical method may be cured by a less radical 
 operation. (See Meatomastoid Operation.) In addition to a less 
 radical procedure, he claims that the hearing is not only conserved, 
 but that it is usually restored to near the normal. The author's ex- 
 perience with the meatomastoid operation is limited to twenty-five 
 cases, and thus far the results obtained have been excellent. The 
 twenty-five cases selected for this operation have been those in which 
 the ossicles were not markedly necrosed, though the perforation in some 
 was marginal. The prognosis as to the permanent cure of the disease 
 by this operation is still open until further experience demonstrates 
 its exact place in otological surgery. That the hearing is temporarily 
 preserved, and usually greatly improved is fairly well demonstrated. 
 
 Treatment. — The treatment of chronic suppurative otitis media 
 does not offer a brilliant therapeutic field. In spite of all that can be 
 done with local treatment, the discharge often persists, or, if checked, 
 recurs within a few weeks or months. Many so-called " cured cases" 
 are in reality only latent, and with the first "cold in the head," or other 
 local irritation, become active again. This tendency is so strong that 
 many otologists have regarded the persistence, or the tendency to recur- 
 rence, as an indication for the radical mastoid operation. While this is 
 probably an extreme view, it is, nevertheless, a more rational one than 
 the view held by some, that most cases of chronic otorrhea may be cured 
 by simple local treatment, or by simple operative measures through the 
 external auditory meatus (Hotz, Theobald). As a matter of fact, each 
 case should be diligently studied as to the local morbid conditions, and 
 
CHRONIC SUPPURATIVE OTITIS MEDIA 745 
 
 as to the main etiological factors. Furthermore, the pathological laws 
 underlying infectious processes in cavities lined with mucous membranes 
 should be well considered. (See Chapter VI.) 
 
 The treatment of chronic suppurative otitis media will be studied, 
 with the foregoing facts in mind, under the following headings : 
 
 The Treatment of Chronic Otorrhea with a Central Perforation of the Mem- 
 brana Tympani. — Chronic suppurative otitis media with a central perfora- 
 tion of the membrana tympani (Fig. 404, a, b, c) usually signifies a simple 
 infection of the mucous membrane of the Eustachian tube and middle 
 ear without involvement of the bony tissue of the tympanic walls, or of 
 the ossicles, and is, therefore, often amenable to simple local treat- 
 ment. Non-marginal perforations indicate a suppurative process in 
 the Eustachian tube, hence the middle ear cannot be cured while the 
 tubal infection continues. In such cases the first attention should 
 be given to the Eustachian tube and the conditions giving rise to its 
 involvement. 
 
 The otorrhea is perpetuated by the discharge of infected secretion from 
 the Eustachian tube into the tympanic cavity, and cannot be cured with- 
 out first overcoming the infection and discharge from this source. The 
 mucous membrane of the Eustachian tube, when normal, is covered by 
 ciliated columnar epithelium, which propels the secretions toward the 
 pharyngeal orifice of the tube. In chronic infectious processes the cilia 
 are lost, or their wave-like motion is inhibited, and the secretions flow 
 in the direction of least resistance. The isthmus of the tube forms a 
 partial barrier to the downward flow of the secretions from the tympanic 
 end of the tube, hence they are retained in the tympanic cavity. The 
 constant irritation of the membrana tympani opposite the tympanic orifice 
 of the tube leads to perforation at this point. The first indication in these 
 cases is to remove the cause of the tubal infection and inflammation. 
 
 If the tubal infection is due to a constriction at the isthmus of the tube, 
 the tube should be dilated with bougies, and astringent and antiseptic 
 solutions forced through it with a Weber-Liel catheter. 
 
 If the infection is due to the presence of epipharyngeal adenoids, 
 or their remnants, they should be removed. 
 
 If the infection is due to an epipharyngitis, it should receive appro- 
 priate treatment. 
 
 Finally, if the tube is infected by the discharge from diseased nasal 
 sinuses, especially the posterior ethmoidal and sphenoidal sinuses, 
 this condition should receive appropriate treatment. 
 
 Having removed the cause of the tubal infection, that in the tympanic 
 cavity tends to disappear with little or no other treatment. In some cases, 
 however, the infectious process in the Eustachian tube is attended by 
 such pronounced tissue changes that additional local treatment of the 
 middle ear is necessary. 
 
 Removal of Adenoids. — If adenoids are present it may be assumed 
 that the ear disease cannot be permanently cured until they are removed, 
 hence the first indication is to remove them and then address the treat- 
 ment to the ears. The tonsils may also require attention. 
 
746 THE EAR 
 
 Epipharyngitis. — Epipharyngitis is usually caused by adenoids, hence 
 the adenoids should be removed and the epipharyngitis treated with 
 weak silver solutions. When overcome, address the treatment to the 
 middle ear and Eustachian tube. 
 
 Sinuitis.. — Chronic posterior ethmoidal and sphenoidal infection cause 
 swelling and infection of the Eustachian tubes and thus perpetuate 
 middle ear infection. Give appropriate attention to these conditions 
 and then direct the treatment to the ears. 
 
 If the above courses of treatment are consistently pursued, many cases 
 may be cured without a mastoid operation. 
 
 Dry Gauze Dressings.- — In 1880-82, Dr. Spencer, of St. Louis, ad- 
 vocated the use of strips of dry gauze in the treatment of acute and 
 chronic suppurative otitis media. Since then the same method of treat- 
 ment has been urged by Gradinego, Pierce, Gradle, and others. 
 
 The fundus of the meatus should be mopped dry with a cotton-wound 
 applicator before the strip of gauze is applied. 
 
 The end of the gauze is then carried to the membrana tympani with a 
 probe packer (Fig. 405). The meatus is then loosely packed with the 
 gauze and a small piece of cotton placed over it. The gauze should be 
 removed every twenty-four hours and the secretions thoroughly removed 
 with a cotton-wound applicator. A new strip of gauze is then applied 
 as before. 
 
 Fig. 405 
 
 F.A.HARDY *.C0. 
 
 Bane-Allport gauze packer 
 
 In some cases the drainage and protection afforded by the gauze leads 
 to the rapid disappearance of the infection and to repair, the perfora- 
 tion often voluntarily closing by granulating from its edges. In other 
 cases it persists, and may be closed by the application of a 33 per cent, 
 solution of trichloracetic acid to its edges at intervals of a few days. 
 No attempt should be made to close the perforation until the secretion 
 is normal. 
 
 In addition to the foregoing method of treatment, alcohol in varying 
 strength may be instilled into the middle ear through the meatus. 
 
 The middle ear may also be cleared by inflation through the Eusta- 
 chian tube if the otorrhea persists after several treatments. 
 
 Treatment via Weber-Liel Catheter. — The local treatment of the 
 infected Eustachian tube and tympanic cavity consists in the use of 
 the dry gauze treatment and in the use of mild astringents and anti- 
 septic solutions through the Eustachian tube, a Weber-Liel catheter 
 being used for this purpose. The Weber-Liel catheter consists of a 
 small, long, flexible rubber catheter, placed inside of a larger catheter 
 of the usual length. The larger catheter is passed to the pharyngeal 
 orifice of the tube, and the smaller one is introduced through it to 
 the isthmus of the Eustachian tube. A small syringe, filled with 
 an alkaline antiseptic solution, is then attached to the smaller catheter 
 
CHRONIC SUPPURATIVE OTITIS MEDIA 747 
 
 and the fluid forced into the middle ear. This course of treatment, 
 following the removal of the conditions causing the tubal and middle 
 ear infection, is often attended by a complete cure of the chronic 
 otorrhea. 
 
 The Treatment of Chronic Otorrhea with Marginal Perforations of the 
 Membrana Tympani. — As marginal perforations of the membrana tym- 
 pani usually signify necrosis of the ossicles, the bony tympanic walls, 
 the tegmen tympani or tegmen antri, and the other contiguous bony 
 structures, the treatment of chronic otorrhea thus characterized is 
 not as simple as in central perforations. The same fundamental 
 principles of treatment should, however, be observed. The drainage 
 and the removal of the morbid material are absolutely essential to 
 success. 
 
 The methods of establishing drainage and of removing the morbid 
 material are radically different, for anatomical and pathological reasons, 
 from those pursued in otorrhea with central perforations. It is obviously 
 impossible to materially facilitate drainage by dressings in the external 
 auditory meatus when the obstruction is in the antrum or aditus ad 
 antrum. It is equally obvious that the morbid material cannot, under 
 such conditions, be removed through the auditory meatus. Surgical 
 measures are usually required in these cases, as follows: 
 
 1. When the perforation is just above the short process of the malleus 
 (Fig. 404, e), the head of the malleus is probably necrosed, and the malleus 
 should be removed. (See Ossiculectomy.) A 2 per cent, solution of 
 the nitrate of silver may, however, be injected through the perforation 
 to promote healthy granulation, with the hope of healing the diseased 
 ossicle and thus avoiding the necessity of removing it. 
 
 2. When there is a perforation at the upper margin of the membrane 
 (Fig. 404,/), and it involves not only the membrana flaccida but the supe- 
 rior wall of the auditory meatus, the tegmen tympani is probably ne- 
 crosed. Even in these cases ossiculectomy is sometimes attended by a 
 cure of the chronic infection and otorrhea. If the floor of the attic is 
 blocked, the removal of the malleus and incus may establish free drain- 
 age, and thus effect a cure. In other instances, ossiculectomy will not 
 effect a cure, probably because the case is complicated by epipharyngitis, 
 salpingitis, or necrosis of the antrum walls. Ossiculectomy is, there- 
 fore, only applicable to those cases in which the tegmen tympani is alone 
 necrotic, the complicated cases being amenable to the meatomastoid and 
 the radical operations. 
 
 3. When the chronic otorrhea is attended by a marginal perforation 
 at the postsuperior quadrant of the membrana tympani, as shown in 
 Fig. 404, g, necrosis of the antrum is probably present. The incus also 
 may be necrosed. To establish drainage, and to remove the morbid 
 material, either the radical or the meatomastoid operation should be 
 performed. It is barely possible, however, that by irrigating the attic 
 through the perforation, drainage may be established through the aditus 
 ad antrum and a cure effected. To these cases the meatomastoid opera- 
 tion appears to be well adapted. 
 
748 THE EAR 
 
 4. With a perforation at the inferior margin of the membrana tym- 
 pani (Fig. 404, d), the necrosed bone may be removed with a curette 
 introduced through the auditory meatus. If septic symptoms are 
 present, the floor of the tympanic cavity should be cautiously explored, 
 as the necrosis may be due to an extension from the jugular bulb. If 
 septic symptoms are present in such a case, the rational procedure would 
 be to perform either the radical or the meatomastoid operation, and 
 then expose the sigmoid portion of the lateral sinus and the jugular 
 bulb. If septic symptoms are absent, the floor of the tympanum should 
 be explored with a blunt probe for necrotic bone, and if found it should 
 be carefully removed through the perforation with a bent curette. The 
 perforation should be previously enlarged by two divergent incisions. 
 After curettement, the meatus should be loosely packed with sterile 
 gauze, as recommended in simple central perforations. The gauze 
 should be removed daily, the meatus freed of secretions, and repacked 
 with gauze, until the necrotic area is healed and the perforation closed. 
 If the secretions disappear and the perforation persists, the perforation 
 may be closed by the application of a 33 per cent, solution of trichlor- 
 acetic acid to its margins. 
 
 5. Otorrhea attended by a perforation of the membrana tympani at 
 its anterior margin usually signifies necrosis in this region. As the 
 carotid artery passes upward through the temporal bone near the ante- 
 rior boundary of the cavum tympani, curettement should be cautiously 
 performed in this region (Fig. 404). (See Surgical Treatment.) 
 
 Other Methods of Treatment. — Curettage of the attic via the external 
 auditory meatus should be undertaken with great reluctance and cau- 
 tion. If granulations are present, it is quite probable that the tegmen 
 tympani is necrosed and that the granulations are thrown around and 
 over it to wall off the invading pathogenic bacteria from the meninges. 
 The removal of the granulation tissue without at the same time estab- 
 lishing free drainage of the secretions from the tympanic cavity might 
 lead to infection of the meninges. Such a condition may be much more 
 successfully, safely, and conservatively treated by either the radical or 
 the meatomastoid operation. 
 
 The alcohol treatment has been held in high esteem in chronic suppu- 
 rative otitis media. Its field of usefulness is chiefly limited to central 
 perforations, especially after the causes of the tubal infection have been 
 removed (see p. 745). 
 
 In otorrhea with a marginal perforation, alcohol only relieves the 
 symptoms, but does not cure the disease. 
 
 The alcohol may be used in various dilutions, ranging from 25 to 95 
 per cent., beginning with the milder solution and gradually increasing the 
 strength. The alcohol should be left in the cleansed ear for twenty 
 minutes at each treatment. 
 
 Alcohol holding boric acid or iodoform in solution or suspension may 
 be used in otorrhea with a central perforation, though it is probable 
 that its therapeutic value is not increased by the addition of the boric 
 acid or iodoform. 
 
CHOLESTEATOMA 749 
 
 In fetid otorrhea the instillation of the compound tincture of benzoin 
 may be used to remove the fetor. It is also an antiseptic and astringent, 
 and acts favorably upon the diseased tissues. The fundus of the 
 meatus should be mopped dry before applying the compound tincture 
 of benzoin. 
 
 When there are exuberant granulations in the middle ear, a 95 per 
 cent, solution of carbolic acid may be applied, care being exercised to 
 prevent the acid coming into contact with the meatal skin. At the 
 expiration of one minute alcohol should be instilled into the ear to 
 check the action of the acid, after which the ear should be mopped 
 with a cotton-wound applicator. The meatus should then be loosely 
 packed with dry, sterile gauze. 
 
 CHOLESTEATOMA. 
 
 Cholesteatoma of the middle ear is characterized by the formation of 
 masses of epidermoid cells arranged in concentric layers, between which 
 are found cholesterin crystals. 
 
 Etiology. — About the year 1840, J. Miiller described new formations 
 in the temporal bone, resembling pearly growths. They were composed 
 of concentric layers of epidermoid cells with cholesterin crystals between 
 them. They are commonly found in the atrium and attic, and are 
 covered with a delicate membrane which is closely adherent to the peri- 
 osteum of the bone to which they are attached. This variety is known as 
 primary cholesteatoma, as it seems to have its origin in the cavity where 
 it is found. The secondary and most common type is due to an exten- 
 sion of the epidermis of the external meatus and membrana tympani 
 into the middle ear through a perforation in the drumhead. 
 
 Primary Cholesteatoma. — Primary cholesteatoma is variously believed 
 to be heteroplastic, possibly arising from the epithelium of the ductus 
 vestibule; that is, it is a remnant of the second visceral cleft left behind 
 after its closure. Mild inflammatory action in the middle ear favors its 
 growth, whereas severe inflammation hinders it. Primary cholesteatoma 
 is probably quite rare. Its existence might well be doubted if it were not 
 for the fact that eminent observers have made full and detailed reports 
 of such cases. Other equally eminent observers claim there is no such 
 condition, all cases being secondary to suppurative processes in the 
 tympanic cavities. Von Troltsch, Habermann, Politzer, and others 
 hold this opinion. 
 
 Secondary Cholesteatoma. — This is the type found in practice, the 
 primary form being chiefly limited to the literature. The masses in 
 all probability have their origin from extensions of epidermis from the 
 external meatus and drumhead. The conditions favoring this extension 
 are: 
 
 (a) A marginal perforation of the drumhead. 
 
 (6) A mild chronic suppurative inflammation of the mucosa of the 
 middle ear. 
 
750 THE EAR 
 
 (c) A fistulous opening in the posterior or superior wall of the 
 meatus. 
 
 (d) Adhesions at the margin of the perforation. 
 
 (e) Adhesion of the end of the handle of the malleus to the promontory. 
 
 If) Aup al polypi- 
 Perforations in the posterior portion of the membrana flaccida are 
 especially liable to be followed by cholesteatoma on account of the tongue- 
 like thickened extension of epithelium from the superior wall of the 
 meatus to the drumhead at this point. Politzer reports a case in which 
 the growth seemed to have its origin in a fistulous opening in the mastoid 
 process. 
 
 The cholesteatomatous masses are of a pearly gray color, and slightly 
 lustrous. Upon section they are found to be composed of concentric 
 layers of epidermic cells intermixed with detritus and cholesterin crystals. 
 If the conditions are favorable the masses grow larger and larger, and 
 cause eccentric pressure atrophy of the bony walls of the cavity involved. 
 In some cases the bone is necrosed, exposing the brain, lateral sinus, 
 and labyrinth. The masses are broken down in their centres, richly 
 odorous, and loaded with pathogenic microorganisms. The central 
 breaking down is due to putrefaction. 
 
 Aural polypi, with mild suppurative inflammation, are often attended 
 with cholesteatomatous formations. If there is an active or profuse 
 pus discharge, the growths are checked or altogether dissipated. The 
 free drainage incident to a profuse discharge seems to prevent the further 
 inward extension of the epidermic process, the masses gradually dis- 
 appearing, and the cavity healing with a layer of flat epithelial covering 
 or matrix. The size of the cholesteatomatous masses varies from a 
 hemp-seed to a large walnut. Their shape either conforms to that of the 
 cavity in which they form, or they are round, oval, or very irregular in 
 outline. 
 
 Extensions of the cholesteatoma into the Haversian canals have been 
 demonstrated, which may, in part, account for the marked tendency to 
 recurrences in spite of thorough operative interference. E. B. Dench has 
 called attention to the presence of small masses of cholesterin crystals 
 without epithelial cells, the etiology and pathology of which are not 
 known. He reported two such cases operated by the radical method 
 with good results. 
 
 Symptoms. — The masses may be present for years without giving 
 rise to distinct symptoms. Sudden swelling of the mass from the en- 
 trance of moisture into the external meatus, as from sweating, bathing, 
 syringing, etc., may cause pressure symptoms, as pain and necrosis. 
 In this event there may be a feeling of fulness or pain in the affected 
 ear, with headache, nausea, vomiting, nystagmus, staggering £ait, fever, 
 and aprosexia. The moisture causes the horny cells to swell, and the 
 sudden pressure thus exerted causes the above signs of pressure and of 
 intracranial irritation. 
 
 Inspection of the meatus shows it to be more or less filled with a pearly 
 gray mass, admixed with granulations or aural polypi. If a portion is 
 
CHOLESTEATOMA 751 
 
 removed and placed in water, it appears as shreds of delicate tissue 
 with the golden grains of cholesterin, which are characteristic of this 
 growth. If the mass is favorably located, it may be removed with the 
 syringe or ear spoon. In other cases it is necessary to resort to the radical 
 mastoid operation. Even then it may be necessary to repeat the opera- 
 tion one or more times before a satisfactory result is obtained. 
 
 The termination of cholesteatoma may be (a) by epidermization after 
 the spontaneous or instrumental removal of the mass; (6) by forcing 
 it through the Eustachian tube into the epipharynx, or into the maxil- 
 lary articulation through the anterior wall of the meatus; (c) by its 
 breaking through the walls of the semicircular canals (Jansen); (d) 
 in some cases by pushing its way through the external plate of the 
 mastoid process and presenting the appearance of a mastoid abscess; 
 (e) in still other cases by causing necrosis of the tegmen antri and 
 tympani and causing death from involvement of the cranial contents; 
 (/) sepsis arising from the absorption of the retained secretions, causing 
 death; (g) and from meningitis, brain abscess, sinus thrombosis, or 
 thrombosis of the jugular vein with a similar result. 
 
 Diagnosis. — The diagnosis may be made by the removal of the growth 
 and subjecting it to microscopic examination. It may be removed with 
 a curette, probe, or syringe when the growth is in the middle ear. If in 
 the antrum, it can only be removed by a mastoid operation. Sydacker 
 has called attention to the sedimentation of the washings of the ear, 
 which, when microscopically examined, show the epithelial cells with 
 nuclei staining very faintly. Particles of bone dust are also shown as 
 highly refractile crystals. Bruhl and Politzer have called attention to the 
 use of a chloroform solution of the cholesteatomatous masses in which 
 the cholesterin produces a greenish discoloration. 
 
 Prognosis. — The prognosis is bad. In those cases in which there is a 
 spontaneous or instrumental expulsion of the cholesteatoma the cavity 
 usually becomes refilled. Even after the most thorough radical opera- 
 tion the disease may persist. This is not at all difficult to understand 
 when we recall the fact that the cholesteatoma forces its way into the 
 Haversian canals of the bone, thus effectually forming focal centres 
 from which it may extend again. Sac-like prolongations into the bone 
 have also been observed, thereby making it difficult to entirely eradicate 
 the process. The uncertainty of cure leaves the possible complications, 
 as meningitis, brain abscess, pyemia, sinus and jugular thrombosis, 
 a menace to the health and life of the patient. A cure is, however, 
 usually effected, and we are warranted in attempting thorough surgical 
 measures for its relief. 
 
 Treatment. — The treatment in uncomplicated cases may be begun 
 by the removal of the cholesteatoma through the perforation in the 
 drumhead with small curettes, ear hooks, etc., or with a syringe. In 
 some instances it is found to be advantageous to force sterile fluid through 
 the Eustachian tube into the middle ear, thus getting the force of the 
 stream of water behind the mass, and forcing it into the external meatus. 
 
 Should polypi be present, they should be removed. If there is necrosis 
 
752 . THE EAR 
 
 of the ossicles, they should be removed. Adhesion of the edges of the 
 perforation to the inner wall of the tympanum or adhesion of the end 
 of the handle of the malleus to the promontory should be overcome. 
 After having removed the tumor the parts should be dusted with an 
 antiseptic powder. 
 
 Should these simple measures prove ineffective, recourse must be had 
 to the radical mastoid operation, elsewhere described in this work. The 
 meatomastoid operation is not indicated, as the chief object of this 
 operation is to preserve or improve the hearing. In these cases this 
 object is defeated by the unavoidable dislocation of the ossicles in 
 removing the cholesteatoma. 
 
CHAPTER XLIY. 
 
 THE SEQUELAE OF SUPPURATIVE OTITIS MEDIA, MASTOIDITIS, 
 AND CHOLESTEATOMA. SUPPURATION OF THE LABYRINTH. 
 
 DISEASES OF THE MASTOID PROCESS. 
 
 Primary infection and inflammation of the mastoid process is very 
 rare. Disease of the mastoid is usually secondary to a suppurative 
 process in the middle ear, but there are cases of pneumococcus and more 
 especially influenza infection which sometimes appear in the mastoid 
 process without first affecting the middle ear. As a matter of fact, 
 all, or nearly all, suppurative middle-ear inflammations probably also 
 involve the mastoid cells. 
 
 It is difficult to separate the suppurative processes of the middle ear 
 from those of the mastoid cells. Clinically the disease is subdivided upon 
 an arbitrary basis according to the focal manifestations present. The 
 anatomical distribution of the pneumatic spaces of the temporal bone is 
 so complex that it is advantageous to subdivide suppurative inflamma- 
 tions within them according to the focal centre of involvement, while, 
 on the other hand, it is more rational to regard the process as one disease 
 regardless of the focal symptoms. The antrum is perhaps the axial 
 centre of the pneumatic spaces of the ear, the mastoid cells communi- 
 cating with it, while the attic and atrium (middle ear) communicate with 
 it anteriorly through the aditus ad antrum. If the case requires external 
 surgical treatment, it is most centrally attacked by way of the antrum, 
 the operative field being extended posteriorly into the mastoid cells and 
 anteriorly into the middle ear, according to the conditions present. If 
 the disease is focalized in the middle ear without mastoid symptoms, it 
 may be regarded as middle ear disease. In those acute cases termin- 
 ating without focal mastoid symptoms it has been customary to speak 
 of them as acute otitis medias, regardless of the fact that the mastoid 
 cells were also involved. 
 
 With this understanding the various diseases of the mastoid process 
 will be described. 
 
 ACUTE SIMPLE MASTOIDITIS WITHOUT INTRACRANIAL LESIONS. 
 
 Symptoms. — It is probable that in nearly every case of acute infection 
 
 of the middle ear, the mastoid cells and antrum are also involved. It 
 
 is chiefly in those cases in which free drainage is interfered with that 
 
 the mastoid symptoms become manifest. These symptoms are chiefly 
 
 48 
 
754 THE EAR 
 
 those of pressure from retention of the secretions within the cells. They 
 are pain, redness, swelling, and tenderness upon pressure or percus- 
 sion over the mastoid process. When such symptoms supervene, the 
 original disease sinks into a place of secondary importance, while the 
 secondary condition comes forward as the object of greatest interest. 
 The disease is no longer called otitis media, but is called mastoiditis. 
 
 There is a sudden rise of temperature accompanied by rigors of 
 varying intensity. Many cases, however, have but slight elevation of 
 temperature at any time during the disease. In others the rise is as 
 high as 104° F. 
 
 The pain originates behind the auricle and radiates toward the teeth 
 and shoulders (Politzer), the occiput, neck, and face. Mastication may 
 be painful on account of an involvement of the bony portion of the 
 external meatus, which is in close proximity to the glenoid fossa. 
 
 The sternocleidomastoid and the other muscles of the neck attached 
 to the mastoid account for the pain upon movements of the head. Torti- 
 collis may be present, and is due to a fixation of the muscle to avoid 
 pain upon movement. It has been shown by others (Broca and Lubet- 
 Barbon) that it is sometimes due to enlargement of the cervical glands 
 and to infection from measles, in which otitis media was not present.- 
 In measles the torticollis is probably due to glandular enlargement from 
 infection. 
 
 Schwartze called attention to the intolerance of pressure over the whole 
 mastoid, but more particularly immediately below the zygomatic ridge 
 (antrum), as a symptom of mastoiditis 
 
 The skin over the mastoid process may become red and swollen. In 
 some cases the auricle stands forward, even approaching a right angle to 
 the side of the head. In these cases a subperiosteal abscess is present. 
 
 The aural discharge may be scanty or profuse. Redness and swelling 
 of the posterior wall of the external meatus near the drumhead are 
 commonly present. This condition is variously spoken of as the "dip," 
 "chute," or " bulging" of the postsuperior wall. Under the pathology 
 of the mastoid reference has already been made to the presence of pneu- 
 matic mastoid cells (the border cells), which are found between the 
 antrum and meatus. These break down, and the retained secretions 
 cause the wall to thus "dip" or "bulge." This sign is pathognomonic of 
 mastoiditis of a destructive type, and is therefore a strong indication 
 for an immediate operation. 
 
 The diagnostic value of this sign has been emphasized by Schwartze, 
 Macewen, Holmes, Sheppard, Duplay, and many others. Politzer 
 thinks it is not necessarily an indication for the mastoid operation, while 
 Schwartze, Broca, and Lubet-Barbon hold the contrary view. 
 
 Delay in operating subjects the patient to almost certain danger, 
 even though it does not become apparent for years. The author can recall 
 but one case (following an attack of influenza) in which the "dip" and 
 all other signs of middle ear and mastoid disease seemed to disappear. 
 The word "seemed" is used advisedly, for there is little doubt as to a 
 subsequent recurrence in such cases. There are exceptions to all rules 
 
MASTOIDITIS WITHOUT INTRACRANIAL LESION 755 
 
 and the case just mentioned was probably one of them. Nevertheless, 
 the rule and not the exceptions should guide us. 
 
 A central perforation of the drumhead nearly always exists. It is 
 usually small and filled with pus and debris, which pulsates synchro- 
 nously with the heart beat. Should the infection be very intense, great 
 destruction of tissue may result, in which event the perforation may be 
 marginal. 
 
 Granulations sometimes protrude through the opening and block 
 the discharge of the secretion. The removal of the granulations is often 
 sufficient to establish free drainage and relieve the acute mastoid symp- 
 toms. It may be doubted whether it really cures the mastoiditis, as this 
 may remain in a latent form for years before culminating in an alarming 
 exacerbation. 
 
 In still other cases the perforation is large and discharges but little 
 pus. In these cases the aditus ad antrum is obstructed and pain is 
 pronounced. This is of interest as a diagnostic and prognostic point. 
 It enables the attending physician to locate the obstruction prior to the 
 operation, and to determine whether relief may be expected from a 
 simple middle ear operation (incision of the membrana tympani) or 
 whether it will be necessary to perforin a postauricular mastoid operation. 
 
 Spontaneous cures should be looked upon with .suspicion, as in nearly 
 every case it amounts to nothing more than a remission. Politzer 
 Schwartze, Duplay, Holmes, Ballenger, Stucky, Macewen, Dench, 
 St. John Roosa, Hollinger, Pierce, Whiting, and many others report 
 recurrences in cases which had seemed to be cured. 
 
 One should be extremely modest in claiming to have "cured" mastoid- 
 itis without surgical intervention. That such terminations occur cannot 
 be denied, but they are rare. 
 
 Treatment. — If the case is seen before spontaneous perforation of the 
 eardrum has occurred the drum should be freely incised at the point of 
 greatest bulging. This is done to promote the reaction of inflammation 
 and to relieve the pressure, and the tissue necrosis. The tissues in the 
 presence of an acute infectious process are very susceptible to necrosis 
 while pressure is maintained, hence the necessity of an early incision. 
 The incision should be a long and curved one, so as to make as free 
 an opening as possible. Some writers advise carrying the incision into 
 the meatus, thus cutting through the annular plexus of vessels sur- 
 rounding the attachment of the membrana tympani. The free bleeding 
 thus produced acts favorably upon the progress of the inflammatory 
 process; that is, it promotes the reaction of inflammation and favors free 
 drainage. Some writers condemn the extension of the incision through 
 the annular plexus of vessels, on account of the liability of extending 
 the infection through these vessels. If there is a virulent streptococcus 
 infection the incision should not be thus extended, while in the milder 
 infections it is safe to do so. The author does not often carry the incision 
 into the external meatus. If the destructive process is not great, there 
 is no necessity for so doing, whereas if it is great, there are dangers 
 attending such a procedure. 
 
756 THE EAR 
 
 Cold applications by means of an ice-bag or a Leiter coil may be made 
 over the mastoid process if the case is seen within thirty-six hours of the 
 onset, and if there is great pain and scanty discharge of pus. Cold re- 
 duces the inflammatory reaction, diminishes the swelling of the mucous 
 membrane, and thus overcomes the obstruction to the flow of the secre- 
 tions. If the applications fail to remove the tenderness and pain, and 
 to establish a better discharge of secretions, they should be discon- 
 tinued and leeches applied. Leeching is much more efficacious than 
 ice. In some cases the cold applications mask the symptoms and lead 
 the surgeon to believe the disease is conquered. The real problem in 
 acute mastoiditis is not to bring about an abatement of the acute symp- 
 toms, but to relieve the patient of the suppurative process by promoting 
 the reaction of inflammation. Even though the acute symptoms disap- 
 pear and the patient appears to be well, but still has an ear discharge, a 
 cure is not effected. Too much attention has been given to the relief of 
 the acute symptoms, and too little to the cure of the suppurative process. 
 The acute symptoms will usually subside if nothing is done for the patient, 
 but in most cases less damage follows if appropriate attention is given 
 during their manifestation. Eradication of the suppurative process 
 should be the ultimate aim of the treatment. The attending surgeon 
 should not be satisfied, therefore, to relieve the pain, redness, tender- 
 ness, and temperature, but should also institute such remedial measures 
 as will modify the acute symptoms and at the same time eradicate the 
 infection. 
 
 To accomplish the foregoing results it may become necessary to per- 
 form a mastoid operation, which, if done at a sufficiently early period, 
 need not be an extensive or formidable affair. On the other hand, the 
 delay of a few days or weeks may make it necessary to perform a radical 
 operation. The cold applications, the incision of the eardrum, leeching, 
 etc., should therefore be tried early, so as to determine as quickly as 
 possible whether the disease can be aborted. If the mastoid is still tender 
 upon pressure and the discharge continues, there is a strong probability 
 that the acute process will merge into a chronic one if surgical interference 
 is not instituted. The point to be emphasized is that the simple operation 
 may be performed within the first three or four weeks of the onset of the 
 disease, whereas if delayed to a later period, the meatomastoid operation 
 may be necessary. There are hundreds of cases of chronic otorrhea 
 which would never have existed had they been operated on sufficiently 
 early, or had the meatomastoid or the radical operation been performed 
 when, on account of delay, a cure by the simple mastoid operation was 
 impossible. Just when to operate, and the kind of an operation to per- 
 form, is the great problem in acute suppurative otitis media complicated 
 by mastoiditis. It should also be stated in this connection that all cases 
 do not need to be operated upon. Many get well without such inter- 
 ference. If the pain over the mastoid persists after the incision of the 
 membrana tympani and the use of the leeches, an operation is indicated; 
 that is, the disease will probably persist as a chronic otorrhea unless an 
 operation is performed. The object of the operation is to prevent 
 
MASTOIDITIS WITHOUT IXTRACRAXIAL LESIOX 757 
 
 further mischief, rather than to avert immediate danger. It is not good 
 practice to wait for dangerous symptoms, as the mortality under these 
 conditions is much higher. Chronic otorrhea is a signal of impending 
 disaster, and every effort should be exerted to prevent it, even though 
 a mastoid operation is necessary to accomplish it. 
 
 The Leiter coil should be connected by rubber tubing with a tank or 
 bucket of iced water, and the water passed through it by siphonage and 
 allowed to escape into a vessel through another tube attached to the 
 opposite end of the coil. The iced water should be renewed each time 
 the tank becomes empty, and continued for about one hour, or until 
 the pain ceases and the purulent discharge becomes more profuse. 
 
 An ice-bag filled with cracked ice, and fastened over the mastoid 
 process by bands of linen, may be used instead of the Leiter coil. The 
 ice should be renewed as often as it becomes melted. 
 
 Hot irrigations of the bichloride of mercury solution, 1 to 5000, may be 
 used every hour to promote the reaction of inflammation. 
 
 Bier's treatment by constriction of the neck, if judiciously applied, 
 often exerts a favorable influence upon the course of the disease. The 
 patient should be placed in a bed, the foot of which is raised several 
 inches from the floor, and an Esmarch elastic band applied around 
 the neck. It should produce no pain or discomfort, and only slight 
 cyanosis of the face. It should be applied four times daily, with two- 
 hour intervals between applications. If the bandage is applied tight 
 enough to produce pain, it may do great damage. 
 
 The object of Bier's treatment is to promote the reaction of inflamma- 
 tion; that is, to increase the passive hyperemia and the migration of 
 leukocytes, so as to remove the bacteria and their toxins. Ice, in view 
 of these principles, is usually not indicated, as it diminishes the reaction 
 of inflammation. Encapsulated organs, such as the mastoid, however, 
 sometimes become so distended by inflammatory swelling that the 
 flow of blood through them is very much blocked. Ice relieves the dis- 
 tention and establishes the flow of blood, and is indicated under the 
 circumstances. When the distention or pressure symptoms (excessive 
 pain and scanty discharge of pus) are relieved, ice should be discontinued 
 and measures adopted that promote the reaction of inflammation. 
 
 Other methods of promoting the reaction of inflammation are leeches, 
 light, heat, hot poultices, etc. (See Chapter VII.) Of these, leeching, 
 the leukodescent light, and Bier's treatment are of special value in the 
 treatment of acute mastoiditis. 
 
 Leeching should be more generally used, as it is one of the best means 
 of promoting the reaction of inflammation. Cases following measles 
 running a temperature of 102° to 104°, often rapidly subside after the 
 use of leeches. 
 
 Should these simple measures fail, the simple mastoid operation 
 should be performed. (See Chapter XLVIII.) 
 
 Subacute Mastoiditis.— This form of mastoiditis has been referred 
 to under Acute Mastoiditis as the stage following the subsidence of the 
 acute symptoms. It should be regarded as a chronic disease even if 
 
758 THE EAR 
 
 the conditions present are of recent origin, as it only responds to treat- 
 ment suited to chronic cases. The infectious agent is usually the staphylo- 
 coccus, the usual germ of chronic suppuration. 
 
 Subacute mastoiditis is, therefore, the persistent remains of an acute 
 mastoiditis, in which the more active microorganisms have disappeared, 
 the staphylococcus perpetuating the inflammatory process. It is amen- 
 able to such treatment as is recommended for chronic mastoiditis. 
 
 ACUTE PERIOSTITIS OF THE MASTOID PROCESS; SUBPERIOSTEAL 
 
 MASTOID ABSCESS. 
 
 Subperiosteal mastoid abscess is characterized by a pronounced 
 bulging outward of the affected ear. The auricle at its superior portion 
 stands well out, while its entire free border is almost at right angles to 
 the plane of the side of the head. In other words, the outline of the ear, 
 as seen from either the front or the rear, falls from the upright toward the 
 horizontal plane of the head. 
 
 Upon manipulation the swelling above the auricle fluctuates more or 
 less in proportion to the amount of pus beneath the soft tissues. Duplay 
 says that before the pus forms externally one feels the elevation and 
 depression, under pressure, of the external table of the mastoid. 
 
 The alarm occasioned by an abscess of this type is out of proportion 
 to the danger attending it, as it rarely proves fatal. 
 
 Etiology. — It usually has its origin in an infectious otitis media which 
 extends to the antrum and mastoid cells. In young children the middle 
 ear and antrum alone are involved, as the mastoid cells are not yet formed. 
 
 The periosteum over the squamous portion of the temporal bone is 
 more easily separated (Macewen) than over the mastoid process. In 
 consequence the pus passes upward and causes the outward bulging 
 of the upper portion of the auricle. 
 
 Chronic otitis media suppurativa predisposes to the formation of the 
 abscess. A low stage of vitality is usually present. It occurs more often 
 in children, on account of the loose articulation of the bony plates. 
 
 Treatment. — In acute cases it is often only necessary to make a free 
 incision through the skin and periosteum covering the mastoid process 
 and evacuate the purulent accumulation. As the abscess is of otitic 
 origin, it may in some cases be necessary to perform a mastoid operation 
 either at the time of the incision or subsequently. In chronic sub- 
 periosteal abscess the simple incision (Wilde's) may not effect a cure, as 
 the ear disease is well established and may require an operation. 
 
 CHRONIC MASTOIDITIS. 
 
 Symptoms and Diagnosis. — Chronic mastoiditis is not necessarily 
 characterized by any special symptom other than those present in 
 chronic suppurative otitis media. Mastoid pain and tenderness and 
 
 
CHROXIC MASTOIDITIS 7oQ 
 
 other focal symptoms are often absent. The mastoid bone often under- 
 goes an eburnizing sclerosis in the course of the disease, the cortex 
 becoming quite dense and the cells replaced by dense bone. It is 
 not unusual to find the mastoid process with a few small cells, while 
 the remainder of the process is as hard as ivory. In this case the antrum 
 may be smaller than normal. When the cortex is dense, external 
 pressure symptoms are not present. The cranial aspect of the mastoid 
 process does not always undergo the sclerosing process, hence intra- 
 cranial complications, as sinus thrombosis, meningitis, brain abscess, 
 etc., may be the first focal symptoms to develop. A neuralgic pain often 
 accompanies the osteosclerosis of the mastoid process, which may be 
 relieved, according to Schwartze, by the removal of a wedge of bone from 
 the process. 
 
 The inspection of the drumhead and the middle ear cavity often 
 affords useful information as to the diagnosis. The drumhead is usually 
 almost or entirely destroyed. Usually the short process and the head 
 of the malleus are present, while the handle is gone. The incus is often 
 entirely destroyed, though it may be present in the more recent cases. A 
 fetid purulent secretion fills the meatus and the middle ear cavity. 
 When this is removed and suction is applied with Siegle's otoscope, 
 the secretion may be seen trickling from the attic into the atrium. 
 After the middle ear cavity is thoroughly cleansed, a fetid odor from 
 the foul pus which continues to enter the antrum from the inaccessible 
 attic and antrum is present, giving evidence of mastoid involvement. 
 
 Another evidence of chronic mastoiditis is the necrosis or entire de- 
 struction of the incus. In the section on perforations of the eardrum 
 attention was called to the significance of a marginal perforation in the 
 postsuperior quadrant of the eardrum and the associated necrosis of the 
 incus, as signs of necrosis in the antrum. An increased quantity of 
 purulent secretion is also a sign of mastoid involvement, although such an 
 involvement may be present with scanty discharge. Macewen calls 
 attention to the fact that in many cases the discharge is so slight as to 
 escape attention. In some of the cases granulations or polypi are the 
 only evidence of mastoid disease. The attachment of the polypi, when 
 examined with a delicate curved probe, may be traced to the attic. 
 Polypi generally signify bone necrosis. If, after cleansing the antrum 
 of all secretions, suction is applied through the Siegle otoscope, and pus 
 trickles down one of the fragments of the ossicles, attic and antral 
 involvement may be safely inferred. The presence of a persistent puru- 
 lent discharge unchecked by local treatment is fairly good evidence 
 of chronic otitis media plus mastoiditis. Macewen also calls atten- 
 tion to the fact that chronic suppuration of the middle ear extending 
 over a period of two or more years is usually attended by necrosis. 
 Neuralgic pains in the mastoid region occur in those cases attended by 
 eburnizing osteosclerosis of the mastoid process. In cases in which 
 acute exacerbations occur there may be headache, especially at night. 
 The mastoid skin may be slightly red, swollen, and hot and the 
 temperature rises 1° or 2° above normal. The meatus is slightly 
 
760 THE EAR 
 
 swollen and hyperemia and the postsuperior portion near the eardrum is 
 tense and swollen, or distinctly bulging. A cessation or diminution of 
 the discharge is attended with pain, and signifies an obstruction to the 
 discharge, the obstruction being due to acute swelling of the mucosa 
 or to the formation of polypi. 
 
 The progress of the disease varies greatly in different cases. In some 
 it runs a long and uneventful course without distinct symptoms other 
 than the intermittent discharge. In others acute exacerbations occur 
 every few weeks or months with the acute symptoms described under 
 acute mastoiditis. In still others the discharge is so slight as to escape 
 attention unless the attic of the tympanum is explored with a probe. 
 Any of these types may develop one or more of the labyrinthine or intra- 
 cranial complications and become a very serious disease. 
 
 Caries and necrosis of the mastoid process frequently follow the reten- 
 tion of the purulent secretion. Most cases of two or more years' dura- 
 tion are thus affected. Such destruction may take place without marked 
 symptoms. The insidious progress of the disease makes it a formidable 
 process. As Mace wen has so well said, one with a chronic otorrhea is 
 likened unto one with a charge of dynamite in the head: he does not 
 know when it will explode. Safety lies in removing the " charge" or 
 diseased process. Tuberculous patients are especially subject to caries 
 and necrosis, and do not heal so readily after operation. One of the 
 author's cases on whom a radical operation was performed, could not 
 be removed from the hospital for six weeks. Subsequently a secondary 
 operation was performed, and it was again six weeks before it was pos- 
 sible to remove her from the hospital. At the second operation Thiersch 
 grafts were applied with success, the entire cavity being thus covered 
 by epidermis. 
 
 In caries and necrosis careful examination will generally develop 
 tenderness upon pressure, as the periosteum is apt to be swollen and 
 inflamed. If in such cases the temperature is recorded every four hours, 
 the record will show a typical septic curve. In cases attended with 
 necrosis paralysis of the facial nerve may be present. A bony seques- 
 trum sometimes becomes separated and may be removed through the 
 meatus. Goldstein reported a case in which the entire cochlea was 
 exfoliated. 
 
 Prognosis. — The prognosis varies with the focal centre of the disease, 
 the extent of the necrosis, and the presence or absence of intracranial in- 
 volvement. When there is free drainage and only the mucous membrane 
 is involved, the disease is not essentially a serious one. When extensive 
 necrosis and intracranial complications are present, the danger to life is 
 imminent. Chronic sepsis, as evidenced by a yellow pasty skin and an 
 increased leukocytosis, while not serious, undermines the general health 
 and paves the way for the development of other serious diseases. Accord- 
 ing to T. Mark Hovell, attacks of partial or complete unconsciousness, 
 restlessness, and feverishness are always of grave import when occurring 
 in a person suffering from disease of the mastoid process. 
 
CHRONIC MASTOIDITIS 761 
 
 Treatment. — The local medical treatment of chronic mastoiditis is the 
 same as that given for chronic suppurative otitis media. AYhen this has 
 been tried for a few weeks without effecting a cure, the mastoid antrum 
 and cells and the middle ear may be opened. The object of this mode 
 of treatment is to (a) establish free drainage, and (6) remove the morbid 
 material, and establish the reaction of inflammation. 
 
 General Indications for the Radical Mastoid Operation. — There are 
 practically but three general types of mastoid operation now practised: 
 one, the simple mastoid operation for acute mastoiditis, wherein only the 
 mastoid antrum and cells are opened; another, the radical mastoid opera- 
 tion for subacute and chronic mastoiditis, wherein the mastoid antrum 
 and cells and the middle ear are thrown into one large irregular but freely 
 communicating cavity; the other the meatomastoid operation, which may 
 sometimes be used instead of the radical operation. The indications 
 for the mastoid operations are in general those phenomena present in a 
 persistent otorrhea which do not yield to local treatment (including 
 the associated nasal and throat diseases) or which do not yield to opera- 
 tions through the external auditory meatus. The more specific indica- 
 tions are as follows: 
 
 1. Persistent tenderness over the mastoid process, with or without 
 copious ear discharge. 
 
 2. Persistent ear discharge and polypi. 
 
 3. Fistulous opening into the roof or postsuperior wall of the external 
 auditory meatus. 
 
 4. Caries of the attic, as shown by probing or by bone dust in the ear 
 washings. 
 
 5. Facial paralysis. 
 
 6. Labyrinthine involvement, as shown by nystagmus, dizziness, 
 nausea, staggering gait, and profound deafness. 
 
 7. Chronic ear discharge with neuralgic pains over the mastoid process. 
 
 8. Chronic ear discharge and septicemia. 
 
 9. Intracranial complications and a history of chronic otorrhea. 
 These and other signs may indicate the same type of mastoid operation. 
 
 In view of the fact that life insurance companies refuse to insure persons 
 affected with chronic otorrhea, the otorrhea alone may be a positive in- 
 dication for the radical operation. 
 
CHAPTER XLV. 
 
 PRINCIPLES OF TREATMENT AND GENERAL CONSIDERATIONS 
 IN SUPPURATIVE OTITIS MEDIA. 
 
 There are four cardinal principles to be considered in the treat- 
 ment of suppurative inflammations of the middle ear and mastoid cells, 
 namely: (1) the promotion of the reaction of inflammation to aid Nature 
 in combating the host of invading pathogenic microorganisms; (2) the 
 establishment of free drainage and the reduction of pressure; (3) the 
 removal of the morbid material; and (4) the maintenance of asepsis 
 while repair is taking place. 
 
 1. The Promotion of the Reaction of Inflammation. — As shown in 
 Chapter VI, on inflammation, the reaction of inflammation is a benefi- 
 cent process, the object of which is to combat the infectious micro- 
 organisms. It is a threefold process, namely: (a) increased hyperemia, 
 (b) increased nutrition, and (c) increased leukocytosis in the affected 
 tissues. 
 
 The increased hyperemia floods the tissues with nutrition and thus 
 raises their resistance. The increased migration of leukocytes into 
 the tissues provides a fighting force which destroys the pathogenic 
 bacteria and disposes of the dead cells of the tissues. As the reaction 
 of inflammation is usually inadequate to successfully and quickly destroy 
 the pathogenic bacteria, the therapeutic indications are to adopt measures 
 which will increase, or promote, this reaction. Various modalities 
 may be used for this purpose, some of which are, for anatomical and 
 physiological reasons, especially well adapted to the treatment of the 
 ear. (See Chapter VII.) 
 
 As stated in Chapter VII, heat, irrigation with alkaline solutions, 
 incisions, leeching, massage operations, and radiant energy may be used 
 to promote the reaction of inflammation. 
 
 Heat has long been used in the treatment of inflammation. Every 
 one has observed the increased redness of the skin under its influence. 
 The hyperemia thus produced increases the nutrition, and it is now 
 believed increases the migration of leukocytes into the tissues. 
 
 There are differences in heat, as there are differences in silk and 
 calico. Heat is produced by a wide range of vibrations. Some wave- 
 lengths of wide amplitude and slow vibration produce heat of slight 
 penetrating power. Other wave-lengths of short amplitude and rapid 
 vibration produce heat of high penetrating power. The shorter the 
 wave-length and the more rapid the vibrations, the higher the penetrat- 
 ing power. Heat from a hot-water bag or low candle-power incandescent 
 lamp is of long wave-length and slow vibration, and, therefore, of slight 
 
SUPPURATIVE OTITIS MEDIA 763 
 
 penetrating power. Heat from a 500 candle-power incandescent lamp 
 is of short wave-length and rapid vibration, and is consequently of high 
 penetrating power. The therapeutic value of heat is proportionate to its 
 penetrating power. In selecting the modality for the application of heat 
 these principles should be borne in mind. If the inflammation is super- 
 ficial, a hot-water bottle or a low candle-power (16 to 100) lamp may be 
 used, though a higher candle-power lamp will produce better results in 
 a shorter time. If the inflammation is deep seated, a high candle-power 
 incandescent lamp (300 to 500 candle-power) or an arc light is indicated. 
 
 Radiant light as given by the leukodescent lamp is a remedy of 
 some value in suppurative otitis media. It not only gives off heat of 
 high penetrating power, but it gives off rays possessing a high degree 
 of chemical activity. The spectrum of the leukodescent lamp is rich in 
 the blue violet rays which effect chemical changes in the tissues exposed 
 to them. Such a lamp is, therefore, a mechanical device furnishing 
 two powerful therapeutic agents, namely, heat with high penetrating 
 power, and blue violet rays of chemical activity. In the opinion of the 
 author, however, the leukodescent light is not as good or as quick a 
 remedy in acute suppurative otitis media as incision of the membrana 
 tympani and leeching. The progress of the disease is so rapid, and the 
 structures of such vital physiological importance, that it is imperative 
 that immediate improvement be obtained. 
 
 Incision of the inflamed tissue has long been a therapeutic measure 
 of acknowledged efficacy. In the treatment of acute catarrhal and the 
 pre-perforative stage of suppurative otitis media, incision of the mem- 
 brana tympani is one of the most efficient modes of treatment. The good 
 effects following such an incision are not altogether due to the increased 
 hyperemia and leukocytosis, though this influence is greater than is 
 generally believed. In addition to the increased reaction of inflammation, 
 the incision establishes free drainage, relieves the pressure, and favors 
 the removal of the morbid material. 
 
 Incisioti of the membrana tympani is an almost ideal therapeutic 
 measure in the early or pre-perforative stage of acute suppurative otitis 
 media, though it is of little value in the later stages of the disease, and 
 in the chronic type. Little can be done by promoting the reaction of 
 inflammation in chronic suppurative otitis media. In such cases the 
 establishment of free drainage and the total removal of the morbid 
 material should be accomplished. In acute cases the incision of the 
 membrana tympani should be long and curved, or V-shaped, to permit 
 the secretions to flow through it. 
 
 Leeching is another old and all but discarded remedy in the treatment 
 of acute inflammation. In the author's hands it has proved one of the 
 most satisfactory methods of combating acute catarrhal and suppurative 
 otitis media. It is best to apply from three to five leeches over the mastoid 
 process and one to the tragus in front of the ear. If applied in the 
 pre-perforative stage, or when the mastoid is swollen and tender, or 
 when pain is present, the improvement is usually prompt, the case often 
 proceeding toward rapid resolution. 
 
764 THE EAR 
 
 Leeching increases the hyperemia and the migration of leukocytes 
 into the inflamed tissues, and thus favors the destruction of the patho- 
 genic bacteria and the repair of the tissues. 
 
 Artificial leeching is, perhaps, of equal value, and is easier of applica- 
 tion. The skin over the mastoid process should be incised, as shown 
 in Fig. 395, the circular knife being adjusted with a set screw so as to 
 cut the desired depth. When the incision is made the exhaust pump 
 should be applied, as shown in Fig. 396, and the air exhausted by turning 
 the hand screw. An ounce of blood may thus be drawn from the in- 
 flamed tissues. The effect of this procedure is to overcome the venous 
 stasis and edema, thus establishing a more rapid arterial flow of blood 
 through the tissues. The nutrition of the tissues is raised and the migra- 
 tion of leukocytes increased. 
 
 Massage is of little value in promoting the reaction of inflammation in 
 otitis media. In tubal catarrh, however, external mechanical vibratory 
 massage under the angle of the jaw over the course of the Eustachian 
 tube will often quickly relieve the edematous obstruction to this tube. 
 
 2. Establishing Free Drainage. — The second principle of treatment, the 
 establishment of free drainage, is a very important part of the treatment 
 of suppurative otitis media. If free drainage is maintained, pressure 
 necrosis is not apt to occur; indeed, if present, it may disappear. 
 
 In the early stage of acute otitis media free drainage may be established 
 by incising the membrana tympani, the Eustachian tube being, for the 
 time, inadequate to carry away the excess of secretions. A free incision 
 of the membrana tympani affords an accessory outlet for the secretions, 
 and, in addition, it promotes the reaction of inflammation and relieves 
 the pressure and attending necrosis. 
 
 If the obstruction is in the aditus ad antrum, incision of the membrana 
 tympani may fail to establish free drainage, in which case it may be 
 necessary to perform a mastoid operation. In some cases of chronic 
 otorrhea the obstruction is due to the heads of the malleus and incus, 
 together with the ligamentous bands and adventitious cicatricial tissue 
 resulting from the inflammatory process. In such cases the removal of 
 the malleus and incus establish free drainage. Heath claims that 
 the Eustachian tube is usually adequate to drain the tympanic cavity, 
 even when diseased, but that it is inadequate to also drain the diseased 
 mastoid antrum and cells. He therefore recommends that the secretions 
 from the antrum and mastoid cells be diverted from the aditus ad antrum 
 to the external auditory meatus, as described in the meatomastoid 
 operation. 
 
 3. Removal of Morbid Material. — Whatever method of treatment is 
 adopted, earnest effort should be made to remove all obstruction to the 
 flow of secretions from the tympanic cavity. In infants and children the 
 removal of the adenoids may accomplish the purpose by unblocking 
 the Eustachian tubes. The removal of aural polypi or granulations 
 may temporarily establish drainage. Incision of the membrana tympani, 
 leeching, hot irrigations, dry heat, etc., may act favorably, but in many 
 cases it will be necessary to resort to a mastoid operation. In simple 
 
SUPPURATIVE OTITIS MEDIA 
 
 705 
 
 cases the morbid material consists of the purulent secretions, which are 
 successfully removed by drainage. In the more complicated cases, in 
 which granulations and necrosed bone are present, an operation may be 
 required to accomplish the result. 
 
 To remove the granulations it may be necessary to enlarge the perfora- 
 tion in the drumhead by radiating incisions. Through this opening 
 the granulations can be still further examined and removed, either 
 with a snare (Fig. 406) or with a small spoon curette. Local anesthesia 
 may be induced with cocaine (10 to 20 per cent.), or with the following 
 mixture : 
 
 I^ — Cocaine crystals, 
 
 Carbolic add crystals, 
 Menthol crystals .... 
 
 Mix by rubbing in a mortar, and 
 
 5i— M. 
 
 jyrupy fluid is formed. 
 
 The above solution, when dropped into the meatus, will produce loca 
 anesthesia when cocaine fails to do so. 
 
 If the obstruction is in the aditus the problem becomes at once more 
 difficult and serious. It is practically impossible to reach the canal 
 
 Fig. 406 
 
 Showing the removal of an aural polyp which projects into the meatus through a perforation 
 
 in the membrana tympani. 
 
 through the external auditory meatus without resorting to a mastoid 
 operation. Sometimes, if the malleus and incus are removed, the obstruc- 
 tion will gradually disappear without the mastoid operation. The 
 advantage to be gained by the operation is that the disintegration which 
 occurs with such rapidity under retention pressure is checked before 
 serious and extended destruction of the tissue takes place, and the danger 
 of meningeal and cranial involvement is thereby reduced to the minimum. 
 If the pain is associated with bulging and redness of the postsuperior 
 
766 THE EAR 
 
 wall of the meatus near the drumhead, the indications for immediate 
 operation are imperative. If the bulging and redness are not present, 
 other treatment may be tried. In the meantime close observation of 
 the case should be maintained. A rapid rise in temperature, with chills 
 or chilliness and profuse sweating, strongly indicate septic poisoning, 
 possibly from sinus thrombosis. 
 
 4. Maintaining Asepsis. — Having promoted the reaction of inflamma- 
 tion, established free drainage, removed the pressure and the morbid 
 material from the diseased ear or mastoid cells, there remains but little 
 to do to maintain the parts surgically clean. Loose gauze dressings 
 applied to the auditory meatus or to the mastoid wound is all that is 
 necessary for this purpose. Extraneous infection is thus prevented 
 while the reparative process is in progress. 
 
 THE TREATMENT OF CHRONIC SUPURATIVE OTITIS MEDIA 
 AND MASTOIDITIS 
 
 The consideration of this subject will not be divided into medical 
 and surgical treatment, as is usually done, but will be considered accord- 
 ing to the 'predominance of the type and location of the morbid process. 
 
 Suppuration of the atrium (lower chamber of the middle ear), perhaps, 
 does not exist alone, there being usually associated with it the same type 
 of inflammation in the attic, antrum, and mastoid cells. The focal centre 
 of the process may, however, be located in the atrium, and the case may 
 be successfully treated via the auditory meatus. 
 
 The dry gauze treatment (e. g., sl strip of sterile gauze loosely packed 
 in the meatus) should be faithfully practised for several weeks. In 
 chronic cases the perforation in the drumhead is usually quite large, 
 sometimes involving the entire membrane. When such is the case it is 
 not necessary to enlarge the perforation or incise the drumhead. The 
 gauze wick should be introduced into the cavity of the middle ear, and 
 the meatus loosely packed. It is usually sufficient to apply the gauze 
 every alternate day, although it may be necessary to do it oftener. 
 
 The Alcohol Treatment. — This treatment should be preceded by a 
 thorough cleansing of the secretions from the meatus with cotton-wound 
 applicators and inflating the middle ear. 
 
 The alcohol should vary in strength (25 to 95 per cent.) according to 
 the pain produced by its introduction, and should be left in the middle 
 ear for from five to twenty minutes, the patient inclining the head to one 
 side. Some cases tolerate the 95 per cent, solution from the start, while 
 others will complain of pain if a greater strength than 25 per cent, is 
 used. In such cases begin with the weaker solution, and then instil 
 a stronger until the full strength solutions are used. 
 
 In the interims between treatments the ear may be left without special 
 protection other than a loose piece of sterile gauze in the external meatus. 
 
 The treatments may be repeated on alternate days, or as often as 
 indicated. 
 
SUPPURATIVE OTITIS MEDIA AXD MASTOIDITIS 
 
 /t>/ 
 
 Some writers advocate the addition of boric acid to the alcohol, while 
 others use an etheric-alcohol solution of iodoform. 
 
 Alcohol acts as a hygroscopic agent, which depletes the edematous 
 membrane and granulation tissue. It is an antiseptic and astringent, 
 and excites the reaction of inflammation. 
 
 The Compound Tincture of Benzoin. — During the last ten years the 
 author has used the compound tincture of benzoin in nearly every case of 
 otorrhea treated, with great satisfaction. Its efficacy is in part due to the 
 alcohol in its composition, but not altogether. It is more soothing than 
 plain alcohol, more antiseptic and more healing. It has proved to be of 
 special value in those cases in which the fetid odor is present. This 
 speedily disappears and the other features of the case also improve. 
 
 The compound tincture of benzoin should be dropped into the meatus, 
 the head being inclined toward the opposite side. After such a treatment 
 if the discharge is not too profuse the gauze may be allowed to remain 
 in the ear and meatus for two or three days without developing fetor. 
 
 The middle ear should be previously cleansed as described above, 
 but after a few applications of the remedy it may be abandoned, as the 
 discharge often rapidly decreases until there is scarcely a drop on the 
 gauze when removed. 
 
 It is not to be inferred from what has been said that the otorrhea will 
 not return after the discontinuance of the benzoin, for it is very apt to do 
 so in most cases, no matter what form of local treatment is pursued. 
 
 Irrigation. — The use of the syringe is not indicated, as it is in acute 
 cases. It may be used to advantage, however, when there is a consider- 
 able accumulation of desiccated or tenacious mucus and pus in the 
 atrium of the middle ear. The force of the stream loosens and propels 
 the secretions from the middle ear, and thus prepares the tissues for 
 treatment by other methods. Sterile water or normal salt solution 
 should be used as hot as can be comfortably borne by the patient, one- 
 half gallon being the correct amount for each treatment. 
 
 The Boric Acid Powder Treatment. — This method of treatment is of 
 less value in chronic than in the acute inflammations of the middle ear. 
 If the discharge is profuse it may be used, although other measures afford 
 more relief. If used the powder should be blown, not poured into the 
 meatus. 
 
 Camphoroxol has recently been highly recommended by Hotz and 
 others in obstinate otorrhea in which other methods of treatment had 
 failed. Hotz reports several cases in which the remedy seemed to 
 give speedy and satisfactory relief. He injects it into the middle ear 
 through the Eustachian tube by means of the Weber-Liel catheter. 
 Further observations along this line are needed, however, before the 
 real value of this remedy can be estimated. 
 
768 THE EAR 
 
 THE TREATMENT OF SUPPURATION INVOLVING THE ATRIUM 
 
 AND ATTIC. 
 
 Under this caption are included those cases in which the attic is chiefly 
 involved, and in which this centre forms the chief source of annoyance 
 and danger. The consideration of the best methods of treatment will 
 therefore hinge upon the structure and arrangement of the parts com- 
 posing the attic. 
 
 The point of chief interest is the lower boundary or floor of the attic, 
 namely, the heads of the malleus and incus, and the ligaments and ad- 
 ventitious fibrous bands uniting them to the walls of the tympanum. 
 Another point of clinical interest is Shrapnell's membrane, or the mem- 
 brana flaccida. Perforation of this membrane affords one of the most 
 obvious signs of attic suppuration. Irrigation of the attic may be ac- 
 complished with a curved cannula inserted through the perforation in 
 Shrapnell's membrane, and local medication and explorations may be 
 carried on through it. 
 
 The floor of the attic is of importance because, whereas in health it 
 affords ample drainage for the secretions, it is ofteatimes inadequate 
 in chronic otorrhea. The inadequacy may be due to the excessive and 
 heavy secretions, or to a more or less complete obstruction by the adven- 
 titious fibrous tissue of the spaces in the floor of the attic. Either condi- 
 tion will cause the secretions to remain in the attic, which may give rise 
 to serious pathological changes, as necrosis and septicemia. 
 
 While the principles of treatment remain the same, the motive for 
 treatment increases tenfold. 
 
 Free drainage is imperative and should be established by surgical 
 interference. This may be facilitated by enlarging the perforation in 
 Shrapnell's membrane by an incision extending anteriorly and pos- 
 teriorly. The treatment should be addressed not alone to the attic, 
 but to the atrium also. In other words, the treatment described in the 
 preceding section should be used, and in addition thereto the following 
 measures should be instituted: 
 
 The attic should be kept as free of secretions as possible by applying 
 suction to the external auditory meatus with Siegle's otoscope or Del- 
 stanche's rarefacteur. The spaces of the attic should be irrigated through 
 the perforation in Shrapnell's membrane, and a 2 to 4 per cent, solu- 
 tion of the nitrate of silver applied with delicate cotton-wound applicators. 
 Should these measures fail, the radical mastoid operation may be per- 
 formed, special care being taken to remove the external wall of the 
 attic (roof of the meatus near the drumhead). By so doing the attic is 
 fully exposed in the after-treatment. 
 
