M <" '' i ., -s> » G V ^ vV' ^ \4 V «/> *++. $ V- <^V « ; : > y °.'f> v * . ' , ' f . <&' ■\\ v ^ ^ I* A v * ^O <^ '' : S s x X A* - o o •4. -/ -V 5 ^ DISEASES OF THE EAR, NOSE, AND THROAT AND THEIR ACCESSORY CAVITIES. A Condensed Text-book. / BY Seth Scott Bishop, M.D., LL.D., Professor in the Chicago Post-Graduate Medical School and Hospital; Surgeon to the Illinois Char- itable Eye and Ear Infirmary; Consulting Surgeon to the Illinois Masonic Orphans' Home and to the Silver Cross Hospital of Joliet ; Formerly Surgeon to the South-Side Free Dispensary and to the West-Side Free Dispensary ; Member of the International Medical Congress, The Pan-American Medical Congress, The American Medical Association, The State Medical "Societies of Illinois and Wisconsin, The Chicago Patho- logical Society, etc. Illustrated uuith One Hundred Colored Ldthographs and One hundred and Sixty-eight Additional Illustrations. PHILADELPHIA, NEW YORK, CHICAGO : ' THE F. A. DAVIS COMPANY, PUBLISHERS. 1897. COPYRIGHT, 1897, BY THE F. A. DAVIS COMPANY. [Registered at Stationers' Hall, London, Eng.] Philadelphia, Pa., U. S. A. The Medical Bulletin Printing-House, 191'", Cherry Street. IN RECOGNITION OF HIS DISTINGUISHED SERVICES ADVANCEMENT OF SURGERY, THIS BOOK IS AFFECTIONATELY DEDICATED TO PROF. NICHOLAS SENN, M.D., Ph.D., LL.D., BY THE AUTHOR. PREFACE. Frequent requests from medical students and general practitioners for a book on diseases of the ear, nose, and throat especially adapted for their needs have prompted the writer to endeavor to meet this demand. This work was designed, first, to help students in pre- paring for their degree ; second, for those progressive prac- titioners who wish to acquire the proficiency necessary to properly treat those patients who are unable to visit special- ists ; and, third, for those who are gradually exchanging their general practice for special work in these branches. The subjects are simplified and condensed so as to con- stitute this book a key, or introduction, to the exhaustive treatises already in the field. The place of the latter is not expected to be filled by this unpretentious book, for it was not intended primarily for specialists. Yet it is hoped that it may modestly serve their interests in bringing information on the subjects down to the present date, and as a work of ready reference. Several subjects are treated in greater detail than char- acterizes the work as a whole, for the following reasons : No book, equivalent to this, is now available containing the latest developments concerning diphtheria, the blood-serum therapy, the medical and surgical management of mastoid diseases y the most successful treatment of hay fever, the improved com- pressed-air instruments,' vaporizing apparatus, inhalents, etc. Therefore these subjects are given especial prominence. The opinions and experiences of a large number of eminent au- thorities are presented on the subjects of diphtheria, antitoxin therapy, and hay fever. Like works on general medicine and surgery, little space is devoted to the anatomy of the various organs. It is assumed that the reader either has a fair understanding of anatomy or (v) VI PREFACE. possesses such a book for reference.. This fact, taken with the use of the descriptive illustrations, permits the devotion of most of our pages to diseases and their treatment. The new atlas of colored drawings by Professor Politzer is recommended as an aid in these studies. The writer has freely consulted many books and journals, ami desires to fully and frankly acknowledge his very great indebtedness to them. Chiefly among these are the works of Politzer (Dodd's translation), Sajous, Burnett, Gruber, Roosa, Browne, Mackenzie, Ingals, Bosworth, Tuttle, the American Year-book, etc. For generous contributions of valuable figures and plates I am under deep obligations to Politzer, Sajous; Truax, Greene & Company; Holmes, and Krieger, and, for photographing, to Gramm, Coover, and Place. Commendation is due to my assistants: C. L. Enslee, for the laborious task of preparing the statistical table of 15,000 cases from my clinical record-books, and A. T. Haight, for the article entitled " Eye Affections in Relation to Diseases of the Nose." It remains to express my sincere appreciation of the cor- dial co-operation and the artistic execution of the publishers' important part in the work by The F. A. Davis Company. The author indulges the hope that his labor may lighten the task of his readers in acquiring an understanding of the subjects taught. S. S. B. 103 State Stbeet, Chicago, February 7. 1887. CONTENTS. PART I. DISEASES OF THE EAR. CHAPTER I. page A General Consideration of Diseases of the Ear, Nose, and Throat Based on a Study of Twenty-one Thousand Cases 3 CHAPTER II. Examination of Patients . .... . . 12 Instruments and apparatus. Tests for hearing. Recording cases CHAPTER III. Compressed-Air Appliances and their Uses . . . . 24 Accurate methods of treatment with compressed air. High- and low- pressure devices. How to use high pressure safe]}'. The advan- tages of improved air-condensers over rubber bags. Details of treatment with air- meters, or regulators. CHAPTER IV. Methods of Producing and Using Compressed Air . 32 The most useful devices for hand- and water- power pressure. Politzer- ization. Catheterization. Auscultation. CHAPTER V. Diseases of the External Ear 40 Frost-bite. Eczema. Lupus. Gangrene. Epithelioma. Perichondritis. Hsematoma. Cystoma. Intertrigo. Herpes. Pemphigus. Syphilis. Deformities of the auricle. Hypertrophied auricle. Scroll-auricle and associated deformities. CHAPTER VI. Diseases of the External Auditory Canal 50 Inspissated and impacted cerumen. Diffuse inflammation of the external meatus. Furuncles. Parasitic inflammation, or otomycosis. Ex- ostoses. Imperforate meatus. Foreign bodies in the meatus. CHAPTER VII. Diseases of the Middle Ear 62 Injuries of the drum-head. Inflammation of the drum-head. Eustachian tubal catarrh. Acute inflammation of the middle ear. (vii) Vlll CONTENTS. i IIAPTER VIII. page Diseases of the Middle Ear, Continued 74 Acute suppurative Inflammation of the middle ear. Chronic non-suppu- rative inflammation of the middle ear. Hypertrophic, or secretive, catarrh of the middle ear. CHAPTER IX. Diseases of the Middle Eae, Continued 86 Sclerosis, or the adhesive inflammation of the middle ear. CHAPTER X. Diseases of the Middle Eae, Continued 100 Surgical treatment of sclerosis. Mobilization of the ossicles. Incision of the posterior fold of the drum-head. Multiple incisions of the drum- head. Excision of sections of the drum-head. Division of the tensor tympani. Excision of the membrana tympani and ossicles. Stapedectomy. CHAPTER XI. Diseases of the Middle Eae, Continued . 112 Chronic suppurative inflammation of the middle ear. Aspiration of the tympanic cavity. CHAPTER XII. Diseases of the Middle Eae, Concluded . . 122 Sequels of middle-ear inflammation. Granulations. Polypi. Caries and necrosis of the tympanic cavity. Necrosis of the ossicles. Ad- hesions, cicatrices, and perforations of the membrana tympani. Artificial drum-heads. Deafness following suppuration. Tinnitus of purulent inflammation. Cholesteatoma. Facial-nerve paresis and paralysis. Carious processes in the temporal bone. CHAPTER XIII. Extension of Eae Diseases to the Ceanial Cavity ..... ... 136 Meningitis. Subdural abscess. Cerebral abscess. Cerebellar abscess. Surgical treatment of brain-abscesses. Sinus-phlebitis and sinus- thrombosis. CHAPTER XIV. Diseases of the Mastoid Peocess 143 Medical treatment. Indications and preparations for mastoid operations. Instruments required. CHAPTER XV. Tin. M \stoii) Opeeations 155 The simple, or Schwartze, operation. The radical, or Stacke, operation. The modified mastoid operation. Abscess of the neck from middle- ear and mastoid suppuration. CONTENTS. IX CHAPTER XVI. page Diseases of the Internal Ear . . 168 Hyperemia and anaemia of the labyrinth. Inflammation of the labyrinth. Panotitis. Haemorrhage into the labyrinth. Meniere's disease. Leucocythaemic deafness. Syphilis of the labyrinth. Diseases of the auditory nerve. Neuroses of the perceptive apparatus. Hyper- audition. Hyperesthesia. Paracusis. Paracusis Willisii. Sub- jective, sounds, or tinnitus aurium. Nervous tinnitus. Spasmodic noises. Paresis and paralysis of the auditory nerve. Cerebral causes of deafness. New growths of the internal ear. CHAPTER XVII. Diseases of the Internal Ear, Concluded . . 180 Injuries of the labyrinth. Deaf-mutism. Education of the deaf. Hear- ing-instruments. PART II. DISEASES OF THE NOSE. CHAPTER XVIII. Examination and Instruments . . 189 Examination of patients. Instruments. Atomizers. Vaporizers. Sprays. Inhalents. Inhaler. CHAPTER XIX. Diseases of the Nasal Cavities . 203 Influenza. Acute rhinitis, or coryza. Simple chronic rhinitis. Chronic nasal catarrh. CHAPTER XX. Diseases of the Nasal Cavities, Continued 214 Hay fever. The neurotic theory. Uric acid as a cause of hay fever. CHAPTER XXI. Diseases of the Nasal Cavities, Continued 231 Hay fever, continued. Symptomatology. Diagnosis. Prognosis. Abort- ive treatment. Local self-treatment. Anti-uric-acid treatment. Hygienic measures. Symposium of medical opinions. CHAPTER XXII. Diseases of the Nasal Cavities, Continued 243 Hypertrophic rhinitis. Galvano-cautery apparatus. Operations for hypertrophies. Atrophic rhinitis, or dry catarrh. Ozaena. \ CONTENTS. CHAPTEB XXIII. DISEASES OF THE Nasal CAVITIBS, Continued Epistaxls, or nose-bleeding. Mucous polypi. Fibrous polypi. Cystic polypi. Papillomata. Erectile tumors. Cbondromata. Osteo- mata. Exostoses. Rhiuoliths. Vascular tumors. Sarcomata. Carcinomata. CHAPTER XXIV. Diseases of the Nasal Cavities, Concluded ... Tuberculosis of the nose. Syphilis of the nose. Lupus of the Nose. Glanders. Furuuculosis. Anosmia. Parosmia. Deformities and diseases of the nasal septum. Blood-tumors of the nasal septum. Abscess of the septum. Perforation of the septum. Fractures of the nose. Foreign bodies in the nose. Animate objects in the nose. CHAPTER XXV. Diseases OF the Accessory Cavities of the Nose Inflammation of the antrum of Highmore, or maxillary sinus. Ethmoid diseases. Sphenoid diseases. Diseases of the frontal sinuses. Eye affections in relation to diseases of the nose. CHAPTER XXVI. Diseases of the Nasopharyngeal Cavity .... ....... Naso-pharyj^geal catarrh. Atrophic catarrh of the naso-pharynx. Fi- brous polypi of the naso-pharynx. Fibromucous polypi of the naso-pharynx. Malignant tumors. Adenoid vegetations in the vault of the pharynx. PART III. DISEASES OF THE PHARYNX. CHAPTER XXVII. Diseases of the Phabynx 305 Acute pharyngitis, or simple sore throat. Simple chronic pharyngitis. Acute rheumatic pharyngitis. Chronic rheumatic sore throat. CHAPTER XXVIII. Diseases of the Phabynx, Continued 319 throal of measles, scarlet fever, and small-pox. Follicular pharyn- gitis. Membranous sore throat, non-diphtheric. CHAPTER XXIX. Diseases of ire Phabynx, Continued 328 Diphtheria. Pathology. Etiology. Symptomatology. Diagnosis. Piog- CONTENTS. XI CHAPTEE XXX. page Diseases of the Phaeyxx, Continued 339 Diphtheria, continued. Treatment. Examination of diphtheric patients. Isolation. Local and constitutional treatment. CHAPTER XXXI. Diseases of the Phaeyxx, Continued 350 Diphtheria, continued. Serum therapy, or the antitoxin treatment of diphtheria. The production and action of antitoxin. The time and methods for using antitoxin. The dosage. The results of blood-serum therapy. Symposium of opinions and experiences, both for and against antitoxin treatment. CHAPTER XXXII. Diseases of the Pharynx, Continued 373 Tonsillitis. Phlegmonous tonsillitis. Hypertrophy of the tonsils. Ton- sillotomy. Instruments and methods of operating. CHAPTER XXXIII. Diseases of the Phaeyxx, Continued 3^9 Mycosis, or parasitic disease of the pharynx. Concretions in the tonsil. Non-malignant tumors of the pharynx. Adhesions and false mem- branes in the pharynx. Uvulitis. Malformations of the uvula. Tuberculosis of the pharynx. Syphilis of the pharynx. Cancer of the pharynx. CHAPTER XXXIV. Diseases of the Phaeyxx, Concluded . . . 404 Retropharyngeal abscess. Neuroses of the pharynx. Neuroses of sen- sation. Hyperesthesia. Anesthesia. Paresthesia. Neuroses of motion. Paralysis of the pharynx. Burns and scalds of the pharynx. Foreign bodies in the pharynx. PART IV. DISEASES OF THE LARYNX. CHAPTER XXXV. Diseases of the Laeyxx 415 Laryngoscopy. Instruments. Apparatus. Difficulties of laryngoscopy. CHAPTER XXXVI. Diseases of the Laeyxx, Continued 4*21 Acute laryngitis. CHAPTER XXXVII. Diseases of t^e Laeyxx, Coxtixued 428 Croup. Comparison >f true croup with laryngeal diphtheria. Ml CONTENTS. CHAPTER XXXVIII. page Diseases of the Laeynx, Continued . ■ . 435 Intubation of the larynx. Instruments, method, and results. Care and feeding of patients. Tracheotomy. CHAPTER XXXIX. Diseases ^v the Laeynx, Continued 446 Chronic laryngitis. Atrophic laryngitis. Suppurative laryngitis. Ab- scess of the larynx. Granulations of the vocal cords. (Edema of the larynx. CHAPTER XL. Diseases of the Laeynx, Continued . . ............. 459 Neuroses. Spasmodic croup. Anomalies of sensation. Nervous aphonia. Paralyses. CHAPTER XLI. Diseases of the Laeynx, Continued ... 468 Tuberculosis of the larynx. Syphilis of the larynx. CHAPTER XLII. Diseases of the Laeynx, Concluded . . 477 Tumors. Innocent tumors. Papillomata. Fibromata. Malignant tumors. Epitheliomata. Sarcomata. Foreign bodies in the larynx. LIST OF ILLUSTRATIONS. FIG. PAGE 1. Arrangement of instruments and apparatus Facing 12 2. Pynchon's cabinet for instruments, etc Facing 12 3. Author's light-condenser 13 4. Spring-band mirror-holder 14 5. The author's adjustable bracket 15 6. Toynbee's ear-specula 15 7. Gruber's ear-specula 15 8. The author's massage otoscope 16 9. The author's cotton-carrier 17 10. Normal drum-head of right ear 17 11. Normal drum-head of left ear . 17 12. Outer surface of the left tympanic membrane of an adult 18 13. The author's automatic tuning-fork 20 14. Galton's whistle 22 15. Politzer's acoumeter 23 16. The author's original compressed-air meter 25 17. Davidson cut-off 26 18. Hand-dilator and combined air-reservoir and hand-pump 33 19. Hydraulic pump 34 20. Hand air-pump . . 34 21. Air-meter of improved pattern 35 22. Politzer's air-bag 35 23. Buttle's inflator 36 24. The author's improved inflator * 36 25. Eustachian catheter 36 26. Vertical section of the naso-pharynx with catheter introduced into Eustachian tube 37 27. Fixation of the catheter with the left hand 38 28. Toynbee's auscultation-tube 39 29. Gangrene of ear ; mastoid operation 43 30. Hypertrophied auricle 46 31. Alpha syringe 52 32. Author's small powder-blower 54 33. Rupture of the anteroinferior half of the drum-head caused by a box on the ear . . 62 34. Section through the tympanic membrane, malleus, and upper and outer tympanic wall of a decalcified preparation 63 35. Eustachian tube and tympanic cavity 65 36. Radiate vascular injection of the drum-head 69 37. Radiate vascular appearance in acute inflammation of the middle-ear 70 38. Convexity of the drum-head due to pressure from within 74 39. Nipple-shaped bulging of the posterior portion of the drum-head, on the siirnmit of which is the perforation 77 40. Fluid effusion in the tympanic cavity, marked by a bright line 79 41. Circumscribed bulging of the drum-head due to pressure of fluid in the middle ear . . 79 42. Great concavity of the drum-head and foreshortening of the hammer-handle SO 43. Semilunar chalky deposit in front of the handle of the mallet 87 44. Niche of the fenestra ovalis, with the crurse of the stapes, in the normal ear of an adult 87 45. Marked retraction of the drum-head 92 46. Circumscribed depression in the anteroinferior quadrant of the left drum-head ... 92 47. Circumscribed adhesion of the membrana tympani to the promontory underneath the handle of the mallet 92 48. The author's ossicle-vibrator 100 49. Section of the posterior fold of the membrana tympani 101 50. Internal surface of the left membrana tympani 102 51. Vertical section of the external meatus, membrani tympani, and tympanic cavity . . 103 52. Triangular resection of the drum-head 103 53. Middle-ear instruments and handle 107 (xiii) \iv LIST OF ILLUSTRATIONS. PAGE 64 Th6 author's ossicle-hook 108 Politser'e pineette 108 ■tensive destruction of the drum-head 112 57. Pear-shaped perforation of the drum-head 113 'erf oration of the posterior half of the right drum-head 113 -unction of the inferior half of the membrana tympani, laying bare the promon- tory and niehe of the round window 113 irge perforation of the right drum-head 113 t'd. Destruction of inferior half of the drum-head. Globular granulations on the inner wall of the middle ear 115 be author's large powder-blower 118 ti:i. The author's ear-aspirator 121 61 Politser's polypus-forceps 123 The author's middle-ear ease 123 66. The author's eanstie applicator on flexible shank 124 ertical section of middle ear ; drum-head in contact with the inner wall 125 ml-like cords between the lower end of the hammer-ban die and the stapedo-incudal articulation 125 entral perforation of the drum-head and calcareous deposits 126 To. Appearance in facial paralysis, the patient laughing Facing 130 71. Same as Fiir. 70, three months after Stacke operation and treatment with electricity. Facing 130 72. The author's ear-electrodes, attached to band 131 73. Sequestra of dead bone, and the ossicles. Actual size Facing 132 74. Post-mortem section of the temporal bone, showing a perforation of the lateral sinus Facing 132 7"). The author's middle-ear curette 134 76. Horizontal section of the ear 135 77. Interior of base of skull Facing 143 78. The author's aural ice-bag . . . . .- 147 79. Back's mastoid knife 148 80. J. B. Hamilton's scalpel 150 tuck's mastoid chisels 150 82. The author's long mastoid gouges 151 83. Lead-filled mallet 151 84. The author's set of curettes 152 85. The author's mastoid guide 152 86. Mathieu's tongue-holding forceps 152 87. The author's periosteum separator 153 B8. The author's double retractors 153 89. Side-view of a skull, showing opening in mastoid process for Schwartze operation. Facing 156 Schwartze operation Facing 156 91. Horizontal section through right temporal bone 156 92. Opening of the antrum 157 93. Horizontal section through right temporal bone, showing distance between lateral Sinus and external canal 158 B4. Horizontal section through right temporal bone, cut near centre of external meatus 159 Perpendicular section through right temporal hone 160 96. Adhesive-plaster dressing for mastoid wound Facing 161 J7. lane of incision healed two months after a Schwartze operation Facing 161 98. The Stacke operation completed 162 Side of skull, showing Stacke operation Facing 162 100. Vertical section through the ear Facing 162 10L Horizontal section of temporal hone, cut near floor of external meatus 164 102. Six weeks after Stacke operation Facing 164 ppearance two weeks after a modified operation. Healed five weeks after operation. Facing 164 104. Post-mortem section of mastoid process Facing 166 L05. Appearance three weeks after a modified Stacke, and an operation for a neck-abscess. Facing 166 L06. The conical conversation-tube 185 107. The London horn 185 ' lectric [nominator 189 LOO. Lngals' nasal speculum 190 LIST OF ILLUSTRATIONS. XV FIG. PAGE 110. The author's nasal speculum 190 111. Bosworth's tongue-depressor 191 112. Throat mirrors 192 113. White's palate-retractor 192 114. The rhinoscopic image 193 115. Hard-rubber palate-elevator 193 116. Davidson spray 194 117. DeVilbiss universal spray 194 118. Lavolin atomizer 195 119. Truax, Greene & Company's atomizer 196 120. The universal vaporizer 196 121. The globe nebulizer 197 122 to 127. Methods of receiving sprays and inhalents 198 128. The author's camphor-menthol inhaler 201 129. Goodwillie's nasal dilator, or tube 213 130. Nasal synechia Facing 243 131. Posterior view of osseous bridge shown in Fig. 130 Facing 243 132. Flemming cautery battery 245 133. Truax storage battery 246 134. Cautery electrodes 247 135. Cautery knife 247 136. American cautery handle, with windlass 247 137. Hobby's steel snare 250 138. The author's septum-knife 251 139. Webster's nasal saws 251 140. Bellocq's cannula introduced 257 141. Biting curette 259 142. Casselberry's saw-tooth scissors 259 143. The author's nasal supporter 265 144. Hartman's forceps ' 274 145. Dissection showing nasal duct and its relations 282 146. Ducts connecting the nose with the accessory sinuses and the eye 286 147. Tear-gland and drainage 288 148. Mouth-breather Facing 298 149. F. C. Greene's mouth-gag 299 150. Position of child for adenoid operation or intubation ; mouth-gag introduced 300 151. Gottstein's ring-curette 300 152. Diphtheria bacilli 329 153. Diphtheria bacilli 330 154. Streptococcus pyogenes 331 155. The author's tonsillotome, with excised tonsil 383 156. Adhesion of soft palate to the posterior wall of the pharynx Facing 391 157. Destruction of velum palati Facing 397 158. Mackenzie's lateral throat- forceps 411 159. DeVilbiss illuminator 416 160. O'Dwyer's intubation-tubes 435 161. Scale 435 162. O'Dwyer's introducer, with tube attached 436 163. O'Dwyer's extractor 436 164. Roswell Park's aluminium tracheal tube 442 165. Hard-rubber tracheal tubes 442 166. Cohen's sponge- or cotton- holding forceps 452 167. Tobold's set of six forceps, knives, etc 479 168. Mackenzie's antero-posterior laryngeal forceps 480 PART Diseases of the Ear CHAPTER I. A GENERAL CONSIDERATION OF DISEASES OF THE EAR, NOSE, AND THROAT BASED ON A STUDY OF TWENTY- ONE THOUSAND CASES. The following statistical tables represent the records of 21,000 cases treated during the past seventeen years at the Illinois Charitable Eye and Ear Infirmary in Chicago. The first table formed a part of a report made by the author to the Ninth International Medical Congress in 1887 ; the second was compiled for me by my assistant, Charles L. Enslee. A rela- tively small number of unselected cases have been added from the records of my private practice to supply the place of those whose records were incomplete. The first classification was in- stituted for the purpose of establishing a basis of calculation of the influence, if any, exerted by occupation, age, or sex in the causation of ear diseases. The condition of each patient at the time he first presented himself at the clinic is given in order to determine the relative frequency of the different diseases. As is common in charity hospitals, a considerable number of those who applied for treatment belonged to that class of laboring-people who have no definite trade or fixed occupation. In order to facilitate investigation and simplify the tables as far as possible, all those occupations that were closely related to each other in nature and effects were grouped under one head- ing. For example, under the classification of clerks were em- braced salesmen, book-keepers, office employees, etc. ; with teamsters were grouped car-drivers, peddlers, etc.; cooks and bakers were classed together; brass-molders, iron-molders, etc., were classified with iron-workers ; plumbers, gas- and steam- fitters appear together ; such closely-allied occupations as stone- cutters, stone-masons, brick-layers, and plasterers, in which the influences and exposures are very similar, are grouped together (3) 4 DISEASES OF THE EAR, NOSE, AND THROAT. under the head of day -la borers, — a term borrowed from the laborers themselves. The abbreviations employed are: \V. No., for whole number. Ac. for acute inflammation of the middle ear. A.c. s.. for acute suppurative inflammation of the middle ear. ('. N., for chronic non-suppurative inflammation of the middle ear. ('. S., for chronic suppurative inflammation of the middle ear. Ext., for diseases of the external ear. Int.. for diseases of the internal ear. I). ML, for deaf-mutes. P. 1}., for foreign body. In. C, for inspissated cerumen. Fur., for furuncle. Ac S. N., for acute suppurative with a chronic non-suppurative inflamma- tion of the middle ears. An. P., for aural polypus. .M. D., for mastoid disease. X. Ph., for naso-pharyngeal catarrh. Ad., for adenoid growths in the vault of the pharynx. Hy. T.,' for hypertrophied tonsils. Occupation. c < w CJ < 32 6 a Miners . 10 10 10 11 12 13 15 16 19 20 22 22 30 31 38 47 47 58 74 80 84 85 108 232 496 1 1 1 2 2 1 i • l 3 1 2 3 4 12 6 17 27 *3 1 1 1 3 4 2 2 2 2 2 I 5 1 4 u 4 13 19 26 6 9 5 6 8 *8 7 10 9 14 14 10 18 26 26 28 35 55 57 54 33 59 117 300 4 1 1 3 2 2 3 1 3 5 1 4 12 8 3 10 9 12 18 8 11 23 19 39 77 l 5 3 1 4 I 2 5 6 5 3 6 10 6 9 36 60 Firemen ( 'oopers Butchers Packing-house laborers . . Engineers .... . . 1 Cigar-makers Plumbers Boiler-makers Tinners Shoe-makers 1 Bakers Printers 1 Tailors . 1 Blacksmiths Painters • • Sailors ... 1 1 2 Railroad-laborers Farmers . . Carpenters .... 1 2 [ron-workers Teamsters 1 Factory-hands Clerks Day-laborers .... 2 4 6 Totai 1590 85 109 922 279 171 24 GENERAL CONSIDERATION. Summary. 6 Ac. X < * w 'J Ext. ►^ Adult males without occupation . . . 810 1662 557 562 243 276 1590 43 75 35 32 11 11 85 31 03 28 22 21 26 109 485 1070 230 225 41 45 922 197 46 317 106 205 34 232 35 125 26 139 38 279 171 7 27 19 11 8 9 24 1 4 Boys, 6 to 15 years . Girls, 6 to 15 years Boys under 6 years . Girls under 6 years With occupations 6 5 11 8 Total ...... ... 5700 292 300 3018 1494 456 105 35 Percentage of W. No 5.1 5.3 53. 20. 8. 2. 0.0 The combined tables show that, of the 21.000 cases, there are 11,167 patients with occupations, classified under 28 head- ings. Of this number, 3813 had out-door and 7354 in-door work. In the first table a larger proportion would undoubt- edly have appeared as belonging to in-door occupations, had as much care been exercised in eliciting the exact nature of the vocations of so-called day-laborers as was used during the time covered by the second table. About 34 per cent, are out-door and 66 per cent, in-door occupations, or about twice as many in-door occupations as out-door. The largest number of any one class were in-door workers, — 3014 domestic servants. Next in order were about half that number of the out-door class, or 1493 day-laborers. Then fol- low groups of the next highest numbers: 858 clerks, 460 iron- workers, 452 carpenters, 420 factory-workers of all kinds, and 400 sewing-women, — all in-door occupations until we reach the out-door class again in going down the scale. While the great stores and factories furnish a large num- ber of patients, the homes contribute 5615 females, including the servants, seamstresses, and women without occupation, or more than one-fourth the whole number of the combined tables. These facts are significant when we take into account the slight difference between the number of males and females affected under the age of 15 years. Out of 6154 children under 15 DISEASES OF THE EAR, NOSE, AND THROAT. .1 Ml •pv 'I.I * K (I ©* . . lH r- irr 01 03 co 01 ^ © os Jul 00 CM •Soy CMCM . «0 . "* CO 10 00 Tft t- , .TflT^TH OOtHtHt-I-HH tH CM t-i CO ^ § CO •S'OV CM CM . 03 O? CM tH CM . ^ ^ ^ "tf ^ IO CM ■^ ^ T— 1 . . "tf 00 CO CM tH CO CO CM ^■r^l(0i>00CMCO^ T-I T-l CO CO as CM 7. ■•>v CM CM CO . tH T-I CM . CO . CM CO •"* CM "tf CM t- "* ■1 "0V ■^ CM CM CM O O IO . 00 .T*^ ...'*... ^ CO r^ CM . ^ . t^ OS n -'v «r-Tj( .CM . 00 CM T-I . US CM tH . CO CM . . Tf< CO ">* ^ CM O CO tH 00 ■an j •"•■ *& . 03 . . CM . t-I . CM LO ... CM "^ tH $ 7) hi - • - S. fOCXC^CClW^ (M CO O OC©HHl"*l-00 IO - OH- X X X X fc- t- t*< IO 1— O^rHlO- OS CM «r-«ri«THMHH LOt-hCMCMCMO^CO TH CM CM rH tH O <35 CO tH h\* ..."«* ."^ . O0 Tf< T- 1 . CM Ol Ct tH CM . i-H CM t-I 2 jx;i . CM CM CO CM . . X CO T-. IO .00^ 00 . .CMtH . . CMCM . 00 t- . CM OS .CDOO^^CM'* CM CM CO t-h t- CO 00 CO <* "X A\ Xt?i?>XXXCOTjiTl .: 1: - 1? 1- c ci a rt c w t- c « « w t- •* th g m- — Tt< X' rt< © — ' rt< CM -t 1— T- 1-1 t-i T- CO OCMCOCOCMOOCiOOt-OOOT-i OCCic-WHQOWWOSt- TtTHrl t^thOI-OCSOCOt-i . • • : Factory workers .... Farmers Iron -workers Janitors Miners CO TJ co C s i : Bakers ........ Blacksmiths ... Batchers Carpenters Cigar-makers . Clerks Coopers Day -laborers ..... Domestics Fnoinpprs . . . r/ a 5 c/ C .£ a t/ ._ Rail road -laborers Sailors Sewing women . . . Shoe-makers .... Tailors . . ... Teachers i s F- Tinners .... No occupation, males No occupation, females Boys, 6 to 15 years . . Girls, 6 to 15 years Boys under 6 years . Girls under 6 years < Eh O H GENERAL CONSIDERATION. i years there were 1484 boys and 1582 girls between the ages of 6 and 15 years and 1641 boys and 1447 girls under 6 years. Of all these children 3029 were girls and 3125 boys, leaving a difference of only 96 more males than females under 15 years. Between the ages of 6 and 15 years there were 95 more girls than boys. Under 6 years there were 194 more males than females. Sex seems to have no influence in the production or pre- vention of diseases of the ear, nose, and throat. It appears that up to the age of 15 years both sexes suffer nearly equally. Possibly a reason for this may be found in the similarity of the lives and habits of the sexes during this early period. But the classes of society that afford clinical material at the medical charity institutions are such that necessity requires them to abandon the pursuit of an education at about the fifteenth year, and to enter upon bread-earning vocations. Thenceforth the divergence in habits and environments increases. The males are either out-of-doors more than ever or confined chiefly to mercantile houses and factories. The females become domes- tics, clerks, shop-girls, and seamstresses. An interesting question pertains to the relative frequency of diseases of the right and of the left ear, and of diseases of one ear as compared with diseases existing coincidently in both ears. The second table shows that in acute inflammation of the middle ear there is but a very slight difference in the fre- quency of involvement between the two ears, and both ears were affected in 43 per cent, of all the cases. In acute suppuration of the middle ear, again, there is too little difference between the two ears to take into account. In 15 per cent, of all these cases both ears were involved. In the 5809 cases of chronic non-suppurative inflammation of the middle ear the two sides were about equally affected, but a great contrast is now offered in the relative frequency with which both ears are involved in the various middle-ear diseases, for in this instance nearly 82 per cent, of all the cases presented bilateral aural affection. Sufficient importance must be at- tached to these undeniable figures in formulating our prognosis 8 DISEASES OF THE EAR, NOSE, AND THROAT. \\\\en only one ear is already diseased, for it follows, almost as the night the day, that if one ear has become seriously affected, especially with the sclerotic form of dry catarrh, the other falls under the same destructive process. In chronic suppurative otitis media the two ears suffer nearly equally, and it appears that both ears are simultaneously affected in a little more than 60 per cent, of the cases. In 3185 instances of unilateral ear diseases there was an excess of only 23 cases of the right over the left ear. This fact is mentioned particularly because the opinion has often been expressed that one ear was much often er affected than the other, some specialists believing that the right was by far the more frequently diseased. The tables show that about 13 per cent, were afflicted with naso-pharyngeal diseases, but the actual number would be far in excess of this figure. The institution being an eye and ear hospital strictly, not as great prominence has been given to the nose and throat affections as would be desirable, this part of the diagnosis sometimes being entered on the patients' cards instead of upon the record- books. About t 8 q of 1 per cent, had diseases of the mastoid process, which was nearly twice as prevalent in males as in females. Deaf-mutes formed about £ of 1 per cent, of the 21,000 cases. There were three times as many males as females. The largest number of any one class of diseases was 8827 with chronic non-suppurative inflammatory processes of the middle ear, or 42 per cent, of the whole number. Next in numerical order come 3664 cases of chronic suppurative inflam- mation, or 17 per cent. ; and the next highest number 1009 cases of acute suppuration, or 5 per cent. American residences and business houses are heated in cold weather by dry hot air and kept at a temperature of 70° F. or higher. The inmates are subjected to the action of this dry heat, often laden with dust and noxious gases, the greater part of every day. The skin, consequently, is very active in its functions, and kept moist by free perspiration. But, though constant exposure renders the soldier, Spartan-like, indifferent GENERAL CONSIDERATION. 9 to cold and storms, housing the body makes it tender, like the hot-house plant, and sensitive to sudden and extreme changes in the air. After working all a winter-day in a temperature of summer-heat, these people, with the powers of resistance reduced by fatigue and hunger, pass out immediately into a frigid atmosphere, with the temperature perhaps from 40° to 70° F. lower than that of the work-shop. The skin is chilled, the perspiration checked, and a determination of blood to some internal organ occurs. Naso-pharyngeal catarrh is probably the most frequent consequence. This result is aggravated by high winds and the inhalation of dust. In fact, a very large percentage of naso-pharyngeal catarrh is undoubtedly due to the irritating effects of dust, and this, operating in conjunction with cold, damp air, is largely responsible for the wide-spread existence of naso-pharyngeal catarrh among Americans. It is undoubtedly the most prevalent disease in the United States. The importance of this fact is obvious when we consider that so large a number of middle-ear affections originate in naso- pharyngeal inflammation which extends through the Eustachian tube to the tympanum. Critical examination of the throat demonstrates the existence of throat trouble in a large pro- portion of these cases. Hence, whatever causes a catarrh of the nose and throat is interesting to the otologist as a proximate cause of ear disease. The exanthemata are frequent causes of ear trouble during childhood, but youth seems to predispose to coryza, which is often a forerunner of tubal and tympanic catarrh. Children under 15 years of age constitute about 29 per cent., or more than one-fourth of the whole number of cases. Very many of them dated back to attacks of scarlet fever, measles, and the earaches and ;i running-ears " of infancy ; so that a much larger percentage than appears should probably be credited to the period of childhood. Only a small proportion of children were brought for treatment during the acute stage of inflamma- tion. Only about 10 per cent, were acute cases, leaving 90 per cent., or nine times as many, who had not applied for treatment until the inflammation had reached a chronic stage. 10 DISEASES OF THE EAR, NOSE, AND THROAT. Indeed, only 13 per cent, of the adults were seen in the acute stage. The tables show a large percentage of diseases of the ex- ternal ear. Since impacted cerumen may be regarded as a symptom and a consequence of chronic non-suppurative inflam- mation of the middle ear, due consideration should be given this fact in estimating the relative frequency of affections of the middle and of the external ear as shown in the tables. It may be permissible to cite a few facts that do not appear in the statistics, but which, nevertheless, were impressed upon me by a personal study of this class of patients. Although the whole state of Illinois contributed largely to the number em- braced by these statistics, a large majority were residents of Chicago, — a very cosmopolitan city. The foreign element predominates. The nationalities were not recorded except in resident infirmary cases, but the Irish constituted a very large and the French a very small percentage of our clinical material. The north of Europe furnishes a far greater percentage of our population than the southern portions. After considering the nationalities it will not be surprising when it is stated that the blondes exceed the brunettes in number. Another matter of interest to the etiologist, and to the student of sociology as well, was the conspicuous absence of baldness among these people, for cold draughts of air on heads deprived of nature's covering are considered by some authors as being a prolific cause of catarrh. This brings us to a consideration of the last topic of this chapter, — climatic causes. In speaking of climatic conditions as standing in a causative relation to these diseases, it should be understood that reference is had to those atmospheric con- ditions that are characteristic of the vicinity of the Great Lakes and the Mississippi Valley, although they may not be peculiar to it. A sudden great fall of temperature, accompanied with increased humidity of the air, is usually followed by an increase in the number of new patients with acute diseases of the ear, and of chronic cases with acute symptoms. These effects of atmospheric variations occur with such uniformity that we may GENERAL CONSIDERATION. 11 predict an increase or decrease in the number of acute diseases with a reasonable degree of accuracy by observing the meteor- ological variations. Our climate is rugged, but the people born and reared in it do not seem to partake of its robust character. The altitude is low in the Mississippi Valley and the thermo- metric changes are sudden and great. It is not unusual for the thermometer to fall 20° or 30° F. or more in a few hours. Indeed, cold waves sweep suddenly over the country in summer- time, cooling the heated atmosphere so quickly and so thor- oughly that one must needs change from summer to winter clothing with haste or suffer from the chilling winds. Add to these causes of great circulatory disturbances the irritating effects of constantly-inhaled dust, which the ceaseless winds keep in never-ending motion, and the problem of the prev- alence of naso-pharyngeal, tubal, and tympanic catarrh in our climate is, in a great measure, solved. CHAPTER II. EXAMINATION OF PATIENTS. The examination of patients should be conducted so systematically that no discoverable pathological process can escape detection. Beginning with the right ear, both ears, both nares, and the throat should be minutely inspected. Patients often direct the surgeon's attention to one ear and re- mark that there is no trouble with the other, when examination reveals that both are affected in different degrees. The ex- aminer should not be misled, but should investigate for himself; otherwise lie is not in a position to do credit to himself or his art or do justice to his patron. A most convenient arrangement of instruments, illumi- nating and compressed-air apparatus, etc., is shown in Fig. 1, illustrating a corner of the author's private-treatment room (Professor Adam Politzer's portrait in the background). Fig. 2 shows Edwin Pynchon's cabinet for instruments, medicines, and sprays. The aurist should sit facing the right side of his patient to begin the examination, with the light immediately behind the patient's head and on a level with his ear if it is an adult. In the case of a child the light should be on a level with the physician's eye. Time will be economized and labor facilitated by the use of an armless revolving-chair (Fig. 1) for the patient. The seat should be easily raised and lowered by a supporting centre- screw, fitted with sufficient nicety to prevent a rocking motion. The back should be unyielding and only high enough to sup- port the patient's back beneath his shoulders. After examining the right ear neither the physician nor the patient need rise to bring the left ear into the field of vision, for the patient's chair is easily turned half-way around, and the positions are correct to proceed, the lamp then resting in front of the patient. d'2) A 111! • ^ ^ ■ r akll i E 1 We; ' Jj B^TF^Ij ■*>^ M k JBL ■ • 'D MlRKOR-IIOT.DER. EXAMINATION OF PATIENTS. 15 contained in a cylinder to which is attached forty-six centi- metres (eighteen inches) of soft-rubber tubing and a diminutive air-syringe. The apex of the funnel is covered with a section of soft-rubber tubing to allow of its being fitted hermetically \:'^./.:~:.7t:'Z-Zu: ::!:Tu:::!^:.,ir7m ^a.- Fig. 5.— The Author's Adjustable Bracket. into the external auditory canal without causing discomfort. The mirror focuses the light upon the drum-head, and the syringe alternately rarefies and condenses the column of air in the air-chamber and meatus. The lens in the eye-piece gives a 1RAUX, 6BEENE k CO. O O o Fig. 6.— Toyxbee's Eak-specula. OO o Fig. 7.— Gruber's Ear-specula. clear view of the drum-head and mallet under brilliant illumi- nation and passive motion. By holding the otoscope with the axis of its cylinder at a right angle to the source of light, the rays are projected upon the drum-head. The easiest method is with the operator standing in front and a little to one side of 1() DISEASES OF THE EAR, NOSE, AND THROAT. the patient, the otoscope in the left hand for the right ear, and the right hand with the pump on the top of the patient's head. The position is reversed for the left ear. As soon as the light is thrown through the funnel the otoscope must be held steadily in its relation to the lamp, and if the drum-head is not in the field of vision the hand upon the patient's head must tip or turn his head until the drum is brought into view. Now the sight is fixed upon the hammer, while the piston-rod is drawn out- ward sufficiently to produce an outward excursion of the drum- head. Then it is pushed inward to condense the rarefied air and move the membrane inward. While these movements are iG.8.— The Author's Massage Otoscope. being effected it is observed whether the mallet moves with the drum-head or not, and, if it does, how much freedom of move- ment is present as compared with the normal mobility. In i some old cases of sclerosis the mallet remains entirely motion- less, while the membrane about it vibrates. In the normal ear both move freely in response to every inward and outward motion of the air-piston. No more force should be applied than is necessary to obtain the natural excursion of the drum-head and mallet, and ordinarily no discomfort is caused unless the funnel is pressed very firmly against the canal-wall. If a deep blush overspread Shrapnell's membrane and the mallet, the procedure should EXAMINATION OF PATIENTS. 17 cease for the time, so as not to occasion too great hyperaemia. The forehead-mirror is not used with this instrument, since it contains its own mirror. Care mnst be taken to not allow the fingers to shade the reflector. Cotton-carriers are best made of soft silver, with round, twisted handle and roughened tip to engage the cotton (Fig. 9). It should be very delicate, so as to consume as little space as possible in addition to the cotton twisted upon it. In many Fig. 9.— The Author's Cotton-carrier. instances cerumen or discharges have to be removed before the drum-head can be inspected. The cotton-carrier usually suf- fices, but the beginner must be reminded that the drum is more superficial in infants than in adults, and in no case should the membrana tympani be bruised. The novice ought to accustom himself to the appearance of the normal drum by inspecting patients who have healthy ears. Students may profitably study each other. The healthy Fig. 10. -Normal Drum-head of Right Ear. (After Politzer.) Fig. 11.— Normal Drum-head of Left Ear. (After Politzer.) drum-head (Figs. 10 and 11) has a pearly-blue tint, is trans- lucent, lustrous, and always presents a triangular reflection of light, the apex of which is at the lower extremity of the mallet- handle. This luminous triangle extends downward and for- ward toward the periphery of the antero-inferior quadrant of the membrane. The long leg of the anvil can often be seen extending downward and backward to articulate with the stirrup, the posterior leg of which is sometimes visible running 18 DISEASES OF THE EAR, NOSE, AND THROAT. upward and backward, both together forming a V-shaped figure posterior to the upper portion of the hammer-handle. Ex- tending from the short process of the mallet, which is a yellow,* dot-like projection of the upper end of the handle, are two nearly horizontal folds stretching forward and backward to the peripheral attachment of the membrane and separating the tense lower section from the membrana fiaccida, or ShrapnelPs mem- brane, above (Fig. 12). For convenience of description the drum-head is divided into four sections by a projec- tion of the axis of the handle of the mallet to intersect the circumference of the membrane above and below and an hori- zontal line intersecting the drum-head at its centre. Diseased appearances are de- scribed in their proper chapters. Tests for Hearing. s ms s Fig. 12.— Outer Surface of the Left Tympanic Membrane of an Adult, Enlarged Three and One-half TI3IES. (After Politzer.) v, segment of the tympanic membrane lying in front of the handle of the malleus ; h, posterior segment of the tympanic mem- brane ; s, s, Prussak's striae, passing from the short process of the malleus to the spina tymp. post, et minor; ms, membrana Shrapnelli. It is difficult to test the hearing of one ear in such a manner as to exclude entirely the perception of the test by the other, except in the employ- ment of very delicate sounds, like the ticking of a watch. Even this ticking may be heard by the opposite ear when it is normal. The watch-sounds are the most constant in intensity, the most convenient at hand, and therefore the most universally used. The same side of the same watch should always be employed, since the variations in pitch and volume are great in different watches, and there is sometimes con- siderable difference in the loudness of the sounds emitted from the opposite sides of the same watch. Many tests should be made with adult persons of normal hearing to fix the average hearing-distance for any test-watch. This distance EXAMINATION OF PATIENTS. 19 usually varies from 30 to 60 inches (76 to 152 centimetres), and fixes the denominator of the fraction that expresses the hearing-power of any tested ear. The number of inches or centimetres at which the watch is heard gives the numerator. For example : A patient hears my 30-inch (76 centimetres) watch only 10 inches (25 centimetres) with his right ear and only 6 inches (15 centimetres) with his left. We record the watch-test as follows: H. D. R., £# (ff); H. D. L., ^ (H)l which reads : Hearing-distance for right ear is -J-J, or ^ of the normal ; for the left ear, ^\, or ^ of the normal distance. During the test the patient must keep his eyes closed, to eliminate the element of imagination. The watch should always be brought slowly from a distance toward the ear until the patient indicates that he distinctly hears the sound. This process needs to be repeated several times until it is demon- strated beyond doubt that he perceives the sound at the same point repeatedly. If the watch is not heard by bone-conduction it is brought into contact with the auricle, and if heard there the hearing is expressed as follows: -£$ (y%), meaning contact for the watch. If not heard until pressed against the mouth of the meatus, it is recorded thus : ^ (fir)? — pressure for watch. In case the watch cannot be heard at all it is written : ■£$ (yV). In young persons it can be heard by bone-conduction in contact with the mastoid process, upper teeth, forehead, etc., but it is not likely to be perceived from these points of contact by persons over 40 years of age. Great patience is required in testing chil- dren's hearing, for they quickly answer in the affirmative whether they hear the test-sound or not, especially when they can see the source of sound. Tuning-forks are necessary in making a differential diag- nosis between diseases of the transmitting and the receiving- apparatus, and in cases where the watch-sounds are not heard. If but one fork is used it is better to employ one of 512 vibra- tions per second, — the universal standard of pitch. This is C one octave above middle C of the piano. It gives off fewer overtones, or harmonics, if the ends are rounded than if square, 20 DISEASES OF THE EAR, NOSE, AND THROAT. and if the vibrations are caused by an automatic hammer attachment (Fig. 13), producing a moderate and unvarying- blow. Some are made with sliding clamps to prevent overtones and to raise and lower the pitch. The fork-test is made by air-con- duction similarly to the watch-test. For bone-conduction it is placed with the end of the handle resting on the mastoid, vertex, upper teeth, or fore- head, with the shaft at a right angle to the bone-surface. The distance is recorded in terms of inches or metres, and the duration of the perception of sound is taken in seconds. Knowing the average distance and duration for a given fork, the amount of loss or gain in the hearing-power can be quite accurately recorded. Hartmann's set of fiYe forks are tuned to 128, 256, 512, 1024, and 2048 vibrations per second. They are the C's of four octaves upward, beginning at the C below middle C of the piano. In the fork-test especial care must be exer- cised to ascertain that the patient dis- tinguishes between the musical note and the mere tactile perception of the mechanical vibrations. The latter can be perceived by the fingers as well as by the skull. The percussion-stroke must also be distinguished against. The fork must not be held with an edge of its branches opposite the meatus ; and the fork should not be brought to the meatus from before backward or from above downward, otherwise the interference of sound- waves in those positions extinguishes the sound. Weber's Test. — In normal ears the fork is heard better V Fig. 13.— Tiik Author's Auto matic Tuning-fork. EXAMINATION OF PATIENTS. 21 when ill contact with the skull if the auditory canals are closed. If one ear is closed by the ringer the sound is intensified. This phenomenon is probably due to increased resonance of an inclosed space and obstruction to the exit of sound-waves. This has been observed in adhesions, when the middle ear con- tained fluids, and when the drum-head was relaxed. Rhine's Test. — Air-conduction is superior to bone-conduc- tion normally. The fork is heard before the meatus twice as long as on the mastoid. When the vibrations cease to be heard on the bone, if the fork, yet vibrating, is brought to the mouth of the meatus, it will again be heard by the normal ear. If the fork is heard longer by bone there is trouble in the canal or middle ear. If the hearing is impaired equally for air- and bone- conduction, there is labyrinthal trouble. Lesion of the transmitting apparatus is shown by (1) gradual loss of percep- tion of both lowest and highest notes ; (2) by bone-conduction becoming relatively better than air-conduction. Labyrinthal disease is characterized by (1) no alteration in the relative acuteness of perception of sound by air and bone, both being diminished ; (2) by deafness for some tones, generally the higher. Bing's Test. — After the sound of the tuning-fork vibrating on the median line of the vertex or forehead ceases to be heard, if the external canal is then closed by the finger the sound will be again perceived for a time by the normal ear. If this time is too brief, it indicates trouble in the transmitting apparatus. If this interval of secondary perception is normal, an existing ear disease must be referred to the labyrinth or nervous centres. GelWs Test. — The mobility of the stirrup may be deter- mined by condensing the air in the external meatus while the tuning-fork is vibrating on the head. If the stirrup is movable the sound of the fork is heard less distinctly or not at all during condensation, and dizziness or even vertigo may result. The condensation of the air may be produced by the pneumatic otoscope (Fig. 8) or by a rubber bag with an olive nozzle. Galton's Whistle. — This is useful in determining the loss of perception for the highest notes in cases of bilateral ear 22 DISEASES OF THE EAR, NOSE, AND THROAT. diseases. If one ear is affected but little or not at all, the whistle-sounds can scarcely be excluded from it. This instru- ment (Fig. 14) has a compass of about three of the highest octaves. Politzer's Acoumeter. — This is an instrument of precision, which can be heard at a distance of forty-nine feet (fifteen metres) by the normal ear (Fig. 15). It is used very much like the watch directly opposite the opening of the canal, and the hearing-distances are recorded similarly to those of the watch. It is held by the thumb and index ringer resting in the semicir- cular plates, the thumb below, while the percussion-hammer is struck with the second finger. The cylinder which it strikes is tuned to C. To test bone-conduction the metal disc projecting from the perpendicular column is placed in contact with the Fig. 14.— G Alton's Whistle. mastoid process or the temple, while the meatuses are closed. I have observed that in sclerosis a patient may not be able to hear the acoumeter by air-conduction, although he hears all of Hartmann's forks. Speech-test. — This would be the ideal test were it not that no two voices are of the same pitch, volume, and timbre or quality. Indeed, the same voice may vary greatly at different times, and even at the same examination. Yet an excellent idea of the amount of usefulness still retained by the organ of hearing can be demonstrated by the speech-test. It is custo- mary to choose words varying greatly in the relative preponder- ance of vowel and consonant sounds, such as the names of different cities and states, and to request the patient to repeat these words after the examiner. In order to eliminate the possibility of lip-reading the patient is required to keep his eyes EXAMINATION OF PATIENTS. 23 closed during the examination. Since there is a tendency to use the same names repeatedly, in which case patients may introduce the uncertain element of guessing, it is better to employ numerals. This gives a much wider range of sounds and lessens the chance of repeating the same sounds in the same order. Whispered speech is also used in addition to the low and loud tones. In advanced sclerosis and labyrinthal affections whispered speech cannot be interpreted. Vowels are heard much farther than consonants, but both should be used in the examination. The test should be made with each ear separately while the opposite one is kept closed. In unilateral deafness a test should be made with both ears sealed with the moist fingers ; if then the sound is heard as well Fig. 15.