CHAPTER XLVL 
 
 THE GENERAL PATHOLOGY OF OTITIS MEDIA AND 
 MASTOIDITIS. 
 
 Microorganisms are the exciting causes of middle ear and intra- 
 cranial pyogenic processes. Various organisms are active, either alone 
 or in combination, no special one being characteristic of these processes. 
 
 The free communication between the epipharynx and the middle ear, 
 and the perforated drumhead makes infection easy if the local con- 
 ditions are favorable. Such a condition presents itself during the course 
 of one of the exanthema tous fevers when the vitality is lowered. Patho- 
 logical changes occur in the mucosa, microorganisms continue to flourish, 
 and the suppurative process is established. The cilia which normally 
 partially cover the tympanic mucosa are destroyed, or their vitality is 
 so impaired that their propelling function is no longer adequate to drive 
 the secretions toward the Eustachian outlet. Accumulation, decompo- 
 sition, and irritation follow. The mucosa breaks down, the periosteum 
 covering the bone loses its vitality and disintegrates, and the bone 
 depending upon it for nutrition becomes carious. The arteries in the 
 mucosa become thrombosed, and the arterial supply is thus cut off 
 from the membrane and periosteum as well as from the bone. Thus, 
 the process of disintegration proceeds with greater or less activity, often- 
 times without serious symptoms being present. The brain may be ex- 
 posed by the caries of the tegmen tympani and antri, or through various 
 other channels of communication. 
 
 It has been said that about two years of chronic suppuration usually 
 precedes bone necrosis in the middle ear and its accessory cavities. This 
 should be taken only as an approximate estimate, as the time varies with 
 the type of the infection, and with the obstruction offered to the discharge 
 of the morbid secretions. If the flow from the mastoid cells and antrum 
 is free and unobstructed, the process may continue for years without 
 bony necrosis. If, on the other hand, marked obstruction occurs early 
 in the suppurative process, bone necrosis may take place before the two 
 years have elapsed. This is often the case in acute primary mastoiditis. 
 
 It is of great importance in estimating the gravity of a suppurative 
 process in the tympanum to determine definitely the predominant char- 
 acter of the microbic infection present. To this end cultures and micro- 
 scopic examinations should be made. While but few physicians are 
 prepared to make either the cultures or microscopic examinations, 
 nearly all know where they can secure culture tubes and have such 
 examinations made. The attending surgeon should smear the secre- 
 tion from the ear on the contents of the culture tube and send it to a 
 pathologist. 
 49 
 
770 THE EAR 
 
 A few places where the above examinations may be made are : 
 (a) The Health Board of the physician's own city or some neighbor- 
 ing city. 
 
 (6) A neighboring physician. 
 
 (c) The nearest medical college, or the one from which the physician 
 graduated. 
 
 (d) A pathological laboratory established for the purpose of accom- 
 modating those in need of such work. 
 
 The expense of such an examination is small, and the information 
 obtained may be of inestimable value to the patient. 
 
 John Funke has reported the results of his observations as to the 
 "Bacteriology of Otitis Media," and his work seems so conclusive and 
 suggestive that an epitome of it is herewith given : 
 
 The following conclusions are based on a study of the literature of 
 otitis media and his observations: 
 
 1. There is no specific Organism of otitis media. 
 
 2. Acute otitis media is not invariably monomicrobic, as is com- 
 monly held. The pathogenic organism present may be Of a single 
 variety, but with it are frequently found a varying number of associated 
 bacteria, which may or may not be influential in determining the outcome 
 of the case. 
 
 3. The organisms commonly found, in the order of frequency, are: 
 The pneumococcus, streptococcus, pyogenic staphylococci (albus and 
 aureus), and the bacillus of Friedlander. He is strongly inclined toward 
 the belief in a definite grippal otitis, primarily due to the influenza bacil- 
 lus, which, however, becomes quickly associated with, or replaced by, 
 other organisms. 
 
 4. The Bacillus diphtherial is more commonly present in otorrhea 
 than is usually believed; it may be (a) the initial infecting agent, or (b) 
 it may enter with the streptococcus or pneumococcus, or (c) it may be a 
 secondary infection carried to the already infected ear by the fingers of 
 the patient, or otherwise, as held by Babinsky. 
 
 5. It is reasonable to believe, as Funke's observations show, that it 
 persists for a varying period of time in the discharges, and may consti- 
 tute a centre of danger, just as has been thoroughly established concern- 
 ing its prolonged residence in the nasal cavities, pharynx, etc. Its 
 frequent association with the Bacillus pseudodiphtherise has here the 
 same significance as elsewhere, a factor not as yet fully determined. 
 
 6. The streptococcal infections are more grave and persist longer 
 than pure pneumococcal infections, but both are usually supplanted by 
 the staphylococcal sooner or later. 
 
 7. There is a true pneumobacillary otitis, usually acute and quickly 
 converted into a mixed infection. The gravity of the process depends 
 almost exclusively upon the character of the mixed or secondary infection. 
 
 8. Chronic suppurative otitis media is practically always a sequence 
 of the acute. 
 
 9. Like the acute, it possesses no specific organisms. 
 10. Unlike the acute, it is almost always polymicrobic. 
 
GENERAL PATHOLOGY OF OTITIS MEDIA AND MASTOIDITIS 771 
 
 11. Its polymicrobic character may be evinced in any of three 
 ways: (a) A mixed infection of pathogenic organisms; (b) one or more 
 recognized pathogenic organisms (usually pyogenic staphylococci), with 
 one or more bacteria usually regarded as saprophytes; (c) the usual 
 pyogenic and pathogenic bacteria are absent, and the discharges are 
 maintained through the activity of organisms that commonly lead a 
 saprophytic existence. 
 
 12. While anaerobic organisms may play an important part in the 
 pathogenesis of chronic suppurative otitis media, Funke's observations 
 have not established their almost constant presence, as maintained by 
 Rist. 
 
 13. The fetor met in the cases reported here can be explained by 
 the presence of Bacillus pyogenes fetidus without anaerobic organisms. 
 
 14. All clinical and collated bacteriological data indicate that otitic 
 inflammations present different bacteriological findings in different 
 localities. iVccording to Moos, during the influenza epidemic of 1890 
 in Vienna the otitic complications were due to the pneumococcus (Weich- 
 selbaum), and to the streptococcus in Strasburg, Grief swald, and Bonn 
 (Ribbert). 
 
 15. Reports gathered from literature establish the existence of a 
 primary tuberculous otitis, but all observers are of one mind as to the 
 almost utter impossibility of the routine demonstration of the bacillus in 
 discharge. 
 
 16. For the demonstration of the tubercle bacillus in suspected cases 
 Funke recommends an examination of tissue obtained by the curette. 
 
 Middle Ear Suppuration.— Microscopic Examination of One Hundred 
 Cases, with Special Reference to the Presence of Tubercle Bacilli and Acid- 
 fast Bacilli. — YVyatt Wingrave 1 gives the following analysis: Special care 
 was taken in obtaining the discharge. Carbol-fuchsin was used in 
 staining, with methylene blue as a counterstain: 
 
 Cases. 
 
 Squamous and pus cells present together in 41 
 
 Pus alone 38 
 
 Squamous alone 21 
 
 Bacteria. 
 
 Staphylococci 41 
 
 Diplococci 20 
 
 Streptococci 7 
 
 Bacillus proteus vulgaris 14 
 
 Micrococcus tetragenus 4 
 
 Bacillus coli 3 
 
 Gonococci 33 
 
 Bacillus subtilis 2 
 
 Aspergillus niger 1 
 
 Leptothrix 1 
 
 Diphtheria (Klebs-Loeffier) 1 
 
 Yeast 1 
 
 1 Jour. Laryngol., Rhinol., and Otol., March, 1903. 
 
772 THE EAR 
 
 Gradle and others, some years ago, called attention to the odor attend- 
 ing chronic otorrhea, claiming its presence or absence was the "most 
 sensitive criterion of the efficacy of the treatment." 
 
 So long as the pus of the otorrhea smells fetid the treatment em- 
 ployed has exerted no curative influence on the disease; and, conversely, 
 
 The first sign from any treatment of curative influence is its effect 
 upon the odor of the discharges (Gradle). 
 
 Macewen says: "The virulence of a discharge cannot be measured by 
 its odor. Nearly odorless otorrhea may contain pathogenic micrococci, 
 and some of the most serious intracranial inflammatory lesions ensue 
 in the presence of odorless otitis media. It is well, therefore, in esti- 
 mating the gravity of an otorrhea that pus from the middle ear should 
 be stained and examined microscopically and by cultivations." 
 
 He states further that intracranial complications often arise in the 
 course of fetid otorrhea, but that the pathogenic germ is not the one 
 causing the odor, it usually being a non-pathogenic microorganism. 
 
 These views, while they seem to be diametrically opposed to each 
 other, are really not so opposite as they appear. The first is fallacious, 
 in that it leads to the inference that with the disappearance of the odor 
 the patient's condition becomes safe; whereas, the second view tells us 
 the absence of fetor is no criterion as to the non-virulence of the infection . 
 Gradle's views lead, by inference, to the conclusion that absence of fetor 
 is a guide to the mildness of the infection; whereas, Macewen says the 
 absence of fetor gives no information whatever as to the virulence of the 
 infection. He goes still farther and says some of the most virulent intra- 
 cranial infections have occurred in connection with odorless otorrhea. 
 
 The author is inclined to agree with Macewen on this point, although 
 he readily admits Gradle's major proposition, that the disappearance of 
 the odor under the syringe, etc., usually heralds an improved drainage 
 and ventilation. The improvement, however, is not due to the removal 
 of the odor or the germs producing it, but to the removal of the sapro- 
 phytic bacteria and the establishment of free drainage by the removal of 
 the desiccated secretions. The disappearance of the odor is incidental, 
 and signifies that other and more virulent organisms may have been 
 removed also. 
 
 When the true nature of chronic otorrhea is explained to patients, 
 many of them reply that they have had the discharge off and on for many 
 years with no untoward result, and that they do not fear serious compli- 
 cations in the future. They express a belief that is often too prevalent 
 among physicians, namely, that chronicity of otorrhea is a guarantee of 
 its innocent nature. The process of disintegration has been going on, 
 and may continue to do so as long as the otorrhea lasts. Fresh in- 
 vasions of germs, or the encroachment upon a new area, or a lowered 
 vitality of the patient, may give rise to sudden and alarming symptoms. 
 
 It may be said that the more chronic the otorrhea the greater the danger 
 of intracranial or other extension of the infective "process. 
 
 Acute primary otitis media suppurativa rarely extends to the brain or 
 
GENERAL PATHOLOGY OF OTITIS MEDIA AND MASTOIDITIS 773 
 
 meninges, as the process does not continue long enough to break down 
 the mucous membrane, bone, and other tissues enveloping it. 
 
 In infants this protection is not so complete, as the various parts of 
 the temporal bone are not yet united by ossification. The vascular and 
 cartilaginous lines of union afford less resistance to the transmission of 
 microorganisms to the cranial cavity; hence, intracranial involvement is 
 more common in infants in the course of, or subsequent to, an acute 
 primary suppurative otitis media. 
 
 In addition to the infection and consequent ulceration, thrombosis, 
 and necrosis, there are other pathological conditions which are inci- 
 dental to the suppurative process. Adhesive bands often form in the 
 course of this disease, and the ossicles become bound to each other and 
 to the tympanic walls. The handle of the malleus is retracted and may 
 become adherent to the promontory. 
 
 The writer has a case under observation, aged forty years, with adhe- 
 sion of the handle of the malleus to the promontory. When a young 
 child she had suppuration of the middle ear, following scarlet fever. 
 There have been occasional discharges since then. When she came 
 under observation there was a perforation of Shrapnell's membra tie. 
 This healed under applications of the nitrate of silver. Examination 
 with Siegle's otoscope shows the malleus to be adherent to the promon- 
 tory. The anterior half of the drumhead is also adherent in places, 
 while the posterior half is perfectly free. In other cases the adhesions 
 have been severed with great improvement of the hearing. 
 
 Calcareous salts may be deposited in the drumhead and in the tympanic 
 mucosa. The articulations of the ossicles may become ankylosed. The 
 foot plate of the stapes is sometimes ankylosed from the deposit of lime 
 salts in the fibrous ring which unites it to the margin of the oval window 
 (fenestra of vestibule). This condition may be mistaken for hyperostosis 
 of the bony capsule of the labyrinth (spongifying), though in the latter 
 condition the drumhead and Eustachian tube are normal. 
 
 Granulations (aural polypi) are common, especially in old cases, in 
 which the mucosa and periosteum are ulcerated and bone necrosis is 
 present. They are the expression of Nature's effort to repair the tissues. 
 
CHAPTER XLVIL 
 
 INTRACRANIAL AND JUGULAR PYOGENIC DISEASES OF 
 OTITIC ORIGIN. 
 
 General Considerations. — Infection and inflammation of the^middle 
 ear, mastoid cells, and labyrinth are not per se usually a serious menace 
 to life. The real danger is in the extension of the infection to the con- 
 tents of the cranium or to the jugular vein, and thence to the important 
 viscera, as the lungs, spleen, liver, heart, and kidneys, or a general 
 dissemination throughout the body (general septicemia). Pneumonia, 
 splenitis, hepatitis, endocarditis, and nephritis of otitic origin have been 
 observed. The infection more often extends to the intracranial sinuses 
 (veins) and to the jugular vein. 
 
 Of the intracranial pyogenic infections, thrombosis of the sigmoid por- 
 tion of the lateral sinus, and the various types of meningitis, are most 
 often observed. As the symptoms are not always characteristic of the 
 type and field of invasion, the differential diagnosis is often difficult to 
 make. There are, however, certain general characteristic phenomena, 
 especially after the process is well advanced, which usually enable the 
 aural surgeon to diagnosticate the condition present. When, for example, 
 there is a chill, followed by a rapid and excessive rise of temperature, 
 the evidence is conclusive that the system has been invaded by a nu- 
 merous pyogenic host from some source. The most probable source of 
 such an invasion is a disintegrating thrombus. The thrombus, being 
 infected, finally undergoes disintegration, and the pathogenic bacteria 
 are thrown in great numbers into the general circulation. As the sig- 
 moid portion of the lateral sinus is in intimate anatomical relation to 
 the mastoid process, the natural inference to be drawn from the chill 
 and rapid rise of temperature is that lateral sinus thrombosis is pres- 
 ent. If after the lapse of twenty-four hours a similar symptom com- 
 plex recurs, the diagnosis may be more surely made. The thrombus 
 may, however, be in either the superior or the inferior petrosal sinuses, 
 the longitudinal, or the cavernous sinus. These sinuses are, however, 
 usually involved secondarily to the lateral sinus. The symptoms of 
 cavernous thrombosis are so characteristic that, when involved, the 
 diagnosis is easy. 
 
 Diffused purulent meningitis also presents certain characteristic 
 symptoms which render the diagnosis comparatively easy. The tem- 
 perature remains more or less constantly elevated, whereas in thrombosis 
 there are distinct chills followed by a sudden and marked rise in the 
 temperature, and a recession to nearly normal within from six to ten 
 hours. Extradural abscess and brain abscess may be attended by a 
 
MENINGITIS SEROSA 775 
 
 moderate elevation of temperature or none at all, though there are fre- 
 quent exceptions to this rule. 
 
 Lumbar Puncture. — Lumbar puncture for the diagnosis of menin- 
 gitis should be made between the third and fourth lumbar vertebrae. 
 A tapeline or cord passing around the body on a level with the crest 
 of the ilia passes over the spine of the fourth lumbar vertebra; the spine 
 just above is the third lumbar vertebra, and at a point midway between 
 the two spines is the location for making the puncture. The needle 
 should be introduced at a point a little to one side of the median line, 
 and should be five or six inches long and 1 mm. in diameter. The 
 spinal fluid will escape spontaneously when the point of the needle 
 reaches the space in the cord. The increased tension may be estimated 
 by the force and rapidity with which the fluid escapes. If normal, it 
 drips rather freely from the needle, whereas in meningitis it escapes 
 more rapidly. In some cases, however, the tension is not much elevated. 
 
 In infants and young children a simple acute otitis media may give rise 
 to symptoms simulating cerebral complications, as headache, nausea, 
 vomiting, and excessive elevation of temperature (Gradle). If menin- 
 gitis is suspected, the diagnosis may be cleared by making a lumbar 
 puncture and subjecting the removed spinal fluid to microscopic examina- 
 tion. If purulent meningitis is present, the fluid is turbid and loaded 
 with pus cells and pathogenic bacteria, especially streptococci. If 
 the fluid escapes under high pressure, and is clear and contains only 
 a few leukocytes and no demonstrable bacteria, serous meningitis 
 is present, and a mastoid operation should effect a cure without resort- 
 ing to an exposure of the cranial contents other than at the atrium 
 of infection, the tegmen tympani or antri. Lumbar puncture is negative 
 in reference to the other intracranial infections. 
 
 These and other clinical phenomena usually enable the aural sur- 
 geon to differentiate the various extensions of the infection from the ear 
 and mastoid cells to the cranial cavity. In the following presentation of 
 the intracranial and jugular infections only the more typical clinical 
 phenomena will be given. 
 
 MENINGITIS SEROSA. 
 
 This disease is of otitic origin and is characterized by a serous infiltra- 
 tion of the pia mater and an increase in the cerebrospinal fluid in the 
 subarachnoid space and in the ventricles of the brain. 
 
 Etiology. — (a) It is more often a complication of chronic otitis media 
 and mastoiditis, (b) The channels of invasion may be through the 
 tegmen tympani and antri, or through the labyrinth. 
 
 Symptoms. — Headache, dizziness, nystagmus, nausea, vomiting, rest- 
 lessness, ataxia, torticollis, disturbances of vision, etc., are usually present, 
 though not all of them at one time. The symptoms are not different from 
 those in the suppurative form of meningitis, and it is, therefore, difficult 
 to make a diagnosis before operation. If there is a spontaneous cessa- 
 
776 THE EAR 
 
 tion of the meningeal symptoms, or if they cease after a mastoid opera- 
 tion, the disease is probably serous in character, the purulent forms 
 rarely being thus favorably affected. Lumbar puncture is negative. 
 
 Treatment. — A radical mastoid operation and exposure of the dura 
 mater at the tegmen tympani and antri should be performed to evacuate 
 the extradural accumulation if present. The dura should be opened 
 even if pus is not found. If serous fluid is discharged under high press- 
 ure and in a large quantity, and the meningeal symptoms rapidly 
 disappear, the diagnosis of meningitis serosa may be confidently made. 
 
 EXTRADURAL ABSCESS; PACHYMENINGITIS EXTERNA 
 CIRCUMSCRIPTA. 
 
 Definition. — An extradural abscess is a localized or circumscribed 
 pachymeningitis. The thin plate of bone between the attic and the 
 dura, or between the antrum and the dura, undergoes carious and 
 necrotic degeneration, and the dura over this area becomes inflamed, 
 throws out a plastic exudate, and is firmly attached to the bone it covers. 
 After a time the bone is destroyed and the purulent secretion burrows 
 between the dura and the bone, but is prevented from extending over 
 a large area by the plastic exudate. It is generally located in the middle 
 fossa. 
 
 Etiology. — The abscess usually occurs in chronic otorrhea with 
 acute exacerbations of mastoiditis. It also occurs in cholesteatoma 
 with suppuration. The cholesteatomatous mass in the attic or antrum 
 causes pressure necrosis of the tegmen tympani and antri, and thus 
 exposes the dura of the middle fossa to infection. Acute suppurative 
 otitis media, especially of influenzal origin, may also cause it, as the 
 bacillus of influenza is very destructive to bone tissue. An infected 
 embolus or a thrombus from one of the veins or its tributaries may cause 
 an extradural abscess without bone necrosis. 
 
 Symptoms. — The signs of this condition are not well marked, a 
 severe headache with a slight rise in temperature being the most reliable 
 The headache is continuous and is referred to the affected side. When, 
 however there is a sudden profuse discharge of pus from the ear, the 
 headache and the temperature are relieved or disappear altogether. 
 If the membrana tympani is observed by reflected light, and the pus 
 pulsates in the perforation, it may be inferred that it has its origin in 
 the middle fossa of the skull. That is, the pus comes from a cavity 
 surrounded or partly surrounded by a resilient tissue. The dura is such 
 a tissue, hence the inference. If the pus comes from a bony cavity, no 
 such pulsation is present, unless an artery is exposed by the necrotic pro- 
 cess. The internal carotid artery passes close to the anterior portion of 
 the cochlea, and if there is a labyrinthine suppuration, and the artery is 
 exposed, there may be a pulsation of the escaping pus. 
 
 If during a mastoid operation there is a profuse discharge of pus which 
 pulsates synchronously with the heart beat, there is in all probability an 
 
EXTRADURAL ABSCESS 777 
 
 extradural abscess, which may be evacuated and cured by removing the 
 tegmen tympani and tegmen antri. 
 
 Localizing motor symptoms are absent, as the motor tract of the 
 brain is not involved (Fig. 407). 
 
 The abscess is not always located in the middle fossa. Necrosis of the 
 cells posterior to the labyrinth may occur, and thus communicate with the 
 cerebellar fossa back of the pyramid of the temporal bone. Hence 
 vomiting and vertigo may be the prominent symptoms. The headache 
 in these cases is referred to the region of the occiput on the affected side. 
 The temperature is about the same as in extradural abscess of the middle 
 fossa. As the disease progresses, mental dulness and coma develop 
 from the increased intracranial pressure, due to the effusion into the 
 ventricles. 
 
 In a case recently operated on by the author the patient rapidly devel- 
 oped coma during the course of an otitis media and an acute exacerbation 
 of mastoiditis on the right side. The surgeon who was in attendance had 
 placed the patient in a hospital for observation, and had recommended 
 an operation for mastoiditis. This was refused. During the absence of 
 the surgeon from the city the coma developed. When seen by the author 
 the patient was comatose. The nurse stated that he had been com- 
 plaining of pain in the back of the head, but did not know to which 
 side he referred it; a radical mastoid operation was performed upon the 
 right side, and, as a cerebellar abscess was suspected, the operation was 
 extended in the usual way to this region, but without locating the abscess. 
 At the post mortem an extradural abscess containing about 2 drams of 
 thin yellow pus was found on the opposite side on the posterior inferior 
 aspect of the cerebellum. The left ear was not affected. 
 
 Prognosis. — If the abscess becomes latent, and acute exacerbations 
 of the otitic and mastoid inflammation do not occur, the patient's life 
 may not be placed in jeopardy for a long time. If, on the contrary, 
 the abscess occurs during an acute exacerbation, or following an acute 
 attack of influenza, it may break its bounds and penetrate the substance 
 of the brain and lead to a fatal issue 
 
 If the abscess is recognized, located, and successfully operated on, the 
 patient usually recovers. Spontaneous evacuation into the ear or through 
 the outer table of the skull may result in recovery. Knapp reports two 
 such cases which evacuated near the occipital protuberance, both of 
 which recovered. Dench reports 25 cases of extradural abscess, 23 of 
 which recovered and 2 died. Of 10 cases occurring in the author's 
 practice, 8 recovered and 2 died. 
 
 Treatment. — The treatment is surgical; alcoholic stimulants may be 
 given if sepsis is present. 
 
 The surgical treatment of an extradural abscess consists in removing 
 the plate of bone underneath which the abscess rests and evacuating 
 its contents. If the abscess is in the middle fossa, it can be generally 
 reached through the tegmen tympani and antri, which have already been 
 exposed by the radical mastoid operation. A carious opening usually 
 exists, and this should be enlarged until the plastic adhesion to the bone 
 
778 THE EAR 
 
 is reached. This should not be disturbed, as to do so opens the avenues 
 of infection to the healthy dura beyond it. A curved probe introduced 
 through the fistulous opening in the roof of the attic or antrum will enable 
 the operator to define the outlines of the abscess cavity, and he can thereby 
 judge the area of bone to be removed. It will often be necessary to 
 make an opening through the squamous portion of the temporal bone, 
 especially in those cases due to a thrombus or an embolus, in which case 
 the skull on the affected side should be trephined. If there is a point 
 of tenderness, this may be utilized as a tentative means of locating 
 the abscess. If after making the opening healthy dura is found, intro- 
 duce a probe between the dura and the bone and pass it in various 
 directions in an endeavor to locate the abscess. If the abscess is chronic 
 and walled off, do not rupture the plastic barrier if it is possible to 
 reach it by making an opening directly over it, as to do so may set up 
 a diffused meningitis. If, however, the abscess is not directly accessible 
 through an external opening, the plastic wall may be broken down and 
 the pus evacuated through the opening already made by lifting the dura 
 with a heavy probe or spatula and allowing it to escape. The dura 
 should then be irrigated with warm bichloride solution, 1 to 5000. 
 
 If the abscess is between the posterior wall of the pyramid and the 
 dura, it may be reached through the mastoid wound by extending the 
 bony wound from the posterior wall of the antrum backward and to 
 the inner aspect of the sigmoid groove of the lateral sinus. If the sinus 
 is large and well forward, this route is not available. The skull should 
 then be trephined as shown in Fig. 478. 
 
 INTRADURAL ABSCESS; PACHYMENINGITIS INTERIOR 
 CIRCUMSCRIPTA. 
 
 This condition is quite similar to extradural abscess, except that the 
 dura is perforated and the plastic exudate exists between the dura and 
 the pia mater, thus walling off the purulent accumulation from the brain. 
 The symptoms are the same as in extradural abscess. The prognosis 
 is more grave, as the brain is in greater danger of infection. The treat- 
 ment is the same, though the probing must be more carefully prosecuted, 
 as the pia mater is more delicate than the dura. 
 
 LEPTOMENINGITIS DIFFUSA PURULENTA OF OTITIC ORIGIN. 
 
 Leptomeningitis may arise in the course of an otitis media or mas- 
 toiditis from a perforation through the tegmen tympani and antri, the 
 carotid canal, the labyrinth, and through the sheaths of the anastomotic 
 bloodvessel in influenza. Ethmoiditis and sphenoiditis may also give 
 rise to it. 
 
 Symptoms. — Headache at first remittent and later constant, is 
 characteristic of this disease. The temperature is elevated and the face 
 
BRAIN ABSCESS OF OTITIC ORIGIN 779 
 
 flushed. The pulse and respiration are rapid, the latter assuming the 
 Cheyne-Stokes type as a fatal issue is approached. Persistent vomiting 
 of mucus and bile is present. Mental excitement, as irritability, delirium, 
 and extreme restlessness are marked symptoms; as the disease pro- 
 gresses, somnolence and loss of memory develop. Rigors are present, 
 but not so marked as in sinus thrombosis. 
 
 The muscles of the face and extremities become drawn or contracted, 
 but these phenomena finally centre in the muscles of the neck, and the 
 head is retracted. The pupils are contracted. The muscles of the 
 abdomen are drawn in and the abdomen is flat. The motor oculi, troch- 
 lear, and abducens nerves become paralyzed. 
 
 Spinal involvement is shown by WestphaPs symptoms, viz., increased 
 tendon reflexes, and paresthesia and hyperesthesia of the extremities. 
 
 By Quincke's lumbar puncture the increased pressure coagulability 
 and the presence of streptococci may be determined. The virulence 
 of the streptococci may be tested by inoculating a guinea-pig with it. 
 Coma occurs a few hours before death. (See Lumbar Puncture.) 
 
 Prognosis. — Death occurs in nearly every case. Operative interfer- 
 ence is not warranted. 
 
 BRAIN ABSCESS OF OTITIC ORIGIN. 
 
 Bacon emphasizes the significance of a firm, dense mastoid process in 
 the cases operated in which such symptoms as high fever, rapid pulse, 
 etc., do not abate after the operation. He thinks it points to cerebral 
 complications, and should lead the operator to explore the cranial cavity 
 without further delay. Many cases may pass into a most serious condi- 
 tion while the surgeon is waiting, Micawber-like, for something to "turn 
 up." If the pus and debris are removed and drainage is established, 
 the symptoms should at once become better, and they should remain so. 
 If, on the other hand, only the outer pus pocket (mastoid antrum) is 
 evacuated, while the inner pus pocket (brain abscess) remains closed, 
 the septic symptoms will continue. I cannot too strongly impress 
 the needlessness of delay in operating, or doing secondary operations 
 upon the cranial cavity, when the septic symptoms continue without 
 abatement. The dangers attending the exploration of the cranial cavity 
 are small compared with those of delay. 
 
 It is the aural surgeon's business to know when to await developments 
 and when he should operate at once. He should either be a surgeon or 
 have a close friend who is one. 
 
 When, after a mastoid operation, the fever and pain continue and the 
 examination of the fundi of the eyes is negative, the surgeon should not 
 be misled by the negative findings, as many cases are reported in which 
 the subsequent history showed brain involvement to have been present. 
 
 J. F. McKernon writes that when the occipital pain is not relieved by 
 the primary mastoid operation, the aural surgeon should go deeper and 
 explore the cerebellar area, in order, if possible, to determine the cause of 
 
780 THE EAR 
 
 the pain. He recommends a grooved director for exploring the brain 
 substance in place of an aspirating needle, as it allows the thick pus to 
 escape, whereas an aspirating needle does not. 
 
 McKernon formulates the following indications for exploring the 
 cranial cavity when an otitic abscess is suspected: 
 
 1. That a chronic otorrhea is or has been present. 
 
 2. Persistent headaches, general or localized. 
 
 3. Restlessness and irritability of temper. 
 
 4. Tenderness of the affected side on percussion. 
 
 5. Nausea, vomiting, and vertigo. 
 
 6. An almost persistently low temperature. 
 
 7. A slow pulse; later, stupor. Optic neuritis may or may not be 
 present; when present it may aid materially in arriving at a diagnosis, 
 as may also aphasia and motor disturbances. 
 
 He believes head pain (2) is the most significant symptom. 
 
 "In the great majority of cases, other than traumatic or pyemic, the 
 patient has had a chronic purulent discharge from the middle ear, often 
 dating from an attack of one of the exanthematous fevers of childhood, 
 or he has had a chronic ulceration about the nose or mouth" (Macewen). 
 
 The following statement refers to cases of aural origin: I have been 
 told so often by patients in my clinic at the College of Physicians and 
 Surgeons that they have no discharge from the ear, in which, upon 
 casual examination, the pus is easily seen. The patients seem to intend 
 to convey the idea that the discharge, though present, is not profuse 
 enough to run out over the ear and face. Among private patients a more 
 exact statement is usually given, as they are more fastidious, and are 
 annoyed by even slight moisture in the external meatus. 
 
 As Macewen says, "The otorrhea may have given little trouble, and its 
 long continuance without apparent harmful result may have lulled the 
 initial fear, until the ear disease is regarded as of no importance/' 
 
 A person thus affected may suddenly become seriously ill after unusual 
 exposure or injury to the head, or even without any known cause. Per- 
 sistent headache develops without any increase in the pus discharge. 
 Other symptoms follow, and the patient applies to his physician for 
 relief. 
 
 There may be a perforation of the tegmen tympani, which has existed 
 for years without infection of the meninges. The granulations fill the 
 opening and effectually guard the intracranial contents from infection. 
 Such a favorable result is not always to be expected. In removing 
 the granulations from the attic through the external meatus great care 
 should be exercised, lest a perforation in the tegmen be thereby opened 
 and septic infection transmitted to the meninges. 
 
 Symptoms. — According to Macewen the symptoms of the acute brain 
 abscess may be divided into three stages : 
 
 First Stage. — Twelve to seventy-two or more hours. 
 
 (a) Violent (usually) pain in the ear which soon extends into the 
 temporal region, with shooting pains in the frontal and occipital regions. 
 
 (b) Vomiting, usually without nausea, is present. 
 
BRAIN ABSCESS OF OTITIC ORIGIN 
 
 781 
 
 (c) Rigors occur early and are nearly constant. They may vary in 
 intensity from a mere feeling of chilliness to violent shivering and chatter- 
 ing teeth. Cutis anserina is well marked. 
 
 (d) The temperature is slightly above normal. 
 
 (e) The pulse is accelerated. 
 
 (f) The tongue is coated and furred. 
 
 (g) Prostration is marked early. 
 
 (h) Otorrhea ceases or becomes less in quantity. 
 Second Stage. — (a) Pain diminished. 
 
 (6) Percussion over mastoid and squamous portions of temperal bone 
 on the affected side causes the patient to wince. (Compare the two sides.) 
 
 (c) Cerebration is slow. The eyes have a vacant, dreamy appearance. 
 
 (d) Want of sustained attention, and finally mental obscuration. 
 
 Fig. 407 
 
 The cortical centres of the cerebrum, to be used in ocalizing lesions within the skull. 
 
 (e) Inability to apply strength. The strength exists, but the will power 
 to use it is gone. 
 
 (/) Temperature about normal or subnormal. 
 
 (g) Pulse slow and full (50 to 60 per minute). Sometimes weak and 
 soft. 
 
 (h) Respirations slow and regular. 
 
 (i) Constipation the rule. 
 
 (;') The urine occasionally retained 
 
 (k) Loss of appetite (anorexia) the rule. 
 
 (/) Vomiting on moving about. No nausea. 
 
 (m) Convulsions occur occasionally. 
 
 (n) Paralysis may occur from brain necrosis and pressure from the 
 abscess (Fig. 407). 
 
 (o) The face is that of one who is seriously ill. The gray color 
 described by some is not always present. 
 
782 THE EAR 
 
 (p) The breath is putrid. 
 
 (q) Rigors do not often occur, except upon extension to a new area. 
 
 (r) Emaciation toward the latter part of the second stage. 
 
 (s) The reflexes do not give reliable data. 
 
 (t) Optic neuritis frequent in latter part of the second stage. 
 
 (u) Examination of the ear shows otorrhea and granulations and 
 perforation of the drumhead. The curved probe may reveal erosion of 
 the tegmen tympani. 
 
 (v) Swelling and redness over the mastoid usually absent in adults. 
 
 Third or Terminal Stage. — The natural termination is in death. Sur- 
 gical interference often averts this if done in the first or early part of the 
 second stage. Stupor and coma gradually increase. The abscess may 
 break and leak on the surface of the brain or into the ventricles. Such an 
 event is attended with vomiting, flushing, restlessness, rigidity of limbs, 
 clonic spasms, quick pulse and respiration, and high temperature. 
 
 Prognosis. — Koerner reported 92 cases of brain abscess operated 
 upon, with 51 recoveries. The prognosis varies, however, according to the 
 stage in which the operation is performed. If operated in the first stage, 
 the death rate should be small, perhaps less than 10 per cent.; if in the 
 second stage, before stupor develops, it should not exceed 50 per cent. If 
 the operation is postponed until encephalitis has become extensive, or 
 until the pus has escaped from its sac and invaded the meninges and 
 ventricles of the brain, the mortality probably exceeds 90 per cent. 
 Taking the cases as they have been operated upon and reported in the 
 literature, the average death rate is about 50 per cent. 
 
 Treatment. — (See the Surgery of the Temporal Bone.) 
 
 THROMBOSIS. 
 
 A thrombus is a mass formed in the heart or peripheral vessels the 
 component parts of which are derived from the blood (Frazier). They 
 are arterial, venous, capillary, or cardiac in origin, and, according to 
 their composition, are white, red, and mixed thrombi. 
 
 The following four factors enter into the pathogenesis of a thrombus 
 
 1. Infective microorganisms. 
 
 2. Structural changes in the intima of the vessel or organ. 
 
 3. Disturbances of the blood current. 
 
 4. Chemical changes in the blood. 
 
 1. In the non-infective thrombus the microorganisms are absent. It 
 is the infective type, however, with which the otologist has to deal. "The 
 primary causative factor is a pyogenic organism, a primitive lesion a 
 phlebitis, and the terminal process a thrombosis or a thrombophlebitis. 
 Thrombophlebitis, associated with such general septic processes as 
 pyemia and septicemia, was the first to be recognized as to infective 
 origin; subsequently, however, the infective nature of thrombophlebitis 
 has been admitted and recognized in other diseases of infectious origin, 
 as in the various so-called infectious diseases" (Frazier). Streptococci 
 
THROMBOSIS 783 
 
 are the most frequent cause of this disease. A negative bacteriological 
 finding does not necessarily preclude an infectious origin, the toxin 
 remaining being the exciting inflammatory agent. 
 
 2. The structural changes in the intima are due to the irritation by the 
 toxins of the bacteria. The intima becomes rough and adhesive. The 
 injured cells of the intima liberate a fibrin ferment which favors thrombus 
 formation. The roughened projections of the intima into the lumen of 
 the vessel interfere with the velocity of the blood current and thereby 
 favor thrombus formation. 
 
 3. The slowing of the blood current cannot alone cause thrombosis. 
 If associated with changes in the intima and the presence of micro- 
 organisms, it predisposes to thrombus formation. The slowing of the 
 blood current is attended by a rearrangement of the constituents of the 
 blood. The white blood corpuscles incline to the periphery of the cur- 
 rent and are admixed with a few platelets. As the current becomes 
 slower, the white corpuscles diminish and the platelets increase in num- 
 ber. In some instances a projection from the intima causes a whirling 
 motion of the current, which still further favors thrombus formation. 
 
 4. The chemical changes in the blood, while not yet demonstrated, 
 seem to be a factor in thrombosis. A fibrin ferment is probably liberated 
 in the infected thrombus, and it may influence the production of the 
 platelets. 
 
 Pathology. — The thrombus is composed of the constituents of the 
 blood in varying proportions, and are white, red, or mixed, according to 
 whether thev are formed in circulating or stagnant blood. If in cireu- 
 lating blood, they are white or mixed; whereas, if in stagnant blood, 
 they are red, and have no clinical significance. Blood platelets form the 
 nucleus of the white and mixed variety, though in the later stages they 
 may have disappeared. 
 
 According to Frazier, the thrombus, at first composed of the normal 
 constituents of the blood, undergoes various changes, which become an 
 element of considerable danger. The leukocytes undergo fatty degen- 
 eration and necrosis; the red corpuscles are decolorized, irregular in 
 shape, and pigmented. The platelets disappear and are replaced by 
 fibrinous deposits. Softening or liquefaction occurs, and the creamy sub- 
 stance contains granular debris, pus cells, and microorganisms. It is 
 in the septic variety of softening that fragments become separated from 
 the thrombus, and, as infected emboli, are carried off by the circulation 
 and deposited in the internal organs, usually the liver, kidneys, and lungs, 
 where they give rise to secondary or embolic abscesses. 
 
 The terminal stage of a thrombus is organization, or rather a disap- 
 pearance of the thrombic material and the deposit of fibrous material. 
 At the beginning of organization the thrombus becomes infiltrated with 
 leukocytes, and following this there is a proliferation of fixed connective 
 tissue cells derived from the endothelium and the other fixed cells of the 
 intima. Bloodvessels penetrate the clot and form anastomoses with 
 each other and with the vessels above and below the thrombus. The 
 thrombus is absorbed, and is. replaced by embryonic connective tissue 
 
784 THE EAR 
 
 rich in bloodvessels. The fibrous mass becomes firm, contracts, and 
 may completely or partially occlude the vessel. In rare instances the 
 fibrous tissue disappears and leaves the lumen of the vessel unimpaired. 
 Venous thrombi extend toward the heart or with the blood current. 
 In thrombosis of the sigmoid or petrosal sinuses the thrombus may 
 extend to the jugular vein and completely occupy its lumen. 
 
 LATERAL SINUS THROMBOSIS. 
 
 Etiology. — The causes of infective thrombosis of the sigmoid portion 
 of the lateral sinus are chiefly to be found in the loss of integrity of the 
 intima of the membranous sinus from the extension of the destructive 
 process in suppurative mastoid or labyrinthine inflammation. So long 
 as the intima is healthy it inhibits the coagulation of the blood in con- 
 tact with it, but where its vitality is impaired by a necrosing mastoiditis 
 its inhibitory power is lost and the blood fibrin coagulates on the affected 
 area, and a thrombus is thus established. The thrombus may or may 
 not occlude the lumen of the vessel. At the beginning it is limited to the 
 external or bony aspect of the sinus, as this is the part first involved by 
 the necrosis of the bone. The necrosis may extend from the mastoid 
 cells of the process or from the labyrinth (in labyrinthine suppuration) 
 to the cells lying between the labyrinth and the antrum, and thence to 
 the antrum and mastoid cells, from whence it involves the sinus. 
 
 At the beginning the thrombus is not infected. It is only after the wall 
 of the membranous sinus has undergone marked deterioration that 
 the infective microorganisms penetrate it and lodge in the thrombus. 
 There is food for thought in this fact. That is, if the condition is diag- 
 nosticated before infection of the thrombus occurs, the infection and its 
 evil consequences could be thwarted by an exposure of the sinus and the 
 removal of the diseased bone surrounding it without opening the sinus 
 itself. Unfortunately, the diagnosis of thrombosis at this early stage is 
 extremely difficult to make, and is rarely made except during a mastoid 
 operation. 
 
 Symptoms. — The symptoms of lateral sinus thrombosis may be 
 divided into three stages, based upon the pathological changes so mi- 
 nutely described by Macewen in his masterly work on The Pyogenic 
 Diseases of the Brain and Spinal Cord. 
 
 First Stage. — The thrombus, partial or complete; disintegration not 
 established. 
 
 (a) Slight fever. 
 
 (6) Rigors, usually present. Slight rigors exceptional. 
 
 (c) Headache, slight or severe, limited to the affected side. 
 
 (d) Slight tenderness over the region of the mastoid emissary vein. 
 
 (e) Slight edema and tenderness below the tip of the mastoid in the 
 posterior triangle of the neck. 
 
 (/) Leukocytosis with increased polymorphonuclear count. 
 Second Stage. — The thrombosis, partial or complete; disintegration 
 and systemic absorption established. 
 
LATERAL SINUS THROMBOSIS 785 
 
 (a) Temperature always above normal and distinctly fluctuating. 
 
 (b) Frequent rigors. 
 
 (c) Headache and tenderness over the mastoid emissary vein. 
 
 (d) Edema and tenderness below the tip of the mastoid in the pos- 
 terior triangle of the neck. 
 
 (e) Increased leukocytosis and polymorphonuclear count. 
 
 Third Stage. — The thrombosis, partial or complete; disintegration and 
 excessive systemic absorption. 
 
 (a) A chill or rigor followed by great and marked fluctuations of 
 temperature; sometimes subnormal, and then rapidly rising to 104° 
 or 106° F. 
 
 (b) Headache, severe, often excruciating. 
 
 (c) Marked tenderness over the mastoid emissary vein and the pos- 
 terior triangle of the neck. The internal jugular vein may be tender on 
 pressure. 
 
 (d) Metastatic pneumonia, enteritis, or meningitis may be present, 
 with characteristic symptoms. 
 
 (e) Still greater leukocytosis and polymorphonuclear count. 
 
 Note. — The leukocytosis and polymorphonuclear count is greater in 
 sinus thrombosis than in simple mastoiditis. 
 
 (J) Coma as the fatal issue approaches. 
 
 Early Diagnosis. — If diagnosticated in the first stage, and operated 
 at once, nearly all cases recover. If diagnosticated and promptly oper- 
 ated in the second stage, before metastatic extension to the brain, lungs, 
 bowels, spleen, etc., fully 50 per cent, will recover; whereas, if diag- 
 nosticated and operated in the third stage, the mortality rate is very high. 
 
 In view of the foregoing facts, it is evident that all cases of suppurative 
 otitis media, especially if there is a secondary acute manifestation, 
 should be critically studied to detect the earliest sign of sinus involve- 
 ment. Such observations cannot be made unless the patient is placed 
 in bed, with a trained nurse in attendance, and the temperature, pulse, 
 and respiration recorded every three hours. Inquiry as to the presence 
 of a unilateral headache, not necessarily severe, should be made two or 
 three times daily. The surgeon should examine for tenderness over 
 the mastoid emissary vein and the posterior triangle of the neck. The 
 occurrence of a rigor, even if slight, should excite suspicion, and lead to 
 most careful inquiry as to all the other symptoms. 
 
 If a diagnosis is not positively made before a mastoid operation is per- 
 formed, the sigmoid portion of the sinus should be exposed and its mem- 
 branous wall examined. Infective perisinus abscess may be present, 
 without involvement of the intima of the sinus. Sometimes the external 
 surface of the membranous sinus is velvety and granular in appearance, 
 the smooth surface and pearly gray color normal to the sinus being- 
 absent. I have seen cases like this recover after exposing the mem- 
 branous sinus. They recovered because the intima (lining) of the sinus 
 was not yet involved. The drainage of the perisinus abscess checked the 
 inward extension of the infective process, and thus thwarted the forma- 
 tion of a thrombus in the sinus. 
 50 
 
786 THE EAR 
 
 In one case, observed by the author, in which perisinus abscess was 
 present and the lumen of the sinus open, there afterward developed 
 thrombosis of the lateral and the cavernous sinuses. The question as to 
 the advisability of opening such a sinus is of considerable importance. 
 The author believes it should be done, and done thoroughly, the sinus 
 being walled off after exploration and packed with iodoform gauze. 
 
 A partial thrombosis of the sigmoid sinus may sometimes be demon- 
 strated by compressing the sinus with the ringer and noting the uneven 
 or nodular surface when collapsed. The use of a hypodermic needle is 
 useless for diagnostic purposes, as it may penetrate beyond the thrombus, 
 and withdraw blood from the normal blood current. 
 
 In complete thrombosis of the sinus palpation with the finger gives 
 the sense of a doughy resistance. After full exposure of the sinus, it 
 should be palpated to determine, as far as possible, the probable extent 
 of the thrombus. If it is doughy over the full area of the exposure, the 
 clot probably extends to or above the knee, and below to the jugular 
 bulb. 
 
 The knowledge thus gained may determine the advisability of a still 
 further exposure of the jugular bulb. (See Thrombosis of the Jugular 
 Bulb.) In complete thrombosis there is no flow of blood upon incising 
 the sinus, nor will the hypodermic needle draw fresh blood. 
 
 Prognosis. — The prognosis depends chiefly upon the stage in which 
 diagnosis and operative procedures are made. If made in the first stage, 
 nearly all will recover. If in the second, about one-half will recover. 
 If in the third, the mortality rate is high. If not operated, nearly all 
 cases terminate fatally. 
 
 Here is a field in which an early diagnosis and an early operation are 
 the means of saving life; whereas a late diagnosis, even with operative 
 interference, will in a majority of subjects result in death. 
 
 Thrombosis of the Jugular Bulb.— Whiting has formulated the fol- 
 lowing test: Compress the membranous sinus as near the bulb as possible, 
 and draw the finger upward to empty it; the compression is then re- 
 moved, and if the vessel fills from below, it is assumed that the bulb 
 is not thrombosed. Allport believes this procedure is dangerous, as it 
 may liberate infective clots and disseminate the infection to other parts 
 of the body. Such occurrences have not been reported. 
 
 Grunert exposes the jugular bulb by opening the mastoid, exposing 
 the sinus, and ligating the jugular. The retro-auricular and cervical 
 (jugular) incisions are then united and the tip of the mastoid process 
 is resected. The soft parts are then pulled forward and loosened as 
 far as the jugular foramen. The bone should be removed until the 
 jugular bulb is exposed. (See Surgery of the Temporal Bone.) 
 
 Cavernous Sinus Thrombosis. — Thrombosis of the cavernous sinuses 
 is rare. Two cases of otitic origin have occurred in the author's practice, 
 though this is probably an exceptional experience, as many aurists of 
 equally large experience have reported no cases. 
 
 When of otitic origin, it usually extends from the superior or inferior 
 petrosal sinus to the cavernous sinus. When it complicates inflam- 
 
LATERAL SINUS THROMBOSIS 
 
 787 
 
 mation of the nasal accessory sinuses, it extends from the secondarily 
 infected eye through the ophthalmic vein to the cavernous sinuses. 
 
 The general symptoms are similar to those present in thrombus of 
 the lateral sinus. The characteristic symptoms are the marked edema 
 of the periocular tissues and the protrusion of the eyeball, as shown in 
 Fig. 408, which illustrates one of the two cases just mentioned. 
 
 Fig. 408 
 
 The author's case of cavernous sinus thrombosis of otitic origin. The drawing shows the case in 
 the early stage before the thrombus had extended to the left side through the circular sinus. 
 
 The first case occurred in a girl, aged twelve vears, seven years after an 
 attack of scarlet fever, at which time she had an acute otitis media 
 purulenta. During the interim (except the last week of her life) she 
 was said to have had no ear discharge. The mastoid symptoms and 
 otorrhea developed rapidly. When the author saw her on the third day 
 she was greatly prostrated and septic, and eye slightly protruding. The 
 first chill and rigor occurred on the fourth day. The lateral sinus was 
 exposed, but was apparently not thrombosed. Death occurred three days 
 later. 
 
 In the second case the cavernous sinus was thrombosed secondarily 
 to the lateral sinus. The lateral sinus was exposed, and the thrombus 
 
788 THE EAR 
 
 removed as high and as low as possible without establishing a flow of 
 blood. The patient gradually became stupid, finally comatose, and 
 died one week after the lateral sinus was exenterated. 
 
 Symptoms. — The symptoms depend on whether one or both sinuses are 
 affected. It usually begins in one and spreads to the other through the 
 circular sinus. The symptoms shift from one eye to the other, a differ- 
 ential point between thrombosis of the cavernous sinus and inflam- 
 mations confined to the orbital cavity. 
 
 (a) Pain may be occipital, supra- and infra-orbital, and in the vertex. 
 
 (b) Exophthalmos and edema of the eyelids and side of the nose are 
 characteristic symptoms due to venous obstruction. 
 
 (c) Drooping of the eyelids (ptosis), strabismus, and pupillary reac- 
 tions due to pressure on the third nerve are also present. 
 
 (d) Edema of the pharynx and tonsil on the same side is occasionally 
 present. 
 
 The nerves involved are the second, third, fourth, and sixth, and 
 the first division of the fifth. The third is the most constantly involved, 
 as is evidenced by the ptosis. The duration of the disease varies from 
 a few days to several months, generally only a few days. The death rate 
 is extremely high. 
 
 Treatment. — The treatment is chiefly palliative. When tension of the 
 conjunctiva is extreme, it may be slit or punctured. The eyeball may be 
 removed, together with the thrombosed vessels, with a view of affording 
 some relief from the pain and distress. Such interference should be 
 undertaken only in extreme cases, as there is no hope of effecting a cure 
 by this procedure. Attempts to operate upon the sinus have generally 
 failed, though favorable reports have been made. (See Surgery of the 
 Temporal Bone.) 
 
PLATE XII 
 
 Base of the Skull: Left Labyrinth Exposed on the Right Side, 
 
 the Grooves in the Base of the Skull are Shown, also the 
 
 Sinuses of the Dura Mater. 
 
 Two-thirds Lifesize. 
 
 1, crista frontalis (on the left, beginning of the superior longitudinal sinus); 2, foramen cecum (emis- 
 sarium Santorini); 3, crista galli; 4, lamina cribrosa (olfactory nerve); 5, lesser wing of sphenoid; 6, optic 
 foramen (optic nerve, ophthalmic artery); 7, anterior clinoid process; 8, sella turcica, flanked by the 
 median clinoid process; 9, dorsum ephippii, with posterior clinoid process; 10, foramen rotundum (second 
 division of fifth nerve); 11, foramen ovale (third division of fifth nerve); 12, foramen spinosum (middle 
 meningeal artery and recurrent branch of fifth nerve); 13, carotid canal and foramen lacerum anterius 
 (great and lesser superficial petrosal nerves, Eustachian tube, and tensor tympani muscles); 14, antero- 
 superior surface of pyramid; 15, cochlea; 16, semicircular canals; 17, tegmen tympani and roof of antrum 
 laid open; 18, anterior condyloid foramen (twelfth nerve); 19, posterior condyloid foramen (emissarium 
 Santorini); 20, foramen magnum; 21, superior petrosal sinus; 22, transverse sinus (descending portion); 
 23, transverse sinus (horizontal portion); 24, superior longitudinal sinus and torcular Herophili (confluence 
 of the sinuses); 25, occipital sinus; 26, occipital sinus; 27, vein of aqueductus vestibuli (emerging at the 
 external aperture of aqueductus vestibuli); 28, internal auditory vein (emerging in the internal auditory 
 meatus); 29, vein of aqueductus cochlese (emerging at the external aperture of aqueductus cochlea?); 30, 
 inferior petrosal sinus emptying into the cavernous sinus; 31, circular sinus (Ridley); 32, groove traversing 
 anterior fossa of skull; 33, sinus of lesser wing of sphenoid; 34, groove of meningeal artery; 35, transverse 
 groove through middle fossa of the skull; 36, longitudinal groove through petrous portion of temporal 
 bone (tegmen tympani); 37, groove through apex of pyramid; 38, transverse fissure (between posterior 
 condyloid foramen and foramen magnum); 39, longitudinal groove through posterior fossa of skull; 40, 
 impressio carotica (corresponding to the bend in the internal carotid artery); 41, juga cerebralia and 
 impressiones digitata\ (After Bruhl-PoJitzer.) 
 
CHAPTER XLVIIL 
 
 THE SURGERY OF THE TEMPORAL BONE. 
 
 The treatment of the surgical diseases and complications included 
 in this chapter are: (1) acute mastoiditis; (2) chronic mastoiditis; (3) 
 Bezold's mastoiditis; (4) necrosis of the semicircular canals; (5) necrosis 
 and suppuration of the semicircular canals and vestibules; (6) necrosis 
 and infection of the cochlea and semicircular canals; (7) thrombosis of 
 the lateral sinus; (8) thrombosis of the jugular vein; (9) thrombosis 
 of the jugular bulb; (10) extradural abscess in the middle fossa of the 
 skull; (11) serous meningitis; (12) abscess of the cerebrum; (13) abscess 
 of the cerebellum; (14) facial paralysis; and (15) postauricular fistula. 
 
 Ossiculectomy. — The removal of the malleus and the incus for the re- 
 lief and cure of chronic suppurative otitis media has fallen into disuse 
 since Macewen's work on The Pyogenic Diseases of the Brain and Spinal 
 Cord appeared in 1893. His presentation of the efficacy of the radical 
 mastoid operation for this purpose was so convincing that it has been 
 almost universally adopted by otologists throughout the world. There 
 is now a reactionary tendency to differentiate the cases, and to adopt 
 various surgical procedures, according to the characteristics of each 
 case. In some instances the radical mastoid operation is elected as 
 the best method of procedure; in others the meatomastoid operation is 
 preferred ; and in still others the otologist is content to remove the granu- 
 lation tissue and secretions through the external meatus by means of 
 small curettes, the syringe (Figs. 409 and 410), and inflation and irriga- 
 tion through the Eustachian tube by means of a Weber-Liel catheter. 
 
 Technique.— The Anesthetic. — Ossiculectomy may be performed under 
 local anesthesia, though it is usually quite painful. In the author's 
 experience the most reliable anesthetic mixture is composed of equal 
 parts of cocaine, carbolic acid, and menthol. Instil a few drops of this 
 mixture into the meatus, and at the end of twenty minutes its full anes- 
 thetic effect is obtained. 
 
 It is usually preferable, however, to administer a general anesthetic, 
 as this insures a painless operation. 
 
 Preparation of the Ear. — The auricle and external meatus should be 
 scrubbed with soap and water, followed by an alcohol bath. A cotton- 
 wound toothpick or applicator may be used for the purpose. If a general 
 anesthetic is to be given, the patient should be placed in a hospital the 
 day before the operation, and the bowels and diet regulated as for the 
 mastoid operation. 
 
 Incision of the Membrana Tympani. — The incision may begin at the 
 margin, at the junction of the anteroinferior and the anterosuperior 
 
790 
 
 THE EAR 
 
 quadrants of the membrane (Fig. 411), and be extended upward to the 
 malleus, thence downward along the anterior border of the handle to its 
 
 Fig. 409 
 
 Irrigation of the attic through a perforation in the membrana flaccida. 
 
 umbo, or lower extremity, thence 
 upward along its posterior border to 
 the upper limit of the membrane, 
 and thence downward along the 
 posterior margin of the membrane 
 to the junction of the postsuperior 
 and postinferior quadrants of the 
 membrane, as shown in Fig. 411. 
 This incision makes two flaps of the 
 membrana tympani, which drop 
 downward and expose the tympanic 
 cavity (Fig. 411). This operation 
 preserves a large portion of the 
 membrana tympani and favors 
 speedy regeneration in the process 
 of repair. The great objection to 
 it is that the lower half of the 
 membrane interferes with the drain- 
 age of the tympanic cavity. 
 
 Instead of the above incision, the 
 entire membrane, or the fragments 
 of it, if it is largely destroyed, may 
 be removed by making an incision 
 around its entire margin and along both borders of the handle of the 
 malleus. This provides for drainage during the after-treatment. 
 
 1, the attic; 2, suspensory ligament of the 
 malleus; 3, external space of the attic; 4, 
 Prussack's space; 5, malleus; 6, external 
 meatus; 7, incus; 8, ligament attaching mal- 
 leus to inner wall of the tympanic cavity; 9, 
 stapes; 10, promontory; 11, cavum tympani. 
 
THE SURGERY OF THE TEMPORAL BONE 
 
 791 
 
 Removal of the Malleus and Incus. — The malleus should first be re- 
 moved and then the incus. The attachments of the tensor tympani 
 muscle and the tendinous attachments of the malleus to the tympanic 
 wall should be severed. Various instruments have been devised for this 
 purpose, the best of which are Sexton's small angular blades (Fig. 413), 
 which should be passed behind the handle of the malleus and carried 
 
 Fig. 411 
 
 Fig. 412 
 
 The right membrana tympani with a per- 
 foration at the margin of the postsuperior 
 quadrant over the lenticular process of the 
 incus, indicating necrosis of the incus and of 
 the mastoid antrum. The line a 6 is the 
 line of incision preliminary to the removal 
 of the malleus and incus. The flaps of 
 membrane thus made drop down and expose 
 the upper half of the tympanic cavity to 
 view (Fig. 412). 
 
 The incision and flaps preliminary to ossicu- 
 lectomy. 1, perforation in the membrana 
 flaccida; 2, stapes in the oval window; 3, tym- 
 panic orifice of the Eustachian tube; a a, the 
 membrana tympani — flaps turned downward. 
 
 upward to the tendinous attachment of the tensor tympani muscle. It 
 should then be introduced through the space occupied by the membrana 
 (pars) flaccida, to sever the ligamentous attachment to the outer wall of 
 the tympanic cavity. 
 
 Delstanche's ring knife (Fig. 414) may also be used to remove the 
 malleus. Its ring blade should be insinuated around the handle of the 
 
 Fig. 413 
 
 Fig. 414 
 
 F.A.HARDY * CO. 
 
 F.A.HAHDYX CO 
 
 Sexton's ossiculectomy knives. 
 
 Ring curettes for removing the malleus. 
 
 malleus and passed upward as far as possible, cutting the attachment 
 of the tensor tympani muscle. 
 
 Having thus severed some of the attachments of the malleus, it should 
 be removed either with the ring knife or with forceps (Fig. 415). 
 
 The ring knife, or dull ring should encircle the handle of the malleus 
 as high as possible, and then, with a rocking or side-to-side motion, com- 
 
792 
 
 THE EAR 
 
 bined with a downward pull, the malleus is dislodged and removed 
 through the external meatus. 
 
 Fig. 415 
 
 Showing the severance of the ligamentous attachments of the malleus. After this is done the 
 malleus is grasped with the forceps or a ring curette, and drawn downward until its head is dis- 
 engaged from the attic. It is then removed through the external auditory meatus. 
 
 Removal of the incus with the incus hook, after the removal of the malleus. The hook 
 should be introduced posterior to the incus, the incus pushed forward and downward. If it 
 is pushed backward it is apt to become lodged in the aditus ad antrum. 
 
ACUTE PRIMARY MASTOIDITIS 793 
 
 If the forceps are used, the handle of the malleus should be seized as 
 high as possible and removed in the same manner as with the ring knife 
 (Fig. 415). 
 
 The incus is not so easily dislodged from its position, as its long process 
 is often beyond the grasp of the forceps, and even when it can be seized 
 it is so fragile that it is apt to break. The incus hook (Fig. 416) is the 
 best instrument for its removal. Another difficulty encountered is the 
 liability to dislocate it backward into the aditus ad antrum. To obviate 
 this mishap, the incus hook should be introduced behind the body of 
 the incus and passed upward and forward over its body. The hook 
 should then be pressed downward and slightly forward, thus dislodging 
 the incus and bringing it into the lower portion of the tympanic cavity, 
 where it may be removed with the forceps. 
 
 The stapes is never removed in the operation, as to do so would subject 
 the labyrinth to infection and would cause pronounced deafness. 
 
 Hemorrhage. — Bleeding may be controlled by mopping the tympanic 
 cavity with adrenalin or with a hot 1 to 2000 bichloride of mercury 
 solution. 
 
 Dressings and After-treatment. — The best dressing is a loosely applied 
 strip of sterile gauze extending from the tympanic cavity to the auricle. 
 The cavity of the auricle should be loosely filled with gauze and cotton 
 and the whole covered with an ethereal solution of collodion, which holds 
 in place as effectually as a large and cumbersome bandage. 
 
 The after-treatment consists in applying similar dressings and the 
 cleansing of the tympanic cavity with cotton-wound applicators, infla- 
 tion through the Eustachian tube, and the reduction of granulations 
 with carbolic acid or dehydrated crystals of chromic acid, for a period 
 of about one month, or until the ear is dry. 
 
 If the operation is unsuccessful, either the radical or the meatomastoid 
 operation may be performed. The percentage of cures (chronic otitis 
 media purulenta) is very small. 
 
 ACUTE PRIMARY MASTOIDITIS. 
 
 The Indications for Surgical Intervention. — It is taken for granted 
 that the usual abortive therapeutic measures, as (a) the application of 
 leeches (or the artificial leech) over the mastoid process and in front of 
 the tragus, (6) the instillation of a 12 per cent, solution of carbolic acid 
 in glycerin into the auditory meatus, (c) free incision of the membrana 
 tympani, (d) ice over the mastoid process, (e) heat, cathartics, etc., have 
 been used without success. 
 
 1. These and perhaps other therapeutic measures having failed to 
 abort the infectious and destructive process in the cavum tympani and 
 mastoid antrum and cells, the disease tends to become chronic, a fact 
 which may constitute a sufficient reason for performing a simple exen- 
 teration of the mastoid antrum and cells. To wait for other and more 
 definite indications might develop the necessity for a much more radical 
 
794 THE EAR 
 
 operation, or even lead to serious intracranial commplications, and en- 
 danger the life of the patient. Intervention, when threatened chronicity 
 is imminent, requires a comparatively simple surgical procedure, which 
 almost always results in a permanent cure, often with but little or no 
 impairment of the functions of the ear. 
 
 2. Bulging or sagging of the posterior superior wall of the external 
 auditory meatus near the membrana tympani is due to the involvement 
 of the mastoid cells below and anterior to the antrum (cells of Kirchner), 
 and is a positive indication for the mastoid operation. 
 
 3. Pain over the mastoid antrum and tip which is not relieved by the 
 application of ice (one to four hours), alternated with heat, over a period 
 of from twenty-four to forty-eight hours, is an indication for the simple 
 mastoid operation. The pain signifies congestion, edema, or granula- 
 tions which block the drainage of the secretions. Pressure necrosis 
 and toxemia rapidly develop under such conditions, and if the pain 
 persists the mastoid antrum and cells should be opened. 
 
 4. Edema and redness of the mastoid region signify blocking of the 
 secretions, and, if the condition is not relieved by leeching, ice, heat, etc., 
 constitute another indication for surgical intervention. 
 
 5. The presence of a subperiosteal abscess over the mastoid process, 
 especially in adults, having its origin through a fistulous opening in the 
 mastoid cortex, is an indication for the operation. In infants and chil- 
 dren such a condition often has its origin beneath the periosteum of the 
 meatus, the mastoid cortex being intact, hence a subperiosteal abscess 
 and the infection of the ear and mastoid antrum may be cured by an 
 incision (Wilde's) through the skin over the mastoid process. 
 
 6. Meningeal irritation (complicating acute mastoiditis), as evidenced 
 by convulsions (in infants and children), delirium, intense headache, etc., 
 may call for the mastoid operation. 
 
 7. Other and more serious intracranial complications, as circum- 
 scribed meningitis (epidural abscess), serous meningitis, thrombosis of 
 the lateral sinus, etc., constitute positive indications for the mastoid 
 operation. 
 
 The Simple Mastoid Operation in Acute Mastoiditis.— The Tech- 
 nique. — The preparation of the patient and anesthesia will not be dis- 
 cussed farther than to say that the head should be shaved, scrubbed, 
 etc., over an area extending at least three inches from the attachment of 
 the auricle, both above and behind it. Otherwise the patient should be 
 prepared and anesthetized as for any other major surgical operation. 
 
 The incision back of the auricle should be so extended as to fully 
 expose the entire field of the operation. In adults, the primary incision 
 (Fig. 417, a a!) should begin at the mastoid tip, one-half inch posterior to 
 the attachment of the lobule of the auricle, and extend upward behind the 
 auricle, gradually approaching its attachment, until, when near the supe- 
 rior attachment, it should be about one-fourth of an inch posterior to it. 
 It should then be extended anteriorly to a point immediately above the 
 superior attachment of the auricle (Fig. 417, a). If upon retracting 
 the posterior flap the operative field (posteriorly) is not fully exposed, a 
 
ACUTE PRIMARY MASTOIDITIS 
 
 795 
 
 secondary incision (Fig. 417, 6, &') should be made at right angles to the 
 primary one. It should begin on a level with the external auditory 
 meatus and be extended backward for a distance of one inch (Whiting). 
 In those cases in which the mastoid cells extend well back toward the 
 occiput it will be necessary to extend the secondary incision accordingly. 
 The primary incision (Fig. 417, a, a') should be first superficially out- 
 lined with the scalpel to insure clean-cut edges, proper curve, and 
 extension. It should then be carried through the entire substance 
 of the skin, subcutaneous tissue, and the periosteum. 
 
 Fig. 417 
 
 The postauricular mastoid incision, a, a , the primary incision; b. b , the secondary incisi 
 
 The Elevation of the Cutaneous Periosteal Flaps. — The skin and peri- 
 osteum should be elevated together. Great care should be taken to 
 preserve the periosteum, as the subsequent repair of the wound will de- 
 pend somewhat upon the integrity of this structure. With this object in 
 view, the author devised the periosteal elevator shown in Fig. 418. The 
 periosteal blades are at right angles to the axis of the handle of the instru- 
 ment. Experience has shown that this angle is best adapted to the 
 clean elevation of the mastoid periosteum. The instrument is provided 
 with two right-angle elevators, one elevating on the pull, and the other 
 on the push. But little difficulty will be experienced in elevating the 
 upper two-thirds of the anterior and posterior flaps; whereas, the lower 
 third will be elevated with difficulty, as the tendinous fibers of the 
 sternomastoid muscle pierce it. The tendinous bands of this muscle 
 
796 
 
 THE EAR 
 
 should be cut with short, blunt scissors from the external cortex of the 
 mastoid tip before elevation of the periosteum is attempted. If this is 
 not done, long muscle fibers may be pulled from the sternomastoid 
 muscle, thus opening avenues of infection in its substance (Whiting). 
 
 Fig. 418 
 
 The author's mastoid periosteal elevator. 
 
 Fig. 419 
 
 
 The anatomical landmarks for opening the mastoid antrum. The suprameatal triangle, 
 the spine of Henle, and sieve-like depression. 
 
 The Anatomical Landmarks. — Having elevated the cutaneoperiosteal 
 flaps, the external characteristics of the mastoid process and auditory 
 meatus should be noted. To experienced surgeons this requires but 
 a few seconds of time. The first concern should be to determine the 
 location of the mastoid antrum, as it forms the deeper landmark of the 
 
ACUTE PRIMARY MASTOIDITIS 
 
 797 
 
 mastoid process. It is usually located at a depth of about one-half inch 
 beneath the mastoid cortex and a little above and behind the cavum tym- 
 pani. There are four more or less constant external landmarks which 
 will guide the surgeon to the mastoid antrum. The one most constantly 
 present is the area of sieve-like perforations in the mastoid cortex just 
 behind the external opening of the meatus (Fig. 419). These small 
 openings contain minute vessels which bleed after the periosteum is 
 elevated. The surface of the bone should be mopped dry, and in a 
 moment the bleeding points will appear. Another landmark usually 
 present is the suprameatal spine, or the spine of Henle (Fig. 419). It is 
 a small triangle or diamond-shaped bony lip projecting outward and 
 forward from the posterior margin of the external auditory meatus. 
 The point for entering the antrum is immediately behind the spine. 
 The third landmark for locating the mastoid antrum is the suprameatal 
 triangle (Fig. 419). The upper boundary of the triangle is formed by 
 the lower border of the posterior ridge or root of the zygomatic process; 
 the posterior inferior boundary is formed by an imaginary line extend- 
 ing from the posterior end of the root of the zygoma to the inferior por- 
 
 Fig. 420 
 
 The Russian perforator. 
 
 tion of the spine of Henle, or, if this is not present, to the posterior 
 inferior margin of the auditory meatus. An opening made in the anterior 
 portion of this triangle near the auditory meatus will enter the mastoid 
 antrum. The fourth landmark to the antrum is the direction of the 
 posterior superior wall of the bony portion of the auditory meatus. This 
 is ascertained by introducing a straight probe into the meatus along its 
 posterior superior aspect and noting the angle of inclination in relation 
 to the general surface of the mastoid cortex. Having noted the forego- 
 ing anatomical landmarks, the exenteration to expose the antrum should 
 be begun at the point indicated by the first three landmarks described, 
 and extended inward in a direction parallel with the probe, as sug- 
 gested in the description of the fourth landmark. The usual direction 
 of the posterior superior wall of the bony meatus is markedly inward, 
 and slightly downward and forward. After excavating for a depth of 
 one-half inch (sometimes more, rarely less), the outer extension of the 
 mastoid antrum may be looked for. The lateral sinus is sometimes near 
 the surface, and may lie immediately beneath the skin. Should the 
 mastoid cortex be carious, the fistulous tract may be followed to its 
 origin in the antrum or cells without regard to the external landmarks. 
 
798 
 
 THE EAR 
 
 Opening the Mastoid Antrum. — The Russian perforator (Fig. 420) 
 or a gouge may be used to expose the mastoid antrum. Personally, 
 the author prefers the Russian perforator, as its use avoids the shock 
 incident to the blows of the mallet (Fig. 421) in using the gouge. If 
 the Russian perforator is used, its tip should be placed in the supra- 
 meatal triangle (Fig. 419), with the long axis of the instrument parallel 
 with the probe placed against the posterior superior wall of the meatus, 
 as described under External Landmarks. The mastoid cortex is then 
 perforated with a boring movement of the perforator, the bone shavings 
 passing into the hollow chamber of the instrument. The instrument 
 should be removed from time to time to examine the bottom of the 
 bony wound, to see when a pneumatic space is uncovered. When 
 this occurs, a dark spot will be found in the bottom of the wound. When 
 the mastoid cortex is carious the tissue may be excavated with a curette, 
 the anatomical landmarks being disregarded. A curved silver probe 
 
 Fig. 421 
 
 ~"D 
 
 Allport's mastoid mallet. 
 
 should be introduced into the pneumatic space, the curved tip being 
 directed anteriorly. If the pneumatic space is the mastoid antrum, the 
 tip of the probe will pass forward through the aditus ad antrum into the 
 cavum tympani, as shown in Fig. 422. If the pneumatic space is a 
 mastoid cell, the probe will not pass forward through the aditus ad 
 antrum. If the sigmoid portion of the lateral sinus is located anteriorly 
 against the posterior wall of the auditory meatus, the perforator will 
 uncover it, but will not injure its membranous covering. Herein is 
 another reason for preferring the Russian perforator to the gouge. 
 
 As Whiting has so well shown, the external conformation of the mas- 
 toid process will show the position of the sigmoid portion of the lateral 
 sinus. The sinus, being a large vessel, requires space; hence the area 
 of greatest external bulging or convexity of the mastoid cortex may be 
 taken as a guide to the location of the sinus. When the convexity is at 
 the middle portion of the mastoid cortex it is well out of the way in open- 
 ing the antrum. When, however, the anterior portion of the mastoid 
 
ACUTE PRIMARY MASTOIDITIS 
 
 799 
 
 cortex is elevated, and the posterior wall of the meatus drops at right 
 angles from it, the sinus is located anteriorly, and will be exposed in 
 opening the antrum. In such subjects it may be necessary to open the 
 antrum by removing the posterior wall of the meatus after the method of 
 Stacke. 
 
 Having exposed the mastoid antrum, its dimensions and extensions 
 should be determined with a bent probe introduced through the bony 
 wound. The whole outer wall of the antrum should then be removed 
 with a gouge and mallet or the rongeur forceps. 
 
 Fig. 422 
 
 The opening into the mastoid antrum made with the Russian perforator. The fact that the 
 silver probe passes forward through the aditus ad antrum into the cavum tympani is proof that 
 the pneumatic space at the bottom of the wound is the antrum and not a mastoid cell. 
 
 The Removal of the Mastoid Cortex.— -The mastoid cortex mav be 
 removed in parallel shavings (Fig. 423), as recommended by Whiting. 
 From three to four grooves are made, exposing the superficial cells. 
 The gouge may be applied at either the mastoid tip, as shown in the 
 drawing, or at the level of the mastoid antrum. Care should be exer- 
 cised to avoid injuring the mastoid emissary vein shown at the posterior 
 
800 
 
 THE EAR 
 
 portion of the mastoid process (Fig. 423). This vein opens into the 
 sigmoid portion of the lateral sinus, and, when injured, bleeds profusely 
 and persistently. It may be readily closed by placing the tip of some 
 blunt instrument against the opening of its bony canal and tapping it 
 smartly with the mallet. 
 
 Fig. 423 
 
 The removal of the cortex of the mastoid process 
 
 The Exenteration of the Mastoid Cells. — After the cortex is removed 
 the cells should be broken down and removed with the curette and the 
 rongeur forceps. If the intercellular walls are soft or necrosed, they 
 may be removed with a curette. If they are firm, the rongeur forceps is 
 better for the purpose. The overhanging edges of the mastoid cortex 
 should be removed with the rongeur forceps (Fig. 424) until all cells are 
 completely exposed and accessible to curettement. Large mastoid cells 
 are often found in the tip of the process. These may be the focal centre 
 of the infection and the only place where pus is found. The cells 
 
ACUTE PRIMARY MASTOIDITIS 801 
 
 should, therefore, be exposed to the tip in all cases, as otherwise the 
 focal centre of infection may not be exposed and the operation fail 
 of its purpose. All cells should be opened, but not completely oblit- 
 erated, as in the meatomastoid and radical operations. 
 
 The Irrigation of the Wound. — As the infective microorganisms in 
 acute mastoiditis are usually quite active and virulent, and it being almost 
 impossible to prevent them coming in contact with the soft tissues, it is a 
 
 Fig. 424 
 
 The completion of the removal of the mastoid cortex with the rongeur forceps. The cells 
 may also be removed with the same instrument. 
 
 wise precaution to irrigate the wound with a 1 to 4000 bichloride solution 
 at about 110° F. The external auditory meatus should also be scrubbed 
 and irrigated with the same solution, care being exercised to avoid 
 injuring the membrana tympani and dislocating the ossicles. 
 
 The Closure of the Cutaneous Wound. — As drainage must be main- 
 tained for several days, and the cavum tympani is not exposed by the 
 51 
 
802 
 
 THE EAR 
 
 operation, it is necessary to provide for drainage through the posterior 
 
 wound. 1 
 
 The cutaneous wound is not, therefore, completely closed at the time 
 
 of the operation. The upper two-thirds is sutured as shown in Fig. 425, 
 
 while the remaining lower third is left open 
 FlG - 425 for the introduction of the drainage tube 
 
 and gauze. 
 
 The Dressing. — The object of the dress- 
 ing is twofold, namely, to promote drain- 
 age and protect the wound from further 
 infection while the process of repair is in pro- 
 gress. In order to accomplish the first object, 
 the dressing should be so applied as to insure 
 free drainage. According to the author's 
 experience, only so much gauze should be 
 introduced into the depth of the bony wound 
 as to carry off the secretions to the outer 
 absorbent dressing. To pack the wound with 
 gauze is poor practice, as the gauze becomes 
 saturated with the secretions, retains them 
 in the wound, where they bathe its walls, 
 and retard the reparative process. On the 
 other hand, if only a small wick of gauze 
 is carried to the bottom of the bony wound, 
 the secretions are carried out as fast as 
 formed, and the healing process progresses 
 uninterruptedly and rapidly to recovery. A 
 spirally cut, soft rubber tube, with a small 
 wick of gauze placed loosely in its lumen 
 (Fig. 426), should be introduced into the 
 
 mastoid wound. A small wick of gauze is also placed in the external 
 
 auditory meatus. The outer absorbent and protective dressing consists 
 
 Method of closing the mastoid 
 incision after the simple mastoid 
 operation in acute mastoiditis. 
 The spiral rubber tube and gauze 
 drain in the lower angle of the 
 incision prevent disfigurement. 
 
 Fig. 426 
 
 -:1 ' 
 
 A spirally cut rubber tube with a small wick of gauze in its lumen constitutes one of the 
 best drainage dressings after mastoid operation. 
 
 of gauze pads, 5x6 inches, placed over the auricle and mastoid wound, 
 and held in position with a bandage applied in a fan-shaped figure 
 
 (Fig. 447). 
 
 1 In performing the simple mastoid operation for acute mastoiditis it is unnecessary to expose 
 the external auditory meatus, as is shown in the drawings. The drawings are thus made to 
 show the anatomical landmarks for teaching purposes, and for reference in describing the radical 
 and the meatomastoid operations for chronic mastoiditis. 
 
CHRONIC MASTOIDITIS 803 
 
 The bandage should not be applied under the chin or around the neck, 
 as it is uncomfortable and unnecessary. 
 
 The After-treatment. — The first dressing should be removed at the 
 expiration of three days, the wound cavity gently mopped dry with a 
 cotton-wound applicator, and another spiral tube dressing introduced. 
 The meatus should also be mopped until freed of secretions, a fresh 
 gauze wick applied, and the whole covered with gauze pads, as in the 
 first dressing. The sutures should be inspected before redressing the 
 wound, and if stitch abscesses are present they should be removed. 
 If the wound is healthy, they may be left in position until the fourth or 
 fifth day. The wound should be dressed daily as described, until the 
 secretion diminishes to a small amount, after which the tube should be 
 omitted and only a small wick of gauze introduced. The cavity will 
 then rapidly fill in from the bottom with healthy granulation tissue, and 
 at the end of from three to six weeks be entirely healed, with a slight 
 depression at the lower angle of the wound. 
 
 In exceptional cases infection of the labyrinth, sinus thrombosis, etc., 
 may develop subsequent to the operation and modify the course of the 
 reparative process, or even necessitate the adoption of other surgical 
 procedures hereinafter described. 
 
 CHRONIC MASTOIDITIS. 
 
 Chronic mastoiditis is one of those diseases which resists simple methods 
 of treatment, and for the last fifteen years the radical mastoid operation 
 has been the only treatment that insured any real success. Two years 
 ago, however, Charles J. Heath, of London, called attention to the 
 brilliant results obtained by a less radical procedure, whereby the 
 hearing was greatly improved and the disease apparently cured. Kor- 
 ner, Stacke, and others previously described an operation somewhat 
 similar to that described by Heath. Since then the author has performed 
 twenty-five operations with a modified technique, with good results. The 
 difference between the methods is that the author makes a complete 
 exenteration of all the pneumatic cells of the temporal bone and uses a 
 modified Ballance plastic meatal flap, as in the radical operation. To 
 this new operation he has given the name meatomastoid. The (a) radical 
 and the (b) meatomastoid operations will, therefore, be described as 
 remedial measures for the cure of chronic mastoiditis. 
 
 The Radical Mastoid Operation.— Technique. — The Removal of the 
 Cortex and the Exenteration of the Mastoid Cells. — The patient is pre- 
 pared as for the simple mastoid operation in acute mastoiditis. The mas- 
 toid antrum and cells are exenterated as in the simple operation in acute 
 mastoiditis (see Simple Mastoid Operation, Figs. 422, 423, and 424), 
 with this difference: In the simple mastoid operation there is no necessity 
 for making a complete exenteration; whereas in the radical operation 
 all pneumatic spaces in the mastoid process and zygomatic root, as 
 well as those in the posterior wall of the pyramid of the petrous portion 
 
804 THE EAR 
 
 of the temporal bone (Jansen), are removed. It is not enough to ex- 
 pose the cells to view, they must be totally exenterated. To fail in this 
 respect may lead to the necessity of performing a secondary operation. 
 It has been claimed by some operators, who do not completely remove 
 these cells, that it was impossible to tell when all of them had been 
 removed. They also claim that 25 per cent, of the radical mastoid 
 operations had to be followed by secondary operations. While it is 
 true that the operator cannot positively state that all the cells have been 
 removed, he can at least endeavor to remove them, and in the vast 
 majority of cases he will be successful. It has been the author's earnest 
 endeavor during a period of seven years to remove all the pneumatic 
 cells, whether in the mastoid process, zygomatic root, or in the posterior 
 wall of the pyramid, with the result that only one case has required 
 a secondary operation. The good results obtained were partially due 
 to the painstaking removal of all the pneumatic cells in the temporal 
 bone and to certain points of improved technique to be narrated in 
 subsequent paragraphs of this chapter. 
 
 The Removal of the Posterior Wall of the Bony Meatus. — Having com- 
 pleted the exenteration of the mastoid antrum and cells, the posterior 
 wall of the bony meatus is removed with a chisel, as shown in Fig. 427. 
 In the removal of this wall there are certain anatomical structures which 
 may be injured if due care is not exercised to avoid them. These struc- 
 tures are the facial nerve, the external or horizontal semicircular canal 
 (Fig. 427, b), and the dura of the middle fossa of the skull (Fig. 427, e). The 
 facial nerve emerges from the petrous portion of the temporal bone and 
 passes backward along the superior margin of the inner wall of the cavum 
 tympani just above the oval window (Fig. 427). It then courses down- 
 ward across the inner and inferior wall of the aditus ad antrum, imme- 
 diately below the upper and deeper portion of the bony wall of the meatus 
 (Fig. 427, c). From thence it passes downward, deeply buried in the 
 plate of bone forming the posterior wall of the auditory meatus, and 
 emerges just anterior to the styloid process. The nerve is most liable to 
 injury in removing the deep portion of the posterior meatal wall directly 
 over the aditus ad antrum, as it is only protected in this area by a thin 
 but dense bony covering. Should the chisel by any mischance cross the 
 space of the aditus ad antrum (the channel of communication between 
 the cavum tympani and the mastoid antrum) to its inner and inferior 
 wall, across which the facial nerve passes, facial paralysis may follow. 
 In the removal of the posterior wall of the meatus the more superficial 
 parts may be removed without fear of damaging the facial nerve, while 
 the deeper portion should be removed with due care to avoid this danger. 
 
 After the facial nerve crosses the floor of the aditus ad antrum it turns 
 sharply downward and emerges near the styloid process. As it makes 
 the bend (Fig. 427, c) it rises almost to the level of the posterior portion of 
 the annulus tympanicus, to which the membrana tympani is attached. It 
 is obvious, therefore, that the lower portion of the posterior wall of the 
 meatus cannot be removed deeper than the annulus tympanicus without 
 injuring the nerve. 
 
CHRONIC MASTOIDITIS 805 
 
 To recapitulate: The upper portion (patient in erect position) of the 
 posterior wall of the meatus may be removed in its entirety, or down to 
 the aditus ad antrum, whereas the lower portion should only be removed 
 down to the level of the annulus tympanicus or posterior segment of the 
 drumhead. The complete removal of the wall, in so far as it is com- 
 patible with the integrity of the facial nerve, is shown in Fig. 427. In the 
 meatomastoid operation the removal does not include the annulus 
 tympanicus. When completely removed, the upper bony wound extends 
 inward at almost right angles to the lateral plane of the head, whereas the 
 inferior bony wound extends inward and upward at an acute angle to 
 this same plane. 
 
 Fia. 427 
 
 The anatomical landmarks after the complete exenteration of the mastoid process and cavum 
 tympani. a, the round window; b, ridge of horizontal, semicircular canal; c, the facial ridge; d, 
 the stapes in the oval window; e, the dura of the middle fossa exposed through a perforation in 
 the tegmen antri. 
 
 Another important anatomical structure in the immediate vicinity of 
 the facial nerve as it crosses the floor of the aditus ad antrum is the 
 external or horizontal semicircular canal (Fig. 427, b). It is located a 
 little above and behind, and more superficially, than the facial nerve at 
 this point. The precautions taken to avoid injuring the nerve will 
 at the same time protect the semicircular canal. Indiscriminate curet- 
 tage of the inner wall of the cavum tympani (middle ear) may injure 
 
806 THE EAR 
 
 either the facial nerve, the semicircular canal, or the stapes and oval 
 window (Fig. 427, d). 
 
 All these structures should be constantly held in mind during the re- 
 moval of the posterior bony wall of the meatus. The dura of the middle 
 fossa (Fig. 427 e) is in but slight danger of exposure, and even when 
 exposed the probability of infection is slight, as the pathogenic micro- 
 organisms of chronic infection are but moderately virulent. One of the 
 greatest objections to the radical mastoid operation is that the hearing is 
 often impaired, especially after a period of one year. The impairment 
 of the hearing is due to two factors, namely: (a) to the displacement of 
 the foot plate of the stapes in the oval window (Fig. 427, d) at the time 
 of the operation, and (b) to the gradual displacement and fixation of the 
 foot plate of the stapes by cicatrices and contraction subsequent to the 
 operation. On the other hand, it is claimed that the radical operation 
 is justified, because in many cases it is the only known procedure that 
 will cure the chronic otorrhea and protect the patient from the dangers 
 incident to such a pathogenic process in the temporal bone. Life in- 
 surance companies have justly refused policies to persons affected with 
 chronic otorrhea, and have granted them when an aural surgeon of 
 repute has made a written statement that they were cured by the radical 
 operation. 
 
 With these facts in mind, the radical mastoid operation has been and 
 is still a justifiable procedure in properly selected cases. It is impor- 
 tant, however, that the surgeon should take every precaution in the per- 
 formance of the operation, consistent with safety to the life and health of 
 the patient, to preserve the hearing as much as possible. In order to 
 do this, the stapes and the oval window must be protected and extrac- 
 tion of the stapes from the oval window most carefully avoided. Should 
 the latter occur, it opens an avenue of infection to the labyrinth, which 
 means the almost certain loss of hearing. Fortunately, infection has rarely 
 occurred when this accident has happened in the course of the radical 
 operation, as the infective bacteria are usually of low virulency. 
 
 The removal of the posterior bony wall of the meatus converts the 
 cavum tympani, mastoid antrum, and the mastoid cells into one large 
 irregular cavity (Fig. 427), which is easily drained, and, if the plastic 
 surgery of the meatal skin flaps is properly executed, results in a cure 
 of the disease in more than 95 per cent, of the cases. 
 
 The Removal of the Malleus and Incus. — The removal of the malleus 
 and incus, or their necrotic fragments, is an essential part of the radical 
 operation, as it has been held that if they are left in position the attic of 
 the middle ear cavity will not be sufficiently drained. This is true to a 
 degree, as the bodies of these bones partially form the floor of the attic, 
 and their presence interferes somewhat with the exit of the secretions 
 from the attic or upper portion of the cavum tympani. Furthermore, 
 the complete removal of the bony partition involves the fracture and 
 removal of a portion of the annulus tympanicus, to which the membrana 
 tympani is attached. In addition to this the incus, the long process of 
 which projects backward into a sulcus of the bone forming the wall 
 
CHRONIC MASTOIDITIS 
 
 807 
 
 of the aditus ad antrum, would, in many instances, be dislocated and 
 thus rendered useless as a functionating mechanism of the ear. 
 
 The technique of the removal of the malleus and incus is compara- 
 tively simple if the skin incision or incisions have been sufficiently 
 extended to allow the complete exposure of the auditory meatus and 
 cavum tympani. The primary skin incision (Fig. 417, a a') should, at its 
 upper limit, extend one-half inch anterior to the upper attachment of the 
 auricle. This will allow the auricle to be retracted far enough forward 
 to expose the meatus and cavum tympani. 
 
 Fig. 428 
 
 The removal of the malleus and incus iD the radical mastoid operation. 
 
 When the posterior bony wall of the meatus is removed, the middle 
 ear cavity should be packed with cotton saturated with a 1 to 2000 solu- 
 tion of adrenalin chloride to check the hemorrhage. After the lapse 
 of five minutes it should be removed and the contents of the cavum 
 tympani inspected. The manubrium or handle of the malleus should 
 then be seized with small alligator forceps, dislocated downward, and 
 removed. The incus should be likewise removed. Instead of the alli- 
 gator forceps a small curette may be used, though the danger of dislo- 
 cating and extracting the stapes is thereby increased (Fig. 428). 
 
808 
 
 THE EAR 
 
 The Removal of the Outer Wall of the Attic and Atrium. — The outer 
 wall of the attic (superior wall of the external bony meatus) should be 
 removed to fully expose the tegmen tympani to inspection and curette- 
 ment. This procedure also gives the surgeon direct access to this region 
 during the after-treatments. This is accomplished with a chisel or gouge, 
 as shown in Fig. 429, a. 
 
 The outer wall of the atrium (inferior wall of the meatus) should also 
 be removed. This may be done by curetting the anterior and posterior 
 
 margins of the annulus tympani- 
 FlG - 429 cus, and chiselling away the 
 
 deeper portion of the floor of 
 the external meatus (Fig. 429, 
 b). The failure to observe these 
 points of technique may defeat 
 the object of the radical opera- 
 tion and necessitate the perform- 
 ance of a secondary operation. 
 
 The Removal of Necrosed Bone 
 from the Cavum Tympani. — Ne- 
 crosis of the tegmen tympani 
 (roof of the attic) is present in a 
 majority of the subjects of chronic 
 mastoiditis, a fact which gives 
 color to the claim that the radical 
 operation should always, or at 
 least usually, be performed in 
 these cases. This phase of the 
 subject will be more fully dis- 
 cussed under the meatomastoid operation in chronic mastoiditis. All 
 necrosed tissue in the tegmen tympani, or elsewhere in the walls of the 
 cavum tympani, should be carefully but thoroughly removed with a 
 small, sharp curette. The region of the oval window and the promon- 
 tory, as well as the external semicircular canal, should be inspected, under 
 adrenalin ischemia, with a strong reflected light for necrosed bone and 
 granulation tissue, and, if found, the proper surgical procedures should 
 be instituted to improve the conditions of the labyrinth which the necrosis 
 and granulations indicate are present. 
 
 The Curettage of the Eustachian Tube. — Many failures attending the 
 radical mastoid operation are attributed to the infected and purulent 
 discharge from the tympanic end of the Eustachian tube into the cavum 
 tympani, subsequent to the operation. With this fact in view, it has 
 been recommended that the tympanic end of the tube should be curetted, 
 or burred out, to promote its closure by granulation tissue and cicatricial 
 contraction (Fig. 430). The author has repeatedly performed this pro- 
 cedure, with an almost unbroken record of failures. He attributes the 
 failures to the fact that in nearly every instance the suppuration within 
 the tube had its- origin either in a chronic epipharyngitis or a chronic 
 ethmoidal and sphenoidal infection, to which the pharyngitis is often 
 
 Schema showing the removal of the outer wall 
 of the attic (a) (upper deep wall of the meatus) 
 in the radical mastoid operation, to expose the 
 attic in the after-treatments. 
 
CHRONIC MASTOIDITIS 
 
 809 
 
 due. Epipharyngitis may also be caused by the enlargement of the 
 posterior ends of the turbinated bodies, and to the presence of adenoids. 
 If either of these conditions is present, it should be surgically corrected. 
 The failure of the tube to close may also be due to the fact that too large 
 a burr was used. To be successful, the burr should be small enough to 
 reach to the isthmus of the Eustachian tube. If the sinus disease and 
 epipharyngitis are corrected, the curettage of the Eustachian tube would 
 almost invariably result in its permanent closure. 
 
 Fig. 430 
 
 The curettage of the tympanic end of the Eustachian tube to cause it to close. A small 
 burr or curette should be used to reach the isthmus of the tube. 
 
 Inspection of the Bony Wound. — Having completed the surgery of the 
 bone, the wound should be dried with small gauze tampons and the appli- 
 cation of adrenalin. Fistula of the external semicircular canal should 
 be especially searched for. If present, it is indicated by a small granular 
 area just posterior and above the facial ridge in the region of the aditus 
 ad antrum. If found it should not be probed or otherwise disturbed, 
 as this would break down the wall of granulation tissue deposited there, 
 and might give rise to an acute labyrinthine inflammation and cause 
 death. If anything is done at all it should be freely opened, as shown 
 in the surgery of the labyrinth. As a matter of fact, most of these cases 
 
810 
 
 THE EAR 
 
 will recover without an operation other than the radical mastoid opera- 
 tion, as this establishes free drainage and checks the necrotic process. 
 
 The Plastic Surgery of the Cutaneous Meatus. — The success of the 
 radical mastoid operation often largely depends upon the proper use of 
 the skin of the auditory meatus in lining the bony cavity of the mastoid 
 wound. The bone of the mastoid process is frequently sclerosed, and 
 affords scant soil for the formation of granulation tissue with an epider- 
 mis covering. The granulation tissue in such subjects is poorly nour- 
 ished, as the blood supply from the underlying bone is scant, and infec- 
 tion, therefore, often occurs. The reparative process is thus hindered, 
 and the after-treatment may be extended over a period of several months. 
 This deplorable state of affairs may be largely overcome by the proper 
 disposition of the meatal skin flaps against the bony walls of the mastoid 
 wound. The plastic flaps thus reflected become adherent to the walls of 
 the mastoid wound, and immediately cover a large portion of the bone 
 
 Fig. 431 
 
 Curved flat scissors. 
 
 which would otherwise have to depend upon the reparative granu- 
 lation tissue, springing from the bone. In addition to this, the full blood 
 supply of the meatal flaps insures the rapid extension of granulation 
 tissue from their edges. The scant blood supply from the sclerotic bone 
 of the mastoid process is thus complimented by that of the meatal skin 
 flaps, and a speedy regeneration and epidermization of the entire mas- 
 toid wound may be confidently expected. In exceptional cases it will be 
 necessary to resort to plastic skin flaps from the margins of the mastoid 
 wound, or upon Thiersch grafts, as recommended by Charles Ballance. 
 (See Thiersch Grafts.) 
 
 The technique of the formation and application of the plastic flaps of 
 the meatus to be described is after the method recommended by Ballance. 
 The form of the flaps is after Ballance. The suturing to hold them in 
 position is, so far as known, original with the author. 
 
 Before making the incision in the meatus all the tissue on the posterior 
 surface of the cutaneous meatus should be removed with short, stout, 
 curved scissors (Fig. 431). This should be carried to the extent shown 
 in Fig. 433, which shows the whole of the meatus and a portion of the 
 concha divested of all tissue except the cartilage of the concha. The 
 
CHROXIC MASTOIDITIS 
 
 811 
 
 skin of the concha is included in the upper plastic flaps. This extensive 
 removal of all the tissues, as shown, is essential, because by so denuding 
 them the meatal flaps can be more perfectly and extensively applied to 
 the bony walls of the mastoid wound. It is obvious that the meatal flaps, 
 with the thick, tendinous, fibrous, muscular, and cartilaginous tissues 
 attached to them, could not be properly reflected and adapted to the walls 
 of the mastoid wound. 
 
 Fig. 432 
 
 Removing the fibrous and muscular tissue from the posterior surface of the cutaneous 
 meatus and concha, preparatory to making the plastic meatal flaps. 
 
 Having prepared the meatus and concha as described in the preceding 
 paragraphs, and as shown in Fig. 433, the Ballance incision, sometimes 
 referred to as the " shepherd's-crook" incision, should be made. While 
 it is by no means as easy as might be inferred from the schematic draw- 
 ings, it is nevertheless comparatively so if the superfluous tissue is 
 removed as recommended. The blades of Allport's divulsion forceps 
 (Fig. 434) should be introduced into the meatus with the tips at the inner 
 end of the meatal tube. They should then be spread, to put the meatal 
 tube upon a slight tension, and should be placed so that the open space 
 between them is at the posterior inferior segment of the tube, in order 
 
812 
 
 THE EAR 
 
 that the straight incision may be made through this portion of the meatus, 
 while the curved portion is made from the anterior surface of the auricle, 
 as shown in Fig. 435. If the cartilage of the conchal portion of the upper 
 
 Fig. 433 
 
 The Ballance incision. The straight portion is made in the posterior inferior portion of the 
 meatus, and the curved portion in the concha. The curved portion should be made from the an- 
 terior aspect of the concha (Fig. 435). 
 
 flap has not already been removed, it should be done at this time, as it 
 will otherwise interfere with the placement and attachment of the flap 
 to the bony wall of the mastoid wound. 
 
 Fig. 434 
 
 Showing the method of splitting the posterior wall of the skin meatus with Allport's meatus 
 divulsor in position to convert it into flaps for reflecting into the upper and lower portions of the 
 mastoid bone cavity. 
 
 Ballance stitches the flaps to the posterior fleshy surface of the ante- 
 rior or auricular mastoid flap. According to the author's method, the 
 plastic meatal flaps are anchored to the posterior mastoid flaps, as shown 
 
CHRONIC MASTOIDITIS 
 
 813 
 
 Fig. 435 
 
 Fig. 436 
 
 \(>H . , 
 
 The Ballance plastic meatal incision. The 
 incision begins in the posterior wall of the 
 meatus (straight dotted line) and extends into 
 the concha in the form of a shepherd's crook. 
 
 The plastic flaps slightly retracted with the 
 anchor sutures in position. 
 
 Flo. 437 
 
 The plastic meatal flaps with the anchor sutures in position. When the auricle is placed in 
 its proper position and the anchor stitches are drawn over the rolls of gauze (Figs. 438 and 439) 
 the plastic meatal flaps will partially line the mastoid wound. 
 
814 
 
 THE EAR 
 
 in Figs. 436, 437, and 438. Two sutures are used in the superior meatal 
 flap, one in the conchal portion, one in the meatal portion, and but 
 one in the abbreviated inferior meatal flap (Fig. 437). One thread 
 of each suture is introduced beneath the skin and subcutaneous tissue 
 of the posterior mastoid flap for a distance of three-quarters of an inch, 
 and then through these tissues to the surface of the skin. The other 
 thread of each suture is placed in the primary mastoid incision (Figs. 
 436, 437, and 438). Before piercing the mastoid skin with the sutures 
 the auricle and mastoid flaps should be placed in their proper relations 
 
 Fig. 438 
 
 The postauricular incisions closed and the anchor sutures tied over small rolls of gauze. The 
 anchor sutures retract the plastic meatal flaps into the mastoid wound, when they become ahhe- 
 rent and partially cover the bony surface with true skin. The whole surface is finally covered by 
 extension from the borders of the plastic flaps. 
 
 to the head, and traction should be made upon each suture until the 
 flaps assume the proper position in the mastoid wound. The conchal 
 suture should be thus tested and its location determined. The meatal 
 suture of the superior meatal flap should next be tested, and, finally, 
 the inferior meatal suture. The flaps should be properly located and 
 stitches in the posterior mastoid flap placed accordingly. The ends 
 of the sutures should then be secured with artery forceps until the 
 mastoid incision is completely closed by sutures. The anchor sutures 
 should then be tied over small rolls of gauze (Figs. 438 and 439), be- 
 ginning with the upper, and thence to the lower ones, until the flaps 
 
CHRONIC MASTOIDITIS 
 
 815 
 
 assume the desired positions in the mastoid wound. The upper flap is 
 drawn against the roof of the mastoid wound, while the lower is drawn 
 
 Fig. 439 
 
 The drainage dressing consists of a spirally cut soft rubber tube with a small wick of 
 gauze in its lumen. 
 
 Ftg. 440 
 
 ) 
 
 The Siebermann Y-plastic incision of the concha and skin meatus. Three flaps are formed 
 by it, an upper and a lower meatal flap and a V-shaped conchal flap. The cartilage should 
 be removed from the V-shaped conchal flap, and each should be drawn backward into the 
 mastoid wound by sutures and fixed in position. 
 
816 
 
 THE EAR 
 
 over the facial bridge. The bony walls being removed, and the cutaneous 
 flaps reflected into the mastoid cavity, and permanent free drainage 
 and ventilation of the middle ear and mastoid cavities thereby assured, 
 the dressings may be applied via the external auditory meatus, as shown 
 in Fig. 439. Other methods of making the plastic meatal flaps are 
 shown in Figs. 440 to 445. 
 
 Fig. 441 
 
 Showing the Troutmann tongue flap, which should be reflected into the mastoid wound and held 
 in apposition to its posterior surface by small pledgets of gauze packed over cargile membrane. 
 Remove the gauze in forty-eight hours. 
 
 Fig. 442 
 
 Fig. 443 
 
 The Panse plastic incision of the meatal skin. 
 
 The Jansen-Stacke plastic incision. This 
 flap should be used when the sigmoid sinus 
 and jugular bulb are exposed. The flap is 
 turned downward and backward and thus 
 covers these areas. 
 
 After-treatment.- — The primary dressing is identical with that for 
 acute mastoiditis, with the single exception that the spiral tube and 
 gauze are inserted through the enlarged meatal opening in the concha 
 (Fig. 439) instead of through the postauricular wound. The distal end 
 of the tube is placed into the deepest portion of the mastoid wound. 
 
CHRONIC MASTOIDITIS 
 
 817 
 
 This should be removed on the fifth day, or earlier if the temperature 
 persistently remains above 102° F., or if severe pain develops and per- 
 sists. The wound should be mopped dry with a cotton-wound appli- 
 
 Fig. 444 
 
 Showing the method of making the Jansen modification of the Staeke plastic flap of the skin 
 meatus. The inferior large flap should be reflected into the lower portion of the mastoid wound 
 and held in place by anchor stitches. The upper short flap should be reflected into the upper 
 portion of the mastoid wound and held in place by an anchor stitch. 
 
 Fig. 445 
 
 Fig. 446 
 
 A collodion dressing used in the after-treat- 
 ment of operative mastoiditis. A loose wick 
 of gauze is inserted into the mastoid wound 
 through the external meatus and covered with 
 a film of cotton, which is then saturated with 
 an ether solution of collodion to seal it. 
 52 
 
 The appearance of the concha and 
 external auditory meatus, after healing is 
 complete. 
 
818 
 
 THE EAR 
 
 Fig. 447 
 
 cator, inspected for exuberant granulations, and a fresh sterilized tube 
 and gauze inserted. If exuberant granulations are present, they should 
 be reduced by painting them with 95 per cent, carbolic acid, and, after 
 the lapse of one minute, with alcohol, to check the action of the acid. 
 This method of treatment should be continued daily for ten days after the 
 operation. After this the tube may be abandoned and a small wick of 
 gauze inserted into the wound at its most dependent portion and extended 
 to the concha. Small gauze pads should be placed in the concha of the 
 auricle to catch the secretions drawn out by the gauze wick. Large pads 
 are placed over the auricle and mastoid region and secured with the fan- 
 shaped bandage (Fig. 447). After the tenth day the large gauze pad and 
 bandage may be omitted and the dressing applied in the cavity of the 
 auricle instead. This should be secured by placing a thin film of cotton 
 
 over it (Fig. 445) and painting it with 
 an ethereal solution of collodion (Pierce). 
 The mastoid wound usually becomes 
 covered with squamous epithelium in 
 from three weeks to two months, though 
 the process may cover a longer period 
 of time. Various factors may cause a 
 prolongation of the period of repair, 
 chief of which are suppurative inflam- 
 mation of the epipharynx, ethmoiditis, 
 sphenoiditis, and an infection of the 
 Eustachian tube. Certain constitutional 
 dyscrasias, as syphilis, tuberculosis, and 
 struma, may also lower the vitality of 
 the tissues and prolong the reparative 
 process. 
 
 The disfigurement following the Bal- 
 lance plastic meatal flaps is slight (Fig. 
 443). It should be said, however, that 
 chondritis of the auricle with marked 
 shrinkage and deformity may follow any 
 of the plastic operations which include the cartilage of the concha. 
 Every effort should be made to prevent the infection of the wound either 
 during or after the operation. The edges of the conchal wound should 
 be touched with carbolic acid to seal up the lymph spaces. 
 
 The Meato mastoid Operation. — This operation may be called a modified 
 radical mastoid operation, though it does not include the exposure 
 of the middle ear. It does, however, include the plastic meatal flaps 
 and the removal of the posterior bony wall of the meatus down to the 
 annulus tympanicus. The postauricular wound is closed as in the 
 radical operation, and the dressings are applied through the concho- 
 meatal wound. 
 
 The advantages claimed for this operation over the radical operation 
 in chronic mastoiditis are: (a) The preservation of the function of the 
 middle ear contents, and of the membrana tympani; (b) an improve- 
 
 Method of applying a bandage over 
 the ear and mastoid process. 
 
CHRONIC MASTOIDITIS 819 
 
 ment in the hearing, whereas in the radical operation the hearing is 
 either unchanged or impaired; (c) the closure of the perforation in the 
 membrana tympani which often takes place after the necrosis and granu- 
 lations have disappeared; (d) the drainage of the secretions from the 
 antrum and mastoid cells into the auditory meatus through the opening 
 in the posterior wall of the meatus, thus relieving the Eustachian tube 
 of the excess of secretions. 
 
 The principle upon which the operation is based is that if ample 
 drainage is provided the infectious process tends to subside and the dis- 
 eased tissue to heal. The removal of the posterior wall of the bony 
 auditory meatus and the retraction of the plastic meatal skin flaps into 
 the mastoid wound provide for the drainage of the mastoid antrum 
 and cells, and thus remove the stress from the Eustachian tube. The 
 Eustachian tube, being relieved, is usually ample to drain the cavum 
 tympani, even when chronically infected. As a result, the resistance 
 of the diseased membrane, periosteum, and bone is increased, and the 
 infection gradually subsides. The mucous membrane, periosteum, and 
 bone become healthy and "heal out." 
 
 Heath claims that the removal of the fragments of the malleus and 
 incus often disturbs the relation of the stapes to the fenestra vestibuli 
 (oval window), and thus impairs the hearing. That is, the stapedius 
 muscle pulls the stapes backward and displaces the foot plate of the stapes 
 in the window. This could be obviated in the radical operation by 
 severing the tendon of the stapedius muscle. 
 
 The reported cases have been so few in number that it is impossible 
 to estimate the place the operation should have in the surgery of chronic 
 mastoiditis. The results thus far reported have been so good, and the 
 principle upon which the operation is based appears so rational, that the 
 technique of the operation is herewith given. 
 
 Technique. — (a) Prepare the patient as for the simple and radical 
 mastoid operations. Extend the skin incision well forward above the 
 auricle as in the radical operation, as this will allow the external bony 
 meatus and drumhead to be clearly seen during the operation. 
 
 (6) Expose the mastoid antrum and cells as in the radical operation. 
 
 (c) Remove the posterior bony wall of the auditory meatus down to 
 the annulus tympanicus, as shown in Fig. 448. At no time during the 
 operation should the membrana tympani and the ossicles of the cavum 
 tympani be injured by probing or other instrumental procedure. The 
 introduction of a probe into the meatus to determine its depth and direc- 
 tion, as recommended in the radical operation, should be studiously 
 avoided. If this precaution is not observed, the ossicles may be dislocated 
 and the hearing impaired. The posterior wall of the meatus should be 
 removed as widely as possible to provide free drainage and access 
 to the exenterated antrum and cells through the auditory meatus during 
 the after-treatment. It is sometimes necessary to remove some bone from 
 the outer portion of the superior wall of the meatus to fully expose the 
 drumhead to view. Enough should be removed to fully expose the 
 membrana tympani to inspection after the auricle is replaced and 
 
820 
 
 THE EAR 
 
 sutured in position. The proper prosecution of the after-treatment 
 will largely depend upon the completeness with which this step of the 
 operation is carried out. 
 
 (d) The plastic meatal flaps should now be formed as in the radical 
 operation. The operator's individual preference may be used, though it 
 is essential that the skin of the concha be included in the flaps, so as to 
 enlarge the meatal opening and facilitate the application of the dress- 
 
 Fig. 448 
 
 
 The removal of the posterior wall of the external auditory meatus down to the annulus tympanicus 
 in the meatomastoid operation. Dotted lines indicate the amount to be removed. 
 
 ings to the mastoid wound. This procedure also aids in the inspection 
 of the membrana tympani. The author has found the Ballance incision 
 the most satisfactory for this purpose. The reader is referred to Figs. 
 432 to 444 for the details of the various plastic meatal flaps, with the 
 suggestion that in applying them to this operation they should be so 
 utilized as not to obstruct the opening made by the removal of the 
 posterior bony wall of the auditory meatus. 
 
CHRONIC MASTOIDITIS 
 
 821 
 
 (e) Retract the meatal plastic skin flaps with the author's retractor 
 to bring the membrana tympani into view, as shown in Fig. 449. This 
 will greatly facilitate the next step in the operation, as it is necessary 
 to see the membrana tympani during its performance. If the meatal 
 retractor is not used the meatal flaps will constantly obstruct the view 
 and hinder the operator in his work. 
 
 (J) Insert a cannula, as recommended by Heath, into the aditus ad 
 antrum via the antrum (Figs. 449 and 450), and, with an attached rubber 
 bulb, send blasts of air into the cavum tympani. The secretions and 
 
 Fig. 449 
 
 The meatomastoid operation (bony portion) complete. The curved cannula is inserted into the 
 aditus ad antrum, preparatory to blowing blasts of air through the cavum tympani, to remove the 
 secretions and debris. The author's meatus retractor makes the view of the membrana tympani 
 possible during this procedure. 
 
 pedunculated granulations within the middle ear cavity are blown out 
 through the perforation in the membrana tympani into the auditory 
 meatus. The middle ear may also be irrigated with the same apparatus. 
 (g) If granulations or polypi are thus blown through the perforation, 
 they should be grasped by small dressing forceps and removed. If they 
 appear at the perforation, but do not protrude through it, they may be 
 removed by gently pressing the forceps blades (one on either side of the 
 perforation) against the margins of the perforation, thus bringing them 
 within the grasp of the forceps. The blasts of air should be repeated 
 
822 
 
 THE EAR 
 
 until all the secretions, polypi, and debris are expelled from the tym- 
 panic cavity. Tubes of various sizes should be at hand, so that one may 
 be selected that fits the aditus ad antrum. It may be necessary to 
 modify the shape of the antral aspect of the aditus with a small curette 
 or hand burr, to adapt it to the cannula (Heath). If the tube is too 
 small, it may pass so far into the aditus as to dislocate the incus and thus 
 impair the hearing. 
 
 Fig. 450 
 
 Schema of the ear, showing the method of cleansing the tympanic cavity after the meatomas- 
 toid operation, a a, mastoid cells; b, antrum; c, aditus ad antrum; d, membrana tympani; e, per- 
 foration in the membrana tympani; f, annulus tympanicus; h, external meatus, the posterior 
 wall of which is removed; i, the auricle; j, silver cannula introduced through the opening in the 
 posterior opening in the meatus, and thence forward into the aditus ad antrum c; air pressure 
 applied with a rubber bulb forces the secretions, granulations, etc., from the tympanic cavity 
 through the perforation (e) in the membrana tympani into the meatus. 
 
 (h) Having removed the secretions, polypi, and debris from the tym- 
 panic cavity with the air blasts and forceps, place a small wet pad of 
 cotton over the perforation in the membrana tympani, and a small plug 
 of the same material in the antral end of the aditus ad antrum to keep 
 the blood and bone chips from entering the middle ear. 
 
 (i) Anchor the plastic meatal flaps, as in the radical mastoid operation, 
 with suitable stitches (Figs. 438 to 439). 
 
 (j) Close the postauricular incision as in the radical operation. 
 
 (k) Introduce the tube dressing (Fig. 439) through the auditory 
 meatus into the mastoid wound. Do not place it against the membrana 
 tympani, but pass it backward through the opening in the posterior wall 
 of the meatus into the mastoid cavity. If other forms of dressing are 
 preferred, they should be introduced in the same manner. Whatever 
 
CHRONIC MASTOIDITIS 823 
 
 dressing is employed, it should be loosely placed, not packed, as its 
 primary purpose is to facilitate drainage. Some operators recommend 
 that gauze be firmly packed into the mastoid wound to "keep down" the 
 granulations. If the operation is thoroughly done under aseptic con- 
 ditions, exuberant granulations will not form; furthermore, good drainage 
 lessens the tendency to their growth. Exuberant granulations are the 
 product of infection, whereas healthy granulation tissue is formed in the 
 process of repair. Many cases pursue a prolonged process of repair 
 because the dressings are packed in the mastoid wound. If the surgeon 
 grasps the purpose of the wound dressing, namely, to promote drainage 
 (and this alone), he will only insert enough gauze to carry away the 
 secretions. The author uses a one-half to one inch strip of gauze in the 
 rubber tube for this purpose and finds it adequate. If the foregoing 
 technique is observed, exuberant granulations will not form nor will the 
 healing process be prolonged. 
 
 The ear should be covered with several large gauze pads,which should 
 be removed in from three to five days, the wound gently dried with a 
 cotton-wound applicator introduced through the auditory meatus, and a 
 new tube dressing applied. This should be changed daily. The sutures 
 should be removed on the fifth day. 
 
 The membrana tympani should be inspected daily, especially when the 
 blasts of air are forced through the aditus ad antrum. After the mastoid 
 wound is cleansed with the cotton-wound applicator the curved cannula 
 should be introduced into the aditus via the meatus and the opening in 
 the posterior wall of the meatus (Figs. 449 and 450) and blasts of air forced 
 through the tympanic cavity to clear it of secretions and granulations. 
 All granulations or polypi appearing at the perforation in the membrana 
 tympani should be removed with forceps or with caustics. Heath insists 
 upon the value of the blasts of air through the tympanic cavity until 
 the aditus ad antrum becomes closed (eight to fourteen days). The 
 author has followed his method and finds it to be of great value in the 
 after-treatment. By it large quantities of mucus and pus are forced 
 into the external meatus, from which they may be removed with a cotton- 
 wound applicator. The secretions may also be removed by inflation 
 through the Eustachian tube, though this is not as efficacious as Heath's 
 method. 
 
 The secretions and granulations from the middle ear gradually subside 
 as the perforation closes. The mastoid cavity usually becomes filled with 
 connective tissue, thus closing the aditus. It becomes lined with epi- 
 dermis and remains a dry cavity, and the Eustachian tube is no longer 
 burdened with the secretions from this source. 
 
 Of the twenty-five cases thus operated by the author, all have healed 
 and are covered with epidermis. In one complicated by an epidural 
 abscess over the tegmen tympani it was necessary to convert it into a 
 radical operation. The membrana tympani reformed in six cases, and 
 the hearing returned to almost the normal in all but one. In this method 
 of operation the mastoid wound is almost filled in the process of 
 repair. 
 
824 
 
 THE EAR 
 
 Thiersch Grafts in the Mastoid Wound. — To Reinhard, Jansen, and 
 Ballance belong the credit of applying the Thiersch grafts to the mastoid 
 wound. Ballance has, perhaps, used it more constantly and frequently 
 
 Fig. 451 
 
 Hajek's hand bui 
 
 than anyone else, and his technique is generally followed. Personally 
 the author has had but rare occasion to use it, as his cases usually became 
 covered with epidermis in as short a time as is claimed by Ballance after 
 the use of the Thiersch grafts. In only two cases has it been necessary to 
 
 Fig. 452 
 
 After the exenteration of the mastoid cells in chronic mastoiditis, the surface should be made 
 smooth with a curette and burr, to promote rapid healing. 
 
 apply the grafts, and in these they were successfully applied after sec- 
 ondary operations. By using the Ballance plastic meatal skin flaps, and 
 fixing them as in Fig. 441, the author's cases have, with rare exceptions, 
 
CHRONIC MASTOIDITIS 
 
 825 
 
 healed with epidermis over the walls of the mastoid wound in from 
 three to ten weeks, rarely longer. This good showing is due to several 
 factors, chief among which are: (a) The Ballance plastic meatal flaps 
 applied after the author's method, (b) The use of the spiral rubber 
 tubing with a small wick of gauze in its lumen as the sole drainage dress- 
 ing. This dressing, as already explained, provides good drainage, which 
 establishes conditions discouraging the formation of unhealthy granu- 
 lations, (c) Another cause of the rapid epidermization of the mastoid 
 wound is the complete exposure and exenteration of the mastoid antrum 
 and cells. The cells of Kirschner, between the antrum and meatus, and 
 those in the posterior root of the zygoma and in the posterior wall of the 
 pyramid of the petrous portion of the temporal bone are likewise care- 
 fully sought for, and if present removed, (d) Rendering the edges and 
 the surfaces of the bony mastoid wound smooth with a curette and burr 
 also favors a rapid reparative process (Fig. 452). 
 
 Fig. 453 
 
 Thiersch's uraft razor. 
 
 If the surgeon finds that a considerable number of his cases pursue a 
 prolonged course of healing, he should carefully scrutinize his technique, 
 and, if found to be faulty at any point, improve it accordingly. If his 
 cases still refuse to heal properly he may try the Thiersch grafts. 
 
 Technique. — (a) The grafts maybe applied at the close of the primary 
 operation, ten days after the primary operation, or after a secondary 
 operation. Dench applies the grafts at the close of the primary opera- 
 tion. Ballance ten days after the primary operation. The author 
 only after a" secondary operation; that is, only after it is conclusively 
 shown that repair will not follow the primary operation. Since adopting 
 the technique described in the radical mastoid operation, the author has 
 not had more than 1 per cent, of cases requiring a secondary operation, 
 whereas in his earlier practice it was about 10 per cent. 
 
 (6) The patient's arm or thigh should be shaved and scrubbed twenty- 
 four hours before grafting, a moist carbolized dressing applied, and held 
 in position with a bandage. 
 
 (c) The patient should be anesthetized for the reason that (1) it 
 prevents the "goose-flesh" contraction of the skin, which so materially 
 interferes with cutting thin Thiersch grafts, and (2) it also prevents the 
 pain incident to securing the grafts and opening the wound for their 
 application. If the grafting is done at the time of the primary opera- 
 
826 THE EAR 
 
 tion, the patient is already anesthetized and the arm or thigh prepared 
 when the mastoid region was shaved. 
 
 (d) Rescrub the skin after the bandage and dressing are removed. 
 
 (e) With the skin moistened with normal salt solution and drawn 
 tight between the forefinger and thumb, remove the thin cortex by 
 a rapid sawing motion with the broad Thiersch razor (Fig. 453). The 
 razor is flat upon one side, while the other (the upper) is concave. Nor- 
 mal salt solution should be dropped into the hollow surface of the razor 
 to float the graft. The size of the graft should be about 2 x 3 cm., or 
 large enough to cover the entire bony wound. 
 
 Fig. 454 
 
 Thiersch's graft spatula. 
 
 (f) Float the graft from the razor blade to the large spatula (Fig. 
 454), using a teasing needle (Fig. 455) in transferring it. 
 
 (g) The mastoid wound, having been previously opened and freed of 
 all blood and oozing, is made the repository of the graft. With a teasing 
 needle (Fig. 455) the edge of the graft is transfixed to the border of the 
 mastoid wound and the spatula gradually withdrawn. The graft is 
 thus deposited smoothly and evenly over the surface of the wound. If 
 necessary, other grafts are applied. 
 
 (h) The grafts should be pressed against the walls of the wound with a 
 small blunt instrument until they are closely adherent to their uneven 
 surfaces (Fig. 457). A small glass pipette or medicine dropper may be 
 used to withdraw bubbles of air from beneath the grafts. Some operators 
 
 Fig. 455 
 
 saaaiaaaasaaiMi 
 
 Teasing needle for Thiersch's grafting. 
 
 prefer to first fill the mastoid cavity with normal salt solution and float 
 the graft upon its surface. The fluid is then gradually withdrawn with a 
 pipette until the graft rests upon the surface of the bony wound. It is 
 not necessary to engraft the entire surface of the wound, as the interspaces 
 soon become covered by extension from the edges of the grafts. 
 
 (i) Ballance formerly covered the grafts with very thin gold-foil to 
 prevent the small cotton pads adhering to them and dislodging them 
 when the dressing was removed. He now applies the cotton balls 
 directly to the grafts, with good success. As a matter of fact, the grafts 
 will remain in position, if properly adjusted (evenly and closely applied), 
 
CHRONIC MASTOIDITIS 
 
 827 
 
 without either gold-foil or the gauze pads. The postauricular wound 
 should be reclosed with sutures after the grafts are applied and the 
 subsequent dressings applied through the enlarged auditory meatus. 
 
 Fig. 456 
 
 The Thiersch graft being applied to the mastoid wound. 
 
 (;) The small cotton balls are used to hold the grafts in apposition to 
 the granulating bony wound, and they should be removed on the third 
 
 Fig. 457 
 
 The Thiersch graft in position. Other grafts are introduced until the entire bony surface is covered. 
 
 day. Portions of the grafts will not "take" or grow, hence necrosis 
 occurs, giving rise to a horrible stench. The engrafted area should be 
 gently mopped dry with a cotton-wound applicator, the necrosed particles 
 
828 
 
 THE EAR 
 
 removed, and a fresh dressing applied. The dressing should be renewed 
 daily, as after the mastoid operation. 
 
 Fig. 458 
 
 Mastoid incision made in infants, a, a, the proper location of the incision. The lower end of the 
 incision should be about one-half inch posterior to its position in adults in order to avoid injuring 
 the facial nerve at its exit from the mastoid bone at b. a, a, the proper location of the mastoid 
 incision in children. 
 
 Fig. 459 
 
 Bezold's mastoiditis. The wound is closed with Michel's metal clamps, a, spiral tube draining the 
 mastoid wound; b, spiral tube draining the abscess of the anterior triangle of the neck. An acces- 
 sory incision is used to drain the abscess, as this will heal quickly after the tube is removed. Tf 
 the tube makes its exit at the lower portion of the primary incision, healing will be slow and a 
 scar left, as this is in the infected field. The portion of the incision below the mastoid also repre- 
 sents the incision for the excision of the external jugular vein and for the removal of the glands 
 of the neck. 
 
CHRONIC MASTOIDITIS 
 
 829 
 
 It should be borne in mind, however, that Thiersch grafts will rarely 
 be necessary if the cutaneous portion of the external auditory meatus is 
 
 Fig. 460 
 
 Allport's mastoid retractor. 
 Fig. 461 
 
 Jansen's mastoid retractor. 
 Fig. 462 
 
 Allport's bone-crushing forceps. 
 Fig. 463 
 
 McKernon's rongeur forceps. 
 
830 
 
 THE EAR 
 
 properly and intelligently utilized to line the mastoid wound, and if the 
 cells are completely exenterated and the whole surface rendered smooth 
 with a curette and burr. 
 
 The Mastoid Operation in Infants and Young Children. — As the mastoid 
 tip and cells are but slightly developed before the age of puberty, the 
 technique of the mastoid operation should be somewhat modified. 
 The rudimentary tip of the mastoid process is located much higher and 
 more posteriorly than in adults. 
 
 Fig. 464 
 
 Jansen's rongeur forceps. 
 Fig. 465 
 
 Reverdin's needle. 
 
 Fig. 467 
 
 Scheibel's suture forceps. 
 
 Michel's metal clamp suture. 
 
 Fig. 468 
 
 Michel's suture clip forceps. 
 
 The postauricular incision should, therefore, begin higher and more 
 posteriorly, as shown in Fig. 458. Furthermore, the facial nerve makes 
 its exit from the styloid foramen quite near the surface of the mastoid, and, 
 if the incision is made as in adults, it may be injured and cause facial 
 paralysis. The mastoid antrum is almost or fully developed at birth, 
 and is often the only portion of the mastoid bone involved. 
 
SURGERY OF THE LABYRINTH 831 
 
 The Surgical Treatment of Bezold's Mastoiditis. — The early surgical 
 treatment is the only procedure that is applicable in this affection. The 
 usual mastoid incision is made with an extension downward beyond the 
 tip of the mastoid, parallel with the anterior border of the sternomastoid 
 muscle to the lowest portion of the brawny swelling of the neck. The 
 aponeurosis of the sternomastoid muscle is divided and retracted. The 
 mastoid is opened from below upward, toward the antrum. All the 
 mastoid cells are thoroughly curetted until the perforation in its inner 
 plate is located. The perforation is followed into the loose tissues of the 
 neck, and the granulations removed with a dull curette. The rough 
 projections of bone are smoothed with a burr or curette and the ragged 
 edges of the muscles are trimmed off with scissors. If the abscess has 
 burrowed into the neck anteriorly or posteriorly, it is necessary to lay it 
 wide open and thoroughly remove all diseased tissue with a curette. The 
 mastoid portion of the incision should then be closed over a spiral tube 
 with gauze in its lumen, the distal end of which is placed in the mastoid 
 wound (Fig. 459). If the abscess extends into the neck, the incision 
 should be closed over another spiral rubber tube, which is allowed to 
 drain through a separate incision back of the lower end of the neck 
 incision, as shown in Fig. 459. 
 
 The dangers attending this operation are the wounding of the facial 
 nerve at its exit from the bony canal in the mastoid process, and the 
 spinal accessory nerve going to the trapezius muscle. If this nerve is 
 wounded the shoulder will droop. The lateral sinus is also in close 
 proximity to the perforation, hence great care should be taken in oper- 
 ating in this region. 
 