— Politzer's Acoumeter. as before, it is demonstrated that, the sound was perceived by the normal ear. Music is heard much better than speech. Many persons with greatly impaired hearing, unable to understand a lecture or sermon or the drama, can derive pleasure from an orchestra or opera. A record of every case ought to be kept in a convenient book for that purpose. The following headings indicate the method pursued by the author, the details being worked out as su^orested bv the characteristics of each case : — Date. Occupation. Particular Lesions. Xame. "Residence. Results of Tests. Age. History. Complete Diagnosis, Sex. Duration. Cause. Treatment. CHAPTER III. COMPRESSED-AIR APPLIANCES AND THEIR USES. By a series of experiments with the compressed-air gauge I have found that the maximum amount of pressure that can he ohtained with a Politzer air-balloon of the capacity of eight fluidoimces is 6 pounds ; with the six-ounce bag the pressure may be made to reach 10 or 12 pounds. The difference in favor of the smaller bulb represents the greater advantage one has in grasping a small object. This amount was the maximum obtainable by an unusually strong hand, accustomed for years to compressing air-bags handled at the greatest advantage for leverage, — that is, with the larger end of the balloon between the thumb and strongest fingers, and the tapering end under the third and fourth, or weakest fingers. As the reverse method is practiced by many aurists, much less force than 6 and 10 pounds must result. Politzer speaks of ten- and twelve- ounce bags which are manipulated in Vienna by pressing them against the operator's side, but they are not in our markets. The Gruber balloons, with the opening or air- valve at the larger end, might possibly accumulate more force than I have mentioned, by repeatedly compressing them, but, on account of the valves being imperfect or soon becoming useless, I have discontinued their use. Professor Gruber himself prefers the bulb having a perforation in the end to be covered and compressed with the thumb. I have not experimented witli this kind, for one could not be found. The rubber bulb usually supplied by the Davidson Com- pany for hand-sprays and inflators can be made to exert 15 or even 18 pounds, but not by a single compression. However, it is not practicable to employ more than 15 pounds with the T 3 g- incli rubber tubing ordinarily supplied with inflators. A higher pressure distends it, and 18 pounds will rupture it with a loud report. The thick, firm, white tubes accompanying the De (24) COMPRESSED-AIR APPLIANCES AND THEIR USES. 25 Vilbiss atomizers will stand more, for I have tested them with 45 pounds without even distending them. The force necessary to spray the nose and throat is not great. Eight pounds will project continuous sprays of watery solutions or lavolin with sufficient force from the Davidson atomizer. About 12 pounds' pressure is needed to produce a continuous and copious lavolin-spray from the De Vilbiss atomizer, and it requires 30 or 40 pounds to throw a spray of unheated glycerole of tannin. Fig. 16— The Author's Original, Compressed-Air Meter. In adapting the improved compressed-air apparatus to the treatment of the ear the author has endeavored to devise some means of determining and controlling the force and volume of air, or the dosage. As the illustration above (Fig. 16) will show, I have accomplished this by placing a pressure-gauge between two valves on the escape-pipe of the air-receiver. This arrange- ment utilizes the gauge for registering not only the air-pressure in the reservoir, but also the force of the current of air while it 26 DISEASES OF THE EAR, NOSE, AND THROAT. is escaping at the cut-off of the treatment-tube. The cut-off that has proven most satisfactory is known as the Davidson (Fig. 17). The meter is used as follows : By opening the outer, right- hand valve marked 1, by turning the wheel to the left one- fourth of its circumference, pressing the thumb-valve of the cut-off, and opening valve 2, gradually you may obtain any number of pounds' pressure desired at the cut-off, — from 1 to 100. To use 10 pounds: with the cut-off and valve 1 open, turn the valve 2 until the index needle runs up to 10. As long as the cut-off remains open, the needle indicates 10 pounds. If you close the cut-off the needle rises to indicate the whole number of pounds in the reservoir. Now, if you fit a spray-producer to the cut-off and open it, the first impulse of the column of air, which is small in volume, is expended in filling the atomizer and starting the spray. In using the nasal bulb of the inflator (Fig. 24) for treating the ear the first impulse is expended in filling the nasal and superior pharyngeal cavi- ties in addition to inflating the middle ut-off. ear - The volume of air is so small that the needle drops down to 10 at once and remains there as long as the cut-off is kept open. If no more than this amount is desired the cut-off should be opened before the current is turned on and valve No. 2 should be slowly opened until the needle indicates the number of pounds required. No greater pressure will then be exerted unless the cut-off valve is closed. When it is desired to interrupt the air-current for the purpose of producing movements of the membrana tympani and ossicles, or to throw jets of volatilized medicine or sprays into the tympanic cavity, it is a simple matter to control the pressure in this way. Let us assume that we want to use, with the nasal-tipped inflator I have adapted to this purpose, 3 atmospheres, or about 45 pounds. Valve 1 being opened, apply the cut-off to the nasal bulb containing the medicine on sponges; open the cut-off; turn on 20 pounds with wheel 2 and COMPRESSED-AIR APPLIANCES AND THEIR USES. 27 then close the cut-off. The needle rises. Now, if the inflator is inserted into the nostril with the patient's nose firmly closed and cheeks fully distended, the instant the cut-off is opened the needle runs down to 20. Close the cut-off and the needle mounts to 45 pounds. Open the cut-off at that moment and the needle descends again to 20 ; close the cut-off and the needle rises ; the instant it touches the 45 pounds' mark open the cut-off again and so on ; repeatedly opening and clos- ing the cut-off will give repeated impulses at any given pressure. The resistance offered by the sponges is small, — less than one-third of an atmosphere. A little practice will enable any one to measure the doses skillfully and to give effective treatments without fatigue. If very rapid interruptions are required, valve 2 should be opened more freely than in the example given. For 45 pounds' maximum pressure about 30 pounds should be allowed for the uninterrupted current. Experience with this method indi- cates that not more than 60 interruptions per minute should be made in order to produce perceptible vibratory movements of the drum-head and ossicles. The dose of air for ear treatment varies greatly in different individuals. While 15 pounds might endanger the continuity of an infant's drum-head or one greatly weakened by disease, or the thin cicatricial membranes closing old perforations, I have often applied from 60 to 80 pounds to old, thickened, and hardened drum-heads without rupturing them. It is evident that if it require 50 pounds in some cases to propel sprays into the middle ear, it follows that in such in- stances rubber air-bags are insufficient, for they do not average more than 6 to 15 pounds. But with high pressure only a small volume should be used. I would propose the following rule to keep the operator within the limits of safety : The higher the pressure, the lower the volume should be. If the density of the air is greater than one wishes to use, even with a minute volume, it is easy to avoid the high pressure when using the nasal-tipped inflator, by leaving the opposite nostril 28 DISEASES OF THE EAR, NOSE, AND THROAT. open during the first impulse, until the needle descends to the proper point. This allows the surplus air to escape by the opposite nostril. The same purpose is accomplished with the catheter by holding the catheter-tipped inflator (Fig. 16) a little withdrawn from the mouth of the catheter while the cut-off is first slowly opened. The surplus pressure then escapes at the junction of the inflator and catheter. The volume should be proportioned to the density with care in cases of atrophied soft palate, so as not to strain the muscles of the throat by too powerful inflations, especially if they are subject to rheumatic sore throat. It serves a convenient purpose to instruct patients to raise one or both hands every time they feel one or both ears inflated. This obviates the necessity of frequently using the auscultating tube. The warnings against the danger of rupturing the mem- brana tympani by politzerization have been freely sounded. The author has never ruptured a drum-head by compressed air, while he has seen a considerable number that were torn or perforated by blows on the ear. Even in men employed in cais- sons of tunnels, bridges, etc., where they are compelled to work in an atmosphere condensed under a pressure of 40 to 60 pounds, it is rare to find a ruptured drum-head. This may be owing to the fact that they are instructed to innate the ears so as to equalize the pressure on both sides of the membrane. In this connection it must not be forgotten that there is always the natural atmospheric pressure of nearly 15 pounds on the outer surface of the drum. Notwithstanding this, an eminent otol- ogist has asserted that drum-heads have been lacerated by Po- litzer's method. Professor Politzer says: "During thirteen years only four- teen cases of ruptured drum-heads are known. In the case of a normal membrana tympani a pressure of 45 to 60 pounds is required to cause rupture. In treatment, however, we apply only a pressure of about 8 pounds." If there were any fear of rupture, it could probably be prevented by firmly pressing the tragus into the external meatus. COMPRESSED-AIR APPLIANCES AND THEIR USES. 29 As compared with the Valsalvan method of auto-inflation, the application of medicated nasal-tipped inflators as I have fitted them to the compressed-air apparatus makes an effective topical application of various medicaments possible without any active exertion on the part of the patient. In the Valsalvan ex- periment there is no medication of the middle ears, but simply a mechanical effect of moderate pressure and a probable conges- tion resulting from the straining effort. A. Hartman has shown that 4 to 8 pounds' pressure by the Valsalvan method is required to bulge forward a healthy drum-head. In numerous experi- ments the pressure averaged from 20 to 26 pounds in males and from 14 to 22 in females; but owing to swelling of the Eustachian tube or contained secretions this experiment often fails. The unwisdom of advising patients to practice the Valsal- van experiment has often been demonstrated by individuals who have come under my observation with a history of rapid failure of hearing owing to their habit of carrying the aurist's instruc- tions to excess. Politzer's method is far preferable. He says : " The press- ure for the application of my method in practice varies, as a rule, between 15 and 60 pounds." A decided advantage to both patient and operator, in the adaptation of the inflator to the compressed-air apparatus, lies in the fact that it renders it possible to treat most aural patients without the Eustachian catheter. The sponges of the inflator may be saturated with solutions of various remedies in lavolin, and sprays of these medicines can be propelled through the nose and Eustachian tubes into the middle ears with ease and certainty in the majority of cases. This diminishes the danger of syphilitic infection and of irrita- tion of the Eustachian orifices by the catheter. Gentle pressure will often accomplish this. Indeed, pa- tients sometimes feel a spray enter the ear from an ordinary hand-atomizer, especially when the cheeks are distended. By turning on the current of air gently and gradually increas- ing it, the permeability of the tube may be re-established by 30 DISEASES OF THE EAR, NOSE, AND THROAT. a weak air-pressure more easily than by a sudden, forcible current. In practicing this method I have usually found the results most satisfactory when the patient assisted by inflating the cheeks and keeping the lips firmly closed. At the instant the nasal cavities become filled from the inflator the velum palati and base of the tongue press automatically upward and back- ward, completely closing the post-nasal space. When the effort to inflate the middle ears with air or lavo- lin-jets alone fails, it can be made to succeed by adding 6 or 10 drops of sulphuric ether to the sponges in the inflator. The instant the ether enters the ears there is a decided sensation of coolness, followed by a glow of warmth. The stimulating effect can be seen also in the injected condition of the malleal plexus of vessels soon after the treatment. There are some instances in which the ears are more readily inflated during the act of swallowing. It has been suggested that these forcible air-currents might convey discharges into the mastoid cells, but Dr. Michael has '' proved that, especially with the application of strong currents of air, the secretion in the tympanic cavity is always propelled into the external meatus and not into the mastoid process." Occasionally one sees a case in which the current of air from the nasal-tipped inflator fails to open the Eustachian tube. Probably the anterior lip of the orifice of the tube is pressed by the air more firmly than ever against its fellow, closing it like a valve. A case of tubal stenosis resisted 90 pounds with the nasal bulb, but 50 pounds' pressure carried a spray into his middle ears through the catheter. Treatment by the catheter is accomplished with the inflators already mentioned, the catheter-tip being substituted for the nasal bulb. The sprays are thrown through the catheter in interrupted jets without imparting painful movements to the catheter, which is well nigh impossible in the practice of infla- tion with the air-bag fitted with the hard-rubber tube which is inserted directly into the catheter, and without any intervening flexible tube, as the custom is in Vienna. COMPRESSED-AIR APPLIANCES AND THEIR USES. 31 Proper precaution should be taken to prevent dust from entering the air-reservoir, although by the author's methods all air entering the ears is filtered and medicated. Finally, these methods make the middle ears nearly as accessible as the nose and throat for treatment with the various volatile remedies and sprays. CHAPTER IV. METHODS OF PRODUCING AND USING COMPRESSED AIR. For a considerable time I have been using a new kind of instrument called a hand-dilator in connection with the com- pressed-air receiver, and the results have been so satisfactory that I have introduced it into all of my clinics. This instru- ment and process of administering aeriform fluids, although used by a few physicians since 1888, appear to be little known. The hand-dilator (Fig. 18) is not only different in construc- tion, but also in operation, from the various kinds of spray-pro- ducers or nebulizing inhalers. The atomized product projected by it is not properly a spray or a vapor until it expands in the open air. It is so fine, indeed, that before it leaves the glass container the eye cannot discern it. After its exit from the nozzle it expands into a beautiful floating mass that is compar- able to the most delicate undulating cloud. This fine nebula, which is produced and retained until administered under a higher pressure than hand-bulbs afford, may be impregnated with volatile or non- volatile medicaments. While making some experiments with the dilator I dis- covered that medicines three or four times stronger than patients would tolerate from the ordinary atomizers could be thrown into the respiratory passages, and even into the middle ear, without evoking any disagreeable symptoms. No smaller pressure than 20 pounds or more should be employed in order to propel the nebula in sufficient volume and with enough force to dislodge tenacious secretions or crusts, to impress the nebulized remedies on the diseased surfaces, and to dilate the Eustachian tubes, in- flate the middle ears, or to open up stenosed bronchioles and occluded air-cells. While a pressure of 20 pounds may be sufficient, no injury has followed the employment of a much higher pressure, as the excess escapes from the lips. The combined pump and receiver is a very practical and economical form of apparatus where the pumping must be done (32) PRODUCING AND USING COMPRESSED AIR. 33 by hand, it being comparatively easy to obtain 50 pounds. It is provided with a regulating meter- valve for controlling the pressure by the method described in a paper read by me before the section on Otology and Laryngology of the American Med- ical Association at Detroit in 1892. Any spray or inflator can be attached to the cut-off and employed manner. in the usual Ear Treatment. The hand-dilator can some- times be substituted for my im- proved middle-ear inflator for projecting strong medicaments into the ear. With the latter I never use a stronger solution of the camphor-menthol than 3 per cent., while with the dilator I have medicated the tympanic cavity with the 10-per-cent. solution in lavolin without any unpleasant results. The nozzle is fitted into one nostril, while the other is held tightly closed, as in polit- zerization. The cheeks are fully distended with air, and the cur- rent is turned on from the com- pressed-air reservoir. The in- stant the nebula is felt to enter the ear the patient should raise his hand. Then the current is repeatedly interrupted by the cut-off so as to alternately fill the middle-ear with the nebula and allow it to escape. This pro- duces not only inflation of the tube and tympanum and motion in the ossicles and drum-head, but it medicates their mucous flg. 18.— hand-didator and combined Air-reservoir and Hand-pump. 34 DISEASES OF THE EAR, NOSE, AND THROAT. lining, on the same principle that we observe in medicating the mucous membrane of the eye, or the nose, or throat, when it is diseased. This, combined with the aid of the massage otoscope, provides an ideal treatment for dry catarrh of the tympanic cavity. When we reflect that middle-ear diseases are largely consequent upon an inflammatory action in the nose or throat, it becomes apparent how neces- sary it is to employ a thorough medic- inal as well as mechanical treatment addressed to this section of the respira- tory system ; otherwise we cannot hope to effect a permanent improvement. In connection with the use of com- pressed air the question of air-pumps is an important one. In a city with w a t e r- w o r k s the double-act- ing hydraulic pump is the best, since it gives about double the amount of pressure obtained by the single-acting pump (Fig. 19). It requires to be cleansed occasionally, or it fails to afford the required pressure. The maximum of pressure to be had in Chicago with a compound hydraulic pump averages about 45 pounds, — an amount sufficient ordinarily for the aurist, for the air is replenished as fast as it is withdrawn. In the country the surgeon must be satisfied with the hand-pumps (Fig. 20), unless he provides an elevated water-reservoir with sufficient head to furnish the pressure. The combined hand-pump and reservoir made by the Owens Brass and Copper Works, of Chicago, is Fig. 19.— Hydraulic Pump. Fig. 20.— Hand Air-pump. PRODUCING AND USING COMPRESSED AIR. 35 very convenient (Fig. 18). The pump is contained within the reservoir, which is supplied with an air-gauge, treatment-tube, and cut-off. The whole outfit weighs only fourteen pounds, which makes it conveniently portable. Another beautiful apparatus is manufactured by the Cleve- land Faucet Company. It is supplied with a modification of the author's air-meter that registers very accurately the pressure at the will of the operator and keeps it uniformly at any given pressure for which it is set (Fig. 21). Below 30 pounds it Fig. 21.— Air-meter of Improved Pattern. Fig. 22.— Politzer' s Air-bag. operates to a nicety. Pressure above this point can be used nearly to the amount contained in the reservoir, but not with an equal accuracy of regulation. Another excellent modification of the Bishop air-regulator is made by the Owens Company, of Chicago. Politzerization. — The aurist who is not provided with a compressed-air apparatus should possess a Politzer air-bag, and it is well to have one at hand to take the place of the air-pump should it fail to work. The Politzer bag (Fig. 22) is fitted with a nasal tip joined to the bag by eight inches of soft-rubber tube. 36 DISEASES OF THE EAR, NOSE, AND THROAT. One should also have a Buttle inflator (Fig. 23) fitted with hoth nasal and catheter tips. In manipulating these the same rule should be observed as in the use of the author's compressed-air inflator (Fig. 24). The axis of the nasal bulb should be par- Fig. 23.— Butti.e's Infi-atok. ailed to the plane of the floor of the nose. The object is to throw the column of air in the direction of the Eustachian ori- fice — not toward the nasal duct, through which the air is some- times forced, nor toward the frontal sinus. The Politzer bag should be grasped with the larger end between the thumb and Fig. 24.— The Author's Improved Inflator. stronger fingers, so as to be able to exert the greatest force when it is necessary. The rubber tube intervening between the nasal or catheter tip and the bag takes up the motion imparted to the bag by the hand and prevents painful jerkings of the tips and the catheter. Especially in the use of the catheter this is an Fig. 25.— Eustachian Catheter. important matter, and may prevent not only injury to the nose, but irritation or contusion of the Eustachian tube. The six- or eight- ounce bags are preferable to the larger sizes. The eight- ounce bag is the most useful for all purposes, and the rubber should be fresh, soft, and of the finest quality. PRODUCING AND USING COMPRESSED AIR. 37 Catheterization. — The soft-silver catheters are the best (Fig. 25). They can be easily bent to accommodate any irreg- ularities in the nasal passages or in the vicinity of the Eusta- chian tubes. It is desirable to have three sizes. As large a calibre as can be introduced without causing discomfort should be employed. To introduce the catheter, the beak of the in- strument is placed on the floor of the nose just posterior to the Fig. 26.— Vertical Section of the Nasopharynx with the Catheter Introduced into the Eustachian Tube. (After Politzer.) a, inferior turbinated bone; 6, middle turbinated bone; c, superior turbinated bone ; d, hard palate ; e, velum palati ; /, posterior pharyngeal wall ; g, Rosenmiiller's cavity ; h, posterior lip of the orifice of the Eustachian tube. skin-lined fossa at the entrance to the naris. At the first step, the handle is depressed so that the convexity of the beak will not hurt the arch of the nasal opening, but as soon as the beak rests on the floor the handle is raised and at the same time carried onward, bringing the main axis of the catheter to a parallel with the floor. As the instrument enters the nose it must not be forgotten that the patient involuntarily carries his head backward. As soon as the beak touches the posterior 38 DISEASES OF THE EAR, NOSE, AND THROAT. wall of the pharynx we withdraw the catheter about one-eighth of an inch, rotate it so as to turn the beak outward and slightly upward, and its extremity should be opposite the orifice of the tube. Then the hand is carried a little toward the opposite Bide, so as to bring the beak into the tubal opening (Fig. 26). With practice one can determine when the catheter rests in the tube by the sense of fixation imparted to the instrument. During this manipulation the ring on the proximal end of the catheter will indicate the position of the convexity of the distal extremity. No force need be used. In case of certain de- formities of the inferior turbinated bodies the catheter must be rotated through forty-five or ninety degrees, or more, before it Fig. 27.— Fixation of the Catheter with the Left Hand. (After Politzer.) can reach the pharynx. With the head thrown backward the weight of the silver catheter is often sufficient to carry it into the pharynx. The introduction can be facilitated by elevating the tip of the nose with the thumb of the left hand while the fingers rest on the bridge of the nose or on the forehead. However, with the improved compressed-air appliances at hand it is rarely necessary to resort to the catheter. It is des- tined to pass out of vogue to a certain extent, for the reason that air, volatile medicaments, and even fluid- vaselin sprays can be succes>iullv projected into the middle ears by means of the infiator (Fig. 24) adapted to the high-pressure apparatus. To the average patient this is a happy culmination of the inventor's PRODUCING AND USING COMPRESSED AIR. 39 efforts, for it averts positive suffering, the possibility of infection and of irritative effects, and incidentally minimizes the amount of skill required for treatment. If occasion should necessitate the use of the catheter (Fig. 27), the air-pressure must be greatly reduced. If more than 1 or 2 atmospheres (15 to 30 pounds) be used with the catheter- beak not properly adjusted, there is a possibility of forcing the air into the submucous tissues and producing a dangerous em- physema. We have never seen any such results from this cause, but three deaths are recorded. (Since writing this, Dr. Thomas Faith has reported to me a case of emphysema of such character, with recovery.) An aid in both diagnosis and treatment lies in Toynbee's Fig. 28.— Toynbee's Auscultation-tube. auscultation-tube (Fig. 28). One end of the tube should termi- nate in a white tip and the other in a black one, the latter for the patient's ear. By inserting the white tip in the operator's ear while the black one rests snugly in the patient's meatus, any sound produced in the ear of the patient is perceived by the surgeon. Thus, when air is forced through the Eustachian tube and impinges against the inner surface of the membrana tympani, the resulting sound is conveyed along the continuous column of air in the patient's external canal, the rubber tube, and the surgeon's auditory meatus to his drum. It is not difficult, then, to distinguish between the free, breezy puff of air through a patulous Eustachian tube and the high-pitched, squeaking sound occasioned by a stenosis. CHAPTER V. DISEASES OF THE EXTERNAL EAR. The Auricle. There are certain injuries and diseases of the auricle that are not properly classed as ear affections, the treatment of which is conducted on general principles sufficiently amplified in works on surgery. Such affections and injuries as would not require treatment differing* from that demanded by the same conditions in other parts of the body will not greatly encumber our pages. DISEASES OF THE AURICLE. Frost-bite of the Auricle. — The symptoms of this condition are so familiar that a description would be superfluous. The chief object to be accomplished is to prevent a sudden disturb- ance of the circulation in the skin, by insuring a very gradual return to the normal temperature. ' This is best secured by the application of the aural ice-bag (Fig. 78) to the auricle after padding the post-auricular space for support. As the crushed ice melts, the temperature of the bag gradually rises until the ice becomes water, and the temperature of the water slowly arrives at the normal bodily temperature. Then the auricle should be dressed with a thick covering of an ointment consisting of equal parts of benzoinated oxide-of-zinc and carbolic-acid ointments. The parts should be protected with gauze or absorbent cotton. Eczema. — This skin disease is so common and so well de- scribed in general works that we may best confine ourselves to the subject of treatment. It is usually associated with a chronic suppurative inflammation of the middle ear, and is a result of that disease. The external canal is likely to be involved at the same time. The acrid, irritating discharges set up the derma- titis wherever they spread, even to the neck, side of the face, and head. So long as these discharges continue to bathe the skin, just so long will the treatment of the eczema prove un- availing. The ear must be so cleansed and kept free from pus, (40) DISEASES OF THE EXTERNAL EAR. 41 by constant vigilance and the treatment outlined in the chapter on suppuration, that the discharges cease to reach the auricle and surrounding parts. If there are crusts, they are softened and removed by means of Castile soap and warm water. When the surface is thoroughly clean it is covered thickly with ben- zoinated oxide-of-zinc ointment, which must be strictly fresh and prepared with the purest zinc oxide. This is retained in place by a gauze or fine-linen dressing. In case of great itching or burning the carbolic-acid ointment is added to the zinc ointment in the proportion of one-fourth or one-half carbolic ointment. This acts not only as an antiseptic, but as a grateful local anaes- thetic also. In obstinate cases a 3-per-cent. salicylic-acid oint- ment of lanolin has proven rapidly curative, and the same may be said of the yellow-oxide-of-mercury ointment, 5 grains to the ounce of vaselin (1 per cent.). When the raw-appearing surface rapidly exudes drops of serum, weeping eczema, it should be gently dried by merely touching witli absorbent cotton without any friction, and then covered with aristol powder. Prompt drying and cicatriza- tion follows. General treatment may be needed for an impover- ished condition of the system, and, if so, Fowler's solution of arsenic is a valuable addition to internal medication. Lupus. — Lupus vulgaris generally attacks the auricle sec- ondarily to its existence in the face. Yet we have seen it con- fined to the auricle and external canal following, like eczema, a chronic suppuration of the middle ear. Brown tubercles about the size of a pin-head or a small pea form in the concha, about the mouth of the auditory canal, or in other parts of the auricle. They may be covered with brown crusts or scales. Sometimes they shrink up so as to form cicatrices, which, in turn, may break out later. Lupus exulcerans appears in the form of ulcers covered with brown crusts, underneath which is a spongy, moist, or bleeding surface. Nodules may be seen in the periphery of the ulcers and aid materially in making a certain diagnosis. There is no considerable pain, as a rule, nor intense itching as in eczema. The skin is of a darker hue than in the latter disease. A case in my practice, a lawyer and prominent politician of 60 42 DISEASES OF THE EAR, NOSE, AND THROAT. years, resulted from a chronic suppuration of the middle ear. After stopping the suppuration the ulcers in the meatus and on the auricle healed under aristol. After three years, however, the disease again attacked the auricle, during his absence in the West, and destroyed it. (Since writing the above he has died.) All the diseased tissue is best removed by the curette, the galvano-cautery, nitrate-of-silver stick, acetic acid, etc., under cocaine anaesthesia, and the wound is dressed with aristol or iodoform covered with dry iodoform gauze. The prognosis must be guarded, on account of the strong tendency to recurrence. Gangrene. — Gangrene of the auricle is a very rare disease. It may arise without any assignable cause ; but any condition that vitiates the blood and lowers the vitality and powers of re- sistance in the presence of a local exciting cause, such as intense cold, pressure, acrid discharges, burns, destructive chemicals, etc., predisposes to this necrotic process. I have seen one case only. This applied at my clinic at the Chicago Commons Dis- pensary with the following history : A boy, 2 years old, had been an inmate of an orphan asylum five months. Two months be- fore I saw him a suppuration of the right ear began. Five days before I admitted him to the infirmary the skin covering the concha turned black and emitted a foul stench. Both sides of the auricle were necrotic, as well as the adjoining skin of the mastoid process. The necrotic tissue was cut away and the bone was found involved, necessitating a mastoid operation (Fig. 29). After the operation the child, in common with other members of his family, had measles. His brother died, and our patient was attacked with pneumonia, from which he died. The autopsy showed pulmonary tuberculosis. If gangrene is seen early enough, warmth should be ap- plied to stimulate the circulation until the necrotic tissue sepa- rates from the healthy; otherwise operative measures as indicated above an' called for. Epithelioma of the Auricle. — This more frequently arises on the auricle or in the external meatus than in the middle car or mastoid process. It begins with a sensation of irritation or itching, which the patient increases by persistent efforts to DISEASES OF THE EXTERNAL EAR. 43 relieve. The development is slow at first and rapid afterward. The irritation is supplanted by ulceration, which, however, is easily distinguished from other similar conditions. While in lupus exulcerans the ulcer is deep, excoriating, and penetrating, in epithelioma the ulcerating surface is raised above the sur- rounding tissues, exuberant granulations often projecting to a considerable degree. If the lateral cervical glands become Fig. 29.— Gangrene of Ear: Mastoid Operation. infiltrated the diagnosis^ is more certain, but they are slow to participate. The ulceration may extend to the tympanic cavity, laby- rinth, and cranial cavity, producing facial paralysis, haemor- rhages, meningitis, brain-abscess, or thrombosis, and, after great suffering, death. The treatment consists in complete extirpa- tion of the diseased tissue when possible, the knife penetrating beyond the disease into the surrounding healthy tissue. If the auricle is extensively involved it should be amputated, and if 44 DISEASES OF THE EAR, NOSE, AND THROAT. the cervical glands are affected they must be excised at the same time. Should it be necessary to invade the external meatus, a plastic operation may preserve its patency, which is important on account of the hearing. After-treatment is the same as for lupus. Perichondritis of the Auricle. — This is not a frequent dis- ease, but early treatment is important to prevent deformity. In the early stage there occurs a swelling of a part or the whole of the auricle, with a dusky-red surface, accompanied by heat and pain. I have seen the auricle increased to an enormous size by the effusion of a syrup-like fluid between the cartilage and the perichondrium. Treatment consists first in the application of cold by means of the ice-bag (Fig. 78). If there is great swelling with fluct- uation it must be incised, the fluid pressed out, and the cavity irrigated with antiseptic solutions. I have obtained the best results from injecting equal parts of tincture of iodine and water or alcohol, and applying pressure with cotton and a bandage. Hcematoma of the Auricle. — Othematoma is an effusion of blood between the cartilage and the perichondrium. . It rarely arises spontaneously, but is generally the result of traumatism. It occurs suddenly after a blow on the ear or pulling the auricle. It is a rather frequent occurrence in the mentally defective, and possibly indicates a disease of the base of the brain. Brown- Sequard has shown that section of the restiform body in animals is followed by this disease. The appearance of the tumor is accompanied by heat and pain. It nearly always occupies the anterior aspect of the auricle, and may cover a large portion of that surface. The natural outlines are obliterated, and in their place is a fluctuating, pale, bulging tumor. It may rupture spontaneously or suppurate, or in rare instances it disappears. Daring the first, or inflammatory, stage, when there are heat and pain, cold is indicated (Fig. 78). If an ice-bag is not ob- tainable, a bladder can be filled with ice or snow as a substitute. If the swelling does not diminish it must be incised, in one of the natural folds to prevent disfiguration, and emptied of its (•on tents. Most satisfactory results have followed washing out DISEASES OF THE EXTERNAL EAR. 45 the cavity with a 5-per-cent. aqueous solution of carbolic acid, insufflating with aristol, and binding it with an absorbent- cotton compress. Randall opens the sac, curettes it, rubs with iodine glycerite, packs with iodoform gauze, and covers with pressure bandage. In this connection it is our duty to condemn in the strongest terms the brutal practice of pulling and boxing the ears of children indulged in by ignorant parents and teachers. I have seen many cases of deformities, ruptured drum-heads, abscesses, and deafness resulting from this inhuman habit. Cyst of the Auricle. — Cystoma is a tumefaction usually found on the anterior aspect of the auricle. Its appearance is similar to the blood-tumor already described, but it contains, instead of blood, a serous fluid, which is sometimes of a syrupy consistence and appearance. It arises suddenly from an unknown cause, without a previous injury or inflammation. The treatment is the same as for hematoma, — incision, etc. Intertrigo. — An excoriated condition of the skin en the adjoining surfaces of the auricle and mastoid process is of frequent occurrence among children of* the poor. It may be due to an impoverished condition of the blood, but is more likely to be caused by uncleanliness and the harmful habit of binding the ears down against the head by close-fitting caps. The skin denuded of its cuticle presents a red, raw, moist appearance, but it is smooth and without thickening, in this respect differing from eczema, which may be engrafted upon it. The trouble is aggravated by the efforts of the child to relieve the intense itching by scratching. The treatment is similar to that for eczema, except that dry applications are indicated, as in the weeping form of eczema. Powders are preferable, and of these aristol is sufficient. The binding caps must be interdicted and the irritated surfaces kept apart. Miscellaneous. — Herpes, pemphigus, and syphilis of the auricle are very infrequent lesions that differ in no way from the same affections of other parts of the cutaneous system and require no different treatment. Not being diseases peculiar to the ear, their description will be omitted here. 4t; DISEASES OF THE EAR, NOSE, AND THROAT. DEFORMITIES OF THE AURICLE. Arrested and excessive development of the auricle in rela- tion to degeneration have heen made the subject of extensive investigation by E. S. Talbot, of Chicago; Spitzka, and others; but the discussion of this phase of the subject lies without the province of this book. Dr. Talbot's illustrated article, from which Fig. 30 is taken, will be found in the Journal of the American Medical Association for January 11, 1896. Auricular deformities may be divided for convenience into congenital and acquired. Congenital deformities may be classi- fied as correctible and irremediable. Acquired deformities fall under two headings: those resulting from disease and those IV om injuries. Fig. 30.— Hypertrophied Auricle. Hypertrophied Auricle. — The most common defect is the large, flattened, wing-like ear that stands out conspicuously from the side of the head (Fig. 30). This ear-mark serves as a butt of jest for the child's companions, and makes life a burden to the bearer. Its exaggerated prominence suggests its prototype among the lower animals, the mule-ear. The natural surface inequalities are diminished, the border of the helix is often thin and expanded, and the whole flaring pinna appears as if it had been subjected to constant pulling or pressure. While a large percentage of these cases are congenital, that barbarous mode of petty punishment — pulling the ears — may account for a certain amount of this deformity. I have DISEASES OF THE EXTERNAL EAR. 47 been led to this conclusion by information elicited in many in- stances. The pressure produced by the tight caps so much in vogue with some people may be a factor. The treatment is operative. I have proceeded in two ways: by reducing the actual size of the auricle, and by effecting a corrective amount of adhesion between the auricle and the mastoid process. The first operation is done by removing an elliptical section of the cartilaginous frame-work and corre- sponding integument on the posterior surface and bringing the edges together with sutures, including the cartilage. The long- diameter of the ellipse is, of course, vertical. The cartilage must be dissected out without penetrating the skin of the an- terior surface. By making accurate measurements and marking the size and shape of the section to be removed, the result will be satisfactory. The auricle is then to be dressed with aristol, iodoform gauze, and the net bandage. This bandage is made of white mosquito-netting, moistened through just before apply- ing, and it dries in place like the plaster bandage. Union by first intention is had and the stitches are removed as soon as the adhesion is firm. This method is superior to the removal of the skin alone, in which case the resilience of the cartilage tends to tear out the sutures or bulge forward the anterior surface unduly. The second method is easier to practice, and I have given it preference for a number of years. The auricle is pressed against the side of the head in such a way as to give it in every part a little less projection than it ought to have. Now the line of junction is marked throughout its whole extent on both auricle and head. The section of skin included within these lines is dissected out in a thin layer so as to leave a denuded surface ; the edges of the wound are approximated and sutured with the stitches close together and penetrating the subcuta- neous tissues. The dressing and subsequent treatment are the same as after the first operation. This corrects a most unsightly deformity and may result in a beneficial influence on the temper and happiness of the patient for the remainder of his life. So far as I have been able to 48 DISEASES OF THE EAR, NOSE, AND THROAT. learn, this method of operating had not been practiced pre- viously to its introduction by the author. Scroll-car and Associated Deformities. — There is a de- formity of the auricle in which the border of the helix turns forward and downward in a scroll-like roll. In such cases as I have seen the auricle is diminutive in size and does not present favorable conditions for an operation. In certain instances this condition amounts almost to obliteration of the pinna, and the auditory canal is absent. To illustrate, we will cite one of the cases reported by myself in the Tenth International Medical Congress held in Berlin : — A girl, 8 weeks old, was brought to my clinic October 10, 1885. There was a congenital deformity of one auricle and absence of the external auditory meatus of the same ear. The auricle was rudimentary and doubled forward upon itself. It appeared shrunken and pinched, and had a large, hard nodule and several indentations in that part of the helix that corre- sponds to the key-stone of an arch. It is interesting to note, in this connection, that the mother attributed the deformity of the auricle to the fact that, about the fifth month of gestation, her elder child bit the mother's ear severely, at just that point that corresponds to the greatest auricular deformity in the baby. At the point where the canal ought to have been there was a depression or cid-de-sac that yielded to pressure, and imparted to the touch an impression as if there were an opening in the bone beneath. Four months later careful tests led me to believe that the child could hear with that ear. I operated to correct, as far as possible, the deformity of the auricle, and to ascertain if there were any bony meatus. On cutting down into the cul-de-sac where the canal should have been, I found nothing but a de- pression in the bone. No bony canal could be found, and I did not consider that further operative interference would be justifiable. However, I maintained a sufficient opening to give quite a respectable appearance of an external meatus. Virchow's Archives says: "Congenital anomalies of the " DISEASES OF THE EXTERNAL EAR. 49 external ear and its neighborhood are to be referred to early disturbances in the closure of the first branchial cleft, and are often associated with fistulse of the other branchial clefts, cleft palate, and other forms of arrest of development in the facial bones, — as, for instance, with unilateral atrophy of the face." Certain acquired deformities have already been noticed in connection with the diseases that produce them, — perichondritis, etc. Treatment can hardly avail to remedy them. Those re- sulting from injuries must be treated on general surgical prin- ciples, with care to prevent any closure of the auditory canal. The latter subject will be presented in the following chapter. CHAPTER VI. DISEASES OF THE EXTERNAL AUDITORY CANAL. Inspissated and Impacted Cerumen. Impacted wax is a common condition that may give rise to serious results. It is really a symptom of disease, and often is provocative of other pathological manifestations. Recurring hyperemia or eczema of the external canal may excite the ceruminous glands to hypersecretion, and anomalies of the canal may prevent the natural process of elimination of the cerumen; so that for these two reasons it becomes dried and im- pacted. With the movements of the lower jaw, corresponding motion is imparted to the cartilaginous portion of the canal, which has the effect of working the accumulations of wax out- ward ; but, when the mouth of the canal is very narrow and when exostosis or other mechanical obstructions occur, they prevent the outward movement of the secretion, and it stops up the canal effectually. Patients often contribute to this impact- ing process by their efforts to cleanse the canal with towels, etc., at the bath. The middle ear may not be involved in the dis- eased process, or both parts may participate in trophoneurotic changes due to central causes. There may be, moreover, a simple desquamative inflammation with an abundant exfoliation of the epidermis. In these cases the ceruminous plugs consist of the fatty secretion, epithelial scales, hairs, etc., which are often horn-like in their hardness. Symptomatology. — The hearing may not be perceptibly diminished, providing the middle ear is in its integrity and the plug does not completely fill the lumen of the canal ; but sudden impairment of hearing and a stuffy sensation in the ear, with confusion, may supervene directly after a bath or profuse perspiring, occasioned by absorption of moisture and swelling in the plug. On the other hand, there is a gradual diminution of the hearing-power going on for years, and scarcely observed (50) DISEASES OF THE EXTERNAL AUDITORY CANAL. 51 by the patient until his friends call his attention to it. Tinnitus often occurs, and with complete blocking of the canal, subject- ive noises ; autophony, or a hollow sound to one's own voice ; neuralgia of the ear or the temporal and supra-orbital regions ; numbness about the ear and side of the face, reflex cough of a spasmodic character, and mental dullness. Children are often chided for inattention or inaptitude when they are the unfortu- nate victims of such an ear disease. In the latter case both ears will probably be found to be affected. Impacted cerumen gives rise to even more serious symptoms, for the plug, which is, in effect, a foreign body, works inward until it impinges upon the drum-head, causing perforation or intra-labyrinthal pressure, vertigo, and epileptiform seizures. After a suppuration of the middle ear has ceased I have found these large plugs blocking the exit for pus when a fresh cold has set up another suppu- rative inflammation. In such cases the pus may burrow inward and fill the mastoid cells, and even seek the cranial cavity before it can dislodge or penetrate these stone-like plugs. Their pres- ence sometimes is sufficient to cause absorption of the canal- walls and an immense increase in the size of the canal. After their removal the skin beneath is often inflamed and appears more like mucous membrane than healthy integument. Diagnosis. — The diagnosis is easily made on inspection of the canal, for the dark-brown or black mass is plainly visible, obstructing a view of the drum-head. Prognosis. — The prognosis depends upon the condition of the middle ear and labyrinth. If they are healthy the hearing- will be restored and the subjective symptoms removed with the extraction of the cerumen. Treatment. — The treatment consists (1) in the complete removal of (he plug and (2) in remedies addressed to any patho- logical condition revealed by its extraction. If one is adept in the manipulation of ear instruments he can dexterously pull out the plug with the little lever found in the author's middle-ear set of instruments. It should be passed into the canal with the lever horizontal, next the roof, and carried far enough so that when the lever is turned downward it will imbed itself in the 52 DISEASES OF THE EAR, NOSE, AND THROAT. cerumen. The latter may be so hard that quite a considerable pressure must be exerted to penetrate it, or it may be so soft that only a part, instead of the whole plug, will glide out with the lever when traction is exerted. Care should be taken not to produce any abrasion of the canal-wall with the lever. Those who are not practiced in ear-work had far better use the syringe. The continuous-flow rubber syringe with hand-bulb to regulate the pressure is the best. The glass syringes usually sold under the name of ear-syringes are of no account whatever for this purpose. The hard-rubber piston syringe is made for the ear with a flange to prevent its being introduced too far, but patients are likely to insert the nozzle so far that the flange stops up the canal opening, thus forcing the plug farther inward, or, when the plug is out, ex- erting undue pressure on the drum-membrane or even rupturing it. The Davidson alpha or omega syringe (Fig. 31) has proved even more effective than the fountain irrigator. The stream should FKi. ai.-ALPHA syrikgk. be thrown so as to enter any space that may be seen be- tween the canal-wall and the cerumen, rather than against the centre of the plug, iis much force should be employed as the patient can bear with comfort, and without producing dizziness ; and the water must be as warm as can be easily borne, and a quart or more may be necessary at a sitting. The emulsifying and disintegration of the ceruminous mass can be much facili- tated by preceding the use of the syringe with an instillation of a 4-per-cent. solution of bicarbonate of sodium in glycerin and water, equal parts. The ear should be filled with this fluid warmed, several times during the day, allowing it to remain a quarter of an hour ; then the mass breaks up readily and washes out with the injections. The canal should afterward be dried, smeared with warm vaselin, and protected for a few days with clean cotton. Any dermatitis should be treated DISEASES OF THE EXTERNAL AUDITORY CANAL. 53 according to the principles laid down under the following heading. Diffuse Inflammation of the External Meatus. Diffuse inflammation may be acute or chronic in character and may include the whole extent of the canal, although it is usually confined either to the osseous or to the cartilaginous por- tion. In my experience it more often has affected only that part of the meatus that adjoins the drum-membrane, and frequently it was limited to the superior half of the canal and invaded the membrana flaccida, Pathology. — If seen early the canal-wall presents a bright- red and smooth aspect. When the inflammation becomes in- tense and infiltration of the integument causes it to swell, the lumen of the canal is so encroached upon as to make an ex- amination of the drum-membrane difficult or impossible. The walls then lie in contact and even press upon each other; so that introduction of the smallest funnel is impracticable. When the membrana tympani is involved and can be seen, it may look red and swollen and the hammer-handle may be wholly invisible. A white coating of epidermis is frequently found lying loosely in the canal, and can be easily detached and removed in casts. In an advanced stage ulceration and granulations are found. Etiology. — The common habit of working at the ears with ear-spoons, hair-pins, common pins, and other hard substances is a prolific cause of inflammation of the canal. Instilling oil that becomes rancid, foreign bodies, and vegetable parasites act as exciting causes. Symptomatology. — In the first stage, or hyperemia, there may be no pain or impairment of function, and the patient remains unconscious of any unusual condition except for the itching. His attempts to relieve this only serve to increase the irritation, and, as the disease progresses, pain of a severe char- acter is developed. The movements of the jaw and pressure about the ear aggravate the pain. With the occurrence of pro- fuse transudation the hearing is dulled, and tinnitus and even vertigo may ensue. The more copious the exudation, the 54 DISEASES OF THE EAR, NOSE, AND THROAT. greater the stenosis and impairment of hearing. In very old cases the canal is found full of an offensive, thick, and greasy secretion. Diagnosis. — The diagnosis is not easy to make when the Btenosis is great. It may be impossible to differentiate between an affection of the canal alone and one affecting both the canal and middle ear. A microscopical examination of the exfoliated epidermis for micrococci and vegetable fungi may clear up the diagnosis. Prognosis. — This depends upon the extent of the inflam- matory process. It may invade the tympanic cavity and pro- duce suppuration. It may extend to the bony walls and even to the mastoid cells and cranial cavity, but such results are rare. The lumen of the meatus may be permanently contracted or obstructed by adhesive processes. But the usual course under proper treatment is favorable. Treatment. — If the inflamma- tion is very active and painful and the stenosis complete, the ice-bag (Fig. 78) should be applied. Ab- straction of blood by leeches may give relief, two being applied in front of the tragus. If the canal is sufficiently open to permit of washing it out, a 3-per-cent. hot solution of carbolic acid should be used until the canal is thoroughly cleansed. Then it should be dried with cotton without friction, and covered with a coating of aristol by means of the small powder-blower (Fig. 32). If this does not stop the secretion in a few days, the fine boric powder should be substituted. Furunculosis. Synonyms. — Furuncle; boil; follicular or circumscribed inflammation of the external meatus. Pathology. — Furuncles are mostly limited to the cartil- FlG. 32. ■Author's Small Pow- der-blower. DISEASES OF THE EXTERNAL AUDITORY CANAL. 55 aginous portion and most frequently to the posterior or anterior wall of the canal. Although they may be secondary to a middle-ear inflammation, they are essentially idiopathic in char- acter. Furuncles appear singly, in groups, and in successive crops, and probably are due to the staphylococcus entering the hair-follicle or sebaceous gland, or to some trophic change in the nervous supply of the meatus. Etiology. — Any irritation of the canal predisposes to furuncle: foreign bodies, irritating instillations, ear-spoons, discharges from the tympanic cavity, too frequent syringing, and vegetable parasites. The same may be said of a general impairment of health, diabetes, anaemia, and dyspepsia. Symptomatology. — The onset of the attack is attended with a sense of fullness or itching, followed by tenderness on touch, pains of a throbbing character, and, as the swelling increases, impaired hearing and subjective noises. The pain becomes intense for a day or two and subsides on the ruptur- ing of the boil. Movements of the jaw increase the pain to such an extent that mastication is out of the question. When the furuncle is located on the anterior wall, the tragus becomes red, swollen, prominent, and sensitive ; when it is on the back wall, the swelling may be sufficient to protrude the auricle and simulate the appearance of mastoid periostitis. Occasionally the cervical glands, and the lymphatic glands over the mastoid process, when they are present, become infiltrated. For the first two or three days the fever, headache, and furred tongue denote a general systemic disturbance. Diagnosis. — This is not difficult on careful inspection with brilliant illumination. This disease is not likely to be con- founded with any other, when we consider the prominent symp- toms. The tender points are easily detected with the probe. Prognosis. — The disease usually runs its course in about a week, and unless successive crops occur, or unless the general health is impaired, the trouble is over. But it should not be forgotten that in certain instances the inflammation has invaded the tympanum, the mastoid, and even the cranial cavity. Treatment. — The first indication is to allay pain, for which 56 DISEASES OF THE EAR, NOSE, AND THROAT. bromidia internally and cocaine locally are effective, the former in teaspoon fnl doses in water every half-hour or hour for an adult until pain ceases, and the latter in a warm, 10-per-cent. solution. As soon as the pain is relieved we should cleanse the meatus with dioxide of hydrogen (peroxide) comfortably warm. It can be warmed to a little above blood-heat without impairing its effectiveness. Its effervescent action washes out the canal, and its antiseptic property strikes at the root of the trouble. After cleansing I have found a 20-per-cent. solution of camphor-menthol in lavolin to exert a comforting and cura- tive influence. It is to some degree a local anaesthetic, anti- septic, and a constrictor of the capillary blood-vessels. A 12-per-cent. solution of carbolic acid in glycerin acts similarly. They are applied, like the cocaine, on cotton. As soon as a distinct fluctuation can be made out, it should be incised deeply through the centre, under cocaine, and pressure exerted about the base to express all pus or necrotic tissue. Subsequent treatment consists in the application of a small amount of yellow-oxide-of-mercury ointment, 5 grains to the ounce ; salicylic-acid ointment, 3-per-cent. ; or carbolic-acid oint- ment. Proper treatment is addressed to the general health. Parasitic Inflammation of the External Meatus. Synonyms. — Mycosis; otomycosis; mycomyringitis; asper- gillus ; myringitis parasitica ; ear-mold ; aural fungi. Pathology. — Vegetable parasites in large variety are found in the auditory canal, but it is beyond the scope of this work to give a detailed description of the microscopical appearances of these fungi. For an extended study of this subject the reader is referred to Burnett. The most frequent varieties are the dark-brown aspergillus, or nigricans ; the yellow, or flaves- cens ; the green, or glaucus ; and the grayish black, or fumi- gatis. When these parasites once find lodgment in the ear they multiply rapidly. This usually begins upon the drum- head, and the growth and the resulting inflammation extend outward until the whole meatus may be involved. These cases are not often seen until they are so far advanced that the con- DISEASES OF THE EXTERNAL AUDITORY CANAL. 57 dition is generally one of complete covering of the membrane and meatus with the mold. On removing the growth, which I have pealed out in a complete cast of the canal, the skin is red and raw in appearance, as though robbed of its epidermis. Etiology. — A damp atmosphere favors the growth of these parasites. The middle-aged and poor are the most frequently attacked. The common use of oils by the laity predisposes to this disease, as does any decomposing secretion or substance in the ear. Symptomatology. — Ear-mold may exist for a long time without the patient becoming aware of its presence, but when an active inflammation supervenes decisive symptoms develop. At first there is only an itching or irritation or feeling of full- ness, followed by pain, subjective noises, and diminished hear- ing. In my experience there is rarely a discharge except when the disease is secondary to a suppuration of the tympanic cavity ; but if the inflammatory action is severe a serous exu- dation occurs. Inspection shows in the black variety what is easily mistaken for a long-standing plug of inspissated cerumen were it not that the surface of the obstruction has a velvety or coal-dust appearance. In case of the yellow aspergillus, the parts look as though they had been sprinkled with finely- powdered mustard or yellow pollen. On removing the false membrane formed by the mold, its surface next the skin is of a dirty, grayish-white color. I have found this growth ingrafted on ceruminous plugs which required considerable time and care in removing. After their removal there was revealed not only the characteristic inflammatory condition, but an enormous ex- pansion of the meatus, due to pressure and the absorption of the canal-walls. Diagnosis. — Having the appearances described in mind, this is not difficult under good illumination, but a microscopical examination will set all doubts at rest. Prognosis.— This disease is rapidly amenable to the follow- ing method of treatment, a few days or weeks, at most, effecting a cure. Treatment.— The ear should be syringed with a quite warm 58 DISEASES OF THE EAR, NOSE, AND THROAT. solution of bichloride of mercury in water, 1 to 5000. Enough should be used to dislodge and remove all cerumen, discharges, false membrane, and debris that the ear may contain. The class of people in whom the mold is found work or live in a dirty atmosphere, and the ears are a label of this fact. After absolute cleanliness has been effected, the meatus should be filled with warm dioxide of hydrogen (peroxide, H 2 2 ). This is left as long as it effervesces, then removed, and the canal is gently dried with absorbent cotton. Now the meatus is rilled with a 12-per-cent. solution of carbolic acid in glycerin for ten minutes; then this is removed and a saturated solution of iodo- form in alcohol is substituted. The carbolic acid does not corrode the tissues in this combination, but acts as an antiseptic, besides anaesthetizing the inflamed skin sufficiently to admit of the strong alcoholic solution being used without producing pain. The iodoform solution is left in the ear with the patient's head inclined to the opposite shoulder for ten minutes, when it is allowed to drain slowly out, leaving a covering of iodoform powder on the surface of the drum-head and walls of the meatus. This treatment destroys any remaining fungi. The canal is then dried and dusted with a coating of aristol, and stoppered with absorbent cotton until the next treatment on the following or second day. Should there be a considerable ex- udation of serum, boric-acid powder may take the place of aristol or may be added to it. If the drum-head has been perforated or if the mastoid cells have been invaded, suitable treatment, such as will be detailed in the chapters on those subjects, must be adapted to such complications. Exostoses or bony growths from the osseous section of the external meatus are so rare that we will not enter into their consideration here, except to remark that unless they occasion serious trouble they do not require attention ; but if they become obstructive they must be removed. Imperforate External Meatus. At the Tenth International Medical Congress the author reported four cases of complete closure or absence of the DISEASES OF THE EXTERNAL AUDITORY CANAL. 59 meatus, — two traumatic and two congenital. In the two con- genital cases no external canal could be demonstrated. One of the traumatic cases was produced by a railroad accident that amputated the auricle, which was replaced and carelessly sewed over the canal to present a good appearance at the funeral ; but the patient recovered. A few years afterward I made a new canal, maintained its patency by means of a hard-rubber tube, and succeeded in restoring the usefulness of the organ. The other traumatic case was a man 32 years of age. It was caused by a wagon-wheel severing the auricle from the head when the patient was 3 years old. The same error was committed in stitching the auricle over the mouth of the canal. When the patient came for treatment there was a discharge of pus from a very minute fistula in the roof of what should have been the canal. I opened the canal, cauterized the cicatricial tissues, and maintained the opening by means of a vulcanite tube. In the two congenital cases I operated on one, a girl 6 months old, but found no osseous canal; in the other, an infant of 14 months, no operation was advised. Adhesions causing closure of the canal are very rare. Some of our authorities speak of imperforate external auditory canals as though they were of frequent occurrence ; but among the records of the Illinois Charitable Eye and Ear Infirmary at Chicago, embracing more than 21,000 cases of diseases of the ear, I found but 1 case of closure from exostosis, 3 cases of congenital absence of the meatus, and 3 of traumatic closure. Of course, we have found numerous cases of narrow- ing, and various irregularities of the canal, from causes that are not uncommon. Foreign Bodies in the External Meatus. It is a common occurrence to find peas, beans, pebbles, and glass beads that children have introduced into their own or their companions' ears. We have found flies, bed-bugs, live moth-millers, etc„ but flies are oftener found in suppurating ears. It is not uncommon to find oats and other foreign bodies that have remained in the ears for years without provoking 60 DISEASES OF THE EAR, NOSE, AND THROAT. symptoms that made their presence known. Notwithstanding this, a foreign hody is a menace to the integrity of the hearing organ so long as it remains in the canal. It may at any time up an inflammation either by mechanical irritation or, if it be an organic substance, by swelling and by decomposition. These bodies are easily seen if the forehead-mirror, bright light, and a funnel are employed. But the funnel must not be allowed to crowd the body down farther into the canal. In- sects, if alive, should either be immediately picked out with the delicate forceps or drowned by filling the ear at once with warm water. Beans, corn, peas, etc., absorb moisture and swell so as to completely fill the canal until their pressure becomes painful. They are easiest removed by passing the little sharp hook, con- tained in the author's middle-ear case, over the grain with the hook lying in an horizontal plane next the canal-roof; or, if there is greater space at any other point, we should choose it and carry the hook well over the berry, then turn the point toward the centre of the berry and press it firmly so as to imbed it in its substance. Careful traction will then extract it. Hard, inorganic bodies are not so easily extracted. Syringing is safest, with the head inclined toward the basin so that gravity will aid in their expulsion. They may be wedged into the meatus so that the current of water cannot dislodge them. Then the little blunt lever, instead of the sharp hook, may be passed behind the body and drawn upon, care being had not to allow it to slip over or around the body, leaving the latter behind. When glass beads work into the middle ear, the operation for extraction is not so simple a matter. I have the ornament of a " ruby " ring that could not be removed from the tympanic cavity until we had detached the auricle and chiseled away a section of the bony canal. The " ruby " is five-sixteenths of an inch (eight millimetres) in diameter and cut similarly to a diamond ; so that instruments could gain no hold upon the facets. Extreme care should be exercised, in efforts to remove foreign bodies, not to injure either the canal or drum-head and ossicles. I have seen numerous instances in which unskillful practitioners had mutilated the canal-walls and drum-mem- ■ DISEASES OF THE EXTERNAL AUDITORY CANAL. 