 If the disease is recognized early and prompt and thorough surgical 
 measures are instituted the prognosis is fair, although the recovery may 
 extend over several weeks, as the healing of the wound after such an 
 extensive operation requires considerable time, and not infrequently a 
 secondary abscess forms in the neck because of poor drainage. 
 
 SURGERY OF THE LABYRINTH. 
 
 Indications. — The extent to which the labyrinth may be surgically 
 exenterated is still to be determined by additional experience. That it 
 may be successfully invaded has been already demonstrated. The 
 dangers arising from the possible and probable extension of the infec- 
 tion from the labyrinth to the cranial contents are so grave that the 
 surgeon is occasionally justified in opening the labyrinth, at least suffi- 
 ciently to establish free drainage of the cochlea, vestibule, and the semi- 
 circular canals. The dangers attending the complete exposure of the two 
 and one-half coils of the cochlea are so great that it is extremely doubtful 
 if such an operation should ever be attempted in those cases in which 
 the labyrinthine infection is virulent and progressive. In cases in which 
 the bony perforation is covered by granulation tissue and the infection 
 and destructive processes are not active the granulations should not 
 
832 THE EAR 
 
 be disturbed by probing, nor should the labyrinth be operated. Such 
 cases should be carefully observed for a few days after the radical mas- 
 toid operation, and if threatening symptoms develop, the mastoid wound 
 should be exposed and the labyrinth drained by one of the methods 
 to be described. The surgeon should be extremely conservative about 
 opening the labyrinth so long as it still functionates, i. e., so long as 
 either spontaneous or induced nystagmus and hearing are present. If 
 the static and auditory functions are lost and suppuration and necrosis 
 of the labyrinth are present, the labyrinth may be operated upon to 
 prevent the extension of the infection to the brain. (See Functional 
 Tests of the Vestibular Apparatus.) 
 
 Indications for the Labyrinth Operation in Labyrinthitis. — 
 Labyrinthitis may heal spontaneously, by being limited through the 
 action of leukocytes and the organization of the exudate forming- con- 
 nective tissue, which later ossifies. It may also heal by sequestration and 
 granulation. When healing does not take place the labyrinthitis may 
 remain circumscribed for an indefinite period, but is always subject to 
 acute exacerbation when it becomes diffused. 
 
 Acute diffused labyrinthitis is exceedingly dangerous to life, as it is 
 so often promptly followed by either brain abscess or meningitis. In 
 consequence of the large death rate the question of operation must be 
 considered, especially as the operation is not particularly dangerous or 
 complicated (Politzer). When there is a profuse discharge with pain upon 
 pressure over the mastoid, or periosteal abscess, fever, and headache, 
 the radical mastoid and labyrinth operation must be done promptly. If 
 these urgent symptoms are not present, it may be advisable to wait ten 
 days until the suppuration is walled off by granulation tissue. 
 
 In circumscribed labyrinthitis, which is, of course, a chronic disease, 
 the question of operation should be determined first by the probability 
 of an acute exacerbation. This is most likely to occur in the unintelli- 
 gent and uncleanly, who cannot be made to appreciate the advantage 
 of being under more or less constant observation, and second, in cases 
 with masses of cholesteatoma, the formation of which is difficult to 
 control. 
 
 Marked deafness in the diseased ear speaks for the operation, even 
 though not complete, as there is little to be lost. 
 
 Deafness in the opposite ear, when either complete or partial, and 
 the fact that conversational speech is only heard in the diseased ear, 
 contra-indicates the operation. 
 
 When the attacks of vertigo are severe and frequent the patient may be 
 so incapacitated by them as to make the operation necessary even when 
 the hearing in the affected ear is relatively good. 
 
 If the hearing in the opposite ear has been lost or is very bad, the 
 destruction of one labyrinth by operation would cause a disability 
 without the redeeming feature of periods of freedom from attacks. It 
 will be necessary to consider this very carefully and perhaps direct 
 the effort first toward improvement of the hearing in the otherwise 
 sound ear. 
 
SURGERY OF THE LABYRINTH 833 
 
 Some patients with circumscribed labyrinthitis (fistula) complain of 
 bad hearing with subjective noises in the ear at one time, and at another 
 are quite free of these conditions. These are usually cases of long 
 standing with rather severe attacks of vertigo. When there is no contra- 
 indication from the other ear or the general health, it is better to operate. 
 The radical mastoid operation may be sufficient, though it must be 
 remembered that after healing of fistula the attacks of vertigo sometimes 
 last for years ultimately requiring the labyrinth operation. 
 
 If the radical mastoid operation alone is performed, the fistula must 
 not be touched. If by chance the fistula is disturbed, the labyrinth 
 operation must be performed at once, as an acute exacerbation and 
 diffused suppurative labyrinthitis will probably occur. 
 
 In addition to the foregoing specific indications, it must be said that 
 in general a functionating labyrinth should not be opened unless positive 
 indications to the contrary exist; and that a non-functionating labyrinth 
 (deafness and non-irritability of the vestibular apparatus) with active 
 disease is an indication for the labyrinth operation when suppuration 
 and necrosis of the labyrinth are known to be present. 
 
 General Technique. — As the suppuration and necrosis of the labyrinth 
 is usually associated with and is secondary to mastoiditis, the prelimi- 
 nary stage of the surgical treatment of the labyrinth disease is the radical 
 mastoid operation. The disease of the labyrinth is often only dis- 
 covered during the course of the mastoid operation, though if the func- 
 tional tests of hearing and of the vestibular portion of the labyrinth were 
 uniformly used in all cases of mastoiditis, previous to the operation, 
 the disease of the labyrinth would nearly always be determined. Richards 
 reports cases in which the functional tests failed to indicate the laby- 
 rinthine disease. He does not, however, fully describe the nature of the 
 tests employed, and the author is inclined to suspect that he is mistaken 
 in his suggestion, in relation to the unreliability of the tests, for it is 
 generally conceded that labyrinthine disease may with a fair degree of 
 certainty be demonstrated by the functional tests when carefully and 
 understanding!}* applied. 
 
 Richards very properly divides the labyrinthine cases into two classes, 
 namely: (1) Those in which the horizontal (external) semicircular canal 
 is alone necrosed, and (2) those in which the cochlea, vestibule, and semi- 
 circular canals are involved. 
 
 In the first class of cases the surgical treatment is quite simple, and does 
 not require special preparation of the surgical field. In the second he 
 recommends a wider exposure of the cavum tympani than is required in 
 the radical mastoid operation. If the extensive exenteration of the laby- 
 rinth recommended by him in extreme cases is to be performed, the 
 exposure should be as shown in Plate XIII, as a less extensive exposure 
 would not allow the instrumentation necessary to successfully accomplish 
 the work. If only the bony wall between the oval and round windows 
 and the portion of the promontory covering the first or lower half of the 
 first coil of the cochlea are to be removed, a less extensive exposure of 
 the operative field is required. 
 53 
 
834 THE EAR 
 
 The Anatomical Landmarks. — The radical mastoid operation is first 
 performed in the usual manner, the bony capsule of the sigmoid portion 
 of the lateral sinus (Plate XIII, n) being fully exposed by removing all 
 cells and cancellous bone in front of and above its knee; the angle above 
 the knee and posterior to the antrum is completely exenterated, thus 
 giving the necessary space for introducing the instruments in opening the 
 canals (Plate XIII, b, c, d); a portion of the posterior zygomatic root and 
 upper wall of the meatus are also removed to give better access to the 
 semicircular canals and the petrous portion of the pyramid. The deeper 
 portion of the floor of the external auditory meatus is removed to expose 
 the hypotympanic space. The anterior wall of the external auditory 
 meatus is removed (Plate XIII, i) to expose the cochlea in front, and the 
 anterior wall of the Eustachian tube (Plate XIII, h), which should be 
 removed. The stapedius muscle should also be divulsed. As the carotid 
 canal is immediately behind the posterior wall of the Eustachian tube, care 
 should be exercised to avoid injuring it in curetting the tube, a procedure 
 recommended by Richards to prevent hemorrhage, which would otherwise 
 obstruct the view of the operative field. The carotid artery (Plate XIII, j) 
 is shown passing upward parallel with the ramus of the jaw, and upward 
 just in front of the cochlea, where it makes a sharp turn forward and 
 inward, a very thin plate of bone separating it from the posterior wall of 
 the Eustachian tube. The promontory (Plate XIII, g) and the oval and 
 round windows (Plate XIII, e, /) are fully exposed to view. The facial 
 nerve (Plate XIII, a, a, a) as it makes its exit from the Fallopian canal and 
 the bone covering it in its upper course are shown clearly dissected. The 
 external portion of the lower wall of the meatus is removed (Plate XIII, k). 
 
 THE SURGERY OF THE HORIZONTAL SEMICIRCULAR CANAL. 
 
 When only the exposed wall of the horizontal semicircular canal is 
 necrosed, the surgical treatment is usually very simple and easy of execu- 
 tion, though, as previously stated, the surgical treatment of this condition 
 is rarely necessary, as the radical mastoid operation is usually followed 
 by a caseation of the labyrinthine disease. This may be accounted for 
 through the free drainage and the cessation of the irritation in the hitherto 
 constricted aditus ad antrum, the location of the external portion of the 
 horizontal semicircular canal. This canal crosses the floor and inner 
 wall of the aditus ad antrum (Plate XIII, b), the point of greatest con- 
 striction between the cavum tympani and mastoid antrum, where it is 
 exposed to great irritation by the constant discharge of infected secre- 
 tions (Richards). In performing the mastoid operation this area should 
 always be inspected for caries and granulations, and if present they may 
 be removed, the diseased process being followed to the extent it involves 
 the canal or system of canals, or non-interference may be tried. 
 
 Technique. — The carious wall of the canal may be removed with a 
 sharp curette, due precautions being taken to avoid the ridge of the facial 
 canal (Plate XIII, a, a, a), which is situated just below and anterior to the 
 
PLATE XIII 
 
 The Exposure Required for an Extensive Operation 
 upon the Labyrinth. 
 
 a, a, a, the facial ridge and nerve; b, the horizontal semicircular canal; c, the oblique semicircular canal; 
 d, the perpendicular semicircular canal; e, the oval window; f, the round window; g, the promontory; h, 
 the tympanic end of the Eustachian tube; i, the fragment of the anterior bony wall of the meatus; :/", the 
 internal carotid artery; k, the remaining portion of the floor of the meatus, the deeper portion of the floor 
 of the meatus lias been removed to expose the hypotympanum; /, the internal jugular vein and bulb; 
 m, a section of the bone covering the facial nerve; n, the sigmoid portion of the lateral sinus. 
 
THE SURGERY OF THE HORIZONTAL SEMICIRCULAR CANAL 835 
 
 carious wall of the semicircular canal. The curette should be directed 
 backward and upward away from the facial ridge. Richards prefers to 
 remove the diseased area with a small sharp chisel, the cutting edge of 
 which is placed well above the facial ridge and is directed upward and 
 inward to prevent fracture of the facial canal. Bourguet's method of 
 opening the horizontal canal is, perhaps, the safest and best. He has 
 devised an instrument (Fig. 469) for the protection of the facial nerve 
 during the procedure for the opening of the canal. The instrument is 
 provided with a semlunar plate, 3x2 mm. in size. The convex border 
 of the plate has a heel or toe projecting from it somewhat like the toe of 
 a horseshoe. The heel or toe is inserted into the oval window, while the 
 convex border of the plate is directed upward. The body of the plate is 
 thus located over the facial canal. When the instrument is thus adjusted 
 the convexity in the plate is a guide to the junction of the horizontal and 
 perpendicular semicircular canals. A small sharp gouge is placed in the 
 convexity of the plate, and with a few rotary motions it penetrates the 
 bone and exposes the ampullary space beneath the angle. The external 
 arm of the horizontal semicircular canal may then be exposed to its 
 posterior limit, and, if necessary, the external arm of the perpendicular 
 canal may also be exposed by removing its outer wall upward from the 
 primary opening at the petrous angle of the two canals (Fig. 470). 
 
 Fig. 469 
 
 Bourguet's guide and protector. 
 
 The Bourguet protector and guide is in position, protecting the facial 
 ridge and guiding the gouge to the petrous angle at the junction of the 
 two canals. 
 
 Having thus removed the necrosed tissue, a small wick of gauze should 
 be placed against the opening and the mastoid wound loosely packed 
 with gauze. The disturbance due to the opening of the canal, as the 
 loss of equilibrium, dizziness, nausea, vomiting, and nystagmus will 
 disappear within a few hours or days. 
 
 The Complete Exenteration of the Semicircular Canals.— When the 
 entire system of semicircular canals is filled with granulations it may 
 become necessary to open them through their entire extent. If they are 
 only infected and contain purulent matter, the opening at the petrous 
 angle of the horizontal and perpendicular canals and the removal of the 
 outer wall of the horizontal canal may be sufficient to establish drainage 
 of the entire system. Should this be regarded as insufficient (because the 
 canals are filled with granulations), the entire system should be opened. 
 The hearing is necessarily greatly damaged when only the outer w T all_of 
 
836 
 
 THE EAR 
 
 the horizontal canal is opened, as described in the preceding section. 
 This objection to opening the canals is, therefore, not valid, as the hearing 
 will not be rendered worse by it. The chief objection is the difficulty 
 involved in the procedure and the possible fracture of the cranial plate 
 on the superior and posterior surfaces of the petrous portion of the tem- 
 poral bone, which might give rise to meningitis. The complete dissec- 
 tion of the bony walls of the canals before opening them will largely 
 obviate these difficulties. 
 
 Fig. 470 
 
 Schema showing Bourguet's operation upon the horizontal semicircular canal. The facial 
 nerve is not actually exposed in the operation. 
 
 Technique. — (a) Complete the radical mastoid operation. 
 
 (b) Remove the portion of the zygomatic root and of the roof of the 
 external auditory meatus, as shown in Plate XIII, to facilitate the use 
 of the curette in removing the bony tissue surrounding the canals. 
 
 (c) Having exposed the contour of the canals to view (Plate XIII, b, c, d), 
 introduce Bourguet's guide and protector (Fig. 469) with its heel or toe in 
 the oval window and its semilunar plate over the facial ridge, as shown 
 in Fig. 470. 
 
 (e) Proceed to open the petrous angle of the horizontal and perpen- 
 dicular canals as described in the Surgery of the Horizontal Semicir- 
 cular Canal (Fig. 470). 
 
THE SURGERY OF THE HORIZONTAL SEMICIRCULAR CANAL 837 
 
 (J) Extend the opening upward and backward, thus removing the 
 outer walls of the horizontal and perpendicular semicircular canals 
 (Fig. 471). 
 
 (g) With a small curved gouge introduced above and beyond the outer 
 limit of the horizontal canal (Fig. 471) remove the superior wall of the 
 oblique canal. 
 
 (h) Proceed to complete the opening of the horizontal and perpendic- 
 ular canals with a small curved gouge and a small thin chisel. The 
 major portion of the work should be done with the gouge, a rotary or 
 boring motion being used, as the blows of the mallet are liable to fracture 
 the bone in unexpected directions and cause meningitis. 
 
 Fig. 471 
 
 Schema showing Bourguet's operation upon the semicircular canals, vestibule, and cochlea. 
 The semicircular canals are opened, as shown in Fig. 470, with the protector and guide in posi- 
 tion. The facial nerve is not exposed in the actual operation. 
 
 (i) Endeavor to open the upper portion of the vestibule, as this will 
 insure better results, as the semicircular canals open into it. This should 
 be done with a small thin chisel curved on the flat. The petrous angle 
 of the horizontal and perpendicular canals, directly above the oval 
 window, should first be opened as shown in Fig. 471, and the chisel used 
 to extend the opening downward to the vestibule. The force of the blows 
 of the mallet should not be expended upon the facial ridge. That is, the 
 chisel should be well above the facial ridge (not resting upon it), as to use 
 
THE EAR 
 
 the facial ridge as a fulcrum in loosening the chips of bone might frac- 
 ture it and cause facial paralysis (Richards). 
 
 (y) The dressing and after-treatment should be as described in the 
 Surgery of the Horizontal Semicircular Canal. 
 
 Richards says that this route to the vestibule is safer than that via the 
 inner wall of the cavum tympani, as there are no vulnerable points to be 
 encountered except the facial ridge, whereas in opening it by removing 
 the bridge of bone between the oval and round windows and a portion 
 of the promontory, the inner thin wall of the vestibule is more liable to 
 injury, especially as the vestibule is shallow at this level and its inner 
 wall very thin. Bourguet's method appears to be the safer one. 
 
 THE SURGERY OF THE VESTIBULE VIA THE INNER WALL OF THE 
 CAVUM TYMPANI BELOW THE FACIAL NERVE. 
 
 Fig. 472 
 
 Bourguet's Method. — When granulations and pus extrude from the 
 oval window, the vestibule is profoundly affected and should be opened. 
 The cochlea, or at least the lower turn of it, is also often involved. It 
 is imperative that the vestibule be opened, the granulations removed, and 
 
 better drainage established. It may 
 be necessary to exenterate the semi- 
 circular canals, as described in the 
 preceding sections, as they may also 
 be involved. 
 
 Technique. — (a) The radical mas- 
 toid operation. 
 
 (h) Check the hemorrhage by cur- 
 etting the tympanic end of the 
 Eustachian tube (Fig. 430). Also ap- 
 ply pledgets of cotton saturated with 
 adrenalin solution to the cavum 
 tympani. 
 
 (c) Remove the pledgets of cotton 
 after a few minutes, and introduce 
 the heel of Bourguet's protector and 
 guide into the oval window, as shown 
 in Fig. 470, to protect the facial nerve 
 from injury. 
 
 (d) Remove the bridge of bone between the oval and round windows 
 with a thin sharp chisel, thus exposing the lower space of the vestibule 
 (Fig. 471). 
 
 (e) Enlarge the opening, if necessary, to expose a portion of the lower 
 coil of the cochlea (Fig. 471). (This figure also shows the horizontal and 
 perpendicular semicircular canals opened.) 
 
 (/) Gently remove granulations from the vestibule, and bear in mind 
 that the inner wall of the lower portion is thin and easily fractured. 
 (g) The after-treatment is as heretofore described. 
 
 Schema showing a cross-section through 
 the cochlea from apex to base. The central 
 shaded portion (a) is the modiolus. If 
 more than the upper apecial coil is removed, 
 the internal auditory canal (6) at its base 
 would be opened, thus exposing the patient 
 to the dangers of meningitis. 
 
THE SURGERY OF THE VESTIBULE 839 
 
 The Partial Exenteration of the Cochlea. — The extent to which the 
 cochlea may be exenterated is still an open question. According to 
 Richards, it may be opened in its entirety; that is, its two and one-half 
 coils may be completely uncapped. To do this it is necessary to remove 
 the upper coil and a portion of the modiolus. Herein lies the danger. 
 The modiolus (Fig. 472) is a hollow cone at its base, but is solid at its 
 apex, where it supports the cupola of the cochlea. If the modiolus is 
 removed so low or deep as to open the cone-shaped cavity at its base, 
 the cerebrospinal fluid will escape into the cavum tympani, and patho- 
 genic microorganisms may enter the cranial cavity and cause meningitis. 
 In attempting to remove the apex of the modiolus the blow of the mallet 
 may accidentally fracture it at its base (Richards), and thus cause 
 leakage of the cerebrospinal fluid, meningitis, and death. 
 
 It is obvious, therefore, that under nearly all circumstances the uncov- 
 ering of the cochlea should be limited to the removal of the outer walls of 
 the coils, the modiolus and deeper walls being unmolested. In this 
 description the limit of safety will be observed, and it is only when the 
 cochlea is choked with granulations and extensive necrosis is present 
 that this much of an exposure is justifiable. 
 
 Technique. — (a) Preliminary radical mastoid operation, plus the more 
 extended exposure shown in Plate XIII. 
 
 (b) Check hemorrhage with adrenalin and the curettage of the Eusta- 
 chian tube. 
 
 (c) Expose the vestibule and semicircular canals as previously de- 
 scribed. 
 
 (d) Remove the lower promontory wall covering the first half of the 
 first coil of the cochlea, as shown in Fig. 471. A small chisel, a little 
 wider than the cochlear canal, should be used to uncap it. The chisel 
 should be directed inward and backward, carefully following the canal 
 as it curves upward and disappears in the deeper structures of the bone, 
 where the dissection should be discontinued. 
 
 (e) Next uncap the cupola, first locating it by noting the contour of 
 the inner wall of the cavum tympani at a point above the anterior exten- 
 sion of the lower coil already exposed. The slight elevation at this point 
 gives the location of the cupola or apex of the cochlea. A small gouge 
 is better for this part of the procedure, as it may be rotated, thus boring 
 an opening into the upper coil of the cochlea. The outer wall of the bone 
 may be thus removed from the upper coil, or one and one-half coils (Fig. 
 473). Having exposed the outer aspect of the coils of the cochlea, cease 
 the operation without attempting to extend it farther, as to do so might, 
 and probably would, cause meningitis and death. 
 
 The dressing and after-treatment are as previously described. 
 
 The Complete Exenteration of the Cochlea. — As already stated in 
 the preliminary discussion under Partial Exenteration of the Cochlea, 
 the complete exenteration is rarely, if ever, justifiable, certainly not in the 
 hands of the average surgeon, unless he has done extensive dead-house 
 work to prepare him for it. Even then the dangers are great and almost 
 beyond control. Richards had two deaths from such an operation, which 
 
840 
 
 THE EAR 
 
 he ascribes to operative interference. He states, however, that he believes 
 he could in future avoid such accidents. In the meantime we should 
 remember that the operation, even in the hands of an expert who has 
 devoted much thought to it and has had much experience in dead-house 
 work, as well as work upon the living, is fraught with extreme hazard. 
 
 Technique. — The technique of the complete exenteration of the laby- 
 rinth will not be given, as it is not the author's purpose to recommend it 
 as a justifiable procedure, at least in the present status of the subject. 
 
 Fig. 473 
 
 An extensive exposure of the canals and cochlea. The apecial whorl is removed. A more 
 extensive exposure is attended by great danger, and should rarely be attempted. 
 
 In Fig. 474 is shown the complete exposure of the cochlea, its cupola 
 or upper coil being removed with the apex of the modiolus. The black 
 spot in the centre of the coils is an opening into the internal auditory 
 canal, through which cerebrospinal fluid would escape, and through 
 which infection of the cranial contents might occur. Only the basal 
 coil and half of the second remain. The vestibule and all of the semi- 
 circular canals are also shown exposed by surgical interference. 
 
 Caution.— Before undertaking the surgery of the labyrinth the surgeon 
 should consider the following facts: 
 
 (a) But few cases of otorrhea and mastoiditis have been found to be 
 complicated by suppurative labyrinthitis, though doubtless many such 
 complications have been present and not discovered. 
 
THE SURGERY OF THE VESTIBULE 
 
 841 
 
 (b) Most of the labyrinthine suppurations observed have not been 
 treated surgically, and in nearly every instance recovery has occurred. 
 
 (c) Those operated have invariably been followed by marked deafness, 
 whereas those not operated have been attended by less pronounced 
 deafness. 
 
 (d) In view of these facts surgical intervention should be undertaken 
 with reluctance, except in those cases in which the deafness is already 
 profound, or in which meningeal irritation is already present, or appears 
 to be imminent, as shown by the location and extent of the morbid 
 lesions. 
 
 Fig. 474 
 
 Richards' radical operation upon the cochlea and canals. The cupola or apecial whorl is removed, 
 including the 'modiolus. This radical exposure of the cochlea should rarely be performed, and 
 only then by a surgeon qualified to do it. 
 
 Facial Paralysis Resulting from the Surgery of the Labyrinth. — 
 
 Facial paralysis resulting from the surgery of the labyrinth, as described 
 in the above surgical procedures, should only occur in those cases in 
 which the facial canal is involved in the necrotic process. It is never 
 necessary to uncover the facial nerve to expose the semicircular canals, 
 vestibule, or cochlea sufficiently to establish good drainage. Accidental 
 injury of the nerve may usually be avoided by heeding the precautions 
 given in the descriptions of the various surgical procedures. Bourguet's 
 guide and protector is a valuable addition to the instrumentarium, and 
 
842 THE EAR 
 
 largely solves the problem of protecting the facial nerve as it crosses the 
 upper and outer wall of the vestibule. The vestibule may be opened 
 above the facial nerve or below it, as described, but under no circum- 
 stances, other than the presence of marked necrosis of its bony canal, 
 should the bridge of bone containing the nerve be removed. While 
 facial paralysis may and has followed the surgery of the labyrinth, it 
 may, with added experience and an improved technique and instru- 
 mentarium, be avoided. 
 
 THE SURGERY OF BRAIN ABSCESS. 
 
 The Surgery of Cerebral Abscess. — Abscess of that portion of the 
 cerebrum embraced within the temporosphenoidal lobe may be opened 
 through two routes, namely, (a) the tegmen tympani and antri, and (b) 
 the squamous portion of the temporal bone. In some cases both routes 
 should be employed, especially if the abscess is located high above the 
 tegmen tympani and contains large masses of debris and broken-down 
 
 Fig. 475 
 
 Avenues of approach to brain abscess, a, through the squamous plate to the temporosphe- 
 noidal lobe; 6, through the tegmen tympani to the temporosphenoidal lobe; c, through the mas- 
 toid wound to the cerebellar fossa; d, through the cranial cortex (one and one-quarter inches 
 posterior to the cavum tympani) to the cerebellar fossa. 
 
 brain substance which cannot be removed through the perforation in the 
 tegmen. In those cases in which the abscess is located near the tegmen 
 tympani (roof of the cavum tympani) and in which the contents of the 
 abscess are purulent or fluid, the route through the enlarged perforation 
 in the tegmen may prove adequate for the drainage. 
 
 Drainage through the Tegmen Tympani.— (a) A preliminary 
 radical mastoid operation is first performed, not only to cure the mas- 
 
THE SURGERY OF BRAIN ABSCESS 843 
 
 toiditis and otitis media, but to expose the tegmen, or roof of the cavum 
 tympani, the atrium of the brain infection. 
 
 (6) The middle ear cavity (cavum tympani) is mopped with a cotton- 
 wound applicator to free it of pus and blood, and if necessary adrenalin 
 chloride solution should be applied to check the hemorrhage. 
 
 (c) The tegmen tympani should then be inspected under strong re- 
 flected light for oozing pus, and for the dehiscence or perforation result- 
 ing from necrosis. A probe may also be used to explore for rough and 
 necrosed bone. 
 
 (d) Having located the point from which pus oozes, or where the granu- 
 lations protrude from the necrosed area of the tegmen, it should be gently 
 curetted to remove the granulations, and to expose the necrotic bone 
 and the perforation through it. The opening should be enlarged by 
 removing all the necrosed bone (Fig. 475, b), a dull curette being used 
 for the purpose. 
 
 (e) If the abscess is located near the floor of the middle fossa imme- 
 diately over the perforation in the tegmen tympani it may be readily 
 drained through this enlarged opening. The dura and brain substance 
 may be incised to enlarge the channel of communication between the 
 abscess cavity and the cavum tympani. In one case coming under the 
 author's observation the abscess cavity extended into the brain substance 
 for the distance of one and one-half inches, and communicated freely 
 with the cavum tympani. Large cholesteatomatous masses were ad- 
 mixed with the pus, which were readily removed through the tegmen 
 opening. In most cases in which the abscess is located as high as this, 
 and in which large cholesteatomatous masses are present, it is impossible 
 to evacuate the abscess through the tegmen. 
 
 (/) If the abscess is acute, simple drainage and irrigation are usually 
 quickly followed by complete recovery. If the abscess is chronic, and the 
 walls are lined with necrotic sloughs of brain substance, the healing 
 process is much prolonged and requires careful after-treatment. 
 
 Drainage through the Squamous Plate — The drainage of cerebral 
 abscess through the squamous plate of the temporal bone is indicated 
 when (a) the opening through the tegmen tympani is not large enough 
 to insure adequate drainage; (6) when the abscess is located high in the 
 brain substance, and only communicates with the perforation in the teg- 
 men through a small fistulous tract; and (c) when the associated necrotic 
 or cholesteatomatous masses are too large to escape through the tegmen 
 opening, or are inaccessible through the tegmen tympani. 
 
 Technique.— (a) It is presumed, if the abscess is of otitic origin, that 
 the radical mastoid operation has been performed. The skin incision 
 should be extended from the postauricular mastoid incision in a curved 
 direction backward, upward, and then forward, as shown in Fig. 476, e, f. 
 The flaps are then elevated and retracted with the periosteum. 
 
 (6) A circular plate of bone one-half inch in diameter is then removed 
 from the squamous portion of the temporal bone, with a circular trephine 
 (Fig. 477). The centre pin of the trephine should be located at a point 
 one inch above the posterior wall of the meatus within the square area 
 
844 
 
 THE EAR 
 
 shown in Fig. 477. As the bone is of unequal thickness, one section of 
 the circle may be penetrated before the others. The centre pin should 
 be set one-eighth of an inch flush with the plane of the teeth of the 
 
 Fig. 476 
 
 Fig. 477 
 
 The incisions for brain abscess, a, b, the primary mastoid incision; c, c, the secondary mastoid 
 incision; c, d, an extension of the secondary incision for cerebellar abscess; e, f, the incision for 
 abscess of the temporosphenoidal lobe of the cerebrum. 
 
 trephine, as this is the average thickness of the squamous plate in this 
 region. The trephine should be removed from time to time, and a small 
 
 probe introduced into all parts of the circu- 
 lar cut to remove the bone-dust, and to de- 
 termine if the bone has been cut through at 
 any given point. If it has, the trephine should 
 be slightly tilted, so as to cut only at the intact 
 portions. When the entire button of bone is 
 severed from its attachments, a thin elevator 
 or spatula should be inserted into the cut 
 and the button gently lifted from the dura. 
 The button of bone should be wrapped in a 
 piece of sterile gauze and placed in a sterile 
 or antiseptic solution ready for reinsertion 
 should it be needed — that is, if pus is not 
 
 Circular trephine. IOUnQ. 
 
THE SURGERY OF BRAIN ABSCESS 
 
 845 
 
 (c) Inspect the exposed dura for the following conditions: (1) The 
 presence of pus from an associated meningitis. (2) The presence of con- 
 gested and infiltrated membranes. (3) The presence of brain pulsation. 
 
 Fig. 478 
 
 Kronlein's landmarks, b, b, the German horizontal line, or Read's base line, extending from 
 the lower margin of the orbit to the occipital protuberance; a, a, the upper horizontal line extending 
 from the supra-orbital margin parallel with the German line. A, e, the anterior vertical line, ex- 
 tending upward from the middle of the zygoma at right angles to the German line b, 6; d, the middle 
 vertical line passing through the condyle of the inferior maxilla at right angles to the German 
 line b, b; c, c, the posterior vertical line extending from the posterior margin of the mastoid process 
 at right angles to the German line b,b. A, 1 represents the location of the central fissure of Rolando; 
 A,g represents the fissure of Sylvius; A, B represents the points for trephining to evacuate blood 
 from a ruptured middle meningeal artery. Von Bergmann's area is enclosed within the square 
 outlined by the heavy, black lines. Otitic abscess and abscess of the temporal lobe may be 
 drained through this area. The upper line of the square represents the area for tapping the lateral 
 ventricle, c, B, the sigmoid portion of the lateral sinus; h, the point for entering the antrum; 
 x (in small square), area for trephining a cerebellar abscess. 
 
 Brain pulsation is usually present when the abscess is large and deeply 
 located in the brain substance, or when the abscess is small and super- 
 ficial. The absence of pulsation may, therefore, be taken to indicate a 
 
846 
 
 THE EAR 
 
 small deep-seated pus cavity or a large superficial one. Leptomeningitis 
 with pachymeningitis may result in the fusion of the meningeal mem- 
 branes, and thus obscure the pulsations which would otherwise be present. 
 
 (d) The dura should be incised layer by layer near the centre of the 
 opening until its entire thickness is penetrated. It should then be seized 
 with forceps, lifted from the underlying structures, and incised the whole 
 diameter of the opening. If necessary, a cross incision may be made to 
 overcome the tension. The bloodvessels crossing the field should be cut 
 one at a time, pinched with artery forceps, and ligated if necessary, as 
 the blood might otherwise penetrate between the membranes and produce 
 pressure, or carry infection to other parts. 
 
 (e) The exposed membranes, brain substance, and bone edges should 
 be dusted with iodoform powder to protect them from the infected pus 
 when the abscess is opened. 
 
 Fig. 479 
 
 MASTOID CELLS' 
 
 EUSTACHIAN TUBE 
 
 A transparent skull showing the relation of the sutures, ventricles, Eustachian tube, tympanic 
 cavity, mastoid cells, and lateral sinus of the left side of the head. 
 
 (/) The choice of an instrument for opening the abscess, or for explor- 
 ing for it, is a matter of some importance. A hollow needle or cannula has 
 commonly been chosen for this purpose. The late Christian Fenger 
 preferred a long, slender-bladed scalpel, as it inflicted less damage to the 
 brain substance, and at the same time was superior in locating and evacu- 
 ating the pus. The needle and cannula are objectionable on account of 
 the brain substance entering their lumen when suction is applied, thus 
 interfering with the detection and withdrawal of the pus. 
 
 The knife should be passed a distance of one inch into the brain 
 substance, then slightly rotated and lifted to open the channel for the 
 
THE SURGERY OF BRAIN ABSCESS 847 
 
 discharge of the pus. If pus does not appear, it should be introduced a 
 half inch deeper and similarly rotated and lifted. The knife should be 
 passed to a greater depth than this with great caution, as the lateral 
 ventricles (Fig. 479) may be opened and exposed to infection. If pus is 
 not found, the knife should be withdrawn and reinserted in another 
 plane, and if necessary in several planes, until the abscess is located and 
 evacuated. If care is taken to keep the exposed area of the surface of the 
 brain and the knife surgically clean, there is but slight danger from this 
 method of procedure, even when several punctures are made. The parts 
 of the brain thus incised are not functionally injured, as the incision is 
 clean cut, and the instrument is sterile. 
 
 (g) If the pus is too thick to flow readily through the incision, or the 
 necrotic sloughs of brain substance are too large to pass through the 
 incised channel, the encephaloscope designed by Whiting should be 
 used. It should be introduced over the blade of the knife while it is 
 still in the brain, the blade acting as a guide to the abscess. Through the 
 opening thus obtained the pus escapes, and the sloughs may be removed 
 with forceps. When the abscess cavity is emptied its walls may be in- 
 spected by the aid of reflected light. If they are necrotic they should be 
 curetted until healthy brain substance is exposed. Should such material 
 be left in the cavity, the infection and inflammation will be much pro- 
 longed. Whiting's encephaloscope affords a means of treatment of great 
 advantage that should be utilized whenever the conditions present war- 
 rant it. 
 
 (h) The abscess cavity should be irrigated with a warm antiseptic 
 solution until the return flow is clear. With Whiting's encephaloscope 
 or brain speculum the irrigation is a simple matter, as it allows the nozzle 
 of the syringe to be introduced and at the same time allows the fluid to 
 make its exit into the pus basin. If the encephaloscope is not used, a 
 cannula should be introduced, the lumen of which is larger than the one 
 attached to the syringe, as this allows a return flow of the pus and irriga- 
 tion solution. This provision is necessary, because, if the outflow of the 
 irrigating solution is blocked, the pressure of the retained fluid may cause 
 it to extend beyond the walls of the abscess cavity to other parts of the 
 brain. 
 
 (i) The first dressing should consist of a drainage wick of gauze, a 
 protective covering of antiseptic powder, and an outer absorbent 
 gauze pad. The drainage wick should be within the cavity and in 
 contact with the external absorbent gauze pad. The proximal end 
 of the gauze wick should be folded over the bony wound and dusted 
 with a mixture of iodoform and boric acid (1 to 5), to prevent adhesion 
 between the gauze wick and the outer absorbent gauze pad, as it may 
 be necessary to leave the gauze wick in position for several days; 
 whereas the outer gauze pad may, and in many instances should 
 be removed daily. In acute cases the walls of the abscess cavity may 
 collapse and heal in a day or two. Chronic cases require several days 
 or weeks to heal. Macewen recommends that in some acute cases 
 only the outer gauze pad be used, and if there is no temperature or pain, 
 
848 THE EAR 
 
 that it be left undisturbed for three weeks, the obvious purpose being to 
 avoid the possibility of infecting the wound by removing the dressing. 
 When, however, the discharge is sufficient to soil the outer gauze pad, it 
 should be removed daily until healing is completed. 
 
 THE SURGERY OF CEREBELLAR ABSCESS. 
 
 There are three routes available for evacuating abscess of the cere- 
 bellum, namely: (a) through the mastoid wound via the recess at the 
 angle of the sigmoid knee (Fig. 475, c), that is, through the recess between 
 the inner wall of the antrum and the knee of the sigmoid sinus; (b) 
 through the inner wall of the sigmoid sinus when the vessel is thrombosed 
 and has been exenterated ; (c) through the skull one and one-fourth inches 
 posterior to the meatus, and below the level of the lateral sinus (Fig. 
 478, x). The lower border of the lateral sinus may be determined by an 
 imaginary line passing from the upper margin of the zygoma to the upper 
 boundary of the external auditory meatus, and thence backward to the 
 occipital protuberance (Fig. 478, b b). Having constructed this line, 
 trephine below it one and one-fourth inches posterior to the auditory 
 meatus. This will open the skull below the lateral sinus and will afford 
 the most available external route to the cerebellar abscess. 
 
 (a) If the abscess is immediately behind the petrous pyramid of the 
 temporal bone it may be easily reached through the mastoid wound 
 via the recess between the knee of the lateral sinus and the antrum. 
 
 (b) If the lateral sinus is thrombosed (and it is often the source of the 
 cerebellar abscess), its walls should be carefully searched for necrotic 
 areas, not alone as an avenue of approach to the abscess, but as a means 
 of tracing the location of the abscess through the fistulous tract lead- 
 ing from the sinus to the abscess cavity. This route may be utilized 
 to evacuate the abscess, though the subsequent treatment through this 
 route is difficult to carry out on account of the restricted and deep situa- 
 tion of the opening in the mastoid wound. This is also true of the first 
 (a) route. 
 
 (c) The external route through the skull (Figs. 475, d, and 478, x), 
 is generally preferable on account of its accessibility. 
 
 The technique of the operation is otherwise similar to that described 
 for cerebral abscess. 
 
 THE SURGICAL TREATMENT OF SEROUS MENINGITIS. 
 
 Serous meningitis has no characteristic symptoms by which it may be 
 positively diagnosticated from purulent meningitis. If, however, after 
 completing the radical mastoid operation the tegmen tympani or antri 
 is opened and serous fluid escapes, and the meningeal symptoms sub- 
 side, the diagnosis of serous meningitis may be made (Fig. 475 b, c). 
 
 The surgical treatment consists in removing the tegmen tympani or 
 
SURGICAL TREATMENT OF THROMBOSIS OF LATERAL SINUS 849 
 
 the tegmen antri and allowing the serous effusion to escape. The after- 
 treatment consists in the usual mastoid dressings. 
 
 Repeated lumbar punctures and the escape of the cerebrospinal 
 fluid has been attended with brilliant success in some cases. 
 
 THE SURGICAL TREATMENT OF EXTRADURAL ABSCESS OR 
 PACHYMENINGITIS CIRCUMSCRIPTA. 
 
 Circumscribed pachymeningitis, or extradural abscess, located over the 
 tegmen tympani or antri in the middle fossa of the skull, may be success- 
 fully treated in nearly all cases by first performing the radical mastoid 
 operation, and then removing the roof of the cavum tympani and 
 antrum, and evacuating the purulent secretion. An extradural abscess 
 is a localized meningitis, the circumference of which is walled off by a 
 plastic exudate. 
 
 An early operation upon these cases prevents the spread of the infec- 
 tion in the form of a brain abscess and leptomeningitis, which are more 
 serious affections. Leptomeningitis is usually fatal, though a few cases 
 have recovered under surgical drainage. 
 
 THE SURGICAL TREATMENT OF THROMBOSIS OF THE 
 LATERAL SINUS. 
 
 An infective thrombus is more often found in the sigmoid portion of the 
 lateral sinus than in any other of the intracranial sinuses. Early recog- 
 nition and surgical treatment is of the greatest advantage to the patient, 
 as many cases thus recognized and treated recover. 
 
 Technique. — (a) A preliminary mastoid operation is performed. If 
 the mastoiditis and otitis are acute, the simple mastoid operation may be 
 all that is necessary, the cavum tympani being unmolested; if, however, 
 the mastoiditis and otitis are chronic, and the labyrinth is involved 
 by the infective process, the radical mastoid operation should be per- 
 formed. Richards reports 11 cases of labyrinthine disease upon which 
 he operated, performing more or less extensive exenterations of the 
 labyrinth, of which three were affected by thrombosis of the lateral 
 sinus. This, as he says, points strongly to the labyrinth as a possible 
 atrium of infection (Figs. 470 to 474, and the technique of the mastoid 
 operations). 
 
 (b) Remove the dense or necrosed bone covering the mastoid aspect 
 of the lateral sinus as extensively as possible, thus exposing the mem- 
 branous sinus to observation and operation. Determine whether a 
 perisinus abscess (extradural abscess of the sinus) is present. Note 
 the texture of the membranous sinus, whether velvety, covered with 
 granulations at certain points, or necrosed. Palpate it with the finger to 
 determine its resistance, whether doughy, hard, or fluid. Some surgeons 
 recommend that the sinus be exposed in every mastoid operation, and 
 54 
 
850 
 
 THE EAR 
 
 that a portion of its contents be withdrawn with a hypodermic needle to 
 ascertain if pus is present. This is a reprehensible practice, as it is an un- 
 reliable method of determining the presence of pus, and exposes the sinus 
 to the danger of infection. Whiting recommends that the tip of the finger 
 be placed as near the jugular bulb as possible and then drawn upward 
 toward the knee, noting whether the stripped sinus refills below the 
 finger. If it does, the jugular bulb is open. The sinus should then be 
 stripped from above downward toward the jugular bulb, and the same 
 observation made of the upper portion of the sinus. If it refills, the sinus 
 is open above; if it does not, it is closed by a thrombus. Having deter- 
 mined to open the membranous sheath of the sinus, see that iodoform and 
 boric acid powder (1 to 5) and a strip of iodoform gauze (1 x\24 in.) are 
 in readiness in case free hemorrhage occurs. 
 
 Fig. 480 
 
 Thrombus of the lateral sinus exposed. 
 
 (c) Incise the whole length of the exposed portion of the membranous 
 sinus (Fig. 480), and if the hemorrhage is free it should be closed by turn- 
 ing in the cut edges of the membrane and packing the bony opening with 
 the strip of iodoform gauze. A few moments of hemorrhage should be 
 allowed, as it may wash out the infective material and lead to recovery. 
 
 If the incision is not followed by hemorrhage, the thrombic clot, 
 whether it be solid or undergoing disintegration, should be removed 
 
RESECTION OF THE INTERNAL JUGULAR VEIN 851 
 
 with a dull curette. The portion of the clot near the jugular bulb should 
 be curetted until blood appears at the lower end of the opening. The 
 curette should then be passed upward through the knee of the sinus, 
 and the clot removed from this part of the sinus. The flow of blood 
 from this end of the sinus is evidence that this portion has been cleared 
 of the thrombus. Both ends of the sinus should give forth blood. The 
 lower or jugular end should be kept closed with the finger while the 
 upper end is being curetted, as too much blood might otherwise be lost, 
 or the surgeon be impelled to work with undue haste. Having cleared 
 the sinus of the clot, it should be filled with the iodoform boric acid 
 powder, the edges of the membrane turned in and the bony aperture 
 filled with iodoform gauze, and the usual mastoid drainage and absorbent 
 dressings applied. 
 
 (d) The dressing may be removed at the end of from twenty-four to 
 forty-eight hours, and the gauze removed from the bony aperture of the 
 lateral sinus without danger of hemorrhage. 
 
 (e) The after-treatment consists in the usual mastoid dressings here- 
 tofore described. 
 
 Should pain, chills, and a rise of temperature occur, the dressings 
 should be removed at once and the parts examined to determine the con- 
 ditions which gave rise to the symptoms. If pus is present, endeavor to 
 trace it to its source. It will usually be necessary to reopen the sinus and 
 extend the curettement, as the sepsis is probably from within the sinus, 
 caused by fragments of the thrombus that were probably left at the time 
 of the primary sinus operation. The sepsis may, however, have its origin 
 from a perisinus abscess, and it may become necessary to resect the 
 jugular vein and bulb. 
 
 RESECTION OF THE INTERNAL JUGULAR VEIN. 
 
 The indications for the ligation and resection of the internal jugular 
 vein have not been fully established. It is still a question as to when 
 the resection increases the danger of spreading the infection, and when 
 it prevents spreading the infection from a thrombosed lateral sinus. 
 If the internal jugular vein is ligated and resected, the anastomotic 
 channels, of which there are many, will receive the venous blood cur- 
 rent, provided there is a flow of blood through the sinus. If only the 
 lower portion of the lateral sinus is closed by an infected thrombus, 
 the blood may be forced into the superior petrosal sinus and cause 
 thrombosis in it and the cavernous sinus, with which it communicates. 
 If the entire sigmoid portion of the sinus is blocked by a thrombus, the 
 blood current maybe forced backward into the superior longitudinal sinus. 
 If the thrombus is limited to the jugular bulb, the blood current may be 
 forced into almost any or all of the intracranial sinuses. In ligating the 
 internal jugular vein the effect upon the blood current is the same as that 
 in jugular bulb thrombus. The question as to when the jugular vein 
 should be ligated and removed from the neck resolves itself into the con- 
 sideration of the foregoing facts, and may be stated as follows: 
 
852 THE EAR 
 
 (a) It may be ligated and removed when the entire sigmoid sinus and 
 jugular vein are thrombosed and should be obliterated by operative 
 procedure. The jugular vein should be removed first, however, to 
 obviate the danger of disseminating particles of the thrombus which 
 may become detached during the exenteration of the sigmoid sinus. 
 
 (b) The internal jugular vein may be ligated and removed when the 
 jugular bulb is thrombosed, the jugular bulb being removed after the 
 resection of the vein, provided the sigmoid and lateral sinuses are entirely 
 free from infection, or the sigmoid sinus is obliterated at the same 
 time, whether it is infected or not. If the sigmoid sinus is left open, the 
 infective material from the jugular bulb may be forced backward 
 through this sinus, and thence through the petrosal to the cavernous 
 sinuses. 
 
 (c) The internal jugular vein may be ligated and resected when it is 
 thrombosed by extension from a similar condition in the sigmoid sinus 
 and jugular bulb. 
 
 (d) The jugular vein should not be ligated and resected when there is a 
 flow of blood through the sigmoid sinus. 
 
 (e) In a general way, it may be said that the jugular vein may be 
 ligated and resected when the sigmoid sinus is completely blocked with 
 an infected thrombus. 
 
 The object of the ligation and resection of the internal jugular vein is 
 to prevent the dissemination of the infection to other parts of the body, 
 as the lungs, spleen, liver, kidneys, intestines, etc. Statistics show more 
 favorable results if this is done when there is complete blockage of the 
 sigmoid sinus, and worse results when the sigmoid sinus has a current 
 of blood passing through it. 
 
 Technique. — (a) Extend the mastoid incision downward along the 
 anterior border of the sternomastoid muscle to the sternal notch (Plate 
 XIV and Fig. 459). 
 
 (6) Retract the sternomastoid muscle backward and separate the 
 fascia and other structures by blunt dissection until the internal jugular 
 vein is exposed. 
 
 (c) The pneumogastric nerve runs between the internal jugular vein 
 and the carotid artery, and should be respected. 
 
 (d) Ligate the internal jugular vein just above the sternum and just 
 below the floor of the external auditory meatus (Plate XIV). 
 
 (e) Ligate all the branches of the vein given off between the upper and 
 lower ligations of the jugular vein (Plate XIV). 
 
 (/) Sever the jugular vein just above the lower and just below the upper 
 ligatures. Then sever all the branches close to the jugular vein, and 
 remove the vein from the neck. A gauze pad should be placed under the 
 vein before resecting it to protect the tissues from infection. 
 
 (g) The sigmoid sinus is next opened and the thrombus removed as 
 described in the preceding section. The danger of disseminating the 
 disintegrating thrombus through the jugular vein is largely obviated by 
 its removal, though the anastomotic communications are not altogether 
 obliterated. 
 
PLATE XIV 
 
 The Combined Operation for the Removal of a Thrombosed 
 Sigmoid Sinus, Jugular Vein, and Jugular Bulb. 
 
 The sigmoid portion of the lateral sinus has been exenterated and packed with gauze. The jugular 
 vein and its brandies have been ligated and severed, and the floor of the meatus is being removed with a 
 Gigli saw to expose the jugular bulb. The facial nerve has been exposed and retracted forward with a 
 gauze tape to permit the bone which encloses it to be removed, as it is in the operator's pathway to the 
 jugular bulb, though this was not necessary in this particular dissection. 
 
THE SURGERY OF THE JUGULAR BULB 853 
 
 (h) The sigmoid sinus should be packed and obliterated (Plate XIV), 
 and the mastoid wound dressed as previously described, with the exception 
 that the lower half of the mastoid incision be left open so that the region of 
 the exenterated sigmoid sinus may be subsequently inspected and dressed 
 through it. The incision in the neck should be closed throughout its 
 entire length, a secondary incision being made one inch posterior to the 
 lower angle. This incision should be made to communicate with the 
 primary neck wound by tunnelling beneath the skin. A spiral tube con- 
 taining a small wick of gauze should be introduced into the secondary inci- 
 sion and extended beneath the skin to the lower portion of the primary 
 neck wound, as shown in Fig. 459. The object of the secondary incision 
 is to prevent an unsightly scar. As the primary wound was occupied 
 by an infected and thrombosed vein, the tissues may have become con- 
 taminated. Under these circumstances, if the tube dressing were intro- 
 duced into the wound through the primary incision, the tissues around 
 the tube dressing would heal slowly and cause a retracted and disfiguring 
 scar. The secondary incision, being removed from the region of infec- 
 tion, will, after the tube is discontinued, heal quickly with little scar 
 and disfigurement. 
 
 (h) The after-treatment, in so far as the wound in the neck is con- 
 cerned, consists in the removal of the drainage tube dressing at the end of 
 the third day, or earlier if pain and temperature arise and persist. In 
 those cases in which the neck wound is not infected, the tube dressing 
 may be dispensed with after the first dressing, a small gauze wick being 
 inserted only a little distance into the wound to carry away the excess of 
 secretions. The channel occupied by the tube will quickly fill by granu- 
 lation, and at the third dressing the gauze wick may be omitted to 
 allow the cutaneous edges of the incision to approximate and unite. The 
 scar resulting will be slight and the cosmetic effect good. 
 
 The sigmoid and mastoid wounds should be dressed as previously 
 described. 
 
 THE SURGERY OF THE JUGULAR BULB. 
 
 The indications for the removal of the jugular bulb are (a) extensive 
 necrosis in the region of the bulb; (b) severe systemic infection from the 
 disintegrating thrombic clots; and (c) the desire to remove every vestige 
 of the foci of infection in order to give the patient the greatest chance of 
 recovery. 
 
 Technique. — (a) The mastoid operation is first performed as pre- 
 viously described. The simple mastoid operation is performed if the 
 case is acute and there are no special indications, as labyrinthine sup- 
 puration and necrosis, for opening the cavum tympani. Cerebral abscess 
 with the atrium of infection through the tegmen tympani, and sigmoid 
 sinus thrombosis with the atrium of infection through the labyrinth, 
 etc., necessitate the performance of the radical mastoid operation. 
 
 (6) The internal jugular vein is next resected as described in the 
 preceding section (Plate XIV). 
 
854 
 
 THE EAR 
 
 (c) The sigmoid sinus is exposed, exenterated, and packed with 
 gauze (Plate XIV). 
 
 Fig. 481 
 
 Fig. 482 
 
 The first step of the Mosetig-Moorhof plas- 
 tic operation for the closure of a persistent 
 retro-auricular opening. 
 
 The second step of the Mosetig-Moorhof plastic 
 operation. 
 
 Fig. 484 
 
 The third step of the Mosetig-Moorhof plastic 
 operation for the closure of a persistent retro- 
 auricular opening. 
 
 The fourth step of the Mosetig-Moorhof 
 plastic operation for the closure of a per- 
 sistent retro-auricular opening. 
 
 (d) The floor of the external auditory meatus is removed, as it is in the 
 pathway to the bulb (Plates XIV and XV). 
 
PLATE XV 
 
 The Anatomy of the Grunert-Panse Exposure of the Jugular- 
 Bulb. Grunert removes the tip of the mastoid process and 
 then proceeds toward the jugular foramen at the base of the 
 skull. When the jugular foramen is reached he removes the 
 outer and posterior portion of the bony ring encircling the 
 vein. As shown in the drawing, the facial nerve lies in the 
 way. Panse exposes it, removes it from its canal, displaces 
 it forward, and proceeds to expose the jugular bulb. 
 
 1, tympanic cavity; 2, malleus; 3, incus; 4, posterior semicircular canal; 5, saccus endolymphaticus; 
 6, mastoid emissary vein; 7, lateral sinus; 8. occipital vein; 9, spinal accessory nerve; 10, facial nerve. 
 (After Bardeleben.) 
 
THE SURGERY OF THE JUGULAR BULB 
 
 855 
 
 (e) The facial nerve may be exposed, as recommended by Panse, when 
 it lies in the pathway to the blub. The nerve should be lifted from its 
 exposed canal, a strip of gauze passed around it, with which it is retracted 
 anteriorly, as shown in Plates XIV and XV. 
 
 (J) The styloid process, together with the lower portion of the bone 
 which previously supported the facial nerve, and that portion of the 
 mastoid tip which obstructs the path to the bulb, should be removed 
 with a chisel, bone forceps, or a Gigli saw, as shown in Plate XIV. The 
 saw should be placed in front of the fragment of the floor of the meatus, 
 the anterior wall having been previously removed. One end should be 
 passed backward beneath the tip of the mastoid process (the sternomas- 
 toid muscle being partially severed (Plate XIV), and the other backward 
 
 Fig. 485 
 
 Fig 486 
 
 / 
 
 The second step in the Passow-Trautmann 
 plastic operation for the closure of a persis- 
 tent retro-auricular-opening. The sutures a b 
 and c d are to be tied to the opposite sutures 
 to bring the periosteum together. 
 
 The third step of the Passow-Trautmann plastic 
 operation. Closing the skin. 
 
 and over it, and the bone, including the styloid attachment and the ante- 
 rior portion of the mastoid tip, sawn through (Plates XIV and XV). The 
 remaining portion of the bone, especially that lying beneath the floor of 
 the meatus, may be removed with bone forceps. 
 
 (g) If the transverse process of the atlas projects outward into the 
 field of operation, it should be removed, care being exercised to avoid 
 injuring the vertebral artery (Bardeleben). 
 
 (h) The outer portion of the thin bone encircling the jugular bulb 
 should be removed with bone forceps. 
 
 (i) The jugular bulb, being exposed to surgical interference, should 
 be examined, and its condition noted for scientific purposes. As the 
 
856 THE EAR 
 
 sigmoid sinus above and the internal jugular vein below have already 
 been obliterated and removed, there is no added danger in removing the 
 bulb which forms the connecting link between them (Plate XVI) . 
 
 (J) The jugular bulb should be removed from the jugular fossa with a 
 curette. 
 
 (k) The primary dressing should consist of a gauze wick, the distal 
 end of which is inserted into the jugular fossa, and the proximal end in 
 contact with the external absorbent dressing. The mastoid, sigmoid 
 sinus, and neck wounds should also be drained by spiral tubes with a 
 small gauze wick in each. 
 
 (/) The after-treatment consists in applying suitable internal drainage 
 and external absorbent dressings until all suppuration ceases and the 
 cavities have healed. The mastoid wound should heal by granulation, 
 finally becoming covered with epidermis. Should exuberant granula- 
 tions form, they should be reduced with caustic applications or with 
 the electric cautery, though they will disappear in a few days if Emil 
 Beck's bismuth paste (bismuth subnitrate, 1 part; vaseline, 2 parts) is 
 used to fill the mastoid wound. The paste should be used daily and 
 strands of catgut introduced to promote drainage. Should the mastoid 
 bony surface fail to heal within from four to ten weeks, it should be 
 freely exposed (the postauricular wound is left open at the time of the 
 primary operation), curetted, the hemorrhage checked, and Thiersch 
 grafts applied as previously described. 
 
 CLOSURE OF POSTAURICULAR FISTULA. 
 
 The Mosetig-Moorhof Method. — This method is adapted to the 
 closure of small openings, and is performed as follows : (a) The edges of 
 the fistulous openings are freshened; (b) a skin flap corresponding in 
 size with the opening is made below it, a pedicled attachment being 
 left at the upper portion of the flap; (c) the flap is then turned upward 
 and placed in the fistulous opening, with the skin surface inward; (d) 
 it is then fixed in this position by four sutures; (e) finally, the fresh- 
 ened edges of the fistulous opening are brought together over the raw 
 surface of the skin flap, thus forming an epithelial lining on the inside as 
 well as on the outside of the fistulous opening (Figs. 481, 482, 483, 484). 
 
 Passow-Trautmann Method. — (a) Make a circular incision about 
 one-eighth inch or more (Trautmann) from the edge of the fistulous 
 opening, and separate the periosteum and skin within the incised circle 
 from the bone beneath; (b) unite the everted margins of the periosteum 
 thus loosened with absorbable catgut sutures; (c) loosen the skin exter- 
 nal to the incision and unite the edges over the first periosteal flaps with 
 sutures (Figs. 485 and 486). 
 
PLATE XVI 
 
 The Exposure of the Jugular Bulb Completed, the Sigmoid 
 Sinus Exenterated and Packed with Gauze, and the Facial 
 Nerve Lifted from its Canal and Retracted Anteriorly. The 
 facial ridge is usually located more anteriorly over the jugular 
 bulb than shown in the drawing. 
 
CHAPTER XLIX. 
 
 FACIAL PARALYSIS. 
 
 Fig. 487 
 
 The Plastic Surgery of the Facial and Hypoglossal Nerves. — The 
 facial nerve is subject to the same diseases peculiar to other peripheral 
 nerves, the most frequent affection being paresis or paralysis. 
 
 Paralysis is characterized by facial deformity, due to the immobility 
 of the muscles supplied by the facial nerve. The manifestations are the 
 inability to raise the eyebrow, the 
 skin of the forehead, lip, and cheek, 
 and to completely close the eye. 
 The attempt to distend the buccal 
 cavity is attended by the escape of 
 air through the paralyzed side of the 
 mouth. There is also inability to 
 pucker the lips in whistling, because 
 the angle of the mouth droops; 
 this causes the patient a certain 
 embarrassment in speech (Fig. 487). 
 
 Etiology. — 1. Exposure to cold 
 and wet, followed by neuritis and 
 perineuritis of the facial nerve. 
 
 2. A neuritis due to toxemia, 
 syphilis, rheumatism, diabetes, gout, 
 leukemia, diphtheria, and other in- 
 fectious diseases. 
 
 3. Tumors affecting any part of 
 the course of the facial nerve, as intra- 
 cranial, intra-osseous, and external 
 neoplasms. 
 
 4. Traumatism, one of the most 
 frequent causes of facial paralysis, 
 and one which concerns the otolo- 
 gist. The facial paralysis may arise 
 during suppuration of the middle and 
 internal ear, especially chronic sup- 
 puration, or suppuration persisting after operative procedures for its cure. 
 
 Facial paralysis may also result from packing the mastoid wound too 
 tightly after a mastoid operation. It is known to have been caused 
 by the very means devised for the protection of the facial nerve during 
 an operation, namely, Stacke's protector in the hands of an inexperienced 
 assistant, who presses it too firmly against the facial canal or twists it 
 while it is in the aditus ad antrum. 
 
 Facial paralysis of otitic origin. The 
 patient is attempting to close both eyes 
 and to draw the mouth on both sides; the 
 right facial nerve being paralyzed, he is 
 unable to close the right eye or to contract 
 the right angle of the mouth. 
 
858 THE EAR 
 
 Curettage of the middle ear for granulations, where the facial nerve is 
 not covered by bone, may injure the nerve and cause paralysis. 
 
 The vigorous cauterization of granulations in the middle ear with 
 chromic or other caustic acids may also produce facial paralysis. One 
 such case came under the author's observation. 
 
 Treatment. — The treatment is divided into : 
 
 1. Medical (local and expectant). 
 
 2. Surgical. 
 
 Paralysis of toxic origin, following exposure to cold or infectious 
 diseases, is usually slight, recovery occurring in from one to six months 
 by the natural process of repair. The usual treatment in such cases 
 is elimination of the toxins by catharsis, the administration of strych- 
 nine and other tonics, facial massage, and electricity. These procedures 
 are used principally to keep up the muscular tonicity while the nerve 
 is regaining its normal function. Paralysis after a mastoid operation 
 from too firm packing, or violent reaction, usually subsides within a 
 short time after the cause is removed. When a tumor is pressing upon 
 the facial nerve, or the nerve is injured in the removal of the tumor, 
 the paralysis frequently disappears soon after the completion of the 
 operation. 
 
 In all other conditions causing facial paralysis, wherein the continuity 
 of structure of the nerve has been destroyed for a greater distance than 
 the process of repair will bridge over, a surgical operation is required 
 to effect a cure. 
 
 In order to understand the surgery of the facial nerve it is necessary 
 to have a clear conception of its anatomy and physiology. 
 
 The facial nerve arises from a large group of cells situated in the 
 upper portion of the medulla oblongata near the junction of the medulla 
 and the pons. 
 
 From this nucleus it passes up to the fourth ventricle, forming a 
 knee, to the nucleus of the sixth nerve, and comes out at the junction of 
 the pons and medulla in connection with the sixth nerve. The fibers of 
 the facial lie on the inner side of this composite nerve. From this point 
 the nerve passes through the internal auditory meatus, through the Fallo- 
 pian canal, beneath the posterior and lower border of the annulus tym- 
 panicus, through the anterior border of the mastoid process, and then 
 emerges from the stylomastoid foramen. From this point it passes for- 
 ward into the substance of the parotid gland, within which it divides into 
 three great branches, known as the pes anserinus (goose foot). One 
 branch goes to the muscles of the forehead, the eyelid, and the upper 
 portion of the malar zygomatic region. The second passes across the 
 face, supplying the angle of the nose and the muscles that raise the upper 
 lip. The third supplies the muscle at the angle of the mouth, the 
 lower lip, the platysma, and the stylopharyngeus muscle. 
 
 At the exit of the nerve from the stylomastoid foramen one branch, the 
 auricularis posterioris profunda, is given off, and goes to the muscles of 
 the neck. The interosseous portion of the facial nerve gives off a num- 
 ber of small branches, communicating with other nerves, as the fifth 
 
THE SURGERY OF THE FACIAL NERVE 859 
 
 and the pharyngeus. The pneumogastric and sympathetic also give off 
 special branches, the petrosals, stapedius, and chorda tympani. 
 
 The function of the nerve is to supply the muscles of expression, as 
 mentioned above, and it is, therefore, a motor nerve. However, a certain 
 amount of sensitive fibers are contained within it, due to its gross associ- 
 ation with the other intracranial nerves. 
 