61 branes, and even extracted the little bones before they discovered that there really had been no foreign body in the ear. Such practices are appalling. It is frequently necessary to assure anxious parents that they and their children are mistaken, when they bring their little ones to have foreign bodies extracted, for we often find that there is absolutely no evidence that any foreign body has been there. CHAPTER VII. DISEASES OF THE MIDDLE EAR. Injuries of the Drum-head. The drum-head is occasionally ruptured by blows (Fig. 33) explosions, concussions from fire-arms, the pushing of pencils or straws into the ear, or by pulling the ears of children. The mere rupture of the membrane is not of serious import, for it will probably close in a few days without treatment ; but con- cussions or wounds may penetrate sufficiently to affect seriously the middle or internal ear. If no inflammation follow such accidents, the perforation itself requires no treatment further Fig. 33.— Rupture of the Anteroinferior Half of the Drum-head Caused by a Box on the Ear. (After Politzer.) than to protect it from the air-currents by a light pledget of sterilized cotton. The consequent affections are treated in their proper classifications. Inflammation of the Drum-head. Synonym. — Myringitis. Pathology. — Myringitis is of frequent occurrence and gen- erally begins with an injection of the malleal plexus of vessels. At first they can be distinctly seen like minute red threads running down along the hammer-handle, but as the hyperemia increases they appear to coalesce until there is an even diffusion of redness enveloping the handle and overspreading the mem- (62) DISEASES OF THE MIDDLE EAR. 63 brana flaccida like an intense blush. This condition may co- exist with a dermatitis of the superior integumentary wall of the external meatus. In these cases one cannot discern any line of demarkation between the lining of the wall and the drum- membrane. I remember to have seen an abscess in the drum- head of a violinist. It was seated in Prussak's space (Fig. 34). The hook-knife was introduced into the opening above and brought downward and outward, dividing the external wall, thus laying the little abscess-walls open to view. Occasionally hemorrhagic effu- sions are seen, but the blisters described by Politzer I have rarely observed. When the inflammation extends over the whole area of the membrane it assumes a cherry-red color, shining at first, and swollen and dusky after serous infiltration takes place. Etiology. — The cause usually lies in wind or cold water reaching the drum-head, swimming, instillations of irritating substances into the ear, fungi, or acute cold in the head. Symptomatology. — The hearing is not necessarily diminished for speech, but, on the other hand, there may be increased sensitiveness to noises. The pain is often severe and throbbing in character, accompanied with a feeling of fullness and pressure and subjective noises. Pain may be referred to the side of the head and neck, as well as to the ear itself. Diagnosis. — In the early stage this is not difficult, for the symptoms are not at all indicative of middle-ear inflammation except the appearance of the membrane. In mild cases the patient may not be aware of the presence of the trouble, although inspection reveals it, and the hearing is believed to be normal ; but in acute middle-ear inflammation the Eustachian Fig. 34. — Section Through the Tympanic Membrane, Malleus, and Upper and Outer Tympanic Wall of a Decalcified Prepara- tion. (After Politzer.) U, ligament, mall. sup. : le. ligament, mall, ext.: s. mem- brana Shrapnelli : o, Prussak's space : r, system of cavities be- tween the body of the malleus and incus and the external tym- panic wall : t, tendon of tbe muse, tens. tymp. 64 DISEASES OF THE EAR, NOSE, AND THROAT. tube is usually involved, a rapid serous exudation takes place, and swelling of the membrane, with marked impairment of hearing. All the symptoms are characteristic of a more pro- found disturbance. After the inflammation extends from the drum-head to the middle ear the differential diagnosis is out of the question and immaterial. Prognosis. — This is favorable, the disease being generally limited to a few days or a week. Treatment. — If the pain is not severe the symptoms subside on warming pure vaselin and letting it run down upon the drum- membrane. Then the ear is closed with cotton to retain it for twenty-four hours. In severe pain a 10-per-cent. solution of cocaine, quite warm, gives relief used in the same manner. No other treatment is necessary except for complications or after-effects of the disease. Eustachian Tubal Catarrh. Pathology. — In Eustachian salpingitis the mucous mem- brane lining the tube may be simply hypersemic or highly inflamed. Since it is lined with a continuation of the same mucous lining of the naso-pharynx, on the one hand, and of the tympanic cavity, on the other (Fig. 35), any inflammatory action in one is likely to spread along the membrane to another part, just as an erysipelatous inflammation of the skin travels along the integument from one part of the body to another. In a transitory inflammation of the tube, mild in character, the mu- cous membrane alone may be affected, with only slight swell- ing and diminishing of its calibre ; but in a severer grade the submucous layer becomes involved, transudation of the fluid elements of the blood takes place, and great swelling and ste- nosis or complete closure of the tube occur. Asa result of the latter condition, new connective-tissue formation may make the narrowing or imperviousness of the tube permanent. Both the inflammation and the constriction are mostly confined to the cartilaginous part of the tube, and the connective-tissue strict- ures to the middle of this portion. Granulations sometimes result from the inflammation. DISEASES OF THE MIDDLE EAR. 60 Etiology. — Tubal catarrh is rarely an idiopathic disease, but results either from an attack of acute coryza, or pharyngitis, or from a middle-ear catarrh. Cold winds blowing on the side of the neck, a blow, or irritating fluids in the naso-pharynx may act as causes. The presence of hypertrophied oral or pharyn- geal tonsils, or of adenoid vegetations in the vault of the phar- g h t a Fig. 35.— Eustachian Tube and Tympanic Cavity (After Pulitzer.) a, membrana tympani ; b, head of the malleus ; c, lower end of the handle of the malleus ; d, body 6f the incus : e, short process of the incus : /. tensor tympani ; g, orifice of the Eustachian tube : h, isthmus of the tube : i, tympanic mouth of the tube. ynx, which are the seat of frequently-recurring attacks of inflammation, predisposes to the disease. Symptomatology. — In light attacks there are only slight deafness and subjective noises, which increase with the severity of the inflammation. When the tube becomes greatly swollen there may be vertigo, and pain referred to the side of the neck, back of the ramus of the lower jaw. Pressure toward the course of the tube reveals tenderness. Auscultation gives a b 66 DISEASES OF THE EAR, NOSE, AND THROAT. high-pitched, squeaking noise during politzerization, and, if mucus is present, a rale also in a swollen condition of the tube. These are not necessarily present in the constriction due to con- nective-tissue growth. In the latter the noise may be want- ing. It is difficult or impossible to inflate the ear, or it will require high pressure to do so. The drum-head is sunken on account of the rapid absorption of air in the tympanic cavity and loss of the normal ventilation by the tube. The lower extremity of the mallet may lie in contact with the inner wall of the cavity, giving the hammer-handle a foreshortened appear- ance, and causing the short process to project outward promi- nently toward the eye. The membrane about this process looks stretched and drawn into folds. Diagnosis. — This is not difficult and the principal points have been indicated in what has already been said. With no middle-ear involvement, the most striking result is obtained from inflation. The hearing is immediately restored and the differential diagnosis confirmed. Prognosis. — The attack of acute catarrh of the tube is readily subdued, and proper treatment will soon restore the parts to a normal condition. Treatment. — This must be directed to the condition of the tube itself, to the causes that induce the attacks, and to the pre- disposing causes. The most immediate relief is afforded the patient if we can at once inflate the middle ear. This restores the normal hearing, relieves the tension on the drum-membrane, reduces the engorgement of the blood-vessels by relieving the partial vacuum ; removes the cause of dizziness, the impaction of the stirrup ; and lifts the patient out of his mental gloom, — a condition characteristic of this disease. The catheter should be avoided, since its introduction into the orifice of the inflamed tube serves only to increase the irritation. Politzerization is, by far, preferable, at first with air alone, to gently and gradually fill the tympanic cavity and restore the drum-head to its normal position. Too sudden inflation in this state may cause distress, vertigo, and nausea by the disturbance of the intra-labyrinthal fluid. The tube being opened, it is my practice to inject with DISEASES OF THE MIDDLE EAR. 67 the improved inflator (Fig. 24) either pure lavolin — a purified non-irritating fluid vaselin — or a weak solution of camphor- menthol in vaselin, 3 per cent. The former is bland and emoll- ient, as well as protective to the inflamed membrane. The latter relieves the pain, constricts the capillary blood-vessels, reduces the swelling and stenosis, and acts as an antiseptic and protective. If the tube does not readily yield to the inflation, 6 or 10 drops of sulphuric ether may be placed on the sponges of the inflator, and, with sufficient pressure from the compressed- air reservoir and while the patient swallows, this will, in most cases, reach the middle ear. There is not sufficient ether to produce irritation, but it is so volatile that it will penetrate where air alone fails to go. My experience differs somewhat from that of other ob- servers concerning tubal affections. I have rarely met cases of constriction that I was not able to overcome without the use of the bougie. This may be attributed, perhaps, to the greater air-pressure employed in my work. Moreover, it is rarely found necessary to introduce the catheter, — for the same reason, no doubt. Hand-bags are little used in my private practice or in my three hospital and college clinics, but, instead, we make use of air in reservoirs compressed by hydraulic compound pumps, Westinghouse air-pumps, or some other device supply- ing at least three or four times the amount of force obtainable from the rubber air-bags. But the amount of pressure is regu- lated by valves and air-meters so as to place it under the control of the operator and render it safe. Bougies have their disadvantages. They may abrade or lacerate the membrane of the tube and penetrate its weakened walls, or they may be carried onward into the tympanic cavity and dislocate the ossicles or perforate the membrana tympani. Air and emollient or stimulating medicaments are devoid of these dangers. Generally but a few treatments are required to open the tube and maintain its patency. I remember but one case in which it required as long as three weeks of treatment without the bougie to effect this result. That was in a chronic catarrhal condition with connective-tissue stricture, but the result was 68 DISEASES OE THE EAR, NOSE, AND THROAT. satisfactory. The second indication for treatment is the reduc tion of the naso-pharyngeal or tympanic catarrh that may have given rise to the tubal trouble. But, since these conditions and the predisposing causes are treated of in their proper places, we will not repeat here. Acute Inflammation of the Middle Ear. Synonym, — Otitis media acuta. Pathology. — Otitis media acuta presents at first a glow of redness of the lining mucous membrane of the middle ear, due to the beginning hyperemia. This is perceptible through the translucent drum-head, and is followed rapidly by an effusion of serum and mucus into the tympanic cavity. These stages of inflammation follow each other in quick succession, and the disease itself is of short duration. The mucous membrane becomes tumefied and the epithelium becomes opaque and exfoliated. In a certain form of acute inflammation which is especially characteristic of the epidemic influenza, or, as it is generally known, the grip, there is so sudden an exudation as to cause rupture of the blood-vessels, and within twelve or twenty- four hours of the onset there is a copious, bloody, serous effu- sion and rupture of the membrana tympani. I have observed an influx of this type of the disease within a few days of the breaking out of the epidemic influenza in Chicago. Etiology. — This affection most often results from a cold in the head, and may be caused by an inflammation of any portion of the upper respiratory tract and by the eruptive fevers. Cold winds blowing j n the ear, getting wet, bathing, influenza, cauter- izing the nose and throat, pouring or sniffing cold fluids into the nose, and the entrance of soap and water into the meatus are prolific causes. It is more common to childhood than adult life. Symptomatology. — Sensations of itching in the ear some- times call the patient's attention to it before the actual pain begins, but the pains in other instances come on suddenly and without warning, and rapidly increase in intensity until they become unbearable. Especially is this the case in children, who DISEASES OF THE MIDDLE EAR. 69 are thrown into a fever, delirium, and even convulsions, so exquisite is the suffering. The pain is increased by sneezing, swallowing, and coughing, and it may radiate to the side of the head and teeth, or there is a sensation of numbness in the cor- responding side of the head. Autophony, or a peculiar sound of the patient's voice as perceived by himself, adds to his dis- comfort. If great pressure is exerted by an abundance of exudation, giddiness is experienced. Undoubtedly the labyrinth often participates in the disturbance to the extent of becoming hyperaemic, in which case subjective sounds become intense and even rhythmic, varying synchronously with the heart's pulsa- tions. It is not unusual to meet witli a mild type of this disease in which all the symptoms are diminished in intensity and some are absent. Hearing before the exudation may show «%■ Fig. 36.— Radiate Vascular Injection of the Drum-head. (Aft^r Politzer.) no impairment, but afterward it decreases proportionately to the amount of tumefaction and secretion. Bone-conduction is normal. Inspection reveals, in the beginning of the attack, a drum- head presenting the appearance described under the caption of " Myringitis " (Fig. 36). The malleal plexus of vessels is injected with blood ; their tracery along the upper region of the ham- mer-handle is distinctly made out ; a red areola shows about the processus brevis, and later a glow of redness covers the mem- brana flaccida. As the inflammation progresses the red appear- ance extends to every part of the membrane until it looks like a cherry in the ear. Later, as the serous infiltration increases, the outlines of the handle become dimmed and disappear ; the lustre of the membrane is lost, and in its place a dull, swollen "70 DISEASES OF THE EAR, NOSE, AND THROAT. surface presents. When the tympanic cavity becomes filled with secretions, inequalities of the surface of the membrane are visible, and a bulging in some part may indicate the pressure of fluid from within. Indeed, the whole membrane may become bulged outward, and the radiate traceries of the injected vessels show like the spokes of a wheel (Fig. 37). As the inflammation subsides the redness of the drum-head fades away, the pain ceases, the hearing improves, the noises diminish, and a general sense of relief takes the place of a stormy experience. The membrana tympani assumes a lustre- less, ashy-gray color, and its opacity remains for a considerable time, and may become permanent. Diagnosis. — There is little likelihood of confounding this disease with any other save myringitis alone. The latter forms Fig. 37.— Radiate Vascular Appearance in acute Inflammation of the Middle Ear. (After Politzer.) a factor in the present case and can, without much confusion, be separated from it. In the inflammation involving the whole of the cavity all the symptoms of inflammation of the drum- head alone are augmented, while others are ingrafted upon it. The great impairment of hearing after effusion, the general symptoms, and their duration are decisive. Children work at the affected ear, press it against warm objects, or incline the head to the diseased side. Prognosis. — The tendency is to resolution in healthy patients under favoring circumstances. In the opposite con- dition the tendency is either to suppuration and perforation of the drum-head or to a chronic catarrhal state. Treatment. — In the first stage, or before the serous effusion has taken place or the pain become severe, gentle inflation and DISEASES OF THE MIDDLE EAK. 71 filling the ear-canal with warmed pure vaselin will suffice to give relief. When the pain has become intense, inflation must be made under very low pressure, as the movements of the drum-head, like those of an inflamed joint, are exquisitely painful. The patient in this stage should be put to bed to keep the temperature equable, a warm 10- or 20-per-cent. solu- tion of cocaine may be instilled into the ear, and, if deemed necessary, i grain of morphia can be given in combination with 4^0" g ram °f atropia for an adult. If for any reason the morphia and atropia should not be prescribed, bromidia may be substituted in teaspoonful doses, in water, every half-hour until relief is obtained. Then it should be discontinued. The bowels and general health should receive proper attention. I have often found that leeches gave speedy relief. Two Spanish leeches may be applied in front of the tragus and two behind the auricle for adults. The external canal is stoppered with cotton so that the leeches cannot enter it. The skin is pricked until a drop of blood appears ; then the leech in a two-drachm vial, with its mouth at the opening of the bottle, is placed so that its mouth covers the drop of blood. The vial is held in position until the leech takes secure hold. Then the bottle is removed and the leech allowed to fill and drop off. This man- ner of applying leeches is given because few seem to be conver- sant with the subject, and this method removes the common objection to handling such repulsive animals. Especial care should be exercised to abstract the blood in middle-ear inflam- mation as much as possible from the region of the tragus, on account of the intimate relation of the blood-vessels of this region and the anterior wall of the meatus with the vessels of the tympanic cavity. If enough blood has not been abstracted after the leeches fill and fall off, more can be had by applying napkins wrung out of warm water. If there should be any difficulty in stopping the bleeding of the leech-bites, pressure applied to them will succeed. The artificial leech is also an excellent device, but occasions more discomfort. The practice indulged in by the laity of pouring oils, onion- juice, etc., into thp ear is a vicious one, since these become V2 DISEASES OF THE EAR, NOSE, AND THROAT rancid and irritating and predispose to a subsequent inflam- mation. Poultices are also mischievous and favor suppuration, and perforation of the drum-membrane. I have seen the follow- ing simple device, always convenient, give grateful relief: A piece of cotton is placed lightly in the mouth of the canal. A pipe is partly filled with tobacco and lighted. Then a piece of clean cloth is placed over the mouth of the pipe-bowl and gently blown through, while the lip-piece of the pipe-stem rests against the cotton pledget. This filters the warm smoke through the cotton into the canal, and a grateful sedative effect is soon ob- tained. I do not remember to have seen this remedy mentioned in the books, but I have witnessed its efficacy in the absence of other remedies. Fever calls for antipyrin or its equivalent in some febri- fuge that is less of a cardiac depressant. Phenacetin and ace- tanilid act well. Quinine, the enemy of the ear, must not be used. It aggravates the existing hyperemia and conduces to permanent deafness. Alcoholic drinks and smoking are pro- hibited, and any inflammatory condition of the respiratory tract must be vigorously combated. If the pain and bulging of the drum-head continue, not- withstanding all efforts to counteract the disease, and rupture of the membrane should threaten, it should be incised with the paracentesis-knife (Fig. 53, No. 2), in the postero-inferior quad- rant, so as to afford the most perfect drainage. A warm, 20- per-cent. solution of cocaine should be left in the ear for twenty minutes before the paracentesis, and, if the pain does not soon cease after perforating, more cocaine should be instilled, as hot as can be comfortably borne, so as to percolate through the perforation and reach the mucous membrane within. This will give freedom from suffering. The incision should be a long- one, cutting through the entire area of the postero-inferior quadrant vertically. The longer it is, the more it relieves the tension on the nerves of the membrane and the freer the drain- age. The paracentesis-knife must be absolutely sharp and dipped in alcohol before using. The perforation generally heals in a few days if no pus has formed. If we find suppuration has DISEASES OF THE MIDDLE EAR. 73 taken place, then we have a condition which is considered in the following chapter. After the pain is relieved, which should be the object of our first efforts, the ear may be inflated with as low pressure as will accomplish it. The air-pressure in the tympanic cavity promotes absorption of any fluid contents and will likely im- prove the hearing. This treatment is administered daily for a few days. As improvement progresses the treatments can be given at greater intervals until the normal condition is established. Diet, exercise, and clothing should be regulated on general hygienic principles. CHAPTER VIII. DISEASES OF THE MIDDLE EAR, CONTINUED. Acute Suppurative Inflammation of the Middle Ear. Synonym. — Otitis media acuta suppurativa. Pathology. — The tissue changes already set forth in the description of acute inflammation of the middle ear take place in the affection now under consideration previously to pus forma- tion. In the suppurative form the inflammatory action is more intense ; the tissues break down ; the drum-head bulges with the pressure of the accumulated fluids (Fig. 38), becomes softened, and, yielding to the consequent pressure, ruptures. The whole tympanic cavity becomes involved, and the purulent Fig. 3S.— Convexity of the Drum-head Due to Pressure from Within. (After Politzer.) discharge may find its way into the mastoid antrum and cells. This disease is practically a sequel of the one described in the foregoing chapter. Etiology. — The causes of acute inflammation of the tympanum and those that give rise to suppuration are identical, and to avoid unnecessary repetition the reader is referred to the preceding chapter. But, in the case of suppuration, there is probably an invasion of the middle ear by micro-organisms through the Eustachian tube. Bezold found the diplococcus pneumoniae in suppuration of the middle ear in pneumonia. Streptococci or pneumococci are usually found in acute suppu- ration, followed by the staphylococci pyogenes. (74) DISEASES OF THE MIDDLE EAR. 75 Symptomatology. — The symptoms here are a repetition of those already described in treating of acute inflammation up to the point of pus production, but in a certain proportion of cases the acute inflammation runs its course without the train of distressing symptoms there described. It often happens, especially in children, that the first intimation the parents have of any ailment is the appearance of a discharge from the little one's ear. On the other hand, some children are so violently affected as to suggest meningeal or brain disease. In such attacks as simulate intra-cranial affection the physician should never fail to examine the ears. Diagnosis. — Before perforation takes place it may be im- possible to differentiate between a simple acute inflammation with serous exudation into the tympanic cavity and a suppura- tive inflammation. As soon as rupture of the membrane occurs and the muco-purulent fluid is discharged into the meatus the diagnosis is cleared up. The appearance of the perforation, which can generally be seen after removing the discharge, and the presence of the latter not being due to an inflammation of the meatus, together with the whistling sound resulting from forcing the air through the perforation during politzerization, present the factors of a positive diagnosis. Prognosis. — If the habits of the body are bad, — tubercular, syphilitic, etc., — or if the suppuration result from diphtheria or scarlet fever, the prognosis is unfavorable ; otherwise, when all the symptoms are ameliorated soon after the discharge appears, the outlook is favorable. There is reason for apprehension if the severity of the symptoms continue unabated after an exit for the secretions has been provided either by nature or the surgeon. I have many times observed that when the inflamed parts showed pulsation and were very sensitive to the gentlest touch of the cotton-fluff, etc., suppuration was difficult to cure. The pulsation, which is synchronous with the heart-beats, can be seen distinctly if bright light is caused to be reflected from a moist spot on the drum-head. The pulse can easily be counted in this manner. Bulging of either the posterior or superior wall of the meatus, or symptoms referable to the mastoid process, 76 DISEASES OF THE EAR, NOSE, AND THROAT. burrowing of pus, periostitis, or osteitis are indicative of serious complications. Treatment. — In the preceding chapter, in treating of acute inflammation of the middle ear, are given in detail the methods that should be adopted in acute inflammation up to the time of suppuration and rupture or paracentesis of the membrana tym- pani. to which the reader is referred. Taking up the subject then, at the point where rupture has occurred by the efforts of nature to cast off noxious material and relieve pressure, the first observation to be made is relative to the capacity of the perforation to meet the necessity for free drainage. If the fluids are copious and the opening is too minute to admit of sufficient freedom of exit to the discharge, especially if the pain be con- tinuous, the perforation should be enlarged vertically, as has been already described in the treatment of otitis media acuta. The tympanum must also be rendered freely accessible to the surgeon for the purposes of cleansing, disinfecting, and medi- cating the inflamed membrane within. Assuming now a free perforation, the external canal is dried out very gently with a fluffy cotton-twist projecting a quarter of an inch beyond the end of a small soft-silver cotton- carrier (Fig. 9). The cotton is rolled over the point of the carrier firmly enough to prevent it from penetrating the cotton and wounding the tissues, but beyond the twisted portion the cotton should be left in a downy tuft to absorb rapidly the fluids and to avoid any abrasion of the membrane. The cotton can be carried down into the fundus of the canal and brought in contact with the drum-head until all the secretions are absorbed and extracted. As the last of these are dried up, the fluid from within the cavity may be seen oozing out, a drop at a time, or rolling down from a nipple-like perforation (Fig. 39). If one is not expert in the manipulation of these instruments, it is better to cleanse the canal by syringing it with a quart of water as warm as can be comfortably borne, the water having been sterilized by boiling for ten minutes. After freeing the meatus of all discharges the ear is care- fully inflated with as low pressure as will propel a column of DISEASES OF THE MIDDLE EAR. 77 air outward through the perforation. The discharges are hy this means projected through the perforation into the canal with a whistling or bubbling sound. If too great force is exerted, unnecessary pain is caused. Any fluids ejected into the meatus are then removed ; the canal is well dried and insufflated with aristol from the small powder-blower (Fig. 32). This remedy is preferable to boric acid in that it possesses a feeble anaesthetic property. It is the best cicatrizant we have, and, being the finest kind of a powder, it can be dusted through a narrow per- foration. A small pledget of absorbent cotton is then introduced lightly into the mouth of the meatus and allowed to remain until further discharge appears. Patients are instructed to let their ears entirely alone in case they remain dry after treatment, but if the cotton becomes moist with the discharge they are to Fig. 39.— Nipple-shaped Bulging of the Posterior Portion of the Drux- HEAD, ON THE SUMMIT OF WHICH IS THE PERFORATION. (After Politzei.) syringe the ear (Fig. 31) as previously described, and instill a warm, saturated solution of boric acid in water or rose-water, allow it to remain ten minutes, then let it escape, and close the ear lightly again with clean cotton. The cotton stopper protects the sensitive drum from cold winds or drafts and absorbs moisture. This constitutes an ideal dry dressing, and in suppuration of the ear, as of other organs, the drier the treatment, the better the results. The ear already presents the most favorable condition for the development and propagation of bacteria, — warmth and moisture. This con- dition we must combat ; so that, whatever our treatment may consist in, the aim should be to leave the parts as dry as possible. For this reason boric acid is an excellent dressing, especially when all acute symptoms have subsided. However, 78 DISEASES OF THE EAR, NOSE, AND THROAT. during the acute stage boric acid may cause pain for several hours after its application. I have met with quite a number of such instances in which it became necessary to discontinue the use of this powder. I have suspected that certain indi- viduals possess an idiosyncrasy against it, but, if it produce no discomfort, excellent results may be expected. It absorbs moisture and dries the tissues. If fluids come in contact with it a saturated solution of boric acid is formed, which may per- colate through the perforation into the middle ear and there exercise its feebly germicidal power. No powder, however, should be firmly packed into the ear, for it would prevent the escape of discharges and cause them to seek an outlet else- where : through the Eustachian tube if it were fortunately pervious, or through the mastoid antrum and cells, or even by way of the internal meatus or the tympanic roof to the cranial cavity. Moreover, it should never be forgotten how intimately the middle ear and mastoid spaces are related to the contents of the cranial cavity by the connecting blood-vessels, lym- phatics, and by occasional defects in the superior surface of the temporal bone. These conditions emphasize the necessity of always keeping the passage-way for the flow outward unob- structed. In case the drum-membrane and the canal remain very sensitive and pain continues unabated in the ear, a 12-per-cent. solution of carbolic acid in glycerin generally gives relief. The acid anaesthetizes and disinfects without corroding the tissues when combined with glycerin, and the latter unloads the blood-vessels of their superabundant serum. The tumes- cence of the vessels is diminished and the pain relieved. Gen- eral treatment is to be resorted to when the conditions demand it. The body should be protected from sudden atmospheric changes by wearing wool next the skin. Further elucidation of tiiis subject will be found under the heading of "Treat- ment" of coryza. Since the disease under consideration is largely the result of acute catarrh of the nose and throat, coincident treatment should always be addressed to the naso-pharyngeal affection, DISEASES OF THE MIDDLE EAR. 79 and our efforts must be directed toward removing any perma- nent causes of recurring attacks, such as hypertrophies in the nasal chambers, adenoid growths in the pharynx, and enlarged tonsils. (See chapters on these subjects.) Chronic Non-suppurative Inflammation of the Middle Ear. Under this name are classed hypertrophic middle-ear catarrh and adhesive middle-ear catarrh, — sclerosis (see Chapter IX). Fig. 40.— Fluid Effusion in the Tympanic Cavity, Marked by a Bright Line. (After Politzer.) HYPERTROPHIC, OR SECRETIVE, CATARRH OF THE MIDDLE EAR. Pathology. — Hypertrophic, or secretive, catarrh of the mid- dle ear occurs in association with a similar condition of the nose and naso-pharynx. There is an hypereemic condition of the mu- cous membrane lining the tympanic cavity, with hypersecretion Fig. 41.— Circumscribed Bulging of the Drum-head, Due to Pressure of Fluid in the Middle Ear. (After Politzer.) of a serous or mucous character. The exudation may be visible (Figs. 40 and 41) if the drum-head has not lost its translucency, more especially when air has been forced through the Eusta- chian tube into the fluid, thereby causing bubbles or a frothy appearance. In this disease the tube generally participates to the extent of losing its patency; so that the normal supply of 80 DISEASES OF THE EAK, NOSE, AND THROAT. air in the middle ear is cut off. The result is that the air in the middle ear is absorhed ; so that the resistance of the drum-head to the outward atmospheric pressure of nearly fif- teen pounds to the square inch is lost, and the membrane is forced inward toward the inner tympanic wall. The effect of this encroachment upon the tympanic space is easily visible in the increased concavity of the membrane, the foreshortening of the hammer-handle, the emphasizing of the posterior fold, and the changed location of the reflection of light. The drum-head yields to the atmospheric pressure from without when the counteracting air-pressure from within is lost, and lies, perhaps, in contact with the inner wall, especially the posterior half. In this case it may so embrace the long process of the anvil and the posterior cms of the" stirrup as to show Fig. 42— Ctkeat Concavity of the Drum-head and Foreshortening of the Hammer-handle. (After Pulitzer.) their projecting outlines and those of the promontory and round window. The mallet-handle may at first seem to be invisible until one looks from below upward as much as possible, when it is seen occupying an almost horizontal position (Fig. 42), running directly inward until its lower extremity lies in contact with the inner wall of the cavity. The short process is thrown outward by this position toward the examiner's eye like a little yellow knuckle covered with membrane that is stretched into tense folds above. If the drum-head is still lustrous the triangle of light has been moved from its normal position, or there is a circular reflection of light from the most depressed section, or there may be several dots of light, owing to the irregular surface produced by the varying degrees of depression in different parts of the membrane. In an advanced stage these irregularities of retrac- DISEASES OF THE MIDDLE EAR. 81 tion are due to an atrophied condition of one or more parts of the membrane, and, unless a careful inspection is made, these atropines may be easily mistaken for cicatrices. The latter, how- ever, are more clearly defined by the distinct line forming a bor- der to a previous perforation and now separating the cicatricial tissue from the opaque, thickened membrane surrounding. The atrophic area blends gradually in more indefinite outlines with the adjoining hypertrophic tissue. The massage otoscope (Fig. 8) shows these atrophic and cicatricial sections with unmistakable clearness. When the air is rarefied in the canal, these spots bulge outward like balloons, as if they might burst. Indeed, they probably could be easily ruptured if much force were exerted. They show exaggerated movements when the remainder of the membrane and the mallet are completely quiescent. But, when the drum-head is depressed against the inner tympanic wall and has become ad- herent to it by organic adhesions, these adhesions prevent the depressed area from responding to the pneumatic otoscope. In the more advanced stage of this disease the drum-head becomes very greatly thickened and of a milky opacity, and hypersecretion and impaction of cerumen are frequently found. Etiology. — Acute colds in the head, influenza, the eruptive fevers, chronic naso-pharyngeal catarrh, and syphilis act as the exciting causes of this affection. Impermeability of the Eustachian tube, with consequent rarefaction of the air in the middle ear, causes an exudation of serous fluid, retraction of the drum-head, etc., which may only prove to be transitory if the cause of the tubal stenosis is speedily removed, or, if it is not, permanent tissue changes may occur, resulting in the more serious conditions described. Symptomatology . — This is not a painful affection, although in the early stages slight twinges or darting and shooting tran- sitory pains may occur. Sensations of fullness in the ear, press- ure, and as if something w 7 ere moving in the ear are complained of. The last symptom is produced by movements of the fluid contents of the tympanic cavity, ow 7 ing to the varying positions of the head and to the entrance of air into the fluid through 82 DISEASES OF THE EAK, NOSE, AND THROAT. the tube. The last cause also gives rise to bubbling, snapping, and crackling sounds. These rales result from the separating of the walls of the Eustachian tube also, when it is involved, as air passes through. The viscous mucous secretion agglutin- ates the walls together, and as they separate the clinging mucus first sticks, then stretches into filaments, and the breaking of these occasions the crackling noises. The movements of the jaw aggravate these symptoms. Sensations of numbness in tlie corresponding side of the head, confusion of ideas and speech, irritability of temper, and autophony — or a disagreeable hollow sound of one's own voice, as if talking into an empty barrel — are characteristic of this disease. The swelling of the tissues and increased tension of the drum-head and ossicles may produce labyrinthal pressure with a sense of light-headedness, giddiness, and subjective noises, although the latter constitute one of the principal symptoms of sclerosis. The hearing varies greatly with the weather con- ditions. Low barometer and thermometer, with great humidity of the atmosphere, increase the impairment of hearing, the sen- sations of stuffiness and fullness, and tinnitus aurium. Sudden changes to these atmospheric conditions from a warm, dry air are certain to aggravate the aural symptoms. Patients can pre- dict approaching weather changes by the phenomena mentioned. Alcoholic stimulants and colds in the head also increase these distressing symptoms. Diagnosis. — It is not difficult to determine the presence of the secretive form of catarrh. If the drum-head is yet trans- parent the line in the membrane indicating the surface of the liquid can be made out unless it extends above into the attic, or the propelling of air into it can be heard to produce bubbling sounds, and in the early stages the hearing may not be greatly impaired or it is much improved by politzerization. The patient is generally young, bone-conduction for the watch and tuning- fork is good, and the disease is far more amenable to treatment than is sclerosis. Prognosis. — This is favorable if we can exclude heredity, bad sanitary influences, and general ill health, and if the attack DISEASES OF THE MIDDLE EAR. 83 is not of long duration. Especially is this so if inflation of the ear and removal of any contained fluid result in decided improvement in the symptoms and if the bone-conduction is good. But examination of the nose and throat will throw im- portant light on this subject. If there are no hypertrophies and exostoses, but a simple catarrh of recent origin, a cure is readily effected. Treatment — Attention must first be directed to the pass- ages that lead to the middle ear. If there exist a catarrhal con- dition of the nose and throat that may have given rise to the middle-ear disease, it should receive proper treatment at the same time with the Eustachian tube and tympanum. Per- manent cure of the ear affection cannot be effected so long as the exciting cause of such attacks remains in the nasopharyn- geal tract. The Eustachian tube, if diseased, should be the subject of proper measures to render it permanently patulous and healthy. The air-douche by the Politzer air-bag or the compressed-air apparatus is sufficient in many recent cases to cause absorption of secretions in the middle ear and the reduc- tion of hyperaemia and swelling of the mucous membrane. By this means the natural ventilation by the canal is effected and the drum-head is restored to its normal position and tension. This inflation should be carried out daily until the improvement obtained at each sitting remains permanent until the next ; then the time is lengthened to two, three, or four days or more, or a week or two between the treatments, according to this rule, until the cure is complete. As soon as the organ is apparently restored to its normal condition treatment should be discon- tinued, as a retrograde may otherwise occur. Overtreatment is certainly to be avoided. At each sitting the inflations are re- peated from two to four or six times, with not enough pressure to cause pain or bright redness of the membrana flaccida. The vessels along the upper portion of the handle of the mallet often become injected even after gentle inflation. Massage by the pneumatic otoscope is practiced after the in- flation sufficiently to insure the normal mobility of the ossicles, but not to produce discomfort in the drum or any irritation. 84 DISEASES OF THE EAR, NOSE, AND THROAT. For the removal of the fluid contents of the tympanic cavity that do not disappear after inflation, a number of years ago 1 devised a method that I have never seen mentioned ex- cept once, which was in a journal article that appeared about three years after my publication. The patient inclines his head forward and a little toward the opposite side, and practices an experiment that just reverses the Valsalvan method. He closes the nose with thumb and forefinger and draws the air from the naso-pharyngeal space down into his throat. This method exhausts the air of the cavities above the pharynx and sucks the secretions from the middle ear and Eustachian tube into the throat ; they can be seen immediately afterward trickling down the side of the pharynx from the region of the tube-orifice. When the drum-head was perforated I have utilized this same method to draw medicated solutions from the external meatus through the middle ear and tube into the pharynx or nose. This thoroughly washes these surfaces with the remedies used. The treatment outlined does not mention the catheter for the reason that, since the introduction of the modern improved instruments for treating the ear, nose, and throat with com- pressed air, the catheter is rarely a necessary instrument. It is — in my practice, at least — relegated to the company of instru- ments rarely honored by use. The reason of this is that the ■ improved inflator (Fig. 24) will inflate the middle ear in almost every instance in which it is properly employed. This saves the patient suffering, prevents injury to the inflamed walls of the tube, and avoids the possibility of infection, as the inflator is not carried into contact with the mucous surfaces as the catheter is. If my method of auto-aspiration of the tympanic cavity through the Eustachian tube should not suffice on account of the thick, tough character of the secretion, paracentesis should be made under antiseptic precautions as described in the treat- ment of acute inflammation of the middle ear. After opening the membrane air is thrown through the tube and tympanum so as to eject all discharges from them into the external meatus. There need be no fear that any permanent damage may be DISEASES OF THE MIDDLE EAR. 85 done by the paracentesis, for it will undoubtedly close in a few days. The expelled secretions should be absorbed by cotton on a carrier and the canal left dry. The meatus is then closed with absorbent cotton. Should fluid accumulation recur the membrane may have to be re-opened, even repeatedly in excep- tional cases. A few days or weeks of this treatment generally suffice for a cure, but the more obstinate conditions require months for their eradication. The treatment for associated rhinitis and pharyngitis will be found under those headings. Medicinal applications may be advantageously employed when simple air-douches fail to reduce the tumefaction and hyperemia of the lining tympanic membrane. A number of years ago I introduced the use of purified liquid vaselin, and later camphor-menthol in lavolin, for treating tubal and tym- panic catarrh. The physiological action of camphor-menthol is given in Chapter XVIII. Sprays of these remedies are thrown into the tube and middle ear by means of the improved inflator. The sponges it contains are moistened with the liquid and, by applying the cut-ofT of the compressed-air tube to the inflator, a jet of the remedy- is projected into the tube and tympanum. I have learned that Charles Delstanche, of Brussels, preceded me in the use of liquid vaselin in the middle ear. This treat- ment is usually best followed by the massage otoscope. After the treatment has effected all that is possible I have observed that patients maintain their improvement and even continue to improve, after changing their residence from low and damp sur- roundings to a high, dry, and equable climate. Operations on the drum-head are treated of in Chapter X, and hygienic measures are considered in the treatment of acute rhinitis, or corvza. CHAPTER IX. DISEASES OF THE MIDDLE EAR, CONTINUED. Sclerosis, or Adhesive Inflammation, of the Middle Ear. The line of demarkation cannot be distinctly and unmis- takably drawn between the early adhesive and the late hyper- trophic form of middle-ear catarrh. The latter may merge by imperceptible degrees into the adhesive variety, and the sclerotic processes may pass through their initial stage during the activity of the hypertrophic inflammation. But the most intractable forms of deafness — involving ankylosis of the ossicles, especially immobility of the stapes, and labyrinthal involvement — characterize the adhesive, or sclerotic, catarrh. Pathology. — While this form of catarrh may affect the whole lining membrane of the middle ear, it may be circum- scribed and limited to the tissues surrounding the oval and round windows. A distinguishing characteristic is an insidious interstitial inflammation, induration, and chronic thickening of the tissues, or sclerosis. But in a considerable proportion of cases there is progressive atrophy; pale, thin membrane, and calcareous degeneration. Again, there may be an excessive proliferation of connective tissue, filling and even obliterating the cavity of the attic and of the oval and round fenestra and binding down the ossicles to such a degree as to impede or pre- vent their normal movements. Bands connecting the membrana tympani and ossicles together increase the normal tension of the conducting apparatus, resulting in varying degrees of deafness. These bands become the seat of calcareous degeneration, with the result of binding the ossicles to. each other, to the membrana tympani, and to the tympanic walls with rigid or bone-like bridges. The drum-head is often the seat of these chalky de- posits, which generally appear like miniature drifts of snow in crescentic forms below and about the mallet (Fig. 43). Ankylosis of the ossicles takes place either by increased (86) DISEASES OF THE MIDDLE EAR. 87 fibrous-tissue formation or by bony growth. Ankylosis is in- frequent between the anvil and stirrup, but is frequent between the mallet and anvil, and between the stirrup-plate and the border of the oval window. Indeed, we may have all these Fig. 43.— Semilunar Chalky Deposit in Front of the Handle of the Mallet. (After Politzer.) ankyloses combined with bands of adhesions binding the mem- brana tympani and ossicles together, and hypertrophy and calcareous degeneration of the membrane of the round window. The natural filaments and bridges of mucous membrane con- necting the crura of the stirrup with the oval foramen (Fig. 4-i) favor the fixation of this bone when fibrous or calcareous r, JS Fig. 44.— Niche of the Fenestra Ovalis, with the Crur.e of the Stapes, in the Normal Ear of an Adult. (After Politzer.) Net-work of bands extending from the neck of the stapes to the walls of the niche, c, head of the stapts ; s, s, crura? of the stapes. changes occur. Calcification or ossification may take place in the ligamentous ring of the stirrup, and bony union with the oval window may result, Calcareous deposits have been found in the malleo-incudal joint, and I have suspected that in patients 88 DISEASES OF THE EAR, NOSE, AND THROAT. of a uric-acid diathesis there might occur deposits of urate of soda in these joints as well as in the other articulations. Kichey believes sclerosis to he closely related to progressive arthritis de- formans. In a conversation with Professor Politzer upon this subject, in 1893, I asked him if he had ever discovered such a deposit, but he replied that he had not, since, in his method of preparing specimens, any evidence of such deposits would be destroyed. The Eustachian tube may participate in a diffuse form of this inflammatory process and become stenosed, but it is often normally permeable and even abnormally patulous. Etiology. — The hypertrophic, or secretive, inflammation of the middle ear predisposes to the adhesive or dry sclerotic form. The latter is noticeably hereditary and can be often traced to the father and his family or to the mother and hers. The brothers or sisters are often more or less afflicted. General dis- eases that are destructive of tissues and exhausting to the gen- eral strength promote this form of middle-ear catarrh. Chronic catarrh of the nose and throat and excessive indulgence in alcohol and smoking bear a close causative relation to sclerosis. Yet I cannot place the emphasis on smoking that some authors do, since I have seen the worst examples of this disease in both women and men who were not at all addicted to the use of tobacco. The hypertrophic form might be spoken of as a disease of childhood, during which it is very common ; but sclerosis is a disease of middle and old age. In my experience it nearly always is seen in persons over 30 years of age, rarely in those younger, and mostly in those much older. It generally affects both ears, and, although patients often aver that only one ear is troublesome, the surgeon should never fail to examine both — and the naso-pharynx as well. Symptomatology. — Tinnitus aurium constitutes the most distressing symptom. Patients often declare that if the noises only can be conquered they will be satisfied, whether their hear- ing can be improved or not. These are variously described as high-pitched ringing, like that produced by quinine or by boxing DISEASES OF THE MIDDLE EAR. 89 the ears; like roaring or rushing of waters ; crickets ; hissing ; the singing of a tea-kettle ; sighing of the winds, . etc. The in- tensity of the tinnitus is usually in proportion to the loss of hearing, until the miserable subject can hear little or nothing but the interminable storm of confusing and crazing noises, compared to which the clanging and crashing of the kettle- drums and cymbals in a Wagnerian overture are a heavenly melody. The suffering is increased by cold, wet, and windy weather ; taking cold, alcoholic drinks, speaking or reading aloud, and anything that produces excitement or depression of the strength or spirits. Sometimes a startling loud sound rings out suddenly, without any apparent cause, like a stroke from a hammer on a high-pitched bell ; then gradually it dies away until it is lost in the confusion of other less intense subjective sounds. Often patients declare that the noises are not in the ear itself, but refer them to the side of the head and even to the occiput. Most frequently, however, I have noticed that they place the tips of their fingers over the hearing- centre in the brain when locating the sounds outside of the ear. They sometimes believe it is possible for others to hear these noises if the observer's ear were to be placed close to their own. I have known some patients to insist that crickets or other animals were in their ears, and that I must remove them, when the symptoms were entirely subjective. On the other hand, persons of discipline of mind and strong will suppress mentally these besieging enemies to con- secutive thought and intelligent action until they are scarcely conscious of their presence while engaged in active occupations. But when the mind becomes disengaged for a time in a quiet place, or more especially when there is occasion for listening intently to a speaker, the noises seem to surge back into the presence of the conscious mind with furious intensity. Very nervous individuals are so overwhelmed by this symptom that they may succumb, and part with their reason. Severe or continuous pain is not a symptom of sclerosis, but sharp, stinging pains lasting but a few seconds or minutes 90 DISEASES OF THE EAR, NOSE, AND THROAT. are not uncommon. Great sensitiveness to certain sounds and to concussions of the air exists. The slamming of a door may- he painful, owing to the noise or to the concussion or both. With increased tension of the conducting apparatus and impac- tion of the foot-plate of the stirrup in the oval window, there is an increase of labyrinthal pressure and more or less vertigo and sense of tightness or pressure in the head, although the patient may not be able to particularize or localize it unless he possesses a very observant mind. The hearing is generally much worse in sclerosis than in hypertrophic catarrh, and shows less variation either with or without treatment. The hearing may vary during the day. One individual hears better in the morning and worse in the evening. Another hears better until 4 o'clock in the afternoon, when the hearing becomes dull, to remain so the rest of the evening. Another hears worse in the morning until he has his breakfast and boards the train for the city, when the jar of the car appears to produce a commotion in his ears, his Eustachian tubes open to the admission of air to the tympanic cavities, and at once he hears better and experiences a sense of clearness and relief in his ears. In the noise lie hears better, even better than those with normal hearing. A locomotive engineer under my care said he could hear better than his companions w 7 hen his engine was in motion, and that his employers, for whom he had worked several years, did not suspect his hearing impairment. He managed to give them no opportunity of conversing with him except in a noise. The vibrations of his engine communi- cated motion to his conducting apparatus, which then conveyed sound-waves that were too feeble of themselves to institute these movements. Another interesting fact has come under my observation. A long-standing catarrh of one ear had so impaired its useful- ness that the patient did not consciously depend upon it. The better ear had lost its usefulness through an attack of epidemic influenza, when the patient was obliged again to depend on the previously worse ear. Then it was found that, although sounds could be distinguished in it, they could not be understood. DISEASES OF THE MIDDLE EAR. 91 Words could be heard, but not interpreted, on account of long disuse of the organ. It became necessary to practice with the various words in common use until they could be distinguished from each other and correctly interpreted. The process was com- parable to learning a new language, but it was accomplished. In this case the sounds of the C and C, 128 and 256 vibrations, are perceived by air and bone at the correct pitch by both ears. The C" and C"' \ 512 and 1024 vibrations are always heard at the proper pitch in the right ear, and by bone in the left ear ; but by air in the left they are perceived as a half-tone above the real pitch. Fork C"", 2048 vibrations, is lieard in both ears faintly, when almost touching the mouth of the meatus, but not by bone with either ear. The patient dis- tinguishes with difficulty between this fork and the subjective ringing, which is of the same pitch. The hearing for speech is the most affected, while hearing for music, etc., may remain fair. The musical composer, Emerson, was afflicted with greatly impaired hearing for speech ; but he mastered the trying requirements of a great musical conductor. Hearing better in a noise, paracusis, is character- istic of this form of ear disease. By the simple expedient of causing sound- vibrations in the air by means of such a device as an electric hammer, or the electric bell with the gong removed, or a spring and ratchet in an electric fan, one with this form of deafness will be able to conduct business communications when otherwise he could not without a conversation-tube or horn. It is not, however, the commotion of the air produced by the fan-wings that aids hearing, but the sound-waves that keep the drum-membrane and ossicles in vibration. Bone-conduction is not so likely to be normal in this as in the hypertrophic process. It is often much diminished or alto- gether absent. But it should not be forgotten that bone-con- duction begins to show reduction after the thirtieth year. The hearing for the highest tones and the very low notes is di- minished or lost in the order named. Certain notes in the medium register may also be unperceived, which indicates labyrinthal implication. 92 DISEASES OF THE EAR, NOSE, AND THROAT. Diagnosis. — The appearances of the drum-head vary greatly. There are thickening and retraction of the membrane (Figs. 45 and 46) with foreshortening of the mallet-handle in Fig. 45.— Maukkd Rktkaction of the Drum-head. (Alter Politzer.) some cases (Fig. 42), while in others there is atrophy with chalky deposits or, in yet other cases, a membrane of quite normal appearance. The adhesive process may be confined to Fig. 46.— Circumscribed Depressions in the Anteroinferior Quadrant of the Left J)rum-head. (After Politzer.) circumscribed areas on the surface of the inner wall which in- spection does not reveal. The Eustachian tubes may have been involved during the early stages, while later in the history of ^m Fir;. 47.