 THE SURGERY OF THE FACIAL NERVE. 
 
 The operative procedures for the cure of facial paralysis are: 
 
 1. Suture of the severed ends of the facial nerve. 
 
 2. Plastic operations. 
 
 (a) The union of the facial and hypoglossal nerves. 
 
 (b) The union of the facial and spinal accessory nerves. 
 
 (c) The union of the facial and the glossopharyngeal nerves. 
 The first procedure, that is, the suturing of the accidentally severed 
 
 ends of the facial nerve, seems to be unnecessary, because, if only moder- 
 ate loss of substance between the two ends exists, the proximal ends of the 
 nerve will regenerate and unite with the distal end without suturing. 
 
 In the plastic operations, the union between either the facial and spinal 
 accessory (b) or the glossopharyngeal (c) gives rise to so many untoward 
 symptoms following the procedures that they have been practically 
 abandoned in favor of the union of the facial and hypoglossal nerves (a). 
 
 The Methods of Anastomosing the Facial and Hypoglossal 
 Nerves. — 
 
 1. End to end. 
 
 2. End to side. 
 
 3. Side to side. 
 
 The easiest method is the end-to-end operation, and it is the most 
 productive of success, but it necessitates paralysis of the muscles of 
 the tongue. The end-to-side operation is to be preferred in all cases, 
 as paralysis of the tongue is avoided. The side-to-side procedure has 
 only been performed once, and with a poor result. 
 
 Plastic Surgery of the Facial and Hypoglossal Nerves; Anasto- 
 mosis of the Facial and Hypoglossal Nerves. — Technique. — (a) Gen- 
 eral anesthesia, the patient having been prepared as for any other major 
 operation. 
 
 (6) An incision of the skin should be made, beginning at the tip of the 
 mastoid process, near the lobe of the auricle, and extending downward 
 and forward along the anterior border of the sternomastoid muscle to 
 the level of the cricoid cartilage of the larynx. 
 
 (c) It should then be carried through the superficial fascia and the 
 platysma muscle, thus exposing the sternomastoid muscle. The external 
 jugular vein is usually sacrificed in this procedure, the severed ends 
 being tied. 
 
 (d) The anterior border of the sternomastoid muscle and the internal 
 jugular vein should be located, and retracted posteriorly, to expose the 
 
860 THE EAR 
 
 hypoglossal nerve, as shown in Plate XVII. The posterior belly of the 
 digastric muscle is located more anteriorly and superiorly, as it extends 
 from the mastoid tip to its pulley. 
 
 (e) The dimensions of the parotid gland, which is situated on the pos- 
 terior border of the ramus of the inferior maxilla, should be determined, 
 as the facial nerve divides into three branches within its substance. 
 Having located the boundaries of the parotid gland, trace the facial nerve 
 to it. The nerve may then be traced backward and upward to its exit 
 from the stylomastoid foramen. 
 
 (/) The hypoglossal nerve should then be isolated from the tissues 
 covering it. It crosses the external carotid artery just below the point 
 where the occipital artery is given off. The nerve should be exposed by 
 blunt dissection as far posteriorly as possible, to free it from the tissues. 
 This allows the hypoglossal nerve to be brought toward the stump of 
 the divided facial, with which it is to be anastomosed. 
 
 (g) The facial nerve should then be drawn from the Fallopian canal 
 as far as possible, and severed at the stylomastoid foramen. If it is not 
 thus drawn from the canal it will be too short to allow the anastomosis 
 of the nerves. 
 
 J. C. Beck has devised a forceps for seizing the facial nerve as it comes 
 from the styloid foramen. With this instrument it may be withdrawn 
 a half-inch from the canal which gives sufficient length for union with 
 the hypoglossal nerve. 
 
 Having severed the facial nerve, the sheath covering its proximal stump 
 should be removed with scissors to expose its axis cylinders (Fig. 488). 
 
 (i) Make an incision one-eighth inch long in the sheath of :he hypo- 
 glossal nerve, in as close proximity to the stump of the facial nerve as 
 possible (Plate XVII). 
 
 (j) The nerve fibers should then be separated with fine pointed dis- 
 secting forceps, so that when the barred axis cylinders of the facial stump 
 are inserted into the hypoglossal incision they will be in direct contact 
 with those of the hypoglossal nerve. 
 
 (k) A fine silk thread with a small round needle on either end should 
 then be passed through the sheath of the facial nerve from without 
 inward, and each needle passed through the sheath of the hypoglossal 
 nerve from within the incision outward. The same procedure is then 
 carried out on the opposite side of the facial nerve, as shown in Fig. 488. 
 
 (/) The operator and the first assistant each handle one suture, and 
 draw it tight, while the second assistant separates the lips of the incision 
 in the hypoglossal nerve, the third assistant guiding the pointed stump 
 of the facial into the hypoglossal incision. 
 
 The anchor sutures (Fig. 488) are then tied and the axis cylinders of 
 the two nerves are thus brought into direct contact. 
 
 The stump of the facial nerve should be directed toward the proximal 
 end of the hypoglossal nerve, so that stimuli from the brain, coming 
 through the hypoglossal, will be more readily transmitted to the facial 
 nerve and carried to the muscles of facial expression. 
 
 The sutures should be tied with the greatest care. If too great a num- 
 
PLATE XVII 
 
 The Anastomosis of the Facial with the Hypoglossal Nerve. 
 er, the parotid gland; 6, the stump of the facial and the facial 
 anastomosed with (g) the hypoglossal nerve; c, the posterior 
 belly of the digastric muscle; tl, the external jugular vein; 
 c, the sternomastoid muscle retracted to expose the hypo- 
 glossal nerve; /, the omohyoid muscle; g 9 the hypoglossal 
 nerve; m, the mastoid process. 
 
THE SURGERY OF THE FACIAL NERVE 
 
 861 
 
 ber of the axis-cylinder fibers of the hypoglossal are caught in the suture, 
 there will be a certain amount of paralysis of the tongue (Fig. 490). 
 
 Fig. 488 
 
 Schema showing the method of suturing the fascia of the facial with the hypoglossal nerve. 
 a, b and c, d, double-needled anchor sutures. 
 
 Too great tension of the hypoglossal nerve will also result in lingual 
 paralysis, hence the necessity of drawing the facial from the Fallopian 
 canal, and dissecting the hypoglossal nerve as far posteriorly as possible, 
 to give it greater freedom of displacement toward the stump of the facial 
 nerve. 
 
 Fig. 489 
 
 b, b, anchor sutures holding the implanted facial nerve in position in the hypoglossal nerve; 
 a, a, a loose running suture closing the longitudinal incision in the hypoglossal nerve. 
 
 (m) A secondary continuous suture should then be passed through the 
 lips of the hypoglossal incision, as shown in Fig. 489, a, a. This suture 
 should not be tied, but drawn tightly. 
 
862 THE EAR 
 
 (n) The anastomosed nerves should be covered with a piece of cargile 
 membrane, and the muscles of the neck replaced in their normal positions. 
 The cargile membrane prevents the formation of scar tissue and ad- 
 hesions, which would greatly interfere with the success of the operation. 
 
 (o) The final step of the operation consists in suturing the superficial 
 fascia and skin, drainage being unnecessary, as the operative field is 
 aseptic. 
 
 After-treatment and Observations. — The skin stitches should be removed 
 in from five to seven days, and as soon thereafter as possible massage, 
 electric and tonic remedies should be instituted. 
 
 Fig. 490 
 
 Partial lingual paralysis shown upon protrusion of the tongue, due to the injury of a few of 
 the fibers of the hypoglossus nerve at the time of the union of the facial and the hypoglossus 
 nerves, a, the area paralyzed. (Dr. J. C. Beck's case.) 
 
 The earliest manifestations of the proper union of the nerves is the 
 appearance of a certain amount of tonicity in the muscles of the paralyzed 
 side of the face. This change is only an indication that anatomical union 
 has occurred, and should not be construed as a beginning of functional 
 activity. On the contrary, it may be weeks, months, or even a few years 
 before functional activity is manifested. 
 
 The first sign of functional activity is a slight contraction of the muscles 
 supplied by the lower of the three branches of the pes anserinus, namely, 
 the muscles of the lower lip and the angle of the mouth. At a little later 
 
THE SURGERY OF THE FACIAL NERVE 863 
 
 period the muscles of the upper lip and the forehead show functional 
 activity. 
 
 A still later development is the contraction of the facial muscles simul- 
 taneously with the act of deglutition. This gradually increases until the 
 contraction on the paralyzed side is greater than on the unaffected side, 
 which is very disagreeable to the patient. 
 
 The simultaneous contraction of the facial and hypoglossal muscles 
 is very annoying and confusing. The patient soon learns, however, to 
 disassociate the movements, and is able to swallow with a constantly 
 decreasing degree of facial distortion, until finally the facial muscles 
 remain quiet during the acts of deglutition. 
 
 The final and most desirable result is the voluntary contraction of the 
 facial muscles independent of the act of swallowing. 
 
 The time required to obtain such a result varies greatly, depending 
 upon the amount of muscle degeneration before the operation, the accu- 
 rate apposition of the two nerves, and the general condition of the 
 patient. 
 
 The reaction of the muscles supplied by the facial nerve should be 
 tested with the electric current in long-standing cases, to determine 
 whether they are still active. If contractions are not produced — that is, 
 if complete atrophy of the muscle is present— it is useless to operate. 
 The contraction of the masseter muscles should not be mistaken for the 
 contraction of the facial muscles. One case of fourteen years' standing 
 was successfully operated. 
 
CHAPTER L. 
 
 DISEASES OF THE PERCEPTION APPARATUS. AUDITORY 
 NERVE APPARATUS. 
 
 HYPEREMIA OF THE LABYRINTH. 
 
 Etiology. — The etiology is generally associated with either congestion 
 of the middle ear or the contents of the cranial cavity. It is rarely 
 primary in the labyrinth. It is usually found in acute suppurative 
 otitis media following scarlet fever, diphtheria, and typhoid fever. It 
 may also be caused by the other exanthematous fevers, pneumonia, 
 encephalitis, mumps, puerperal fever, meningitis, and tumors at the 
 base of the brain. Thrombi in the sinuses of the petrous portion of 
 the temporal bone and the internal jugular vein, goitre, angioneurotic 
 congestion of the cranial vessels, intracranial affections of the trigeminus, 
 diseases of the medulla oblongata, and the internal use of quinine, 
 salicylic acid, and amyl nitrite may also cause it (Politzer.) 
 
 Symptoms. — The symptoms are tinnitus, slight feeling of fulness in the 
 head and ears, nausea, vomiting, and unsteady gait. The handle of the 
 malleus may be injected, and, when present, denotes a general hyper- 
 emia of the organ of hearing. The face and auricle may in rare cases be 
 red. If there is a sense of dazzling whiteness before the eyes, the hyper- 
 emia is probably of intracranial origin. 
 
 Treatment. — If the hyperemia is secondary to middle ear inflamma- 
 tion, special attention should be addressed to that disease, and with the 
 subsidence of the middle ear disease the labyrinthine symptoms will dis- 
 appear. The patient should be put in bed, given laxatives, and have 
 leeches applied to the nape of the neck and mastoid process. If there is 
 active inflammation in the middle ear and mastoid process, the ice-bag or 
 Leiter's coil should be applied to the mastoid reigon for one hour. 
 
 If the disease arises from an intracranial lesion, the treatment should 
 be addressed to that condition, the ice-bag applied to the vertex, saline 
 cathartics given, and alcoholic beverages and tobacco prohibited. In 
 general, the habits should be well regulated, constipation prevented, and 
 the beneficial effects of fresh air and sunshine should be taken advantage 
 of by the patient. 
 
 ANEMIA OF THE LABYRINTH. 
 
 Etiology. — The etiology is usually a co-existing general anemia. It 
 may exist, however, as a local condition, due to the obstruction of the 
 internal auditory artery from aneurysm of the basilar artery, neoplasms 
 
HEMORRHAGE INTO THE LABYRINTH 865 
 
 of the dura or brain extending into the internal auditory canal, emboli of 
 the internal auditory artery, and atheromatous constriction of the internal 
 auditory artery. 
 
 Symptoms. — In the angioneurotic and posthemorrhagic forms the 
 symptoms closely simulate those of seasickness; there is nausea, vomit- 
 ing, severe tinnitus aurium, deafness, facial pallor, and dizziness. All 
 these symptoms disappear with the return of the blood to the normal 
 state. In the chronic form the tinnitus and deafness are the chief symp- 
 toms. 
 
 Treatment. — If the labyrinthine anemia is angioneurotic in origin, 
 the neurosis should receive appropriate attention; perhaps a long sea 
 voyage, residence in the mountains or at the seashore, primitive camp 
 life, etc., might be beneficial. If the cause is an excessive hemorrhage, 
 transfusions of normal saline solution should be given, or spontaneous 
 relief may come after a more or less prolonged period of waiting. If 
 it occurs in one who is subject to repeated severe hemorrhages, the 
 duration of the ear symptoms is somewhat prolonged, and means to 
 prevent the recurrences of the hemorrhages should be carefully con- 
 sidered in the treatment. In the angioneurotic type, the internal ad- 
 ministration of the bromide of soda and the application of the galvanic 
 current to the sympathetic nerves of the neck are indicated. 
 
 HEMORRHAGE INTO THE LABYRINTH. 
 
 Small hemorrhages into the labyrinth may occur during the course 
 of the exanthematous fevers, on account of the increased blood pressure 
 and the rapid degenerative changes which sometimes characterize the 
 progress of these diseases. The hemorrhages also occur in caisson 
 workers and divers, and in prolonged suffocative seizures. Diabetes, 
 nephritis, and sudden cessation of menstruation may also furnish the 
 cause and atheromatous degeneration of the walls of the arteries pre- 
 disposes to labyrinthine hemorrhage. 
 
 More extensive hemorrhages into the labyrinth occur in fractures of 
 the skull, involving the petrous portion of the temporal bone; from 
 severe contusions of the skull; from extension of carious processes in 
 the temporal bone, and from primary and tuberculous meningitis 
 (Politzer). 
 
 Course and Termination. — The course and termination of the 
 hemorrhages into the labyrinth are obviously variable, according to their 
 severity and origin. The blood clots persist in the labyrinth for a variable 
 time, after which they may be absorbed, become organized, or the epi- 
 thelium, connective tissue, nerve elements, etc., involved by the pressure 
 may become atrophied and degenerated. Politzer reports a case which 
 ended in suppuration. 
 
 55 
 
866 THE EAR 
 
 MENIERE'S DISEASE. 
 
 This condition is characterized by sudden and complete loss of hearing, 
 attended with tinnitus, nausea, vomiting, spontaneous nystagmus and 
 vertigo, without a previous history of ear disease. It is supposed to be 
 due to a hemorrhage into the labyrinth. The patient is usually robust, 
 middle aged, and has never previously complained of deafness. At the 
 onset of the attack he sometimes falls unconscious to the ground. In a 
 case seen by the author, the attack came on at night. The patient upon 
 attempting to rise in the morning had severe dizziness (indeed, could not 
 walk), nausea, vomiting, tinnitus, and complete deafness. The history of 
 the case showed that two years previously the left ear was similarly 
 affected, the hearing remaining almost nil in that ear, the right being 
 normal. It is now thirteen years since the last attack, and the hearing 
 is but little improved. 
 
 The hearing by bone conduction is lost if the affection is bilateral, and 
 when unilateral the sound of the tuning-fork, when placed on the vertex, 
 is lateralized to the unaffected side. 
 
 The course of Meniere's disease varies. The unconsciousness rapidly 
 disappears, and the vomiting a little more slowly. The dizziness and 
 staggering gait remain for several days. In the author's case the patient 
 had a tendency to walk to the right for four or five weeks after the 
 apoplectiform attack. He was dazed, and thought slowly for some weeks. 
 His handwriting was not tested. Guye and Politzer report that for a 
 time the handwriting is like that of a tremulous old man. The unsteady 
 gait may persist for years. Relapses usually occur, although there are 
 exceptions to the rule. 
 
 Diagnosis. — The diagnosis of Meniere's disease can only be made with 
 certainty when the patient is examined immediately after the seizure. 
 If the middle ear, drumhead, and Eustachian tubes are normal and 
 the patient gives the clinical picture just described, and there is no 
 paralysis of other cranial nerves, a diagnosis of Meniere's disease may 
 be made. 
 
 This disease should be differentiated from Meniere's symptom com- 
 plex, which is usually due to an intermittent closure of the Eustachian 
 tubes. The rarefaction of the air in the tympanic cavity retracts the 
 membrana tympani and forces the foot plate of the stapes into the oval 
 window, thus increasing the tension of the labyrinthine fluids and 
 giving rise to the symptoms of Meniere's disease. An examination 
 of the drumheads and Eustachian tubes, however, shows retraction of 
 the one and obstruction of the other. After inflation of the tympanic 
 cavity the symptoms disappear and only return when the air in the 
 tympanum becomes rarefied. The history of the case shows repeated 
 recurrences of deafness and Meniere's symptom complex. 
 
 Prognosis. — The prognosis is unfavorable, little improvement being 
 reported in the cases thus far recorded. 
 
MENIERE'S SYMPTOM COMPLEX 867 
 
 Treatment. — The treatment is directed principally to the relief of 
 the dizziness, nausea and vomiting. The patient should be placed in 
 bed with the head slightly raised, to avoid the necessity of changing 
 the position in giving food and medicines, as the movements attending 
 these acts increases the disorders present. This precaution should be 
 observed for a few days while the symptoms are annoying. Cold com- 
 presses to the head, mustard plasters to the nape of the neck and calves 
 of the legs, and the administration of purgatives may hasten the disap- 
 pearance of the annoying symptoms. The tinnitus is often relieved by 
 the administration of quinine and the iodide of potash, or, what is prob- 
 ably preferable, iodonucleoid, in which the iodine is united with nucleinic 
 acid, thus rendering it readily digestible and easily and rapidly ab- 
 sorbed, without irritating the stomach. If the quinine causes mental 
 excitement and increased tinnitus, its use should be discontinued 
 (Charcot). It should be given in 2 grain to 5 grain doses three times 
 daily for six or eight weeks. The iodide of potash (or iodonucleoid) 
 may be given for three or four weeks. 
 
 To promote absorption of the blood clot and exudate, pilocarpine, in 
 2 per cent, solution, may be injected 4 to 10 drops daily; or it may be 
 given internally for the same purpose. Its use should not be begun until 
 about the third week, when the acute symptoms have subsided. 
 
 MENIERE'S SYMPTOM COMPLEX. 
 
 This condition, while similar in its manifestations in many respects to 
 Meniere's disease, should not be confounded with it. Meniere's symp- 
 tom complex is characterized by dizziness, staggering gait, nausea, 
 tinnitus, and more or less deafness, with a distinct history of previous 
 deafness and ear disease. The deafness does not occur suddenly, and is 
 not complete, nor are the profound disturbances found in true Meniere's 
 disease present. The author once saw a case in consultation, in which 
 nearly all the signs of Meniere's disease were present, the exceptions 
 being: (a) there was a history of previous deafness and ear disease; (b) 
 the deafness did not occur suddenly, nor was it profound; (c) inflation 
 of the middle ear through the Eustachian catheter gave immediate and 
 complete relief. The case was one of Eustachian catarrh, complicating 
 a similar process in the epipharynx. The air in the middle ear became 
 gradually rarefied by the absorption of the oxygen by the blood, the 
 drumhead was retracted, and pushed the foot plate of the stapes in- 
 ward, which compressed the intralabyrinthine fluids, and gave rise to 
 the foregoing phenomena. The same phenomena may be due to chronic 
 catarrhal adhesive processes. According to Politzer, a great majority of 
 the cases are due to a temporary congestion of, or exudation into, the 
 labyrinth, arising in the course of middle ear infections, which bring- 
 about an irritation of the vestibular and ampullar nerves. 
 
 Dr. Geo. E. Shambaugh recently advanced the theory that the tinnitus 
 attending this affection was due to a disturbance of the relation of the 
 
868 THE EAR 
 
 membrana tectoria to the hair cells of the organ of Corti. He holds that 
 the membrana tectoria is the resonator of the perception apparatus, 
 whereas according to Helmholtz the basilar membrana is the resonator. 
 (See Physiology of the Labyrinth.) 
 
 The use of the tuning-forks enables the observer to differentiate be- 
 tween cases of middle ear origin and those of labyrinthine origin. If 
 with marked diminution of hearing there is positive Rhine, with hearing 
 for low tones preserved, the lesion is in the labyrinth; if, on the contrary, 
 there is a negative Rinne, with loss of hearing for low tones, the lesion 
 is in the conduction portion of the temporal bone, i. e., in the middle ear 
 and Eustachian tube. If the disease is unilateral, the vibrating tuning- 
 fork placed upon the vertex will, if the lesion is in the middle ear or 
 Eustachian tube, lateralize toward the affected side; whereas, if it is in 
 the labyrinth it will lateralize toward the normal or unaffected side. 
 
 Some cases reported by Urban Pritchard and Richard Lake were of an 
 epileptiform type, with a tendency to fall toward the affected side. The 
 room seemed to whirl, the face became pale, the eyes dull, the skin 
 covered with cold perspiration, and the pulse small and often retarded. 
 
 Fig. 491 
 
 Siegle's otoscope. 
 
 The course of the symptoms is extremely variable, lasting from a few 
 moments to several days or weeks. 
 
 Treatment. — In those cases due to hyperemia of and exudation into 
 the labyrinth the same treatment recommended under hyperemia of the 
 labyrinth is of value. If the lesion is in the Eustachian tube or middle 
 ear the remedies suited to the condition present should be used. Quinine 
 is perhaps more valuable for the relief of the tinnitus than it is in 
 Meniere's disease. Pneumomassage, especially rarefaction (suction) of 
 the air in the external meatus, in either the middle ear or labyrinthine 
 type, is beneficial in many cases. Its rationale in the middle ear type is in 
 the outward movement of the drumhead, which relieves the pressure upon 
 the foot plate of the stapes, and in the labyrinthine type the lessened 
 pressure in the middle ear relieves the labyrinthine congestion. Rare- 
 faction can be practised by means of a rubber tube with a metal tip, the 
 patient supplying the suction power with his mouth at the other end of the 
 tube, or Delstanche's rarefacteur or Siegle's otoscope (Fig. 491) may be 
 used with equally good results. 
 
ARTERIOSCLEROSIS OF THE LABYRINTH 869 
 
 ARTERIOSCLEROSIS OF THE LABYRINTH. 
 
 According to J. J. Kyle, " Arteriosclerosis of the labyrinth may be local, 
 or a part of a general sclerosis of the arterial and cellular structures of the 
 body." 
 
 Etiology. — "The cause of arteriosclerosis of the labyrinth is the same 
 as in any other part of the body, and may be syphilis, laborious occupa- 
 tion, alcoholism, lead poisoning, infectious fevers, auto-intoxication, 
 vasomotor disease, and heredity. 
 
 "Syphilis is probably the most important factor in the etiology of the 
 disease in middle life. 
 
 "The disease may be unilateral or bilateral, and is observed early 
 and late in life." 
 
 Pathology. — "The affection probably begins as a structural change 
 in the vasovasorum, and is fibrous in character. The labyrinthine 
 artery is the single artery of the labyrinth, and as soon as the nutrition 
 in its wall is disturbed, connective-tissue degeneration takes place in the 
 media. Fatty degeneration soon follows in the intima with the deposit 
 of calcareous salts. The vessels may sometimes become narrowed or 
 obliterated. 
 
 "As soon as the nutrition of the basilar membrane and organ of Corti 
 is partially or completely cut off, there is atrophy of the sensory audi- 
 tory cells and connective-tissue proliferation of all the structures. The 
 same change may be observed in the nerve endings of the vestibule and 
 semicircular canals. 
 
 "The change in the brain structures varies according to the amount 
 of nutrition carried to the parts. In endarteritis obliterans of the vessels 
 supplying the centre of hearing and equilibration, there is, on account of 
 the slow change in the arterial walls, degeneration and atrophy of the 
 brain cells." 
 
 Symptoms. — "The symptoms of arteriosclerosis are both general and 
 local. The general symptoms are increased arterial tension, increased 
 tortuosity and prominence of the arteries of the temple, hypertrophy of 
 the heart, and, if the last is present, there is generally a lowered vitality 
 of the individual, a feeling of age, and tiring, as from overwork, followed 
 by an appearance of aging. Analysis of the urine usually shows increase 
 of the urates and long thin hyaline casts, undergoing granular degen- 
 eration. 
 
 "The ear symptoms are unilateral or bilateral tinnitus, slight and 
 progressive deafness, impairment of air and bone conduction, in some 
 cases dizziness early in the disease, and in the later stages hallucinations 
 of hearing may be present. The ear symptoms necessarily vary accord- 
 ing to the extent of the sclerosis." 
 
 Diagnosis. — "The above symptoms, both general and local, should 
 always direct the physician's attention to the possibility of arteriosclerosis. 
 The early diagnostic symptoms are tinnitus, vertigo, and nutritive change 
 in the membrana tympani, that is, the presence of an arcus senilis, and 
 
870 THE EAR 
 
 slight unilateral or bilateral deafness. If the general symptoms, as 
 enumerated above, are present, the diagnosis is usually complete. 
 
 "The location of the lesion, whether in the nuclear or labyrinthine 
 endings of the nerve, may, according to Gradenigo, be shown by the 
 tuning-forks. A diminution in bone conduction and the loss of high 
 tones is indicative of labyrinthine deafness. • In central deafness there 
 is a pronounced loss of perception for both high and low tones. 
 
 "The disease should not be confounded with Meniere's disease, 
 hyperemia of the auditory nerve, hysterical deafness, hemorrhagic 
 extravasation in the labyrinth from a fall or blow upon the head, or 
 nerve deafness from toxic absorption." 
 
 Prognosis. — "The prognosis is usually poor so far as the restoration 
 of hearing or complete cure of the tinnitus is concerned. Under general 
 treatment the symptoms may frequently be relieved and often brought to 
 a standstill." 
 
 Treatment. — "The treatment of arteriosclerosis of the ear is both 
 general and local, depending somewhat upon the exciting cause. Cases 
 with hereditary predisposing factors do not respond to treatment as 
 well as those due to syphilis or acquired diseases. However, in both 
 conditions, the iodide of potassium in from 2 to 5 grain doses, four or 
 five times daily for long periods of time, is indicated." 
 
 INFLAMMATION OF THE LABYRINTH; OTITIS INTERNA; 
 LABYRINTHITIS. 
 
 Acute Primary Inflammation of the Labyrinth (Voltilini). — T^his 
 type of labyrinthitis is usually mistaken for an acute meningitis. There 
 are differences, however, which will enable one to make a differential 
 diagnosis. Voltilini gives the following characteristics : (a) it occurs in 
 children who were previously healthy, (b) there is a sudden rise of temper- 
 ature, (c) the face is very red, (d) vomiting takes place, followed by (e) 
 unconsciousness, delirium, and convulsions; (/) after a few days all these 
 symptoms disappear, leaving the patient totally deaf and with a staggering 
 gait, which persists for some time. Had meningitis been present the dis- 
 ease would have pursued a much longer course. 
 
 Acute Labyrinthitis Secondary to Meningitis. — This is followed 
 by total deafness and sometimes by voluntary nystagmus (see Functional 
 Tests of the Vestibular Apparatus) and a staggering gait. The acute 
 symptoms usually continue for several weeks, whereas in the acute 
 primary inflammation of the labyrinth (Voltilini) the acute symptoms 
 disappear in a few days. Politzer calls attention to the fact that an intra- 
 cranial affection may lead to a total paralysis of the acoustic nerve, 
 generally involving some of the other intracranial nerves as well; but that 
 it does not necessarily do so, as pointed out by Gottstein, in the abortive 
 type of epidemic cerebrospinal meningitis. Hovell also questions 
 Voltilini's conclusions. It seems to the author that, while Voltilini may 
 have erred in reaching such a broad conclusion, namely, that those cases 
 
INFLAMMATION OF THE LABYRINTH 871 
 
 presenting the meningeal symptoms for only a few days, followed by 
 deafness and staggering gait, were all acute primary inflammations of the 
 labyrinth, he should, nevertheless, be given the credit for calling 
 attention to the fact that some of the cases presenting this clinical history 
 are, in all probability, limited to the labyrinth, although some are prob- 
 ably abortive types of meningitis. 
 
 Chronic Primary Inflammation of the Labyrinth. — To Politzer be- 
 longs the honor of first reporting the anatomical and microscopic appear- 
 ances of a case of chronic primary inflammation of the labyrinth. In 
 his case the following facts are of interest: (a) A boy was affected by 
 fever of two weeks' duration; (b) there was aural discharge from both 
 ears until the sixth or seventh year of age; (c) at no time was there a 
 staggering gait; (d) he died at the age of thirteen of acute peritonitis. The 
 postmortem findings : (e) No middle-ear involvement, except ankylosis of 
 the foot plate of the stapes in both ears; (/) the cavities of the cochlea, 
 vestibule, and semicircular canals were filled with newly formed bone 
 tissue; (g) the acoustic (auditory) nerve fibers were unchanged up to the 
 point of entrance into the new bone tissue. 
 
 The types of primary inflammation of the labyrinth are, according to 
 Gruber, plastic and exudative. The first is a simple hyperplasia, while 
 the latter may be serous, serohemorrhagic, or purulent. 
 
 The causes of secondary inflammation of the labyrinth are injuries, 
 and in the purulent type the labyrinth is invaded by germs. The other 
 causes are generally obscure, and are variously designated as result- 
 ing from a "cold," metastasis, etc. Sometimes it is undoubtedly due 
 to syphilis, tuberculosis, and the exanthemata, as well as to menin- 
 gitis. A frequent cause of the secondary inflammation is caries and 
 necrosis extending from the middle ear, especially in connection with a 
 tuberculous process in these parts. 
 
 Pathology. — The pathological findings following inflammation of 
 the labyrinth are: (a) Newly formed connective tissue; (b) calcareous 
 degeneration; (c) hyperostosis of the osseous walls of the labyrinth; (d) 
 bony hyperplasia in the spaces of the labyrinth; (e) angio-connective- 
 tissue growths in the cavity of the labyrinth; (/) thickening of the semi- 
 circular canals, utricle, ampulla?, and saccule; (g) cholesterin, pigmen- 
 tation, and calcium salts in the membranous labyrinth; (/i) epithelial 
 thickening on the inner wall of the saccule, utricle, and scala? of the 
 cochlea (Politzer); (i) fatty degeneration and atrophy of the organ of 
 Corti; (j) necrosis in the tuberculous and syphilitic cases, as well as in 
 those cases having their origin in (k) necrosis of the middle ear.' 
 
 Symptoms. — In Voltilini's type of acute primary inflammation of 
 the labyrinth the disease is ushered in (in children) by a sudden rise in 
 temperature, the face is quite flushed and red, with vomiting, followed by 
 unconsciousness, delirium, and convulsions. Within a few days these 
 symptoms entirely disappear, leaving the patient quite deaf and with a 
 staggering gait, which may persist for a long time. In the type second- 
 ary to meningitis the meningeal symptoms usually persist for several 
 weeks, and leave the patient deaf and sometimes with a staggering gait. 
 
872 THE EAR 
 
 The chief diagnostic point is in the shorter duration of the acute 
 meningeal symptoms in the primary inflammation of the labyrinth of 
 Voltilini. 
 
 In the secondary form the symptoms are more obscure, being compli- 
 cated by those of the primary affection. The functional tests of the 
 ear must be chiefly depended upon for the diagnosis. The signs present 
 are those of cochlear disease in general, namely: (a) diminished bone 
 conduction on the affected side, and (b) loss of hearing for the high tones 
 of the Galton whistle. In exceptional cases the hearing for high tones 
 is not affected, even in pronounced destructive changes. In the use 
 of the tuning-forks, the Weber test shows lateralization of hearing 
 toward the unaffected side, while the Rinne is positive. The tests 
 should be applied on several occasions before pronouncing a final 
 opinion. 
 
 The subjective symptoms are: more or less deafness (often being com- 
 plete and sudden), tinnitus, a feeling of fulness or of pressure in the ears, 
 giddiness, vomiting, and a staggering gait. 
 
 Inflammation of the labyrinth following cerebrospinal meningitis 
 may occur at the beginning of the disease or at its close. The patient 
 being unconscious and in bed, the deafness and staggering gait are 
 often not noticed until the mind is clear and the patient attempts to walk. 
 In the type secondary to scarlet fever and diphtheria the labyrinthine 
 inflammation usually follows an otorrhea. 
 
 Prognosis. — The prognosis is usually unfavorable. According to 
 Moos, the percentage of cures and improvements has been much larger 
 in the hands of the general practitioner than in the hands of specialists; 
 he accounts for this by the fact that the general practitioner sees the 
 case early, before the changes are so marked. Hence, we may con- 
 clude that the prognosis is more favorable if the case is seen early. 
 It is also more favorable when there is unilateral involvement. If, 
 during convalescence, the patient hears subjective sounds and has 
 perception for musical tones, the prognosis is more favorable (Moos). 
 Politzer reports that in his experience there may be a fair return of hear- 
 ing, with subsequent loss of it. If a child is affected before he learns 
 to speak, or soon afterward, he will become a deaf-mute. In the sup- 
 purative type, pachymeningitis in the posterior cranial fossa may occur, 
 the infection passing through the sheath of the auditory nerve. 
 
 Treatment. — The treatment, on the whole, is not likely to result in 
 the restoration of the hearing. There are other considerations, how- 
 ever, that render it quite important that appropriate treatment be 
 given. For example, (a) the extension and severity of the pathological 
 process may be modified; (b) the case may be of recent syphilitic origin, 
 and yield to treatment; (c) the intensity of the fever may be modified, 
 and thus save the life of the patient; and (d) the child may be prevented 
 from becoming a deaf-mute by appropriate training given at the proper 
 time. 
 
 If the disease is secondary to an inflammatory affection of the middle 
 ear or epipharynx, this should be carefully attended to. The func- 
 
LEUKEMIC DEAFNESS 873 
 
 tional activity of the bowels and kidneys should be watched and regu- 
 lated. Calomel, followed by saline cathartics, may prove of value. If 
 the temperature is high, the pulse rapid and hard, and the skin dry, 
 antipyrine in v to x gr. doses, hourly, for four to six hours, followed by 
 gr. x of Dover's powder and a hot lemonade, will lower the temperature 
 and pulse and moisten the skin, and thus greatly relieve the patient of 
 discomfort and delirium. Leeches may also be applied over the mas- 
 toid process for the same purpose. In the meningeal types, and in the 
 acute primary inflammation of the labyrinth, an ice-bag to the head is 
 a great aid in relieving the fever and delirium. Iodide of potassium, or 
 iodonucleoid, and mercury may be given in syphilitic cases, especially 
 if of recent occurrence. They are of no value in congenital syphilis. 
 Blisters and counterirritants over the mastoid and in front of the ear 
 may also be tried. 
 
 If the child has not yet learned to speak, he will surely be a deaf-mute, 
 and should be placed in a school where he will receive careful training. 
 If he has learned to speak, and is under seven years of age, he will 
 almost certainly lose the speech already acquired unless vigorous and 
 intelligent attempts are made to perpetuate it. If he is more than seven 
 years old, he is much more apt to retain his speech and use it in conver- 
 sation. It is important, therefore, that the physician should impress 
 upon the family the need of special training, to prevent the child becom- 
 ing a deaf-mute. He may become deaf, but he need not necessarily also 
 become a mute. (See Deaf-mutism.) 
 
 PANOTITIS. 
 
 This affection is characterized by an inflammation involving, simul- 
 taneously or in rapid succession, the middle ear and labyrinth. Volun- 
 tary or induced nystagmus may be present in the early stage before the 
 vestibular apparatus is completely destroyed. It usually has its origin 
 in scarlatinodiphtheria, affecting both ears, which in a short time causes 
 complete deafness. The prognosis is very unfavorable, although some 
 German writers have reported good results under treatment. Pilo- 
 carpine injections in small doses for several months have apparently 
 given good results in a few cases. The iodide of potassium, iodide 
 of ammonia, or iodonucleoid, and mercury are also recommended. 
 
 LEUKEMIC DEAFNESS. 
 
 Leukemic deafness is characterized by either sudden and complete 
 deafness and Meniere's symptoms, or by moderate deafness, which 
 speedily grows worse until, within a few weeks or months it becomes com- 
 plete. In acute leukemia the deafness and other ear symptoms occur in 
 the early stage of the disease; whereas in chronic leukemia they usually 
 appear in the later stages. The pathological changes consist of accumu- 
 
874 THE EAR 
 
 lations of lymphocytes, and hemorrhages into the labyrinth, followed 
 by a reactionary inflammation of the endosteum and membranous 
 labyrinth, which finally results in connective-tissue obliteration and 
 partial ossification of the labyrinth (Politzer). The prognosis is obviously 
 unfavorable. 
 
 OTITIS INTERNA PAROTITICA. 
 
 Mumps being an infectious disease, and the site of infection being 
 anatomically in close proximity to the labyrinth, the infection may be 
 carried to it by metastasis, or it may be carried through the Gasserian 
 fissure. The symptoms are slight vertigo, with or without vomiting, 
 and sudden deafness on one or both sides. Iodides internally sometimes 
 act favorably upon the course of the disease. 
 
 SYPHILIS OF THE INTERNAL EAR; SYPHILITIC OTITIS INTERNA. 
 
 Syphilitic diseases of the labyrinth usually appear at the end of the 
 secondary or at the beginning of the tertiary stage. Politzer, however, 
 reports a case in which there was labyrinthine involvement seven days 
 after the initial lesion. It may involve the labyrinth in common with 
 the middle ear, or as one of the signs of a general infection, or it may be 
 limited to the internal ear. 
 
 Pathology. — The pathology is but little known, as only a few cases 
 have been carefully studied. From the examinations made it appears 
 that there is present thickening of the periosteum of the vestibule (Toyn- 
 bee, Moos), displacement and fixation of the foot plate of the stapes, 
 small-cell infiltrations and hyperplasia of the connective tissue between 
 the membranous and bony labyrinth; also infiltration of Corti's organ, 
 of the ampulla?, and of the membranous semicircular canals (Moos). 
 The canals and spaces of the labyrinth have also been found filled with 
 new bony tissue. The acoustic nerve may or may not be affected. 
 Adhesive bands, hornifi cation, atrophy and destruction of the ganglionic 
 cells, and syphilitic endarteritis (Baratoux and Virchner) have been 
 reported. 
 
 Symptoms. — The symptoms are those of labyrinthine involvement 
 in general, namely, loss of hearing by bone conduction, and for high 
 tones and voluntary or induced nystagmus in the early acute stage before 
 the vestibular apparatus is destroyed. If the affection is unilateral (rare), 
 the Weber experiment will show lateralization of hearing to the normal 
 side, and Rinne will be decidedly plus upon the affected side. The 
 symptoms may appear suddenly, with tinnitus, deafness, dizziness, 
 nystagmus, and staggering gait. The nystagmus may be spontaneous 
 during the acute stage, whereas in the latent period it only appears 
 upon the use of the rotation and caloric tests. (See Functional Tests 
 of this Vestibular Apparatus.) The deafness may become complete and 
 permanent, the tinnitus increasing at the same time. The staggering gait 
 
SYPHILIS OF THE INTERNAL EAR 875 
 
 and dizziness may disappear after a few weeks or months. Diplacusis 
 and pain in the ear may be present, the pain being due to a periosteal 
 growth in the labyrinth. 1 
 
 Objectively, the signs of syphilis of the internal ear may be wanting. 
 It is only when the middle ear, or Eustachian tube, and labyrinth are 
 simultaneously involved that objective signs are found. There may 
 then be the usual appearance of a catarrhal otitis media, or the char- 
 acteristic swelling of the mucosa of the Eustachian tube. Syphilitic 
 ozena of the nose and epipharynx may also be present. 
 
 Course. — In most cases the deafness develops gradually for some 
 weeks or months, remains stationary, and then, after a variable interval, 
 suddenly becomes much worse. More rarely the deafness comes on sud- 
 denly. Slight exciting causes may bring on a rapid increase in the deaf- 
 ness. Concussions on the head, blows, etc., have been known to do the 
 same thing. In rare cases improvement and recovery take place, and 
 hearing by bone conduction gradually returns. 
 
 Diagnosis. — The differential diagnosis between syphilis, hyperostosis 
 of the bony capsule of the labyrinth, and other forms of labyrinthine 
 disease is not always easy, except when there are evidences of the second- 
 ary or tertiary manifestations of syphilis. Unfortunately, in many cases 
 no such obvious signs are present. Politzer observes that "those forms 
 of severe or total deafness which usually develop in both ears during 
 childhood must be regarded as syphilitic affections of the labyrinth. 
 Such cases were formerly supposed to be due to scrofula." The diag- 
 nosis of hereditary syphilis is aided by the presence of middle ear catarrh, 
 purulent otitis media, adhesive processes of the middle ear, and chronic 
 interstitial keratitis (opacity of the cornea). 
 
 Prognosis. — Recent cases offer a favorable prognosis, while older 
 ones are quite unfavorable. The degree of deafness is not a safe guide 
 in giving a prognosis, as totally deaf cases have been known to recover, 
 while others, with mild deafness, have remained unimproved. General 
 debilitating diseases render the prognosis more grave. The hereditary 
 type, with opacity of the cornea, is unfavorable. 
 
 Treatment. — Mercurial injections, with the internal administration 
 of iodonucleoid or iodide of potassium, are indicated. Pilocarpine 
 injections, 4 to 12 drops daily, beginning with 4 drops and increasing 
 to 12 drops, sometimes influences the case favorably (Politzer, Bacon, 
 Gradenigo). The injection of solutions of the iodide of potassium into 
 the middle ear through the Eustachian catheter, as recommended by 
 Politzer, is not to be generally favored. The technique of such a pro- 
 cedure gives rise to the extreme liability of carrying infection into the 
 middle ear. Under strict antiseptic precautions and a knowledge of 
 the extremely small size of the tympanic cavity, and the technique of the 
 whole procedure, the danger of infection disappears; and it is possible, 
 though in the author's opinion not probable, that the injection of a solu- 
 tion of the iodide of potassium will affect the course of the disease favor- 
 
 1 Moss and Steinbrugge, Zeits. f. Ohrenh., vol. xiv. 
 
876 THE EAR 
 
 ably. The injections of iodoform, iodine vasogen, mercurial ointments, 
 etc., are more rational methods of treatment. It should not be forgotten, 
 however, that the disease is essentially a systemic one. 
 
 SUPPURATION AND NECROSIS OF THE LABYRINTH. 
 
 Labyrinthine suppuration probably occurs in about 1 per cent, of the 
 cases of middle ear suppuration. It has rarely been diagnosticated, be- 
 cause the subjective symptoms are not absolutely characteristic, and 
 because the condition has not been generally understood by otologists 
 until within the last few years. Suppurative leptomeningitis is a serious 
 sequela or complication of labyrinthine suppuration, and the symptoms 
 in some respects are quite similar, hence it is quite probable that many 
 of the cases diagnosticated as leptomeningitis have been labyrinthine 
 suppuration, at least in their initial manifestation. 
 
 Etiology. — Suppurative otitis media, with involvement of the mas- 
 toid antrum, is the most common cause of the disease, though scarlet 
 fever, measles, influenza, and tuberculosis may also cause it. In the 45 
 cases reported by Bezold about 50 per cent, were in children. The vulner- 
 able points through which the infection may take place are the round 
 and oval window and the pneumatic spaces around the labyrinth. The 
 retention of the secretions and the accumulation of cholesteatomatous 
 material in the attic, aditus ad antrum, and the antrum may cause 
 pressure necrosis, and thus expose the horizontal and perpendicular 
 semicircular canals to infection. The facial nerve may also be exposed 
 by the same process, as it lies in close proximity to the horizontal semi- 
 circular canal in the floor of the antrum. The pneumatic spaces some- 
 times extend behind the labyrinth, hence the latter may be invaded 
 from this direction. The cells beneath the floor of the middle ear also 
 extend beneath the labyrinth, and should necrosis extend in this direc- 
 tion, labyrinthine involvement may follow. The promontory is rarely 
 the seat of necrosis except when there is extensive destruction of bony 
 tissue. When such a condition is present, granulations usually spring 
 from this area, and the use of a probe shows roughened bone or a 
 perforation. 
 
 The extension of the labyrinthine suppuration is explained by the 
 avenues of least resistance which lie in the direction of the internal 
 auditory meatus (sheath of the auditory nerve) and the cochlear duct. 
 The infection may also gain entrance to the cranial cavity through a 
 dehiscence or a necrosis of the perpendicular semicircular canal. If 
 the infection extends through the cochlear duct it enters the subarach- 
 noid spaces and becomes a very dangerous condition. 
 
 The intracranial complications most apt to attend labyrinthine suppu- 
 ration are suppurative meningitis and extradural abscess, though abscess 
 of the cerebrum and cerebellum and infective lateral sinus thrombosis 
 occasionally occur. 
 
 Symptoms. — When rightly understood the symptoms of labyrinthine 
 suppuration are usually very well defined. There are certain charac- 
 
SUPPURATION AND NECROSIS OF THE LABYRINTH 877 
 
 teristic symptoms which should at least lead to a tentative diagnosis. 
 The objective symptoms are not usually obvious, though in some cases 
 the presence of granulations, roughened bone, and the oozing of pus 
 from the inner wall of the middle ear cavity may be seen. When present 
 they may appear at one of four places, namely: (a) the round window, 
 (6) the oval window, (c) the promontory, or (d) the horizontal canal. 
 Facial paralysis may also be present, as the facial nerve is often involved 
 in the necrotic process attending the suppurative labyrinthitis. 
 
 Diagnosis.— The value of ocular nystagmus in the differential diag- 
 nosis of cerebellar abscess and suppuration of the labyrinth is generally 
 accepted. In suppuration of the labyrinth the nystagmus becomes 
 less and less marked, and finally disappears as the suppuration extends; 
 while in cerebellar abscess it increases as the disease progresses. In 
 suppuration of the labyrinth it occurs in the beginning, when the eye is 
 turned toward the diseased side; whereas the strabismus may disappear 
 and the nystagmus still be present when the eye is turned to the un- 
 affected side. In cerebellar abscess the conditions are reversed, and the 
 nystagmus is first observed when the quick component is to the normal 
 side, and is later to the diseased side. When this form of nystagmus 
 is observed a positive diagnosis of cerebellar abscess may be made. 
 Another point in the diagnosis is that after the labyrinth has been 
 opened by operation, if the nystagmus is due to labyrinthine trouble 
 it rapidly subsides, while if due to a cerebellar abscess it remains or in- 
 creases. The diagnosis may be made in many cases without the fore- 
 going objective signs by the presence of pronounced deafness, tinnitus, 
 vertigo, and headache. The deafness is more pronounced than is 
 usual in middle ear disease. The hearing for the tuning-forks and 
 whistles is usually greatly diminished at both the lower and upper 
 limits, more particularly the upper, or it may be entirely lost. Bone 
 conduction is greatly diminished or entirely lost upon the affected side. 
 The vertigo may be accompanied by nausea and vomiting. 
 
 The deafness may be partial or complete, depending upon whether the 
 labyrinth is completely or partially destroyed. Goldstein, of St. Louis, 
 and others have reported cases in which the cochlea was exfoliated, in 
 which considerable hearing apparently still remained. This may have 
 been due, however, to sound waves reaching in one way or another the 
 other ear. Bezold, Hovell, Hartmann, Corradi, Politzer, the author, 
 and others have shown that even with the most complete precautions it 
 is impossible to exclude hearing through the unaffected ear. The meatus 
 of the normal ear may be ever so tightly stopped, and still admit some 
 sound waves which may be heard. Then, too, sound waves may reach 
 the normal ear by bone conduction. Pynchon has suggested the use of a 
 long speaking trumpet, to remove the source of sound as far as pos- 
 sible from the sound ear. Even with all these, and other precaution- 
 ary measures, the sound waves may leak through the barriers to the 
 other ear. It is not probable, or even possible, that the sound waves are 
 perceived by the stump of the auditory nerve after its endings in the 
 labvrinth have been destroyed. 
 
878 THE EAR 
 
 Spontaneous and induced nystagmus are now well recognized symp- 
 toms of acute labyrinthine disease. 
 
 According to Percy Feidenberg, when the irritation is due to hyperemia 
 or toxic edema there is spontaneous nystagmus at intervals, and when 
 the patient is rotated toward the diseased side, it is increased after one or 
 two turns. The coloric test is positive, that is, when cold water is applied 
 to the diseased ear the nystagmus is to the opposite side ; if hot water is 
 used, the nystagmus is to the same side. Circumscribed labyrinthine 
 suppuration and fistula of the horizontal semicircular canal give the same 
 reactions. If a fistula is present, compression of the air in the external 
 meatus elicits nystagmus (marked vertigo, nausea, and occasional vomit- 
 ing may also be present). The deafness may be slight or pronounced, 
 according to the extent of the involvement. When vertigo is present 
 the head turns away from the diseased side, and with the head upright 
 the patient inclines to fall away from the diseased side. If the head is 
 turned toward the diseased side, the patient falls backward, and vice versa. 
 
 In acute diffused inflammation of the labyrinth there is total deaf- 
 ness, with spontaneous nystagmus to the sound side, due to the complete 
 loss of function on the diseased side. The tinnitus and nystagmus 
 persist for some time. Vertigo may be absent. Facial paralysis occurs 
 frequently on account of the extensive disease of the bone. There is 
 a tendency to fall or walk toward the diseased side. This tendency 
 is gradually corrected and compensated for by the tactile and visual 
 senses. The tonus is markedly increased on the diseased side. Re- 
 covery finally takes place with a unilateral loss of static function and the 
 failure to elicit nystagmus upon rotation. 
 
 In chronic diffused inflammation of the labyrinth there is total loss of 
 hearing in the affected ear. Spontaneous nystagmus is no longer present. 
 Nystagmus upon compression of the air in the external meatus (fistula 
 symptom) is absent. When the disease progresses gradually with a 
 subacute course, spontaneous nystagmus and vertigo may be absent, 
 even in the early or acute stage. In both acute and chronic diffused 
 inflammation marked after-nystagmus to the sound (rotation test) side 
 is present. Vertigo is absent. (See Tests of the Vestibular Apparatus, 
 Chapter XXXIII.) 
 
 Paresis or paralysis of the facial nerve is present in all cases in which 
 the cochlea is exfoliated. This is accounted for by the intimate ana- 
 tomical relationship of the parts, the nerve being either pressed upon or 
 destroyed by the necrotic process and the exfoliation of the cochlea. 
 The nerve is affected in about 55 per cent, of the cases. Hovell divides 
 the course of the nerve into four parts, namely: (a) Within the internal 
 meatus, where it is liable to be affected in the exfoliation of the entire 
 labyrinth, and give rise to permanent impairment — complete or partial 
 —of the function of the facial and auditory nerves, (b) The second divi- 
 sion extends from the beginning of the aqueductus Fallopii to the genicu- 
 late ganglion, and is less liable to injury, (c) The third division passes in 
 close proximity to the vestibular walls, and, in case of vestibular necrosis, 
 is in great danger, (d) The fourth division, or lower portion, passes 
 
SUPPURATION AND NECROSIS OF THE LABYRINTH 
 
 S79 
 
 downward through the mastoid process, and is in danger when there 
 is extensive mastoid necrosis, but not in labyrinthine necrosis. Exu- 
 berant granulations may press upon the sequestrum, and thus give rise 
 to facial paralysis. 
 
 Restoration of the Facial Nerve. — Bezold and others have reported 
 cases in which there was undoubted loss of the substance of a portion of 
 the facial nerve in the course of necrosis of the labyrinth, in which there 
 was subsequent regeneration and restoration of its function. The chorda 
 tympani is more often destroyed than the facial nerve, and is often 
 restored. It seems, therefore, that there is a strong regenerative power 
 in the facial nerve when destroyed by necrosis or when severed during 
 an operation. One should not infer from this statement, however, that 
 he should regard the facial nerve with indifference during a mastoid 
 operation, as many do not thus regenerate and resume their function. 
 The surgical anastomosis of the facial with the hypoglossal nerve offers 
 a means for reestablishing the movements of the muscles supplied 
 by it, and the dread of facial paralysis is somewhat lessened, though by 
 no means removed. 
 
 The sequestra vary in size and anatomical composition. The whole 
 petrous portion may come away, the cochlea alone or with contiguous 
 bone, and the cochlea or the semicircular canals (one or more) may be 
 exfoliated. 
 
 Contrary to the opinion expressed by Blake and Reik, in their clas- 
 sical treatise on the Surgical Pathology and Treatment of the Diseases 
 of the Ear, the author believes labyrinthine suppuration may usually be 
 diagnosticated before operative interference is instituted. 
 
 The following comparative table shows the symptoms present in 
 middle ear suppuration, and in middle ear suppuration combined with 
 labyrinthine suppuration : 
 
 Middle Ear Suppuration. 
 
 Middle Ear Suppuration Combined with Laby- 
 rinthine Suppuration. 
 
 1. Moderate deafness. 
 
 2. Range of hearing, lower tone limit lost. 
 
 3. Bone conduction increased. 
 
 4. Aural vertigo absent. 
 
 5. Tinnitus not pronounced. 
 
 6. Facial paralysis is occasionally present. 
 
 7. No granulations, and oozing of pus from 
 
 the inner tympanic wall. 
 
 8. Pus on inner wall when wiped away does 
 
 not soon return. 
 
 9. Probing shows no carious bone on inner 
 
 wall. 
 
 10. Meningeal and intracranial symptoms may 
 
 be present. 
 
 11. #Spinal puncture shows normal spinal fluid. 
 
 12. Nystagmus is absent. 
 
 1. Pronounced deafness. 
 
 2. Low and high tone limits lost, or the 
 
 deafness is complete. 
 
 3. Bone conduction diminished or entirely 
 
 abolished. 
 
 4. Aural vertigo present. 
 
 5. Tinnitus pronounced, especially early 
 
 in the disease. 
 
 6. Facial paralysis is frequently present. 
 
 7. Granulations and pus oozing from the 
 
 inner tympanic wall. 
 
 8. Pus on inner wall when wiped away soon 
 
 returns. 
 
 9. Probing occasionally shows carious bone 
 
 on inner wall. 
 Intracranial symptoms may be present. 
 
 10 
 
 11. Spinal puncture shows cells and bacteria 
 
 if the invasion of the cranium is through 
 the cochlear duct. 
 
 12. In the acute stage spontaneous nystagmus 
 
 may be present, or nystagmus may be 
 induced by two turnings, or by the 
 caloric test. 
 
880 THE EAR 
 
 Prognosis. — The prognosis is always grave, 20 per cent, of the 47 
 cases collected by Bezold ending fatally, though spontaneous recovery 
 (as to life) may occur. The hearing is usually greatly impaired, whether 
 the recovery is spontaneous or through surgical interference. The 
 facial paralysis may or may not be present. If present, it may or may not 
 be permanent. Conservative operative treatment does not add to the 
 mortality rate, though it may increase the degree of permanent deafness. 
 
 Treatment. — The treatment of necrosis and suppuration of the 
 labyrinth is obviously surgical, and the following indications should be 
 met, viz.: (a) The morbid material should be removed; (b) free drainage 
 should be established and maintained; and (c) asepsis (surgical clean- 
 liness) of the parts should be maintained until regeneration (healing) is 
 complete. 
 
 (a) The removal of the morbid material should be effected through the 
 external meatus or the mastoid process. If the meatus is crowded with 
 granulations, they should be removed with Wilde's snare, the forceps, 
 curettes, or caustic applications of chromic acid. The granulations may 
 be still further controlled by the instillation of alcohol. It may then be 
 possible to remove the sequestrum through the meatus without further 
 operative interference. In some cases it will be necessary to remove the 
 posterior wall of the meatus, while in others the mastoid process will 
 have to be opened. Where the sequestrum is large, the radical mastoid 
 operation should be performed. Having removed the sequestrum 
 in one of these ways, the other morbid material, as small particles of 
 bone, granulations, cholesteatomatous material, pus, etc., should be 
 sedulously searched for and removed. 
 
 (b) The maintenance of free drainage is accomplished by removing the 
 morbid material — sequestra and granulations — thereby enlarging the 
 drainage channel, and by the use of gauze dressings in the diseased cavi- 
 ties. The gauze carries the secretions outward to the external gauze 
 pads, and thus free drainage is established. 
 
 (c) The maintenance of asepsis, the third indication, is met by the 
 establishment of free drainage, whereby the infective material is con- 
 stantly discharged, and after a time, there being no more within the 
 wound, the gauze dressing effectually prevents the entrance of further 
 infective material. This state of affairs should be maintained until 
 regeneration or epidermization is complete. 
 
 It may be necessary in those cases where the posterior wall of the 
 meatus is removed, and where a radical mastoid operation is performed, 
 to resort to a skin-grafting operation, as described in connection with the 
 mastoid operation. In all obstinate cases the outer wall of the labyrinth 
 should be removed, to establish free drainage. (See Surgery of the Tem- 
 poral Bone, Bourguet's Operation.) 
 
INJURIES TO THE LABYRINTH 881 
 
 INJURIES TO THE LABYRINTH; CONCUSSION OF THE LABYRINTH. 
 
 Etiology. — The injury may be due to direct or to indirect violence, 
 more commonly the latter. The violence may be transmitted through 
 the bones of the head to the internal ear, or through the air and ossicles 
 in the middle ear cavity, when there is a sudden condensation of the 
 atmosphere by a great explosion, or a blow of the hand over the ear. 
 The bony capsule may be injured while the membranous labyrinth is 
 unharmed, and vice versa. When a fissure of the skull passes through 
 the labyrinth, it usually extends to the middle ear and external audi- 
 tory meatus, hence the leakage of cerebrospinal fluid into the middle 
 ear from which it escapes through the Eustachian tube or the ruptured 
 membrana tympani. Great violence may produce pronounced aural 
 disturbances without fracture of the bone. In these cases it is probable 
 that the terminal nerve filaments of the labyrinth are irritated, and 
 that small hemorrhages occur in the labyrinth. 
 
 Injuries to the labyrinth from powerful compression of the atmosphere 
 by explosions, boxing the ears, etc., may or may not cause rupture of 
 the drumhead. Should the drumhead rupture, however, the labyrinth 
 is probably saved from some of the force of the concussion, as the air in 
 the middle ear escapes through the rupture, thus relieving the tension 
 which would otherwise expend itself upon the foot plate of the stapes 
 in the oval window. 
 
 Detonations from heavy ordnance, or loud reports of guns in shooting 
 galleries, produce a great deal of harm to the terminal nerve filaments 
 of the labyrinth by irritation, and result in more or less deafness and 
 tinnitus (Sexton). 
 
 Symptoms. — The symptoms vary with the severity of the concussion 
 and the location and character of the lesion. If the concussion is power- 
 ful the individual may drop to the ground as though shot, and remain 
 in an unconscious condition for several hours, after which conscious- 
 ness returns, and he finds himself to be entirely deaf. Or, if the con- 
 cussion is light, he may stagger, but not fall, and be stupid or dazed 
 for a short time, with more or less tinnitus and deafness. There may 
 also be nausea and vomiting, with more or less giddiness and nystagmus. 
 (See Chapter XXXIII.) If the blow or concussion causes fracture 
 through the cochlea, the deafness will be pronounced; whereas if it passes 
 through the semicircular canals, a staggering gait and nystagmus will be 
 the prominent symptoms. 
 
 The hearing for high tones is lost or impaired. Diplacusis and hyper- 
 esthesia acoustica are sometimes present. The sensibility of the skin 
 of the auricle and meatus may be diminished. 
 
 According to Politzer, "a medicolegal decision as to the existence of 
 concussion of the labyrinth can be given only in those cases in which 
 there is a fissure of the temporal bone extending to the external meatus, 
 and in which an injury of the labyrinth may be inferred, either from 
 the discharge of cerebrospinal fluid or from complete deafness and the 
 56 
 
882 THE EAR 
 
 absense of perception through the cranial bones." In the cases due to 
 compression of air in the external meatus no opinion can be given 
 (Politzer). It should be said, however, that since the functional tests 
 of the vestibular apparatus have been formulated, an opinion of some 
 value is possible. (See Functional Tests of the Vestibular Apparatus.) 
 
 It may be of medicolegal importance to establish the degree of im- 
 pairment of hearing, as the patient may seek redress in the courts. If 
 he does so he will sometimes be tempted to magnify his auditory dis- 
 ability. By the use of a series of tuning-forks, whistles, and other func- 
 tional tests of hearing a correct diagnosis may be made. It will also be 
 necessary to establish as nearly as possible the condition of his hearing 
 apparatus before the injury. Lateralization of the sound in Weber's 
 experiment to the injured ear signifies that the labyrinth is unaffected, 
 whereas, lateralization toward the sound ear is strongly suggestive of 
 labyrinthine involvement in the injured ear. The loss of high tones 
 in the affected ear also points to labyrinthine disease or injury. It 
 is also necessary to prove or disprove the presence of labyrinthine dis- 
 ease before the date of the injury. This is not often easy to do. The 
 Rhine test is of little value when there is complete deafness, but may 
 prove of some value when there is only partial deafness. 
 
 Treatment. — Rest in bed constitutes the whole of the treatment in 
 most cases, whether there is simple concussion, or fracture through the 
 labyrinth. Pain in the ear may be controlled with leeches applied to the 
 mastoid region. Tinnitus of an aggravating character may be relieved 
 by the administration of the bromide of soda. After the acute symptoms 
 have subsided iodonucleoid or the iodide of potassium should be ad- 
 ministered to hasten the absorption of the inflammatory exudate. 
 
 OCCUPATION DEAFNESS. 
 
 For many years it has been recognized that among those who have been 
 engaged in certain occupations for a long time, especially where contin- 
 uous or frequently recurring sounds are heard, there is apt to be more or 
 less deafness. The terminal nerve filaments of the labyrinth are con- 
 tinuously subjected to irritation, and undergo a degenerative change often 
 amounting to complete atrophy, and consequent deafness. Occupation 
 deafness has been observed among blacksmiths, locksmiths, telephone 
 operators, boilermakers, certain machine-shop workers, weavers, and 
 railroad employees. Among this class of workers it is probable that the 
 continuous noise to which their ears are subjected causes an irritation 
 of the acoustic nervous apparatus of the labyrinth and to the circu- 
 latory apparatus as well, which after a long time causes a disturbance 
 of the nutrition of the parts, and finally leads to degeneration, atrophy, 
 and paralysis. Both ears are usually affected. 
 
 There are other conditions, peculiar to certain occupations, which 
 cause dulness of hearing, as exposure to damp, cold atmosphere, dust, 
 and superheated air. Stokers and engineers are particularly exposed 
 
SIMULATED DEAFNESS 883 
 
 to atmospheric changes, heat, cold, dust, and noxious vapors. They are, 
 therefore, subject to nasal and epipharyngeal catarrh, and its extension 
 to the Eustachian tube and middle ear. Many, after from five to ten 
 years' service on railroads, have well-marked dulness of hearing. Numer- 
 ous observers have written on the subject, and their conclusions are as 
 follows: (a) The deafness and tinnitus may be due to the constant 
 vibratory movement of the locomotive, resulting in irritation to the 
 terminal nerve filaments of the labyrinth; (b) constant straining of the 
 ears to hear above the noise and roar of the train, is thought by some to 
 be a cause; (c) cold draughts of air and the heat from the furnace cause 
 epipharyngeal and aural catarrh; and (d) the inhalation of the noxious 
 gases and vapors cause irritation and catarrhal inflammation of the 
 nose, pharynx, and middle ear. 
 