— CIRCUM8CRIBED ADIIKSION OF THE AlEMBRANA TyMPANI TO THE PRO- hontoky I'ndkrnkath the Handle of the Mallbt. (After Politzer.) a, point of adhesion. the case they may be freely permeable. The massage otoscope will show any adhesion of the membrane to the inner wall (Fig. 47) and the amount of mobility that the mallet may have lost. DISEASES OF THE MIDDLE EAR. 93 It will also reveal bands of adhesion that may exist super- ficially behind the membrane if the latter is pressed by the air inward so as to lie against and embrace these bands. When there is normal freedom of motion of the hammer during the massage, it is certain that its articulation with the anvil and the articulation of the latter with the stirrup cannot be ankylosed ; but the stirrup may be ankylosed in the oval foramen. In such cases with a normal-looking drum-head one must be very guarded in his prognosis, for they are sometimes intractable and hopeless. Prognosis. — From what has been said it will be naturally inferred that brilliant results may not be expected from treat- ment in a large proportion of cases of sclerosis of the middle ear. The outlook will be more favorable if the disease is not of long standing, if tinnitus is either absent or only an oc- casional symptom, if the hearing is not seriously impaired, if bone-conduction is normal, and if treatment produce a decided amelioration of the symptoms. The reverse of these circum- stances renders the prognosis unfavorable. Age, general health, sanitary surroundings, personal habits, heredity, and occupation must also enter into the account. Treatment. — We can hardly speak of treatment in this form of middle-ear catarrh as curative. We must candidly admit that in otology, as well as in other branches of medicine, there are maladies that baffle the most skillful practice of our art. All that we can hope to accomplish is to stay the progress of a persistent process. A patient under my treatment at the present time said, when informed that he had lupus: "Then I will have nothing done." I replied : " If a wolf were biting you, would you not want me to take him oft"? " So in the case of sclerosis ; it is our duty to interpose every possible obstacle to the development and progress of the pathological process that is attended with such distressing and deplorable results. If no more can be accomplished than to relieve the never-ending din of harassing noises that incessantly bombard the brain, it is worth the while. This confusing strife of discordant sounds, this concentration of all the overtones in nature focused on a i)4 DISEASES OF THE EAR, NOSE, AND THROAT. sensitive being almost deprived of normal, intelligible, sweet- toned sounds, too often test the tension of the mind to the breaking-point. The most common and simple treatment is the injection of air; but, in order to accomplish enough movement in the mem- brane and ossicles to stretch or break bands of adhesions and to overcome ankylosis, more force must be applied than is recommended in the simple hypertrophic catarrh. While the latter may require with a patulous tube no more than an atmos- phere, or 15 pounds, or less, I have employed 60 and even 80 pounds without producing much impression on these old, hardened, thickened, leathery drum-heads. This is not men- tioned as an intimation to the unpracticed that they should use so much pressure, but 30 pounds' pressure is often required to produce any motion in the ossicles. Wiirdemann advocates similar treatment, with the air-regulator. When the foot-plate of the stirrup is not ankylosed, some transitory giddiness may be occasioned by this pressure, but in case it is immovable we cannot look for dizziness to occur from inflation. If we can obtain sufficient movement in the stirrup to produce momentary vertigo it brightens the outlook, for it indicates that bony union has not yet taken place between the base of the stirrup and the border of the oval foramen. If inflation and massage are fol- lowed by an amelioration of the symptoms, improved hearing, abatement of the tinnitus, relief of sense of pressure, and a feeling of clearness in the head, then the prospect is encourag- ing. If a few weeks of daily treatment should make no per- ceptible impression of any kind, the opposite is true. But the massage treatment on alternate days is a most important auxil- iary to politzerization, and we can now profitably enter into its detail. The author's massage otoscope (Fig. 8) possesses some advantages over others. As compared with Siegle's pneumatic speculum, the author's otoscope is (1) self-illuminating, not requiring the aid of a hand-mirror or forehead -mirror, the light being accurately focused on the drum ; (2) it affords a mag- nified view of the drum ; (3) it can be operated in a smaller DISEASES OF THE MIDDLE EAR. 95 canal than will admit the speculum ; (4) the bright reflection of light into one's eye by the glass of the speculum, the black background of which converts the glass into a mirror, is avoided in the otoscope by the proper and unvarying relations and the color of its various parts. The directions for manipulating this instrument are given in Chapter II. By alternately rarefying and condensing the air in the meatus the amount of mobility in the drum-head and the chain of bones may be determined under brilliant illumination and magnified inspection. If ankylosis of the joints of the ossicles or if bands of adhesions between the bones and the walls of the tympanum exist, the handle of the malleus will be seen to be impeded in its movements, or it may remain fixed, while the membrane about it may be quite flaccid, and respond to the rarefaction of air by bulging outward about the mallet-handle (Fig. 38). If the membrane is greatly thickened in patches or if it contain calcareous deposits, these portions will be seen to resist the action of the vibrating column of air, while normal parts and areas of thin, cicatricial tissue that indicate the loca- tion of former perforations may respond readily to the experi- ment. In cases where the drum-head is very thick, or where the ossicles are bound down by adhesions to the walls of the tympanum, no perceptible movement may be obtained at first, but decided improvement often follows a persistent use of the pneumatic treatment. In obstinate cases the progress may be hastened by making pressure directly upon the processus brevis by means of a probe covered with a soft-rubber tip or Lucre's pressure-probe. Stiff- ness in the joints may be overcome in this way so as to facilitate the action of the otoscope. One should press gently on the process until the handle moves, then retract the probe until the malleus resumes its former position, press again, and so repeat the movement several times. Then the pneumatic principle of the otoscope should be applied until one is satisfied that the ad- vantage gained will not be lost. The mallet should be moved until the patient experiences a sensation of movement or sound. The utility of passive motion, or massage, in the treatment 96 DISEASES OF THE EAR, NOSE, AND THROAT. of stiff joints and atrophied tissues is well recognized in general surgery. The application of the same principle to the same conditions in aural surgery is also attended with beneficial results. Charles Delstanche, of Brussels, has also devised an excellent massage instrument. The pressure-probe which I devised in 1886, and of which I made mention at the meeting of the American Medical Asso- ciation in 1888, has been superseded by a much better one de- vised by my good friend Professor Lucas, of Berlin. It consists of a delicate shank set parallel to its hollow handle by a right- angle deviation so as to bring the operator's fingers out of the field of vision. The distal extremity terminates in a soft, downy cup that fits over the short process. The handle con- tains a delicate spiral spring surrounding the proximal end of the shank so that pressure on the short process and release of pressure should produce a rebound or to-and-fro excursion of the hammer-handle without removing the cup from the process. This method is painful and causes congestion of the membrana flaccida, but is beneficial. Direct pressure on the line of the short process is the most effective on the stirrup. If treatment by inflation and massage produce redness along the malleal plexus of vessels, extending over the greater part of the mem- brana flaccida, it should not be used further for that treatment. I have found the best results from a systematic plan some- what as follows : For the first week or two lavolin is injected into the middle ear by means of the improved inflator on Mon- day, Wednesday, and Friday, always preceding the ear treat- ment with the necessary cleansing and medication of the nose and throat. On the intervening days the massage otoscope is used sufficiently to obtain as near the normal mobility of the ossicles as possible, or until the hypersemia, mentioned before, is produced. On the second or third week the treatments are gradually separated by intervals of two, three, or four days. The lavolin conduces to the softening and rendering pliable of the adventitious tissues in the middle ear. When stimulation is desired, or the patient or surgeon is in doubt as to the entrance of the jet of lavolin into the tympanic cavity, 6 or 10 drops of DISEASES OF THE MIDDLE EAK. 97 sulphuric ether added to the lavolin in the sponges contained in the infiator will produce stimulation and a sensation of coolness followed by a glow of warmth in the ear, thus demonstrating its presence in the tympanic cavity. Richer advocates the iodine-vapor inflations and iodized cotton in the external canal. Dundas Grant uses a self-inflator charged with chloroform. If it should be desirable to produce the effect of camphor- menthol on the lining membrane of the tympanic walls without carrying a perceptible amount of the menstruum into the cavity, this can be accomplished by substituting the dilator (Fig. 18) for the infiator, with a 3-per-cent. solution of camphor-menthol in lavolin. For the physiological action of camphor-menthol see Chapter XVIII. It is but proper to remark that the bene- ficial results sometimes afforded by this method are even more surprising to the surgeon than to the patient. Formerly the author followed in the footsteps of his pre- decessors in the employment of fumes from resublimed iodine crystals with which to douche the middle ear, but so little per- ceptible good and so much irritation attended its use that it has had no place for this purpose in his practice for a number of years. Pilocarpine, from which so much has been expected by some eminent otologists, has proven, after persistent trials, a dismal failure in the author's experience. I have tried solutions of citrate of lithia, a very soluble form, by injections through the Eustachian tube, in the hope that if deposits of urate of sodium were present in certain gouty patients, and if the anky- losis of the ossicles were due to the presence of this deposit as in other joints of the same individuals, it might be dissolved out. Carbonate of lithia is known to accomplish similar results. The result was nil. Various other solutions and volatile medicaments have been projected into the middle ear for the relief of sclerosis, but it would be a waste of time and space to enumerate most of them. Many are inert, others positively harmful. The injection of fluids through the Eustachian catheter and tube is a painful process attended with irritation of the tnbe and tympanum unless accomplished by exceptionally skillful and gentle hands — and no others should attempt it. 98 DISEASES OF THE EAR, NOSE, AND THROAT. Possibly a little tympanic irritation may prove beneficial, but the probabilities are in favor of its proving harmful. If hyper- emia is desired it can more easily and safely be produced by the prolonged use of the massage otoscope and Lucas's pressure- probe. The Valsalvan method produces congestion of the tympanic tissues, and for that reason patients ought not to be taught or allowed to practice it. They receive a certain amount of temporary relief; consequently they practice it not once or twice a day, but repeatedly, many times a day, until the membrana tympani loses its tension, becomes relaxed and retracted, and no more relief is had. The use of the phonograph, vibrometer, and other expen- sive instruments that produce sound-waves of speech, or musical vibrations that are conveyed to the drum-head by rubber tubes inserted into the external canal, have been vaunted by ill- advised laymen ; but experimental investigation only confirms what a familiarity with the principles involved presages : their utter uselessness. During a discussion of this subject at the meeting of the First Pan-American Medical Congress, the otologists present, including the distinguished Professor Politzer, concurred in these conclusions quite generally. It is worthy of attention that the treatment as outlined above filters all the air and fluids before they reach the ear. All are forced through the finest quality of medicated sponges, which offer a resistance to the air-current of about four pounds. This fact should be given proper consideration in every treat- ment, and all the instruments must be kept scrupulously clean and disinfected in order not to commit the unpardonable sin of infecting a patient. How long shall treatment continue'? Only so long as improvement continues. If it is protracted much beyond the time indicated, it may be followed by an actual retrogression. Too much treatment is pernicious. When improvement takes place and a state is reached in which improvement remains stationary, despite all efforts for a reasonable time, then treat- ment had best cease. The patient should be discharged with proper instructions for the care of himself, and for his return DISEASES OF THE MIDDLE EAR. 99 should be begin to lose the gain already made. Indeed, tbese unfortunates must be gently, but candidly, informed that, so long as life's burden bears upon them, just so long they will suffer the necessity of repeating their sojourneys to the aurist whenever relapses occur. The invariable question " How long must I be treated]" every otologist has to answer. The average length of time required varies from one to three months. Often the patient will remark that his head feels clearer and the noises have diminished or changed in character, which is favorable. If but one ear is affected, its early treat- ment may prevent the other following in the same route. Or if both are affected, if they have not become too seriously involved, we may be able to arrest the progress of the disease and preserve, if not improve, the present state of hearing. The application of the faradic current for ten minutes at a time daily for several weeks has appeared to exert a beneficial effect in certain cases. I have designed electrodes (Fig. 72) adapted to the concentration of the current in the ears, for the older ones diffused the electricity over the side of the head. The tips of the chamois-covered electrodes are wet and covered with a little moistened cotton, inserted into the auditory canals, and buckled in place. Then the cables are attached connecting the electrodes with the battery. In this manner the patient is relieved of the tiresome holding of the electrodes in place. However, I do not attach great importance to electricity in this disease. CHAPTER X. DISEASES OF THE MIDDLE EAR, CONTINUED Operative Treatment of Sclerosis. The author has devised an ossicle-vibrator (Fig. 48) for the purpose of breaking up adhesions in the middle ear and anky- losis of the ossicles. It consists of a shaft of steel armed with two little levers at the distal end, and fashioned at the proximal extremity to fit into the angular handle of the middle-ear instru- ments. It is used in the following manner : An incision is made through the drum-head close to the anterior border of the ham- mer-handle and parallel with it from the short process to its tip under cocaine. Then the end lever, which is curved for the purpose, is carried through this slit and behind the mallet, Fro. 48.— The Author's Ossicle-vibrator. when the handle falls between the two little levers. Then they are slipped along upward embracing the handle until the stronger part of the bone is reached and the levers fit the handle somewhat closely. Now the retracted handle is slowly and very gently drawn upon until it is felt to move, or until the adhesions are felt to give way, and to the extent of bringing the handle to its normal position. The gentlest care must be had or the adhesions may give way very suddenly with a jerk and the mallet might possibly be dislocated, or the handle might be fractured, especially if the instrument were allowed to slide downward upon the weaker portion of the handle. I have not known these accidents to attend the use of my instrument, but one can conceive that they are within the range of possibilities. Again, a patient has become pale just as the adhesions yielded (100) DISEASES OF THE MIDDLE EAR. 101 to the traction, and fainted. This was probably due to the dis- turbance of the intra-labyrinthal fluid as exaggerated motion was effected in the stirrup. Some most remarkably beneficial results have followed the use of this simple method of mobili- zation of the ossicles. No harm has been known from it. After making the incision and before introducing the vibrator, it conduces to the comfort of the patient to instill a few warm drops of 10-per-cent. cocaine solution. Incision of the posterior fold of the drum-head is indicated when there is great sinking inward of the membrane, with fore- shortening of the mallet-handle, and prominence of the short process, with a stretched appearance of the membrane about it. This condition, associated with serious impairment of hearing and head noises that are unimproved by the treatment already Fig. 49.— Section of the Posterior Fot,d of the JIembhaka Tympani. (After I'olitzer.) detailed, calls for this simple operation. The section is best made about midway in the folds (Fig. 49) and the knife (Fig. 53, No. 2) is made to cut from above downward with care that it is not carried deeper than is required to sever the fold. Other- wise the chorda tympani may be severed and paralysis of taste produced (Figs. 50 and 51). Although I have made such sec- tions frequently, I have never known this to follow, but such results are reported. Patients generally observe a sense of relief from pressure, clearness in the head, diminishing of subjective noises, and sometimes improvement in hearing. In the class of cases in which I have mostly practiced this operation I have not been able to follow up the results for years, but have known the benefit in a few to persist for several years. In others of a worse type the improvement has been transient. lO'J DISEASES OF THE EAR, NOSE, AND THROAT. Multiple incisions of the drum-head have proven beneficial in some instances. In 1886 T reported the results of a series of cases to the meeting of the American Medical Association, from which I quote: "For the purpose of making a crucial test of the efficacy of this procedure, I have made it the last resort in those cases which afforded no real hope for relief from any other treatment. Perhaps the propriety of operating on those patients that seemed to promise no results might be questioned, were it not for the facts that in nearlv all of them there was an Fig. 50.— Internal Surface of the Left JMembrana Tympani. (After Politzer.) a, head of the malleus; b, neck of the malleus; c, tendon of the musculus tensor tympani and anterior fold of the inembrana tympani; d, inferior extremity of the handle of the malleus: e, anterior portion of the inembrana tympani; /, chorda tym- pani and posterior fold of the membrana tympani ; g, incus ; h, short process of the incus : i, long process of the incus. unexpected improvement and that no unfortunate consequences followed the operation. The cases I have chosen to operate on were far more hopeless than those with chronic suppurative inflammation. The consideration that the former respond so little to our efforts, while the latter are so amenable to treatment with inflations, cleansing, peroxide of hydrogen, boric acid, bichloride of mercury, etc., with the result of not only arresting the disease, but of improving the hearing, has led me to seri- ously contemplate the advisability of establishing the suppura- tive process in proliferous inflammation of the middle ear. In DISEASES OF THE MIDDLE EAR. 103 three cases only in my practice has this condition followed the procedure under discussion, and the results in the series of cases reported were satisfactory, especially when it is considered that / 6 k Fig. 51.— Vertical Section- of the External Meatus, Hekbbana Tympani. and Tympanic Cavity. (After Politzer.) a, cellular spaces in the superior wall of the meatus connected with the middle ear: 6, roof of the tympanic cavity: c. inferior wall ; d, tympanic cavity: e. membrana tympani : /, head of" the malleus : g, handle of the malleus ; h, incus : i'. stapes ; k. Fal- lopian canal : 1, fossa jugularis : />;. apertures of glands in the external meatus. they were the most unpromising and had proven the most in- tractable to the usual methods of treatment. But, as remarked above, this experimental work, which was carried out mostly in dispensary practice, did not afford opportunities to follow up Fig. 52.— Teiaxgulae Resection of the Drum-head. (After Politzer.' the results for a number of consecutive years. The simple in- cision, of course, closed in a few days, but the tension of the drum-head apparently was restored to more nearly the normal." 104 DISEASES OF THE EAR, NOSE, AND THROAT. Another method that I have since pursued with consider- able success was the excision of areas of the drum-head, usually triangular in shape (Fig. 52). Under cocaine I made triangular flaps with the apex above, and then severed the attached base, removing this piece of the membrane entire. It was sometimes easiest after making the two sides of the triangle to grasp the apex witli delicate forceps in one hand while the base incision was made with the other. The improvement in some patients in whom there was no labyrinthal disease was very gratifying, and in private patients I was able to demonstrate the possibility of maintaining the aperture for a considerable time. In one in- stance it had remained open a year and a half when the patient removed from the State. A peculiar experience was had with the other ear. The first operation afforded so much improve- ment that he requested that the same operation be performed on his right ear. It was done, and a slight, muco-purulent dis- charge followed, but soon ceased. While the discharge lasted, the hearing was considerably improved and the tinnitus relieved. After the discharge ceased the hearing began to diminish, when he expressed regret that the ear had not continued moist. This led me to moisten it with warm, pure vaselin, but when I re? moved it a few days afterward the very large perforation was entirely closed. The removal of sections of the drum-membrane may prove otherwise advantageous. It affords accessibility to the tympanic cavity for the instillation of various remedies and the destruc- tion of the adhesions, and it reveals whether the entire resection of the drum-head would improve the hearing. In case the membrane is so thickened and sclerosed and infiltrated with calcareous deposits as to preclude the possibility of its respond- ing to any except extraordinary sound-waves, and the labyrinth is not involved, the opening of a window in the drum-head will admit sound to the stirrup and to the round window and prove whether the entire absence of the membrane would prove reme- dial. If the adhesive process has not ankylosed the stirrup in the oval window nor invaded the round window, vibrations can reach the labyrinth if the barrier to their admission be removed. DISEASES OF THE MIDDLE EAK. 105 I have employed this test to determine whether excision of the entire drum-head would afford successful results. Division of the tensor tympani tendon is not much in favor among American aurists. The indications for it are not clearly defined, and the appearances that suggest the shortening of this muscle — retraction of the membrana tympani and foreshortening of the mallet-handle — are also just as characteristic of the pres- ence of membranous folds and bands of adhesion. The results of tenotomy have been either so unsatisfactory or so positively detrimental that the operation is not encouraging. Greene and Pomeroy prefer a blunt-pointed knife curved on the flat to sever the tensor tympani. EXCISION OF THE MEMBRANA TYMPANI AND OSSICLES. This operation for sclerosis is a subject concerning which there is probably less unanimity of opinion among otologists than any other. While a few American aurists, especially Bur- nett, Sexton, Blake, and Jack, have been enthusiastic advocates of the operation, and some others have followed their lead for a time, the majority appear to have receded to a more conserva- tive position. At the meeting of the section of Otology at the Tenth International Medical Congress in Berlin in 1890 the Continental leaders in this specialty expressed themselves in very conservative terms on the subject. Several years ago the writer, through the columns of the Journal of the American Medical Association., invited all who had performed this opera- tion to communicate the results to him for the purpose of pub- lishing a collection of experiences that would afford a just esti- mate of the average value of this operation. The responses were so few and so unsatisfactory as to force the conclusion that the operation was either little practiced or was disappointing. There is probably little or no diversity of opinion concerning the utility of the operation in suppuration of the middle ear, especially when there is ossicular necrosis ; but as practiced for sclerosis there has been so much division of opinion and sad, disappointing experiences reported during the past ten years that candor requires that the subject be treated with reference to both 1(H) DISEASES OF THE EAR, NOSE, AND THROAT. the ill and the good results. A number of cases have been under my observation upon whom the operation has been per- formed by surgeons both East and West, with the effects of producing a suppuration of the middle ear, destroying the hear- ing, apparently intensifying the noises, and producing more or less vertigo. At the present time I have under treatment a physician from a far-western State whose ossicles were removed from one ear by an aural surgeon several years ago. All the ill results enumerated followed the operation, and, although the hearing was two inches for the watch before the operation, that ear lias been totally deaf since, and the opposite ear has deteri- orated. This is a fair type of numerous similar instances that have come to my personal knowledge, and under the observa- tion of other physicians who have been kind enough to report them to me. Wiirdemann had the courage to report several similar results at the meeting of the American Medical Association in 1892. It is worthy of mention that nearly all of these unfortunate cases were operated upon by specialists in eye and ear diseases ; so that the results cannot be attributed to the want of familiarity with the subject. It is not our purpose to inveigh against this procedure as an operation, but to emphasize the necessity not only of the utmost precision and gentleness in operating, but also the most painstaking preliminary examina- tion and experiments to determine the possibility or otherwise of beneficial results. For example, if the hearing- tests demon- strate that the labyrinth is involved in the disease, the inutility of the operation is established. If no improvement follow a resection of a portion of the drum-head so as to admit sound- waves to the fenestrse leading to the internal ear, no help can be expected from excision of the whole membrane. We do not lose sight of the fact that by removing the drum-membrane and the two larger ossicles we are afforded access to the stirrup so as to mobilize it. Some advantage certainly is to be conceded to this measure, although mobilization of the stirrup is not as simple an act as one might believe. Even with every vestige of the membrane removed, the stirrup is situated so high that a DISEASES OF THE MIDDLE EAR. 107 good view of it is difficult to obtain, and I have found it easy to dislocate when it was not ankylosed. OPERATION FOR EXCISION OF THE OSSICLES. The ear should be prepared by syringing with a warm solu- tion of bichloride of mercury, 1 to 1000, and the instruments should be immersed for three minutes in boiling soda-water. For several years past the author has used ether to the exclu- sion of chloroform, instructing the anaesthetizer to administer only so much as is absolutely necessary to secure quiet and freedom from suffering. Cocaine anaesthesia is not as effective as ether. After removing all debris of any nature from the j — > c i>* 33 32 ' rT —~* 1 Fig. 58.— Middle-Ear Instruments and Handle. canal, it is dried and closed with absorbent cotton until the operation commences. If ether is used, the patient must occupy a recumbent position. I use tables high enough to bring the patient's ear opposite my eye as I sit facing the table. A brilliant illumination is needed. I have used mostly the Argand gas- lamp and light-condenser (Fig. 5) or the sixty-candle-power Welsbach gas-burner. One will have a clearer view of the field of operation if the room is darkened so that no light penetrates the operator's eye except that reflected from the ear-cavity. The instruments necessary (Fig. 53) are a paracentesis- knife (Xo. 2) ; a blunt-pointed bistoury (Xo. 1) ; two angular knives, right and left (Xos. -4 and 5) ; two ossicle-hooks, right 108 DISEASES OF THE EAR, NOSE, AND THROAT. and left (Fig'. 54); a pincette (Fig. 5b); a dozen cotton-carriers armed with cotton; a quart of hot, sterilized water, and a syringe. The operation proceeds as follows : The drum-head is in- cised near the periphery, behind the short process of the mallet. Into this opening- the blunt-pointed knife (No. 1) is inserted "W FiG. 54.— The Author's Ossicj.e-iiook. and carried first below, then sweeping the lower and the an- terior attachments until the roof is reached; then this attach- ment is severed until the whole circular incision is completed, ending at the first entrance. The knife is best carried first from above downward for the reason that less haemorrhage is likely to obstruct the view than if the more vascular membrana flao cida were first cut. There is less haemorrhage also if the knife is kept a little way from the periphery of the membrane. Now Via. 55.— Poutzer's Pincette. the angular knife is used to separate the articulation of the anvil and stirrup (Fig. 51). The anvil is extracted by aid of the hooked probe, and the attachments of the mallet are then divided, when it is brought away with the pincette. Stacke detaches the auricle and removes the integumentary canal first. The operation is a very short one, requiring but a few DISEASES OF THE MIDDLE EAR. 109 minutes ordinarily if there is not much haemorrhage or if the adhesions are not embarrassing. Rapid use of the cotton-car- riers, which should be kept prepared by a nurse, will keep the field quite clear; but in case of considerable bleeding the syringe and quite hot water can be brought into requisition. It is dif- ficult to avoid severing the chorda tympani, but the resulting paralysis of taste is of short duration. The ear-cavity should be dried after bleeding has ceased, covered with a layer of aristol from the small powder-blower (Fig. 32), and the canal closed with iodoform gauze. While there is considerable reaction in some cases, followed by discharges of a muco-purulent character, in others there is little or no disturbance. The patient should be kept quiet, and his diet restricted until healing takes place. By properly restricting the diet both before and after the oper- ation, there is less tendency to regeneration of the drum-head. The latter occurrence is quite frequent. In the case of the physician just spoken of there is a false drum-head which I have not removed, for the reason that no possible good could come of it. In another case of a very robust man from Kansas I re- moved the third adventitious membrana tympani, at his request. In the spring of 1893 a surgeon had removed his drum-head and mallet. In seven days after the operation he says the drum- head had been reproduced. This was removed, and in seven days more the surgeon said that another had closed the tym- panum. A third operation was had, and in fourteen days another drum-head had formed. Two years afterward the patient came to me with the request that I remove this remain- ing fourth drum-head with which nature had supplied him. He suffered from great tinnitus and uncomfortable sensations of pressure, etc. Examination revealed labyrinthal involvement and I discouraged the procedure. But, notwithstanding the assurance that no improvement was to be expected, the patient insisted upon the operation, with the hope that it might afford some relief to the tinnitus and pressure-symptoms. Therefore I removed the drum-membrane and anvil at the Post-Graduate Medical School and Hospital, June 21, 1895, and cauterized 110 DISEASES OF THE EAR, NOSE, AND THROAT. the periphery of the drum-head so as to completely destroy the whole circular attachment. A few days afterward I found the stirrup dislocated and removed it. No unfavorable symptoms followed ; the membrane has not been reproduced, and the slight discharge following the operation soon ceased. The ear has remained in good condition ever since, but, although the patient imagined himself better, I could discern no improvement. The tinnitus and other symptoms were neither removed nor considerably improved. The patient thought he could hear, but accurate tests proved the contrary. This case is instructive in showing that the thorough galvano-cauterizing of the periph- eral attachment of the membrane will prevent its regeneration. I do not often employ this cautery in the ear on account of the great heat generated in so minute an inclosed space, but the chromic acid has too superficial an effect to accomplish the purpose. While I mention these unfavorable cases, — and I might cite others who have come under my care, one of whom is the most distinguished of American editors, — it is not for the purpose of condemning the operation itself, for I believe that these unfortu- nate results are attributable either to an unwise selection of cases or to unforeseen accidents attending the operation. For example : Why should two inches of hearing for the watch be exchanged for total deafness, vertigo, etc. ] The results point toward an injury to at least one of the fenestras opening into the labyrinth. But the reverse of this picture presents some excellent and even brilliant results. Some cases that have proved intractable to the usual measures have yielded to this ; but these are the ones in which the labyrinth has not been involved, and the adhesive process has not destroyed the useful- ness of the stirrup and membrane of the round window, and in which excision of a small section of the membrana tympani would demonstrate the possibilities of the operation. Barclay, Sexton, Burnett, Blake, and Jack favor excision of the ossicles. Gleason {Atlantic Medical Monthly, March 23, 1895) severs the incudo-stapedial articulation to improve hearing in sclerosis. Mobilization of the stirrup has been practiced with favor- DISEASES OF THE MIDDLE EAR. Ill able results, especially by Jack ; but the crura of the stirrup are so exceedingly delicate and fragile that they are quite likely to break on applying side-pressure to them or on trac- tion with the hook. This maneuvre is not in favor with otologists generally. After the membrana tympani has been removed for sclerosis the conditions are most favorable for mobilization. The probe can then be introduced alongside the stirrup and pressure exerted in all directions to break up ad- hesions and effect mobility. The hook can then be engaged in the apex of the converging legs of the bonelet and drawn upon until slight motion is had. But if the adhesion give way suddenly, the stirrup will be dislodged or extracted unless great care is exercised. Excision of the ossicles for persistent suppuration is a common practice among otologists, especially in the case of caries and necrosis of these bones or of the walls of the tym- panic cavity. Great cleanliness must precede these operations, which can more easily be accomplished under a 20-per-cent. solution of cocaine than in dry catarrh. I have often operated under cocaine without any difficulty, especially when the patients were possessed of considerable self-control. The same instruments and methods are employed as in sclerosis. If much curetting of the bone is necessary, a general anaesthetic (ether) had better be used. Out of twenty-two cases of stapedectomy reported by Blake there was only one improvement, and in this the fixation of the stapes was not complete. Some became worse after the operation both as to hearing and tinnitus. In five cases vertigo came on and persisted. Stapedectomy is now disapproved of by Blake, Cozzolino, and Gelle. CHAPTER XL DISEASES OF THE MIDDLE EAR, CONTINUED. Chronic Suppurative Inflammation of the Middle Ear. This is a common sequel of acute suppuration and fall of Import to the afflicted patient. While the laity, and unfortu- nately certain members of the medical profession who are not well informed upon the consequences of the disease, minimize its importance and advise that it be let alone and that children will outgrow it, the patient's life may pay the penalty of its neglect. The disease may outgrow the patient. The close rela- tions of the tympanic and cranial cavities should suggest to the mind of- every thoughtful physician the importance of prompt Fig. 5;i.— Extensive Destruction of the Drum-head. (After Politzer.) and skillful interference with the progressive destructive ravages of the suppurative process. It is not self-limited; it does not tend toward resolution, but toward dissolution, and no trifling makeshift is pardonable. Pathol of the existing inflammation. Moreover, the natural tendency >f this trouble is toward the bone. The mucous membrane of he middle ear answers the purpose of a periosteum, and the intimate relation of these structures jeopardizes the integrity of the osseous tissue when destructive processes are going on in the membranous lining. It has also been shown that mastoid sup- puration is an offspring of middle-ear inflammation. The same may be said of phlebitis and sinus-thrombosis, meningitis, subdural abscess, pyaemia, and abscess of the brain. Only with proper treatment is the prognosis good. Treatment. — More brilliant results are obtained here than in the adhesive catarrhal form of inflammation. The first object is absolute cleanliness. This is best obtained by syringing the ear with at least a quart, or more if necessary, of sterilized water, or bichloride solution, 1 to 5000, as warm as is comfort- able to the patient. Unless a considerable quantity is used, all of the inspissated, greasy debris often found in a neglected suppurating ear is not removed. As much force as can be easily borne is generally required at the first cleansing, to remove all the discharges from the middle ear. The water need not be thrown with so strong a current as to produce giddiness or nausea. The continuous-flow syringe, like the alpha (Fig. 31), is the most satisfactory, as it admits of most perfect control over the temperature of the water and the force of the current. The stream is directed a little toward the roof of the canal, rather than directly in a line with its axis, so as to return along its floor. The patient, if an adult, can hold some conveniently-shaped receptacle pressed closely against the side of the neck just beneath the lobule to catch the returning solution. The water once injected into the ear must under no circumstances be re-injected. I have found people (physicians !) committing that act. Crusts, inspissated pus, and cerumen not expelled by the water can be removed with cotton or a blunt probe. Delstanche has devised a tympanic syringe to inject the attic. After cleansing thoroughly with the syringe, the ear is 1 1 8 DISEASES OF THE EAR, NOSE, AND THROAT. inflated so as to eject any possible secretion remaining in the Eustachian tube or middle ear. The parts are then dried with absorbent cotton, and a coating of aristol is dusted over the surface of the middle ear with the small powder-blower (Fig. 32) or boric acid with the large powder-blower (Fig. 62). Aristol is the first choice on account of its antiseptic, anaesthetic, and cicatrizant properties. It never causes pain and does not inter- fere with the hearing by clogging the canal or impeding the movements of the drum-head and ossicles. If the discharge does not show perceptible decrease in the course of a week or two, it is advantageous to substitute boric acid for the aristol or to throw a coating of boric acid over the aristol dressing. This can be done without dislodging the latter, for it sticks Fig. 62.— The Author's Large Powder-blower. tenaciously to the surface of the tissues. This adds the drying effect of boric acid to all the excellent qualities of aristol, and constitutes an ideal treatment for such individuals as we have mentioned who have an idiosyncrasy against boric acid. I have met a few such instances with this disease, although they are oftener encountered among the acute cases. After the first few treatments of this kind it is advisable to resort to an entirely dry method, relying on the absorbent-cotton driers, inflation, and the powders, for cases often do much better with the dry than with the wet method. The discharges often cease after three or four treatments, and occasionally after the first one. The results of painstaking methods are more sur- prising to the surgeon than to the patient, who may have been harassed for long years with annoying discharges. DISEASES OF THE MIDDLE EAR. 119 Many other remedies are commonly used, but it is the Liithor's purpose to give what years of experience have proven be most efficacious and to inform the practitioner upon the relative merits of those that have been given extensive trials. iome will be mentioned merely for the purpose of saving the Oder's time in experimenting with the useless. Iodoform in fine powder is useful when the odor of the ischarge and other signs indicate the presence of dead bone ; otherwise it is not preferable to aristol, and its disgusting odor is usually very objectionable to fastidious people. The old-time remedy, silver-nitrate solution, was formerly extensively used in my clinics, but for many years I have not employed it. Having tried it in solutions varying in strength from 1 per cent, to a saturated solution, it became apparent that its remedial qualities in this disease were inferior to remedies less objectionable. The blackening of everything it touches renders it especially dis- advantageous in private practice. Zinc sulphate exerts too little influence to merit our confidence. Salicylic-acid powder, highly recommended a few years ago, has proven, in my hands, a total failure. Moreover, the violent irritation of the hares and attacks of sneezing its unavoidable inhalation produces during the insufflation would preclude the possibility of its employment, were it not otherwise impotent. Europhen is valueless in this disease. I have persisted in experimentation with it alone and combined with aristol, and am forced to the conclusion that the total value of europhen-aristol lies in the latter ingredient. Indeed, the aristol alone is more potent. After extended trials with yellow pyoktanin no appreciable effect could be observed in arresting the discharge, and the same is true of dermatol, alumnol, and iodol. Let us suppose now that we have a more intractable type of suppuration. The mucous membrane lining the tympanic cavity appears very red, suggestive of the glow of dull, red-hot iron ; it is much thickened and tumefied ; the drum-head par- takes of the same characteristics, is very sensitive to the touch, and shows rhythmic pulsations. These characteristics obtain in a small proportion of old cases. It is difficult to adapt the 120 DISEASES OF THE EAR, NOSE, AND THROAT. dry method of treatment to such conditions, for the touching of the drum-membrane with the cotton to absorb the discharges is productive of great pain. It is best then to syringe and allow all the water to run out ; then dioxide (peroxide) of hydrogen ( 1 1 ,0.,) is warmed slightly, only sufficiently to make it comfort- able to the ear, and is used to fill the canal While the head is inclined to the opposite shoulder. Or, better still, the patient lies upon the opposite side. Warming the dioxide to the tem- perature of the body does not impair its efficacy, as I have often demonstrated. It is allowed to remain in the ear until efferves- cence ceases. This requires about five or ten minutes, accord- ing to the amount of pus present and the purity of the remedy. It must not have a strong acid reaction or it will cause pain, and it should contain not less than fifteen volumes of available oxygen. The dioxide decomposes pus-corpuscles, during which action free oxygen is liberated to exert its germicidal property upon bacteria. Besides this the active effervescence that takes place dislodges debris, and its mechanical action brings to the surface materials that even syringing fails to dislodge, — for ex- ample, aristol that may have remained from a previous treat- ment. This boiling out of the middle ear appears to cleanse the attic even better than the intra-tympanic syringe, and no unpleasant results have ever attended my use of it. In suspected retained discharges in the attic or mastoid antrum, especially when the perforation is too small to admit of free drainage, it should be enlarged as already described in the preceding chapter. But there are frequent instances in which the discharge does not diminish after thorough efforts at cleansing, disinfecting, and medicating. This failure may be owing to the impossibility of the means employed to remove all the retained secretions and the consequent failure of the medic- aments to reach the diseased surfaces to a large extent. The author has devised an instrument to meet this condition. It consists of an improved miniature air-pump (Fig. 63), contain- ing a metallic valve that does not get out of order, fitted to a glass reservoir. The tip of the reservoir is covered with a soft- rubber tube so as to permit of its being fitted with firmness and DISEASES OF THE MIDDLE EAR. 121 nicety into the external meatus. A gentle traction on the piston-ring exhausts the air in the middle ear and accessory chambers and causes the ejection of any discharges within them into the canal, whence they are removed with the cotton absorb- ent. After the piston is moved the whole length of the cylinder once or twice the instrument is removed and the canal inspected. Then, after drying it of the secretions brought to view, the proc- ess is repeated two or three times. When no more discharges can be drawn from their hiding-places, it is safe to conclude that all have been evacuated. The traction need not be rapid nor strong enough to occasion discomfort or the exudation of any blood; although, if the latter occur, no harm is done, for the discharges are the more thoroughly swept away and the tissues are stimulated. The instrument is held in such a way as to grasp both air-pump and receiver in the fingers at the same Fig. 63.— The Author's Ear-aspirator time, so as to prevent their being separated while the pump is in action. In order to satisfy myself as to the value of this simple device, I have given the most thorough treatment by the old methods without diminishing the discharges, and then have resorted to this treatment in addition to the old methods, with the result of stopping the flux promptly. In such cases, after cleansing as much as possible by syringing, the dioxide, etc., I have applied the aspirator and drawn an astonishing quantity of discharges that must, from their amount and character, have been stored in the mastoid antrum and cells, and these cases have recovered without mastoid operations. MacBride (Edinburgh Medical Journal, June, 1895) opens the mastoid process and middle ear to cure chronic suppurative inflammation, and Jones (Liverpool Medico- ChirurgicalJournal, July, 1894) advocates excision of the ossicles. CHAPTER XII. DISEASES OF THE MIDDLE EAR, CONCLUDED. Sequels of Middle-Ear Suppuration. granulations. The presence of granulations in the middle ear or on the drum-head protracts the cure. If they are small and not very extensive, they can he made to shrink up and disappear by the use of alcohol. At first it is advisable to dilute the alcohol one-half. In the event of no pain being caused by that it can be used stronger, and if the patient easily bear it the full strength should be employed. The period in the treatment to use it is just after the cleansing process is finished, and the alcohol should remain in- the ear ten minutes or longer. After it runs out the granulations that appeared very red before its application are blanched to a pale-gray color after the con- tact of the alcohol for a sufficient length of time. Then the treatment should be completed with the powders as before. When the granulations are very large and abundant, suggestive of beginning polypi, these are best removed by the curette under a warm, 20-per-cent. solution of cocaine. The bleeding- is stopped by pressing a pledget of cotton against the curetted surface for a few minutes, a few drops of cocaine solution is used on them, and then the alcohol as before. Chromic acid may also be employed as described in the next paragraph. POLYPI. Suppuration cannot be cured so long as a polypoid growth is present. This is best removed under cocaine by a polypus- forceps (Fig. 64) or the snare found in the middle-ear case (Fig. 65). It requires less skill to use the forceps. The polypus should be detached as close to the attachment of its pedicle as possible, and, the method being so simple and identical with the same procedure in other fields of surgery, it (122) DISEASES OF THE MIDDLE EAR. 123 is un necessary to enter into the details here. The bleeding ceases soon and can be stanched as described in treating of granulations. Then cocaine is applied and the attachment cauterized with chromic acid. Tlie loop of the caustic applicator (Fig. 66) is dipped into the dry crystals of chromic acid and these are held over a small flame for a few seconds until they are melting. Just at the instant the crystals are fused in the form of a drop on the most convenient site of the loop for application the instrument is withdrawn from the heat and the drop of fused acid blown upon to cool it suddenly into Fig. 64.— Politzek's Polypus-fokceps. Fig. 65.— The Author's Middle-Ear Case. a bead. Unless the attachment of the polypus is well cauter- ized it is likely to grow again. It can be removed with a fenestrated curette of good size, like the larger one in the middle-ear set, by placing the curette so as to engage the 124 DISEASES OF THE EAR, NOSE, AND THROAT. pedicle in the aperture. Then, by pressing firmly against it and drawing outward, it is detached and extracted. CARIES AND NECROSIS OF THE MIDDLE EAR. When the tympanic walls are denuded of their lining mem- brane, which is, in effect, its periosteum, the treatment requires much patience and persistence. After cleansing by water, dioxide of hydrogen, and the aspirator, as outlined, a 12-per-cent. solu- tion of carbolic acid in glycerin is poured into the ear. This does not require warming. After it has remained long enough to produce the anaesthetic effect of the acid — about six minutes — it is removed and replaced by a saturated solution of iodoform in alcohol. If the solution is agitated so that some of the powder is held in suspension, so much the better, for when the solution is allowed to run out after five or ten minutes a fine coating of Fig. 66.— The Author's Caustic Applicator on Flexible Shank. iodoform powder is left covering the diseased tissues. This solu- tion penetrates the diseased cavities deeply. Then the treatment is completed as already described for suppuration. In cases where denuded bone could be felt with the probe, this method has effected cures. Indeed, sequestra of necrosed bone may have been cast off and discharged with the pus, leaving the living bone to become healed over by granulation. But if dead bone be present it acts as a local irritant similarly to a foreign body, and must be removed with the curette before healing will take place. A foul odor, notwithstanding scrupulous cleanliness in the treatment, indicates the presence of osseous necrosis. As long as this foul odor continues the discharge cannot be stopped, but the disappearance of the odor is a very favorable symptom, as H. Gradle has shown. Persistence in this treatment will often remove the odor and discharge. There are occasionally persons with whom the alcoholic solution of iodoform does not agree. The integument of the canal becomes swollen, tender, and excoriated, and the toxic iodoform must give way to other DISEASES OF THE MIDDLE EAR, 125 remedies. The bichloride of mercury occasionally is not well borne, and if used in too strong a solution a similar condition ensues, and even ulceration of the integument. NECROSIS OF THE OSSICULA. The anvil, the first to yield to the necrotic process, is some- times lost before patients apply for treatment, but when it is a c Fig. 67.— Vertical section of Middle Ear ; Droi-head in Contact with the Inner Wall. (After Politzer.) a. ledge-shaped remnant of the membrane : 6. c, the lateral portions of the cicatrix, extending; from the remnant of the membrane to .the inner wall of the tympanic cavity ; d, portion of the cicatrix applied to the inner wall. present and is diseased it should be removed. The same is true of the mallet. In such cases they are of no value to the patient, and only serve to excite a continuation of the inflam- Fig. fr?.— Band-like Cords Between the Lower End of the Hammer- HANDLE AND THE STAPEDO-INCEDAL ARTICULATION. (After Politzer.) matory process and to hinder the free evacuation of the retained secretions. Their excision, if skillfully accomplished, does not impair the hearing and may conserve it. The question of their removal in this instance is not a parallel case to that in sclerosis. The operation is described in Chapter X, V2i\ DISEASES OF THE EAR, NOSE, AND THROAT. Adhesions of the remnant or of cicatrices of the membrana tympani to the inner wall of the tympanic cavity may occur after the suppuration is cured (Fig. 67). This results in a cup-shaped depression in the drum-head. Adhesions and false membranes also form within the tympanum, subdividing it into several cavities (Fig. 68). Connective tissue and chalky deposits (Fig. 69) sometimes fill completely the middle ear, im- bedding the chain of bones so firmly that their functions are entirely destroyed. In case the adhesions cause serious impair- ment of hearing by embarrassing the vibrations of the ossicles or by preventing sound-waves from reaching the labyrinth, they can be divided or excised. Connective- tissue formations and cretaceous deposits can be treated like cholesteatomatous masses, which are considered later. Fig. -Central Perforation of the Drum-head and Calcareous Deposits. (After Politzer.) PERFORATIONS OF THE DRUM-HEAD. Perforations, if they are large, generally remain open and require no treatment. The edges become covered with a con- tinuation of the epidermis of the drum-head. The membranous lining of the middle ear becomes habituated to the presence of air that reaches it directly through the meatus, so that it acquires a tolerance for it, like the nasal mucous membrane. The hearing remains better with than without the perforation, but there are exceptional instances in which the hearing is im- proved by closing the perforation with cotton or a thin rubber disc. The latter exceptions can be treated by freshening the edges of the perforation after the discharge ceases, and covering the aperture accurately with a moist disc of sized paper. The DISEASES OF THE MIDDLE EAR. 127 presence of this foreign body will excite sufficient irritation to increase the circulation in its vicinity to the extent of causing a proliferation of cells, growth of granulations, and consequent closure of the opening. But the cases are rare in which the patient's interest is best subserved by closing the perforation, for the remainder of the drum-head is usually opaque, hypertro- phied, or calcified (Fig. 69) and leathery; so that it is unfitted for transmitting sound-waves. With an opening through it the vibrations have direct access to the foot-plate of the stirrup and the membrane of the round window, and through them reach the perceptive apparatus. Artificial drum-heads should receive mention in this con- nection. I have seen a few persons who believed they were able to hear better with discs or cones of soft rubber inserted so as to lie in contact with the membrana tympani ; but the remote ill effects more than counterbalance the immediate ap- parent increase in hearing-power. When there is suppuration they impede the outward flow and promote decomposition of the discharge. In any event, they act as foreign bodies, giving rise to irritation and resulting increase in connective-tissue formation. This increased thickening of the drum-membrane insures a still greater decrease in hearing. DEAFNESS FOLLOWING SUPPURATION. Deafness following suppurative inflammation calls for treat- ment after the suppuration ceases. Politzerization to overcome adhesions between the ossicles or drum-head and the walls of the tympanum may be practiced three or four times a week. Better still, if the perforation has closed, is the method of throw- ing a spray of lavolin into the middle ear with the improved in- flator (Fig. 24). The lavolin takes the place of the discharge, and it is commonly observed that the hearing is better while the middle ear remains moist. The lavolin is a bland, non- irritating liquid vaselin, and does not become rancid like oil. It softens the dried and hardened tissues, increases their supple- ness, and promotes greater freedom of mobility. This injection is followed by the use of the massage otoscope (Fig. 8). The 128 DISEASES OF THE EAR, NOSE, AND THROAT. drum -head is caused to make a dozen or more excursions, with the endeavor to approximate as nearly as possible the natural limits of movement. This is after the fashion of the machinist, who first oils his machine and then works it. This method is best pursued for three or four weeks, or as long as perceptible progress is made in improvement, and then discontinued. As long as the benefit obtained is stationary the ear had best be let alone. It is well to instruct these patients that when retrogres- sion sets in they should return for further treatment. Tinnitus is not a very common symptom in purulent inflammation, but it is an occasional sequel of that trouble. The treatment just detailed for the deafness is the best adapted for this condition also. CHOLESTEATOMA. In this disease there is an excessive growth of epidermis in the external auditory canal and desquamation of epithelial cells in the middle ear. Lumps of epidermis and shiny, pearl-like, little masses are found, both during and after suppuration. Bezold believes them to be the result of an extension of epider- mic formation from the external canal to the middle ear. Lucas reports a case without any suppurative process. Virchow believes they are true heteroplastic tumors. The epidermis of the external meatus spreads over the walls of the middle ear, and even invades the mastoid antrum in rare cases, but the latter is the result of excessive prolifera- tion of epidermis accompanied with exfoliation. The concre- tions are of a caseous appearance, containing, besides epithelial cells, fat-globules, bacteria, and crystals of cholesterin. The mastoid process is more often the seat of these masses than the tympanic cavity. They increase to a large size as the bone is destroyed, either by advancing caries or necrosis or as the result of absorption due to pressure. The diagnosis is not difficult if the excessive formation and desquamation of epidermis are noticeable in the external meatus, and if the epidermic masses are visible in the middle ear through a perforation. Chunks of foul-smelling, gritty, DISEASES OF THE MIDDLE EAR. 129 cheesy particles may be found in the washings from the ear. The perforations are most likely to be found in ShrapnelPs membrane, for the growth of epidermis inward is marked on the upper Avail of the canal. Long continued and obstinate suppuration is characteristic of this disease. The masses constitute a dam against the free exit of the discharges, and decomposition of pus and the growth of polypi are encour- aged. This condition forms a fruitful soil for the propagation of bacteria. When the cholesteatoma is situated in the tympanic attic or in the mastoid antrum the diagnosis is difficult, if not impossible, to determine, unless the masses disintegrate and are evacuated during the cleansing treatment, or unless the mastoid cortex breaks down and exposes the condition present. If the diagnosis can once be positively made out, the question of oper- ative measures is settled. The methods of treatment are found under the headings of " Chronic Suppuration " and " Mastoid Operations." Bezold advises epidermic transplantations in cholesteatomatous cavities, after the Thiersch method. FACIAL-NERVE PARESIS AND PARALYSIS. Impairment or loss of function of the facial nerve is due to a variety of causes. The facial canal and neurilemma may par- ticipate in a middle-ear inflammation ; ulceration and necrosis of the bone may involve the nerve ; an exudate, a callus, a sequestrum, or a tumor may produce pressure ; syphilitic or other central nervous disease may exist at the origin of the nerve, or traumatic injury may partly or wholly paralyze it. The lower branches supplying the nose, side of the face, and angle of the mouth are generally more affected in paresis from the mastoid operation than the upper branches distributed to the orbicularis palpebrarum. But in some cases the forehead and face are for a time seriously affected, even when the eye can be closed completely, but slowly, and with an effort. The same side of the velum palati may be involved in the paralysis. If the muscles of the side of the face and angle of the mouth are paralyzed, the patient cannot drink liquids 130 diseases of the ear, nose, and throat. without their escaping from the lips ; he cannot inflate the cheeks without the air escaping from the paralyzed corner of the mouth ; in laughing the face is drawn to the unaffected side, giving a crooked appearance to the countenance (Fig. 70). The facial expression is entirely lost on the side that is par- alyzed. The inability to close the eye exposes it to winds, sunlight, and dust, resulting in chronic conjunctivitis. Recovery may be expected from paresis due to an acute inflammation of the Fallopian canal and the sheath of the facial nerve secondary to middle-ear inflammation, and from slight injuries to the nerve during mastoid operations (Fig. 71). Paralysis, or complete loss of conduction of the nerve, resulting from caries or necrosis of the facial canal, or from division of the nerve during the operation, presents an unfavorable prog- nosis. In this condition the eye cannot be closed. Dench says : " Injury to the facial nerve is not a serious accident, function being restored in from three to five weeks, in most cases, under the use of the faradic current." The author is not in accord with this view. If the whole calibre of the nerve-trunk is not affected, but only certain bundles, spontaneous resolution may occur and complete restoration of function in three or six months, but I have never seen a case of recovery take place after complete, total paralysis of all its branches had occurred from injury to the nerve during an operation. I have seen varying degrees of interrupted transmission in the different branches of the nerve, with corresponding variations in the re- covery. The eye being the least and the side of the face and mouth next least affected would recover completely, while the occipito-frontalis remained powerless, giving a noticeable droop- ing effect to the eyebrow. On the other hand, I have had paresis affecting all the branches, occurring after the operation for excision of the os- sicles through the meatus, recover completely after the use of the galvano-faradic current for three or four months. In the course of the nerve which is most exposed to trau- matism during the mastoid operation the bundles distributed to the obicularis oris, the muscles of the side of the face, the Fig. 70.