 The chief symptom of the catarrhal cases of occupation deafness are 
 more or less dulness of hearing, tinnitus, and in some cases giddiness. 
 Rinne may be positive or negative according to the degree of deafness 
 present. Hearing by bone conduction is increased. If the labyrinth is 
 also involved the tests are somewhat confused, especially as to the rela- 
 tive length of air and bone conduction, both of which are diminished. If 
 there is also loss of hearing for high tones, the labyrinth may be safely said 
 to be affected. 
 
 SIMULATED DEAFNESS. 
 
 Various motives lead to simulation of ear disease. Hysterical individ- 
 uals sometimes do it to excite attention or sympathy. Soldiers in the 
 army and men drafted to fill the ranks, who desire to avoid duty, and 
 those injured on railways, streets, and in shops, who wish to collect 
 damages through the courts, sometimes exaggerate or assume deafness 
 or artificially produce ear disease. 
 
 Tests for Simulated Deafness. — (a) First make a careful objective 
 examination of the external ear, external auditory meatus, drumhead, 
 and the Eustachian tube. It is a significant fact that in the army most 
 cases of suspected simulated deafness are unilateral. This arises from 
 the fact that a double deafness would have previously attracted atten- 
 tion, whereas a one-sided deafness might have existed without being 
 discovered. In other words, it is easier to simulate one-sided deafness, 
 hence its greater frequency among malingerers. The malingerer often 
 artificially produces an obvious cause for the deafness he wishes to 
 assume by dropping strong solutions of silver nitrate, carbolic acid, 
 creosote, tincture of cantharides, etc., into the meatus. The skin and 
 drumhead are thus cauterized and simulate in some degree suppura- 
 tive otitis media. A careful examination will usually reveal the source of 
 the inflammation. If silver is used, a dark brown stain will be seen; 
 whereas if carbolic acid is used, the- bleached skin will aid in arriving 
 at a correct conclusion. A bandage placed over the ear and sealed, 
 will in these cases lead to a speedy recovery, as the malingerer is unable 
 to continue the caustic applications. Foreign bodies placed in the 
 
884 THE EAR 
 
 meatus to simulate deafness and ear disease may be detected by a 
 careful examination. 
 
 (b) It is in cases in which there are no objective signs of ear disease 
 that the real difficulty of detecting malingering arises. The would-be 
 patient often studies the subjective signs of labyrinthine deafness so 
 well that, if he is especially shrewd, it is well-nigh impossible to detect 
 him. In making the examination of this class of cases the eyes of the 
 suspect must be bandaged, thus rendering it somewhat difficult for 
 him to judge distances in testing with the voice, acoumeter, or watch. 
 If he hears the instrument at greatly varying distances with the deaf 
 ear (the other being tightly plugged) it is fair to presume he is malinger- 
 ing. If, on the other hand, during repeated short testings, he hears at 
 about the same distance, it is fair to presume that he is really deaf. 
 
 (c) Erhard's Test. — When a normal ear is tightly closed a loud ticking 
 watch (the Ingersoll watch) may be heard at three or four feet. The 
 patient should have the supposed deaf ear tightly closed, and when the 
 watch is within three or four feet of the normal ear, he should be com- 
 manded to count the beats, which he will, of course, readily do. The 
 sound ear should then be closed, the supposed deaf one being open, and 
 the same test made on the open deaf ear. If when the watch is within 
 two or three feet of the ear he says he does not hear it, it is fair to pre- 
 sume that he is simulating the deafness, as at that distance he would 
 hear the watch with the closed normal ear. 
 
 (d) Chimani-Moos Test. — In one-sided deafness a large vibrating 
 c 2 fork is alternately held at an equal distance from each ear, until the 
 suspected malingerer makes it plain to himself that he hears the fork 
 loudest before the normal ear. The vibrating fork is then placed on 
 the vertex, bridge of the nose, or median line of the incisor teeth, 
 and the patient is asked in which ear he hears the fork the plainer. A 
 patient with true unilateral middle ear disease will, without hesitation, 
 say that he hears it louder on the affected side; whereas a malingerer 
 will hesitate, as he hears it equally well on both sides, or he may say he 
 does not hear the fork at all in the suspected ear. The normal ear should 
 now be tightly closed and the vibrating fork again placed on the median 
 line of the skull, and the malingerer will probably say he does not hear 
 it at all, or but faintly; whereas in true one-sided deafness the patient 
 will say he hears the tone louder in the affected side. This only applies 
 to disease, or simulated disease, of the middle ear. If disease of the 
 labyrinth is being simulated, the problem becomes more difficult. 
 
 (e) A common stethoscope, having one tube closed with a wooden 
 plug, may be used to detect simulated unilateral deafness. The stetho- 
 scope should be adjusted to the patient's ears, the open tube leading to 
 the suspected ear, the closed one to the normal ear. The physician should 
 now speak into the bell of the stethoscope, having the patient repeat what 
 he hears. The instrument should then be removed, the normal ear tightly 
 closed, and the same formula repeated to the patient. He will say he 
 cannot hear, whereas he has already repeated after you, with the normal 
 ear tightly closed with the plugged arm of the stethoscope. In other 
 
PARESES AND PARALYSIS 885 
 
 words, he heard with his suspected ear through the open tube of the 
 stethoscope (the one leading to the normal ear being tightly closed), 
 thinking, of course, that he would lead the examiner to believe he heard 
 with the normal ear. 
 
 (/) The use of four ear specula, two open and two half filled with wax, 
 may be used to detect malingering. The patient should sit with bandaged 
 eyes facing the wall. The two open specula should be simultaneously 
 introduced, one in each ear, and the examiner (behind the patient) 
 should repeat certain words, or numerals, at varying distances, and 
 thus ascertain his hearing distance with both ears open. He should 
 then change the specula, using one open and one closed, then two open, 
 then two closed, and so on, noting the distances he hears with the vary- 
 ing combinations of the specula. In this way the patient will unwittingly 
 reveal the true condition of his hearing apparatus. 
 
 Repeated examinations and the striking contradictions made by the 
 malingerer during the various examinations will lead to a correct diag- 
 nosis in most cases. 
 
 PARESES AND PARALYSES. 
 
 Angioneurotic Paralysis of the Auditory Nerve. — This is probably 
 a rare affection, or, at least, it has been rarely recognized and described. 
 It is characterized by a transitory facial pallor, nausea, dizziness, tin- 
 nitus, and deafness. The attack lasts but for a few minutes, and when 
 it disappears, the hearing is perfectly normal. The attacks may occur 
 at frequent intervals. 
 
 The treatment consists in the administration of sedatives, tonics, and 
 the application of galvanism over the cervical sympathetics, which have 
 an intimate anatomical connection with the terminal nerve endings in 
 the labyrinth. 
 
 Rheumatic Paralysis of the Auditory Nerve.— This is an obscure 
 affection and difficult to diagnosticate. The diagnosis must largely 
 depend upon the history of rheumatism elsewhere in the body, and upon 
 the involvement of other cranial nerves. It may, however, in rare in- 
 stances involve the auditory nerve alone. Bing reports a case limited to 
 the auditory nerve, and the clinical picture was as follows: (a) Female, 
 aged forty-seven years, exposed to a draught. (6) Complete deafness, 
 and tinnitus in the right ear, the left being less affected, (c) Weber 
 lateralized to the left ear. (d) Inflation of the middle ear did not increase 
 the hearing distance, (e) The case ended in recovery in eight days from 
 the internal administration of the iodide of potassium and the applica- 
 tion of vesicants to the mastoid region. It should be remarked that 
 in these cases there is an absence of the objective signs of middle ear 
 disease 
 
 Symptoms. — The symptoms are those given above, with the addition 
 of the history of rheumatism elsewhere in the body, the involvement of 
 the facial or other cranial nerves, and the signs of labyrinthine involve- 
 ment, as lessened, or loss of bone conduction. If the vestibular portion 
 
886 THE EAR 
 
 of the labyrinth is affected, there will be dizziness or a staggering gait 
 and spontaneous nystagmus; whereas if the lesion is limited to the 
 cochlear portion of the labyrinth, deafness and tinnitus will be the chief 
 symptoms. 
 
 Hysterical Paralysis of the Auditory Nerve.— This form of ear 
 disease is usually unilateral, and is characterized by unilateral deafness, 
 with tactile hyperesthesia, hyposmia, contracted field of vision, and 
 diminished sensibility of the skin on the affected side. The Eustachian 
 tube, drumhead, external meatus, and auricle are occasionally hypes- 
 thetic on the affected side. Weber experiment: tone lateralizes to the 
 normal ear, bone conduction being diminished on the side of the paralysis. 
 Whispered speech can often be heard at six or eight feet, while the tuning- 
 fork may not be heard at all. This is considered by Hammerschlag as 
 characteristic of hysterical paralysis. The same observer calls atten- 
 tion to the fact that a tuning-fork vibrating at its greatest intensity before 
 the affected ear ceases to be heard, and then after a few seconds is 
 heard again. This, he explains, is due to fatigue of the auditory nerve, 
 which after a few moments' rest perceives the sound again (Politzer). 
 
 Slight aural lesions in hysterical individuals may give rise to marked 
 disturbance of hearing. Tinnitus and dizziness, however, are signs of 
 organic labyrinthine disease. In hysterical deafness the degree of 
 deafness varies greatly at different times. 
 
 Treatment. — The treatment of hysterical deafness should embrace the 
 relief of any middle ear disease found, no matter how slight in character, 
 as great improvement, all out of proportion to the apparent lesion, often 
 follows. The nervous and general systems should be built up by tonic 
 and sedative remedies, outdoor life, bathing, etc. The iodonucleoid or 
 the iodide of potash should be given in 3 to 6 grain doses three times 
 daily. Galvanism of the ear and sympathetic system of the neck may 
 also be used to some advantage. 
 
 NEUROSIS OF THE AUDITORY APPARATUS; HYPERESTHESIA. 
 
 1. Hyperacuteness of Hearing. — Oxyecoia is a rare form of hyper- 
 esthesia, and is characterized by a temporary ability to hear music, or 
 at least certain tones, at a much greater distance than others do with 
 normal hearing. It is usually caused by alcoholic and tobacco poisoning, 
 and is especially prone to occur in hysterical and neurasthenic persons. 
 
 2. Paracusis. — Paracusis may be due to a disorder of the nervous 
 apparatus, the labyrinth, or to a disturbed tension of the drumhead and 
 ossicles of the middle ear. In this condition there is a false interpre- 
 tation of the pitch of a tone, often amounting to -j or \ interval. 
 
 Paracusis duplex, or diplacusis, is a variety of disturbed perception of 
 pitch, and is characterized by the hearing of two tones for every sound 
 produced, or in certain cases only for certain tones. It is due to certain 
 unknown influences in the course of acute otitis media, serous middle 
 ear catarrh, chronic suppurative otitis media, and hyperostosis of the bony 
 capsule of the labyrinth. 
 
NEUROSES OF THE AUDITORY APPARATUS 887 
 
 Paracusis Willisii is characterized by the ability to hear better in a 
 noisy place, as on a railway train, street car, or in a machine shop. Its 
 etiology is still a mooted question, although it is commonly present in 
 sclerosis of the middle ear and in hyperostosis or spongifying of the bony 
 capsule of the labyrinth. Some hold that the improved hearing in the 
 presence of noise is due to the increased excitability of the terminal 
 nerve filaments of the labyrinth, while others hold that it is due to the 
 mechanical vibration of the bone and secondarily of the terminal nerve 
 filaments, which increases their auditory power. Still others advance 
 the theory that it is due to a shaking and loosening of the ossicles of the 
 middle ear. The vibration of the cranial bones and the attending 
 stimulation of the nervous apparatus and fluid contents of the labyrinth 
 and cerebrospinal spaces seem to the author to be the most rational 
 explanation. We know from personal observation that mechanical 
 vibration applied to the spinal column and the head improves the hear- 
 ing in some cases. Whether this is due to a stimulation of the nutri- 
 tional centres, or to a stimulation of the nervous apparatus of the laby- 
 rinth, is still an open question. We know also from personal observation 
 that if these patients are placed in bed and given passive exercise (mas- 
 sage) and wholesome food for a few weeks, their hearing will improve. 
 
 3. Hyperesthesia Acoustica. — This condition is characterized by a 
 disagreeable sensation when musical tones or sounds are heard. The 
 condition is usually present in anemic and hysterical individuals, and 
 in those convalescent from severe illness. It may be present in certain 
 forms of neuroses, as hemicrania and trigeminal neuralgia. It is also 
 one of the manifestations attending the administration of quinine and 
 salicylic acid. 
 
 4. Tinnitus Aurium, or Subjective Noises.— This is one of the 
 commonest ear symptoms, and has been repeatedly referred to in this 
 work in the descriptions of numerous ear diseases. Its exact etiology 
 is obscure in spite of the large amount of literature on the subject. 
 Various theories have been advanced, explaining its cause, the one by 
 Shambaugh being the most lucid and satisfactory. 
 
 He advances the interesting and ingenious theory that: "In the first 
 place, the character of tinnitus aurium is usually that of an indefinite 
 sound, like the wind in the forest or the rushing of water, sounds made up 
 of a great complexity of tones and with no definite pitch. Clinically, 
 these subjective sounds arise from a variety of pathological conditions. 
 One of the best known causes of tinnitus is pressure applied to the conduct- 
 ing apparatus, so as to push the foot plate of the stapes into the oval win- 
 dow. This results in tinnitus aurium of the indefinite character described 
 above. What actually takes place when the stapes is thus forced into 
 the oval window is an increase in the tension of the intralabyrinthine 
 fluid. The result of this alteration in tension must be a disturbance 
 of the membrana tectoria (see Anatomy and Physiology of the Laby- 
 rinth), which has apparently the same specific gravity as the endolymph 
 when the latter is under normal pressure. The hairs from the hair cells, 
 as have been shown, normally penetrate into the lower surface of the 
 
THE EAR 
 
 membrana tectoria. Any disturbance in this membrane, however 
 slight, would, therefore, alter the normal relations existing between the 
 membrane and the hair cells. It seems that such an alteration from the 
 normal relation between the membrana tectoria and the hairs of the hair 
 cells would constitute a stimulation of these cells. When the foot plate 
 of the stapes is pushed into the oval window there would result a slight 
 stimulation of perhaps all the hair cells in the cochlea. The result 
 would be exactly what we meet with clinically, a tinnitus aurium of an 
 indefinite character, like the wind in the forest or the roar of a sea-shell. 
 When a sudden increase or decrease in the blood pressure results in 
 tinnitus aurium, the cause is the same as when the stapes is pushed into 
 the oval window. The explanation of the increase or decrease of the 
 intralabyrinthine pressure is here quite evident. The tinnitus aurium 
 arising from the administration of certain drugs is also plausibly explained 
 in the same way as due to an alteration in the blood supply to the laby- 
 rinth with resulting alteration in the pressure of the intralabyrinthine 
 fluid. The tinnitus occurring in Meniere's disease, where there has been 
 an escape of blood into the cochlea, is also similarly accounted for by 
 this conception of the physiology of tone perception. The disturbances 
 in the function of hearing arising from an injury produced by a shrill 
 whistle, or an explosion near the ear, are also readily explained. In the 
 first place, when a permanent disturbance in hearing is thus produced, 
 it can be readily accounted for by a partial severance of the relation 
 between the membrana tectoria and hair cells, so that the hairs from a 
 greater or smaller number of these cells project free in the endolymph 
 and do not come in contact with the membrana tectoria, and therefore 
 cannot receive the stimulation from impulses passing through the endo- 
 lymph. On the other hand, when there results from such an injury a 
 permanent tinnitus aurium, this is explained by a partial, not complete, 
 severance of the membrana tectoria from the hair cells over a certain area. 
 This alteration of the relation existing normally between the hair cells and 
 membrana tectoria may result, as we have repeatedly pointed out, in a 
 stimulation of these cells. This explanation appears all the more rational 
 since the pitch of the tinnitus is often approximately that of the whistle 
 which originally produced the injury." 
 
 The external conditions which influence tinnitus are those which 
 influence catarrhal diseases of the upper respiratory tract, namely, 
 sudden changes in the weather and temperature, living in damp places, 
 improper clothing, etc. Bodily conditions, as fatigue, exhaustion from 
 heat or undue exposure to inclement weather, and bodily depression 
 from overmental application, also aggravate the subjective noises. 
 
 The character of the noises is as various as noises themselves, the 
 usual form being a singing, whistling, chirping, popping, crackling 
 sound, or like the noise of a railway train in the distance. Many other 
 noises are described by patients. They may be intermittent or continu- 
 ous. The remissions usually occur while the patient's mind is engrossed 
 with other matters, hence they are less troublesome in the daytime. 
 Some patients are so distressed by the noises that they are driven to 
 desperate measures, even to suicide. 
 
WORD-DEAFNESS OR SENSORY APHASIA 889 
 
 In some cases the noises increase in proportion to the deafness, in 
 others they cease with marked deafness, while in still others they continue 
 to increase after the deafness is absolute. They may appear in persons 
 who are not deaf, but who are nervous, or exhausted from overmental 
 or physical exertion, or from grief. 
 
 The Hearing of Voices and Music. — Human voices and musical 
 melodies are sometimes heard by persons who have some affection of 
 the cortex of the brain, though rarely or never by subjects with an 
 uncomplicated ear disease. An existing ear disease may aggravate 
 the condition in the cortex of the brain; hence, the cure of the ear dis- 
 ease is often attended by an improvement of the hallucinations. Some 
 persons hear musical melodies repeated over and over, which prove 
 very annoying. The subjective hearing of human voices is more serious, 
 and often the forerunner of melancholia, or progressive paralysis. 
 
 Prognosis. — The prognosis and also the treatment of tinnitus is em- 
 braced in the various diseases in which it occurs as a symptom. It 
 may be said, in general, however, to be comparatively good in cases 
 of simple middle ear and tubal catarrh, and generally unfavorable in 
 hyperostosis and labyrinthine diseases, in noises of cerebral origin, and 
 where the arterial noises have existed for a long time. Paracusis Willisii 
 is usually taken to indicate a well-marked adhesive processes in the 
 middle ear, or in hyperostosis of the bony capsule of the labyrinth, and 
 the prognosis is unfavorable except where suitable remedial measures are 
 used early. In cases in which human voices and musical melodies are 
 heard, the prognosis is very grave, except in rare cases in which the relief 
 of the noises follows the cure of the middle ear disease. 
 
 Treatment. — The treatment of subjective noises is as broad as the 
 subject of ear and brain diseases, hence it will not be given further con- 
 sideration. 
 
 WORD-DEAFNESS OR SENSORY APHASIA. 
 
 This form of deafness is characterized by the ability to hear, with the 
 loss of the power to distinguish words, and is thought to be due to 
 a lesion of the cortex in a portion of the middle convolution of the left 
 temporal lobe, or in the left gyrus of that lobe. It may be questioned, 
 however, whether the auditory (acoustic) centre is so restricted in its 
 distribution. When present, it is generally due to an encephalitis, an 
 exudate following a hemorrhagic pachymeningitis, brain tubercle, or to 
 an embolic softening of the brain. 
 
 Types of Word-deafness. — (a) Amnesic aphasia is characterized 
 by the loss of memory for things, or by the application of wrong names 
 to objects. (b) Monophasia consists in the naming of all objects to 
 which the attention is directed by the same name, (c) Amnesic agraphia 
 is the inability to write words that are spoken, or the names of 
 surrounding objects, and (d) the inability to repeat what is heard and 
 understood. (e) Amusia is a term introduced by Knoblauch to 
 indicate deafness for musical tones. It occurs more frequently than 
 
890 THE BAR 
 
 word-deafness, and is probaby due to a lesion of the first and second 
 convolutions of the left temporal lobe in right-handed persons. Word- 
 deafness and tone-deafness may exist at the same time. In tone-deafness 
 the amusia varies in degree from absolute loss of hearing for musical 
 tones to false interpretations of them. 
 
 DEFECTS OF HEARING DUE TO INTRACRANIAL TUMORS. 
 
 Brain tumors, especially of basilar origin, may give rise to disturb- 
 ances of hearing by pressure upon, or stretching of, the auditory nerve 
 fibers, and by causing an ascending neuritis of the auditory nerve. 
 A lymph stasis at the origin of the auditory nerve may also cause aural 
 disturbances (Gradenigo). This condition is similar to that which 
 occurs in the optic papilla during an increase of intracranial pressure. 
 
 Symptoms. — The symptoms are unilateral tinnitus aurium, deaf- 
 ness, more or less complete, and dizziness. If the tumor involves the 
 vestibular nerve, nystagmus to the opposite side will be produced. 
 (See Chapter XXXIII.) Other symptoms not expressed through the 
 auditory apparatus are a feeling of tightness in the head, glimmering 
 or dull vision, pain or full feeling on the side of the head corresponding 
 to the location of the tumor, slow pulse, choked disk, and motor and 
 sensory paralyses over the areas supplied by the other cranial nerves, 
 which are also usually more or less involved. 
 
 Diagnosis. — The diagnosis must be made chiefly by the disturb- 
 ances arising through the lesions of the other cranial nerves, as the 
 aural symptoms are not characteristic of this form of ear disease. An 
 early diagnosis, therefore, cannot often be made. Facial paralysis and 
 retained perception for the tuning-forks, watch, and acoumeter through 
 the cranial bones, together with dizziness, tinnitus, and deafness, are 
 significant symptoms. The perception of the forks, watch, etc., through 
 the cranial bones exclude labyrinthine disease, even of a mild type. In 
 some cases the perception for high tones often remains unaffected, and in 
 others it is diminished. The age of the patient should be taken into ac- 
 count in connection with the tests of bone conduction and the hearing for 
 high tones. If the patient is more than fifty years old there is a physio- 
 logical diminution in the perception by bone conduction, as well as a 
 restriction of the upper limit of hearing. (See Functional Tests of the 
 Auditory (Cochlear) Apparatus.) Hence, in a case with the above aural 
 symptoms, in which there is a suspicion of brain tumor, the presence of a 
 slight diminution of hearing by bone conduction and the loss of hearing 
 for the higher tones would not necessarily lead to the conclusion that 
 the labyrinth was affected by a brain tumor. As first stated, the chief 
 diagnostic guide is the pareses or paralyses of the other cranial nerves, 
 the facial nerve usually affording the most direct and certain informa- 
 tion. A slight paresis and anesthesia of the skin over the area of nerve 
 distribution, when found in conjunction with deafness, tinnitus, and 
 dizziness, usually points strongly to an ear disturbance having its origin 
 in tumor of the brain. 
 
LOCOMOTOR ATAXIA DEAFNESS 891 
 
 NEOPLASMS OF THE INTERNAL EAR. 
 
 Newgrowths in the internal ear may be primary (rare) or secondary. 
 Primary growths at the root of the acoustic (auditory) nerve have been 
 reported, but nearly all accurately reported cases have been secondary. 
 Epitheliomata and malignant round-cell sarcomata may extend from 
 the middle ear to the labyrinth, and destroy the cochlea, vestibule, or 
 even the whole of the petrous portion of the temporal bone. Neuromata 
 of the auditory nerve have also been observed. Cavernous angiomata 
 of the petrous portion of the temporal bone has been reported by Politzer, 
 and is extremely rare. 
 
 The symptoms vary with the location and size of the growths, and are 
 deafness, tinnitus, dizziness, staggering gait, nausea, nystagmus and 
 vomiting, together with other extraneous symptoms due to lesions of 
 the other cranial nerves. 
 
 LOCOMOTOR ATAXIA DEAFNESS. 
 
 Disturbances of hearing occurring in the course of locomotor ataxia 
 are due to atrophy of the auditory nerve. The atrophy may affect 
 the nervous apparatus anywhere from its cortical origin to its distri- 
 bution in the labyrinth. According to various statistical reports, the 
 hearing is affected in tabes dorsalis in from 1 to 80 per cent, of the cases 
 recorded. The aural symptoms usually develop gradually. The tin- 
 nitus is always present and almost unbearable. The affection is usually 
 bilateral, and dizziness is present in about 65 per cent, of the cases. 
 The author recently examined a case in which there was deafness, 
 intolerable tinnitus, and dizziness. The bone conduction and upper 
 range of hearing were diminished, but not more than the age of the 
 patient (sixty-five years) would account for. Rotating the head on its 
 various axes with the eyes closed did not increase the dizziness or pro- 
 duce nystagmus. The appearance of the drumheads was normal. The 
 hearing for low, deep-toned tuning-forks was normal, Rinne negative, 
 and both ears were affected. 
 
CHAPTEK LI. 
 
 DEAF-MUTISM. 
 
 Holger Mygind 's elaborate and classical treatise on deaf-mutism 
 opens with the following paragraph : 
 
 "Definition. — Deaf-mutism, strictly speaking, signifies the abnormality 
 which is characterized by the co-existence of deafness and dumbness. 
 Various circumstances necessitate, however, a more limited definition. 
 Deaf-mutism may, therefore, be defined as a pathological condition 
 dependent upon an anomaly of the auditory organs, either congenital 
 or acquired, in early childhood, causing so considerable a diminu- 
 tion of the power of hearing as to prevent the acquisition of speech; or, 
 should speech have been acquired before the occurrence of the loss 
 of hearing, it is preserved by the aid of hearing alone. Individuals 
 exhibiting this pathological condition are described as deaf-mutes, even 
 when speech has been acquired by a special system of instruction." 
 
 The foregoing definition will be observed in the consideration of this 
 subject. 
 
 Historical. — It is interesting to know, as Mygind has shown, that 
 deaf-mutism has been referred to in literature from the time Exodus 
 (fourth chapter and second verse) was written. Herodotus, Hippoc- 
 rates, Aristotle, Pliny, Gellius, and others of the ancient period refer 
 to it; and in the Middle Ages, Cananus, Pedro de Ponce, Andreas 
 Laurentius, and Zachias. 
 
 A gradual change of opinion as to the relationship between hearing 
 and speech took place. In the ancient period the idea prevailed that 
 it was due to the inability to use the tongue (Hippocrates and Aristotle). 
 Later, Pliny said, "The man who is born without the power of hearing 
 is also deprived of the power of speech, and none are born deaf who are 
 not also dumb." 
 
 During the Middle Ages the influence of Aristotle's writings was so 
 potent that little progress, beyond the opinion expressed by him, was 
 made. Cardanus, 1501 to 1576, first distinctly stated the true relation- 
 ship, i. e., that deafness is the principal and primary cause of deaf- 
 mutism. 
 
 During the last century, the subject was placed upon a scientific 
 basis, chiefly through the writings of Itard, Schmalz, Wilde, Meissner, 
 Toynbee, von Troltsch, A. Hartman, Lemcke, and Mygind. 
 
 It is true that institutional work and statistical bureaus have aided 
 very materially in the evolution of the subject. The classical work of 
 Mygind probably represents the most advanced and correct statement 
 on the subject that has been given, and it is chiefly from his work that 
 
DEAF-MUTISM 893 
 
 the author gleans the data for this chapter. Direct reference is also 
 made to the works of von Troltsch and Toynbee. 
 
 Classification. — Deaf-mutes may be classified according to the degree 
 of deafness as : 
 
 (a) True deaf-mutes, or those who are totally deaf to speech, and 
 must depend entirely on the other senses to acquire its use. 
 
 (b) Semi-deaf-mutes, or those who have slight power of hearing, or 
 who retain slight speech acquired before deafness supervened. 
 
 Some confuse those who, for other reasons than deafness, have lost the 
 power of speech with deaf-mutism. It should, therefore, be distinctly 
 understood, without question, that deaf-mutism refers to those who have 
 lost or failed to acquire speech on account of deafness. 
 
 Another classification, which is perhaps better as a practical working 
 basis, is that adopted by Mygind, namely: 
 
 (a) Congenital deaf-mutism. 
 
 (6) Acquired deaf-mutism. 
 
 The first class refers to those who are born with some defect of the 
 organ of hearing, which, according to modern statistics, includes about 
 50 per cent, of all the cases. Mygind thinks this estimate too high, as 
 many of the so-called congenital cases are, in all probability, due to some 
 intercurrent disease of the ear which destroys the hearing before articu- 
 late speech is acquired. While the author's observations have been 
 comparatively limited, they have nevertheless been sufficient to recognize 
 the difficulties to be encountered in determining whether certain cases 
 belong to the congenital or to the acquired class. The author is, there- 
 fore, inclined to agree with Mygind that 50 per cent, is too high an 
 estimate to be placed upon the relative proportion of congenital as 
 compared with the acquired types of deaf-mutism. 
 
 The relative 'proportion of deaf-mutes to the total population of the 
 various countries in which statistics are to be found varies from 34 
 (Holland) to 245 (Switzerland) per 100,000 inhabitants. The average in 
 European countries is 79, while in the United States it is 68 per 100,000 
 inhabitants. 
 
 Etiology. — The great variation in the relative number of deaf-mutes 
 in the different countries seems to point to certain localities as pre- 
 disposing to it. Old geological (Escherich) formations, as found in the 
 Alps, were formerly thought to be the cause, but more careful investiga- 
 tions have shown this to be incorrect. In Switzerland, where the rate is 
 so high, it is due to the endemic cretinism so prevalent there. This 
 phase of deaf-mutism is not included in the consideration of this subject. 
 
 Climate probably has no influence. 
 
 Unfavorable social and hygienic conditions play a very important part 
 in the etiology of deaf-mutism. 
 
 H. Schmaltz emphasizes this in his work on Deaf-mutism in Saxony. 
 In conclusion, he says: "The industrial population, and especially that 
 part of it which is worse off from a pecuniary point of view — in fact, all 
 who are in danger of degenerating both morally and physically on 
 account of insufficient means, or poverty, and who, consequently, are 
 
894 THE EAR 
 
 unable, or unwilling, to take the necessary care of their children — all 
 such persons exhibit the highest percentage of deaf-mutes among their 
 descendants. Finally, we found that when, in addition to all these 
 unfavorable conditions under which children are born, they are brought 
 up by a family which, for various reasons, is perhaps already more or 
 less degenerated, and have to undergo all sorts of diseases in infancy 
 without having sufficient power of resistance, then deaf-mutism is an 
 only too common result.'' 
 
 Heredity undoubtedly influences the number of deaf-mutes. Mygind 
 very tersely expresses the present status of our knowledge on this point 
 in the following words : "Deaf-mutism is comparatively frequent among 
 the relatives of the deaf-mutes; it is least frequent in the direct ascend- 
 ing line (grandparents, parents) ; more frequent in the collateral branches 
 (great-uncles, great-aunts, uncles, aunts, cousins, parents' cousins, 
 and. second cousins); and most frequent by far among the brothers 
 and sisters of the deaf-mutes. This is in exact accordance with the 
 result of an investigation into the appearance of deaf-mutism among 
 the relations of congenital deaf-mutes; from this and many of the facts 
 above mentioned, we are justified in supposing that the manner in which 
 deaf-mutism appears in different generations is a result of certain quali- 
 ties appertaining to its congenital form." 
 
 It is not assumed that deaf-mutism per se is transmitted by hereditary 
 influences, but that certain anatomical or nervous states are retained to 
 some extent, and that these may result in deaf-mutism — that is, deaf- 
 mutism is influenced by the transmission of a predisposition to certain 
 ear diseases and to certain nervous disorders. These, in combination, 
 tend to produce the affection. 
 
 Consanguineous marriages seem to influence the number of deaf- 
 mutes, as is shown in the following table: 
 
 Forty-seven Marriages between Blood Relations Produced 
 Seventy-two Deaf-mutes. 
 
 1 marriage between aunt and nephew produced 3 deaf-mutes. 
 
 4 marriages " uncle and niece " 11 " 
 
 26 " " first cousins " 3 
 
 16 " second cousins " 20 " 
 
 Statistics prove that the influence of consanguineous marriages is 
 entirely limited to congenital deaf-mutism. 
 
 Various diseases in parents, as alcoholism, syphilis, general debility, 
 epilepsy, insanity, etc., are etiological factors in the production of deaf- 
 mutism. The offspring of such parents do not receive in utero the vital 
 energy necessary to resist the vicissitudes of life after birth. They are, 
 therefore, more liable to be injured by infections and nervous diseases 
 than the offspring of healthy parents. It may be said in this connec- 
 tion, however, that the parents of deaf-mutes are often remarkably 
 healthy and robust individuals. 
 
 Hemophilia and deaf-mutism are rather commonly associated among 
 the offspring of marriages producing a large number of children. 
 
DEAF-MUTISM 895 
 
 The death rate is higher among children in families in which there are 
 deaf-mutes, probably on account of the stigmata of degeneracy, and 
 because suppurative otitis media adds to the mortality rate. 
 
 Mygind cites statistics to show that first births produce more deaf- 
 mutes than either the second, third, fourth, or fifth. Other weaknesses 
 are also more common among the first born. 
 
 Maternal impressions do not appear to exert a marked influence in the 
 production of deaf-mutism. 
 
 Immediate Causes of Deaf-mutism. — The age at which most cases 
 of deafness occur in the acquired type is from the first to the fifth years, 
 more occurring in the second and third years. In the United States the 
 greater number occur in the third year. 
 
 Brain diseases, more particularly simple meningitis and epidemic 
 cerebrospinal meningitis, are the chief causes of the acquired deaf- 
 mutism. From 12 to 26 per cent, of the European cases have been 
 attributed to epidemic cerebrospinal meningitis. Moos and Knapp 
 were the first to call attention to this disease as one of the causes of 
 deaf-mutism. 
 
 Deafness may occur during epidemic cerebrospinal meningitis resulting 
 from middle ear or labyrinthine lesions. The former occurs more often, 
 but is not so pronounced nor so permanent as that due to the involve- 
 ment of the labyrinth. Deafness of middle ear origin does not so often 
 produce deaf-mutism on this account. Labyrinthine involvement 
 usually occurs about the second week of epidemic meningitis, although 
 it may occur at a much later period (Knapp, Mygind). The deafness 
 occurs suddenly, in contradistinction to that in middle ear deafness. 
 Postmortem examinations have shown most of them to be due to inflam- 
 mation of the membranous labyrinth. "This process leads partly to the 
 more or less complete destruction of the contents of the labyrinth, and 
 partly to the deposit of new tissue. The new tissue may be either fibrous, 
 calcareous, or osseous, and may fill the normal cavity of the labyrinth 
 either completely or partially" (Mygind). 
 
 The original cause of the disease is undoubtedly some microorganism 
 which enters through the ear, nose, or epipharynx, although definite 
 data is not yet at hand to confirm this statement. 
 
 The equilibrium is often disturbed in deafness due to brain disease, as 
 pointed out by Moos. This is due to the involvement of the semi- 
 circular canals and other apparatus of the labyrinth. This may endure 
 for years. 
 
 Other acute infectious diseases as scarlet fever, measles, typhus and 
 typhoid fevers, diphtheria, smallpox, vaccination, chickenpox, erysipe- 
 las, dysentery, influenza, malaria, whooping-cough, mumps, croupous 
 pneumonia, and rheumatic fever, directly or indirectly, cause infantile 
 deafness. The inflammation first attacks the mucosa of the middle ear, 
 which ulcerates, the bone beneath becomes carious, and the meninges 
 and labyrinth are thus exposed to infection. The ossicles of the middle 
 ear, being covered by the mucous membrane, undergo the same changes. 
 If the destruction does not involve the labyrinth, the deafness is not 
 
896 THE EAR 
 
 usually profound enough to cause deaf-mutism. If it involves the laby- 
 rinth, the same changes described under cerebrospinal meningitis 
 take place and result in complete and permanent deafness. If this 
 occurs before speech is acquired, the child becomes a deaf-mute. 
 
 In scarlet fever, measles, and kindred diseases the infection enters the 
 tympanum through the Eustachian tube. The labyrinth is usually 
 invaded through either the oval or round windows, as has been shown 
 in numerous autopsies by the scar on the membrane. In some cases, 
 however, it appears that the middle ear is not involved, the drum mem- 
 brane being normal. It is probable in these cases that the infection 
 reached the labyrinth by metastasis. 
 
 Smallpox does not account for many cases of deaf-mutism in those 
 countries where compulsory vaccination is in vogue. It is barely pos- 
 sible that vaccination may cause deaf-mutism. 
 
 Connor collected the literature of labyrinthine diseases caused by 
 mumps up to 1884, and found 33 cases, 9 of which were fifteen years of 
 age or less. 
 
 Certain constitutional diseases, more particularly syphilis, scrofula, 
 and rickets, are occasional causes of deaf-mutism. Inherited syphilis 
 causes it more often than is shown by the statistics, as it is difficult to 
 ascertain the data concerning this affection. 
 
 Fright, lightning-stroke, sunstroke, quinine poisoning, colds in the 
 head, sudden immersion in water, and traumatisms occasionally cause 
 deaf-mutism. A fuller knowledge of the causes of deaf-mutism should 
 attain among physicians, as it is to them the parents will first appeal for 
 information and relief. Many of the cases may be so educated as to 
 make them useful members of society and a source of gratification 
 to themselves and to their parents, if the needed advice or attention is 
 given them at the proper time, i. e., while their minds are still in the 
 imaginative and perceptive stages of development. (See Lip Reading.) 
 
 Pathology. — Reliable postmortem examinations in 139 cases of deaf- 
 mutism are on record. From these the following facts are gleaned 
 (Mygind) : (The changes in the external ear and the auditory meatus will 
 not be considered, as they could have but little to do with the causation 
 of deaf-mutism.) In the drumhead, perforations, calcareous deposits, 
 adhesions, thickening, and entire absence have been found. 
 
 In the middle ear adhesive processes, calcifications, and ossification 
 from intense inflammation have been found. The oval window is some- 
 times filled in with a mass of bony tissue (hyperostosis), while the round 
 window is contracted in size. The membrane of the round window is 
 sometimes thickened, or thinned, scarred, calcareous, or absent. 
 
 Osseous masses in the attic and other portions of the middle ear cavity 
 have been found. Caries of the bony walls of the middle ear from 
 chronic suppurative inflammation are sometimes present. 
 
 The ossicles are ankylosed, bound down by adhesions, necrotic or 
 entirely destroyed, from suppurative inflammatory processes, in a con- 
 siderable number of cases. One or more of the ossicles may be absent, 
 and the others present, the stapes alone being absent in a number of 
 cases. 
 
DEAF-MUTISM 897 
 
 When atrophy of the ossicula auditus is present, it is probably of 
 congenital origin. 
 
 Ankylosis of the ossicles is very often present. 
 
 Atrophy and caseous degeneration of the tensor tympani and stapedius 
 muscles is often found. The chorda tympani nerve is sometimes absent. 
 
 The mastoid process is found to be affected, as elsewhere described 
 under suppurative diseases of the middle ear and mastoid process. It 
 is sometimes absent from arrested development. 
 
 The Eustachian tubes are sometimes obstructed by fibrous or osseous 
 tissue, as a result of repeated inflammations. 
 
 The Labyrinth. — The most frequent pathological change found in the 
 labyrinth is the deposit of osseous tissue from inflammatory processes. 
 This is sometimes so extensive as to completely obliterate the labyrin- 
 thine canals (Mygind), and gives rise to the idea that there is congenital 
 absence of the labyrinth from arrested development (Montain, Michel, 
 Schwartze, Moos). Chalky pigment and fibrous deposits are also 
 found. 
 
 Absence of the auditory nerve and labyrinth (partial or complete) are 
 also reported. In one of Mygind's cases the labyrinth was completely 
 filled with osseous tissue, except at certain portions where pus was 
 present. It was due to a suppurative process following scarlet fever. 
 
 The membranous labyrinth may be congenitally absent, as shown by 
 Nuhn. 
 
 The vestibule (excepting its aqueductus) is rarely involved, even in 
 congenital cases. When an affection is present, the changes are inflamma- 
 tory in origin. Pathological changes in the contents of the membranous 
 vestibule have often been found. 
 
 The aqueductus vestibidi may be distended, in which case the cochlea 
 is also affected (Ibsen), while the vestibule is not, thereby suggesting 
 an intimate relation between the aqueductus and cochlea rather than 
 the vestibule. Habermann explains the distention of the aqueductus 
 vestibuli as being due to pressure in hydrocephalus, especially when 
 the petrous portion of the temporal bone is rachitic. 
 
 The semicircular canals are quite commonly affected. 
 
 Symptoms. — Deafness may be partial or complete. If partial, there 
 may be hearing for sounds, noises, voice, or speech. One child, for 
 example, may hear a loud noise and not hear speech, or vice versa; or 
 he may hear the voice and not hear articulate speech. Again, he may 
 hear tones of a certain pitch and not hear those of another pitch. 
 
 As stated in the beginning of this chapter, the best classification is 
 (a) true deaf-mutes, and (b) semi-deaf-mutes. In other words, those 
 who have partial hearing and those who have total absence of hearing. 
 It is often difficult to determine this point in young infants, for obvious 
 reasons. In older ones it can be usually done by the use of bells, loud 
 whistles, clapping hands, etc. The child will blink the eyes, or show 
 by a change in its expression that it hears. 
 
 A more accurate method of testing older deaf-mutes may be made 
 with tuning-forks and whistles. The hearing should be tested by both 
 57 
 
898 THE EAR 
 
 air and bone conduction. Hearing by air conduction is tested by hold- 
 ing the vibrating fork near the external auditory meatus and noting 
 the expression of the child; bone conduction is tested by placing the 
 handle of the vibrating fork on the mastoid or the vertex of the head, 
 the expression of the child being meanwhile watched for signs that it 
 experiences a novel sensation. Other instruments, as the watch and 
 the Politzer acoumeter, may be used if there is considerable hearing 
 present. The voice, especially the articulate vowels, is a good test when 
 spoken close to the patient's ears, care being exercised to prevent them 
 seeing the movements of the lips. If they hear the vowels, consonants 
 and words may also be utilized. 
 
 Semi-deaf-mutes hear better at certain times than at others, for the 
 same reasons that those with less pronounced middle-ear disease have 
 variations in hearing. 
 
 The various reports as to the relative number of the totally deaf 
 and partially deaf in the various statistical publications are not reliable, 
 as different tests have been used to determine these facts. There are 
 more cases of profound or total deafness among the acquired than the 
 congenital cases, probably on account of the great severity of postnatal 
 processes in the ear. 
 
 A very significant fact has been announced by Urbantschitsch, namely, 
 that children who had previously reacted to no sound whatever, after 
 certain acoustic exercises, were capable of hearing. This points to the 
 fact that a sensory tract is developed by use. Its powers, or functions, 
 may lie dormant for years, and then be aroused to activity and develop- 
 ment. The fact that a child never has heard is not necessarily proof 
 that it never will. 
 
 Mutism may be the result of the deafness, or it may be due to the 
 same influences which caused the deafness. There may be an arrested 
 or perverted development of the vocal organs, coincident with the dis- 
 turbed development of the ear; or aphasia may be due to a congenital 
 or acquired lesion of the brain. If the speech centres of the brain were 
 injured at the time the ear was affected, the child can never be taught 
 to speak clearly. 
 
 The age at which deafness must occur to produce mutism is not to 
 be stated arbitrarily, as the capacity to learn speech varies greatly in 
 different children. Hartmann says that if deafness occurs before the 
 seventh year, mutism is apt to follow. The slight speech already acquired 
 will gradually disappear unless special pains are taken to cultivate it. 
 
 The speech of deaf-mutes is peculiar, lacking in proper accentuation, 
 which renders it monotonous. The respiratory act is deficient, and 
 the voice feeble. The greater the deafness the more pronounced the 
 peculiarities of the speech become. True deaf-mutes, as well as semi- 
 deaf-mutes, may be taught articulate speech, which is known as "articu- 
 lation." Deaf-mutes experience great difficulty in retaining " articula- 
 tion" when they leave the school-room and mingle with those who 
 can scarcely understand them. Articulation is quite different from 
 ordinary speech, and it is only after hearing it used to a considerable 
 
DEAF-MUTISM • 899 
 
 extent that one learns to understand it. This is one of the difficulties in 
 the way of its more general use among deaf-mutes. Lip reading is 
 learned at the same time as articulation, but, as it requires close atten- 
 tion and good sight, it is also often abandoned when contact with the 
 world at large is established. 
 
 Other ear symptoms, as tinnitus, giddiness, staggering gait, and 
 otorrhea, are present in a certain number of deaf-mutes. Otorrhea is 
 quite common, especially among the acquired cases. 
 
 Sequelae. — An impairment of the mental faculties may or may not 
 be present. When it is remembered that a deaf-mute is barred from 
 many avocations, it is easy to understand that ambition is thereby hin- 
 dered. The temptation to idleness and dependence upon those more 
 fortunate often stultifies the mental and moral faculties. The morbid 
 processes causing the deafness may also impair other portions of the 
 brain, and thus impair the mental faculties. About 50 per cent, of those 
 who are deaf-mutes are notably deficient in mental power. 
 
 The laryngeal muscles are slightly atrophied from non-use; otherwise 
 the larynx is usually normal. 
 
 The lungs of deaf-mutes seem to be less resistant than those of other 
 children, as shown by the fact that so many of them die of tuberculosis. 
 This is still further shown by stethoscopic examinations. Their breath- 
 ing is more superficial and less rhythmical than in normal children. 
 This is also true of children with normal ears who have defects of speech, 
 such as stammering. 
 
 Tuberculosis, scrofula, sterility, left-handedness, and diminution of 
 muscular energy are commonly found among deaf-mutes. 
 
 The auricle is rarely malformed in deaf-mutes, as it develops inde- 
 pendently of the internal ear. The external meatus and membrana 
 tympani show such changes as are incident to middle-ear diseases 
 in general. The same is true of the Eustachian tube and mastoid 
 process. 
 
 Adenoids and catarrhal affections of the nose and epipharynx do not 
 seem to be more common among deaf-mutes than other children. 
 That there is a direct relation between infections which enter the middle 
 ear through the epipharynx and Eustachian tubes there can be no 
 doubt. The same irritation causes the adenoid tissue to enlarge, a 
 fact which explains the apparent etiological relationship of adenoids to 
 deaf-mutism. 
 
 Boucheron advances the ingenious theory that deaf-mutism may be 
 caused by otopiesis, meaning thereby deafness by "producing exhaustion 
 of the air in the middle ear as the result of the closing of the catarrhally 
 affected Eustachian tubes, which process, again, causes overpressure in 
 the inner ear, and consequently degeneration of the terminations of the 
 auditory nerves" (Mygind). 
 
 There are other abnormalities coincident with deaf-mutism, such as 
 malformation of the cranium, the eye (retinitis pigmentosa, hemeralopia, 
 " hen-blindness," panophthalmia, etc.), thyroid gland, nerves, and bones. 
 
900 THE EAR 
 
 They are largely the result of the same influences which primarily cause 
 deaf-mutism. 
 
 The relationship between idiocy and deaf-mutism is not that of cause 
 and effect, as they are both the result of the same primary influences. 
 Deaf-mutism does not cause idiocy. 
 
 Insanity is estimated (Wines) to be four times as common among 
 deaf-mutes as in individuals in general. Mygind shows that this is prob- 
 ably due to the isolated social position and mental depression which 
 naturally attend the loss of one of the chief senses. 
 
 Diagnosis. — The diagnosis is easy in most cases, and is based on the 
 following facts : 
 
 (a) Deafness so pronounced that speech cannot be heard. 
 
 (b) Deafness dates from birth or before the seventh year. 
 
 (c) Deafness and fragmentary speech (semi-deaf-mutes). 
 
 In infants it is difficult to make a diagnosis, as the child does not yet 
 speak, and it is difficult to determine if it hears. Loud bells, clapping 
 of hands, whistles, etc., should be used without letting the child see them, 
 noting the blinking of the eyes or other signs that it recognizes the 
 noises. A negative result is not, however, conclusive of deaf-mutism. 
 Hartmann has called attention to the fact that some children do not have 
 the organ of hearing fully developed at birth, the development being 
 completed at the first year of extra-uterine life. 
 
 Simple mutism (aphasia) may be mistaken for deaf-mutism upon 
 casual examination, although it is seldom congenital or acquired in 
 infancy. Careful examination will show hearing present. 
 
 Simulation of deaf-mutism and hysterical deaf-mutism are rarely seen. 
 
 Prognosis. — A few well authenticated cases are recorded in which 
 the hearing was improved. The great majority, however, are not 
 thus favorably affected. The number of cases reported by men of the 
 highest standing, as being so much improved that they regained enough 
 hearing to carry on conversation with their fellows, warrants the use of 
 every means within our power to alleviate all ear affections, with the hope 
 that those under our care may also be thus favorably influenced. Some 
 cases undoubtedly improve spontaneously. 
 
 Speech will generally improve in proportion to the improvement in 
 hearing. 
 
 Treatment. — The treatment should be such as would be given to 
 similar ear affections in those who are not deaf-mutes. Suppurative 
 disease should receive special attention, to prevent it spreading to 
 neighboring organs. Postnasal adenoids and other diseased processes 
 of the nose and throat should receive appropriate attention according to 
 the methods described elsewhere in this work. 
 
 After having done all that can be done to improve the organ of hear- 
 ing and the general system, the child should be sent to some institution 
 of reputable standing, where he can receive suitable training in the 
 acquirement of speech or other means of communication. Here he will 
 also receive instruction in useful knowledge and manual training, which 
 will fit him for a place in social and economic life. 
 
LIP READING 901 
 
 The prevailing methods of instruction are known as the German and 
 French methods. The first is probably the best for a majority of deaf- 
 mutes, as it teaches them articulate speech. There seems to be no 
 doubt that the use of the vocal organs stimulates the development of the 
 brain and motor tracts. Makuen has called attention to this fact. 
 (See Defects of Speech.) The French method teaches communica- 
 tion by means of signs. This is probably well adapted to some cases. 
 The question of methods should, however, be left to those who are more 
 intimately concerned to decide. It is not the physicians' province to 
 train these unfortunate children. His duty is to relieve the physical 
 conditions as nearly as possible and then recommend the parents to send 
 the child to some reputable institution for deaf-mutes, assuring them 
 that only in this way will he be fitted for a useful place in society. 
 
 LIP READING. 
 
 Deaf-mutes, and persons so deaf as to understand conversation with 
 difficulty, should be taught lip reading whenever possible. It has long 
 been known that persons partially deaf watch the face of the one address- 
 ing them, and by combining what they imperfectly hear with the move- 
 ments of the lips, the facial expression, and the gestures of the speaker, 
 they are enabled to understand what is being said. This suggested 
 the advisability of reducing lip reading to a scientific basis, and schools 
 for this purpose are now established in nearly all large cities. 
 
 The acquirement of facility in lip reading necessitates the closest 
 application on the part of the student, and the most painstaking and 
 persistent effort on the part of the teacher; hence, there is little hope of 
 success outside of a special institution for the purpose. The physician 
 cannot give adequate attention to such patients, and he should recom- 
 mend that they be sent to a school at as early an age as possible, as 
 otherwise the patient will be greatly handicapped in the pursuit of his 
 business in later life. As there are many charlatan schools advertising 
 to give such instruction, the physician should first make diligent inquiry 
 as to which are conducted upon scientific lines before making any 
 recommendation. 
 
 Lip reading may also be profitably studied by adult deaf persons 
 whose early education in this respect was neglected. 
 
INDEX. 
 
 Abels, Hans, 605 
 
 Accessory sinuses. See Sinuses, acces- 
 sory. 
 Adami, 114, 128 
 
 on mucous cells, 112, 114 
 Adenectomy, 326 
 Adenocarcinoma, 531 
 Adenoids, 319 
 
 auditory apparatus in, 332 
 
 danger of mastoiditis in, 324, 332 
 
 deaf-mutism and, 899 
 
 deafness in, 622, 623, 764 
 
 diagnosis of, 324 
 
 ear complications of, 714, 731, 739, 
 
 740, 743, 745, 746 
 effect on epipharynx, 332, 433 
 on labyrinth, 728 
 on voice, 504, 509 
 "face," 325 
 fever attending, 33 
 gothic arch in, 331 
 laryngitis and, 433 
 mentality in, 325 
 mouth breathing in, 323 
 nutritional changes in, 321, 323, 332, 
 
 333 
 pathology of, 319 
 "pigeon chest" in, 333 
 prognosis of, 325 
 respiration in, 333 
 speech defects in, 324, 519 
 surgery of, Author's method, 325 
 Boeckmann-Stubb's curette in, 
 
 328, 329 
 Brandegee's forceps in, 326, 328 
 Ferguson-Pynchon mouth gag 
 
 in, 326 
 Meyer's ring curette in, 325, 331 
 through the nose, 327 
 pharyngeal scissors in, 334 
 preparation of patient for, 327 
 Pynchon-Golding-Bird curette 
 
 in, 328, 331 
 Quinlan's forceps in, 328 
 Shutz adenotome in, 328 
 Stubbs' method, 327 
 symptoms of, 323 
 Thornwaldt's disease in, 333 
 Adenoma of nose, 267 
 Adenopathy of diphtheria, 463 
 Adenosarcoma, 362 
 
 Aditus ad antrum, locating, 798 
 
 obstruction, 755, 764, 765 
 relations, 583, 834 
 
 of facial nerve to, 804 
 Adrenalin and cocaine anesthesia, 401, 
 405, 413 
 in nasal hemorrhage, 273 
 uses of, 57, 343 
 Air, conduction test, 591 
 pressure, negative, 196 
 uses of, 40, 56, 689 
 Aloe nasi, collapse of, correction by par- 
 affin, 285, 288 
 etiology of, 289 
 surgery of, Lack's opera- 
 tion, 289 
 Walsham's operation, 
 289 
 Alcohol, abuse of, laryngitis from, 443 
 influence, on deaf -mutism, 894 
 on labyrinth, 869 
 on morbid hearing, 886 
 on tinnitus, 710, 717, 718 
 injection in hay fever, 19, 251 
 instillations in ear, 746, 767, 880 
 nystagmus from, 609, 613 
 in otomycosis, 656 
 prohibited in labyrinth disease, 864 
 uses of, in diphtheria, 466 
 Alexander, 603 
 
 Alimentary canal, influence of patho- 
 genic organisms from upper respiratory 
 tract on, 30 
 Allen's nasal speculum, 99 
 Allport, Frank, 786, 829 
 Allport's bone crushing forceps, 829 
 divulsion forceps, 811 
 mastoid mallet, 798 
 retractor, 829 
 Alternating nasal stenosis, 66, 137 
 Amnesic agraphia, 889 
 
 aphasia, 889 
 Amusia (tone deafness), 889 
 Anatomy, clinical, of Eustachian tube, 
 577 
 of external ear, 575 
 of middle ear, 576 
 of nose, 17 
 of tonsil, 369, 393 
 Andrews, A. H., 194, 590, 705 
 Andrews' cannula, 194 
 
 on carbolic acid in otitis media, 52 
 sphenoidal knives, 195 
 
904 
 
 INDEX 
 
 Anemia, cause of rhinitis with collapse of 
 swell bodies, 22 
 of labyrinth, 864 
 Anesthesia, in adenectomy, 326 
 bromide of ethyl, 415 
 cocaine, by injection, 19, 401, 405, 
 
 413 
 in direct laryngoscopy, 563 
 in laryngectomy, 547, 548 
 in membrana tympani incision, 671 
 nitrous oxide, 415 
 in retropharyngeal abscess, 494 
 in submucous resection, 85 
 in tonsillectomy, 401, 413, 415 
 in tracheobronchoscopy, 565 
 Aneurysm of aortic arch, 495, 498, 500, 
 502 
 laryngeal spasm in, 486, 493 
 of subclavian artery, laryngeal par- 
 alysis in, 496, 498, 500, 502 
 Aneurysmal cough, 497 
 Angina epiglottidea anterior, 425 
 
 lacunaris of pharyngeal tonsil, 317 
 laryngis, diagnosis of, 452 
 Angioma of ear, 640, 641 
 of nose, 267 
 of pharynx, 359 
 of temporal bone, 891 
 of tonsil, 419 
 Ankylosis of ossicles, 620, 621, 716, 719, 
 
 773 
 Annular ligament, 586 
 Annulus tympanicus, 584 
 
 relation of facial nerve to, 804 
 Anosmia, 21, 23 
 
 Antitoxin, in diphtheria, 353, 463, 464, 
 467 
 immunization by, 466, 467, 471 
 Antrum of Highmore, description of, 166 
 empyema of, 171, 177 
 irrigation of, 170 
 puncture of, 170 
 pus from, 19, 159, 169, 172, 
 
 175, 184 
 surgery of, alveolar method, 225 
 Author's method, 221 
 
 right angle knife in, 221 
 Bishop's trephine in, 224 
 Caldwell-Luc operation, 227 
 Cooper's method, 225 
 Corwin's operation, 223 
 
 chisels in, 222 
 Denker's, operation, 229 
 Krause's trocar in, 219 
 Kuster's operation, 226, 
 
 228, 229 
 Myles' operation, 219 
 Ostrum's forceps in, 223 
 Stein's gouge in, 226 
 Vail's operation, 219 
 
 saws in, 220 
 Wells' trocar in, 224 
 mastoid. See Mastoid antrum, 
 maxillary, 166. See Antrum of High- 
 more. 
 Aphasia, amnesic, 889 
 
 Aphasia in brain abscess, 780 
 
 sensory, 889, 898, 900 
 Aphonia, from foreign body, 554 
 hysterical, 492 
 in laryngeal diphtheria, 461 
 
 neoplasms, 525 
 in laryngitis, 427, 445, 446 
 spastica, 487 
 
 in tuberculosis of larynx, 295 
 Apoplectiform nature of Meniere's dis- 
 ease, 866 
 Apoplexy, laryngeal, 489 
 Appetite in brain abscess, 781 
 Aprosexia, 323, 325, 356, 516, 718, 750 
 Arch, gothic, research on, 58 
 Arheim, 478 
 Aristotle, 892 
 Arnold, Jacob D., 426, 427 
 Arsenic paste in lupus, 292, 294 
 Arteriosclerosis, differentiation from hy- 
 peremia of auditory nerve, 
 870 
 from Meniere's disease, 870 
 of the labyrinth, 869 
 operative hemorrhage in, 272 
 Artery or arteries : 
 
 auditory, labyrinthine anemia in ob- 
 struction of, 864 
 auricular, posterior, 626 
 carotid, external, excision of, 363 
 
 ligation in removal of epi- 
 pharyngeal fibroma, 358 
 internal, 584 
 
 relation to tympanum, 580 
 ethmoidal, anterior, 22 
 
 posterior, 22 
 labyrinthine, 869 
 
 laryngeal, superior and inferior, 547 
 linguae dorsalis, 376 
 meningeal, middle, 21, 584 
 
 small, 376 
 of middle ear, 584 
 nasal, posterior lateral, 21, 23 
 ophthalmic, 35 
 palatine, ascending, 376 
 
 descending, 376 
 pharyngeal, ascending, 376 
 sphenopalatine, 21 
 stylomastoidea, 584 
 thyroid, superior, excision of, 363 
 
 relations of, 529 
 tonsillar, branch of facial, 376, 379, 
 409 
 Arthritis, relation to laryngitis, 428 
 "Articulation" of deaf-mutes, 898 
 Aryepiglottic region, loose texture of 
 
 mucosa of, 436 
 Arytenoid cartilages, ankylosis of, 483 
 
 position in unilateral paralysis, 
 
 497 
 removal of, 483 
 lymphatics, 529 
 " Ascending croup," 462 
 Asch, 68, 80, 97, 280 
 Asch-Mayer operation on septum, 68, 79 
 Asch's septum forceps, 80, 97, 280 
 
INDEX 
 
 905 
 
 Asphyxia, diagnosis of, from reflex dis- 
 turbances, 552 
 in diphtheria, 461, 462 
 in edema of larynx, 441 
 treatment of, 552 
 Asthma, bronchial, 30 
 Miller's, 427 
 nasal origin of, 66, 256 
 rachiticum, 487 
 Atheromatous changes, labyrinthine hem- 
 orrhage in, 865 
 Atkinson, 419 
 Atlas, removal of transverse process of, 
 
 855 
 Attic of ear, 580, 581 
 
 calcification of mucous mem- 
 brane of, 717 
 caries of, 761 
 diseases causing perforation of, 
 
 743 
 divisions of, 585, 586 
 drainage of, 747 
 external, acute inflammation of, 
 
 708 
 irrigation of, 790 
 relations to facial canal, 583 
 removal of outer wall of, 808 
 suppuration of, 669, 766, 768 
 of nose, 242, 243 
 Auditory centre of brain, 586 
 
 functions and sinus disease, 188 
 meatus, infection through, 876 
 paralysis, 885 
 
 hysterical, 886 
 rheumatic, 885 
 Aural symptoms in tabes dorsalis, 891 
 Auricle, absence of, 636 
 angioma of, 640 
 chondritis of, 575, 818 
 cysts of, 642 
 dermatitis of, 647 
 epithelioma of, 642 
 fibroma of, 641 
 frostbite of, 648 
 herpes of, 646, 647 
 infection of, 575 
 keloid of, 642 
 lupus of, 292 
 
 malformations of, 635, 636 
 neoplasms of, 635 
 perichondritis of, 575, 641, 645 
 sarcoma of, 643 
 Aurophones, danger of, in labyrinth hyper- 
 ostosis, 729 
 Auscultation of tympanum, 688, 690, 693, 
 737 
 rales in, 703 
 Auto-intoxication affecting labyrinth, 869 
 Autophony in otitis, 711, 733 
 
 B 
 
 Babes, von, 367 
 Babinski, 607, 670 
 
 mortality in diphtheria, 466 
 
 Bacilli, in upper respiratory tract, 114 
 
 viscosity of, prevents absorption, 371 
 Bacillus leprae, 309 
 
 mallei in glanders, 310 
 
 of rhinoscleroma, 274 
 Bacon, Gorham, 779, 875 
 Bacterial protoplasms excite bacterio- 
 lytic ferments, 374 
 Baginski, 453 
 
 Ball, James B., 335, 336, 386, 392 
 Ballance, Charles, 575, 724, 803, 810, 812, 
 
 813, 818, 820, 824, 825, 826 
 Ballance's flaps, 810, 812, 813, 818, 820, 
 
 824, 825 
 Bane-Allport gauze packer, 746 
 Barany, Robert, 603, 604, 607, 608, 610, 
 