— Appearance in Facial Paralysis, the Patient Laughing. Fig. 71.— Same as Fig. 70, Three Months After Stacke Operation and Treatment with Electricity. DISEASES OF THE MIDDLE EAR, 131 l€cipito-fr on talis, and the corrugator supercilii seem to lie ex- ternal to the fibres composing that part of the anterior temporal branches that supply the orbicularis palpebrarum, for the latter muscle is the least affected in operative paresis and the first to regain its function. Treatment of facial paresis and paralysis depends upon the lesion present. If the latter is an acute inflammation with exudation, upon the subsidence of the inflammation and the absorption of the exudate recovery takes place. If pressure of pus on an exposed nerve in middle-ear suppuration or if a sequestrum produce the pressure, either must be removed. If syphilis is the cause, iodides and mercurials must be employed Tig. 72.— The Author's Ear-electrodes, Attached to Band. on general principles. Sexton mentions facial paralysis due to dental irritation. These cases recover after a course of electricity, the current being used from the primary coil of a faradic battery. The negative pole is applied to the ear of the affected side by means of the ear-electrode (Fig. 72), and the positive to the opposite ear or mastoid region, then to the groups of affected muscles, causing perceptible, though not painful, contractions in them. Such a treatment should be given three or four times a week, continuing ten minutes. This prevents muscular atony or atrophy, while the nerve regains its tone. After the mastoid operation the electric current can be applied directly to the injured section of the facial nerve by sat- urating a pledget of absorbent cotton with sterilized water or 132 DISEASES OF THE EAR, NOSE, AND THROAT. hydrogen dioxide, placing it in the bottom of the wound, and connecting the ear-electrode directly with this. The other pole is then applied to the trunks of the several branches of the nerve distributed to the groups of muscles affected. If one is not familiar with these points he can readily determine them by applying the facial electrode to the opposite side, observing what areas need to be touched in order to contract the desired muscles. In Fig. 102 No. 1 shows the point where the electrode will affect the infra-orbital, malar, and temporal branches of the facial nerve. These supply the muscles of the forehead, the orbicularis palpebrarum, and the muscles of the face, nose, and upper lip. No. 2 shows the point where the electric current will reach the buccal and supramaxillary branches distributed to the buccinator and orbicularis oris and muscles of the lower lip and chin. CARIOUS PROCESSES IN THE TEMPORAL BONE. These do not characterize a large percentage of the cases of middle-ear suppuration. They are sometimes due to tuber- culous and other constitutional taints. While very small areas are likely to be affected, they may extend to involve the whole temporal bone. Scarlatina is one of the most frequent causes, but syphilis and typhoid fever may also give rise to them. The pneumatic portion forming the mastoid process is the most often affected. Next in frequency come the tympanic walls and ad- jacent tissues. The anvil and sometimes the head of the mallet are attacked by the necrotic process. Pain is a pretty constant symptom of caries except in tuberculous individuals, the amount of pain being determined by the extent of periostitis or interference with the discharge of pus. Other distressing symptoms in addition to pain char- acterize this condition : dizziness, noises, nausea or vomiting, insomnia, and fever. The discharge is disgusting, often bloody and irritating. Granulations and polypi are commonly found, and the ossicles may be dislocated so as to wash out when the ear is syringed, together with sequestra of dead bone (Fig. 73). The meatus may be involved, — swollen or ulcerated. If the dis- ease attack the inner tympanic wall, the external wall of the 7 / f 10 n il /3 /* /J Fjg. 73.— Sequestra of Dead Bone, and the Ossicles. Actual, Size. (Author's specimens.) The smooth surfaces of the walls of the tympanic cavity and of the meatus are shown in Nos. 1, 2, 3, U, 5, 6, and 11 ; 13, mallet ; IL, anvil ; 15, stirrup. **d ^ 9 1 1$ M ^4-^m m < 1 * f k i_.n t"<: \ rrrn ; I i [ £Fig. 92.— Opening of the Antrum. (After C. R. Holmes.) W W and Y Y, horizontal and perpendicular planes of the skull ; O, opening: in mas- toid leading to antrum ; OA, antrum : LS, lateral sinus ; 31, mastoid process ; 22, poste- rior wall of external meatus ; 15, styloid process ; 31T, membrana tympani ; Ik, glenoid cavity ; 28, Glaserian fissure ; 17, zygomatic process ; 12 and 13, outlines of hammer and anvil and location of attic ; 16, spina supra meatus ; *, dotted lines showing position of antrum ; E, linea temporalis. ure and stretching by the hooks. If a fistula in the bone is found, it is enlarged ; if there is none, and the antrum is sought, the bone is opened on a level with the superior border of the 158 DISEASES OF THE EAR, NOSE, AND THROAT. external meatus and three-eighths of an inch (one centimetre) hack of its posterior wall (Figs. 89, 90, and 91). The mallet and straight-edged chisels are used to remove the cortex in preference to the trephine or drill. The broad chisel is best here. The strokes of the mallet must always be light enough to run no risk of forcing the chisel through softened bone into the vital parts. The general direction of the cone-shaped mass of bone to \zltxiz Fig. 93.— Horizontal Section Through Right Temporal, Bone, Showing Distance Between Lateral Sinus and External Canal. Cut Begins Below Centre of External Canal, Passing Obliquely Upward and Inward. (After C. R. Holmes.) LS, lateral sinus ; M, mastoid ; JY. facial nerve ; TC, tympanic cavity ; 2, vestibule ; MT, membrana tympani ; C, external canal ; small arrow indicates the point where a perpendicular line from the spina supra meatus would touch. be removed is inward, forward, and a little upward (Fig. 91); but one must always bear in mind that these terms are relative ones, for we speak as if the patient were in an upright, instead of a supine position. A good rule is to keep close to the meatus, follow its direction, and keep above it if the antrum is to be opened (Fig. 92). As soon as the cortex is removed the forehead-mirror (Fig. 4) and brilliant illumination should be used (Fig. 5). If dead bone is reached there is little or no difficulty in distinguishing THE MASTOID OPERATIONS. 159 it from the healthy. It is softer, darker, crumbling, and is often filled with dark, fungus-like granulations as well as pus. It breaks down readily under the curette and should be entirely removed until nothing but healthy tissue is to be seen. The opening in the cortex should be made capacious enough to allow of easy inspection of all the interior of the process. In the adult the oval aperture should be about one-half by three- fourths of an inch in diameter or ten by twelve or fifteen milli- metres, with the long axis in the vertical. The surgeon should Zo a jg^ rc ^^J^&>y mt \li mWm r^m f9@Ml# i < B x /^^m / V i i^**-MP%\\ ^ ivJr^ v" f ■< m *- y 4r*~V~" v ^^^Hsai r. AT 0' &FgSR^g£S3L ■v ^r a*i ^ < ^3S2£i / >f /& Fig. 94.— Horizontal Section Through Right Temporal Bone. Cut Near- Centre of External Meatus, Showing How Close the Lateral Sinus May Come to the External Canal in Some Cases. (After C. R. Holmes.) a, internal carotid artery ; V, internal jugular vein. For explanation of other letters see Fig. 91. be satisfied with nothing but thoroughness of detail. If the carious bone extend to the dura or lateral sinus it is removed thus far, exercising great caution not to injure either, and, although it has often been necessary to expose both, I have never seen any ill results follow. If the lateral sinus should be accidentally opened, the haemorrhage will be profuse and will necessitate tamponing the cavity with iodoform gauze and post- poning further operative procedure for a fortnight. The variation in the distance between the external canal and the lateral sinus is shown in the same individual on the 160 DISEASES OF THE EAR, NOSE, AND THROAT. opposite sides of a skull in my possession (Figs. 77, 93, and 94). The surgical relations and close proximity of the lateral sinus, the facial nerve, and the semicircular canals are plainly visible in Figs. 91, 93, and 95 (LS, N, etc.). In many cases this simple operation suffices to effect a cure and it is not necessary to proceed farther. All projecting spiculse of bone are removed, rough corners rounded off, the wound is Fig. 95.— Perpendicular Section Through the Right Temporal Bone, Beginning at /Line BB, Behind Opening O, in Mastoid (Fig. 92), and Directed Inward and Forward, Cutting Eustachian Tube in its Long Axis. (After C. R. Holmes.) iV, dotted lines show the course of the facial and chorda tympani nerves; M, mas- toid ; Ch, chorda tympani nerve ; MT. membrana tympani ; a, canal for internal carotid ; 10, Eustachian tube ; 9, processus cochliariformis ;~ At, attic ; 7 and 8, showing defects in the bone covering attic and antrum ; OA, opening into antrum (Fig. 92) ; LS, lateral sinus ; * antrum ; O, dotted lines indicating funnel-shaped opening (Fig. 92). syringed with quite warm bichloride solution, 1 to 1000, then dried and sprinkled with aristol (Fig. 32) or iodoform powder (Fig. 62). The upper section of the wound is stitched to a level with the upper border of the bone-opening only. The cavity is packed very lightly with iodoform gauze, covered thickly with absorbent cotton, and the dressing is completed with a net or crinoline bandage. These bandages are not to be applied very firmly, since the sizing they contain, being moistened before Fig. 96.— Adhesive-Pilaster Dressing for Mastoid Wound. (Author's case.) Fig. 97.— Lime of Incision Healed Two Months After a Schwartze Operation. (Author's case.) THE MASTOID OPERATIONS. 161 applying, drys and contracts, setting somewhat like a plaster- of- Paris bandage. Later, an adhesive plaster can be substituted for the bandage (Fig. 96). The wound is kept sufficiently open to permit inspection and treatment until the cavity fills with healthy cicatricial tissue. The patient is now put to bed. If the temperature were high before the operation it usually falls, but it may remain near 100° F. for a few days. The dressing is not disturbed for four or five days unless considerable haemorrhage, discharge, odor, pain, or fever should call for it. Too frequent dressings and forcible irrigations retard new epithelial formation, while too infrequent dressings favor decomposition, septic infection, and exuberant granulations. I have usually made it a rule, even in this simple operation, to so connect the middle ear with the mastoid opening as to permit a current of water to pass into one and out of the other for the sake of absolute cleanliness. The duration of this operation, from the first incision to the completion of the operation and insufflation of the powder, has varied in my practice from fifteen to thirty-five minutes. With good assistants one can acquire dexterity of operation without incurring any risks, and the patients make a better re- covery than when narcosis is protracted. The length of time required for complete recovery varies greatly. I have had patients leave the hospital in a few days or a week and have found them cured at the expiration of the fourth week, while others, for various reasons, extend over three or four months. Six or eight weeks w r ould be a fair average time to give as nec- essary for a cure, and patients should be informed that it may require longer (Fig. 97). The Radical Mastoid Operation (Stacke). The first incision is the same as in the simple operation, except that it is carried above the insertion of the auricle and then forward as far as a point directly superior to the anterior wall of the meatus (Fig. 98). After the periosteum is raised to the mouth of the meatus the periosteal end of the mastoid guide (Fig. 85) is inserted between the posterior wall of the u 162 DISEASES OF THE EAR, NOSE, AND THROAT. osseous canal and its periosteal lining and the latter is raised as far as the membrana tympani. One can tell when the middle ear is readied, for at that instant resistance ceases. The instrument is carried no farther inward, but is moved care- fully around the whole circumference of the canal, separating the membranous lining and preserving its integrity. The integument is now drawn out of the canal like a severed glove-finger and reflected forward with the auricle so as to expose the bony canal and drum-head. The latter is now Fig. 98.— The Stacke Operation Completed. (After C. R. Holmes.) detached. The posterior canal-wall is chiseled away, backward into the antrum and inward as far as the tympanic attic (Fig. 99), removing the wedge-shaped portion of bone constituting the outer boundry of the attic (Fig. 100, No. 4), until a bent probe, in contact with the attic-roof and drawn outward, meets no resistance. The whole inner wall of the tympanum is now exposed to view, and this cavity, the antrum, and the meatus are converted into one cavity. The anvil is detached from its articulation with the stirrup (Fig. 51) and removed with the pincette (Fig. 55) care being taken to not dislocate the Fig. 99.— Side of Skull, Showing Stacke Operation. (Author's specimen.) The postero-superior wall of the meatus is removed. The antrum is seen below 8 and the oval window at the right of 9. Below the oval foramen is seen the round window, and the dark spot above and to the right of the 9 is an opening into the external semicircular canal. The projecting ridge between this and the oval window is the Fallopian, or facial, canal. 12, point for trephining to open the lateral sinus. Fig. 100.— Vertical Section Through the Ear. (Author's specimen.) 4, wedge-shaped portion of bone forming outer boundary of tbe tympanic attic ; dotted line shows the section removed in the Stacke operation ; 5, dotted line shows course of facial nerve ; the bright spot in the dark area between U and 5 is the end of the probe, seen through the aditus ad antrum, resting in the antrum ; 6, remnant of the drum-head. THE MASTOID OPERATIONS. 163 stirrup and thus open the vestibule. The drum-head is re- moved in its entirety together with the mallet. This is a simple maneuver under the present conditions. All carious or necrotic tissue, granulations, or cholesteatomata are curetted away (Fig. 75). When the membranous canal is returned to its place it is incised along the median line of the posterior wall, longitudin- ally, up to the concha, where an incision at right angles to the first is made through the posterior half of its circumference. The two flaps resulting are packed, — the one upward and back- ward and the lower downward and backward into the mastoid cavity. This gives access to one large cavity for after-treatment through the meatus. In this operation we have not only the lateral sinus and dura to avoid, but the facial nerve and semicircular canals. To escape wounding the facial nerve, as soon as we arrive in its vicinity the mastoid guide (Fig. 85) is inserted into the attic and the narrow toe of the foot-plate is passed through the aditus ad antrum and toward the latter cavity. The long handle is brought forward and downward over the cheek so that the end of the handle lies in a direct line with the lower border of the upper teeth or lip. Then the foot-plate falls over the Fallopian canal containing the nerve, and the chisel will strike the guide before it can reach the nerve. An assistant is instructed to hold the guide scrupulously in place and to give the warning instantly when it is touched. The facial canal is sometimes deficient or destroyed, leaving the nerve exposed. It is of the greatest importance to avoid injury of the facial nerve, as it produces a shocking deformity of the face (Fig. 70). I have seen facial paralysis produced, in my opinion, by packing the wound-cavity too firmly with the gauze, producing pressure on the exposed nerve. An anomalous position of the facial nerve renders it liable to injury if one chisels near the floor of the external canal. In using the middle-ear curette one should not forget that the tympanic walls are sometimes as thin as an egg-shell (Figs. 95 and 101). The internal carotid artery and the internal jugular 164 DISEASES OF THE EAR, NOSE, AND THROAT. vein are sometimes very imperfectly protected and liable to be penetrated. As one proceeds upward and backward the ex- ternal and posterior semicircular canals must be avoided. The radical, or Stacke, operation consumes more time than the simple, or Schwartze, operation. The time varies with different operators from one to two hours. Longer time is required for healing also on account of the greater extent of Fig. 101.— Horizontal Section of Temporal Bone, Cut Near Floor op External Meatus. (After C. JR. Holmes.) a, canal for internal carotid ; TO, tympanic cavity ; Ml, membrana tympani ; V, bulbus of internal jugular vein ; iV, facial nerve ; \LS, lateral sinus; M, mastoid. wound surface. Fig. 102 shows progress six weeks after the Stacke operation. The Modified Mastoid Operation. In this operation the incision is the same as in the radical one (Fig. 98). I do not dissect out the whole integumentary canal, but separate only its postero-superior half from its bony wall and then depress it sufficiently to give easy access to the Fig. 102.— Six Weeks After Stacke Operation. (Author's case.) 1, point to apply electric current to affect superior branches of the facial nerve ; 2, to affect inferior branches in treating facial paresis or paralysis. Fig. 103.— Appearance Two Weeks After a Modified Operation. Healed Five Weeks After Operation. (Author's case.) THE MASTOID OPERATIONS. 165 tympanic cavity. By this means one-half of the soft meatus is left undisturbed and the integrity of the integumentary canal is preserved. This method leaves a less extensive wound to heal, and it has afforded the most satisfactory results. The collapse of the canal can be prevented by a light packing of the mastoid wound and by packing the canal or inserting a firm-rubber tube. In other respects this method, which I have preferred for several years, corresponds to the Stacke operation. It is safer not to close the wound entirely until it has healed from the bottom. When the interior has rilled with cicatricial tissue up to the surface of the outer table it is safe to allow it to close. I have had good results after closing the wound completely at the time of the operation, but it is certainly not so safe a plan. The best dressing is one of dithymol diiodide (aristol) sprinkled over the wound surfaces, covering them entirely. Then iodoform gauze should be placed lightly in the mouth of that part of the wound chosen to remain open. It should not be packed down to the bottom of the wound so as to crowd any discharge inward, but it should extend just far enough inward to keep the cutaneous tissues from closing over the su- perficial opening in the bone until the deep wound is well. Dithymol diiodide has two excellent qualities : it is the best cicatrizant we possess, and it has the additional advantage of being to some extent an anaesthetic. While iodoform is irritant and toxic and boric acid sometimes produces pain, dithymol diiodide soothes without any ill effects. After stitching that part of the wound to be closed and dressing the open mouth for drainage, the whole is covered with iodoform gauze, absorbent cotton, and a net bandage. This bandage is made of the common white mosquito-cloth, which, as used in the Northern States, is sized with a prepara- tion of glue. The roll of bandage is dipped in water just before applying, until it is wet through. Then the water is squeezed out and the bandage is applied as usual. When it dries, the layers adhere together firmly, so as to retain their position for many days in succession without any attention. 166 DISEASES OF THE EAR, NOSE, AND THROAT. This operation requires more time than Schwartze's and less than Stacke's, both to perform and for healing. Fig. 103 shows progress two weeks after the modified Stacke operation. Three weeks after the operation taste was suddenly lost, but returned again. The exuberant granulations seen on the right border of the wound were repressed with silver-nitrate stick. Abscess of Neck from Middle Ear and Mastoid Suppuration. This is an occasional complication that requires operative interference. It arises from the purulent process penetrating the bone and burrowing beneath the superficial or deep layer of muscles. If it break through the inferior wall of the tym- panic cavity, the pus-channel may extend along underneath the deep layer of muscles even to the thoracic cavity. If it rupture through the anterior wall of the middle ear, a retropharyngeal abscess or a superficial cervical abscess may develop. When the pus breaks through the inferior surface of the mastoid proc- ess, it burrows under the sterno-mastoid muscle and forms a swelling on the side of the neck. At first the tumor is small, is generally located directly below the lobule of the auricle, is hard to the touch, and may give so little evidence of its presence that it may be overlooked. So slight are the symptoms at first that patients do not mention the neck trouble, and it is only by the habit of close observation that the surgeon himself does not let so serious a matter escape him. While no active symptoms referable to the neck-abscess may occur during the first few days, it often increases rapidly in size. The surrounding tissues become infil- trated ; the tumefaction extends over a larger surface ; the over- lying skin becomes tense and shiny to such a degree as to suggest erysipelas ; the movements of the neck become restricted and painful ; the temperature rises; the tongue becomes coated; headache, loss of appetite, and other febrile disturbances super- vene. Although fluctuation does not occur early, especially if the abscess is deep-seated, the diagnosis is promptly suggested by the presence of the suppuration above. B-: ^■L *75**jJjJB ^^ ^^ >'. f y JB^I^^-tBafc f -'ri'Tw i w ^ JM ^IBV Fig. 104.— Post-mortem Section of Mastoid Process. (Author's specimen.) T, tip of process; 2, fistula below T leading into mastoid cells : 3, opening made by trepbine, probe resting in antrum ; 4, cotton in external meatus. Fig. 105.— Appearance Three Weeks After a Modified Stacke and an Operation for a Neck-abscess. The latter is healed and the former kept open until the wound-cavity filled with healthy tissue. Patient discharged cured fifty-five days after operation. THE MASTOID OPERATIONS. 167 The only treatment is to open and evacuate the cavity and treat it antiseptically until pus formation ceases. Great care must be taken to avoid injury to the net-work of veins, arteries, and nerves in this region. For this reason it is best to open the abscess as far back as possible, and yet open in a dependent position. Further treatment should be on general surgical principles. Fig. 105 shows such a case three weeks after the modified Stacke operation and opening of the neck-abscess, the latter being entirely healed. A drainage-tube was inserted into the neck-opening and brought out through the mastoid wound. CHAPTER XVI. DISEASES OF THE INTERNAL EAR. As compared with affections of the middle ear, diseases of the labyrinth are rare, except as sequels of tympanic diseases. The methods of making a differential diagnosis between these two parts of the ear are sufficiently set forth in the section on hearing- tests. Hyperemia and Anaemia of the Labyrinth. Hyperemia may occur as a result of middle-ear inflamma- tion or some intra-cranial disease, or secondarily to a disturbance of the circulation in the blood-vessels of the neck, such as pressure on the large veins, or it may be due to certain medicines, — quinine, sodium salicylate, amyl-nitrite, etc. It sometimes complicates the fevers. Anaemia of the labyrinth may follow great haemorrhages, exhausting affections, and various anomalies of the circulation. The symptoms need not necessarily include impairment of hearing, but tinnitus and giddiness are the principal- manifes- tations. These conditions will be recognized as accompani- ments to the main diseases which give rise to them, and the diagnosis, prognosis, and treatment will be determined accord- ingly. If hyperaemia is due to active inflammation of the middle ear, the measures laid down in the section on that subject should be brought into requisition : cocaine, local bleed- ing, counter-irritation, catharsis, bromides, rest, the mastoid ice-bag (Fig. 78), etc. In anaemia of the labyrinth the primary condition that causes the anaemia will suggest the treatment. Inflammation of the Labyrinth (Otitis Interna.) Primary inflammation of the internal ear is of very rare occurrence ; but a disease of the surrounding structures, the middle ear, or mastoid may extend to the labyrinth. An intra- (168) DISEASES OF THE INTERNAL EAR. 169 cranial lesion also may involve this organ. Predisposing causes are to be found in the loss of the stirrup, caries and necrosis of the inner wall of the tympanic cavity, etc., by means of which an entrance of bacteria and discharges is effected into the labyrinth. Cases of primary labyrinthitis have been reported by Agnew, Schwartze, Webster, and others. Occasionally cases are seen in which, after a severe cold or some other cause, or even without any discernible cause, sudden deafness of greater or less degree comes on, without traces of middle-ear disease. Giddiness usually accompanies such attacks. The dizziness may disappear, leaving a permanent deafness. In case this deafness is due to a serous exudation into the labyrinth, pro- ducing pressure on the terminal filaments of the auditory nerve, the loss of hearing may not be complete or permanent. Ab- sorption of the exudate may be followed by a clearing up of the subjective symptoms and deafness. Purulent inflammation is of more serious import, since it not only robs the sufferer of the power of hearing, but jeopar- dizes his life. Besides the predisposing causes mentioned above, it is sometimes a result of the eruptive fevers, diphtheria, mumps, variola, typhoid fever, or cerebral meningitis. The latter disease is simulated by the most active form of primary labyrinthitis. The two are easily mistaken for each other, the symptoms are so similar, but the duration of the labyrinthal affection is but a small fraction of the other. Panotitis, or inflammation of both middle and internal ears, is generally the result of scarlet fever or diphtheria, producing irreparable * deafness and for some time a staggering gait. A separate description of this disease is not necessary, since it is a combination of two already presented. The prognosis of inflammation of the labyrinth is unfavor- able. Some cases recover ; more do not. One such case, com- plicated with mastoiditis, recovered entirely after four months, without mastoidectomy, although I was in doubt for a time if further postponement of the operation were justifiable. Another became entirely deaf during meningitis at the age of 2 years. 170 DISEASES OF THE EAR, NOSE, AND THROAT. During the sixth year she began to distinguish sounds. She lias improved under treatment, and has learned to talk without special instruction or lip-reading. I have met with a number of such instances ; yet it is safest to give a very guarded and conservative prognosis. Treatment. — Potassium iodide, pilocarpine, iodine oint- ments, etc. , have been used by Politzer, Moos, Gruber, and others. Of a 2-per-cent. solution of pilocarpine, 2 to 6 drops are injected into the forearm daily, in increasing doses. General antiphlogistic treatment must be resorted to in the acute stage, such as is detailed in the division on acute inflam- mation of the middle ear. In syphilitic infection the iodides and pilocarpine are indicated. In suppuration the methods given for middle-ear suppuration are applicable. HEMORRHAGE INTO THE LABYRINTH. Extravasation of blood into the labyrinth may take place as the result of the same diseases that induce inflammation. of this organ, as well as from atheromatous degeneration, fracture of the temporal bone, concussion, and necrosis. Resolution may take place by absorption, or an inflammatory process may be set up, with its train of consequences, or the clot may undergo organization. Meniere's Disease. Meniere first described a group of symptoms that char- acterized a case of effusion of blood into the labyrinth : deaf- ness, vertigo, and vomiting. This disease comes on suddenly, the patient falling as in an epileptic seizure and presenting an appearance, on regaining consciousness, similar to one coming out of an epileptic fit. In addition to the symptoms mentioned, there may be subjective noises and total deafness. After con- sciousness returns and vomiting ceases, the great deafness, dizzi- ness, and tinnitus remain. Walking with the eyes closed is difficult and the body may incline toward the diseased side. The mental faculties evince impairment. Diagnosis. — This is based on the suddenness of the attack ; DISEASES OF THE INTERNAL EAR. 171 the extreme loss of hearing without previous serious disturbance of function ; the presence of a group of symptoms pointing, in unison, toward aural disease ; absence of disease of the con- ducting apparatus or of any other structure than the auditory nerve. The prognosis is unhappy. Treatment. — Rest in bed and perfect quiet are important. The bowels should be relaxed, the ice-bag applied to the mastoid, and a counter-irritant to the side and back of the neck. Po- tassium iodide in large doses and pilocarpine may be employed as directed for labyrinthitis. LEUCOCYTHiEMIC DEAFNESS. Patients suffering from leucocythaemia are sometimes subject to sudden and complete deafness and vertigo, and even facial paralysis. The ear, like all the other organs, is subject to hemorrhagic and exudative processes, although it is not as fre- quently implicated as the eye. Inflammation may follow, re- sulting in proliferation of connective tissue or bony growths. The treatment consists in measures for the general con- dition and the remedies recommended in Meniere's disease. Syphilis of the Labyrinth. Syphilitic lesions of the labyrinth are most likely to occur during the tertiary stage, but sometimes manifest themselves in the secondary period. The precise pathological changes in this disease are not yet clearly established. The symptoms are very similar to those characterizing Meniere's disease. In most cases subjective noises are added to the great deafness and dizziness. The affection is usually bilateral. Bone-conduction is di- minished or destroyed. The presence of syphilitic lesions in other parts of the body, or a history of a previous infection, combined with the symptoms referred to, clear up the diagnosis. Of all children with inherited syphilis, 10 per cent, have ear trouble (Hutchinson and Jackson). Others claim as high as 33 per cent. The characteristic Hutchinson teeth should be looked for. 172 DISEASES OF THE EAR, NOSE, AND THROAT. The prognosis is unfavorable. In recent affections and in young persons the prospects are more encouraging than in the severe types with age and a generally impoverished condition to combat. The treatment is the same as for constitutional syphilis, with the addition of pilocarpine injections, in 2-per-cent. solu- tion, of 4 to 12 drops in increasing daily doses (Politzer). Any improvement to be had from the pilocarpine should show within two weeks. I generally employ the mixed treatment, — mercury and potassium iodide combined. Max Toeplitz reports, in the New York Medical Journal, October 7, 1893, a case of aural syphilis in which " the laby- rinth was affected primarily in the course of a freshly-acquired case of syphilis. The aural affection began simultaneously with the appearance of roseola. " The special features of this case are as follow : 1. The affection of the labyrinth occurred after the appearance of pharyngeal patches and simultaneously with the appearance of roseola. 2. The aural lesion took place during the secondary stage without attacking the middle ear. 3. The diagnosis of syphilis was made from the ear. " The pathological changes produced by the syphilitic poison, which entered the lymphatic and blood- current of the labyrinth from the pharynx through the aqueduct and the blood- vessels, probably consisted in inflammatory alterations of the membranous portion, the periosteum and the surrounding lymph of the vestibule, and the first turn of the cochlea, with an in- crease of cellular elements and haemorrhages. All these changes disappeared after energetic antiluetic treatment." Diseases of the Auditory Nerve. The acoustic nerve may become the seat of various changes — hyperemia, hypertrophy, atrophy, secondary inflammation, and suppuration — through invasion from the contiguous intra- cranial or tympanic structures. It must be admitted that the present state of our knowledge of these pathological processes affords no basis for a promising system of treatment. diseases of the internal ear. 173 Neuroses of the Perceptive Apparatus, hyperaudition. A .transitory increase in the intensity of the hearing-power affects some individuals. For this condition I propose the term " hyperaudition " as conforming to our system of nomenclature and as heing correctly and briefly expressive. This condition is a symptom of cerebral excitement or irritation, and may con- stitute a precursor of intra-cranial disease. hyperesthesia. Auditory hyperesthesia is an insufferable sensitiveness to sounds or noises. Highly-nervous individuals often present this anomaly, and it is an accompaniment of headaches and intra- cranial affections. It is often observed in sclerosis of the middle ear. The slamming of a door, the firing of a gun, etc., cause much more discomfort than in a state of health. paracusis. This is a false perception of pitch. The tone is heard by air-conduction generally higher than its true pitch, but may be heard lower. This may occur in one ear only, even when both are affected by sclerosis, and it is due to an altered tension of the transmitting mechanism. I have observed in such cases that certain tones only, and mostly the higher, were thus in- correctly perceived by one ear, both being similarly diseased, while all tones were correctly heard by bone-conduction. The apparent alteration in pitch varies in different individuals from one-quarter to one-half tone, or even one or two tones. This trouble unfits a musician for any but solo-playing. Double hearing has been observed in acute middle-ear inflammation. The tone w r as perceived as a primary, accom- panied or followed by a secondary, sound, the latter being in the nature of an echo. This may be due to hearing correctly with the normal ear and incorrectly with the other. 174 DISEASES OF THE EAR, NOSE, AND THROAT. PARACUSIS WILLISII. This is hearing better in a noise, and is pathognomonic of sclerosis. It is undoubtedly due to the fact that, when pow- erful sound-waves set the ossicles in vibration, the lesser vi- brations are carried along with the greater to the perceptive organ. Once arrived at the latter point, the smaller waves are recognized with the larger (see chapter on sclerosis). SUBJECTIVE SOUNDS. These are sounds experienced by the patient as real, but existing only in his own consciousness. They are not always referred to the ears, but to other parts of the head : the region immediately above the ears, the occiput, and even the vertex. They are due to irritation of the auditory nerve and possibly of the hearing-centre. Occasionally they are so intense that the sufferer is led to believe them to be objective sounds and that his friends ought to hear them by placing their ears close to his. They may become so unendurable as to cause melancholia and loss of sleep and memory. Even in greatly-impaired hear- ing and total deafness patients have declared to me that they would not care whether the treatment benefited the hearing, if only the interminable head-noises could be stopped. It is sometimes imagined that insects have gained entrance into the ears, and the surgeon is importuned repeatedly to look for them, being assured that they must be found. One woman persisted in her declarations that there were crickets in her ears, for she could hear their constant chirping. Notwithstanding my examinations and statements to the contrary, she filled her ears with spirit of turpentine. Very susceptible individuals may have their minds unbal- anced by this harassing, unceasing din. I have seen instances in which subjective voices were heard, but they were hallucina- tions of hearing in persons of unsound mind. Whether the psychoses were attributable to the disease or whether the latter was merely a coincident could not be determined. The latter was probably true, and in such cases the tinnitus aggravated the mental aberration. Ear treatment may afford much relief DISEASES OF THE INTERNAL EAR. 175 m such nervous affections by removing the excitant of hearing- hallucinations. There is a wide variation in the character of the subjective noises. Most people call it a ringing of high pitch. In others it is like the roaring of water, the sighing of the winds, the rumbling of wagons, crackling or explosive sounds, or sudden changes from the usual ringing to a loud breaking forth of a tone, as if a small bell had been struck a hard blow. The pitch of the ringing in one ear may be in unison with a fork of 2048 vibrations, or the third C above middle C of the piano, while the pitch of the tinnitus of the other ear may be much lower and the sound of a different quality. The noises are increased during a combination of low ba- rometer with low thermometer, especially so when the air is very humid. Continuous cloudy or rainy weather and winds give rise to them. The same is true of quinine, sodium salicy- late, alcoholic beverages, excessive tobacco-smoking, loss of sleep, sneezing, coughing, much use of the voice, very cold drinks or food, and being in a damp, cold, moldy atmosphere, such as in basements. On the other hand, w 7 arm, sunshiny weather diminishes the noises. They are less observed or entirely suppressed in the presence of objective sounds like those of an orchestra, the noises of the street or cars, etc. Often patients cannot tell whether or not the noises are present when objective sounds can be heard. When tinnitus first appears it may be intermittent, but in advanced sclerosis it becomes interminable. A certain tolerance of the noises is frequently acquired, so that they are not very much noticed when the individual is preoccupied or in a noisy locality ; but in quiet surroundings the noises seem to besiege the brain again with redoubled intensity. Nervous tinnitus is an affection in which the ear is not in- volved. It may arise from reflex causes and requires general, rather than special, treatment. However, the ear should be inspected for any possible lesion. Spasmodic noises, or those occasioned by spasmodic con- tractions of the muscles of the ear, are rare. In one case I could 176 DISEASES OF THE EAR, NOSE, AND THROAT. plainly see, synchronously with the clicking noises, a rhythmical movement of the drum-head, — excursions inward and outward, — undoubtedly occasioned by spasmodic contractions of the ten- sor tympani muscle. Spasmodic contractions of the Eustachian tubal muscles may cause snapping sounds. Mucous rales occur in the middle ear in the same manner as they do in the bronch- ial tubes. Circulatory disturbances of the heart, the internal carotid, or the arteries of the ear give rise to pulsating sounds in unison with the pulse. Prognosis. — This depends principally upon the cause, but, excepting in sclerosis and diseases of the labyrinth and of the brain, the prospect of relief is good. The longer the noises have existed, and the more unvarying and continuous their character, the less promising is the prognosis. Treatment. — Since tinnitus aurium is a symptom of various pathological processes, we can speak of its treatment here in a general way only, otherwise it would involve the measures necessary for the special treatment of all the causative conditions. These will be found in their proper divisions of the subject. It is much more difficult to stop the noises than to improve the hearing. The latter often increases, while the noises prove intractable. We may diminish the noises or change their char- acter, while we cannot by any known means eradicate them, in many cases. It is unwise to promise to cure or even to dimin- ish them. In the majority of instances the tinnitus is a symp- tom of sclerosis. In addition to the treatment outlined for sclerosis I have used counter-irritation with mustard or its oil, and have vesicated with cantharidal collodion. These applica- tions sometimes produce a beneficial effect. When the tinnitus has continued after an acute inflammation of the middle ear has subsided, I have found medium doses of sodium bromide afford complete relief. I attributed this to its sedative effect on the labyrinthal irritation. Charcot and Guye have recom- mended quinine. It may prove serviceable in periodical tin- nitus, but as it produces congestion of the middle ear and laby- rinth, and, in large or continued doses, deafness, its utility in ear affections is very limited. diseases of the internal ear. 177 Paresis and Paralysis. There are certain forms of paresis and paralysis of the au- ditory nerve that are so rarely met with as to merit only a pass- ing notice in a work of such practical brevity as this. In some hysterical subjects anomalies of hearing and subjective noises occur, but in association with anaesthesia or hyperesthesia of other parts of the body that indicate the character of the affection. These attacks are transitory and without apparent changes in that part of the ear that is accessible to inspection. Treatment of these aberrations is largely based on the as- sociated causative conditions ; but, in addition to the general treatment, special measures may be employed by means of the ear-electrodes (Fig. 72). I have generally preferred the primary current of a faradic battery to the galvanic, for the former unites the properties of both currents, as I have shown in my batteries by means of the galvanometer. The negative pole is connected with the electrode that rests in the ear which requires stimula- tion or irritation. The current is turned on very mildly at first and gradually strengthened until it is as strong as can be com- fortably borne, and continued for six to ten minutes. By means of the author's electrodes the current is more limited to the ear than with the older kinds, which diffuse the current mostly over the side of the head. In using these electrodes it is not necessary to fill the meatus with water, as was the former custom, to the detri- ment of the drum-membrane, but the tips of the electrodes are moistened and covered with a wet layer of absorbent cotton. In treating paresis or paralysis of the facial nerve after a mastoid operation the wound can be filled with wet cotton and the electrode placed in contact with it. This conducts the current to the injured nerve. The other electrode is held in contact with the opposite mastoid process. During a part of the treatment the electrode is removed from the opposite ear and applied to the groups of muscles affected (Fig. 102). 12 178 diseases of the ear, nose, and throat. Cerebral Causes of Deafness. Cerebral deafness may arise in two ways : by a disease of the hearing-centres or by an extension of a disease of the brain or the meninges to the origin or course of the acoustic nerve or to the labyrinth. The most frequent cause of intra-cranial deafness is meningitis. The loss of hearing may not become apparent at the time that it occurs, but will be discovered when the patient regains consciousness. The destruction of hearing takes place within the first few weeks of the disease. This form of deafness is not amenable to treatment, the reason for which is apparent when we consider the pathological processes that destroy the function of the nerve : " Softening or thicken- ing of the ependyma of the fourth ventricle, purulent infiltration and softening of the auditory nerve" (Knapp), "imbedding of the latter in meningeal exudation" (Schwartze), "shriveling of the nerve-stem, and purulent inflammation of the membranous labyrinth, the origin of which can be traced to transmission of the inflammation either along the sheath of the auditory nerve (neuritis descendens) or through the aqueducts" (Politzer). The majority of cases of deaf-mutes coming under my ob- servation in which the deafness was acquired, were the result of meningitis. Politzer and Moos observed a staggering gait in half or more of their cases. Such has not been my experience, but it may be accounted for by the fact that my cases have not, as a rule, come under observation until the period of vertigo has passed, for this lasts only three or four months. I have not been able to verify the statement that tinnitus is a frequent symptom, but most of my cases have been children, and they rarely speak of subjective noises. Treatment will be considered only briefly, for its effects are usually nil. If the patient is seen during the meningitis, the ice-bag (Fig. 78) should be applied over the ear as soon as there are aural symptoms. Later, if the deafness is not of too long standing, absorbents and alteratives can be tried, such as potassium iodide and pilocarpine. Many pathological processes in the brain are capable of disturbing the hearing. It has been repeatedly seen that a dis- DISEASES OF THE INTERNAL EAR. 179 ease of the left temporal lobe, involving the first convolution, produces word-deafness. In this peculiar state there is a hear- ing for sounds, but incapacity for interpreting the compound sounds entering into the formation of words. This circum- stance would tend to locate the cortical centre for hearing in this part of the brain. The most frequent cerebral cause of deafness is the presence of tumors. The symptoms are very like those of labyrinthal disease : dizziness, tinnitus, varying degrees of deafness, and gastric disturbances. The diagnosis is often impossible. In the case of tumor, however, facial paralysis may develop, and bone-conduction may not be obliterated as it is in the labyrinthal deafness. Tumors may also produce pressure affecting other nerves than the acoustic or facial. Anaesthesia of the skin of the corresponding side of the head is sometimes found. Symptoms pointing to involvement of the optic or other nerves may aid in arriving at a correct deduction. New Growths of the Internal Ear. New growths of primary formation in the internal ear have been met with but very infrequently, and clinically their con- sideration merits only brief mention. The presence of growths in this situation is usually due to an extension from the cranial or tympanic cavity of epithelioma or sarcoma. CHAPTER XVII. DISEASES OF THE INTERNAL EAR, CONCLUDED. Injuries of the Labyrinth. Penetrating wounds of the labyrinth are of infrequent occurrence, but more often damage is done by fractures of the temporal bone, and concussion transmitted through the bones or through the air and conducting apparatus to the labyrinth. The symptoms of fracture of the bone are : a flow of blood and serous fluid from the ear, inco-ordination, deafness, and vertigo. The symptoms of concussion are the same, with the exception of the bloody and serous discharges. I have seen quite a number of instances in which the symptoms of irritation or paralysis of the auditory nerve supervened upon blows on the skull or on the ear. In the latter, rupture of the drum- head generally was present when the cases were seen early, and in such instances the labyrinthal symptoms were not as severe as when the drum-head was not ruptured, for in the latter case the force of the concussion was spent mostly on the stirrup, probably impacting it into the oval window. I have examined many soldiers of the war between the States, who suffered more or less loss of hearing from concussions produced by cannons, exploding shells, etc., in battle. Instances have also come under my observation in which blows on the head from the " sand- bags " of robbers, and from other weapons, and concussions from falls, have produced total deafness. Many workers in boiler-shops have appeared at the clinics with great dullness of hearing and tinnitus. Their ears were generally full of hardened, impacted plugs of black wax. After removing these the impairment of hearing still remained of high degree. Black- smiths, tinsmiths, coopers, and iron-workers suffer similarly. This is due to the constant concussions of the drum-head, ossicles, and intra-labyrinthal fluid and the auditory nerve from their incessant hammerings. The effect is to produce, in (180) DISEASES OF THE INTERNAL EAR. 181 addition to the labyrinthal affection, the sclerotic form of middle-ear catarrh, the treatment of which has already been given. The treatment for these forms of disturbances of hearing, of co-ordination, etc., is generally of little or no avail if several months or years have elapsed since the injury. In the early stage succeeding the concussion, the treatment laid down for tinnitus aurium and for paralysis of the acoustic nerve is indi- cated. Deaf-mutism. This is the lack or loss of speech due to congenital or acquired deafness. In my experience it is a rare condition. Only J of 1 per cent, of all the cases of ear defects that I have studied in hospital, dispensary, and private practice are of the deaf-mute class. Pathology. — In congenital deaf-mutism the precise con- dition to which it is due cannot be determined. This subject presents an opportunity for the application of the theory of re- version as affecting types of degeneracy. It may be owing to lack of development in some part of the organ of hearing, de- formities of the fenestra of the labyrinth, hydrocephalus, or pathological changes in the course or origin of the acoustic nerve. The acquired form may be due to middle-ear sclerosis, necrosis of the labyrinth, auditory neuritis, meningitis, or cere- britis. The tympanic and labyrinthal cavities may be entirely obliterated by connective-tissue and osseous proliferation. If the hearing is lost under the fifth year there is no speech, because it has not been acquired, while speech which has already been acquired later in life may be more or less perfectly retained after hearing is lost. However, I have many times observed that even in deaf-mute infants the primitive words "mamma" and " papa " only are uttered. I have seen dumbness follow the loss of hearing even after speech was acquired. The ability to articulate words grad- ually declined until nothing more than mumbling and mouthing of unintelligible sounds remained. In about 50 per cent, of 1S2 DISEASES OF THE EAR, NOSE, AND THROAT. deaf-mutes the semicircular canals are affected, which accounts for their peculiar, straddling gait, the feet being kept wide apart, and for their inability to stand with their eyes closed, and especially on one foot. Etiology. — Congenital deaf-mutism may be due to heredity, but it is not a frequent occurrence. A constitutional predispo- sition to this defect exists in some families, several members of which are afflicted. In one family the healthy parents had five daughters with normal senses and six sons who were born deaf (Kramer). Among all the deaf-mutes I have examined I do not know of one whose parents were deaf-mutes, although some have had various middle-ear affections. Consanguineous mar- riages are believed to account for deaf-mutism in quite a large proportion of instances, as well as specific disease and intra- uterine influences. The acquired form may follow injuries during childbirth or infancy, meningitis, scarlatina, typhoid, diphtheria, mumps, syphilis, or inflammation of the labyrinth. I have not seen the epidemic influenza, or grip, given as a cause. I have had recently under treatment the case of a girl, 6 years of age, who had lost her hearing entirely for four years in con- sequence of an attack of the grip. Under treatment the hearing has returned sufficiently at the present time to enable her to hear moderately-loud conversation and to learn to speak many words intelligibly and to form them into sentences. Inspection revealed no change in the drum. Symptomatology . — In infants the defect is not likely to be discovered until about the time that children begin to talk, and even then it may be overlooked by the parents, who attrib- ute the backwardness to slow development. I have often observed that parents believed their children could hear and that some defect in the organs of speech accounted for its absence, and yet they were born deaf-mutes. Failure to respond to sounds and calls can be easily detected if tests are made in such a manner as not to attract the child's attention by move- ments within the range of vision. Calling its name from behind, clapping the hands in such a position as not to produce waves of air that will strike the child, and out of its sight, the DISEASES OF THE INTERNAL EAR. 183 tuning-fork (Fig. 13), the Delstanche whistle, etc., are conclu- sive. If the child hear vowel or other sounds, a change of expression, a lighting up of the countenance, smiles, etc., evince the fact. Diagnosis. — The means of diagnosis have been indicated above. In a large proportion of cases a modicum of hearing is present. The ability to say " mamma " is not significant, since it is frequently present in hopeless cases. Such sounds are primordial and are uttered by the lower animals. While I have seen apparent improvement in a few cases of congenital deaf-mutes, it has not been of such a degree as to admit of understanding the common conversational tone. Loud sounds and some words could be appreciated, without doubt, but even this slight gift proved a pitiful source of happiness. A few cases are on record in which there was a useful development of the hearing after about the sixth year or after puberty. The acquired form is less promising still. Treatment. — In many cases examined by me there were evidences of middle-ear dry catarrh, but whether this bore any significant relation to the absence of hearing-power was a debatable question. It is possible that middle-ear disease in early infantile life may have involved the labyrinth in a destructive inflammatory process ; or, if the labyrinth has escaped, connective- tissue proliferation or osseous growths may have obliterated the round window or may have anchored the stirrup in the oval window so firmly as to preclude the possi- bility of its vibratory movements in response to sound-waves. If the auditory nerve is not destroyed, bone-conduction of sound can be demonstrated. In that case inflation of the middle ear and the application of the massage otoscope (Fig. 8), together with the galvano-faradic current (Fig. 72), may demonstrate the possibility of improvement after a few weeks. In one case of a young man with greatly-thickened and retracted drum-heads, I resected parts of them, which resulted in a considerable improve- ment. He had already been able to perceive the sounds of the vowels, and after the operations he acquired the use of quite a number of words before leaving the city. 184 DISEASES OF THE EAR, NOSE, AND THROAT. Instruction of deaf-mutes should begin as soon as it is shown that there is no hope for the hearing. The younger the pupil, the greater the accomplishment in the schooling. During the World's Fair in Chicago great proficiency was shown in the attainments of very young children in lip-reading and articulate language in the school-exhibits of those who had never heard. The perfect discipline was something to be appreciated by those who have had much experience with the deaf-mute class. Indeed, I have often been led to a correct diagnosis in deaf-mute children before an examination was made, and before any in- formation was imparted, by their irritable temper and incoherent violent actions. Lip-reading and articulate speech should always be taught them, if possible, and the sign-language should be made only an accessory. Some children do, not acquire the former ; so the latter must be employed. The admirable schools for the deaf in Chicago and other large cities go further and impart a useful education and more or less manual training in order to render their graduates self-sup- porting. The education of the deaf should be no more neglected than that of the better favored of our race. Indeed, greater facilities should be afforded for the acquisition of an education and the acquirement of the prerequisites of good and useful citizenship, to counterbalance the unfortunate disadvantage at which they have been placed through no fault of their own. The means already enumerated are efficient. They are pro- vided by private and public schools in the cities, and by the States in their deaf-and-dumb asylums. The subjects are usually intelligent and quick-witted, and their proper care and training will insure adequate returns upon the investment from both economic and humanitarian considerations. Hearing-instruments. Of all the various devices for aiding the hearing two only have proven of actual practical value in my experience. They are the conical conversation-tube (Fig. 106) and the London horn (Fig. 107). The conversation-tube consists of a trumpet- DISEASES OF THE INTERNAL EAR. 185 shaped mouth-piece to collect the sound-waves, connected with an ear-piece — both being of hard rubber — by a conical, elastic, spiral-wire tube covered with rubber and woven silk. The mouth-piece is placed close to the lips of the speaker, when a low, conversational tone can be employed, enabling the listener Fig. 106.— The Conical, Conversation-tubb. to hear words that are inaudible to others. The speaker should never talk loudly or cough or clear his throat with the mouth- piece near his lips, for often the hypersensitiveness of the affected ear renders these harsh, explosive sounds painful and irritating. These tubes are generally worn about the neck, under the coat, or rolled up in the coat-pocket. For near con- versation they are, by far, superior to any other device. Fig. 107.— The London Horn. The London horn (Fig. 107) is an excellent instrument for use at long distances, as in the cTfurch or lecture-room. It is made in three sizes and painted a dead-black preferably. The nickel-plated instruments are far more conspicuous. The horn is applied to the ear as in the case of the tube, and the large, 186 DISEASES OF THE EAR, NOSE, AND THROAT. open end is directed toward the source of sound. There is one serious objection to the metal horns : they convey a metallic, adventitious sound along with the speaker's voice. This defect is especially noticeable in listening to singing and the playing of an orchestra. However, it is preferred to the tube by many. The most distinguished of American newspaper editors is entirely dependent upon it, and cannot be prevailed upon to try the tube. After an extensive destruction of the drum-head the hear- ing is sometimes much improved by placing a pledget of cotton lightly against the handle of the mallet. Sound-waves striking this are then communicated to the ossicles and so transmitted to the perceptive apparatus. In such cases the artificial ear-drum, consisting of a thin disc of soft rubber (TurnbulPs), is inserted into the meatus and nicely adjusted to the exposed mallet. The audiphone, consisting of a fan-shaped disc of vulcan- ized rubber, bent by a silken cord into a convex surface to -be presented toward the source of sound, the edge in contact with the upper teeth, has been used to some extent. I have tested it with numerous patients, but with few exceptions it was of little value. The rubber discs, apparitor auris, cornets, auricles, cones, etc. , made of soft rubber and advertised extensively in the newspapers, are generally of no use to patients, and are pro- vocative of irritation, inflammation, and even ulceration of the canal and tympanic membrane and cavity. Occasionally I have been told by the wearers that their hearing was better while these devices were in their ears. I have frequently found them in contact with the drum-head, bathed in decomposing pus. No efficient and harmless hearing instrument for wearing in the ear has yet been devised. Fame and fortune await the inventor of the aural equivalent of spectacles. PART II. Diseases of the Nose Plate 1. VERTICAL ANTFRO -POSTERIOR SECTION OF THE NASAL CAVITIES, MOUTH, PHARYNX AND LARYNX. ^. S a jo us, Pmxr _Burk&M c Fetr,dge, Lith Phi la CHAPTER XVIII. EXAMINATION AND INSTRUMENTS. Rhinological practice requires an illuminating apparatus like the one shown in Fig. 5, or the electric forehead-lamp, or a student-lamp. Fig. 108 shows an electric light attachable to a portable battery. It consists of a cylinder, telescoping, from one and one-half to two inches (four to five centimetres) long, and is five-eighths of an inch (sixteen millimetres) in diameter, Fig. 108.— Electric Illuminator. provided with two powerful lenses. This instrument, when lighted, throws a white light of six- to eight- candle power directly upon the object in the focus. This instrument is par- ticularly adapted to the wants of the specialist. By removing it from the head-band it may be used as a hand-illuminator in examining other cavities of the body. The examiner should sit at the side of the patient, immediately in front and facing him, using the forehead-mirror, as shown in Fig. 4. Reflected light onlv can be used to advantage in this practice. The surgeon (189) 190 DISEASES OF THE EAR, NOSE, AND THROAT. should wear the mirror over his eye so as to look through the perforation in the mirror, and in such a manner as to shade both eyes from the light. The room is best darkened in order to avoid the contracting effect of the light on the pupils of the surgeon's eyes. During the examination of the nose, one hand of the oper- Fig. 109.— Ingals' Nasal Speculum. ator should rest on the top of the patient's head so as to control and manipulate its movements as is necessary in order to bring all the parts to be examined into the field of vision. The instruments required for anterior rhinoscopy are a nasal speculum (Fig. 109), a cotton-carrier (Fig. 9) to remove secretions that obstruct a view of the parts, and a bent probe for searching out hypersesthetic areas and determining the contour and extent of anomalies. Fig. 110.— The Author's Nasal Speculum. Ingals' speculum is best held in the palm of the hand with the back of the latter directed toward the patient's chin. The handle of the speculum should project straight downward and outward from the bivalves, so as to leave sufficient room between the patient's chin and the surgeon's hand. The valves should be small enough at their tip to use with children. In manipu- EXAMINATION AND INSTRUMENTS. 191 lating the speculum the pressure ought to be exerted mainly on the soft, yielding ala of the nose, and not on the septum. The author's speculum (Fig. 110) is convenient for use in operations in the nose. It is held expanded by a thumb-screw. DeVilbiss also has devised an excellent self- retaining nostril-dilator to be held in place by a rubber band about the head. Anterior rhinoscopy, or the examination of the anterior n ares, reveals the anterior extremities of the turbinated bodies and the side of the septum. The patient's head is tilted back- ward or forward as the upper or lower parts of the nasal cavi- ties are to be inspected. In many instances we can obtain a clear view entirely through the naris to the vault and posterior Fig. 111.— Bos-worth's Tongue-depressor. wall of the pharynx. In others, hypertrophies of the turbinated bodies or of the septum or deflections of the latter occlude the view. In health the color of the mucous membrane covering the lower portions of the naris is a light pink ; that of the superior turbinated body and roof of the nasal arch is yellowish. The nature of the light furnishing the illumination may vary the shade considerably. Posterior rhinoscopy calls for the use of a tongue-depressor (Fig. Ill), rhinoscopic mirrors (Fig. 112), and occasionally a palate-retractor (Fig. 113). The tongue-depressor should not be inserted far enough to cause retching, and the patient is told not to resist the gentle pressure and not to gag. His co-operation 192 DISEASES OF THE EAR, NOSE, AND THROAT. aids materially in the examination, and only a little practice is necessary to success. When the rhinoscopic mirror is intro- duced, the tongue-depressor is held by the left hand and the mirror by the right. Just before introducing the mirror it is warmed by passing the glass side over the lamp for an instant only, to avoid the condensation of the patient's breath on it, Fig. 112.— Rhinoscopic Mirrors. which would prevent a reflection of the post-nasal image. If the mirrror is too greatly heated its backing is destroyed. With the light reflected into the throat by the forehead- mirror, the nasal mirror is carried over the depressed tongue until it nearly, but not quite, touches the posterior pharyngeal wall with the mirror-surface directed upward and forward (Fig. 114). The natural inclination is to breathe through the mouth when it is open, and the patient is directed to breathe through his nose so that the soft palate will fall forward and downward Fig. 113.— White's Palate-retractor. from contact with the post-pharyngeal wall. Then, with the light properly directed upon the mirror, an image of the posterior naris should be seen. If the palate still embarrass the view, it can be lifted and drawn slightly forward by the palate-elevator (Figs. 113 and 115). Painting the uvula and velum with a 4- per-cent. solution of cocaine will facilitate this procedure. The rubber elevator is convenient. It is placed so as to lift the uvula EXAMINATION AND INSTRUMENTS. 193 with the palate, and the handle is held a little to one side, so as not to obstruct the field of vision. ',, <£*■■ Fig. 114.— The Rhinoscopic Ibiage. (After Bosworth.) As large a mirror should be used as the space will permit (one-half to three-fourths of an inch — thirteen to nineteen mil- limetres), but it must be so small as not to necessarily come in Fig. 115.— Hard-Rubber Palate-elevator. contact with the surrounding parts and produce gagging. The mirror is so manipulated as to bring the plane of its surface at 13 194 DISEASES OF THE EAR, NOSE, AND THROAT. „ f about an angle of sixty degrees to the perpendicular plane the posterior nares, in order to obtain a perfect image. The first reflected image to attract the attention is that of the velum palati. By slightly changing the position of the mirror, the septum on the one side and the orifice of the Eusta- DAVIDSON RUBBER Co. Fig. 116.— The Davidson Sprays. chian tube on the other come prominently into view, with the posterior ends of the turbinated bodies in the centre of the field. The two lower ones, of a light-pink hue, are easily distin- guished ; but the superior body, yellowish and dimly outlined in its remote recess, is not so easily seen. Fig. 117.— The DeVilbiss Universal Spray. The vault of the pharynx is rendered visible by tilting up- ward the mirror-handle in varying degrees until one obtains an image of the pharyngeal tonsil. The Davidson atomizers (Fig. 116) are very convenient for cleansing and medicating the nares. They throw a very coarse EXAMINATION AND INSTRUMENTS. 195 spray, bathing the parts profusely. They hold a large amount of fluid, do not leak, and are supplied with curved tips for the naso-pharynx and larynx. The DeVilbiss atomizer (Fig. 117) has the best adjustable tip. It can be turned so as to throw the spray in any direction desired, from the posterior nares to the larynx. The latest device to be used with compressed air has a flange upon which the fingers rest to prevent the column of air from throwing the instrument out of the grasp. It is also made with a broad base so as to prevent it from tipping over upon the table. It can be used with the hand-bulb also, but the dilators and Davidson atomizer cannot, since they require more pressure. The lavolin atomizers (Figs. 118 and 119) are very i Fig. US.— The Lavolin Atomizer. convenient for home treatment. I often prescribe these with a 3-per-cent. solution of camphor-menthol for patients to use at bed-time, to aid in the treatment. By this means they keep the upper respiratory passages cleansed and protected and they are more faithful to the treatment. The results are more satisfactory with this method. Many devices are employed for treating the nasal cavities, 1 but few are necessary. Some are capable of doing actual harm. The Weber nasal douche has thrown watery solutions through j the Eustachian tubes into the middle ears, setting up an inflam- mation. This is especially liable to happen when any stream of fluid is passed into the nostril, for there is a strong inclination 196 DISEASES OF THE EAR, NOSE, AND THROAT. to swallow provoked by the presence of the liquid. In the ac of deglutition the orifices of the tubes open and allow the ct Fig. 119.— Truax, Greene & Company's Atomizer. entrance of the fluid into the tympanic cavity. One of the most useful instruments for medicating the respiratory passages, after they are properly cleansed, is shown in Fig. 120. It con- Fig. 120.— The Universal Vaporizer. sists of a nebulizer which projects the most finely diffused spray obtainable, and admits of the use of much stronger medicaments EXAMINATION AND INSTRUMENTS. . 197 than are ordinarily used. It is so constructed that the medica- ment from one of the nebulizing- globes (E) can be propelled into the nose, throat, or middle ear in a steady current, or with interrupted currents by tapping on the valve (/). Or the inhalents in two or all of the nebulizing globes can be com- bined and used at the same instant. An important addition to this vaporizer is the air-regulating collar below the push-button (/). By this device the amount of pressure is easily controlled and shut off altogether, if desired, when the interrupted current is employed for inflating the middle ears. The compressed air is supplied to the circular tube (H) by Fig. 121.— The Globe Nebulizer. means of attaching the cut-off of the air-reservoir at K. The air is admitted to the globes by opening the keys at G. For those practitioners who are not supplied with a com- pressed-air apparatus the globe nebulizer (Fig. 121) is an ex- cellent substitute for the large vaporizer. It is also fitted for use with compressed air and is employed in the same manner as the vaporizer. Fig. 122 represents an inhalation taken through the aseptible face-mask. Fig. 123 shows the inhalation through a small vulcanite mouth-tube, and in Fig. 124 the returning medicated vapor is seen to issue from both nostrils. Figs. 125 and 126 illustrate the medication of the nasal passages and vault of the pharynx by permitting the vapor to enter one nostril and return through the other or through the mouth. In Fig. 127 198 DISEASES OF THE EAR, NOSE, AND THROAT. the opposite naris is closed while the vapor is made to inflate the middle ears as we have already described. AVith such perfect instruments as are here shown, and with sufficient air-pressure, the most effective treatment is rendered possible with accuracy and ease. Sprays and Inhalents. I have devoted considerable time to the investigation of inhalents, and have endeavored to arrive at definite results. We know well the action of nitrate of silver or sulphate of zinc when applied to mucous membranes, but accurate studies Fig. 122. Fig. 123. Fig. 124. Fig. 125. Fig. 126. Fig. 127 have not been sufficiently devoted to the physiological actions of the large number of inhalents offered for our use. These actions should be determined before we apply a local remedy to a diseased surface, for the same reasons that no inter- nal medicine should be administered without fulfilling a special indication for its use. In the case of camphor-menthol we have no doubt as to its place in therapeutics. We have defined its actions. It con- tracts the capillary blood-vessels of the mucous membrane, reduces swelling ; relieves pain and fullness of the head, or stenosis ; arrests sneezing, checks excessive discharges, and cor- rects perverted secretions. We know, also, that it possesses antiseptic qualities. SPRAYS AND INHALENTS. 199 Since my introduction of this remedy at the meeting of the Mississippi Valley Medical Association, in 1891, it has come into quite general use for catarrhal conditions of the upper respiratory tract. Although I did not recommend it until long after I had dis- covered that the union of these two camphors resulted in a fluid of the chemical formula C 10 H 18 O, and after becoming satisfied that we possessed a valuable remedy in this new drug, I am now able to express greater confidence, and to verify former state- ments by the experience of others as well as by the daily use of it up to the present time. The experimental stage has passed and the efficacy of- this remedy is clearly established. Special- ists who were at first skeptical as to its virtue have since adopted it as a standard remedy in both private and dispensary practice. I have taken pains to ascertain the results of their experiences, and add them to my own. The field of application in which camphor-menthol has proved most efficacious is in the following diseases: Coryza, hay fever, in tumescent rhinitis (intermittent and alternating nasal stenosis), hypertrophic rhinitis, simple sore throat, acute laryn- gitis, tracheitis, bronchitis, and after cauterization to prevent haemorrhages and inflammation. For home use and ordinary office treatment I do not employ a stronger solution than the 3 per cent, in lavolin, and for very sensitive cases, like hay-fever sufferers, the 1- or 2-per-cent. solution at first. The lavolin itself is a bland and soothing pro- tective to the membrane, and in the combinations indicated we have undoubtedly a most effective and harmless remedy. This means a great deal to both patient and physician, for many of the sprays in use give indifferent results — or worse. Patients should be instructed to treat themselves thor- oughly every night at bed-time, by throwing a spray of the 3- per-cent. solution from a lavolin atomizer (Fig. 118) into both nostrils while slowly inhaling. The rubber bulb should be forcibly and rapidly compressed at least eight times for each nostril. For the throat, larynx, or bronchial tubes the spray should be thrown through the mouth during inhalation. 200 DISEASES OF THE EAR, NOSE, AND THROAT. In diphtheria, croup, etc., in infants, when it is very dif- ficult to throw a spray into the throat, the medicine may be made to reach the parts by volatilizing it, by placing a few drops of the pure, undiluted camphor-menthol in a tea-kettle of hot water and causing the patient to breathe the medicated steam ; or a few drops can be heated in a spoon over a lamp, and its fumes will impregnate all the atmosphere of the room. Enough medicine need not be used to cause uncomfortable smarting of the eyes. Inflammation of the throat, larynx, trachea, and bronchi can be effectually treated by inhaling the camphor-menthol steam in this manner. I have found that we can prevent haemorrhage and inflam- mation, following galvano-cauterization of the turbinated bodies, by gently packing a pledget of cotton wet with a 20-per-cent. solution of the camphor-menthol between the burned tissue and the septum, and leaving it there twenty-four or forty-eight hours. It is then replaced by a fresh dressing, and, at the end of four or five days, instead of finding sloughs filling the passages, swelling, and stenosis, the tissues appear shrunken and mum- mified and the strait is clear. Unless the electrode has been allowed to cool before removing, no haemorrhage or only slight oozing occurs. There is also less discomfort following this method than after others. The cotton should not be saturated to dripping with the solution, so as to allow it to trickle down into the throat, and if too much is used it occasions a copious serous secretion. Advantage of this power of the strong solu- tion to cause stimulation of the glands and osmosis can be taken in treating ozaena and dry catarrh of the nose and throat. The weak solutions diminish secretions ; the strong ones increase them. For self-treatment of the nose and throat patients have found much relief by using an inhaler like that shown in Fig. 128, which can be carried in the pocket, and contains a liquified mixture of equal parts, by weight, of camphor and menthol. It has a more soothing and correcting effect on the nerves and vessels than menthol alone. It does not become irritating, like menthol-crystals, after being used for some time. SPRAYS AND INHALENTS. 201 It can be used unnoticed in public places the instant any irrita- tion appears, and thus prevent or cut short attacks. Three or four slow, deep inhalations should be taken from it in one nos- tril while the other is closed, or until the irritation is relieved. The breath should not pass through the inhaler, but out through the mouth instead. ' To treat the throat it should be inhaled through the mouth. If we want a drying, detergent, and protective spray, the pine-needle oil in a 2-per-cent. solution will accomplish the pur- pose, and it is a most agreeable preparation. In those rare cases in which the mucous glands are atrophied and in need of a powerful stimulant to excite them to action, the 4- or 10-per- cent, cubeb-spray is the most effective, especially when com- bined with the 10-per-cent. strength of camphor-menthol and lavolin. There is a prevalent mistaken opinion that the cubeb-spray Fig. 128.— The Author's Camphor-menthol Inhaler. is drying to the mucous membrane, while the opposite effect is the true one. It is a stimulant and disinfectant. It increases the flow of mucus, and if used in too strong a preparation it acts as an irritant. Cubeb is useful as a tonic in chronic irritability of the pharynx and larynx, especially in the hoarseness of public speakers and singers. Eucalyptus is antiseptic, and destructive to low forms of life. It is a stimulating expectorant, and must not be used in very strong solutions, or it becomes an irritant. When com- bined with lavolin in the proportion of 20 grains to the ounce it is not too strong for the majority of patients, but, as a rule, it must be avoided in hay-fever patients. Some of them cannot remain in the room where it is being sprayed without suffering from paroxysms of sneezing. Carbolic acid combined with lavolin, 2 grains to the ounce, is valuable when the antiseptic 202 DISEASES OF THE EAR, NOSE, AND THROAT. and anaesthetic effects are required. It is very useful in ozaena, especially when followed with the aristol. Alkaline and antiseptic aqueous solutions are necessary for properly washing out and cleansing the nasal cavities prepara- tory to the application of other medicaments. DobelPs solution is the most universally used. It consists of biborate and bicar- bonate of sodium, of each 1 drachm ; carbolic-acid crystals, 12 grains ; glycerin, 2 drachms ; water, enough to make 8 ounces. Seller's antiseptic solution is also satisfactory, and is easily and quickly made by dissolving one of the tablets in two ounces of pure water. These solutions dissolve, loosen, and wash out the secretions and crusts, so that the diseased membrane itself can be reached. CHAPTER XIX. DISEASES OF THE NASAL CAVITIES. Influenza. There are two types of this disease. One is an uncompli- cated catarrhal condition of the respiratory tract prevailing generally during the changes of the seasons from fall to winter and from winter to spring, and may appear at any time during the year. The other is of an epidemic nature and is known under several names, as follow : The grip ; grippe ; epidemic catarrh, or catarrhal fever ; blitz catarrh ; epizootic. Since the treatment of the severer variety will include that of the milder, we will consider the subject of the epidemic form. Epidemics of influenza date back beyond the Christian era. and as early as the year 415 B.C. the Athenian army in Sicily was afflicted with this trouble. There is a periodical outbreak of a similar disease, occurring twice a year, in January and August, in the Caroline Islands, from which nearly all the in- habitants suffer ; but this is very suggestive of hay fever. In the year 1510 the British Islands were visited by a very ex- tensive epidemic of influenza, but up to that time no exact records of it were written. Since that period there have been more than twenty outbreaks of a severe type, besides many minor ones. The disease usually is first manifested in the far East, gen- erally in some part of Russia, and travels rapidly from east to west. The greater the facilities for rapid transit, the faster it invades the western countries. It has traveled from near St. Petersburg to Xew York in six weeks. It prevails in all cli- mates and attacks all classes of society, but infants enjoy partial immunity. While it has been made the butt of jest by the uninformed masses and the subject of ridicule by the unthinking trhiers in medicine, it is more to be feared than small-pox or cholera. It cannot be quarantined and controlled by protective (203) 204 DISEASES OF THE EAR, NOSE, AND THROAT. measures like those diseases, and when it does not kill it blights and withers and leaves its deadly sting to blot out one's sight, or hearing, or reason, or sows its morbific seeds in other organs to insure its victims future maladies. When it first appeared in Paris the effects were worse than any of the three epidemics of cholera during the thirty years preceding 1884. The influenza epidemic of 1891 in Chicago, lasting about six weeks, produced the highest mortality the city had ever known. Pathology. — The exact nature, cause, and method of origin and propagation of this disease are not yet definitely determined. It is easier to say what it is not than to say precisely what it is. It is not a simple catarrhal affection. It is a specific, infectious, and contagious disease. The principal manifestations occur in the mucous membrane of the respiratory tract. There are con- gestion and swelling of this membrane in the nose, throat, and pharynx, and sometimes extending as far as the bronchial tubes. In certain cases the inflammation invades the gastro-intestinal canal. Various bacteria have been found in the sputa of persons suffering from this disease. Staphylococci and streptococci were especially abundant, but it is still an open question as to what actually constitutes the specific infection that gives rise to the attack. Some observers believe that the true influenza bacillus has been found, while others are of the opposite opinion and suggest that the micro-organisms found may be the product instead of the cause of the disease. It seems reasonable to assume, from the rapidity with which the whole organism shows the presence of infection, that it first enters the blood. No other theory yet advanced satisfactorily accounts for all the phenomena that it presents. Etiology. — Epidemic influenza is believed by some to be caused by peculiar atmospheric conditions, which would account for its rapid extension over a large part of the globe and ap-. pearing in widely-separated places at nearly the same time. We know that the upper strata of the atmosphere, in which volcanic dust is disseminated, will carry these particles to the remotest regions of the earth, and that dense poisonous gases DISEASES OF THE NASAL CAVITIES. 205 evolved from subterranean sources may be extruded into the great ocean of atmosphere about us and prove detrimental to animal life. During some invasions meteorological records have shown high barometric pressure, drouth, northerly winds, cloudy sky, diminution of ozone, and low electrical charge of the air. While the prevailing winds have varied greatly in different countries during the same epidemic, extremely dry air has been a constant factor. This unusual dryness of the air and earth has led some to believe that the consequent liberating and floating of the result- ing dust in the air and its inhalation and irritating effects upon the respiratory passages accounted for attacks. But a severe epidemic arose in Russia while the country was covered deeply with a carpet of snow, and, moreover, the respiratory system is not invariably involved. It is claimed by some observers that the epidemic does not travel faster than man ; that obstacles to travel, like mountain- ranges, obstruct its progress ; that the most popular means of communication between people of different countries form the routes by which the disease progresses ; and that it first gains foothold in large cities, where persons congregate in the greatest numbers : post-offices, factories, schools, banks, etc. All these facts point to the harboring and conveying of the germs of influenza by human beings. Symptomatology. — The variations of the disease as it ap- pears in different individuals, and even in the same person, are susceptible of classification under three natural divisions of the subject: as it affects (1) the nervous system, (2) the alimentary canal, and (3) the respiratory tract, including the Eustachian tube, middle ear, and pneumatic cells of the mastoid process. We are especially concerned with the latter form. It is not common to see all of these forms affect the same patient at the same time, but it is not uncommon to see two of them co-exist. For example : The great mental depression with extreme prostration of the muscular system that first makes its appearance may be quickly followed by the gastric and intes- tinal disturbances that add to the exhausted condition already 206 DISEASES OF THE EAR, NOSE, AND THROAT. present. We often see the nervous and respiratory forms com-v bined, but not the simultaneous invasion of the air-passages and alimentary canal. Two of the three forms are sometimes consecutive to each other. To illustrate : One of our younger professors in the Post-Graduate School was attacked during the epidemic with vomiting and purging and general prostration, from which he nearly recovered in five days, when he was seized with sneezing, running at the nose, sore throat, hoarseness, and mild bronchitis. Chilliness and heat may often be marked when the tem- perature rises only one or two degrees, but the rise is often to 103° or 104° F. In addition to a sudden sense of great fatigue there often occur shooting pains in the head, pain and muscular soreness in the extremities or abdomen, aching of the back and loins, and in the respiratory form coryza, pharyngitis, and often an invasion of the lower air-tract. We have observed that patients with an unusual form of middle-ear disease begin to present themselves in both private and dispensary practice about one w 7 eek after we become con- scious of the presence of an epidemic of influenza. They often present this story : " Doctor, I was taken a few days ago with a cold in the head, and I had a great pain in my ear last night. It broke during the night and ran blood and water." They present a picture of acute suffering, anxiety of countenance, weakness of the limbs ; coated, indented, and tremulous tongue ; and complain of pain radiating over the corresponding side of the head. The mastoid is more often involved than in the simple middle-ear inflammation complicating influenza between epi- demics. The external-ear canal is found to contain bloody serum ; the drum-head is red, swollen, and bulging ; and the tympanum is filled with discharge. The hearing is usually much impaired. Diagnosis. — As soon as the catarrhal symptoms of the re- spiratory tract make their appearance, the diagnosis is a simple matter. The symptoms already enumerated are sufficient to decide the question, and the presence of an epidemic will suggest the nature of the complaint. DISEASES OF THE NASAL CAVITIES. 207 Prognosis. — Robust individuals are able to resist the attacks sufficiently to recover in a few days or weeks, but persons already debilitated or suffering from diseases of vital organs are prone to succumb either during the attacks or as a sequel to them. While the general statement may be made that a small percentage of cases die during the attacks, this does not convey any adequate idea of the actual damage done by an epidemic, because, in the first place, such vast numbers of the population fall victims to its ravages, and, in the second place, many die or are made defective as its sequel. Treatment. — The patient is put to bed and the bowels relaxed if necessary. When the temperature is high it is re- duced with antipyrin or one of its efficient substitutes, and the pain and other distressing symptoms are relieved by tablets containing a combination of morphia, atropia, and caffeine in the proportion of T V grain of morphia with q^-q grain of atropia and ^ grain of caffeine (Traux, Greene & Com- pany). The morphia relieves the pain and nervous irrita- bility, suppresses the excessive secretions, and stimulates the circulation ; the atropia elevates the tone of the blood-vessels, quickens the pulse, decreases all the secretions except the urine, stimulates the respiratory centre, and counteracts the constipating effects of the morphia ; and the caffeine stimu- lates the nervous centres and the kidneys and diminishes the tendency of the morphia to produce nausea. The sneezing and nasal discharge cease, the nostrils open up, and the pain disappears. We treat the nose and throat with a 3-per-cent. solution of camphor-menthol in lavolin with the atomizer three or four times a day. This treatment, with repetition ol the doses as the symp- toms demand, minimizes the suffering, diminishes the intensity of the disease, and shortens its course. For rheumatic symp- toms salicin or salicylate of sodium should be given. Com- plicating diseases call for their appropriate treatment on general principles. 208 diseases of the ear, nose, and throat. Acute Rhinitis. Synonyms. — Cold in the head ; coryza ; acute nasal catarrh. Pathology. — Simple acute rhinitis is an inflammation of the Schneiderian membrane of one or both nostrils. It is more common to childhood than adult life, and the aged are rarely afflicted with it. Coryza forms one of the symptoms of the eruptive fevers, and sometimes occasions more distress than the disease it accompanies. Etiology. — Taking cold is the commonest cause. The im- pression of cold on certain surfaces of the body appears to paralyze the inhibitory power of the vasomotor nerves con- trolling the capillary circulation of the nasal mucous membrane. The most vulnerable surfaces are the back of the neck and head and the feet. The climatic and meteorological causes are dis- cussed in Chapter I. The nervous temperament predisposes to this affection. Wagner {New Yorlc Medical Journal, October 27, 1894) considers that rhinitic affections are in many cases due to the immigration of micro-organisms from the tonsils when they are diseased. Symptomatology. — The earliest manifestation of cold in the head is a sensation of dryness or irritation in the nostril, prompt- ing one to snuff the air as if to dislodge some foreign substance. This gives place to itching, tickling, or stinging sensations, fol- lowed by paroxysms of sneezing, copious flow of serum and mucus from the nostrils, suffusion of the eyes, lacrymation, flushed countenance, and possibly sensations of constriction and pain over the eyes in the frontal sinuses, and headache. The discharge becomes acrid and irritating to the nasal opening and upper lip, producing redness, excoriations, and cracking of the skin over which it spreads. The efforts of the patient to keep the nose and lip dry result in the removal of the epidermis to such an extent as to leave a raw-appearing surface. One of the most distressing symptoms is the nasal stenosis produced by the great swelling of the nasal membrane and turbinate bodies. This interferes with swallowing as well as Plate II PLATE II. Figure 1. — Posterior view of left nasal cavity in the normal state. 2.— Lateral " " " " " " 3.— Anterior " " " " " " 4. — Rhinoscopic " " " " " " 5. — Rhinoscopic : ' " " " " mirror slightly turned " 6. — Microscopic section of the nasal mucous membrane over the turbinated bones. a, Superior turbinated bone. i, Vestibule. b, Middle " " j, Sphenoid sinus. c, Inferior " " k, Frontal " d, Eustachian orifice. Z, Epithelium. e, Soft palate. m, Submucous layer. /, Uvula. n, Corpora cavernosa. g, Posterior nasal cavity. o, Fossa of Rosenmuller. Figures 7 to 12. — Acute rhinitis, or appearances during an exacerbation of simple chronic rhinitis.* Figure 11. — Rhinoscopic view of hypertrophied adenoid tissue in the posterior wall of the naso-pharynx during an acute exacerbation. Figures 13 to 18. — Hypertrophic rhinitis ; anterior, middle, and posterior hypertro- phies ; fimbriated adenoid vegetations in the naso-pharynx. •^Represented as seen under gaslight. Under natural light the red color is much lighter, Plate II l J SajQus, Pinxil Burk &M C Petri dge, Lith. Phi/a. DISEASES OF THE NASAL CAVITIES. 209 breathing. Respiration takes place entirely through the mouth, and the attempt to swallow liquids results in their being forced upward into the nasal space or even into the Eustachian tubes. The sense of smell is diminished or absent and the voice indi- cates the seat of the trouble. It has a characteristic nasal quality, and the sounds of m and n cannot be produced. The disease may extend to the antrum of Highmore, the frontal sinuses, the ethmoid or sphenoid cells, or the Eustachian tubes and middle ears. Diagnosis. — The group of symptoms described presents so characteristic a picture that there is no likelihood of confound- ing this disease with any other, but it must not be forgotten that it is a symptom of the exanthemata. Prognosis. — If the inflammation does not extend to the accessory cavities, recovery can be expected in a few days, but may be postponed longer in severe attacks. Treatment. — The course pursued in the treatment of in- fluenza, varying according to the severity of the attack, can be relied upon here. Indeed, this disease can be averted by the use of the tablets mentioned for influenza, containing caffeine, morphia, and atropia. By giving one of these at the onset of the attack the symptoms subside with as much certainty as can be affirmed of any medicinal specific. The effect of this remedy lasts several hours, although the dose is small, and it should be repeated in two, four, or six hours if the symptoms begin to re-appear. (See page 207.) This remedy should never be given through prescriptions to patients. I have never allowed them to know the com- position of it, and for this reason no patient has ever contracted a drug habit through my carelessness. It would be much better to give the little tablets gratuitously than to run any risk what- ever of becoming responsible for a harmful habit. Spraying the nose with a 3-per-cent. solution of camphor- menthol in lavolin (Figs. 118 and 119) affords great relief. The physiological effects and uses of this remedy are dwelt upon in Chapter XVIII. The camphor-menthol pocket-inhaler (Fig. 128) affords 14 210 DISEASES OF THE EAR, NOSE, AND THROAT. much relief in mild attacks. Its uses are given in the pre- ceding chapter. It affords not only a very refreshing inhalent, but, if employed as soon as the first nasal irritation is felt, the symptoms may be checked. An important preventive measure is the protection of the body from the vicissitudes of the weather. Fabrics of vegetable fibre, such as cotton and linen, should not be worn next* the skin. Animal fibre, such as woolen or silk, favors absorption and evaporation of the perspiration, keeps the temperature of the surface of the body equable, and prevents chilling. Woolen is preferable to silk, except in the hottest weather, when thick silk underwear affords more comfort and sufficient protection. Simple Chronic Rhinitis. Synonyms. — Chronic coryza ; blennorrhcea ; rhinorrhcea ; purulent catarrh. Pathology. — This is a chronic inflammation of the nasal mucous membrane, generally consequent upon recurring seiz- ures of acute coryza. The membrane is swollen and puffy and the venous sinuses are dilated and relaxed (vasoparesis). Ex- tensive infiltration of the interstitial tissue with serum and leuco- cytes occurs, with a consequent hydrorrhcea and degeneration into pus-cells. The mucous glands are excited to increased activity, necessitating a frequent resort to the handkerchief to prevent dripping from the end of the nose. The membrane is easily irritated by dust, gases, and sudden changes in the weather. Etiology. — Exposure to damp and cold and an atmosphere loaded with irritating gases or dust act as direct exciting causes. A nervous temperament and the strumous diathesis predispose to the disease. Symptomatology. — The increased nasal discharge is the most prominent feature, and the end of the nose may become so irritated as to give it a red and swollen appearance. The secretions consist of mucus and serum, or pus formation takes place to such an extent as to fill the nares with a yellow dis- charge. Its presence provokes frequent hawking and expecto- to- DISEASES OF THE NASAL CAVITIES. 211 ration. Sneezing is not a constant or frequent symptom as compared with acute coryza or hay fever. An annoying sensa- tion of fullness in the head — especially if the infundibulum, or passage-way from the frontal sinus to the nose, is obstructed — may lead one to suspect involvement of the sinus. There is a tendency for this disease to extend to the Eusta- chian tubes, the middle ears, or the nasal ducts, causing impair- ment of hearing and obstruction of the natural tear-passages. The thickening of the membrane and the turgescence of the turbinate bodies so constrict the meatuses as to impart a nasal intonation to the speech. The walls of the passages are frequently seen to be agglutinated together by a viscid, tena- cious secretion, or bathed in pus. The membrane is generally redder than the normal, but in the variety in which the hydrorrhcea is abundant it may appear of a pale-pink tint or even livid. The secretions may become dry and inspissated to the degree of crust formation. These adhering crusts excite a desire to pick at the nose until they are removed. This con- stant source of irritation and depriving the septum of its natural protection in the process of repair result in perforation in that part of the cartilaginous septum near the border of the nares. Diagnosis. — To distinguish between this and hypertrophic nasal catarrh it is essential to use the probe and cocaine. When the probe is pressed upon the turbinals in the simple form it sinks into a body comparable to a wet sponge, for the tissues are distended with the infiltrated fluids. The depression caused by pressure fills slowly like that of a dropsical body. In the hypertrophic variety the probe meets with a firm, resisting, fibrous tissue, which possesses greater resilience. Cocaine contracts the tissues, in the simple form, until they hug the bone, leaving a wide air-space ; but not so in the hypertrophic variety. In the latter the surface is uneven, in the former smooth. Prognosis. — Patients are skeptical as to the curability of nasal catarrh. It is so common an affection, especially in the 212 DISEASES OF THE EAR, NOSE, AND THROAT. region of the Great Lakes, that the inhabitants think that, as a matter of course, they must expect to suffer from it. However, with an advantageous combination of treatment and hygienic measures, a cure can confidently be predicted. But one is not warranted in promising no return of the trouble under provoca- tive conditions. Treatment. — The first requisite to success is cleanliness of the nasal cavities. This is best obtained by the use of sprays such as Dobell's and Seller's solutions, mentioned in Chapter XVIII. These can be injected successfully with the hand- atomizer (Figs. 118 and 119) if one lack a large air-compressor. Eight pounds' pressure is sufficient to thoroughly wash the cavities without any likelihood of invading the Eustachian tubes. After the membrane is thoroughly cleansed oleaginous sprays are indicated to protect the surface, stimulate the absorb- ents, contract the blood-vessels, disinfect, and render the mucosa less sensitive. These remedies are treated of in Chapter XVIII. An effective treatment consists in throwing a fine nebula of a 10-per-cent. solution of camphor-menthol in lavolin, by means of the hand-dilator (Fig. 18), followed by a spray consisting of calendula, 4 parts; hamamelis, 8; pinus strobus, 8; lavolin, 80. Or the following: Eucalyptol, 30 parts; carbolic acid, 10; menthol, 4 ; oleate of aconitine (2 per cent.), 2 ; oil of sassa- fras, 10; lavolin, 944. Camphor-menthol in the nebula does not bathe the membrane with the liquid, but relieves the irrita- bility and stenosis and prepares the parts for the coarser spray which will remain in contact with the diseased surface for many hours. This treatment is best given two or three times a week by the surgeon, while the patient pursues a home treatment with a suitable atomizer and medicament in order to prolong the effect of each office treatment and render it continuous. Cocaine is not mentioned by the author as a therapeutic agent, because it is not of such a nature as to effect permanent results, and because of the imminent danger of converting one's patron into a pemicious-drug slave. Cocaine has no place in my practice except as an anaesthetic in surgical procedures. DISEASES OF THE NASAL CAVITIES. 213 Dilators of medicated gelatin, gum elastic (Fig. 129), hard rubber, and metal are useful in reducing the engorgement of the turbinate bodies and overcoming contact and pressure of these bodies upon the septum. The bougies adapted in contour and size to each individual case are introduced between the turbinals and septum for a few minutes at first, beginning with the smaller, and used on the same principle as sounds and dilators in other departments of surgery. Fig. 129.— Goodwillie's Nasal Dilator, or Tube. When the engorgement of the vessels of the turbinate bodies produces great intumescence of those structures and con- sequent constriction of the nasal passages that proves unyield- ing to the methods already mentioned, the cautery is indicated. The galvano-cautery is the most effective, but in its absence chemical cauteries can be substituted. A detailed description of the apparatus and methods will be found in the treatment of hypertrophic rhinitis. The question of proper clothing is con- sidered in the treatment of acute rhinitis. CHAPTER XX. DISEASES OF THE NASAL CAVITIES, CONTINUED. Hay Fever. Synonyms. — Nervous catarrh; nervous coryza; hay asthma; rose cold ; June cold ; July cold ; peach cold ; summer catarrh ; autumnal catarrh; pollen poisoning. The Latin equivalents are catarrh us sestivus; coryza vasomotoria periodica. French equiv- alents: ca tan-he d'ete ; catarrhe de foin. German equivalents: Friihsommer-catarrh ; Heu-asthma. Italian equivalent: asma dei mietitori. Pathology. — In a paper read before the Section on Psycho- logical Medicine and Nervous Diseases of the Ninth Inter- national Medical Congress in Washington in 1887, the author argued the neurotic character of this disease. The assembly, which was very large and representative, agreed almost unani- mously to the theory that hay fever is a neurosis. Only three members who participated in the discussion dissented fiom this view. The name "hay fever" is a misnomer. It is employed to designate a condition to which numerous other terms have been applied with equal fitness. To the array of names already in use, ill-chosen because they are misleading, I have had the temerity to add another. In a published lecture, delivered in the Chicago Medical College in 1885, I proposed the term "nervous catarrh." Since then several authors have adopted this expression. One writer, however, calls it nervous coryza ; but coryza is from the Greek xopv^a, signifying only a running at the nose, while the word catarrh, from xarappeo, admits of a much broader application and, with properly modifying adjec- tives, may be used to designate affections of various mucous membranes. Coryza is a specific term ; catarrh is generic, and obviously is the more correct one to characterize a disease which is not necessarily confined to the nasal cavities. Nervous catarrh (214) DISEASES OF THE NASAL CAVITIES. 215 is so comprehensive a term, and is so tersely suggestive of the pathology and symptomatology of certain neurotic derange- ments, as to be susceptible of a much larger usefulness than has been accorded it. To illustrate : There is a truly nervous intestinal catarrh which attacks and leaves a certain class of individuals of the nervous temperament as suddenly as an attack of hay fever does. I have, known a musician to suffer from severe attacks of diarrhoea just previously to his appear- ance before an audience which he was announced to entertain. Immediately after his performance all symptoms of intestinal disturbance would vanish, only to return again at his next ap- pearance in public. I might cite a case of an orator of the evening who was similarly afflicted. The nervousness induced by the contemplation of addressing his audience would so react on the nervous supply of the intestinal tract as to cause sudden and copious diarrhoea. No sooner would his oration be finished than all unpleasant symptoms ceased. I have known surgeons to be similarly affected. We have nervous dyspepsia occasioned by mental emotions. A certain combination of objective and subjective causes operating on one individual produces morbid phenomena referable to the mucous membrane of the turbinated bodies, resulting in an attack of hay fever, — nasal nervous ca- tarrh. In another, the seat of the resulting manifestations will be in the bronchial mucous membrane, eventuating in an attack of asthma, — bronchial nervous catarrh. In yet another the in- testinal mucous coats are the scene of this breaking of a nerve- storm, resulting in copious watery discharges, — intestinal nervous catarrh. All these are undoubtedly co-ordinate morbid con- ditions of the nervous system, finding expression in exaggerated and perverted functional activity. The pathology of this disease has been evolved from a chaotic state, in which it remained from the time of its first description by Dr. Bostock, of London, in 1819, until the last decade. Instead of looking upon hay fever as a simple con- gestion or inflammation of the Schneiderian membrane, as emi- nent English authorities have in the past, prominent American authors favor the neurotic theory. In this connection it is inter- 216 DISEASES OF THE EAR, NOSE, AND THROAT. esting to note that a writer for the Lancet treats of common nasal catarrh as a reflex neurosis, and, in support of his position, adduces numerous instances in which purely nerve-remedies succeeded in arresting attacks of acute coryza. Although this malady is essentially due to an abnormal susceptibility of nervous tissue, there exists no organic lesion of the nervous centres to which the disease is attributable. Being a functional disturbance, it never destroys life, and no oppor- tunity is afforded the neuropathologist to make post-mortem ob- servations. But, if the affection be a reflex neurosis, can we hope for microscopy to determine with precision the condition of nervous structure which primarily constitutes the disease \ The arrangement of the nervous supply of the respiratory passages is favorable to the existence of reflex nervous phenom- ena. One sympathetic nervous centre, the sphenopalatine ganglion, supplies branches to the lining membrane of the nose, pharynx, and Eustachian tubes. It has a motor, a sensory, and a sympathetic root. It communicates with the facial and pneu- mogastric nerves, thus uniting in the closest connection the nose, pharynx, middle ear, larynx, and bronchi. Furthermore, the Schneiderian membrane is continuous with the lining mem- brane of the nasal duct and eyelids, the pharynx, Eustachian tubes and tympana, the larynx, trachea, and bronchial tubes. Ablation of the sphenopalatine ganglion sets up a severe catar- rhal state of the Schneiderian membrane. A congestion once started in this structure may extend with unobstructed facility to the contiguous membranes, very like the spreading of an ery- sipelatous inflammation from one area of the skin to another. But the continuousness of the membranes throughout these various organs does not satisfactorily account for all the symp- toms produced in one part by impressions upon another. Cer- tainly an inflammation in the throat may extend along the Eustachian tube to the tympanum, but there is no such reason to account for the sudden transitory tinnitus aurium which occurs in some persons immediately upon the ingestion of a draught of cold water or the inhalation of tobacco-smoke, or for the cough which is occasioned by the contact of instruments DISEASES OF THE NASAL CAVITIES. 217 with the external auditory meatus or with the inferior turbinated body or the septum nasi, or for the paroxysm of sneezing pro- duced by irritating the scalp. All these symptoms are exam- ples of reflex nervous impulses, and these intimate sympathetic relations between various portions of the animal economy ex- hibit themselves with exceptional force in patients of a nervous temperament. The theory that lesions situated in the nasal cavities may be responsible for the existence of common asthma is generally accepted, and this is directly in the line of our reasoning, for it argues the reflex neurotic character of a disease which possesses close kinship to hay fever not only in its etiology, symptoma- tology, and therapeutics, but in the morphology of its secretions. The manner in which exciting causes bring about attacks in hay fever is much the same as in the case of asthma. In a hay- fever subject, let brilliant rays of light fall upon the retina, or dust impinge upon a sensitive area of mucous membrane, and what occurs] The end-organs of the sensory nerves supplying the part affected, being oversensitive to the presence of that particular kind of stimulus, are instantly thrown into a state of intense excitation or irritation. Immediately the impression is flashed along the sensory nerves to a nervous centre, — brain or ganglion ; thence, changed to motor impulse, it is switched back, on the one hand, along the vasomotor nerves to the blood-vessels of the seat of irritation, causing dilatation, engorgement, swell- ing, and flux ; and, on the other hand, along the pneumogastric and sympathetic nerves to the muscles concerned in the act of sneezing, and, through extensive sympathetic nervous relations, all the respiratory tract and its connections may participate in the disturbance and become involved in a fully-developed attack of hay asthma, — sneezing, coughing, wheezing, nasal flux, expectoration, and lacrymation. Thus it appears, from the manner in which paroxysms of hay fever are started and developed, that there are three con- ditions upon which the existence of the disease depends: (1) abnormally susceptible nerve-centres, (2) hyperesthesia of the peripheral termini of the sensory nerves, and (3) the presence 218 DISEASES OF THE EAR, NOSE, AND THROAT. of one of a large variety of irritating agents. Exclude one of these conditions and the paroxysms are prevented. Allay the susceptibility of the nervous centres by certain cerebral sedatives, and an attack is averted or arrested. Anaesthetize the nervous supply of the oversensitive areas and the result is the same. Remove the patient beyond the reach of exciting causes and he is as comfortable as anv mortal. Another fact in support of the theory that this is a func- tional disease of the nervous system is its hereditary character. I might quote many illustrative cases, but three representative ones will suffice: In Dr. Morrill Wyman's family there were six sufferers from hay fever besides himself. In the family of the Hev. Henry Ward Beecher there were two besides himself, and in the family of Chief- Justice Shaw there were six members who had different forms of this distressing malady. To be sure, heredity alone does not establish a neurotic character ; but, taken in connection with all the other facts in the case, it is a weighty argument in support of the assertion that this is a con- stitutional disorder of a neurotic type. Again, the nervous temperament is the predominating one in this class of patients, — an argument which needs no eluci- dation, — and the same may be remarked concerning asthmatic sufferers. The periodicity of the disease points to nothing if not to its nervous nature, for one cannot conceive how the pollen theorists from their point of view can reconcile this feature of the complaint with their own doctrine. Is it reason- able to assume that the pollen of various plants that give rise to attacks in different individuals will be set free to float away on their fructifying pilgrimages on exactly the same day, and at nearly the same hour, each recurring year, and that they will reach the nostrils of sufferers in their varying localities and situations and vocations simultaneously year after year'? The variations that occur in the yearly advance of the seasons pre- clude this hypothesis. And, again, the identity of the different forms of the malady strengthens the nerve theory, while it weakens the pollen argument, for it shows that the disease exists under conditions that are the least favorable to the operation of DISEASES OF THE NASAL CAVITIES. 219 pollen ; in fact, where the pollen theory is inadmissible, — in the winter and spring. I do not undervalue the importance of pollen as an exciting cause, but I wish to be understood as maintaining that it constitutes only one of three factors which render the existence of the disease possible. Other arguments that may be briefly mentioned are the suddenness of the onset and disappearance of attacks, the fact that the most potent palliatives are nerve-sedatives, tonics, and stimulants, and that mental emotion and physical exertion may prevent or arrest paroxysms. The chief argument urged against the nerve theory is that many hay-fever patients have diseased nasal cavities. But we may say the same of that much larger proportion of our popu- lation who have no experience with hay fever. That we should find nasal hypertrophies, etc., concurrent with hay fever is not surprising in this catarrh-producing climate. Indeed, the dis- eased turbinated tissue may be a coincidence or sequence rather than the cause, for it is natural to suppose that years of con- stantly recurring attacks of even a functional disturbance of the vasomotor supply of these parts would result in a passive hyper- emia which would eventuate in proliferation of cells in the mucous and submucous tissues, and the growth of hypertrophies which might serve as a nidus for the reception and retention of irritating agents. But the argument that this condition is responsible for hay fever in infants, youths, and even in adults in whom there is no evidence of inflammatory changes before or between attacks, is not tenable. The paroxysms do not so much resemble symptoms of an inflammation as they do an irregular and explosive discharge of a superfluity of nervous force, — a nerve-storm, if the expression may be permitted. It has been claimed that destructive treatment of the sensitive areas in the nasal cavities would permanently cure hay fever, and many cases have been so treated by American physicians during the last twelve years. However, the most sanguine practitioners of this method have confessed disappointment at the results. Cases that were supposed to have been cured still suffer, while others are benefited. So far as I have been able 220 DISEASES OF THE EAR, NOSE, AND THROAT. to obtain definite data, they demonstrate that not more than one-half the number cauterized are claimed to be cured. This points to the fact that it is not a simple local inflammatory dis- ease. If it were, -the treatment should be attended with greater success. For the reasons set forth one cannot expect this method to cure all ; but, granting that it may cure many, the nerve theory would not suffer in the least by the admission, for it assumes a pathological condition of the receptive end-organs of the nerves as well as of the perceptive nerve-centres. Elimi- nate the susceptibility. of either the central or peripheral nervous system, and you remove an essential element in the disease, — destroy its entity. But what shall we say of that other large proportion of patients in whom paroxysms are produced by irri- tation of the retina, the scalp, etc., or by chilling of the skin? Are we to be logical and, reasoning from analogy, must we destroy the sensitive areas, enucleate our patients' eyes, or scalp or skin them 1 Yet, if you follow the reasoning of this school of theorists to its logical conclusion, it will lead to this reductio ad absiirdum. The neurotic theory is supported by the nature of the fol- lowing causes : Electric light and gaslight ; overexertion ; anxiety ; indigestion ; dampness ; chills ; gases ; feathers ; per- fumes ; odors from animals ; dry, hot, and impure air ; various kinds of fruit, etc. It will be observed that pollen and dust do not necessarily enter into the causative nature of these excitants. This theory receives support also from the fact of the excessive irritability and nervousness which patients experience just preceding and during attacks. The co-ordinate action of muscles is affected, and they complain of feeling jerky and ill- tempered for the time. In studying this disease it should not be forgotten that the statements of sufferers relative to the history and phenomena of their maladies should be given greater credence than is usually accorded the assertions of other classes of patients, inasmuch as they enjoy the distinction of being superior to the average in intelligence and culture. This is far from being an idle asser- DISEASES OF THE NASAL CAVITIES. 