 611, 614, 615, 616, 617, 618 
 Barany's apparatus for estimating nys- 
 tagmus, 610 
 
 theory of caloric tests, 607 
 Baratoux, 874 
 Bardeleben, Karl von, 855 
 Baron, 256 
 Basilar membrane, Helmholtz's theory 
 
 on, 868 
 "Battling" Nelson, 639 
 Beard, F., 362 
 Beck, Emil, 856 
 
 Joseph C, 44, 103, 104, 155, 158, 213, 
 214, 286, 301, 315, 411, 860, 862 
 
 on septal cartilage reformation, 103, 
 104 
 Beck's bismuth paste dressing, 100, 856 
 
 forceps for facial nerve, 860 
 
 frontal sinus operation, 213, 214 
 
 mercury masseur, 44 
 
 paraffin syringe, 286 
 Beck- West tonsil dissection, 411 
 Beckmann's serrated scissors, 145 
 Benzoate of sodium, in tonsillitis, 385 
 Benzoin, compound tincture, as an 
 astringent, 50 
 
 instillations in otorrhea, 749, 767 
 Berard, 313 
 
 Berens, T. Passmore, 583 
 Bergmann, von, 362, 478, 533, 845 
 
 on gastric cancer, 362 
 Bernay's nasal splint, 100, 274 
 Bezold-Edelmann tuning forks, 591, 596 
 Bezold, F., 590, 598, 828, 831, 876, 877, 
 
 879, 880 
 Bezold's mastoiditis, 828, 831 
 Bickel, 317 
 Bier, F., 45, 118 
 Bier's hyperemic treatment, 127, 757 
 
 in mastoiditis, 757 
 Bikeles, 457 
 Bing, 600, 721, 885 
 Bing's tests for hearing, 600 
 Binnafont's method of catheterization, 
 
 686 
 Bird, 328 
 Birkett's, Herbert S., transilluminator, 
 
 182 
 Birmingham's nasal douche, 263 
 Bishop's trephine, 220, 224 
 
906 
 
 INDEX 
 
 Bismuth dressing, 649 
 Bismuth paste dressing, 100, 856 
 Blackley, 246 
 
 Blake, Clarence, 593, 671, 729, 879 
 Bleyer, J. Mount, 54, 511 
 
 on the "hearing centres," 511 
 Blindness, sudden, significance of, 174 
 Blood pressure, in diphtheria, 459 
 
 tinnitus in sudden increase of, 
 888 
 Boeckmann's curette, 326 
 Boeckmann-Stubbs adenoid curette, 328, 
 
 329, 330 
 Boenhaupt, 268 
 Boetcher, 407 
 Bone conduction, in Meniere's disease, 866 
 
 normal, 590 
 Bono and Frisco, researches on micro- 
 organisms, 34 
 Border cells of mastoid, 754 
 Boric acid in irrigation of drumhead, 665 
 in meatal inflammation, 649, 
 
 650, 651 
 in otitis, 767 
 
 in retropharyngeal abscess, 347, 
 348 
 Bostoc, 526 
 Bostroem, 313 
 Bosworth, Francke E., 159, 419, 421, 531 
 
 on septal deformities, 58 
 Bosworth's operation for osseous deflec- 
 tion, 68, 71, 72 
 Boubland, 529 
 Bouche, 353 
 Boucheron, 899 
 Bougies, in stenosis of larynx, 480 
 
 in tubal stenosis, 145, 680, 722, 745 
 Bourguet, 835, 836, 838, 841 
 Bourguet's protector for facial nerve, 835, 
 
 836, 841 
 Boys, singing voices in, 503 
 Brachycardia in diphtheria, 459 
 Brain abscess, from cholesteatoma, 751 
 from chronic otorrhea, 740 
 irritability in, 780 
 from middle-ear infection, 582 
 stupor in, 780, 782 
 from suppurative otitis, 736 
 surgery of, 778, 779, 842 
 vital statistics in, 782 
 cells, degeneration of, 869 
 development and speech, 514 
 diseases and deaf -mutism, 895 
 origin of nystagmus, 609 
 tumor, deafness from, 890 
 laryngeal spasm in, 487 
 paralysis from, 890 
 spasm of pharynx in, 353 
 Brandegee's adenoid forceps, 326, 328 
 Brauers, 536 
 
 Brawley, Frank, 127, 196 
 Breathing, influence of, on laryngeal 
 mucosa, 443 
 methods in singing, 445, 448, 505 
 Briggs and Guerard on antitoxin, 466 
 Bright's disease, edema of larynx in, 440 
 
 Bright's disease, influence on respiration, 
 31 
 nasal hemorrhage in, 2-73 
 Brindel, 321 
 Broca, 754 
 
 Bromide of ethyl anesthesia, 415 
 Brompton Consumption Hospital, 296 
 Bronchi, foreign bodies in, 554 
 Bronchial asthma, uremia in, 31 
 irritation, of nasal origin, 21 
 lymphatic glands, 367 
 syncope, 489 
 Bronchitis and chronic laryngitis, 448 
 imperfect respiration in, 18 
 and laryngeal apoplexy, 490 
 Bronchopneumonia complicating diph- 
 theria, 464 
 Bronchoscopy, 555, 558 
 
 for foreign bodies, 562 
 Brown, H., guarded drill, 97 
 J. S., 643 
 Price, 68, 83 
 Browne, Lennox, 295, 305, 335, 336, 337, 
 340, 351, 354, 355, 359, 480, 481, 
 490, 523 
 Bruhl, 586, 591, 751 
 Bruhl-Politzer, 642 
 Brunk, Thomas H., 675 
 Bruns, 32, 356, 526 
 Bryant, Joseph D., 421 
 Bryant, W. Sohier, 675 
 Buck, A. H., 307, 715 
 Bulb, jugular, resection of, 853 
 Bulbar disease, pharyngeal paralysis in, 
 351, 352 
 lesions, laryngeal paralysis in, 493, 496 
 Bulging, or pouching of drumhead, 619 
 Bulla ethmoidalis, 171, 174, 175, 184, 
 189, 198, 199 
 Author's operation on, 202 
 drainage of, 18 
 obstruction from, 119, 120 
 Burnett, Charles, 426, 427, 625, 634 
 Burow's mixture in eczema of ear, 658 
 Bursa pharyngea, 317 
 Buttle-Pynchon inhaler, 690 
 
 Caisson workers, labyrinthine hemor- 
 
 hage in, 865 
 Calcareous changes, in labyrinth, 871 
 in lacunar tonsillitis, 386, 387 
 in membrana tympani, 619, 665, 
 773 
 Caldwell, 218, 225, 226, 227, 228, 229, 
 
 230, 264 
 Caldwell-Luc operation on frontal sinus, 
 218 
 on maxillary sinus, 225 
 Calomel fumigation, 440 
 
 in membranous laryngitis, 439 
 
 in phlegmonous laryngitis, 437 
 
 Caloric tests, in labyrinthine disease, 601 
 
 nystagmus from, 613 
 
INDEX 
 
 907 
 
 Caloric tests, possible failure of, 609, 610 
 Campbell, J. T., 362 
 Canaliculus carototympanici, 584 
 Cananus, 892 
 Cancer. See Carcinoma. 
 Canfield, 212 
 
 Capsulitis labyrinthii, 725, 726 
 Carbolglycerin, 641, 650, 793 
 Carcinoma, complicated with epiglottitis, 
 426 
 diagnosis of, from actinomycosis, 315 
 from chronic laryngitis, 451 
 from sarcoma, 422 
 of esophagus, 486 
 of larynx, 359, 529 et seq. 
 lymphatic relations of, 530 
 of nose, 270 
 
 of throat and tonsils, 421 
 Cardanus, 892 
 Cardiac reflexes, 552 
 Carotid canal, danger to, in labyrinth 
 
 operation, 834 
 Carter, William Wesley, on nasal perios- 
 teum, 90 
 nasal splint of, 280 
 Cartilage, auricular, deformity of, 635 
 of larynx, 491 
 
 septal, reformation of, 103, 104 
 removal of, 92 
 Cartilaginous meatus of ear, collapse of, 
 
 619 
 Casselberry, 272, 344, 409, 475 
 Casselberry's feeding position, 475, 476 
 nasal scissors, 149 
 
 operation for amputation of uvula, 
 344 
 Catching cold, 382, 427 
 Catheterization, Eustachian, angle of tip 
 in, 687 
 method of, 579, 686, 688 
 from opposite nasal cavity, 688 
 preference for, 692, 693 
 through the mouth, 689 
 value of, 689 
 Cavum tympani, 580 
 Cellar of ear, 586 
 Cells of Kirchner, 794 825 
 Celsus, 627 
 
 Central influence in upper respiratory 
 tract, 33 
 laryngeal paralysis, 496, 499 
 Cerebellar abscess, nystagmus of, 616, 618 
 Cerebral centres of larynx, 492 
 
 hemorrhage, following sinuitis, 187 
 paralysis in diphtheria, 457 
 Cerebrospinal fluid from ear, 661, 881 
 
 meningitis and deaf-mutism, 895, 896 
 rhinorrhea, etiology, etc., 255 
 Cerumen, absence of, 717 
 
 impacted, etiology, etc., 632 
 
 reflex cough from, 886 
 inspissated, defective hearing from, 
 
 619 
 removal of, 633 
 
 secretion of, during furunculosis, 650 
 Cervical cellulitis from tonsillectomy, 378 
 
 Cervical fascia, 348 
 
 glands, 347, 348, 367, 399 
 
 enlarged, pressure paralysis 
 
 from, 496, 502 
 infection through faucial tonsils, 
 
 367 
 suppuration of, 384 
 tuberculous, 303 
 Chaleway's spokeshave, 74 
 Charcot, 876 
 Charsley, 257 
 Cheyne-Stokes respiration in meningitis, 
 
 616 
 Chiari, 316, 448, 478 
 
 on pachydermia laryngis, 478 
 Child-crowing, 487 
 Chimani, 884 
 
 Chimani-Moos' test for supposed deaf- 
 ness, 884 
 Chloroform, deaths from, 327 
 Choanal adhesions around, 357 
 
 relation of, to respiration, 17 
 Choked disk, 616 
 Cholesteatoma, etiology, etc., 749 
 and cerebral abscess, 843 
 defects of hearing from, 619 
 influence of, in labyrinth, 832, 871, 
 
 876 
 and meningitis, 776 
 nature of, 750 
 primary, 749 
 secondary, 749 
 of tympanum, 610, 620 
 Cholesterin in cholesteatoma, 750 
 
 in lacunar tonsillitis, 386 
 Chondromata, subglottic, 524 
 Chorditis nodosa (singer's nodules), 447, 
 448 
 tuberosa, 447 
 Chorea, laryngeal, 487, 488 
 Church, J. F., 625, 626 
 " Chute" of postsuperior wall in mastoid- 
 itis, 754 
 Cigarette drain, 348, 364, 802, 816, 825, 
 
 853, 856 
 Clark, C, 525 
 Clark, J. P., 525, 526, 527 
 Clergyman's sore throat, 339, 509 
 Coakley, C. G., 162, 451 
 Cobb, F. C, on sterility of nose, 25 
 Cocaine : See also Anesthesia, 
 in laryngeal tuberculosis, 300 
 in nasal hemorrhage, 273 
 toleration in larynx, 527 
 Cocaine-adrenalin anesthesia in removal 
 of neoplasms of tonsils, 420 
 in edema of larynx, 441 
 in herpes of auricle, 547 
 Cocaine-carbolic acid anesthesia in ear, 
 705 
 in tonsillar dissection, 401, 413 
 Cocaine-carbolic-menthol anesthesia in 
 
 ear, 765, 789 
 Cochlea, deafness from diseases of, 595 
 symptoms of, 611, 872 
 exenteration of, danger of, 839 
 
INDEX 
 
 Cochlea, fracture through, 881 
 
 function of, 587 
 
 hyperostosis of, 728 
 
 relation to tympanum, 580 
 
 schema of, 838 
 Codeine in relief of cough, 299, 433, 436 
 
 in suppurative otitis, 738 
 Coffin, Lewis A., 164 
 Coghill, 296 
 Cohen, J. Solis, 250, 296, 486, 607 
 
 on necrosis of larynx, 486 
 Cohen, R., 515 
 Colburn, J. E., 187 
 Coley's fluid, 276 
 Collodion dressing, 144, 145, 817 
 Colloid degeneration in nose, 275 
 Compsomyia macellaria, 626 
 Condylomata, on epiglottis, 306 
 Conitzen, 355 
 
 Conjunctivitis, in suppurative otitis, 731 
 Connor, 896 
 Convulsions in brain abscess, 781 
 
 in labyrinthitis, 871 
 
 in meningitis, 616 
 
 in suppurative otitis, 739 
 Coolidge, Frederick, 25, 333 
 Cooper, Sir Astley, 193, 723 
 
 operation on antrum, 193, 225 
 Cooper-Hewitt light in laryngeal dis- 
 eases, 300 
 Corlin, 440 
 Corradi, 877 
 Corti's cells, 586, 587 
 Corwin's chisel, 220, 222, 227 
 
 operation on maxillary sinus, 223 
 Coryza, in chronic glanders, 311 
 
 edematosa, etiology, 253 
 
 extension of, in sinuitis, 188 
 
 pus in, 159 
 
 and suppurative otitis, 739 
 Cosolini, 420 
 Cough, aneurysmal, 497 
 
 in chronic lacunar tonsillitis, 386 
 
 in diphtheritic paralysis, 464 
 
 from epiglottic irritation, 393 
 
 from foreign body, 554 
 
 in laryngeal diphtheria, 461 
 paralysis, 497 
 
 in laryngitis, 431, 433, 446, 449 
 of children, 433, 434 
 membranous, 438 
 phlegmonous, 436 
 
 nervous, 489 
 
 in papilloma of tonsils, 419 
 
 in pharyngitis, 340 
 
 reflex, from ear, 641 " 
 
 from pharyngeal neoplasm, 354 
 from relaxed uvula, 342 
 
 in retropharyngeal abscess, 436 
 
 spasmodic laryngeal, 487, 488 
 
 in stenosis of larynx, 481 
 Cretinism, nasal deformity in, 285 
 Cricoid cartilage, perichondritis of, 435 
 
 membrane, incision of, 551 
 Cricothyroid membrane, lymphatic re- 
 lations of, 530 
 
 Crile, 551 
 Crisp, 426 
 Crista ampullaris, 602, 604, 606, 607, 
 
 608, 614 
 Croup, 437 
 
 false, 487 
 
 idiopathic membranous, 437 
 
 "kettle, 339" 
 
 membranous, 461 
 
 true, 461 
 Cruveilhier's submucous plexus, 359 
 Cunes, 529 
 
 Cunningham, 541, 547 
 Curtis, Holbrook, 448, 449, 505, 508 
 Curtis' method in respiration, 448 . 
 Cyanosis from laryngeal application, 385 
 Cystoma of larynx, 522 
 
 of pharynx, 355 
 
 of tonsil, 420 
 Cysts of ear, 642 
 
 subglottic, 524 
 
 Dabney, William R., 127 
 Dabney and Pynchon, negative air 
 
 pressure apparatus, 196 
 Daly, William, 27 
 Darwin's tubercle, 638 
 Dawbarn, 363, 364, 536 
 Dawson, 367 
 
 theory of scarlet fever infection by 
 tonsils, 367 
 Deaf-mutes, adenoids in, 319 
 
 functional testing of, 897, 898 
 
 instruction of, 901 
 
 occular nystagmus in, 604 
 
 statistics of, 893 
 
 testing for " islands of hearing," 591 
 Deaf-mutism, 515, 520 ' 
 
 definition of, 893 
 
 etiology, 892 
 
 and labyrinthitis, 872, 873 
 
 mental training in, 520 
 
 simulation of, 900 
 Deafness : 
 
 bilateral, 596 
 
 diagnosis between qualities of, 595 
 
 islands of, 728 
 
 leukemic, 873 
 
 massage in, 721, 722 
 
 occupation, 882 
 
 operation for relief of, 724 
 
 physiological law of, 581 
 
 simulated, 883 
 
 unilateral, 597 
 Deafness from: 
 
 acute inflammation of attic, 708 
 
 anemia of labyrinth, 865 
 
 arteriosclerosis, 869 
 
 brain tumor, 890 
 
 catarrh of middle ear, 709 
 
 climatic conditions, 882 
 
 eczema of ear, 656, 657 
 
 epipharyngeal catarrh, 883 
 
INDEX 
 
 909 
 
 Deafness from: 
 
 foreign body, 625, 883, 885 
 
 furunculosis, 649 
 
 inflammation of meatus, 651 
 
 injury to drumhead, 66 
 
 labyrinthitis, 871, 877, 878 
 
 myringitis, 662 
 
 neoplasm, 891 
 
 obstruction, 641, 653 
 
 otomycosis, 655 
 
 otosclerosis, 718, 725 
 
 paralysis of auditory nerve, 885 
 
 perforation of membrana tympani, 
 664 
 
 rheumatic paralysis of the auditory 
 • nerve, 885 
 
 sudden air compression, 881 
 
 suppurative otitis, 733, 735 
 
 syphilis of labyrinth, 874, 875 
 
 syphilitic condyloma, 308 
 
 tabes dorsalis, 891 
 Dehio, 296 
 Deiters, 604 
 
 Deiters' nucleus, 604, 608, 614, 617, 618 
 Dele van, D. B., 526 
 Delstanche, 600, 721, 729, 791 
 Delstanche's aural masseur, 42, 600, 707 
 
 ring knife, 791 
 Dench, E. B., 750 
 Denker, 264, 725 
 
 operation on maxillary sinus, 218, 
 225, 227, 229 
 De Vilbiss, 212 
 De Vilbiss' spray bottles, 56 
 Demme, 296 
 Depres, 307 
 
 Der Aussatz, 308. See Leprosy. 
 Dermatitis congelationis auricula, 648 
 Diabetes, 116 
 
 acute otitis media and, 701, 732 
 
 edema of larynx and, 440 
 
 facial paralysis from, 857 
 
 labyrinthine hemorrhage in, 865 
 
 upper respiratory symptoms in, 31 
 Diagnostic tube, 688, 689 
 Diaphragmatic paralysis, 464 
 Dieulafoy, 366 
 
 inoculation with tonsillar tissue, 366 
 " Dip" of postsuperior wall in mastoiditis, 
 
 754 
 Diphtheria, 113 
 
 anesthesia of pharynx in, 350 
 
 bacteriological diagnosis of, 455, 463 
 
 bronchial, 462 
 
 catarhal, 458 
 
 of ear, 462 
 
 etiology of, 452 
 
 facial paralysis from, 857 
 
 fibrinous, 458 
 
 "fruste," 458 
 
 gangrenous, 457, 459 
 
 general symptomatology of, 459 
 
 hyperemia of labyrinth in, 864 
 
 inflammation of meatus from, 654 
 
 laryngitis and, 434, 437, 439 
 
 of larynx, infections in, 462 
 
 Diphtheria, membrane in, 456 
 
 mentality in, 463, 466 
 
 method of infection in, 454 
 
 paralysis from, 457, 464 
 
 of cricothyroid in, 493, 498 
 pharyngeal in, 351, 352, 353 
 
 phlegmonous, 459 
 
 prophylaxis in, 465 
 
 pseudotabes from, 464 
 
 remedial measures in, 466 
 
 septic, 459 
 
 septum perforation in, 105 
 
 sequela? of, 463 
 
 of trachea, 462 
 
 treatment of, 466 
 
 tubal contractions from, 680 
 Diplacusis from sudden compression, 881 
 
 in syphilis of labyrinth, 874 
 Diplakousis binauralis of dysharmonica, 
 
 589 
 Diplopia in sinuitis, 187 
 Direct laryngoscopy, 565 
 Dizziness in arteriosclerosis, 869 
 
 from ceruminous plug, 633 
 
 in hay fever, 244 
 
 from irrigation of ear, 634 
 
 in labyrinthine disease, 885, 886, 891 
 
 in sinuitis, 163, 172, 177 
 
 in syphilis of the labyrinth, 874 
 
 from tumor, 890 
 Dobel-Pynchon solution, 56 
 Dobel's solution, 527 
 Doutrelpont, 292 
 
 Dressing, compound tincture of benzoin, 
 271 
 
 dry gauze, 746 
 
 after ethmoid exenteration, 237 
 
 of jugular bulb, 856 
 
 after mastoid operation, 818 
 
 nasal, a cause of sinuitis, 177 
 
 in ossiculectomy, 793 
 
 spiral tube and gauze, 802, 825, 853, 
 856 
 
 after submucous resection, 99, 104 
 
 thrombosis operation, 851 
 Duchemin, 511, 512 
 
 Duchemin's method in tone training, 511 
 Duel, Arthur B., 680, 730, 731 
 Dunbar, 251 
 Duplay, 754, 755, 758 
 Dupuy, 671 
 
 Dysentery, infantile, deafness in, 895 
 Dysphagia, 353 
 
 in laryngeal cancer, 533 
 
 in tuberculous laryngitis, 295 
 Dyspnea in atrophic laryngitis, 449 
 
 in epiglottitis, 426, 427 
 
 in hypertrophic laryngitis, 446 
 
 in laryngeal neoplasm, 525, 526 
 
 in paralysis, 497 
 
 in tubercle of larynx, 299 
 
 Ear, actinomycosis of, 315 
 auricle of. See Auricle. 
 
910 
 
 INDEX 
 
 Ear, clinical anatomy of, 575 
 
 eczema of, 619, 634, 647, 656, 657 
 
 tinnitus in, 656 
 "focussing muscles" of, 592 
 forceps, danger in use of, 628 
 foreign body in, removal of, 625 
 granulomata of, 291 
 improper cleansing of, 632 
 influence of gout and lithemia on, 28 
 irrigation of, causing dizziness, 634 
 lupus of, 292 
 nasal influence on, 32 
 neoplasms of, 608 
 ossicles of, 580 
 
 sinus diseases in relation to, 188 
 syphilis of, 307 
 tone education of, 511, 512 
 tympanic muscles of, 580 
 
 Edelmann-Bezold forks, 597, 600, 727 
 
 Edema, bronchial, in membranous 
 laryngitis, 439 
 epiglottic, 426 
 faucial, 425 
 
 glottic, 31, 353, 398, 422 
 laryngeal, 432, 434 
 
 etiology of, 480, 481, 482 
 
 Edinger on nuclei of vagus, 492 
 
 Eisenlohr, 493 
 
 Electrocautery, in angioma of nose, 268 
 in fibroma of nose, 358 
 in laryngeal operations, 524 
 in lupus of nose, 292 
 in nasal hemorrhage, 273 
 in pharyngitis hyperplastica, 341 
 in pharyngeal papilloma, 354 
 in removal of foreign body, 631 
 in tonsillar hyperkeratosis, 397 
 in turbinal hypertrophy, 139 
 
 Electrolysis in actinomycosis, 315 
 in angioma, 641 
 
 in pachydermia laryngis, 478, 479 
 in pharyngeal growths, 359 
 in stricture of meatus, 655 
 in tonsillar neoplasms, 419 
 in tubal stricture, 680 
 
 Elephantiasis grsecorum, 308 
 
 Embolic abscesses, 783 
 
 Encephaloscope of Whiting, 847 
 
 Enchondrosis, diagnosis of, from chronic 
 laryngitis, 451 
 
 Endocarditis from tonsillar infection, 368, 
 377, 384 
 
 Endolymph, 587 
 
 in caloric tests, 607 
 defective hearing from increased 
 tension of, 623 
 
 Entotic test, 600 
 
 Epiglottis, acute infection of, 425 
 condylomata of, 306 
 deformities of, 479 
 lymphatics of, 529 
 
 Epiglottitis, miasmatic, 426, 427 
 
 Epipharyngitis, 324, 332, 445, 509 
 in laryngitis of children, 433 
 and otitis, 709, 713, 731, 738, 739, 
 745, 746, 747 
 
 Epipharyngitis, relation of, to mastoiditis, 
 769 
 to tubal disease, 585, 808, 809 
 Epipharynx, adenoids in, 322 
 adhesions in, 349 
 defects of hearing, from affections of, 
 
 622 
 digestive disturbance, in infection 
 
 from, 28 
 disease of, in otitis media, 698, 699, 
 
 769 
 "dropping," a symptom of nasal ob- 
 struction, 66 
 gargling the, by Troltsch-Swain 
 
 method, 738 
 neoplasms of, 622 
 osteoma of, 269 
 
 relation of, to respiratory current, 17 
 significance of crusts in, 168, 173, 
 
 319 
 space, variation of, 327, 329 
 syphilitic lesions in, 349 
 tonsil of, 335 
 tumors of, 325, 356 
 in voice production, 503, 508, 517 
 Epilepsy, in deaf-mutism, 894 
 
 of nasal origin, 256 
 Epistaxis, 272 
 
 from deviated septum, 67 
 Epithelioma of the ear, 642 
 etiology of, 531 
 glandular involvement in, 533 
 of pharynx, 354 
 Erectile growths, 359 
 
 tissue of nose, functions of, 18 
 Erhard, 884 
 Erhard's test for supposed deafness, 
 
 884 
 Erysipelas of auricle, 647 
 
 infantile deafness and, 895 
 of larynx, 441 
 
 phlegmonous laryngitis and, 436 
 Erythema multiforme, 384 
 
 nodosum, 384 
 Escat, 337 
 
 Escat's position, 170, 171, 172 
 Escherich, 893 
 Esmarch, von, 265, 346 
 Esophagoscopy, direct, 570, 571 
 Esophagus, foreign bodies in, 554 
 paralysis of, 353 
 strictures of, 571 
 
 tumors of, causing laryngeal par- 
 alysis, 496 
 Ethmoid curette, 166 
 Ethmoidal cells, 173 
 
 blood supply of, 273 
 
 drainage of, 118 
 
 infection of, relation to tubal 
 
 disease, 808 
 irrigation of, 194 
 location of pus from, 169, 184 
 low reparative power of, 19 
 obstruction from, 120 
 surgery of, Author's complete 
 exenteration, 234 
 
INDEX 
 
 911 
 
 Ethmoidal cells, surgery of — continued. 
 Author's other methods, 
 
 230, 233 
 Moure's external operation, 
 
 239 
 orbito-ethmoid operation, 
 240 
 turbinotome, 231 
 Ethmoiditis and atropine laryngitis, 449 
 in laryngitis, 428 
 leptomeningitis from, 778 
 in middle-ear disease, 699, 713 
 reflex headache from, 36 
 Eucaine, 363 
 Eustachian catarrh, 581, 621, 622 
 
 negative air pressure in, 129 
 catheter, hearing through, 600 
 isthmus, 578 
 "tonsil," 622 
 tubes, adenoids and, 332 
 
 in chronic otorrhea, 745, 746 
 clinical anatomy of, 577 
 closure of, 576 
 
 curettage of, in mastoid opera- 
 tion, 808 
 in deaf-mutism, 897 
 defects of hearing from affec- 
 tions of, 621 
 foreign bodies in, 601 
 functions of, 585, 621, 764 
 infection through, 32, 303 
 inflation of, 579, 580 
 massage of, 6S2 
 mastoiditis and, 769 
 otitis media and, 769 
 patency of, in hyperostosis 
 about oval window, 727, 728 
 relation to carotid artery, 834 
 
 to tonsils, 383, 399" 
 result of obstruction of, 576, 578, 
 866 
 Evans, 511 
 
 Exanthemata, infantile deafness in, 895, 
 896 
 labyrinthitis in, 864, 865, 871, 876 
 middle-ear diseases and, 701 
 panotitis in, 873 
 Exanthema tous fevers, bacterial influence 
 of, on ear, 708 
 laryngitis and, 428, 437 
 suppurative otitis media and, 
 730, 740 
 Exophthalmos, in cavernous thrombosis, 
 788 
 in ethmoidal disease, 168 
 Exostosis of meatus, 652, 654 
 Extradural abscess, 776 
 
 from labyrinthine suppuration, 876 
 Eye, disease of, due to disease of nose, 
 32, 35 
 muscles involved from diphtheria, 
 
 464 
 in relation to sinus disease, 164, 
 186 
 Eyelids, edema of, in suppurative otitis, 
 731 
 
 Facial nerve, danger to, in excision of 
 external carotid, 364 
 relations of, in children, 830 
 in Fallopian canal, 860 
 to horizontal semicircular 
 canal, 835 
 paralysis, 857 
 
 brain tumor and, 890 
 from ceruminous plug, 633 
 complicating pharyngeal paraly- 
 sis, 353 
 epipharyngeal tumor and, 877 
 following surgery of labyrinth, 
 
 841 
 indication for mastoid opera- 
 tion. 761 
 labyrinthine suppuration and, 
 877 
 ridge, 805 
 False croup, 433. See also Laryngitis. 
 Falsetto voice, 518 
 Faradism in pharyngeal neuroses, 353 
 Farlow, John W., 359, 411, 419 
 Farlow's tonsil punch-forceps, 411 
 Fauces, arches of, 508 
 
 defects of speech and, 517 
 edema of, 425 
 
 inflammatory diseases of, 338 
 papillomata of, 354 
 pillars of, spasm of, 486 
 Fan nl. 525 
 Fauvel, 523 
 Fenger, Christian, 846 
 Ferguson mouth-gag, 566 
 Ferguson-Pynchon mouth gag, 326 
 Ferreri, 524 
 Fetterolf's file-saw, 81 
 Fibro-enchondroma of tonsils, 420 
 Fibroma of external ear, 641 
 laryngeal, 522 
 nasal, 265 
 
 pharyngeal, etiology, etc., 356 
 subglottic, 524 
 tonsillar, 419 
 Field of vision in hysterical auditory 
 
 paralysis, 886 
 Finsen light, 126, 292, 294 
 Fish, H. M., 164, 186 
 Fisher. W. A.. 202 
 Fistula in.auris congenita, 636 
 
 of external semicircular canal, 809 
 of labyrinth, 610, 612 
 postauricular, plastic closure of, 856 
 Flautau, 419 
 Flemming, 370 
 Fletcher, John R., 601 
 
 on periosteum of septum, 88 
 Fletcher's law in coloric tests, 608 
 Flourens, 605 
 
 Foramen, stylomastoid, 858, 860 
 Foreign bodies in air passages, 554 
 
 removal of, by bron- 
 choscop3 r , 568 
 in ear, 625, 626 
 
912 
 
 INDEX 
 
 Foreign bodies in ear, external operation 
 for, 629 
 Voltolini's method of re- 
 moval by electricity, 631 
 , in esophagus, 554, 571, 572 
 in larynx, 435 
 
 bronchoscopy in, 554, 562, 
 563 
 in nose, 177 
 
 pharyngeal spasm from, 353 
 in subglottic space, 485, 572 
 in trachea, 554, 562 
 Forks, tuning, irregularity of, 590 
 Fossa, Rosenmiiller's, 687 
 
 adhesive bands in, 699 
 supratonsillar, 370, 377, 402 
 Fossula fenestras cochleae, 583 
 Foster, Hal., 277 
 Foster-Ballenger forceps for septum, 
 
 95, 98 
 Foucher, 337 
 
 Fourth ventricle, relation to nucleus of 
 pneumogastric, 496, 499 
 toxic influence on centres of, 613 
 Fraenkel, B., 257, 534, 538 
 Fraenkel, E., 296 
 Frank, Ira, 192 
 Frazier, 782 
 Fredet, 426 
 
 Freeman on gothic arch, 58 
 Freer, Otto, 85, 87, 102, 103 
 Freer's mucoperichondrium elevator, 87, 
 283 
 submucous resection, open method 
 in, 102, 103 
 Freidenburg, Percy, 878 
 Freudenthal, Wolff, 276, 300 
 Frey, 603 
 Friedlander, 771 
 Friedreich, E. P., 27, 365 
 "Frog-face" in epipharyngeal fibromata, 
 356 
 in nasal obstruction, 268 
 Frontonasal canal, 191, 192 
 
 variation of opening of, 164 
 Funke, John, 770, 771 
 Furunculosis, 272 
 
 complicating eczema, 657 
 
 of ear, 619, 648 
 
 of nose, etiology, etc., 276 
 
 Gallagher, 300 
 
 Galton whistle, 872 
 
 Galton-Edelmann whistle, 595 
 
 Galvanic test of labyrinthine disease, 603 
 in latent labyrinthitis, 615 
 
 Galvanism in hysterical auditory par- 
 alysis, 886 
 in laryngeal paralysis, 494 
 in nerve degeneration, 352 
 in pharyngeal neuroses, 353 
 
 Galvanocautery. See Electrocautery. 
 
 Ganglion jsphenopalatinum, 19, 20 
 
 Ganglionic cells of auditory nerve, 587 
 Gastro-intestinal disturbances causing 
 coryza, 254 
 reflex cough, 489 
 Gastroscope, 573 
 Gautier, 315 
 
 Gavage, feeding by, in intubation, 475 
 Gelle, 600 • 
 
 test for hearing, 600 
 Gellius, 892 
 
 Geniculate ganglion, 353 
 Gerhardt, 522, 532 
 " Germ centres" of the tonsils, 370 
 German horizontal line of skull, 845 
 Getchell, 490 
 Gibb, 426 
 Giddiness in chronic otitis, 709 
 
 in deaf -mutism, 899 
 
 in labyrinthitis, 872 
 
 in otosclerosis, 727 
 
 in sclerosis of middle ear, 718 
 
 from sudden air compression, 881 
 Gigli saw, 213, 271, 855 
 Glanders, 310 
 Glands, cervical, 356 
 
 enlarged, at angle of jaw, 493, 533 
 a cause of paralysis, 493 
 
 parotid, abscess of, 575 
 
 sebaceous of ear, 576 
 
 supraclavicular, lymphatics of, 530 
 Glandular hypertrophies of vocal cords, 
 
 448 
 Glass, 276 
 Gleason, Edward B., 68, 76, 78, 79 
 
 operation for deviated septum, 68, 
 76 
 Gleitsmann, 296, 300 
 Globus hystericus and hypertrophic 
 
 pharyngitis, 350 
 Glossodynia and lingual tonsil, 337 
 Glosso-epiglottic ligament, 334 
 Glosso-epiglottidean folds, 392 
 Glottis, deformities of, 479 
 
 edema of, pharyngeal spasm in, 353 
 
 spasm of, 487, 489 
 Gluck, 535 
 
 Glycerin-carbolic solution, 650, 651 
 in acute otitis media, 705 
 Glycosuria in diphtheria, 458 
 Goitre, hyperemia of labyrinth in, 864 
 
 nasal association of, 257 
 
 pressure of, causing laryngeal par- 
 alysis, 496 
 Golding, 328 
 Goldstein, Max A., 277, 278, 303, 721, 
 
 760, 877 
 Goldstein's operation for septal perfora- 
 tion, 105, 107 
 
 subcutaneous use of chromic acid, 54, 
 141, 142 
 Good, 200, 203 
 
 Good's intranasal operation on frontal 
 sinus, 206, 207 
 
 rasp and guide for frontal sinus, 207, 
 214 
 Goodale, 275, 296, 366, 371, 372, 382 
 
INDEX 
 
 913 
 
 Goodale's absorption experiments on 
 tonsils, 366 
 
 drainage of tonsillar crypts, 45 
 Goodsir, germ centres of, 320 
 Gottstein, 492, 652, 870 
 Gould, Dr. Henrietta, case of, 144 
 Gout, exostosis of meatus and, 653 
 
 facial paralysis from, 857 
 
 hypertrophic laryngitis and, 447 
 
 otosclerosis and, 725, 729 
 
 pharyngitis and, 340, 341 
 
 throat symptoms of, 339 
 Gradinego, 591, 746, 870, 875, 890 
 Gradle, H., 329, 746, 772, 775 
 Gradle's adenotome, 329 
 Grant, Dundas, 99 
 
 Granulomata, a cause of septal perfora- 
 tion, 104 
 
 of nose, throat, and ear, 291 
 Graves' disease, nasal origin of, 257 
 Green, 529 
 Grober, J., 370, 374, 375, 376 
 
 on tuberculous infection, 376 
 Grosvenor, 420 
 Gruber, 257, 663, 871 
 Grunert, 786 
 Grunwald, 154, 156, 202 
 Griinwald's forceps, 222, 230 
 Gulland, 370 
 Gummata, causing laryngeal paralysis, 
 
 496 
 Guns, 155 
 
 Guye, 289, 323, 516, 519, 866 
 Guyon, 359 
 Guyot, 686 
 
 Gyrus prefontalis location of pneumo- 
 gastric nuclei, 496 
 
 Habermann, 749, 897 
 Hair cells of organ of Corti, 355 
 " Hairy pharyngeal polypi," 355 
 Hay lever, etiology, etc., 243 ct seq. 
 
 and deviated septum, 244, 249 
 relation of, to sinuitis, 244 
 Hajek, 161, 169, 241, 257, 425, 448 
 
 on laryngeal mucosa, 425 
 Hajek's gouges for removal of vomer, 96, 
 98 
 hand burr, 824 
 periosteal elevator, 280 
 sphenoidal forceps, 224 
 submucous incision, 85, 86, 92 
 Hajek-Luc operation on frontal sinus, 209, 
 
 210 
 Halle, Max, 200, 203 
 Halle's frontal sinus operation, 214 
 trephine for, 214 
 Halstead, 554 - 
 
 Halstead's subdennal suture, 214 
 Hammerschlag, 603, 886 
 Handwriting in Meniere's disease, 866 
 Hansen, 309 
 Harpy, 299 
 58 
 
 i Harris' buried suture, 423 
 Hartley, Frank, 536 
 I Hartmann, A., 877, 892, 898, 900 
 J Hartz, 729 
 
 Hautige Briiune (croup), 437 
 j Hawley, George F., spray tube of, 45 
 Hazeltine's operation for septal perfora- 
 tion, 106, 107 
 Health Department, City of New York, 
 
 rules for prevention of diphtheria, 465 
 Heart diseases and larynx, 440, 443 
 
 lesions in diphtheria, 457, 464, 466 
 operative, hemorrhage in, 272 
 Heath, Charles J., 803 
 
 Clarence, 744, 764, 819, 821, 822, 823 
 Heath's drainage of mastoid antrum of, 
 
 45 
 Hearing, acoumeter test for, 594 
 acoustic law of, 619, 620 
 after opening semicircular canals, 835 
 before mastoid operation, 833 
 defective, 619 
 
 from adenoids, 323 
 
 from auricular malformation, 
 
 635 
 from ceruminous plug, 633 
 from cholesteatoma, 752 
 from foreign body, 619 
 from infection, 622 
 from intracranial tumor, 890 
 from labyrinthine involvement, 
 
 623, 624, 865, 866 
 from middle ear disease, 620 
 from obstruction, 619 
 from perforation, 744 
 loss of high tones in, 595 
 of low tones in, 596 
 functional tests of, 590 
 in Meniere's disease, sudden loss of, 
 
 866 
 in tabes dorsalis, 891 
 morbid acuteness of, 886 
 neuroses of, 623, 886 
 normal range of, 590, 595 
 tests for, Bing's, 600 
 
 Galton-Edelmann whistle, 595 
 galvanic, 603 
 Gelle's, 600 
 Rhine's, 598 
 Schwabach's, 598 
 vestibular, 600 
 voice, 593 
 watch, 592 
 Weber's, 596 
 "voices," 889 
 without ossicles, 581 
 Heinze, 296 
 Heitzmann on adrenalin and cocaine in 
 
 tonsillar injection, 401 
 Helmholtz, 587, 588, 590, 868 
 Hematoma following submucous re- 
 section, 104 
 paraffin injection, 287 
 Hemophilia, 272, 400 
 
 and deaf-mutism, 894 
 Hemorrhage, adrenalin in, 57 
 
914 
 
 INDEX 
 
 Hemorrhage of brain, pharyngeal para- 
 lysis due to, 351 
 labyrinthine anemia in, 865 
 
 defective hearing in, 623, 624, 
 865, 866 
 nasal causes of, 67, 272 
 tonsillar source of, 379 et seq. 
 Hemorrhagic laryngitis, etiology, 450 
 Henle, spine of, 797 
 Hennebert, 611 
 Hensen, 607 
 Heredity, 116 
 ^j in deaf-mutism, 894 
 
 on labyrinth, 860 
 f^W influence of, in otosclerosis, 725 
 Herodotus, 892 
 Herpes, of auricle, 646, 647 
 Herpetic eruptions in myringitis, 662 
 Hertz, Henry J., 725 
 Heysinger, 636 
 
 Hiatus semilunaris, drainage of, 118, 119 
 Highmore, antrum of, 166. See Antrum 
 
 of Highmore. 
 Hillis' position for feeding in intubation, 
 
 475, 477 
 Himly, 723 
 Hippocrates, 892 
 
 Hoarseness a symptom of laryngeal neo- 
 plasm, 525 
 an early sign of laryngeal cancer, 531 
 in acute laryngeal catarrh, 427 
 in nasal obstruction, 505 
 in spasm of superior laryngeal nerve, 
 340 
 Hodgkin's disease, relation to lympho- 
 sarcoma, 361 
 tonsillar lymphadenoma in, 421 
 Holadin, 363 
 Holinger, 387, 598, 755 
 Hollander, 293 
 
 Holmes, C. R., 187, 623, 754, 755 
 Holmes' frontal sinus probe, 193 
 nasal scissors, 150, 151, 261 
 saw, 145 
 Hoople, Heber Nelson, theory of nasal 
 
 pressure asthenopia, 35 
 Hopkins, 398 
 Horsley, 492, 496 
 Hotz, 744, 767 
 Ho veil, T. Mark, 641, 665, 694, 700, 705, 
 
 760, 870, 877, 878 
 Hubbard, Thomas, 692 
 Hubbard's inflation apparatus, 692 
 Huizinga, T. G., 187 
 Hunt, 292 
 
 Hurd's forceps for deviated vomer, 97, 99 
 Hydrophobia, laryngeal spasm in, 486 
 
 pharyngeal spasm in, 353 
 Hydrops laryngis, 431 
 Hydrorrhea, 254 
 Hyoid bone, 335 
 Hyperesthesia acoustica, 680, 861, 887 
 
 in hysterical auditory paralysis, 
 
 886 
 in sclerosis of middle ear, 718 
 of pharynx, 350 
 
 Hyperkeratosis of the tonsil, 392 et sc<). 
 
 tonsillitis and, 393 
 Hyperkinesis, 351, 486 
 Hyperosmia, 242 
 
 Hyperostosis of labyrinthine capsule, 598, 
 622, 624, 711 
 
 diagnosis of, from calcareous deposits, 
 773 
 in labyrinthitis, 871 
 
 of meatus, etiology, etc., 652 
 Hypertrophy of the Eustachian tube, 621 
 
 of nasal septum, 71 
 
 of tonsils, evidence of a diseased pro- 
 cess, 399 
 
 of turbinated bodies, 25 
 Hypopharynx diverticulum, 570 
 Hyposmia in hysterical auditory paraly- 
 sis, 886 
 Hypothetical sinus cases, 169 
 Hypotympanic recess, 586, 834 
 Hysteria, aphonia in, 492 
 
 complicated by ear symptoms, 616 
 
 deafness in, 870, 883, 886 
 
 morbid acuteness of hearing in, 886 
 
 pharyngeal manifestation of, 350 
 
 of upper respiratory tract, 29 
 
 Ibsen, 897 
 
 Idiocy and deaf -mutism, 900 
 Incudostapedial junction, 586 
 Incus, attachment of, 580 
 necrosis of, 747, 759 
 
 perforation in, 743 
 range of movement of, 590 
 removal of, 583, 600, 789 
 Inflammation, causes of, 121 
 
 promoting reaction of, 123 
 Inflammatory diseases of nose and acces- 
 sory sinus, 112, 113' 
 leukodescent lamp in, 47 
 Inflation, diagnostic importance of, 595 
 of tympanic cavity, 581 
 various methods of, 692 
 Influenza, influence of, in infantile deaf- 
 ness, 895 
 Infralaryngoscopy, 485 
 Infundibulum, drainage of, 18, 118, 119, 
 120 
 obstruction of, 188, 198 
 Ingals, E. Fletcher, 200, 201, 203, 208, 
 
 419, 557 
 Ingals' operation on frontal sinus, 208, 
 
 209 
 Insanity, chondritis of auricle in, 575 
 and deaf -mutism, 894, 900 
 othematoma in, 638 
 perichondritis of auricle in, 575 
 Interarytenoid space, deformities of, 479 
 Intestinal disturbances and middle -ear 
 diseases, 701 
 and laryngeal spasm, 487 
 intoxication, nystagmus from, 609, 
 613 
 
INDEX 
 
 915 
 
 Introitus esophagi, 571 
 Intubation, asphyxia and reflex disturb- 
 ance in, 552 
 feeding of patient in, 475 
 indications for, 433, 436, 438, 463, 
 
 464, 468, 471, 480, 485, 487, 502 
 O'Dwyer's instruments for, 469 
 preparation of child for, 472 
 removal of tube in, 473 
 technique of, 471 
 Iodoform emulsion, 346, 347, 348 
 Iodonucleoid, a substitute for iodide of 
 potash, 315, 481, 498, 867, 873, 882, 
 886 
 Irrigation, influence of, in promoting reac- 
 tion of inflammation, 125 
 Itard, 892 
 
 Jacobson, 596 
 Jacobson's tubercle, 489 
 Jack, 729 
 
 Jackson, Chevalier, 485, 493, 527, 533, 
 535, 555, 556, 557, 558, 560, 565, 
 566, 567, 568, 570, 571, 573 
 Jackson's aspirator pump, 560 
 aural massage, 42 
 bronchoscopy forceps, 568 
 esophagoscopy tubes, 571 
 safety pin closer, 567 
 split tube spatula, 557, 566 
 Jansen, 151, 362, 461, 584, 655, 804, 816, 
 
 817, 824, 829, 830 
 Jansen 's mastoid retractor, 461, 829 
 modification of Stacke's plastic- 
 
 meatal flap, 816, 817 
 rongeur forceps, 830 
 Japanese wrestlers, othematoma among, 
 
 639 
 Jarvis on deviated septa, 58 
 Jensen's mouse tumor, 362 
 Joan of Arc, "hearing voices," 710 
 Johnson, 300 
 
 Jugular bulb disease, drumhead perfora- 
 tion in, 743 
 in otorrhea, 748 
 relations to tympanum, 582 
 surgery of, 858 
 thrombosis of, 786 
 vein, resection of, 851 
 
 Kahn, Harry, 267, 594 
 
 Kalisko, 457 
 
 Kanasugi, 295 
 
 Kaposi, 275 
 
 Katz, 726 
 
 Kauffmann, 55, 377, 387, 392 
 
 Keen, W. W., 546, 548 
 
 Keimer, 419 
 
 Keishaber, 536 
 
 Keloid of auricle, 642 
 
 Keloid of nose, 275, 276 
 
 Keratosis obturans in external meatus, 
 
 634 
 Kierstein's head lamp, 41, 103, 556 
 Killian, Gustav, 19, 70, 86, 87, 90, 92, 
 162, 184, 201, 213, 214, 215, 216, 217, 
 218, 240, 249, 253, 371, 525, 527, 555, 
 556, 557, 559, 561, 562, 563, 570 
 Killian's incision in submucous resection, 
 70, 86, 87, 90, 92 
 operation, on frontal sinus, 213 et 
 seq. 
 Kirchner, 794 
 
 cells of, 825 
 Klebs-Loeffler bacillus, 384, 385, 435, 
 
 437, 452, 455, 458, 459, 461, 467 
 Knapp, H., 777, 895 
 Knight, Charles H., 296 
 Knoblauch, 889 
 Kocher, 535, 544, 567 
 Koch's tuberculin treatment, 304 
 Koerner, 575, 782, 803 
 Kowalzig, E., 265, 346 
 Kramer method of catheterization, 686 
 Kraus, 492, 496 
 
 on cerebral localization, 492 
 Krause-Heryng laryngeal forceps, 528 
 Krause's maxillary cannula, 219 
 
 nasal snare, 149 
 Kronlein's landmarks, 845 
 Kuhnt-Luc, operation on frontal sinus, 
 
 211, 218 
 Kuster's operation on maxillary sinus, 
 225, 226, 228, 229 
 osteoplastic operation on frontal 
 sinus, 212 
 Kyle, D. Braden, 69, 81, 82, 154, 155, 
 
 243, 259, 267, 270, 314, 398, 404, 432 
 Kyle's crypt knife, 404 
 
 malleable tube-splints, 82 
 operation for septal deviation, 69, 
 
 81, 82 m 
 prescription in laryngitis, 432 
 Kyle, J. J., 869 
 
 Labium tympani, 588 
 vestibularis, 588 
 
 Labyrinth, acute destruction of, 614, 615 
 adenoid infection of, 333 
 affections of, 596 et seq. 
 anemia of, etiology, etc., 864 
 changes of, in deaf-mutism, 897 
 in chronic otorrhea, 740 
 complications in mastoiditis, 760 
 congenital defects of, 623, 624 
 in deafness, 595 
 disease, diagnosis of, 879 
 endolymph of, 589 
 in epidemic meningitis, 895 
 erosions of, 610 
 
 exanthemata, influence on, 869 
 hemorrhage into, 865, 870, 874 
 hyperemia of, etiology, etc., 657, 864 
 
916 
 
 INDEX 
 
 Labyrinth in sinus thrombosis, 849 
 in lead poisoning, 869 
 in leukemic deafness, 874 
 in mastoiditis, 761 
 membranous, 587 
 
 fluid of, 587 
 necrosis of, 876 
 neoplasms of, 891 
 relation of, to Eustachian tube, 585 
 
 to tympanum, 582, 591 
 in rheumatic paralysis of auditory 
 
 nerve, 885 
 in sclerosis, 719 
 
 spongifying of bony capsule of, 581, 
 590, 598, 711, 716, 717, 725 
 lowered bone conduction in, 670 
 suppuration of, 876 
 in suppurative otitis, 74, 733, 734, 
 
 736, 739 
 surgery of, 617, 618, 831, 832, 833, 
 
 834, 880 
 syphilis of, 874 
 in tuberculosis, 303 
 Labyrinthine, irritation, 867, 881, 891 
 
 nystagmus, diagnosis, 610, 618 
 Labyrinthitis, considerations on, 840, 
 870, 871 
 defects of hearing in, 623 
 delirium in, 871 
 traumatic, 612 
 Lack's method in collapsed alse nasi, 289 
 La grippe, influence of bacillus of, on 
 
 auricle, 575 
 Lake, Richard, 634, 868 
 Laminaria tents, 654, 655 
 Lancereaux, 296 
 Landois, 369, 595 
 Langenbeck, von, 268, 422 
 Langenbeck's, von, external removal of 
 tonsil, 422 
 operation on superior maxilla, 266 
 La Petse, 308. See Leprosy. 
 Laryngeal apoplexy, 489 
 aura, 490 
 cough, 487, 488 
 crises, 33 
 
 lancet, 433, 436, 441 
 syncope, 489 
 vertigo, 489 
 Laryngectomy, technique, 545 
 Laryngismus stridulus (spasm of adduc- 
 tion), 439, 487 
 Laryngitis, atrophic, 442, 449 
 catarrhal, acute, 427 
 
 treatment of, 433 
 chronic, 442, 478 
 
 differential diagnosis of, 535 
 in children, 433, 434 
 croupous, etiology, etc., 437 
 danger of, in children, 430, 432 
 discrete, etiology, etc., 446 
 hemorrhagic, and prolapse of ven- 
 tricles, 451 
 influence of, on singing voice, 512 
 membranous, etiology, etc., 437 
 in nasal obstruction, 505 
 
 Laryngitis, phlegmonous, 436 
 
 stridulosa, 433, 435 
 Laryngocele, 479 
 Laryngofissure, 307, 468, 524, 526, 534 
 
 technique, 541 
 Laryngoscopy, 307 
 
 direct, 524, 526, 527, 563 
 
 indirect, technique of, 527 
 Laryngospasmus infantum, 486 
 Laryngotomy, intrathyroid, 524 
 Larynx, akinesis of, 486 
 
 cancer of, 529 et seq. 
 
 cartilages of, 491 
 
 chondritis of, 483 
 
 deformities of, 479 
 
 difference of tissue of, from pharynx, 
 360 
 
 diphtheria of, 461 
 
 diseases of, 425 
 
 edema of, etiology, etc., 440 
 
 foreign bodies in, 554 
 
 glanders of, 312 
 
 influence of gout and lithemia on, 28 
 
 landmarks of, 528, 529 
 
 lupus of, 292 
 
 lymphatic drainage of, 530 
 
 malignant neoplasms of, 359 
 
 massage of, in acute laryngitis, 125, 
 448, 449 
 
 muscles of, 491 
 
 neoplasms of, etiology, etc., 518, 522, 
 531, 532, 535, 536, 537 
 
 nerve supply of muscles of, 496 
 
 neuralgia of, 488 
 
 neuroses of, 486 
 
 pachydermia of, 478 
 
 paralysis of intrinsic muscles of, 490 
 
 perichondritis of, 435, 440, 518, 531, 
 535 
 
 "placement" of, 503 
 
 removal of, 541 
 
 rheumatism of, 518 
 
 spasm of, 438, 445, 486, 490, 493 
 
 stenosis of, 478, 480, 482, 483, 509 
 pressure treatment in, 485 
 
 syphilis of, 306 
 
 tuberculosis of, 55, 295, 297 
 
 tumors of, Schmidt's table of, 522 
 
 in voice production, 505 
 Laurentius, Andreas, 892 
 "Le con proconsulair" symptom in 
 
 diphtheria, 463 
 Leech, artificial, 663, 706 
 Leiter coil, 389, 390, 640, 650, 651, 756, 
 
 757, 864 
 Lemcke, 892 
 
 Leontiasis, 308. See Leprosy. 
 Lepra anesthetica seu nervosa, 310 
 Leprosy, etiology, etc., 308 
 
 anesthetic, 310 
 Leptomeningitis, influence of, on menin- 
 ges, 846 
 
 of otitic origin^ 778, 876 
 Leptothrix (mycosis tonsillaris), 382, 
 
 392 
 Lermoyez, 325 
 
INDEX 
 
 917 
 
 Leukocytosis in reaction of inflammation, 
 
 112, 123, 124, 126, 127, 129 
 Leukodescent lamp, 47, 190, 292, 300, 
 
 342, 390, 705, 757, 763 
 Leutert, 42, 577, 743 
 Levy, Robert, 259, 300, 302 
 
 revolving chair of, 37 
 Lewin, G., 336 
 Liebreich, 251 
 Life insurance and chronic otorrhea, 740, 
 
 761 
 Ligamentum spirale, 588 
 Ligation of external carotid, 538 
 Lingual tonsils, development of, 370 
 
 varix, 336 
 Lipoma of larynx, 522 
 of nose, 269 
 of pharynx, 358 
 of tonsil, 419 
 Lip reading, 729, 898, 901 
 Lips, paralysis of, in bulbar disease, 352 
 Lockard, 300 
 
 Loeb, H. W., 162, 251, 260 
 Loeffler, 454, 455 
 Loewy on gothic arch, 58 
 Lohnberg, 301 
 Louis, 426 
 Lowenberg, 627, 687 
 
 method of catheterization, 687 
 Lubert-Barbon, 754 
 Luc, 218, 225, -226, 227, 228, 229, 230, 
 
 264 
 Lucae, 594, 598, 721 
 Lucae's aural probe massage, 721 
 Ludwig's angina, 440 
 Lumbar puncture, 775, 779, 849 
 Lung, vulnerability of right apex of, 
 
 374 
 Lupus of nose, throat, and ear, 291 
 Lymphadenitis, tonsillectomy in, 368 
 Lymphadenoma of pharynx, 355 
 
 of tonsils, 421 
 Lymphatic communication of respiratory 
 tract, 429 
 glands and vessels of neck, 374 
 
 hypertrophy of, under bacterial 
 
 stimulation, 319 
 influence of diphtheria on, 458 
 infection through tonsils, 365, 367, 
 
 368, 373, 374, 376 
 system, infection through, 33 
 vessels of faucial tonsils, 373 
 
 drainage of, 373, 374 
 of larynx, 529 et seq. 
 of nasal mucosa and cranial 
 
 cavity, connection of, 519 
 of neck in syphilis, 306 
 Lymphoid hypertrophy in Eustachian 
 tube, 621, 622 
 tissue in adenoids, 321 
 
 of faucial tonsil, 369, 370 
 of lingual tonsil, 334, 337 
 of pharynx, 340, 341, 509 
 of upper respiratory tract, 392 
 tumor of pharynx, 355 
 Lymphoma of nose, 267 
 
 M 
 
 McAuliff, G., 640 
 
 McBride, P., 255, 319, 321, 323, 324, 714 
 McKernon, J. F., 779, 829 
 McKernon's rongeur forceps, 463, 829 
 Macdonald, Greville, 157, 356 
 Macewen, 754, 755, 758, 759, 772, 780, 
 
 784, 789, 847 
 Mackenzie, 626 
 Mackenzie, G. Hunter, 527 
 Mackenzie, John, 304 
 Mackenzie, Sir Morell, 398, 508, 509, 523, 
 
 525 
 Mackenzie's reflex area, 35 
 Macrotia (overdevelopment of auricle), 
 
 636, 637 
 Makuen, G. Hudson, 514, 901 
 Malaria, influence of, in infantile deafness, 
 895 
 on ear, nose, and 
 throat, 30 
 Malherbe, 668, 669, 723 
 Mallein in diagnosis of glanders, 311 
 Malleus, 576 
 
 attachment of, 580 
 fracture of, 619 
 removal of, 583, 789 
 I Manicatide, 457 
 Manometer in aural inflation, 688, 690, 
 
 737 
 Margo supratonsillaris, 391, 404, 408, 409, 
 
 413, 492 
 ! Martin, 459 
 Maschziker, 636 
 Masini, 378 
 
 Massage, action of, in promoting reaction 
 of inflammation, 125 
 of ear, 41, 43, 682, 692, 707, 708, 
 715, 721, 729, 764 
 ! Massei, 485 
 • Mastoid : 
 
 antrum, axillary centre of pneu- 
 matic cells, 753 
 in children, 830 
 chronic mastoiditis of, 759 
 embryologically part of middle 
 
 ear, 583 
 location of, 796, 798, 799 
 necrosis of, 577, 747 
 relation of, to Eustachian tube, 
 585 
 to tympanum, 580 
 suppuration of, 734, 766 
 cells, adenoid infection of, 332 
 distribution of, 584 
 relation of, to Eustachian tube, 
 585 
 to tympanum, 580 
 disease (mastoditis) : 
 
 abscess, subperiosteal, 758 
 acute primary mastoiditis, 793 
 Bezold's mastoiditis, 828 
 chronic mastoiditis, 758, 803 
 
 otorrhea and, 732, 735, 
 738, 761, 897 
 
918 
 
 INDEX 
 
 Mastoid — continued. 
 
 disease, defective hearing from, 623 
 differentiated from furunculosis, 
 
 649 
 exanthemata and, 734 
 facial paralysis in, 761 
 labyrinth involvement in, 761 
 meningitis "and, 616 
 microbic factor in, 769 
 pathology of, 769 
 prognosis in, 760 
 simple mastoiditis, 753, 760 
 sinuitis and, 188 
 spontaneous cure of, 755 
 subacute mastoiditis, 757 
 symptoms of, 753 
 
 "dip" of postsuperior me- 
 
 atal wall, 754 
 Schwartze's point of tender- 
 ness, 754 
 treatment of, 755, 761, 766, 803 
 tuberculosis and, 303, 304 
 surgery of : 
 
 anatomical landmarks, 796 
 antrum, locating the, 796, 798, 
 799 
 opening the, 798, 799 
 Author's meatomastoid opera- 
 tion, 803, 810, 818 
 Bezold's statistics, 880 
 Bourguet's method, 838 
 cells, exenteration of, 800 
 
 landmarks after, 805 
 cortex removal, 799, 800, 801 
 curettage of Eustachian tube, 
 
 809 
 effect upon hearing, 744 
 flap methods, Author's meatal, 
 803, 810, 818, 820 
 Ballance's "shepherd's 
 
 crook," 811 m 
 Jansen's plastic, S04, 
 
 817 
 Siebenmann's " Y," 815 
 Stake's plastic, 799, 817 
 Trautmann's tongue, 
 816 
 facial paralysis following, 841, 
 857 
 regeneration from, 879 
 incision, 812, 813, 820 
 
 in infants and children, 
 
 828, 830 
 Whiting's, 795 
 Wilde's, 758, 794 
 indications for, 793, 794 
 labyrinth involvement, 832, 840 
 perichondritis after, 575, 645 
 radical operation, 746, 752. 761, 
 
 793, 794, 803, 836, 838, 839 
 simple operation, 761, 794 
 stricture of meatus after, 654 
 treatment after, 803, 816, 818 
 wounds of, after treatment of 
 by Mosetig-Moorhof's plastic 
 operation, 855, 856 
 
 Mastoid — continued. 
 
 surgery of, wounds of, after treat- 
 ment by paraffin injection, 
 285, 288 
 by Passow-Trautmann's plastic 
 
 operation, 855, 856 
 by Thiersch's grafts, 824 et seq. 
 Mastoiditis. See Mastoid disease. 
 Matas, 253 
 
 Mathieu's tonsillotome, 401 
 Maxilla, superior, resection for nasal 
 
 growth, 265 
 Maxillary sinus. See Antrum of High- 
 more. 
 Maxwell, George, Troup, 400 
 Mayer, Emil, 276, 291, 631 
 Mayer's, nasal tubes, 80, 81 
 Mayo, 297 
 
 Meatomastoid operation, drainage in, 819, 
 822 
 indications for, 744, 747, 748, 
 761, 764, 789, 793, 803 
 Meatus, auditory, external, 575 
 
 croupous, inflammation of, 
 
 652 
 diffused inflammation of, 
 
 650 
 exostosis of, 652 
 furunculosis of, 648 
 hemorrhagic inflammation 
 
 of, 651 
 mycosis of, 655 
 obstruction of, 596 
 plastic surgery of, in mas- 
 toid operation, 810 
 relations of, 583 
 stricture of, 654 
 in suppurative otitis, 732 
 Mediastinal tumors, laryngeal paralysis 
 
 from, 496, 497, 500, 502 
 Melancholia at menopause, 351 
 Membrana basilaris, 588 
 
 flaccida (Shrapnell's membrane), 577 
 
 significance of perforation, 743 
 tectoria, 588 
 
 Shambaugh's theory on, 868 
 tympani (eardrum), 584, 666 
 absence of, 744 
 
 adhesions of, operation for, 724 
 anesthesia of, Dupuy's, 671 
 atrophy of, 665, 692 
 bulging of Shrapnell's mem- 
 brane, 708 
 calcareous, 670, 712 
 in chronic mastoiditis, 759 
 diseases of, 660 
 functions of, 579, 585 
 herpes zoster of, 647 
 in hyperostosis of cochlea, 728 
 incision of, 667, 668, 672, 703, 
 704, 730, 737, 755, 763, 
 764 
 knife for, 666 
 
 for ossiculectomy, 789, 791 
 for relief of deafness, 724 
 inflammation of, 619, 662 
 
INDEX 
 
 919 
 
 Membrana tympani, injuries of, 660 
 malformations of, 660 
 normal characteristics, 576, 711, 
 
 712 
 physiological law concerning, 
 
 581 
 significance of perforations of, 
 302, 577, 660, 664, 665, 667, 
 742, 744, 748 
 in suppurative otitis, 732, 736 
 tuberculous, 302 
 Membrane of Reissner, 589 
 Meniere's disease, 866 
 Meningitis, after ethmoid exenteration, 
 238 
 after turbinotomy, 233 
 from mastoiditis, 794 
 from operation on cochlea, 839 
 from operation on semicircular canal, 
 
 836, 837 
 hyperemia of labyrinth in, 864 
 influence on labyrinthitis, 871 
 labyrinthine hemorrhage in, 865 
 laryngeal spasm from, 487 
 nystagmus in, 609, 616, 617 
 serous, 775 
 
 surgical treatment of, 848 
 Menopause, pharyngeal neuroses in, 350 
 Menstrual disturbance, labyrinthine hem- 
 orrhage in, 865 
 periods, nasal hyperemia in, 256. See 
 also, Nose, neuroses of. 
 Mesopharynx, a barrier to downward in- 
 vasion of inflammation, 424 
 inflammatory diseases of, 338 
 Metchnikoff, 372 
 Meyer, William, 27 
 Meyer's ring curette, 328, 330, 331 
 Meyjer, 426 
 
 Miasmatic epiglottitis, 427 
 Michel, 425, 897 
 Michel's metal suture, 828, 830 
 Microbic infection in otorrhea, 769, 770 
 Microorganisms, a cause of sinuitis, 177 
 in mastoiditis, 769, 770 
 role of, in inflammation, 121 
 Microtia (arrested development of 
 
 auricle), 636, 637 
 Middle ear, acute suppuration of, 620, 750 
 adenoids and, 322 
 adhesions in, 577, 712, 713, 735. 
 