221 tion, for it voices the experience of the best authorities and is borne out by a reference to the list of membership of the United States Hay Fever Association. I cannot consider the treatment of this subject as approach- ing completeness without referring briefly to two other important points. Microscopists have examined the nasal and bronchial secretions from hay-fever and asthmatic sufferers, with the result, it is claimed, of establishing the kinship of the two dis- eases by demonstrating the presence in both of products called " gravel." It is believed that this so-called gravel accumulates in the secretions of the respiratory passages, and acts as a local irritant in the same manner that any foreign body would. The force and analogy apparent in the following facts relating to neuroses of the skin serve to emphasize the truth in the nerve theory : Intense itching over the surface of the whole body may be produced by morbid alterations in the ovaries or uterus, anomalies of menstruation, diseases of the kidneys, liver, etc. Neumann says : " There is no doubt that a large proportion of cutaneous diseases depend upon disorders of the vasomotor nerves which cause certain derangements of circu- lation in the arteries, veins, and cutaneous glands. Anaemia and hyperemia of the skin happen from vasomotor irregularities, — some from the brain, some from the spinal cord, — or from the action of cold, or the electric current, etc." Now, since it is admitted that there are both immediate and reflex functional nervous disorders of the skin, with what show of reason can it be denied that there are similar neurotic disturbances of that other skin which covers the interior surfaces of the body 1 The latter membrane is more vascular, more delicate, more sensitive, and more highly organized than the skin. It possesses sus- ceptibility to all agents which affect the skin, and to many others besides. For example, noxious gases, to which the skin is insensible, will irritate the mucous lining of the respiratory organs. The same laws that govern the action of the vaso- motor nerves of the skin also regulate the vasomotor supply of the mucous membranes. If itching and burning of the skin are produced by morbid alterations in the ovaries, so is pruritus 222 DISEASES OF THE EAR, NOSE, AND THROAT. ure throe produced by disease of the bladder; pruritus nasi is generally accepted as a sign of worms in children ; urticaria results from irritation of the gastric or intestinal mucous mem- brane ; so may asthma arise in the same manner or from an irritant applied to the post-nasal mucous surface ; ear-cough is occasioned by contact of instruments with the skin ol the ex- ternal auditory canal ; and hay-fever paroxysms result from irritation of the retina, the upper lip, or the scalp, or from chilling the skin. All the facts in our possession force us to the conclusion that the weight of testimony is in favor of the doctrine that hay fever is a reflex functional nervous disease. URIC ACID AS A CAUSE OF HAY FEVER. Uric acid exists in the blood in the proportion of about one to thirty-three of urea in health. When this proportion is dis- turbed by a relative increase of the uric acid, certain disturb- ances of a vascular and neurotic character arise. The effects of uric acid in producing these disturbances have been the subject of an extensive and interesting series of experiments by Alex- ander Ilaig. For years he was a sufferer from migraine, and studied in his own person the relation of uric acid to the pro- duction of attacks of this disease, and the effects of anti-uric- acid treatment in subduing attacks, and of diet in preventing them. I desire at the outset to acknowledge my great indebt- edness to this paintaking observer for many of the facts adduced here. (See " Uric Acid in the Causation of Disease," Haig, 1896.) First, let us consider what the effects of an excess of uric acid in the blood are. The disorders of the nervous system that Murchison associated with lithoemia are : aching pains in the limbs and lassitude, pain in the shoulder, hepatic neuralgia, severe cramps in the legs, headache, vertigo and temporary dim- ness of vision, convulsions, paralysis, noises in the ears, sleep- lessness, depression of spirits, irritability of temper, cerebral symptoms, and typhoid state. Ilaig maintains that the presence of uric acid in excess DISEASES OF THE NASAL CAVITIES. 223 accounts for the exacerbation of pains in rheumatism and gout, and Lever contends that these diseases are primarily due to the action of this acid on the brain, the spinal cord, or the solar plexus of nerves. In persons suffering from intense pruritus, uric acid and the urates have been found in excess. Ebstein believes that uric-acid deposition acts as an exciter of inflammation in the tissues in which it is deposited. Quinquaud studied the effects of uric acid on the skin. He administered 3 to 6 grains a day to the human subject. The most common results were boils and patches resembling eczema, — the dermal analogue of coryza. Thomas J. Mays attributes attacks of angina pectoris to " the increased formation of uric acid, which is incidental to the gouty and rheumatic diathesis." lie agrees with Ilaig in attributing migraine to the irritating effects of uric acid. Conklin details a number of well- marked cases of nervous, mental, nephritic, and other diseases that support the proposi- tion that they are the result of the action of uric acid. N. S. Davis and others add the following to the list of manifestations of uricacidsemia : Loss of appetite, nausea and vomiting, flatulent indigestion, diarrhoea, intense itching, asthma, blindness, deafness, numbness of the skin and creep- ing sensations, hyperesthesia and pain in the skin, impaired memory, melancholia, delirium, epilepsy, and coma. Observe the symptoms of uric-acid irritation that are closely allied to paroxysms of nervous catarrh : asthma, intense itching, oversensitiveness and other nervous disturbances of the skin, neuralgia, sick headache, irritability of temper, etc. The first three symptoms often characterize attacks of nervous catarrh, and highly moral persons, like the late Henry Ward Beech er, are seized with an almost irresistible impulse to accompany their storms of sneezing with a shower of profanity. Sick headache sometimes alternates with these attacks, and at other times takes the place of them. While suffering from migraine Ilaig found the uric acid increased to the proportion of one in twenty or twenty-five of urea, whereas before and after attacks he found it as one to 224 DISEASES OF THE EAR, NOSE, AND THROAT. forty, and the headache was proportioned to the excess of uric acid over the urea, and not to the amount of alkali used to bring the uric acid out. The mental condition varied directly with the relative amount of uric acid in the urine. The excre- tion of the acid was greatly diminished before the attacks, — i.e., during mental exaltation. I have learned, while writing upon this subject, that Leflaive analyzed the urine before and during attacks of hay fever, and found uric acid in great quantity just before the attack and half that quantity during the attack. Some of this may have been washed out of the system through the profuse perspiration that occurs during the violent sneezing. In 1893 I proposed the uric-acid theory of hay fever in the first prize-essay of the United States Hay Fever Association, and at the meeting of the American Medical Association the same year I advocated the same theory. So far as I knew, I was the first to propose this doctrine. In 1894 I learned that Shawe Tyrrel, of Toronto, had published a paper in 1892, entitled "A Predisposing Cause of Hay Fever," advocating the same theory. Independently of each other, our studies of the subject forced us to arrive at the same conclusions, and I wish to accord Dr. Tyrrel full credit for his work. Had I known of it before publishing my two essays on the subject, I should have taken pleasure in referring to his paper. Haig says: "Uric acid in the blood contracts the arterioles and capillaries all over the body, producing the cold surface and extremities, raising tension of pulse, and, according to Marcy's law, that pulse-rate varies inversely as the arterial tension, slow- ing the heart. Headache is a local vascular effect of the uric acid. Excretion of this acid may even explain the mental depression and irritability and their results in the excess of suicides and murders in July. There is an excessive secretion of this acid in the warm months, and a minus excretion in cold weather. During plus excretion there will be high arterial tension, with anaemia of the brain, bad temper, etc. At this time a dose of acid would free the brain circulation from the power of the uric acid, and produce, as Roy and Sherrington DISEASES OF THE NASAL CAVITIES. 225 have shown, an increase in its size and a free flow of blood in its vessels." Peiper says that alkalescence of the blood is diminished in all fevers. Corroborative of this, Haig found, during an attack of influenza in 1890, that there was a rise in the acidity of his blood, urine, and tissue-fluids, thus driving the uric acid out of these fluids, diminishing its excretion, and causing its retention in the body. Bertillon says that suicides increased 40 per cent, in France after the influenza epidemic. This may be accounted for by the accumulation of uric acid in the body during the diminished alkalinity of the blood, and when the blood regained its normal alkalinity the stored acid was taken into the circulation and produced its characteristic irritability and depressing effects. In health about 5 to 8 grains of uric acid are secreted every twenty-four hours, and it is readily soluble in the blood, which is slightly alkaline. If there is increased formation of this acid, no harm results so long as it is properly eliminated and the ratio between it and the urea is not disturbed. Haig found that by diminishing the alkalinity of the blood he freed it from uric acid, relaxed the arterioles, and relieved headache and mental depression. Increasing the alkalinity augmented the acid excretion, contracted the arterioles, slowed the circulation of the blood, and caused languor, depression, headache, and, in epileptics, a fit. Epilepsy, migraine, spas- modic asthma, etc., are, like neurotic catarrh, functional nervous diseases. What Haig says concerning epilepsy and migraine may be affirmed of asthma and nervous catarrh : " They may come on early in life, last for years or the whole of life, tend to recur at more or less regular intervals, are met with in members of the same family, and may afflict one and the same patient, — now a fit, now a headache, — alternating or together. Epilepsy and headache, gout and rheumatism are very commonly met with in the same family." Broadbent thinks that the convulsions of epilepsy are brought on by the slowing of the circulation and consequent cerebral anaemia, in the same way as convulsions after great haemorrhage. 15 226 DISEASES OF THE EAR, NOSE, AND THROAT. As we have seen, the effect of an excess of uric acid in the blood-vessels is to contract them, which, in the vessels of the brain, produces cerebral anaemia. This condition appears to obtain in nervous catarrh, and the attacks are relieved by such remedies as nitrite of amyl, etc., which relieve anaemia of the brain. This uric-acid theory of nervous catarrh is not antagonistic to the present status of medical opinion or surgical treatment, but, on the contrary, explains questions that were inexplicable before. As a tumor or hypertrophied bone may give rise to convulsive seizures in epilepsy, and as its removal may be fol- lowed by relief when no other structural cause exists, so in nervous catarrh, where new growths and other lesions of the nasal mucous membrane are present, the attack may be started by the accumulation and the suddenly setting free of uric acid. This precipitates the paroxysm by its irritant action, which finds expression in the group of symptoms characteristic of nervous catarrh or asthma, instead of some one of the other allied dis- eases. The particular form of manifestation may be determined by the growth, or seat of irritation, located in the nasal cavities. Where this is the onlv determining: factor of the nature of the morbid symptoms, no other organic disease having resulted from the long-standing trouble, the removal of such a peripheral source of irritation may give relief from these symptoms, but it may not prevent the uricacidaemia from switching off into other kindred lines of disturbances if it be not corrected. The uric-acid theory makes clear the reasons why some persons suffer from attacks of nervous coryza under certain favorable conditions in winter, as well as during the warm months. It also unifies all the various forms of hay fever. They are all variations of nervous catarrh. Patients of this class are sometimes affected more or less by functional aphasia. Haig's father suffered, from time to time for a large part of his life, from this trouble, and in old age had organic aphasia with right hemiplegia. The same functional disturbance afflicted ITaig very markedly, at times of excess of uric acid in the blood, with mental depression, lethargy, and DISEASES OF THE NASAL CAVITIES. 227 headache. The histories of such cases are paralleled by the histories of nervous catarrh in many families. The periodicity of nervous catarrh has a counterpart in migraine that comes once in every seven, ten, fourteen, or thirty days, for years or for life. It may last one day or less, rarely two, and is worse in the morning. In the last published paper of the late A. Reeves Jackson he expressed his conviction that various neurasthenic symptoms — sleeplessness, headache, vertigo, neuralgia, vague pelvic symp- toms, muscular twitchings, vasomotor disturbances, etc. — are dependent really upon the lithic-acid diathesis. He wrote : " If this fact were duly recognized it would remove some of the cases from the list of those which are an opprobrium." L. C. Gray says : " Influenza, ague, and other fevers store up uric acid in the body." There are several causes that determine the manner in which the irritation produced by an excess of uric acid may express itself. These are central, peripheral, and hereditary causes. " The structure of the nerve-centres and the distribution of its vessels not only determine the kind of disturbances which uricacidasmia will produce in any given case, but also explains why one individual suffers in this way from functional nervous disorders, while another, with about as much uric acid in his blood and body, escapes. When the nervous system is depressed by fatigue, deficient food, etc., a smaller amount of uric acid in the blood will suffice to produce dis- turbance of function than at other times. If uricacidaemia is prevented, the nervous system will not itself originate disturb- ances. This knowledge of the effects of lithaemia gives complete power to produce or remove the vascular conditions, and the nervous disorders which are secondary to (consequent upon) these conditions, by proper diet and treatment " (Haig). The arguments that apply to migraine are just as forceful in the case of nervous catarrh. The peripheral causes — neoplasms, hyper- trophies, etc. — have already been considered. Heredity is probably the chief factor in determining the direction in which the uric-acid diathesis will afflict an indi- vidual, whether it results in migraine, angina pectoris, asthma, 228 DISEASES OF THE EAR, NOSE, AND THROAT. nervous catarrh, or some other neurosis ; but undoubtedly acci- dental or acquired conditions may act as directing or localizing agents. For example of the latter class : a student who is pre- disposed to such a neurosis accidentally inhales the fumes of burning phosphorus in the laboratory, and this excites the first attack of his nervous disorder, which naturally, under these conditions, takes the form of asthma. On the other hand, many attacks of severe cold, some injury to the nose, or the devel- opment of a polypus may determine the nasal form of neurosis, or nervous catarrh. I have such cases in mind. We can produce and control attacks of nervous catarrh at will by treatment and diet the same as we can migraine. I was first led to experiment with an anti-uric-acid treatment of nerv- ous catarrh by my endeavors to find a solution to the problem why paroxysms of this disease attack sufferers regularly in the morning. These attacks come on about the same time, morning- after morning, although the previous afternoon and evening- may have been free from suffering, and the night one of restful repose, with no direct access to dust-laden atmosphere from without and no change in the contents of the sleeping apart- ments. The following facts appear to answer this question : The blood is the most strongly alkaline between the small hours of the morning and 9 a.m., when it reaches its greatest alka- linity. The more alkaline the blood, the more freely soluble is the uric acid. Therefore, in the morning hours the blood is the most heavily charged with this irritant, and during these hours patients suffer the most from angina pectoris, migraine, nervous catarrh, and other functional nervous disorders. The blood is the most acid during the hours of bodily activity, and it reaches its maximum of acidity about midnight. During this time there is only a small secretion of uric acid, and the amount circulating in the blood is minute. As the blood begins to increase in alkalinity in the morning it dissolves the uric acid out of the more alkaline tissues in which it has been stored, — the liver, spleen, cartilages, joints, and fibrous tissues, — and with the increasing alkalinity and solvent proper- ties of the blood it becomes rich in uric acid until it produces DISEASES OF THE NASAL CAVITIES. 229 the drowsiness, heaviness, or other nervous phenomena peculiar to any given case. Joal found, among 127 cases of hay-fever patients, a family history pointing to the uric-acid diathesis in 107 cases, and in 67 cases among his 71 adult patients the diathesis was marked. Evidences of neurasthenia were elicited in 101 of his 127 patients. In 42 of 107 patients of all ages the nasal mucous membrane appeared to be normal {Revue de Laryngologie, Xos. 7 and 8, 1895). PREDISPOSING AND AGGRAVATING CAUSES. Heredity and the temperaments classed as nervous are, strictly speaking, the predisposing causes. Broadly speaking, whatever diminishes the powers of resistance predisposes one to attacks. Most foreign substances that are liable to come in contact with the nasal mucous membrane will provoke parox- ysms, inasmuch as the mere contact of a polished silver probe will excite sneezing. Dust, pollen, infusoria; dry, hot air; cold, damp, or foggy air; smoke, gas, bright light from the sun, electric light, gaslight, sunlight reflected from snow, etc., are prolific causes. Much may depend on the character of the dust, for this is determined by the geological formation of any given locality. So wide is the distribution of dust by the vary- ing currents of the air that places which would naturally afford immunity from this disease may be visited by storms of noxious foreign pollen. A sea-voyage is considered a certain cure for an impending attack, but even there the enemy may lurk unseen in the folds of the canvas or clothing or in the upper currents of the atmosphere. Darwin has shown that pollen has been wafted many miles over the Atlantic. Showers of pollen have fallen hundreds of miles distant from its native soil. Dust may be deposited in curtains, carpets, etc., and be retained for indefinite periods before finding lodgment in the respiratory tract. The upper strata of the air may be laden with pollen, as it is at times with volcanic dust, which may be so dense as to darken the sky at great distances from the source of supply. These truths illustrate the omnipresent and occult character of the exciting causes. 230 DISEASES OF THE EAR, NOSE, AND THROAT. The greatest suffering occurs from May to October, espe- cially in the country, and for the following reasons : At this season the air swarms with the fecundating dust of plants and flowers ; the dry, hot air of the country is not moistened during the day except by occasional rains ; the dry surface-soil affords the winds a never-failing supply of dust, and one is not pro- tected from the dazzling brilliancy of the sun by tall buildings in the country as he may be while pursuing the vocations of city- life. The streets of cities are deluged with water in summer ; the dust is laid ; the air is cooled and moistened by evaporation. Great buildings afford protection from the scorching rays of the sun. The denser the population, the less the vegetation and the greater the relief to asthmatics and hay-fever patients. The irritating effect of dry, hot air causes great activity of the muciparous follicles and imposes a heavy burden on the glands to pour out sufficient mucus to keep the membrane moist. One must avoid dry heat from stoves and furnaces. Much-thumbed books and newspapers that are a little musty are exciting causes that I have not seen mentioned. CHAPTER XXI. DISEASES OF THE NASAL CAVITIES, CONTINUED. Hay Fever, Concluded. Symptomatology. — A reciprocal relation exists between the capillary circulation of the skin and that of the internal organs, but more especially affecting the mucous membrane lining the air-passages. Let the surface of a hay-fever patient become chilled, the skin anaemic, the perspiration checked, and imme- diately there follow a corresponding hyperaemia of the mucous membrane of the respiratory passages, an increased activity of the muciparous follicles, exquisite tickling and painful itching in the nose and pharynx, succeeded by violent sneezing, profuse discharge of nasal mucus, suffused and tear-bedimmed eyes, photophobia, a rush of blood to the head and face, severe head- ache, complete occlusion of the nostrils, nervous exhaustion, and such a desperate shaking up of the whole being as is compar- able to a wrecked vessel in a terrific storm. But in this violent agitation of the body I have discerned a blessing in disguise, for it restores the balance of circulation to the skin, the tempera- ture rises, the sudoriferous glands resume their activity, and the skin is again bathed in perspiration. At this juncture the vicarious suffering of the respiratory surface is relieved and the normal equipoise of functional activity ensues. In one who suffers from the asthmatic form of hay fever, to the symptoms already enumerated should be added the characteristic symptoms of asthma proper. These alone make one's lot hard enough, but when added to the so-called " aristocratic " disease they present a highly-colored picture of the refinement of torture. The sneezing is often so violent and continuous that the patient is scarcely able to catch sufficient breath to properly oxygenate the blood. The hydrorrhea is so profuse as to satu- rate many handkerchiefs, — a dozen or a score in a day, in severe cases. One peculiar symptom I have observed, but have never (231) 232 DISEASES OF THE EAR, NOSE, AND THROAT. seen mentioned by other writers is : the instant some patients begin to sneeze, they also swell up so that the clothes about the abdomen and waist must immediately be loosened to afford relief from the constriction. These attacks come on at precisely the same time and last the same length of time at each recurring season. A sudden mental excitement may prevent an impending paroxysm or abbreviate one after its onset. The attack is as instantaneous in its invasion as asthma, striking one at any moment of day or night, awaking one from sound slumber, or taking one unawares during the pleasant engagements of the day, and leaving as quickly and mysteriously as it came. Some functional nervous diseases are transmutable, one into another. I have witnessed cerebral hyperemia decline and disappear as hay fever superseded it, and after several years' duration the hay fever has, in turn, been displaced by asthma, as spasmodic and characteristic in its nature as the hay fever itself. Simple asthma may not only supplant, but may complicate it, constituting hay asthma proper. Inspection of the nasal cavities during attacks reveals the turbinated bodies enormously swollen and water-soaked, the mucous membrane very vascular, and the passages completely closed. The membrane is exquisitely sensitive and often pain- ful. In sleep it is necessary to breathe through the mouth, which occasions distressing dryness of the throat. The breath must be held while masticating or swallowing food, and with every act of deglutition the air is forced into the Eustachian tubes, and even particles of food seem to take the same course. In the intervals between the seasons of suffering, and even between paroxysms from day to day, the nasal membrane may present no unusual appearance. Indeed, just before a seizure the nostrils may seem more patulous than normal, affording perfect freedom of respiration. In some cases I have been unable to find any appearances whatever of a diseased condition between attacks. Others have the same hypertrophies that are common to other patients. There are considerable variations in the experiences of hay- DISEASES OF THE NASAL CAVITIES. 233 fever sufferers, both with respect to their symptoms and the times of their attacks. It is very common for them to awaken in the morning feeling perfectly well, with the nasal passages comfort- able and free ; but the moment they arise and touch their bare feet to the cool floor, or feel the air strike the lower extremities or body, or even before rising, a few minutes of wakefulness are followed by sensations of dryness and irritation in the nose and miserable paroxysms of sneezing, as though they had taken a severe cold. The attack may last for a few minutes only, or until the morning meal with coffee, when all the symptoms sub- side. The attacks may re-appear at intervals during the day, with or without a feeling of rawness of the nasal membrane between the spasms of sneezing. Unlike the occasional sneeze of an individual who is not subject to hay fever, the act of sneezing is unaccompanied by any sense of pleasure or satisfaction. It is positively distressing, and makes the sufferer wretched. He is harassed by a con- sciousness of impatience and irritability of temper ; his muscles act in a jerky, inco-ordinate way, causing him to drop things or knock them together ; he must always be on the alert to avoid or escape those excitants of suffering that beset his path on every hand. The time these attacks usually come on is the 18th of August, but may vary from the 15th to the 20th in different individuals, although there is little, if any, variation in the case of any given patient. The season of suffering generally lasts until a severe frost occurs in September or October, when the season ends, and the refugees who have fled to the mountains or lakes of immune regions return to their homes to enjoy life until the following summer. In a small proportion of cases the attacks are more or less perennial. Exposure to sunlight reflected from snow, or to close, hot, impure or dusty air in winter, will result in suffering. Some are attacked in June or in July, when certain grasses ripen and the haying season is at hand. The presence of roses or certain other flowers may pro- voke sneezing at any season. Diagnosis. — Considering the characteristics and the descrip- 234 DISEASES OF THE EAR, NOSE, AND THROAT. tion given, the matter of diagnosis is so simple as to require no further mention. Prognosis. — Hay fever is not dangerous to life, although it causes serious suffering and incapacitates one for business while it lasts. It does not tend to disappear of itself permanently, but is amenable to treatment. Abortive Treatment. — With the uric-acid phenomena in mind, I attempted to break up the morning attacks of sneezing and nasal stenosis by doses of acid at bed-time and on first awakening in the morning. The experiment was a success. A series of wretched mornings was followed by freedom of res- piration and a sense of well-being that seemed like a physical millennium. After this result of preventing the morning in- crease in the alkalinity of the blood, in order to prove the cor- rectness of my deductions, I used an alkaline treatment, and was both delighted and disgusted with the results. The old enemy raged again, but here was clinical proof of my first proposition. I have successfully repeated these experiments until I am satisfied of the correctness of these conclusions. The first acid I used for these experiments was the dilute sulphuric acid in doses of 20 or 30 drops in water, but, on account of the griping pains and diarrhoea that it produced in the early morning, I was obliged to substitute another. It occurred to me to try Horsford's acid phosphate that I had used for other purposes for some years, on the recommendation of the late Professor Jewell. I used teaspoonful doses of this without any ill-effects, and with the result of giving complete immunity from suffering. One or 2 teaspoonfuls in a glass of water at bed-time and on first awakening in the morning were sufficient to break up the habit entirely. In a few days, after the symptoms ceased to appear in the morning, this dose was omitted. The night dose was continued until the habit seemed to be entirely broken up. If any nasal irritation re- appeared, a dose or two would dispel it. By adding sugar to this acidulated drink it makes an agreeable lemonade, but it is better to avoid the sugar, and as much as possible all other uric-acid-producing substances. DISEASES OF THE NASAL CAVITIES. 235 While I have depended on the mineral acids to keep down the morning alkalinity of the blood, Bence Jones claims that citric acid (lemonade) will accomplish the same result. I have made it a point to have the morning dose well diluted with water, for the purpose of starting perspiration, for I have ob- served that as soon as a patient has sneezed violently enough to produce free sweating the symptoms either decreased or disap- peared. The sweating carries off uric acid and helps to free the blood. I am aware of the differences of opinion that exist con- cerning the influence of an excess of dilute phosphoric acid on the elimination of uric acid, the effects of acid on the tubules of the kidneys, and the relation of a meat-and- vegetable diet to the formation of uric acid. I am careful to use only so much acid as is required to prevent the maximum of alkalinity from occurring. The acid is used not with the expectation of elim- inating, but of clearing the blood of uric acid, for the purpose of preventing attacks during the season of suffering. If the overwrought nerves are relieved of this source of irritation, they are much less likely to respond to other excitants; and, if the morbidly-susceptible condition of the nervous centres is due to the action of the uric acid, its oversensitiveness to all ex- citants may be relieved by correcting the uricacidaemia. After relieving the suffering with the acid phosphate I have produced it again by neutralizing the acid with an excess of bicarbonate of sodium and employing the usual doses. This converted the acid into a ready solvent of uric acid, flooded the blood with it, and produced the attacks. In turn, I have followed this up with the acid, relieved all the catarrhal symptoms by precipitating the uric acid from the blood into the tissues, and produced the characteristic gouty pains. Again, by substituting drachm doses of phosphate of sodium for the acid I have precipitated all the symptoms of a severe nasal catarrh. Some other remedies produce effects parallel to the acid treatment. Nitroglycerin, nitrite of sodium, nitrite of amyl, antipyrin, etc., have a similar effect. Opium raises the acidity of urine, diminishes the alkalinity of the blood, and reduces the 236 DISEASES OF THE EAR, NOSE, AND THROAT. amount of uric acid. It relaxes the arterioles and improves the circulation of the brain. Iron and lead have a similar effect. Mercury reduces the excretion of uric acid, reduces tension of pulse, and produces diuresis. If opium is employed, its ill effects should be prevented by following up its use with salicylate of soda for a few days to free the system of uric acid. Quinine, so generally used, is contra-indicated, for, according to Quain, it brings uric acid into the blood. There is one remedy that has proved, in my hands, invariably unfailing in giving relief, especially when given at the beginning of an attack of nervous catarrh or common colds. It is for tem- porary use only, like the acid treatment. I have employed it for the last sixteen years or more, but in this case it is, like old wine, the better for age. I refer to a combination of atropia and morphia, in the proportion of 1 part of atropia to 50 of morphia. The ordinary adult dose is from -^ to | grain of this mixture, according to the severity of the attack. It may be repeated in an hour or two, if the first dose does not entirely relieve the sneezing, running at the nose, and stenosis. I do not believe it has ever failed to stop an attack when properly adapted to the case. No person has ever acquired the drug habit through my prescribing it. I never write a prescription for it nor allow a patient to know the composition of the remedy, — not for mercenary purposes, for I have more often given it away than I have charged for it, but in order to obviate the possibility of being responsible for a drug habit. The morphia clears the blood of uric acid, diminishes the nervous irritability, suppresses oversecretion from the muciparous glands, and stimulates the circulation and activity of the nervous centres, while the atropia elevates the tone of the blood-vessels, quickens the pulse, decreases all the secretions except the urine, sustains bodily temperature, stimulates the respiratory centre, counteracts the constipating effects of the morphia, and acts as an anti- spasmodic. Caffeine, I grain, may be added to this dose to stimulate the nervous centres and kidneys. Local Self-treatment. — The most useful self-treatment j have found is (1) the use of a*convenient pocket-inhaler (Fig. DISEASES OF THE NASAL CAVITIES. . 237 128) that I have devised for patients who take cold easily. It is called the " camenthol inhaler." It can be used in an incon- spicuous and expeditious manner in public places, where it would be impracticable to combat a sudden seizure with other and slower measures. Several gentle, prolonged inhalations should be taken through one nostril while the opposite one is closed, until the irritation is relieved. The breath should not be allowed to pass back through the inhaler, but through the mouth instead. The camphor-menthol does not become irri- tating to the membrane, like menthol alone, after having been used a considerable time. It is blander and more soothing than the menthol crystals, iodine, or carbolic acid. When the throat is involved, it can be inhaled through the mouth for self-treat- ment. 2. For home treatment, morning and night, I usually prescribe a solution of camphor-menthol in lavolin, to be sprayed into the nostrils and throat. The 1- and 3-per-cent. solutions are the most satisfactory. It is best to begin witli the weaker, and increase gradually to the 3-per-cent. solution. Preventive Treatment. — The treatment to eliminate uric acid cannot be undertaken to advantage during the season of attacks, except so far as relates to diet and the use of lithia. Haig does not believe that excessive uric-acid formation takes place; but, from a considerable study of this subject, I am forced .to the conclusion that an excess of uric acid in the system is not due alone to continued retention and storage of the small normal overflow by the renal vein, but to an increased formation also. In a conversation with N. S. Davis, that eminent authority corroborated the latter view. It follows, then, that it is neces- sary to reduce as much as possible the use of those foods that increase the actual formation of uric acid, such as meats, sweets, beer, wine, etc., and limit the diet largely to fruits, vegetables, milk, fats, etc. Exercise also aids in the excretion of uric acid, although there may be an actual increase in the amount of acid. Lange treats periodical mental depression successfully by reducing the amount of food and by systematic exercise. A diet of milk with occasional very small quantities of egg 238 DISEASES OF THE EAR, NOSE, AND THROAT. and fish, with no other animal food, will prevent suffering from sick headache entirely, without medicinal treatment. With this diet the natural ratio between uric acid and urea — 1 to 33 — is maintained. Haig claims that, by a uric-acid-producing diet, one can store up in the body several ounces of uric acid in a few years, or, by a correct diet, not as many grains. He has been on such a diet over eight years with very seldom a head- ache. By eating meat and drinking wine two or three days in any single week, he is sure to bring on the migraine. A course of salicylate, salicin, lithium, etc., will remove the excess of uric acid. If an alkali is given it is likely to pro- duce uricacidsemia and precipitate an attack of the trouble we are endeavoring to prevent. For an attack, then, a dose of acid should be given to free the blood of uric acid ; then the salicy- late of sodium should be given for two or three days or longer, to sweep it out of the body; but the salicylate should not be given during the attack, for it may aggravate the symptoms. For a fortnight or a month, perhaps longer, preceding the regu- lar season of attacks of nervous catarrh, from 2 to 6 grains of the salicylate should be given every day or two, in order to get and keep the quantity of the acid in the body down to the normal amount. The copious use of the stronger lithia-waters is advantageous, also. Warner's 3-grain tablets of effervescing citrate of lithia are excellent. This treatment, combined with proper diet, should be suc- cessful, provided that there is no organic disease of the struct- ures, central or peripheral. Any organic disease — hypertrophy, polypus, etc. — must receive such attention as to secure the harmonious co-ordination of their functions, for this treatment is directed against uricacidasmia only, as a cause of suffering; but it should not be forgotten that there are other causes that may operate to produce attacks, just as in the case of spasmodic asthma arising from bronchitis, irritating gases, and other excitants. I am of the opinion that, with this new theory, therapeutics, and proper diet of this disease, the medical profession need no longer say to hay-fever patients, in a patronizing way, " Suffer DISEASES OF THE NASAL CAVITIES. 239 little children, for of such is the kingdom of heaven." But we must recognize and combat the uric-acid diathesis if we would bring comfort to these patients and obliterate a stigma that dims the lustre of our great art. ^ MEDICAL OPINIONS. I have written to a large number of specialists and writers on this subject to obtain their latest views and treatment. There were some whose recent publications made it unnecessary to write, and others who were inaccessible ; so I have in such cases searched the literature and endeavored to present a fair and im- partial account of the present status of medical opinion on the nature and treatment of hay fever. From some articles I have been unable to gather any definite knowledge of the opinions of the writers on the nature of the disease, and have stricken out much for that reason, but I have, in every case presented, striven to give a natural and unbiased interpretation of the author's views. The methods of treatment often indicated these. The opinion of each writer on the pathology, whether he believes it to be a neurotic or local affection, is indicated by a single word following his name, — neurosis or local. E. L. Shurly. Neurosis. " I am very glad that yon will present the subject of the treatment of hay fever. It is a very important one, and does not receive the. intellectual attention which it deserves. It is my belief that some cases can be relieved by counter-irritation in almost any part of the bod} 7 , as well as in the nasal passages. I also believe that its purely nasal origin is overestimated. I have found snnn° of daturine with starch sometimes more effective than the galvano-eautery." He uses tincture of iodine, etc., over the neck and chest, as recommended by Faulkner. If there are new growths he removes them. W. E. Casselberry. Neurosis. " I believe ha} 7 fever to be amen- able to thorough surgical treatment, establishing a complete cure in a minority of cases only, — those particularly which present gross deform- ities of the septum and the turbinates, and potypi. In the large majority the condition can be materially mitigated, the degree of improvement being in accordance (1) with the degree of structural disease present in the nose and (2) with the thoroughness of the treatment. A small minority are not amenable to surgical treatment. They include the highly-neurotic individuals in whose noses, between the paroxj-sms, little or no structural change is apparent. Much can be accomplished toward 240 DISEASES OF THE EAR, NOSE, AND THROAT. palliation b} T both systemic and local medicinal treatment. But in my experience medicinal treatment is nearly, if not quite, powerless to effect a permanent cure. Such, however, may take place in the course of years, perhaps, assisted b}- supportive and tonic treatment, as the individual's general health improves and the neurotic element lessens. Of local pal- liative remedies, cocaine is probabty the most powerful and at the same time the most dangerous remedy. Its use and sale should be regulated by law." C. H. Knight. Neiwosis. Destroys all enlargements. " When it is impossible to define a distinct abnormalit}^ the nasal membrane through- out being sensitive and irritable, good results seem to me to follow painting the mucous membrane with a solution of perchloride of mercury, muriate of quinine, and glycerite of carbolic acid. Of course, general treatment is alwa} T s essential. I must confess that my proportion of cures is small. I feel quite pleased if I succeed in mitigating the severit}^ of the sjmiptoms and lessening their duration, etc." W. C. Glasgow. Neurosis. " Surgical treatment has given little or no permanent relief. Symptomatic treatment will ameliorate the symptoms and keep the patients in comparative comfort during attacks. The Constitutional treatment with potassium iodide, belladonna, anti- pyrin, etc., lessens the disturbance and sometimes controls it." Jonathan Wright. Neurosis. " I have seen several cases with no appreciable intranasal lesion except the acute condition during the attack. I have operated a few times for intra-nasal lesions of various kinds. All were improved somewhat, — some markedly, some slightly. My im- pression is that the relief in these cases is too limited to make it of value." R. W. Seiss. Neurosis. " Operations in the nose should be re- sorted to cautiously, and only when absolutely necessary." He recom- mends strychnine and bromides internally, and benzoate of sodium, 10 to 20 grains to the ounce, or menthol, 10 to 30 grains, for a spray. E. J. Kuh. Neurosis. A sufferer from hay asthma. He found the most relief from the following spray : Camphor, -J part ; menthol, 1 part ; creasote, 1 ; oil of eucalyptus, 2 ; oil of pine-needles, 2 ; albolene, 93J parts. J. O. Roe. Local. He believes that there is always a diseased condition of the nose causing hay fever. These diseased tissues must be removed or destroyed. He denies the neurotic character of the disease. He says : " Irritation reflected from other situations to the nasal cham- bers is not hay fever." F. H. Bosworth. Neurosis. He believes that intra-nasal surgery affords permanent relief. This method is clear in its indications, easy of accomplishment, and promises not only more immediate, but more permanent, relief than an}' other method. He believes that hay fever and spasmodic asthma are pathologically identical. DISEASES OF THE NASAL CAVITIES. 241 J. N. Mackenzie. Neurosis. Better results were obtained from constitutional than from local treatment. He gives zinc, nux vomica, quinine, and arsenic. W. H. Daly. Local. He thinks it is simply a deformity in the nose, and that a large proportion of cases can be cured b} r surgical operations. J. Solts-Coiien. Neurosis. Any local nasal trouble maj r be simply incidental. He prescribes tonic treatment and restricts the use of meat. H. Gradle. Neurosis. He removes any nasal growths. Kitchen, of New York. Local. He believes it is due to the mem- brane being deficient in the epithelial covering, etc., that calls for local remedies. B. 0. Kinnear. Neurosis. He believes it to be due to irritation of the gray matter composing the centres of the fifth, glossopharyngeal, the facial nerves, and some of the pneumogastric. He found that treat- ment addressed to this condition was successful. He used the well-known ice-bags of J. Chapman, of Paris, along the spine between the shoulders, from the fourth cervical to the third dorsal vertebra, to dilate the arterioles of the whole body, thus evenly distributing the circulation and withdrawing the blood from the congested centres. The applications lasted from sixty to ninety minutes, one to three times a da}\ E. F. Ingals. Neurosis. About 40 or 50 per cent, of cases may be cured by cauterization. He gives tonics and uses cocaine locally. M. It. Brown. Neurosis. The supersensitive areas should be de- stroyed with the cautery. Atropine, T J F grain, once or twice daily or a 4-per-cent. solution of cocaine locally may give temporary relief. H. II. Curtis. Neurosis. He sears the enlarged tissues with chromic acid in preference to all other escharotics. C. E. Sajous. Neurosis. He believes that if cauterization fail to cure, it is because it is not carried deeply enough. He uses glacial acetic acid or nitric acid. He gives strychnine and coca-wine after meals. Willtam Cheatham, of Louisville. Neui^osis. He praises anti- P3'rin in 10 to 30 grains ; also acetanilid, 4 to 6 grains a day. T. M. Hardie. Neurosis. He believes that operations will benefit a large proportion, but constitutional treatment is necessary in most instances. J. It. Davey. Neiwosis. He removes enlargements and gives potassium iodide and tonics. Beverly Robinson. Neurosis. Soothing applications and con- stitutional medication. He advises against surgical interference except when there are positively-diseased growths. I. Gluck. Local. He believes the nervous element to be a result, instead of the cause, of the disease. He uses a 10-percent, solution of atropine after anaesthetizing with cocaine-phenol. He gives aconitine 16 242 DISEASES OF THE EAR, NOSE, AND THROAT. every hour or two, affording relief and aborting attacks in from two to five days. Carl Seiler. Neurosis. He uses sprays of cocaine and plugs of cotton saturated with it. A sponge worn in the nose to filter the air is recommended. Quinine in large doses is advised and tonics and atropine for the fever. In the later stages iodide and bromide of sodium are given. Morphine hypodermatically is advised. All enlargements should be removed ; he gives dilute phosphoric acid, 30 drops a day. De Lamalleree. Neurosis. He believes it a neurosis of nasal origin, and claims to subdue morbid sensitiveness of the membrane by douches of carbonic-acid gases locally for fifteen minutes at a time, three times a day. Sir Andrew Clark. Neurosis. He resorts to constitutional remedies and applies to the nostril with a camel's hair pencil this mixt- ure : 1 ounce each of glycerin and carbolic acid, 1 drachm of quinine, and soVff P ar * °f tDe perchloride of mercury. Heat must be used to dissolve the quinine. P. McBride. Neurosis. He treats it as a nervous disease, and if this fail he uses cocaine and the galvano-cautery. He deprecates indis- criminate burning, however. D. B. Lees. Neurosis. He claims to abort it with bromide and belladonna. Gouguenheim. Neurosis. He uses nervines and cocaine locally. The author operates with the galvano-cautery or by other methods when there are positive indications for such measures. Plate III PLATE III. Figure 1. — Female, set. 23; posterior view of large posterior hypertrophy of left in- ferior turbinated body ; removed with snare. Figure 2. — Female, get. 26 ; hypertrophy of middle and inferior turbinated bodies, both sides, causing bilateral stenosis ; removed with snare. Figure 3. — Complete occlusion of both nasal cavities by hypertrophies, complicated with adenoid vegetations of the vault. Figure 4. — Lateral section of larynx and pharynx ; g, Section of mass of hypertro- phied adenoid tissue of the naso-pharynx seen in Fig. 6 (uvu]a cut off). Figure 5. — Anterior section of above, showing relation between nasal cavities and the larynx. (The vocal bauds in the latter are in the cadaveric position.) a, Superior turbinated bone. e, Junction of the hard with the soft 6, Middle " " palate (the latter being cut off). c, Inferior " " g, Anterior portion of the pharyn- d, Orifice of Eustachian tube. geal vault or posterior nasal cavity. p, Posterior aspect of septum. Figure 6. — Posterior section of pharynx, showing mass of hypertrophied tissue in the posterior portion of the pharyngeal vault, as seen in a patient in whom congenital absence of the uvula existed. Figure 7. — Posterior view of left cavity in atrophic rhinitis. 8.— Lateral 9.— Anterior " " " " " 10. — Rbinoscopic view of left cavity ; " " 11. — " " " " mirror slightly turned. 12. — Microscopic section of the mucous membrane in atrophic rhinitis. [Note. — The Nos. 4, 5, and 6 had to be shortened one inch from below the Eusta- chian prominences so as to enable them to be represented. The other proportions are accurate.] te ill t Sajous, Pinxit £ur«&M c Fetr,dge,L~g Cauteky Battery. incandescent electric lights are not a part of their office equip- ment, the Flemming cautery battery (Fig. 132) is satisfactory. It has the advantage of the pedal mechanism, which prevents the immersion of the zinc and carbon elements in the cautery fluid except when in actual use. This extends the life of the battery very materially. It has one fault, — that of permitting a slopping over of the fluid, which is destructive to carpets or Mosaic floors. The author has remedied this by having a rubber hydrostat constructed that effectually overcomes this 246 DISEASES OF THE EAR, NOSE, AND THROAT. defect. By keeping a fresh supply of the fluid on hand, one need never be disappointed by the battery not working. If the physician's office is wired for incandescent electric lights, or if he is not remote from conveniences for storing his battery, the one shown in Fig. 133 is to be recommended. It is more easily portable than the fluid battery, and will give a white heat if desired. Unlike the fluid battery, it deteriorates in con- sequence of disuse, and is better for being worked at least three Fig. 133.— Trtjax Storage Battery. times a week. When lying idle it sulphates ; that is, sulphate of lead forms on the plates and renders it inoperative. Figs. 134 and 135 show several of the most useful cautery electrodes, and Fig. 136 a convenient handle. One must select the electrode according to the individual characteristics of each case. If the physician does not happen to have the conveniences of the electro-cautery, he may resort to chromic, or nitric, or DISEASES OF THE NASAL CAVITIES. 247 monochloracetic acid. Of these the chromic acid possesses de- cided advantages over the others. It is fusible into an easily manageable bead on the chromic-acid applicator (Fig. 66). To accomplish this, the platinum loop is dipped into the dry acid Fig. 134.— Cautery Electrodes. crystals and held over a small flame to heat. As soon as the acid begins to melt it is quickly removed from the flame and blown upon to cool it rapidly into the form and size of bead desired. One should be careful not to apply the acid on a very » ^^_ ^ Fig. 135.— Cautery Knife. moist surface too long, or sufficient moisture will be rapidly ab- sorbed to loosen the bead and allow it to fall off the loop, and thus cauterize tissue that does not need it. In the use of liquid acids all the surplus fluid must be pressed out of the cotton Fig. 136.— American Cautery Handle, with Windlass. It answers for snaring as well as for holding electrodes. pledget by which it is applied before introducing it into the nose, otherwise it will spread over the surrounding surface. Ten or fifteen minutes before cauterizing the mucous mem- brane a 10-per-cent. solution of cocaine hydrochlorate is to be 248 DISEASES OF THE EAR, NOSE, AND THROAT. applied. It must not be sprayed into the nose, for toxic effects and collapse may result from an overdose. It is best to twist a piece of absorbent cotton loosely on the carrier (Fig. 9), dip it into the cocaine solution, and then adjust it nicely to the particular area we desire to cauterize and blip it off the carrier, leaving it pressed between the septum and turbinals. Like the liquid acids, the surplus of cocaine solution should be pressed out in the mouth of the medicine-container before introducing it. The patient is directed not to swallow any that may trickle into his throat. In about ten or fifteen minutes the membrane should be sufficiently anaesthetized to burn without pain. It need hardly be repeated that the membrane must be thoroughly cleansed before the treatment, for if thick discharges are present they prevent the action of the drug upon the tissues as well as weaken it by dilution. I find it useful to instruct the patient to raise his hand if he should begin to experience any severe pain from the cautery. However, by employing a strong preparation of cocaine and leaving it a considerable time, even twenty minutes, in contact with the membrane by means of the cotton pack, it is possible to burn deeply without causing much discomfort. There is an advantage in cauterizing deeply. As cicatrization takes place a furrow forms, which, together with the subsequent contraction, leaves a capacious breathing-space between the turbinate body and the septum. The electrode must not be allowed to cool while in contact with the tissue, for if it does it tears away the burned parts during the removal, and leaves a raw, unprotected, bleeding- surface. It must be removed while it is still hot, care being taken to avoid touching any but the cocainized spot. If the electrode is permitted to touch the border of the naris in its withdrawal, the resulting burn will cause much annoyance. Only a small area should be cauterized at one treatment. Not more than one-third or less of the turbinate body should be treated to a single cauterization, for if more is included the reac- tion occasions considerable swelling, a copious serous discharge, pain, headache, irritation of the corresponding eye, and even DISEASES OF THE NASAL CAVITIES. 249 tumefaction and discoloration of the cheek and loose areolar tissue of the lower eyelid. It is generally best to allow about a week to intervene between cauterizations of the same side, but when patients from a distance can remain but a brief period the opposite nostril can be burned in about four or five days after the first, if the burned areas are not too extensive. After each cauterization the most satisfactory results are obtained by introducing a packing between the burned surface and the septum, consisting of a pledget of cotton moistened with a 20-per-cent. solution of camphor-menthol in lavolin. The packing is only large enough to cover the cauterized area, and not enough of the solution is used to press out and run from the nose. This is exchanged for a fresh dressing daily for four or five days, when the tissues will appear shrunken and mummified instead of swollen, succulent, and covered with a slough, as they do without this method. Under the treatment outlined there is little or no haemorrhage, pain, or reaction, but the parts pursue a placid course to recovery. For headaches due to intra nasal irritation, and especially to middle turbinate pressure, Ilanau W. Loeb uses cocaine and albolene sprays. He advocates correcting all nasal abnormalities that may be a source of irritation. The use of the cautery is really a simple operation, but care must be exercised to not approach too near the orifice of the Eustachian tube. I have seen acute suppurative inflam- mation of the middle ear result from such procedures. Seiss (TJierapeiUlc Gazette, November 15, 1894) cites cases of ear disease made worse by nasal treatment. The membrane being cocainized, a speculum is introduced and the light from the forehead-mirror is thrown into the nostril. The chosen elec- trode is introduced cold and placed on the anaesthetized area, when the current is turned on sufficiently to give a bright-red glow. If the patient evince pain, or if the electrode is seen to burn as deeply as is desired, the current is interrupted and at the same instant the electrode is moved outward so as to part from the tissues before cooling. If the whole lower turbinal is hypertrophied, the anterior third is cauterized first and at inter- 250 DISEASES OF THE EAR, NOSE, AND THROAT. vals of about a week the contraction and consequent opening will be sufficient to admit of treating the middle and posterior thirds. Unless the camphor-menthol packing is used, swelling occludes the passage until about the fourth or sixth day, when the slough separates. When the cauterization is extensive or deep, some considerable pain may be experienced for a number of hours, unless a pledget of cocainized cotton is left covering the surface. Occasionally a little pain is experienced in the upper incisors. If the septum is not hypertrophied the electrode should be kept pressed away from it, and the burning is not carried deeply enough to include the periosteum. On the days following cauterizations the nose is sprayed with the alkaline antiseptic solutions already mentioned, and Fig. 137.— Hobby's Steel, Snare. then by a 4-per-cent. solution of eucalyptol in lavolin, or the same strength of pine-needle oil, or benzoinated lavolin. For posterior hypertrophies Seiss prefers curettement. The snare (Fig. 137) is preferred by many specialists. It is intro- duced with the loop open, as shown in Fig. 136, and passed over the enlargement so as to engage it as near its base as pos- sible, when, by drawing upon the handle or turning the wheel, the loop is made to sever the tissues. The Jarvis transfixing needle facilitates this maneuvre. The needle is passed through the hypertrophy until it projects beyond ; the snare-loop is passed over both ends of the needle so as to lie on its under surface and to cut between the needle and the base of the growth. The cutting is done by a turn of the wheel at a time, taking from one-half to an hour for the operation. The more time, the less DISEASES OF THE NASAL CAVITIES. 251 blood. In removing posterior growths the rhinoscopic mirror is required, in order to view the field of operation. When deformities of the cartilaginous septum necessitate their removal, this is best accomplished by means of a specially fashioned knife having a tapering point (Fig. 138). After cocainizing, the hypertrophy is severed by entering the blunt truax cbeeme8c0 Fig. 138.— The Author's Septum-knife. point of the knife below and cutting upward. In this manner the occlusion of the field by haemorrhage is avoided if the cutting is done rapidly. Exostoses are sawed off in a like manner (Fig. 139). The motion of the saw should be rapid, and one should not bear too hard upon the handle so as to make the saw catch and stick. Fig. 139.— Webster's Nasal Saws. With practice one can work rapidly w T ith this instrument. The electric drill is a very efficient instrument and is manipulated like a dentist's drill. Hygienic measures and internal treatment must be em- ployed according to the indications and on general principles, and the matter of clothing is touched upon in the treatment of acute rhinitis. 