 750, 773 
 bacilli in, 694, 770, 771 
 caries of walls of, 620 
 catarrhal inflammation of, 578, 
 
 581 
 cerebrospinal fluid in, 661 
 changes in deaf-mutism, 896 
 chronic moist catarrh of, 709, 716 
 
 suppuration of, 620, 652 
 clinical anatomy of, 576 
 congenital defects of, 620 
 dry catarrh of, 715 
 exploration of, 670 
 facial paralysis from curettage, 
 of, 857 
 
 Middle ear, foreign body in, 628 
 fracture through, 881 
 granulations of, 620, 621 
 hearing in diseases of, 620 
 herpes in disease of, 646 
 inflammation of, bacteria in, 694 
 
 danger of, 753, 774 
 meningitis from suppuration of, 
 
 616 
 necrosis and labyrinthitis, 871 
 proliferous inflammation of, 715 
 sclerosis of, 620, 715, 720, 887 
 suppuration. diagnosis from 
 labyrinthine disease, 879 
 in eczema, 656 
 facial paralysis from, 857 
 treatment of, 762 
 tonsillar infection of, 383, 399, 
 579 
 Mikulicz cells, 275 
 Miller, 434, 448, 449 
 Miller's asthma, 433, 434, 487 
 Milligan, A. W., 301, 302 
 Minot, 636 
 Miot, 690 
 
 Modiolus of cochlea, removal of, 839 
 Mogiphonia (difficult v of making sounds), 
 
 489 
 Mojoechi, 315 
 Moll, 478 
 Montain, S97 
 Monti, 458, 462 
 Monophasia, 889 
 
 ; Moos, Robert E., 401, 771, 872, 874, 884, 
 895, 897 
 Morgagni on deviated septum, 58 
 Moschziker, 636 
 Mosetig-Moorhof plastic operation, 556, 
 
 854 
 Mosher, 58, 567 
 
 Mosher's safety pin holder, 567 
 Moss, 875 
 Most, 529 
 
 Moure, 327, 330, 525, 542 
 Moure's operation for septal deviation, 83, 
 84| 
 on ethmoid cells, 239 
 Mouth-breathing in adenoids, 323 
 
 in laryngeal irritation, 443, 523 
 Mouth-gag in tonsillar operations, 402, 
 
 415 
 Mucin in hydrorrhea, 254 
 Mucoperichondrium, nasal, elevation of, 
 
 86 
 Mucosa loose in aryepiglottic region, 436 
 Mucous membrane, of nose, causes of, 
 inflammation of, 121, 122 
 law of infection of, 114, 121 
 lined cavities, law of, 578 
 of tympanum, continuity of. 
 580 
 Miiller, J., 749 
 
 Mumps, labyrinth in, 874, 896 
 Muscle or muscles: 
 
 constrictor of pharynx, superior, 370, 
 377, 404, 409 
 
920 
 
 INDEX 
 
 Muscle or muscles — continued. 
 
 digastric, relation of, in excision of 
 
 external carotid, 364 
 of larynx, 491 
 levator palati, influence of, on 
 
 Eustachian tube, 578 
 palatoglossus, 373, 377, 508 
 palatopharyngeus, 373, 377, 508 
 
 influence on Eustachiantube, 579 
 stapedius, 581, 582, 586, 620, 621 
 sternocleidomastoid, lymphatic re- 
 lations of, 373, 531, 536 
 in mastoiditis, 754 
 stylohyoid, relation in excision of 
 
 external carotid, 364 
 stylopharyngeus, 858 
 tensor palati, influence on Eusta- 
 chian tube, 578 
 tympani, 581, 582, 586, 620, 621 
 tenotomy of, 668 
 Mutism, 898 
 
 Mycosis of external meatus, 655 
 leptothricea, 392 
 tonsillaris, 392 
 Mygind, Holger, 292, 892, 893, 894, 895, 
 
 896, 897, 900 
 Myles, Robert C, 219, 227, 662 
 Myles' cannula, 194, 227 
 
 operation on maxillary sinus, 219 
 Myringitis, etiology, etc., 662 
 acute abscess in, 668 
 cocaine-carbolic-menthol in, 663, 667 
 defective hearing in, 620 
 Myxocystoma of larynx, 522 
 Myxoma (nasal polypus), 258 
 Myxomata of pharynx, 356 
 syphilitic, 524 
 
 N 
 
 Nasal chambers, functions of, 17, 24, 25 
 influence on voice, 510, 512, 516 
 conditions influencing middle-ear 
 
 disease, 698 
 diphtheria, 459, 460, 463 
 hemorrhage, etiology, etc., 272 
 hydrorrhea, etiology, etc., 254 
 obstruction, 21, 116, 120 
 origin of defects of speech, 516 
 reflex phenomena, 21 
 secretions of leprosy, contagiousness 
 of, 309 
 Nasal septum, clinical anatomy of, 19, 23 
 deflection of, in hyperesthetic 
 rhinitis, 244, 249 
 in hyperplastic rhinitis, 118 
 in laryngitis, 443 
 perforation of, 104, 105 
 surgery of, 105 
 
 Author's mucosa 
 
 swivel knife in, 106 
 Goldstein's plastic flap 
 
 in, 105 
 Hazletine's operation 
 in, 106, 107 
 
 Nasal septum — continued. 
 
 perforation of, surgery of, Yan- 
 kauer's suture in, 106, 108, 
 109 
 pressure, symptoms of, 117 
 surgery of, deviations, 58 
 
 Author's submucous resec- 
 tion operation, 85 
 et seq. 
 elevation of mucoperi- 
 chondrium, 89, 90, 91 
 elevators, 98 
 forceps for perpendicu- 
 lar plate, 98 
 gouge, 98 
 
 incision, Hajek's, 85, 86 
 Killian's,86,87,90 
 removal of vomer, 95 
 specula, 92, 99 
 splints, 99 
 swivel cartilage knife, 
 
 92, 93, 94, 97 
 treatment after opera- 
 tion, 100 
 Bosworth's operation in, 71 
 Brown's guarded drill in, 97 
 cautery of hypertrophies in, 
 
 71 
 Chaleway's spokeshave in, 
 
 74 
 Fetterolf's V-file in, 81 
 Forster-Ballenger forceps in, 
 
 98 
 Forster's speculum in, 92 
 Freer's open method in, 102 
 Gleason's operation in, 76, 
 
 77, 78 
 Hurd's vomer forceps in, 
 
 97, 99 
 Kyle's operation in, 82 
 Moure's operation in, 83 
 Price-Brown's operation in, 
 
 82 
 Roe's operation in, 79 
 Sluder's operation in, 75 
 Watson's operation in, 74 
 periosteum, theory of Carter, 90 
 
 of Neumann, 88, 90 
 spurs, removal of, 69, 70 
 Nasal stenosis after ethmoid exentera- 
 tion, 238 
 suppuration, 159 
 tachycardia, 257 
 Nausea in brain abscess, 780 
 from cholesteatoma, 750 
 in labyrinthine irritation. 864, 865, 
 
 877, 881 
 in Meniere's disease, 866 
 in nystagmus, 607 
 in otosclerosis, 727 
 in tubal disease, 676 
 Negroes, exemption from diphtheria, 452 
 
 nasal obstructions rare among, 452 
 Neisser, Ernst, polar granules, 455 
 Nephritis, labyrinthine hemorrhage in, 
 865 
 
INDEX 
 
 921 
 
 Nerve or nerves — continued. 
 
 acusticus, 493, 496, 499, 586, 587 
 auditory, neoplasms at root of, 891 
 auditory, paralysis of, 870, 885, 886 
 auricularis posterioris profunda, 858 
 chorda tympani, 859 
 
 regeneration of, 879 
 relations of, 581, 582 
 ethmoidalis anterioris, 19 
 facial, 493, 499, 587 
 anatomy of, 858 
 danger to in mastoid operation, 
 
 804 
 paralysis of, 857, 858, 878 
 regeneration of, 879 
 relation to tympanum, 580, 583 
 surgery of, 851, 859 
 glossopharyngeal, 493, 496, 587, 589 
 hvpoglossal, relation in excision of 
 external carotid, 363, 364, 859, 
 860 
 surgery of, 857 
 laryngeal, recurrent, paralysis of, 494 
 relations of, 491, 495, 496, 
 
 498 
 spasm from irritation of, 486 
 superior, relations of, 491, 496 
 nasopalatine, 19 
 olfactory, description of, 19, 21 
 optic, relation of, to sphenoidal sinus, 
 
 169 
 orbital, inferior, relation to maxillary 
 
 sinus, 167 
 petrosal, 859 
 pharyngeal, 364, 859 
 
 paralysis of muscular supply of, 
 353 
 pneumogastric, 364, 491, 493, 496, 
 499, 859 
 relations of, 496, 852 
 shock in irritation of, 551, 557 
 spinal accessory, 493, 496, 859 
 stapedial, 859 
 sympathetic, 859 
 trigeminus, 647 
 
 hyperemia of labyrinth from 
 affections of, 864 
 Neumann, 116, 601, 603, 617, 618 
 
 on periosteum of septum, 88, 90 
 Neuralgia of larynx, 488 
 
 pharyngeal spasm from, 353 
 in suppurative otitis, 732 
 from tonsillar affections, 337, 386 
 Neurasthenia, laryngeal apoplexy in, 490 
 paralysis in, 500, 501 
 morbid hearing in, 886 
 nystagmus in, 607, 613 
 tinnitus in, 710. See also, Nose, 
 neuroses of 
 Newkirk, 331 
 Nobel-Cordes forceps, 224 
 Nodules, singers', 447, 448 
 Northrup, 457, 458, 461, 468 
 Nose, actinomycosis of, 312 
 acute edema of, 253 
 areas causing reflex cough, 489 
 
 Nose, attic of, 24 
 
 cartilage of, destruction in leprosy, 
 
 310 
 chronic granulomata of, 291 
 cleansing solutions for, 55 
 clinical anatomy of, 17 
 deformities, correction of, 85, 107, 
 
 279, 282, 283, 284 
 drainage of, 116 
 erectile tissue of, 18 
 as a filter, 25 
 fivefold functions of, 26 
 foreign bodies in, 277 
 general medicine and, 27 
 glanders of, 312 
 
 influence of disease of, on voice, 503 
 neoplasms of, 258, 270 
 neuroses of, 242 
 resection of, for malignant growths, 
 
 271 
 sterility of, 304, 305 
 submucous operation. See Nasal 
 
 septum. 
 " swell bodies" of, 18 
 syphilis of, 304, 305 
 Nuhn, 897 
 Nutrition, influence on, from imperfect 
 
 nasal respiration, 18 
 Nystagmus, after, 604, 609, 612, 613, 615 
 from intracranial causes, 616, 877 
 from labyrinthine irritation, 600, 661, 
 
 739, 870, 874, 877, 878 
 from Meniere's disease, 866 
 pathological, duration of, 610, 614, 
 
 616 
 pf^siological, duration of, 604, 605 
 primary, 604 
 
 reversed, importance of, 609 
 spontaneous, always pathological, 
 
 607, 609 
 from suppurative otitis, 739, 740 
 from tabes dorsalis, 133 
 
 Occupation, deafness, 882 
 Ochsner, 638 
 
 Ochsner's horsehair suture, 638 
 Ocular disturbances in hay fever, 244 
 
 muscles in relation to maxillary 
 sinus, 187 
 
 nystagmus, 603 et seq. 
 
 symptoms of sinuitis, 169 
 Odor, subjective, significance of, 173 
 O'Dwyer intubation method,- 469 et seq. 
 Odynophagia (painful swallowing), 427 
 Office equipment, 37 
 Ogsten-Luc operation on frontal sinus, 209 
 Olfaction, neuroses of, 242 
 Olfactory fissure, obstruction of, 21, 120 
 pus in, 19, 160, 168 
 
 lobes, irritation of, 242 
 
 nerve, description of, 21, 23 
 Ollier's operation, 270, 271 
 Ophthalmic veins, infection through, 33 
 
922 
 
 INDEX 
 
 Opsonic theory, 127, 128 
 Optic neuritis, 616 
 
 in brain abscess, 780, 782 
 from sinuitis, 169, 187 
 Orbital edema, significance of, 787 
 
 emphysema after ethmoid ex- 
 enteration, 238 
 Orbito-ethmoid operation, 240 
 Organ of Corti, 588 
 Orth, 296 
 Orthoform in tuberculosis of larynx, 298, 
 
 300 
 Osier, 309, 310 
 Ossicles, 581 
 
 ankylosis of, 711 
 caries of, 620, 736, 747 
 in deaf -mutism, 896, 897 
 fracture of, 661 
 massage of, by probe, 721 
 Ossicular chain, tension of, 716 
 Ossiculectomy, indications, 583, 747, 751, 
 764, 765 
 incision for, 672 
 technique, 789, 806, 807 
 Osteitis vascularis chronica, 726 
 Osteoma of nose, 268 
 Osteomyelitis infection through tonsils, 
 
 367 
 Osteosclerosis of mastoid process, 759 
 Ostrom's forward cutting forceps, 223, 224 
 marker for superior oblique pulley, 
 217 
 Othematoma, diagnosis of, from cavern- 
 ous angioma, 641 
 resemblance to perichondritis, 645 
 Otitic abscess, drainage of, 845 
 
 cerebellar abscess, nystagmus in, 617 
 Otitis, acute, in tuberculous disease, 303 
 crouposa, 652 
 diffusa, 650 
 externa, 648 
 
 parasitica, 655 
 hemorrhagica, 651 
 interna, 870 
 
 parotitica, 874 
 media, abscess of, drumhead in, 662 
 acute catarrhal, 694 
 pain in, 702 
 suppurative, 730 
 in children, 738 
 incision in, 669 
 adenoids and. 324, 332 
 atrophic, inflation in, 688 
 catarrhalis sicca, 715 
 chronic catarrhal, 709 
 incision in, 668 
 suppurative, 303, 740, 741 
 
 perforation in, 742 
 treatment of, 744 
 in diphtheria, 463 
 exanthemata and, 694, 730, 734, 
 
 739 
 hyperostosis at oval window 
 
 and, 728 
 infection in, 695, 700 
 intracranial infection from, 774 
 
 Otitis media, irrigation in, 767 
 
 labyrinth and, 864, 872, 876 
 mastoiditis, and, 769 
 meningitis following, 734, 775 
 neuralgia in, 732 
 pathology of, 769 
 sinuitis and, 188 
 tonsillitis and, 384 
 Otomycosis, etiology, etc., 655 
 Otopiesis (deafness from labyrinthine 
 
 pressure), 899 
 Otorrhea, acute, alcohol in, 52 
 
 brain abscess and, 780, 781, 782 
 chronic, a danger signal, 654, 741, 
 745, 757, 772, 774 
 disqualifies for life insurance, 
 
 806 
 indication for mastoid operation, 
 761 
 deaf-mutism and, 899 
 duration of, before necrosis, 769 
 marginal perforation in, 747 
 Otosclerosis, 725, 726 
 Oval window (fenestra vestibuli), 582, 
 586 
 danger to, in mastoid opera- 
 tion, 806 
 rarefying osteitis around, 620 
 Overtones, undesirable in tuning fork, 597 
 Oxyecoia (morbid acuteness of hearing), 
 
 886 
 Ozena, due to sinuitis, 120 
 syphilitica, 306 
 
 Pachydermia laryngis, 448, 451, 478 
 Pachymeningitis, etiology, etc., 776 
 
 circumscripta, surgical treatment of, 
 849 
 Packard, Francis R., research on tonsils 
 
 in lower animals, 366 
 Page, La Fayette, 519 
 Palate, in adenoids, 331 
 
 arches of, 508 
 
 "gothic arch," 331 
 
 nerve supply of, 19 
 
 syphilitic destruction of, 348 
 
 in voice production, 503 
 Panotitis, 735, 873 
 Panse, 575, 816, 855 
 
 plastic meatal incision of, 816 
 Papilloma, differentiated from chorditis 
 nodosa, 452 
 
 of larynx, 480, 482, 505, 522, 523, 524 
 
 of nose, 264 
 
 of pharynx, 354 
 
 of tonsils, 419 
 Paracusis (perversion of hearing), 886 
 
 duplex, 886 
 
 Willisii, 711, 727, 887, 889 _ 
 Paraffin injection in atrophic rhinitis, 158 
 complications of, 287 
 in nasal work, 101, 284 
 
INDEX 
 
 923 
 
 Paralysis in brain abscess, 781 
 diphtheritic, 464 
 facial, 857, 878 
 laryngeal, 490 et seq. 
 
 abductor and adductor, origin 
 of, 493 
 lingual, 862 
 palatine, 378, 621, 622 
 pharyngeal, 351, 486, 490, 491, 
 
 497, 518 
 of recurrent nerves, 494, 495, 498 
 Parker, 338, 339 
 Parosmia, 242. See also Nose, neuroses 
 
 of. 
 Parotid gland, danger to ducts in excision 
 of external carotid, 364 
 relation of facial nerve to, 858, 
 860 
 Pars tensa of membrana tympani, 584 
 Partils, 339 
 Passow-Trautmann, plastic operation, 
 
 855, 856 
 Paul of Mgina, 629 
 Payson, J., 525 
 Pean, 537 
 
 Peltesohn, Felix, 317, 318 
 Pericarditis, following tonsillitis, 384 
 
 laryngeal paralysis in, 493, 496 
 Perilymph, 587 
 
 Periosteum, elevation of, in submucous 
 operations, 86 
 necessity to preserve in mastoid 
 
 operations, 795 
 of temporal bone, peculiarity of, 758 
 Perisinus abscess, 785, 849 
 Peritonsillitis, 341, 384, 388 
 chronic, 389 
 
 differentiation from diphtheria, 563 
 and edema of larynx, 440 
 origin of infection in, 389 
 Permanganate of potash solution in 
 
 tonsillar hemorrhage, 406, 411 
 Pes anserinus (terminal radiations of 
 
 facial nerve), 364, 85S, 862 
 Pharyngeal scissors, 333, 35S 
 
 tonsils, development of, 370 
 Pharyngitis, alcohol gargle in, 52 
 chronic, etiology, etc., 339 
 follicular, and follicular tonsillitis, 
 
 400 
 galvanocautery in, 54 
 hyperplastica laterals, 341 
 lacunar, 339 
 simple acute, catarrhal, etiology, etc. 
 
 338 
 voice impairment from, 509 
 Pharyngoscopy, direct, 570 
 Pharyngotomy, technique in, 543 
 Pharynx, actinomycosis of, 313 
 akinesis of, 351 
 edema of, 788 
 and fauces, diseases of, 317 
 follicles of, 353, 355 
 functional neuroses of, 350, 351 
 glanders of, 292 
 influence of gout and lithemia in, 28 
 
 Pharynx, malformations of, 348 
 in meningitis, 351 
 neoplasms of, 354 
 paralysis of, 351 
 
 complicating facial paralysis, 
 353 
 paresthesia of, 335, 336, 350 
 sensitive areas of, 350 
 spasm of, 351 
 stenosis of, 348 
 syphilis of, 304 
 tuberculosis of, 294 
 Phillips, 419 
 
 Phonation, in abductor laryngeal paraly- 
 sis, 497 
 Photophobia in suppurative otitis, 731 
 Piera, 366 
 
 Pierce, Norval H., 54, 251, 746, 755, 818 
 Pierce's subcutaneous use of chromic 
 
 acid, 54 
 " Pigeon chest" in adenoid subjects, 333 
 Pilocarpine injection in panotitis, 873 
 in laryngitis, 432, 450 
 in Meniere's disease, 867 
 in sclerosis, 720 
 in syphilis of labyrinth, 875 
 Piotrawski, 337 
 
 Pischel's collodion dressing in nasal sur- 
 gery, 73, 145 
 Pleurisy a cause of laryngeal paralysis, 
 
 486, 493, 496 
 Plica salpingopharvngeus, 687 
 
 supratonsillaris, 371, 382, 386, 391 
 tonsillaris, 371, 382, 391, 392, 409 
 triangularis, 373, 386, 403 
 Pliny, 892 
 Pneumococcus, 382 
 
 Pneumonia from aspirated infection, 346, 
 552, 566 
 following bulbar paralysis, 352 
 complication from foreign bodies, 
 
 555, 558 
 croupous, infantile deafness in, 895 
 hyperemia of labyrinth in, 864 
 a sequence of cricothyroid paralysis, 
 494 
 Polar granules, 455 
 
 Politzer, A., 579, 586, 590, 591, 594, 
 596, 597, 600, 616, 636, 640, 641, 647. 
 650, 651, 652, 658, 663, 664, 667, 685, 
 687, 689, 690, 691, 692, 693. 706, 708, 
 714, 715, 716, 718, 720, 722, 724, 726, 
 728. 732, 734, 735, 749, 750, 751, 754, 
 755, 832, 864, 865, 866, 867, 870, 871, 
 872, 874, 875, 877, 881, 886, 891 
 Politzer's acoumeter, 594 
 
 bag for inflation of ear, 690, 691, 
 
 693 
 experiment on normal patency of 
 
 Eustachian tube, 579 
 formula in sclerosis, 720 
 Pollen, influence of, in hay fever, 249 
 Polyotia, 636 
 
 Polypi, aural, obstruction from, 765 
 in chronic mastoiditis, 759 
 otorrhea, 773 
 
924 
 
 INDEX 
 
 Polypi of epipharynx, defective hearing 
 from, 622 
 in epilepsy, 256 
 in ethmoid cells, 233 
 influence on cholesteatoma, 750 
 on laryngitis, 443 
 on vocal resonance, 504 
 of larynx, 522 
 of middle ear, 620, 741 
 nasal, 172, 177, 184 
 
 etiology, etc., 258 
 of pharynx, 355 
 predisposing cause of hay fever, 245, 
 
 246, 248 
 reflex irritation of, 21 
 subglottic, 524 
 Polypoid degeneration in septal deform- 
 ity, 63 
 Ponce. Pedro de, 892 
 Posey, W. C, 186, 292 
 Position, Casselberry's, for feeding, in in- 
 tubation, 475, 476 
 of child for tonsillotomy, 415 
 of head in excision of external car- 
 otid, 363 
 Hillis', for feeding in intubation, 475, 
 
 477 
 of patient in intubation, 472, 473 
 after laryngectomy, 547, 550 
 for removal of adenoids, 326 
 in tonsil operation, 402 
 in tracheobronchoscopy, 565, 
 572 
 Postnasal " dripping," significance of, 173, 
 
 174 
 Potassium iodide, in actinomycosis, 315 
 in hysterical auditory paralysis, 
 
 886 
 in labyrinthitis, 873 
 in pachydermia laryngis, 478 
 in syphilitic labyrinthitis, 875 
 in tinnitus, 882, 867 
 laryngeal stenosis from, 485 
 Poucet, 313 
 Powers, 535 
 
 Pregnancy, aggravation of tuberculosis 
 by, 301 
 influence of, in otosclerosis, 725 
 Pritchard, Urban, 868 
 Prominentia canalis facialis, 582 
 semicularis lateralis, 583 
 Promontorium, 582 
 Proust, 493 
 Prout, 493 
 Prout's method of recording watch test, 
 
 593 
 Prussak's space, 584, 586 
 
 exudation in, 708 
 Pseudocroup, 433, 463 
 Pseudodiphtheria, 456, 463 
 Pseudomembrane in tonsillitis, 384 
 Pseudomembranous croup, 435, 437 
 
 sore throat, 352 
 Ptosis in thrombosis of cavernous sinus, 
 
 788 
 Puberty, influence of, on voice, 503 
 
 Public schools, inspection of, 465 
 Pulmonary gangrene from tonsil infection, 
 
 368 > 
 Pyemic infarction from tonsillar infec- 
 tion, 386 
 Pyer, 595 
 
 Pynchon, Edwin, 41, 42, 127, 269, 328, 
 331, 386, 392, 398, 413, 414, 689, 701, 
 707,877 
 Pynchon's aural ma.sseur, 42 
 
 compressed air regulator, 689 
 modification of Golding-Bird's cu- 
 rette, 328, 331 
 tonsillar dissection by electrocautery, 
 413, 414 
 Pynchon-Hubbard air tank, 41 
 Pyogenic diseases of brain and spinal 
 
 cord, 784 
 Pyriform fosssp, 571 
 
 Q 
 
 Quenu, 337 
 
 Quincke, 779 
 
 Quinine, a remedy in tinnitus, 867 
 hyperemia of labyrinth from, 864 
 influence on deaf-mutism, 896 
 
 Quinsy, etiology, etc., 388 
 
 Author's operation for, 391 
 
 Radiotherapy, in laryngeal disease, 300 
 
 in lupus, 292 
 
 in otitis media, 763 
 Radium, in laryngeal disease, 301 
 
 in lupus, 292 
 Rarefaction of external meatus in scle- 
 rosis of middle ear, 721 
 Ray fungus, 312 
 Read's base line of skull, 845 
 Rebinski, 296 
 
 Recessus epitympanicus, 582, 586 
 Rectal alimentation, 548, 552 
 
 in intubated cases, 477 
 
 etherization in laryngectomy, 477 
 Reflex irritation, from bronchoscopy, 560 
 laryngeal spasm from, 486 
 
 neuroses, 243 
 
 phenomena of nasal origin, 21, 242 
 
 toxemic, 30 
 Reflexes, deep, impaired by diphtheria, 
 
 464 
 Refraction troubles in sinuitis, 185 
 Reik, 879 
 Reinhard, 824 
 Reininger, 154 
 Reissner, 589 
 Respiration, adenoids and, 322, 331, 333 
 
 brain abscess and, 781 
 
 deaf-mutism and, 899 
 
 diphtheritic paralysis and, 464 
 
 faulty methods of, 503 
 
INDEX 
 
 925 
 
 Respiration influenced by pressure on 
 angle of jaw, 487 
 by traction on tongue, 487 
 in laryngitis in children, 431, 434 
 nasal stenosis and, 17 
 Respiratory tract, epithelium of, varia- 
 tions of, 428 
 inflammatory extension in, 428 
 inoperable cancer of, 363 
 upper, function of, 27 
 Reszke, Jean de, 24, 505 
 
 on voice and nose, 505 
 Retropharyngeal abscess, 345 
 
 diagnosis of, from membranous 
 laryngitis, 439 
 Retzius, 519 
 Reverdin's needle, 830 
 Rheumatic conditions and the pharynx, 
 340, 341, 351 
 facial paralysis, 857 
 fever, and infantile deafness, 895 
 larvngitis and laryngeal cancer, 447, 
 
 531 
 otosclerosis, 725, 729 
 paralysis of auditory nerve, 885 
 tonsillar infection 367, 384, 387, 
 400 
 Rhinal hydrorrhea, 254 
 Rhinitis, acute, etiology, etc., 130 
 atrophic, 154, 156, 157, 243 
 
 paraffin injection in, 285, 288 
 catarrh of middle ear and, 709 
 chronic, 137, 153 
 complicating specific fevers, 130 
 hyperesthetic, 243 
 hyperplastic, 120, 147 
 hypertrophic, 142 
 negative air pressure in, 129 
 pharyngitis and, 339 
 phlegmonous, 277 
 septal deformity and, 63, 118 
 sinuitis and, 120, 156 
 suppurative, not a disease, 159 
 and suppurative otitis, 731 
 swell bodies, collapsed in, 18, 153 
 
 turgescent in, 18 
 syphilitic, 277, 278 
 turgescent, gal vano cautery in, 54 
 vasomotor influence in, 21 
 Rhinolalia pata, paraffin injection in, 
 
 285 
 Rhinorrhea, cerebrospinal; 255 
 Rhinoscleroma, 274, 485 
 
 differentiation from hypertrophic 
 laryngitis, 447 
 Rhodes' tonsil punch-forceps, 411 
 Ribbert, 771 
 Richards, George L., 833, 834, 835, 838, 
 
 839, 841, 849 
 Richards' dissection of tonsil by finger, 
 418 
 method of adenectomy, 328 
 Richardson's, Charles, dissection of tonsil 
 
 by finger, 418 
 Rickets, eczema of ear and, 656 
 influence on deaf -mutism, 896 
 
 of membrana 
 
 on maxillary sinus, 229 
 358, 402, 558, 559, 569 
 
 Rinne, 599 
 
 Rhine's test, 598, 599 
 
 after incision 
 tympani, 704 
 
 in acute otitis media, 702 
 
 in hyperostosis of cochlea, 727 
 
 in sclerosis, 719 
 
 in suppurative otitis, 735 
 Riverias, 627 
 Rivinian foramen, 708 
 segment, 584 
 
 a factor in suppurative otitis, 731 
 Robertson, Charles M., 297, 412, 413 
 Robertson's operation for removal of 
 
 tonsil by scissors, 412, 414 
 Roe's forceps for perpendicular plate, 69, 
 
 79 
 Rontgen rays, 126 
 
 in laryngeal diseases, 300 
 
 in lupus, 292 
 
 in lymphadenoma of tonsils, 421 
 
 in rhinoscleroma, 276 
 
 in sarcoma, 644 
 Roosa, St. John, 755 
 Root, A. G., 502 
 Rose's operation, 
 position, 271, 
 Rosenback, 497 
 Rosenmuller's fossae, 319, 325, 327, 580 
 
 adhesions in, 675 
 Rossenberg, 526 
 
 Round window (fenestra cochlea), 582, 586 
 Roux, 459 
 Rubenstein, 291 
 
 Ruault, tonsil punch -forceps, 411 
 Rumbold, T. F., 592, 593, 621 
 Russell's fuchsinophiles, 275 
 Russian perforator, 797, 798 
 
 Sachus, on facial skeleton, 58 
 Saissy, 636, 686, 687 
 Sajous, 442, 445, 447, 485 
 
 on subglottic space, 485 
 Sajous' laryngeal forceps, 442, 445, 447 
 Salpingitis, 675 
 Salpingopharyngeal fold, 318 
 Santorini, 575 
 
 fissures of, 575 
 Sarcoma, 531 
 
 of auricle, 643 
 
 of nose, 270, 273 
 
 of pharynx, 360 
 
 of tonsil, 421 
 Satellite veins, 337 
 Satyriasis. See Leprosy, 308 
 Scala vestibuli, 589 
 Scarlet fever, infection by tonsils, 367 
 septum perforation in, 105 
 Schadle, J. E., 244, 251 
 Scheibel's suture forceps, 830 
 Schmaltz, H., 892. 893 
 ! Schmidt, Moritz, 255, 359, 522, 524, 525 
 I on laryngeal tumors, 522 
 
926 
 
 INDEX 
 
 Schmiedkam, 607 
 Schmitzler, 525 
 Schrotter, 483, 525, 532 
 Schrotter's laryngeal tubes, 483 
 Schwabach, 598 
 
 Schwabach's test for hearing, 598, 727 
 Schwalbe, 519 
 
 Schwartze, 636, 714, 717, 754, 755, 759, 897 
 Sclerosis of Eustachian tube, 621 
 influence on labyrinth, 869 
 of middle ear, 620, 715, 718 
 paracusis Willesii in, 887 
 Scoliosis, a cause of laryngeal paralysis, 
 
 493, 496 
 Screw worms in ear, 625, 626 
 
 in nose, 272, 277 
 Scrofula, eczema of, ear in, 656 
 
 influence on deaf-mutism, 896 
 
 on diseases of middle ear, 699 
 in otosclerosis, 725 
 Seasickness, nystagmus from, 609 
 Seifert, 336, 337 
 Seller's solution, 56, 341, 527 
 Seiss, 337 
 
 Semicircular canals, connective tissue, 
 changes in, 869, 871 
 danger to in mastoid operation, 
 
 804 
 disturbances following opening 
 
 of, 835 
 exenteration of, 835, 836 
 fracture through, 881 
 functions of, 587 
 horizontal, relation of facial 
 
 nerve to, 805, 806 
 hyperostosis of, 728 
 nature of nystagmus of, 605 
 necrosis of, 833, 876, 
 stimulation of, 602, 607 
 surgery of, 834 
 Semon, Sir Felix, 251, 398, 492, 496, 
 497, 522, 524, 531, 532, 533, 534, 
 535 
 on laryngeal neoplasms, 524 
 Semon' s law of degeneration, 497, 534 
 Senator, 493 
 Senn, Nicholas, 313 
 Sepsis from cholesteatoma, 751 
 Septicemia, from chronic otorrhea, 736, 
 
 740 
 Septum nasi. See Nasal septum. 
 Serumtherapy in hay fever, 251 
 in lupus of nose, 292 
 in tuberculous otitis, 303 
 Sexton, Samuel, 629, 791 ; 881 
 Sexton's foreign body forceps, 629 
 knives for ossiculectomy, 791 
 Sexual excesses, influence in otosclerosis, 
 725 
 laryngeal spasm in, 487. Seq 
 also, Nose, neuroses of. 
 Shambaugh, George, 587, 588, 728, 867, 
 
 868, 887 
 Shambaugh's theory of tone perception, 
 
 587 
 Sheppard, 754 
 
 ShrapnelPs membrane (pars naccida), 577, 
 584, 733 
 incision of, 669 
 
 significance of perforation of, 
 768 773 
 Shurley, E. L.,296, 470, 526 
 Shutz's adenotome, 328 
 Siebenmann, 575, 598, 726, 815 
 Siebenmann's plastic meatal incision, 815 
 Siegle's otoscope, 128, 577, 584, 707, 708, 
 
 _ 719, 733, 738, 759, 768, 773, 868 
 Silent croup, 438 
 Simon, 464 
 
 Simpson's sponge tents, 99 
 Simulated deafness, tests for, 883 
 Singer's nodules, 447, 448, 518, 522, 523 
 Sinuitis (inflammation of one or more of 
 the accessory sinuses), 161, 176, 
 189, 190 
 aprosexia in, 171, 172 
 auditory symptoms in, 187 
 digestive disturbances from, 28 
 dizziness in, 163, 177, 186 
 empyema of, 169 et seq. 
 headache in, 163, 168, 171, 177, 180, 
 
 185 
 hypothetical cases of, 169 et seq. 
 intracranial complications in, 164 
 laryngitis and, 428, 443, 449 
 leptomeningitis from, 778 
 middle ear disease in, 699, 709, 713 
 nasal causes of, 63, 177 
 ocular svmptoms in, 164, 169, 174, 
 
 179, 186 
 otorrhea and, 745, 746 
 pain in, 163, 185 
 pathology of, 178 
 polypi a result of, 177, 180, 184 
 predisposing causes of, 114, 177, 197 
 pus, location of, in, 163, 168, 170, 
 
 171, 184 
 symptoms of, 163, 164, 181, 184, 
 
 185, 186 
 syphilis and, 176 
 tenderness on pressure in, 162, 163, 
 
 171, 185 
 treatment of, 188, 189, 190 
 by lavage, 195 
 by operation, 200, 241 
 tuberculosis and, 176 
 voice affection from, 512 
 Sinus or sinuses: 
 
 accessory of the nose, 176 
 
 are resonant chambers for the 
 
 voice, 504 
 divisions of, 161, 167, 169, 173 
 Loeb's projections of, 162 
 skiagraphy of, 161, 162, 
 
 164, 172, 182, 183, 201 
 transillumination of, 182 
 ethmoidal. See Ethmoidal cells, 
 frontal, anatomical variations 
 of, 161, 163, 164 
 empyema of. See Sinuitis. 
 irrigation of, 171, 173, 175, 
 190 
 
INDEX 
 
 927 
 
 Sinus or sinuses — continued. 
 accessory, of the nose: 
 
 frontal, locating pus from, 19, 
 163, 169, 170, 171, 172 
 probing the, 172, 191, 193 
 surgery of, 200 
 
 Author's intranasal 
 
 operation, 202 
 Beck's osteoplastic 
 
 operation, 213 
 Good's operation, 206 
 Hejek-Luc's operation, 
 
 210 
 Halle's operation, 204, 
 
 206 
 Ingals' operation, 208, 
 Killian's operation, 215 
 Kuhnt-Luc's operation, 
 
 211 
 Kuhnt's opera tion, 211 
 Kuster's operation, 212 
 treatment after, 204, 
 207, 209, 214, 217 
 maxillary. See Antrum of High- 
 more, 
 sphenoidal, anatomy of, 168 
 empyema of. See Sinuitis. 
 infection of, in tubal disease, 
 
 808 
 irrigation of, 173, 174, 194 
 locating pus from, 168, 184 
 ocular relations of, 169, 174, 
 
 179 
 probing the, 194, 195 
 surgcrv of, Author's 
 method, 241 
 tonsillaris, 369, 370, 373, 379, 391, 
 
 400, 406, 410 
 venous, of the cranium: 
 
 cavernous, 786, 787, 851 
 lateral, 784, 849 
 
 sigmoid portion of, 853, 856 
 longitudinal superior, 851 
 petrosal, superior, 851 
 thrombosis of : 
 
 from cholesteatoma, 751 
 from chronic otorrhea, 736, 
 
 740 
 influence of exanthemata 
 
 in, 701, 734 
 from labyrinthitis, 876 
 of lateral sinuses, 784, 849, 
 
 876 
 in mastoiditis, 849 
 sjmiptoms of, 766 
 Skiagraphy for foreign bodies in larynx, 
 
 555, 562 
 Sluder, Greenfield, operation for septal 
 
 deviation, 68. 75 
 Smith, Harmon^ 525, 526 
 Sneezing, 243 
 Sondermann, 128 
 Sore throat, clergyman's, 339, 509 
 Spasmus glottidis, 487 
 Spedalskhed. See Leprosy. 308. 
 Speech defects. 514 et seq. 
 
 I Spencer, 746 
 
 ; Sphenomaxillary fissure, growths in, 357 
 Sphenopalatine ganglion, 246 
 i Spinal cord, changes in, due to diphtheria, 
 
 457 
 : Spine of Henle, 797 
 Spirillum in membranous laryngitis, 438 
 Splint for nasal deformity, 280, 281 
 Spokeshave, 73, 145. 146 
 Spongifying of labyrinthine capsule, 716, 
 
 717, 725, 726 
 Spray tubes, utility of, 45 
 Spur, nasal, obstruction from, 118, 138 
 Squamous plate, drainage of cerebral 
 
 abscess through, 843 
 Squint in relation to sinuitis, 187 
 Stacke, 799, 803 
 Stacke's operation. 583 
 
 protector, 857 
 Staggering gait, in deaf-mutism, 899 
 
 in labyrinthitis, 871 
 Stahl, 635 
 Stammering, 515 
 
 respiration in, 899 
 and tuberculosis, 518 
 Stapedectomy in hyperostosis of laby- 
 rinth, 729 
 Stapes, attachment of, 580 
 
 danger to in mastoid operation, 806 
 hyperostosis of, 727 
 normal movement of, 590 
 Staphylococci, development of, 456 
 in membranous laryngitis, 438 
 tonsils an incubator for, 368 
 ; Steele, J. S., 227, 278, 280 
 Steele's septum forceps, 280 
 Stein, O. J., 19, 224, 226, 251, 252, 253, 
 
 268, 304, 533 
 Stein on alcohol injection in hay fever, 
 
 251, 252, 253 
 Stein's gouge for antral wall, 224, 226 
 Steinbrugge, 875 
 | Stenosis nasal, influence on respiration, 
 
 I 17 
 
 Sterilizer for instruments, 48 
 Sticker, 309 
 Stirling, 369, 595 
 i Stoerk, 551 
 Stohr, 367, 368, 369 
 Strabismus, in cavernous thrombosis, 788 
 
 in sinuitis, 174 
 Strassmann, 365 
 Street's syringe for tonsillar injection, 401 , 
 
 402 
 Streifen of Hensen, 588 
 Streptococcus aureus, development of, 
 456 
 in infectious epiglottitis, 426 
 influence of, in otorrhea, 771 
 in membranous laryngitis, 438 
 pyogenes, 382 
 
 severity of, in tonsillar infection, 416 
 tonsils incubators for, 368 
 Stubbs' method in adenectomv, 327 
 Stucky, J. A., 116, 164, 339," 427, 541, 
 547, 723, 755 
 
928 
 
 INDEX 
 
 Styloid process, removal of, 855 
 Subglottic laryngitis, 434 
 neoplasms, 524 
 space, importance of, 485 
 stenosis, 485 
 tumors, 485 
 Submucous resection, 85 
 Suffocation, labyrinthine, hemorrhage 
 
 from, 865 
 Suker, George F., 187, 637, 722 
 Sulcus tympanicus, 584 
 Sunshine, overstimulation of, 351 
 Sunstroke, influence on deaf-mutism, 
 896 
 pharyngeal paralysis from, 352 
 Suprameatal triangle, 797 
 Supratonsillar fossa, 370 
 Sutton, Bland, 355 
 Swain, H. L., 250, 337, 527, 738 
 Swell bodies. See Turbinated bodies. 
 Swivel cartilage knife, 104 
 Sydacker, 751 
 
 Syphilis, bony nasal growths in 268 
 bulbar disease following, 352 
 diagnosis of, from actinomvcosis, 
 315 
 from adenoids, 325 
 from chronic laryngitis, 451 
 hereditary, 875 
 
 from hyperostosis of labyrin- 
 thine capsule, 875 
 from laryngeal carcinoma, 531, 
 
 535 
 from pharyngitis, 338 
 from tuberculosis of larynx, 
 299 
 of pharynx, 295 
 of ear, 34, 307 
 erosions of larynx from, 479 
 exostosis of meatus from, 653 
 facial paralysis from, 857 
 of fauces, 304 
 
 hemorrhagic laryngitis in, 450 
 infiltration of ventricles of Morgagni 
 
 in, 480 
 influence of on reparative processes, 
 176, 426, 428, 431, 446, 523, 699, 
 704, 731, 818, 871, 872, 873, 894, 
 896 
 of labyrinth, 623, 869, 874, 875 
 laryngeal edema from, 440 
 
 paralysis from, 497, 499, 500 
 spasm from, 487 
 of larynx, etiology, etc., 306 et seq., 
 
 482, 483, 524 
 of nose, 34, 304, 306 
 otosclerosis from, 725 
 pachydermia laryngitis in, 478, 479 
 pharyngeal paralysis from, 352 
 
 stenosis from, 348 
 of pharynx, 304, 354 
 septal perforation from, 104 
 of subglottic space, 485 
 of throat, 34 
 of tonsils, 304 
 tubal constriction from, 680 
 
 Tabes dorsalis, aural symptoms in, 891 
 
 laryngeal disturbance in, 38, 486 
 Tachycardia in diphtheria, 459 
 
 of nasal origin, 257 
 Talbot, Eugene S., 58, 636 
 Teeth, caries a cause of sinuitis, 177 
 influence of adenoids on, 330, 332 
 in relation to maxillary sinus, 225 
 Tegmen tympani, abscess over, 849 
 
 cerebral drainage through, 842 
 necrosis of, 577, 808, 843 
 relations of, 580, 582 
 Telangiectasis of larynx, 522 
 Temporal bone, surgery of, 789 
 Teratomata of pharynx, 354, 355 
 Terminal auditory apparatus, 586, 587 
 Terry, W. J., 534 
 Tests, differentiating middle-ear from 
 
 labyrinthine disease, 603, 868 
 Tetanus, laryngeal spasm in, 486 
 Texas screw-worm (Compsomyia macel- 
 
 laria), 626 
 Theisen, 425, 426 
 Theobold, 744 
 
 Thiersch's grafts after operation, 760, 
 824, 856 
 in nasal deformity, 281 
 in surgery of jugular bulb, 856 
 Thiosinamin, uses" of, 276, 722, 723 
 Thompson, J. S., 331 
 Thompson, St, Clair. 254, 255 
 Thorner, Max, 293 
 Thornwaldt's disease, 317, 319, 333, 334 
 
 Author's operation for, 334 
 Throat, chronic granulomata of, 291 
 pricking sensations in, 417 
 in relation to general medicine, 27 
 Thrombophlebitis, 368, 389, 782 
 Thrombosis, cavernous, 786, 787 
 
 differentiated from orbital in- 
 flammation, 788 
 infection from otorrhea, 774 
 of jugular vein, 751, 787 
 of lateral sinus, 582, 782, 784, 848, 
 850, 864 
 Thymus asthma, 487 
 
 gland, influence of diphtheria on, 458 
 laryngeal spasm from pressure 
 of, 487 
 Thyrohyoid membrane, transit of lym- 
 phatics through, 529, 530 
 Thyroid isthmuses, lymphatic relations 
 of, 530 
 pressure, laryngeal paralysis from, 
 498, 499 
 Thyroidectin in hyperostosis of labyrin- 
 thine capsule, 729 
 Thyrotomy, 480, 524, 526, 536 
 Tilley, Herbert, 225 
 Timbre, or voice quality, 506 
 Tinnitus aurium, 589 
 ankylosis and, 621 
 arteriosclerosis and, 869 
 brain tumor and. 890 
 
INDEX 
 
 929 
 
 Tinnitus, conditions influencing, 589, 888 
 condyloma of meatus and, 308 
 from" abnormal tension, 621, 622, 674 
 in deaf-mutism, 899 
 in herpes, 646 
 in labyrinthine anemia, 865 
 
 disease, 872, 874, 877, 886, 891 
 hyperemia, 864 
 in inflammation of meatus, 649, 651, 
 
 657 
 in injury to drumhead, 661, 662, 664 
 in Meniere's disease, 866, 867 
 in middle ear disease, 709, 714, 735 
 in multiple sclerosis, 33 
 in otomycosis, 655 
 in otosclerosis, 717, 726 
 in paralysis of auditory nerve, 885 
 physiological law of, 581 
 pressure and, 881 
 significance of pitch of, 710 
 in tabes dorsalis, 891 
 in tonsillar inflammation, 383 
 treatment of, 623, 882 
 
 by massage, 126, 721, 722 
 by operation, 669, 724 
 in tubal catarrh, 677 
 Tobacco, laryngeal cancer from, 532 
 neuroses from, 350 
 laryngitis from, 443 
 morbid hearing from, 886 
 nystagmus from, 609, 613 
 pharyngitis from, 339, 340 
 prohibited, in hyperemia of laby- 
 rinth. Mil 
 tinnitus from, 710 
 Tompkins, 426 
 Tongue, carcinoma of, 421 
 
 influence of, in speech defects, 518 
 
 in voice production, 503 
 
 paralysis after anastomosis of facial 
 
 nerve, 859, 861 
 tie, 510 
 
 traction on, to provoke respiration, 
 487 
 Tone islands, 589 
 
 muscular regulators of, 591 
 perception, 592 
 
 in sclerosis, 719 
 placement. 448 
 Tonsillitis, acute lacunar, 382 
 alcohol gargle in, 52 
 bacteria of, 382 
 
 chronic follicular, indication for 
 tonsillectomy, 400 
 lacunar, 386 
 diagnosis of, from diphtheria, 384, 
 
 463 
 glandular involvement in, 383 
 influence in otosclerosis, 725 
 lingual acute, 335 
 
 lacunar, 335 
 phlegmonous, 335 
 and fail rial tonsillitis, 384 
 pleurisy following, 384 
 negative air pressure in, 129 
 phlegmonous, 388 
 59 
 
 Tonsillitis, sequela- of, 384 
 silver nitrate in, 49 
 and specific fevers, 383 
 from surgical trauma, 382 
 Tonsil or tonsils : 
 
 absorptive properties of, 371 
 
 actinomycosis of, 313 
 
 adhesions of, 373 
 
 anatomy of, 369 
 
 bacteriotysis in, 372 
 
 barrier against microorganisms, 368 
 
 blood-supply of, 376 
 
 calculus deposits in, 387 
 
 capsule of, 370, 401, 409 
 
 clinically of greater importance than 
 
 the appendix, 418 
 crypts of, 392 
 
 deafness from diseased, 622 ; 623 
 difference of, in adults and children, 
 
 391 
 digestive disturbances from dis- 
 eased, 28 
 epithelium of, 394 et seq. 
 follicles (lymphoid nodules), 367 
 hilus of, 371 
 hornv material in, 393 
 hyperplasia of, 391, 392 
 hypertrophy of, 391, 392 
 
 with adenoids, 324 
 infection of, 372, 382, 399 
 influence on voice, 504, 508 
 internal secretion of, 378 
 leptothrix of, 392 
 lingual, 334 
 
 hyperplasia of, a cause of phar- 
 yngeal neuroses, 350 
 hypertrophy of, etiology, etc., 
 
 335, 337 
 removal of, 336 
 tonsillitis of, 335 
 lobes of, 401 
 
 lymphatic relations of, 531 
 in middle ear disease, 699, 713 
 neoplasms of, 419, 421 
 
 snare in, 420 
 normal in adult, not to be seen or 
 
 felt, 623 
 pharvngeal, acute lacunar inflamma- 
 tion of, 317 
 neuroses and, 350 
 tonsillitis of, 384 
 portals of infection, 365, 367, 373, 
 
 376 
 removal of, in singers, 369 
 source of danger, 367 
 submerged of Pynchon, 392 
 in suppurative otitis, 731, 739, 745 
 surgery of: 
 
 Author's complete operation 
 with right angle knife and 
 ecraseur, 401 
 operation with scalpel, 407 
 right angle knife, 401 
 scalpel, 408 
 vulsellum forceps, 402 
 cautery dissection, 509 
 
930 
 
 INDEX 
 
 Tonsil or tonsils — continued. 
 
 surgery of, contra-indicated in vio- 
 lent inflammation, 381 
 crypts, slitting of, 377, 387 
 by decapitation, 378 
 by external route, 422 
 by finger dissection, 41 
 hemorrhage, source of, 379 
 hemostat, Boetcher's, 407 
 
 Pynchon's, 406 
 infection following, 416 
 irrigation syringe in, 418 
 punches in, how to use, 412 
 Robertson's operation, 412 
 
 scissors, 413 
 sequelae of, 415 
 Street's hypodermic in, 402 
 tonsillectomy, 418 
 
 a hospital operation, 418 
 tonsillotome, 391, 412 
 tonsillotomy, 415 
 
 recurrences after, 377, 398 
 with tonsillotome and punch, 411 
 syphilis of, 305 
 in tubal disease, 579 
 tuberculosis of, 294, 297, 303, 367 
 vestigial organs, 366 
 Tonsillar edema in sinus thrombosis, 
 788 
 patches from debris, 383, 384 
 ring (Waldeyer's), 317, 367 
 Torticollis in mastoiditis, 754 
 Toynbee, 716, 874, 892, 893 
 Trachea, foreign bodies in, 554, 562 
 
 lymphatic relations of, 530 
 Tracheal diphtheria, 554 
 Tracheobronchoscopy, 564, 565, 566, 567, 
 
 568, 569 
 Tracheoscopy, 555, 556, 558 
 Tracheotomy, 307, 349 
 after-effects of, 469 
 after-treatment of, 470 
 in diphtheria, 463, 464, 468 
 in edema of epiglottis, 427 
 
 of larynx, 441 
 high operation, 468 
 in hypertrophic la^ngitis, 447 
 indications for, 427, 432, 436, 437, 
 438, 441, 442, 447, 463, 464, 468, 
 480, 482, 483, 485, 487, 502, 524, 
 525, 526, 527, 538, 547, 553, 555, 
 556 
 in laryngeal abscess, 442 
 malformations, 480 
 in laryngitis, 432, 436, 437 
 low operation, 569 
 management of tube in, 469, 470, 
 
 480, 482 
 treatment of the wound in, 569 
 Trachoma of vocal cords, 447 
 Transillumination of sinuses, 171, 172, 
 
 174 
 Trautmann, 816, 856 
 Trautmann's meatal flaps, 816 
 Trendelenburg on gothic arch, 58 
 position in laryngectomy, 547 
 
 Troltsch, von, 629, 630, 660, 677, 716, 738, 
 
 749, 892, 893 
 Trousseau, 468 
 Trousseau's dilator, 569 
 Trypsin treatment of malignant neo- 
 plasms, 362 
 Tubal catarrh, 578, 596, 675, 678 
 
 differentiated from Meniere' 
 
 disease, 867 
 infection of tympanum with, 
 699, 743 
 obstruction, etiology, etc., 679 
 patency in hyperostosis of cochlea, 
 679, 728 
 Tuberculosis aggravated by pregnancy, 
 301 
 ankylosis of arytenoid cartilages in, 
 
 483 
 edema of larynx in, 440 
 epiglottic infection in, 426 
 Grober's experiments on, 376 
 labyrinthitis in, 623, 871, 876 
 laryngeal, 428, 518, 524 
 
 "ashen color" in, 297, 298 
 cancer, 531, 535 
 erosions of, 479 
 etiology of, 295 et seq. 
 growths in, 523 
 hemorrhagic, 450 
 pachydermia in, 478, 479 
 papilloma in, 525 
 paralysis in, 493 
 stenosis in, 482, 483 
 of nose, 293, 297 
 pharyngeal paralysis in, 352 
 recuperative powers in, 760, 818 
 septum perforation in, 104 
 sinuitis in, 176 
 subglottic, 485 
 
 tonsillar origin of, 365, 377, 400 
 tubal contractions in, 680 
 ventricles of Morgagni, infiltration in. 
 480 
 Tuberculous leprosy, 308 
 
 middle-ear affections, 301, 699, 704, 
 
 771 
 perforations of drumhead, 743 
 Tuning fork test, in Meniere's disease, 866 
 
 value of, 596 
 Turbinated bodies, clinical anatomy of, 
 17, 18, 19, 23 
 hyperplasia of, 149 
 hypertrophies of, 25, 142 
 inferior, cauterization of, 139 
 paraffin injection of, in 
 atrophic rhinitis, 285, 288 
 pressure of, 117 
 turgescence of, 119 
 middle,' blood supply of, 273 
 edema of, 198 
 hemorrhage from, 152 
 obstruction from, 198, 199 
 anosmia from, 242 
 asthenopia from, 36 
 causing sinuitis. 188 
 relation to respiration, 17 
 
INDEX 
 
 931 
 
 Turbinated bodies as sites of fibromata, 
 356 
 symptoms of pressure of, 66, 
 117, 119 
 Turbinectomv, Author's swivel knife for, 
 
 146 
 Tiirck, 301 
 
 Turner, Logan, 119, 164, 319, 321, 323, 
 324, 525, 714 
 on frontonasal canal, 119, 164 
 Turning test in labyrinthine disease, 603, 
 604 
 nystagmus from (schema of), 606 
 value of, 615, 616 
 Tympanic cavity, 580 
 
 inflation of, 683 et seq. 
 methods of, 685 
 in otitis media, 705 
 value of, 685 
 membrane, adhesions of, 577 
 
 deafness from defects of, 619 
 influence of adenoids on, 332 
 Tympanum, physiological admittance of 
 air to, 578 
 clinical anatomy of, 790 
 coronal section of, 586 
 divisions of, 585 
 functions of, 585 
 inflammatory diseases of, 694 
 pathological secretions in, 700 
 relations of, 580 
 
 of facial nerve to. 804, 805, 806 
 walls of, 582 
 Typhoid fever, hyperemia of labyrinth in, 
 864 
 paralysis of cricothyroid in, 493 
 septum perforation in, 105 
 
 Ultra-violet rays in laryngeal disease, 
 300 
 in lupus, 292 
 Uncinate process, 119, 174, 199 
 Upper respiratory tract, toxemia from 
 
 diseases of, 519 
 Urbantschitsch, 607, 630, 680, S98 
 Uterine disease a cause of laryngeal 
 
 spasm, 487 
 Utricle, receiving twigs of auditory nerve, 
 
 587 
 Uveal tract, diseases of and sinuitis, 187 
 Uvula, amputation of, 343 
 
 Casselberry's operation, 344 
 edema of, 341, 342 
 elastic, Author's case of, 343 
 neoplasms of. 354 
 pharyngitis and, 339, 340, 341, 342, 
 
 352 
 svphilitic destruction of, 348 
 voice and, 503, 504, 507 
 
 Vaccination and deaf-mutism, 896 
 Vagus and sphenopalatine ganglion, 20 
 
 Vagus, Edinger on nuclei of, 492 
 Vails' operation on maxillary sinus, 219, 
 220 
 saw, 145, 220, 227 
 Valsalva, 664 
 
 Valsalva's method of inflation. 685, 686, 
 692, 693 
 caution regarding, 686 
 Varix, lingual, 336, 337, 490 
 Vasomotor disease, labyrinth in, 869 
 neuroses, 243 
 
 system, laryngitis and, 444 
 lingual tonsil and, 337 
 middle-ear diseases and, 700 
 Vein, emissary of mastoid, 799 
 
 jugular, internal, danger in excision 
 of external carotid, 364 
 relation of lymphatics to, 
 530 
 to pneumogastric 
 nerve, 852, 
 resection of, 851 
 Ventilation of dwellings, 696 
 Ventricles of larynx, prolapse of, 478, 
 
 480, 482 
 Ventricular eversion of sacculus laryngis, 
 
 482, 483 
 Verneuil, 337 
 
 Vertigo, arterisoclerosis and, 869 
 brain abscess and, 780 
 labyrinthine diseases and, 610, 613, 
 
 833, 877 
 Meniere's disease and, S66 
 nystagmus and, 607 
 sinuitis and, 163 
 Vestibular apparatus, functions of, 587 
 changes in deaf-mutism, 897 
 irritation, 867 
 nystagmus, 603 et seq. 
 tests, 596, 600, 882 
 Vestibule, connective-tissue changes in, 
 869 
 relation of, to tympanum, 580 
 surgery of, 838 
 Vibration (mechanical massage), 46 
 Victor massage apparatus, 707 
 Vieussens, 154 
 Villar, 355 
 Virchner, 874 
 
 Virchow, 420, 482, 532, 636 
 Vicious circle of nose, 119, 121, 197, 200, 
 201. 202, 203, 208, 212, 218, 25S 
 polypi within, 258 
 Vision, characteristics of, in nystagmus, 
 
 610, 614 
 Vocal apparatus. 503. See also Larynx, 
 bands, removal of, 502 
 cords, cadaveric position of, 495, 497, 
 499 
 fibrosis of, 525 
 lymphatics of, 529 
 muscles of, schema of nerve sup- 
 ply of, 491 
 in neuroses of larynx, 486 
 normal color of, 444 
 paralysis of, 490 et seq. 
 
932 
 
 INDEX 
 
 Vocal cords, trachoma of, 447 
 Voice in carcinoma of tonsil, 422 
 in chronic lacunar tonsillitis, 387 
 in edema of larynx, 441 
 in epipharyngeal fibromata, 356 
 falsetto, 518 
 
 after laryngeal operations, 552 
 in laryngeal paralysis, 494, 497 
 in laryngitis, 431, 438, 444, 452 
 in pachydermia lanmgis, 478 
 after pharyngeal paralysis, 352 
 pharyngitis from overuse of, 339 
 physical condition and, 512 
 production, 503 
 resonators of, 507 
 in retropharyngeal abscess, 345 
 the singing, 503 et seq. 
 Volkmann, 726 
 Voltolini, 631, 870, 871, 872 
 Vomer, removal of, 95 
 Vomiting in brain abscess, 781 
 
 from labyrinthine disturbance, 864, 
 
 865, 871, 872, 877, 881 
 in Meniere's disease, 866 
 in nystagmus, 607 
 in suppurative otitis, 739 
 
 W 
 
 Wade, 362 
 
 Waldeyer's ring (lymphatic tissue ring), 
 
 324, 367 
 Wale, 584 
 Walsh, 452 
 Walsham denies tuberculous process in 
 
 tonsils, 367 
 Walsham's operation for collapsed alae 
 
 nasi, 289 
 Watson ; Spencer, 257 
 
 operation for septal deviation, 68, 
 74, 83 
 Waxam, F. E., 470 
 Weaver's intratympanic masseur, 681, 
 
 682 
 Weber, 593, 598, 599 
 Weber's test in acute otitis media, 702 
 
 on bone conduction, 590, 596, 
 
 597, 633 
 after incision of membrana tym- 
 
 pani, 704 
 in suppurative otitis, 733 
 Weber-Liel catheter, 745 
 Weichselbaum, 771 
 Weiss, 739 
 
 Welcker, on gothic arch, 58 
 Wells' trocar, 220, 224 
 Werckmeister, 535 
 West, John M., 411 
 
 WestphaPs symptom in leptomeningitis, 
 
 Whalen, 490 
 White, 535 
 
 Whiting, 755, 786, 795, 796, 798, 799, 
 847, 850 
 
 encephaloscope, 847 
 Whooping cough, and infantile deafness, 
 
 895 
 Wild, 562 
 
 Wilde, 758, 794, 892 
 Wilde's incision, 758, 794 
 
 snare, 880 
 Williams, Watson, 20, 256, 257, 366, 447, 
 
 480 
 Willis, paracusis of, 711 
 Wilson, 391, 570 
 Wilson, N. L., 398 
 
 on bilateral abductor paralysis, 500 
 Wines, 900 
 
 Wingrave, Wyatt, 771 
 Wippern, A. G., 265 
 Woakes, 116, 427 
 Wolf, Oscar, 593 
 Wood, 164 
 Wood, C. A., 187 
 Wood, G. B., 392 
 Woodruff, Major, 593 
 Word deafness, 889 
 Wreden, 634 
 
 Wright, Jonathan, 45, 292, 367, 371, 372, 
 377, 382, 522, 524, 525 
 
 on drainage of tonsillar crypts, 45 
 
 on laryngeal growths, 524 
 
 on tonsillar absorption, 371, 372 
 
 on tonsillar tuberculosis, 367 
 Wright's opsonic theory, 127, 128 
 
 Yankauer, Sidnev, 101, 106, 108, 109 
 Yankauer's intranasal suture, 106, 108, 
 109 
 needles, 345, 359 
 Yersin, 454 
 
 Zachias, 892 
 
 Zaufal, 315, 577, 627, 694. 742 
 
 Zeim, 146 
 
 Ziemssen, 353, 531 
 
 Zuckerkandl, 58, 104, 337 
 
 on congenital septal perforation, 104 
 
 on gothic arch, 58 
 Zwaardemaker, 595 
 
rroPY nn to cat. oiv. 
 
 NOV 13.1909 
 
JW'I8.»» 
 
LIBRARY OF CONGRESS 
 
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