252 DISEASES OF THE ear, nose, and throat. Atrophic Rhinitis. Synonyms. — Ozsena ; fetid catarrh ; cirrhotic rhinitis, etc. Pathology. — This form of nasal catarrh is a sequel of a pre existing* inflammation ; indeed, it may he said to he the third stage of rhinitis in the logical order in which we have treated of the subject: (1) simple rhinitis, (2) hypertrophic rhinitis, and (3) atrophic rhinitis. In the latter variety there occurs an absorption and contraction of the newly-formed connective tissue, obliteration of the venous sinuses, and atrophy of the mucous membrane (Plate III). The turbinate bodies are reduced by this sclerotic process to less than their normal cali- bre, and the nasal cavities are correspondingly increased in size. The mucous glands participate in the general cirrhotic condition and exude less secretion, which leaves the membrane dry ; or the mucus becomes dried into scales or crusts, which decompose and emit a foul odor. The latter condition is not always present, and is probably dependent upon a strumous diathesis. Etiology. — This is generally a sequel of a chronic rhinitis. Symptomatology. — In most cases of atrophic rhinitis the nasal membrane is of a very pale color and is dry in appear- ance. The lumen of the passages is enormously increased, so that one can see through to the throat. One or more of the tur- binals may remain somewhat hypertrophied, indicating the pre- vious condition, while the others are shrunken into miniatures of the normal bodies. On account of the dilatation of the cavi- ties the patient is unable to bring sufficient air-pressure to bear to dislodge the drying secretions, and they are permitted to stick fast until decomposition renders them fetid and indescribably odoriferous. In this form, or ozaena, smell is lost — a beneficent provision — and taste is impaired, and sometimes the hearing also. A muco-purulent discharge is often found in such cases, and this, on drying into crusts, presents a green or dark-brown color. Diagnosis. — This is not difficult, for the appearance of the parts in the simple atrophy and a smell of the sickening, dis- gusting fetor of ozaena are distinctly characteristic. Suppura- DISEASES OF THE NASAL CAVITIES. 253 tion of the accessory cavities is generally unilateral. In syphilis necrotic bone may he detached with the probe, or the bridge may become depressed and the septum eroded away. Prognosis. — As this disease is usually found between pu- berty and the thirty-fifth year only, it may be expected to dis- appear in time of itself; but its disgusting character, as much as its possible deleterious effect on the patient's general health, calls for persistent treatment. This must be measured by months, and it may take a year or more to eradicate the ozoena; but this can be done. Treatment. — In the simple, dry, non-odorous atrophy stim- ulating applications, — like a 4-per-cent. solution of iodine in lavolin, — fumes of resublimed iodine crystals from the infiator (Fig. 24), and gentle massage of the parts with the smooth probe will increase the circulation and nutrition. Norval H. Pierce speaks of the vibratory-massage treatment as follows: "After thoroughly testing* Braun's vibratory massage in Chiari's Vienna clinics, one of my conclusions was that to the cleanliness which is so essentially a part of this mode of treatment is due most of the speedy reliefs of disagreeable symptoms, — fetid secretions. Braun claimed that under his treatment the atrophic turbinated bodies returned to their natural proportions. My experience has not substantiated this latter statement. During the past year I have modified Braun's methods in the following manner: The patient comes to me daily. A piece of absorbent cotton loosely pulled from the roll is torn to a size which will completely, but loosely, fit the inferior meatus and space in- cluded between the middle of the inferior turbinated body and septum. This dry cotton is held in the holder and the vi- bratory movements are carried over the mucous membrane of the inferior, middle, and superior turbinated bodies, pharynx, meatus (as far as possible), septum, and floor of the nose. From three to six pledgets of cotton may be necessary in each nostril to entirely bring- away the discharge, scabs, etc. This absolute cleanliness cannot be too strongly insisted on. On examination after this massage the mucous membrane looks pink and clean, and the patient often experiences a feeling of 254 DISEASES OF THE EAR", NOSE, AND THROAT. comfortable warmth and relief in the nose. Immediately after- ward we may use balsam of Peru, 10-per-cent. iodoglycerin, thymol in albolene, or any of the many good things recom- mended for the disease, provided they are not too irritating. But I am convinced that the vibratory massage, carried forth as above described, has a distinct worth, and will shorten the treatment of fetid rhinitis by many months." Brown, Dionisio, and Laker {Journal of Laryngology ; 1894) advocate intra-nasal vibratory massage by stroking and vibration with hand or electric cotton-covered probes. For the ozsena, washes of an alkaline, antiseptic character must be copiously used to free the cavities of all decomposing masses. The nasal douche so often advised is mentioned only to condemn, on account of the possibility of damaging the Eusta- chian tubes and ears. Seiler's solution is excellent and should be thrown in a coarse spray until all the crusts are loosened and expelled, leaving a free, clean membrane to receive the curative medicaments. Listerin, glycothymolin, and micrazotol are excellent, despite their names. The latter contains boroglyc- eride, eucalyptol, thymol, resorcin, menthol, and benzoic acid. The patient should be given a wash to use morning and night, after which he should spray the nostrils and throat thor- oughly with a 3-per-cent. solution of camphor-menthol in lavo- lin. Two or three times a week the surgeon, after cleansing the cavities, should spray them with such remedies as carbolic acid and iodine in lavolin (4 per cent.), and then dust the membrane all over with aristol powder (Fig. 32). When the odor is very foul the powder application should be preceded by a spray of a 10-per-cent. solution of camphor-menthol in lavolin. Tonic and alterative constitutional treatment and hygienic measures must be resorted to on general principles. CHAPTER XXIII. DISEASES OF THE NASAL CAVITIES, CONTINUED. Epistaxis. Synonyms. — Nose-bleeding ; nasal haemorrhage ; haemor- rhagia narium. General Considerations. — Bleeding from the nose may have its origin in the nasal cavities proper or in the adjoining sinuses. It is frequent in childhood, occasional in old age, and rare in middle life. Pathology. — The bleeding-point is most often found on the side of the septum, near the floor, and adjacent to the opening of the nose. Vessels may, however, rupture in any part of the membrane, or the haemorrhage may proceed from one of the accessory cavities. Probably the bleeding occurs most fre- quently from ulceration of the membrane, by means of which the blood-vessels are penetrated by an extension of the erosion to their walls. This process perforates the septum ; crusts form on the ulcerating parts, and upon their removal a raw, bleeding surface remains. Etiology. — Falls and blows, the bad habit of picking the nose, foreign bodies, fractures, vicarious haemorrhage, purpura haemorrhagica, etc. , cause nasal haemorrhages. Symptomatology. — Bleeding may come on without any premonitory symptoms, and even during sleep. The blood usually trickles from one nostril, a drop at a time, but sometimes runs in a stream. Only a slight amount is lost ordinarily, but it may amount to an alarming quantity and may even prove fatal. Frequent haemorrhages tend to produce anaemia and demand corrective measures. Diagnosis. — The condition is usually made out without difficulty. Prognosis. — This is ordinarily good, but in old age it may be indicative of degeneration in the walls of the blood- (255) 256 DISEASES OF THE EAR, NOSE, AND THROAT. vessels. In low fevers and diphtheria it is an ominous symptom. Treatment. — The most common means adopted to check bleeding from the nose is to keep the head upright and com- press the nostrils with the thumb and forefinger, or apply cold to the nose or the back of the head and spine. Hot water is recommended by some to be applied to the nose or injected into the bleeding nostril. The ice-bag (Fig. 78) is a convenient means of using continuous cold. Pulverized alum and tannin are useful. The latter is used in powder or, as mentioned later, in connection with tampons. A 10-per-cent. solution of cocaine on a cotton pledget packed firmly between the bleeding-point and the opposite wall is effective. It is sometimes difficult, even with good reflected light, to locate the source of haemorrhage, but this should be accom- plished if possible. Antipyrin in 3-per-cent. watery solution or in powder and the liquor ferri perchloridi are useful. Some writers speak highly of the galvano-cautery, but I cannot indorse it for this purpose. If the simpler measures fail, resort must be had to tampons! I have found the following method the most efficacious : A long strip of lint, linen, or cotton cloth, three-eighths of an inch (one centimetre) wide, is immersed in a saturated solution of tannic acid in water, and then the water is pressed out, leaving the cloth thoroughly medicated. One end of this is carried by the delicate angular forceps or probe as far into the nose as the case requires. Then the remainder of the tampon is packed in, a small loop at a time, until it is pressed firmly into all the sinuosities, and the cavity is completely filled. Any surplus of the strip is then cut off. Should tamponing of the anterior naris fail, posterior plugging must be added to it. In this case the posterior nares must be plugged first, as follows: Bellocq's cannula (Fig. 140), is threaded through the eye in the end of the spring with a strong string. The thumb-screw is adjusted so that it will throw the spring out, as shown in the cut. Then the sound is introduced like the Eustachian catheter until the distal DISEASES OF THE NASAL CAVITIES. 257 extremity projects downward over the velum palati. At this moment the spring is extruded until it, with the string, is seen through the open mouth. With hook or forceps one end of the string is brought out of the mouth and a pledget of cotton or lint as large as an adult's thumb is tied firmly to it. This is drawn backward and upward through the mouth and throat into the posterior nares. It should be made to plug effectually both posterior nares, for otherwise haemorrhage might continue through the free one. In passing the tampon behind the palate, the finger should be introduced to prevent drawing the palate upward with the cotton. Then the finger can pack the tampon well into the nares. The string protruding from the anterior naris is fastened back of the ear with adhesive plaster. In hot weather this must be watched, or the perspiration will Fig. 140.— Bellocq's Cannula Introduced. loosen it and allow the tampon to become displaced or swal- lowed. After a day or two the packing must be removed to prevent septicaemia. In the absence of Bellocq's cannula the Eustachian catheter can be substituted, and I have succeeded with a silver male catheter in an emergency. Constitutional treatment may be required, — iron, ergot, etc. Nasal Polypi. There are three varieties of benign neoplasms to which the term " nasal polypi " is applied : mucous, fibrous, and cystic. MUCOUS POLYPI. These occur in multiple form, and sometimes they -are very numerous (Plate IV). They are a pale-pink or ashy- gray color, and are most troublesome in damp weather, when 258 DISEASES OF THE EAR, NOSE, AND THROAT. they absorb moisture, causing them to swell and occupy in- creased space. They are usually found in middle life, from 20 to 40 years, and occasion stenosis of the nares and mouth- breathing (Fig. 148). The mucoid variety is the most com- mon. Patients often observe movements in these polypi, which are occasioned by forcible currents of air in sniffing or blowing the nose. FIBROUS POLYPI. This variety presents a single, dense, resisting surface to the probe. It may develop into so large a mass as to invade the naso-pharynx (Plate IV) or project from the nostril. It causes stenosis and supra-orbital headache, and its expansion causes pressure and deflection of the septum, as well as absorp- tion of the turbinals. Necrosis of the bones and invasion of the adjacent sinuses may occur. The nose in some cases is bulged outward at the sides, which gives the arch a flattened appearance. CYSTIC POLYPI. These are very rare, and consist of a cyst or sac filled with a yellowish or bloody, serous fluid. Treatment. — Polypi should be removed preferably with the cold-wire snare (Fig. 137). The loop of the snare is intro- duced expanded, as seen in the electric snare (Fig. 136), and made to embrace the pear-like tumor and to slide up to its attachment. The polypus is then slowly cut off and the point of attachment is cauterized with the galvano-cautery or chromic acid to prevent a return of the growth. This is preferable to removal with the forceps or scissors, and if the evulsion is not too rapidly accomplished little haemorrhage ensues. The biting curette (Fig. 141) is serviceable for searching out and removing the mere buds of polypi in the upper nasal passages. After-treatment is the same as after removal of hypertrophies, already given. Papillomata. These are benign neoplasms of infrequent occurrence. They may be single or multiple, and are most often attached to DISEASES OF THE NASAL CAVITIES. 259 the lower part of the septum or inferior turbinal. (See " Treat- ment " under " Erectile Tumors.") Erectile Tumors. These are very rare. They have the appearance of an hypertrophy of the turbinate body, except that pulsation can be Fig. 141.— Bitixg Curette. detected in them. This is in consequence of their close relation- ship to an artery, and their removal is likely to be attended with considerable haemorrhage. Treatment consists in removal of the growths either by chemical or mechanical means. Chromic acid or the galvano- Fig. 142.— Casselberry's Saw-tooth Scissors. cautery may suffice, or the nasal scissors (Fig. 142) may prove preferable. Chondromata. Cartilaginous tumors are rare growths occurring about the age of puberty and springing from the septal cartilage. Their location, unyielding firmness, and sessile shape distinguish them from fibromata. The color is a light pink, and they have not 260 DISEASES OF THE EAR, NOSE, AND THROAT. the smooth surface of fibrous tumors, but are indented by numerous depressions. Treatment. — If these growths prove troublesome they should be removed. Many methods are in use, — the knife, saw, chisels, punch, dental or electric drills and trephines, the galvano-cautery, etc. The cartilaginous growth is easily removed, under cocaine, by the author's septum-knife (Fig. 138). The cutting should be done as already described, and care must be taken not to perforate the septum. It is claimed by some rhinologists that healing does not take place so readily after the galvano-cautery as after cutting, but I have not been able to confirm this opinion. OSTEOMATA. The bony tumors are also very rare. They are offshoots from the mucous membrane and the product of an osseous degeneration of connective tissue. Their pressure produces headache, occasional haemorrhage, and ulceration with a puru- lent discharge. Unlike rhinoliths, they resist a needle and do not crumble. (See " Treatment " under " Exostoses.") Exostoses. Osseous growths are frequently met with in the nose. They usually take the form of ridges or spurs upon the bony septum, encroaching upon the lumen of the passage sometimes to a con- siderable extent. Occasionally the growth attains to consider- able proportions until pressure is produced on the opposite turbinal or adhesion to it occurs, forming a synechia or bridge across the canal. Figures 130 and 131 show such a condition. In Fig. 130 the probe is inserted to the point of adhesion between the exostosis and the inferior turbinate bone. The contour of the latter will be seen in Fig. 131 to have been altered, by the pressure, from a convexity, like the opposite one, to a concavity. The septum is deflected toward the exostosis. These growths arise from the periosteum and may occasion no inconvenience if no pressure is exerted on surrounding tissues, but, when they impinge on the posterior portion of the DISEASES OF THE NASAL CAVITIES. 261 inferior turbinal, reflex asthma may result. They are hard, immovable, light pink, and bleed easily on pressure with the probe (Plate IV). Treatment — Osteomata and exostoses should be removed when they have attained to such a size as to occasion symptoms of their presence. The former may be removed by the snare, strong saw-tooth scissors, curette, or forceps ; the latter by the saw (Fig. 139). A strong solution of cocaine must be used, preferably 20 per cent. The electric trephine and drills are convenient for this purpose, and the dental motor also is effective. Rhinoliths. Deposits of the salts of the nasal secretion are infrequently found in the nasal chambers and are, in effect, foreign bodies. 'They are generally found in the anterior part of the cavities, and are of irregular shapes and sizes and of gray or dark color. The discharges envelop them and obscure their identity until washing reveals their nature. Rhinoliths may develop to such a size as to obstruct the nasal passages and give rise to a foul discharge and epistaxis. The treatment consists in their removal. Sarcomata of the Nose and Vascular Tumors. These are, fortunately, rare occurrences. Sarcoma and carcinoma are sometimes developed in this region. Sarcoma does not differ in this locality from its characteristics in other situations. It is more likely to be found on the septum, but may invade the other nasal walls. It gives rise to pain, obstruc- tion of respiration, fetid discharge, and possibly difficulty in swallowing and impaired hearing when it extends to the naso- pharynx. If it invade the nasal vault the cranial cavity may become involved, resulting in a fatal termination. Sarcomata are of rapid growth and present a dark, rough- ened surface in some instances ; in others they are pale. As pressure develops laterally, bulging of the nasal walls becomes apparent in the contour of the nose and the prominence of the eyes. The gravity of the disease is manifested in a general 262 DISEASES OF THE EAR, NOSE, AND THROAT. constitutional disturbance. The probe causes bleeding and dis- covers a soft, fleshy mass. This is a rapidly-fatal disease of less than a year's duration. Treatment. — Complete extirpation is the only remedy. Anodyne and astringent applications after the disinfecting and cleansing washes are only palliatives. Carcinoma. Cancer of the nasal passages differs in no way from the same disease elsewhere. An ulcerating surface with a brown, serous fluid, pain and haemorrhage, infiltration of the cervical glands, and constitutional symptoms characterize this disease. The end is death. Treatment. — There is no curative treatment. The growth may be somewhat retarded and the suffering ameliorated by anodyne and astringent applications. Cocaine and aristol are the best. Plate IV. PLATE IV. Figure 1. — Male, set. 38 ; hypertrophy of the entire mucous membrane of the nasal cavities ; relieved by means of bougies and galvano-cautery. Figure 3. — Rhinoscopic view of above (normal size). Figure 2. — Male, set. 30 ; syphilitic perforation and exostosis of septum ; mercurial treatment and mitigated stick locally. Figure 4. — Rhinoscopic view showing exostosis of septum in the above (normal size). Figure 5. — Female, set. 26 ; appearance of nasal cavity after loss of septum and turbinated bones, and enlargement of the orifice of the antrum through syph- ilitic necrosis. Mercurials aud iodides ; extraction of necrosed bones with forceps. Potassium-permanganate washes. Figure 7. — Rhinoscopic view of above with mirror facing obliquely from left to right (normal size). Figure 6. — Female, set. 17 ; syphilitic perforation of hard and soft palate ; mercurials and iodides ; mitigated stick locally. Figure 8. — View of palate through the mouth (in state of active inflam- mation). Figure 9. — Female, set. 19 ; mucous polypi ; removed with snare ; subsequent galvanic cauterizations. Figure 11. — Anterior view of above (normal size). Figure 10. — Female, set. 45 ; large mucous polypi ; removed with snare ; sub- sequent galvanic cauterizations. Figure 12. — Anterior view of above (normal size). Figure 13. — Female, set. 30; large fibrous polypus of laryngeal vault; re- moved with galvanic snare. Figure 14. — Male, set. 28; central curvature and exostosis of septum ; longi- tudinal incision with knife ; oakum plugs ; exostosis removed with saw. [Note. — Represented as seen by gaslight. By daylight the red color appears much paler.] Plate IV Sajous,P/nxit. Bunk & M c Fetr,dge, Lith Phi/a CHAPTER XXIV. DISEASES OF THE NASAL CAVITIES, CONCLUDED. Tuberculosis of the Nose. Fortunately this is a rare affection. It appears in two different forms : an ulceration and a neoplasm, or tumor. The ulcer appears on the septum near the orifice of the nostril, and may extend from this point to other parts of the nose and it may even invade the upper lip. It is more likely to be secondary to tuberculous affections of other organs than a primary mani- festation. The ulcer appears as a yellow or gray surface with a round, elevated, uneven border. There is a purulent discharge, more or less tinged with blood, and of a disagreeable odor. There is no tendency toward cicatrization, and after being once healed it has a strong disposition to break out again. Pain is not a common symptom. Sooner or later the disease, which is now generally conceded to be due to the bacillus tuberculosis, invades the larynx and lungs and terminates in death. Treatment. — Cleansing, antiseptic solutions, such as are noted in Chapter XVIII, must be freely used. Curettement, the galvano-cautery, or chromic or lactic acid, — the latter in 50- per-cent. strength, — may be resorted to for the removal of the caseous, tuberculous material that forms the base of the ulcer. In case of a tumor, it should be removed with the snare and the attachment cauterized. Astringents and iodoform are useful in retarding disintegration and the invasion of adjacent structures. If pain is present, morphine or cocaine may afford temporary relief. Codliver-oil should be given, and guaiacol in doses of 1 to 10 minims after each meal. This is best administered in glycerin, milk-broths, or wine. Creasote is often useful. Syphilis of the Nose. The manifestations of syphilis in the nose correspond to the three stages of syphilis as met with in other organs. It (263) 264 DISEASES OF THE EAR, NOSE, AND THROAT. may be hereditary or acquired. In the former it appears either before the third month of childlife or between the third year and the beginning of adolescence. In infants the affection simulates coryza, but tends strongly toward suppuration. The discharge is more acrid and irritating than that of simple rhini- tis, and produces a red and raw appearance of the upper lip. The borders of the nostrils are cracked and chapped. Nasal respiration is embarrassed, and, in consequence of the interfer- ence with sucking, the babe is ill nourished and puny. If the disease attack the cartilage or bone, an offensive odor is imparted to the discharge. The later form of hereditary syphilis presents manifesta- tions of the tertiary form. It attacks the cartilaginous and osseous septum and then the turbinate bodies, and by carious and necrotic processes they undergo more or less complete destruction. The supports to the end and bridge of the nose disappear and the end may drop down toward the upper lip, or, if it remain supported by a remnant of the cartilaginous septum, the centre of the bridge may cave in and produce the pug-nose deformity. Diagnosis. — With care one will be able to distinguish the obstinate, persistent, pus-producing rhinitis of a syphilitic infant from an ordinary cold in the head which in an uninfected child tends toward speedy resolution. Mucous patches may be dis- cernible in the nares and a papular eruption on the skin. These children are often badly nourished, old looking, and unprom- ising. After taking into account all the characteristics men- tioned, if in the later form there exist any doubt as to the nature of the disease, a course of antisyphilitic treatment will dispel the uncertainty. Prognosis. — If the pathological process has not involved the cartilaginous or bony walls, and if the patient is not greatly debilitated, the chances of recovery are good. Treatment. — Cleanliness and specific medication are often rewarded by brilliant results. The antiseptic alkaline sprays given in Chapter XVIII are indicated, after which tincture of iodine applied to the ulcerating surfaces will be followed by DISEASES OF THE NASAL CAVITIES. 265 healthy granulations and cicatrization. If the ulcers do not cicatrize promptly, it is advantageous to dust the parts with aristol (Fig. 32) after the cleansing process. I generally use the mixed treatment, — small doses of mercury with potassium iodide. The latter may have to be given in increasing doses until the system is saturated. This treatment, vigorously pursued and carefully watched, gives gratifying results. In great debility and malnutrition codliver-oil, tonics, and improved sanitary surroundings may be necessary. When extensive deformity of the nose takes place, it may become necessary to resort to a rhinoplastic operation to restore the contour and continuity of the organ. \Yhen the cartilaginous support of the end of the nose has been destroyed so as to let the tip fall upon the upper lip, I have restored the natural lines Fig. 143.— The Author's Xasal supporter. by a device shown in Fig. 143, which I have named a ,; nasal supporter." It is fashioned to fit into the tip of the nose, so that the sides or wings of the supporter will correspond to the alae nasi. It is so placed as not to be visible when in position. I first had them constructed of aluminium, but the bright, reflecting surface was observable. Later I experimented with vulcanized rubber, and found that, after making the surface a dead black, it answered all requirements. The improvement in the facial appearance after restoring the pendulous nose to its normal position is something to be appreciated. Destruction of the major portion of the septum nasi does not necessarily result in external deformity. I have under observation such cases in which there is no external discover- able evidence of the internal architectural desolation. 266 diseases of the ear, nose, and throat. Lupus of the Nose. Lupus affecting the nasal cavities is a rare affection except as an extension from primary lupus of the face or pharynx. The nodules — which are found more abundantly on the septum than on the turbinals — break down, ulcerate, and discharge a foul-smelling, purulent secretion. In and about the prominent border of the ulcer can be seen the hard, but resilient, tumefac- tions, or nodules. As the discharges dry upon the ulcers, brown or greenish crusts form, offering more or less obstruction to the nasal respiration. Pain, radiating to the surrounding structures, is complained of, and the ulcer is sensitive to touch. Treatment. — In addition to the detergent and antiseptic sprays mentioned in treating of ozaena, etc., the treatment is the same as that given for lupus of the ear. Glanders. Glanders is a disease derived from the horse and is encount- ered among horse-farriers, coachmen, etc. It is due to a specific contagion and manifests its presence by the formation of pustules which give way to ulcers of the skin. It attacks the nose and throat, from which a bloody pus is discharged in large quan- tities. Constitutional symptoms characteristic of a serious sys- temic invasion or toxaemia indicate the gravity of the disease. When the infection extends to the lymphatic glands and skin in various parts of the body it is termed "farcy." This disease is either acute or chronic. The acute form is ushered in by symptoms similar to those of the eruptive fevers: chills, nausea, vomiting, fever, and red rash on the nose and face resembling erysipelas. This is followed by the appearance of blisters, which burst and leave their contents on the skin to dry into crusts. On removing these an ulcerating surface is dis- closed that shows no inclination to heal, but rather to extend over the surrounding parts. The pustular eruption invades the nose and throat, causing embarrassment of respiration. The copious, tenacious discharges from the nose and throat, and sometimes from the eyes keep the patient occupied to free the passages. In the chronic variety the secretion is not so copious, m DISEASES OF THE NASAL CAVITIES. 267 and it may be lacking, except in the desiccated form of scabs on the nasal and pharyngeal membrane. Symptoms suggestive of tuberculosis come on later : col- liquative diarrhoea and sweats, huskiness of the voice, and dif- ficulty of deglutition and respiration from tumefaction of the mucous membrane of the pharynx and about the glottis. Great prostration and delirium precede death. The acute form is rapidly fatal, lasting only about a week, while the chronic variety may persist for several months or a year. About half of all the cases die. The diagnosis may be obscured by the many symptoms that are characteristic of other affections, such as typhoid fever, rheumatism, syphilis, pyaemia, etc., but the history of the pa- tient, exposure to infection from horses, and lack of further pathognomonic symptoms of other diseases must be considered. As distinguished from typhoid, we have the pronounced nose, throat, and skin eruptions and discharges and ulcerations ; from articular rheumatism, pains in the muscles and tenderness surrounding the joints ; from syphilis, the constitutional dis- turbance and absence of proving by specific remedies ; from pyaemia, even when abscesses are found there is little or no chilliness. Treatment. — No antitoxin has yet been evolved that acts as a specific for this disease. From the nature of the case it is to be expected that such a remedy will yet be found. No treatment so far tried has decided influence in curing or retarding the progress of this virulent affection. It must be left to the practitioner to meet symptoms and indications as they arise and appeal to his knowledge of the general principles of medicine. FURUNCULOSIS OF THE NOSE. Boils in the nose are a common source of discomfort. They occur repeatedly in some individuals and cause soreness, redness, and swelling of the end of the nose. Small furuncles often develop just within the opening of the nostril, especially on the upper border, and originate in a hair-follicle. They render blowing and wiping of the nose very painful. 268 DISEASES OF THE EAR, NOSE, AND THROAT. Treatment consists in local and constitutional remedies. To the boil situated within the border of the naris a pledget of cotton is applied after moistening it with a 20-per-cent. solution of camphor-menthol in lavolin, or a 12-per-cent. solution of carbolic acid in glycerin may be substituted, as recommended in the treatment of furuncle of the ear. When pus is found it is evacuated, giving an opportunity for the remedies to enter the cavity. This treatment should be followed by the application of the yellow-oxide-of-mercury ointment, 5 grains to the ounce in vaselin, or the carbolic-acid ointment. Sulphide of calcium has a reputation of repressing or preventing pus formation, and can be given in those cases in which recurring crops of furuncles torment the patient. I have used with satisfactory results arsenious acid in doses of -^ grain three times a day, increasing gradually to two or three times that quantity for a short time, until the patient was free from these symptoms, and, if they re- appeared after a few months, repeating the treatment with larger doses continued for a longer time. This treatment has been successful in breaking up what appeared to be an established habit of body in which furuncles broke out with every spring- open in g. Anosmia. Absence or loss of the sense of smell may be due to central lesion or peripheral diseases. Affections of the Schneiderian membrane may destroy the nerve-termini or offer such obstruc- tions as to render them inaccessible to odors. Acute inflam- mation of this membrane and suppuration of the adjacent cavities (such as the frontal sinuses), that cause the membrane to become bathed in purulent discharges, and syphilis and atrophic rhinitis, ozeena, etc. (that produce destruction of the membrane), cause, on the one hand, temporary impairment or absence of the function of the olfactory nerve, and, on the other, irreparable loss of smell. Blows in the region of the olfactory bulb, and occasionally on other parts of the skull, cause injuries to the bulb from which it does not recover. Excessive tobacco-smoking, snuff-taking, and opium-using either blunt or obliterate the sensibilities of the DISEASES OF THE NASAL CAVITIES. 269 olfactory nerve. The sense of taste generally suffers more or less in all these instances. Treatment. — Anosmia due to acute inflammation of the nasal and connecting cavities generally disappears when the cause of it is removed. The appropriate treatment then is the same as for the inflammation that produces it. When the loss of smell has existed for several years the outlook for its restora- tion is not encouraging. Yet I have seen a partial return after the whole mucous lining of the nasal cavities had gone through a protracted siege of ulceration in consequence of an irregular physician spraying the cavities with a corroding fluid by mistake, resulting in a complete loss of the sense. To complicate the case there was syphilitic infection. In such cases the treatment detailed for syphilis of the nose and ozasna is appropriate. Ab- solute cleanliness and nerve-tonics, such as strychnia and the faradic current, are indicated. The negative electrode is placed over the root of the nose and the positive on the occiput, both electrodes being saturated with salt water. Parosmia. In parosmia the sense of olfaction is perverted. This happens even where the sense is normal for all objective odors. Various subjective odors are complained of, all disagreeable, such as oils, carrion, kerosene, etc. A physician under my care is annoyed by a constant subjective odor of " greasy rags or soap- grease." This symptom may be due to disease of the nasal mucous membrane, the decomposition of retained nasal secre- tions, disease of the olfactory nerve, or cerebral lesion and over- stimulation of the nerve. As an example of the latter : I have under treatment a gentleman who for many years has been engaged in the perfume business and during that time has grad- ually lost his sense of smell without any apparent causative lesion in the nasal cavities. Perverted olfactory function has been observed in the insane and epileptics. Treatment. — If the nasal membrane is diseased and if hypertrophies, polypi, etc., are present to account for increased, retained, and perverted secretions, suitable treatment, such as 270 DISEASES OF THE EAR, NOSE, AND THROAT. has already been discussed, may remove the disgusting symptom, but if the cause lie in the nerve or its origin, or exist in the imagination as an hallucination, the indications for treatment are not so plain. If the olfactory bulb is the seat of the disease, galvanization or faradization as mentioned for anosmia may prove beneficial. Deformities and Diseases of the Nasal Septum. Exostoses and synechias have already been considered and are illustrated by Figs. 130 and 131 and Plate IV. It is un- usual to find a nose with an interior that is architecturally sym- metrical. The septum in many instances is either curved, thick- ened, or even doubly curved so as to present a sigmoid flexure or a corrugated appearance. If the deformity is not sufficient to produce pressure on the turbinate bodies and consequent irri- tation, epistaxis, and obstruction to nasal respiration (Plate V) no symptoms referable to the anomaly are present. According to Zuckerkandl, the septum is not found deviated before the seventh year, but I have under observation a boy 5 years and 9 months of age with deflection, spurs on both sides, hypertro- phied turbinals, and adenoids. The causes of malformed septa are not known, but the theories are many. The deflection may be so exaggerated as to give a twisted or bent appearance to the whole nose. The irregularity is limited to the anterior and middle sections of the septum. Symptoms of nasal irritation — epistaxis, discharge, reflex neurosis (such as asthma), nasal voice, naso-pharyngeal catarrh, etc. — result from considerable septal deformities. The diag- nosis is readily made on inspection with brilliant, reflected illumination. Treatment. — If the deformity is limited to the cartilaginous septum the most satisfactory procedure in my experience has been the amputation of the offending projection by means of the septum-knife (Fig. 138). The method is described in con- nection with the figure. I have always taken pains to avoid perforating the septum, but I have seen many cases in which DISEASES OF THE NASAL CAVITIES. 271 surgeons had made apertures without any unpleasant con- sequences. When the bony partition is involved the saw or the drills are called for. Various punches have been con- structed to fracture and restore the deviated septum, after which splints and tampons are employed to maintain the reduced deformity in proper position. BLOOD-TUMORS OF THE NASAL SEPTUM. Haemorrhage takes place between the mucous membrane and the cartilage from blows, etc. Fractures of the septum occasionally result in hsematomata. These tumors are easily recognized and should be opened before their contents degen- erate into a purulent mass, resulting in abscess. (See "Treat- ment " under " Abscess.") ABSCESS OF THE NASAL SEPTUM. Like blood-tumors, abscesses are generally in the cartil- aginous portion of the septum. They may assume such pro- portions as to completely blockade the nostrils and compel mouth-breathing. In a case recently under my care the swellings were symmetrical and had attained such a size as to protrude sufficiently from the nostrils to be plainly visible. They are usually the result of blows, and their history and appearance render the diagnosis easy. Treatment. — Abscesses of the septum, like blood-tumors, should be opened, their contents evacuated, and the cavities cleansed with dioxide of hydrogen. Then equal parts of alco- hol and tincture of iodine should be injected so as to wash out the cavity. The dressing is completed by packing aristol gauze between the opposite wall and the septum so as to cause coap- tation of the separated mucous membrane to the cartilage again. This method may prevent perforation of the cartilage, which is a frequent sequel of these diseases. PERFORATION OF THE NASAL SEPTUM. An aperture is not infrequently found in the cartilaginous part of the septum when patients are unaware of its presence *27*J DISEASES OF THE EAR, NOSE, AND THROAT. (Plate IV), but occasionally a small perforation causes a whis- tling sound as the current of air moves rapidly over it, annoying the patient and attracting the attention of others. A prominent educator of my acquaintance is troubled in this manner. He is apparently in excellent health and there is no assignable cause for the anomaly. Perforations are usually considered as indica- tive of syphilis, but they are not necessarily so. I have often been unable to trace them to any specific taint. They may occur as the result of impaired nutrition or the habit of picking at the nose with the fingers. Abrasions are produced, and the crusts that form over them are not allowed to remain until heal- ing occurs beneath. In the course of exhausting diseases, such as tuberculosis and typhoid pneumonia, the septum may become perforated. Treatment. — Unless the perforation causes a whistling sound perceptible to others or annoying to the patient, no treatment is required except the application of vaselin or some stimulating ointment to the border of the perforation. Treatment does not result in its closure. If disagreeable sounds are produced the opening can be changed in shape so that its long axis shall cor- respond to the air-current. In operations on the nose Delavan (Journal of Laryngology, 1895) deprecates perforating the vomer on account of the dis- proportionate shock resulting. French (New York Medical Journal, December 1, 1894) perforates the septum when neces- sary for breathing-space, but insists on proper after-treatment, and Wright insists on thorough antiseptic treatment before and after operations on the nose. Fractures of the Nose. The bones of the nose are not easily or often broken. The arched contour and the cartilaginous portion serve to protect against such accidents. A blow or fall upon the nose sideways, however, may drive the bones inward and produce deformity, or a powerful force, like the kick of a horse, may shatter the osseous arch. The deformity produced by such accidents is shocking. The sense of smell is likely to be destroyed on DISEASES OF THE NASAL CAVITIES. 273 account of the damage done to the olfactory nerves. Examina- tion under ether will reveal the nature and extent of the injury, which is readily apparent. The fact that such accidents are liable to produce concussion of the brain should not be lost sight of in forming a prognosis. Treatment. — Pain, bleeding, oedema, swelling, and emphy- sema of the tissues demand immediate attention to check the haemorrhage, relieve the pain, and reduce the swelling. Ano- dynes and the ice-bag (Fig. 78) meet these requirements. Then the fractures must be reduced to as perfect coaptation of the parts as possible, since nasal deformity, above all others, influ- ences the business and social interests of the patient. The solid- silver Eustachian catheter can be bent to the proper shape and inserted beneath the depressed bones to elevate them to their correct level while the fingers of one hand support them from without and assist in nicely adjusting them. If restored to their normal relations they remain so, since there is no muscular contraction to again displace them. Union usually takes place rapidly. Congenital Deformities of the Nose. These are exceedingly infrequent occurrences. If a de- formity consist of an impervious membrane of the posterior nares it must be perforated to establish nasal respiration. Foreign Bodies in the Nose. The nose, like the ear, is a favorite receptacle for foreign bodies introduced by children and the insane. Beans, peas, pebbles, etc., are not infrequently found lodged in these cavities. The act of vomiting occasionally forces the ejected matter into the post-nasal space. Bodies inserted into the nostrils are gen- erally located near the vestibule in the inferior meatus and are readily seen on inspection. Sneezing, lacrymation, nasal ob- struction and discharges are the symptoms that point toward the invader. Berries so absorb the serum and swell that their increased calibre and the tumefaction of the mucous membrane occlude the offended nostril. Unless the body is removed it 18 274 DISEASES OF THE EAR, NOSE, AND THROAT. provokes inflammation and ulceration, with frontal and facial neuralgia and a purulent discharge more or less discolored with blood. The inflammatory process may extend backward to the post-nasal space and to the opposite nostril, compelling oral respiration and causing loss of smell and impairment of hearing from involvement of the Eustachian tube. Decomposition of the retained secretions causes a fetid odor and the occasional expulsion of cheese-like masses. If the obstructing body has been crowded or snuffed back- ward into the middle portion of the meatus, it may be shielded from view by the swollen turbinal or by a covering of the dis- charges. The secretions should be soaked up by the careful Fig. 144.— Hartman's Forceps. application of absorbent cotton on the carrier. This is better than to syringe or spray the nose, for there is less liability of forcing the body farther out of reach. After drying the cavity a 10-per-cent. solution of cocaine is applied to the tumefied turbinal, so as to contract it and afford a view of the whole interior of the cavity. The probe will then detect any alien substance. Treatment. — Foreign bodies should be removed as early as possible to prevent serious consequences. This can generally be accomplished by the angular forceps (Fig. 144). They should be applied with care not to crowd the body farther inward. It is best not to close the jaws of the instrument until til DISEASES OF THE NASAL CAVITIES. 275 one is certain that it embraces the body a little beyond its centre, otherwise it is likely to slip off, and in doing so propel the body still farther from view. In the case of a berry of a plant, like the bean that has become softened and enlarged by the absorp- tion of moisture, a sharp hook like the one found in the author's middle-ear case can be made to imbed itself in the substance of the body and glide it out of the canal. In some instances a blunt hook, the snare, or mouse-tooth forceps offers some advantages. Maggots in the Nose. This is a condition rarely found except in tropical climates. The eggs of flies are deposited in or about the nares, maggots are hatched, and destruction of the soft tissues and even of the nasal bones results. Itching, crawling, gnawing sensations and intense pain are experienced. A bloody, purulent discharge of fetid character appears. The intense inflammation may invade the surrounding structures, causing redness and oedema of the face and meningitis, with convulsions, coma, and death. Inspection readily reveals the cause of the trouble. Treatment. — Chloroform is the most efficient remedy. In- halation may be sufficient to destroy the larvae ; if not, it should be injected into the nose after enough has been inhaled to pre- vent pain. This is made to syringe out all the maggots and effectually empty the cavities. After-treatment should be at- tended to according to the condition present until the health of the membrane is restored. CHAPTER XXV. DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. Inflammation of the Antrum of Highmore, or Maxillary Sinus. This disease occurs sometimes as a complication of acute rhinitis, and if severe is accompanied by a sense of uneasiness or pain and tenderness in the antral, orbital, and frontal regions. These symptoms are more likely when there is obstruction to the outward flow of the secretions. If the disease does not subside coincidently with the subsidence of the rhinitis, a chronic suppuration results, or empyema. It may arise as a sequel to diseases of the teeth, especially the first and second molars, or in connection with the eruptive fevers and syphilis. This affection is generally unilateral. Examination reveals a purulent discharge in the middle meatus and its foul odor is noticed by the patient, showing the difference between this and ozsena, in which the sense of smell is destroyed. Empyema of long standing affects the general health to such a degree that a constitutional disturbance is readily apparent. Diagnosis. — This is aided by the use of a 10-per-cent. solution of cocaine in the nose to contract the turbinals. If a rhythmic pulsation is seen in the pus lying in the middle meatus, antral suppuration is suggested. The pus should be removed and observation made to determine if it re-appear from the antral cavity, issuing from below the middle turbinal. Pressure over the maxillary sinus or tapping upon a tooth may reveal tenderness. If hydrogen dioxide (peroxide) can be in- jected into the antrum through the opening beneath the middle turbinal, the usual effervescence will disclose the presence of pus. Some operators prefer to enter the cavity through the (276) DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 277 socket of a tooth, which may need to be sacrificed for this purpose, while others open the wall of the inferior meatus. Still others perforate the thinner wall of the middle meatus, Lnder cocaine, going outward and downward to avoid the orbit, 'hen, the author's aspirator (Fig. 63) may succeed in sucking the pus from the cavity. The patient is instructed to make a continuous effort, as in pronouncing the consonant part of &, so as to elevate the palate and close the post-nasal space. Then the air-pump is manipulated, to prove the presence of pus. Prognosis. — This is not an inspiring one. The nature of the case is unfavorable for spontaneous resolution, and if the bone is necrotic a tedious time is to be expected. Treatment. — As a complication of acute rhinitis, the treat- ment for the latter is indicated. If the mouth of the sinus is closed it should be cleansed with the antiseptic sprays mentioned in Chapter XVIII, with dioxide of hydrogen, and then moistened with a cocaine solution to contract the tissues and open the hiatus. If there is much pus in the antrum or if it is inspis- sated, it is not an easy matter to evacuate and cleanse the sinus through the ostium maxillare. The opening is so small that it may be necessary to penetrate the bone. Some operators, like the late Dr. Gunn, make a crucial incision in the cheek, and perforate through the canine fossa, but it is better to penetrate through the alveolus of a tooth, especially as a molar may prove to be the exciting cause of the trouble. The weight of argument and experience is in favor of entering the sinus through the nose, just below the natural opening. A curved drill or cannula and trochar are best adapted for this purpose, for the cannula can be left in position until the cavity is thoroughly cleansed and medicated. The after-treatment should be conducted similarly to the medicinal treatment detailed for middle-ear suppuration. Miscellaneous. — Phlegmonous inflammation of the antrum is a very rapidly fatal form of inflammation. Tumors of the antrum are exceedingly rare, but require extirpation through the anterior wall. Daly {New York Med- icalJournal, November 10, 1894) urges early operation in antral 278 DISEASES OF THE EAR, NOSE, AND THROAT. disease to prevent the transformation of a benign growth into a malignant one. Ethmoid Diseases. An inflammation of the nasal membrane sometimes extends into the ethmoid cells, the membrane of which, like that of the mastoid cells, lines the osseous cavities and serves as a perios- teum. Hence an inflammation of this membrane is readily communicated to the bony walls themselves, resulting in caries and necrosis. Pain is referred to the root of the nose and the orbital and temporal regions. The disease may extend so as to produce a bulging prominence between the eye and the root of the nose, and the eyeball may protrude abnormally. In a girl of 17 years, now under treatment (Fig. 148), the arch of the nasal bones was widened, the vault of the nares was filled with mucous polypi, and the flow of the muco-purulent dis- charge was enormous, necessitating the carrying about of a bundle of cloths instead of a handkerchief. There were also adenoids in the vault of the pharynx, hypertrophied tonsils, and chronic suppuration of both middle ears. The polypi, adenoids, and tonsils were removed, but the polypi were reproduced with mushroom-like rapidity. The ethmoid cells were opened up and curetted, and she is improving satisfactorily, the discharges from the ethmoid cells and ears having ceased. Diagnosis. — The antrum is often involved coincidently, and it is sometimes difficult to make a differential diagnosis between the two. However, the pain in ethmoiditis is referred to the root of the nose and back of the eye, and the eye symp- toms serve to clear up the uncertainty. The discharge is gen- erally seen where it occurs in antral suppuration, but the smell, in this disease, is more likely to be impaired or lost. Prognosis. — When ethmoiditis is a simple concomitant of acute rhinitis it subsides together with the principal disease. Suppuration is a serious condition, for it may invade the orbit or extend to the cerebral meninges. Treatment. — Antiseptic, detergent washes already given in the first chapter of Part II — dioxide of hydrogen, etc. — DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 279 must be employed for cleansing purposes. All polypi should be removed and then the curettes shown in Fig. 84 can be used to scrape out carious and necrotic tissue. If the middle turbinate body is too large to admit of proper observation and manip- ulation, it must be removed as already described. The anterior ethmoid cells are in communication with this turbinal; hence the advantage of its excision. After-treatment is the same as for antral suppuration. Polypi sometimes take their origin from the ethmoid cells, producing pressure on the surrounding structures. The result is apparent, especially in the increased breadth of the nose and the prominence of the eye. Osteomata produce like appear- ances. The treatment for growths in this locality consists in extirpation. Sphenoid Disease. It may be observed that I have departed from the custom of adding " al " to the adjectives ethmoid and sphenoid. This is because it is etymologically correct to do so ; it is in keeping with the American tendency to brevity and terseness, and in conformity to the common use of the corresponding term " mas- toid " instead of "mastoidal." These terms are Greek adjec- tives merely transferred into English, and are not rendered more perfect by additional terminations. Sphenoiditis occurs as a complication or sequel of inflam- mation of the nasal and accessory cavities and of meningitis. The symptoms are not pathognomonic and this affection is difficult to differentiate from disease of the ethmoid cells. The pain is deeply seated, the discharge empties into the throat, and dimness of vision, strabismus, and prominence of the eyeball are symptoms characteristic of this disease. The prognosis is unfavorable on account of the tendency to invade the cranial cavity. Treatment. — The methods already described for diseases of the accessory cavities are applicable here. If it should become necessary to open and curette the sphenoid sinus, the instrument should be passed over the middle turbinal, backward and up- ward until it enters the lower part of the cavity. The sinus 280 DISEASES OF THE EAR, NOSE, AND THROAT. can be opened through its under wall, also by perforating through the pharyngeal vault immediately back of the posterior nares. Subsequent treatment has been indicated in treating of the other sinuses. Tumors are rare in the sphenoid sinuses, but if they pro- duce blindness or other serious symptoms they must be removed. Diseases of the Frontal Sinuses. Inflammation of these cavities occurs from extension of rhinitis. It is not to be expected under the twentieth year, since these sinuses, being developed from the anterior ethmoid cells, are not formed earlier. Acute inflammation is characterized by a severe, continuous, frontal headache and pain about the eyes. There is tenderness over the sinuses on percussion and on press- ure beneath the supra-orbital ridge. Nausea and vomiting are occasionally present. The pain may not be due entirely to the swelling of the mucous membrane lining the cavities, but to loss of the natural air-pressure, for I have observed that the propelling of air impregnated with a nebula of camphor-menthol into the sinuses gave decided relief. When the infundibulum, or passage between the nasal and frontal cavities (Fig. 146), becomes clogged, the retained secretions, mucus or pus, will cause great pain. The press- ure may be sufficient to cause absorption of the osseous partition separating these sinuses, or bulging may take place downward and outward so as to encroach and press upon the eyeball. Suppuration of the frontal sinuses is an infrequent disease. The pus can be seen in the middle meatus under good illumi- nation, flowing downward from the region of the sinus-opening. It should be wiped away and the area watched to see the source of the discharge. If the pus break through the posterior wall of the sinus, there are symptoms of brain compression, drowsi- ness, headache, stupefaction, etc. This complication induces purulent meningitis. The symptoms point quite distinctly to the seat of the trouble, and are not so obscure as in sphenoiditis. The electric DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 281 lamp and condenser of Heryng are useful in making diagnoses in this class of diseases. Transillumination of the frontal sinus is accomplished by applying it to the lower border of the supra-orbital ridge and inner angle of the orbit while the room is made dark. In health the sinus is illuminated up to the superciliary ridge, but in case of the presence of pus it is dark. Treatment — The first indication is to subdue the pain. If the inflammation occur in the course of acute rhinitis the treatment for that is appropriate and effective here. An appli- cation of a 10-per-cent. solution of cocaine to the sinus-opening may so contract the swollen tissues as to open the duct, give exit to the pent-up secretions, and relieve the pain. The deter- gent, antiseptic sprays given in Chapter XVIII are useful in this affection. After cleansing the cavities by sprays and having the patient repeatedly blow his nose, great relief is afforded by throwing a nebula or vapor of a 10-per-cent. solu- tion of camphor-menthol in lavolin into the nostrils with the air-current directed toward the naso-frontal duct. This tends to evacuate any retained secretions and to restore the normal air-pressure in the sinuses, besides medicating the remote mem- brane as ordinary treatment fails to accomplish. In the acute stage the ice-bag (Fig. 78) is indicated to subdue and avert the inflammation. It should be applied over the frontal protuberances and the root of the nose. If this should not afford relief, or if it prove irritating, hot fomentations may be substituted. Any obstructing hypertrophies or tumors must be removed as previously described. If the discharge contained in the sinuses cannot be liberated by opening the naso-frontal duct with air-pressure, cocaine, or a probe, it may be necessary to penetrate the sinus directly, near the internal angle of the orbit, at which point the cortex is quite thin. This procedure is similar to that which has already been detailed for opening the mastoid antrum and removing the dis- eased contents. Tumors of the frontal sinuses are treated on the principles already laid down for tumors of the other acces- sory cavities. 282 DISEASES OF THE EAR, NOSE, AND THROAT. Eye Affections in Relation to Diseases of the Nose.* The eye is directly connected with the nasal cavities by the nasal duct (Fig. 145), which is lined throughout with mucous membrane the same as that lining the nasal cavities, covering the globe of the eye and lining the lids. The lacrymal artery — through its branch, the anterior ethmoid — supplies both the lacrymal sac and the nasal duct, and the nerve-supply is Fig. 145.— Dissection Showing Nasal Duct and its Relations. 1, inferior turbinate bone; 2, nasal duct and valves; 3, middle turbinate body; A, lacrymal sac ; 5, lacrymal canaliculi and their orifices. received in common from branches of the ophthalmic nerve and Gasserian ganglion. We have, therefore, a direct route through the nasal duct for the passage of morbific germs from the nose to the eye ; and the nose, under certain pathological conditions, becomes a nidus for aggravating causes of ocular symptoms. *By Allen T. Haight, M.D., Assistant Surgeon to the Illinois Charitable Eye and Ear Infirmary ; Lecturer on the Ear, Nose, and Throat in the Illinois Medical College ; Assistant in Ophthalmology at the Chicago Polyclinic. DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 283 The common blood-supply, with anastomoses and veins from the duct and sac, and the direct relation of accompanying nerves show that certain mechanical or pathological conditions existing in one may produce pronounced symptoms in the other. For instance, irritation of the Schneiderian mucous membrane may produce lacrymation, and we may have more or less severe ocular symptoms accompanying common coryza, measles, etc. The principal ocular symptoms which in certain cases depend on pathological conditions existing in the nose are lac- rymation, photophobia, conjunctival injection, pericorneal injec- tion ; smarting, burning, and swelling of the lids ; phlyctenular troubles, epiphora, purulent ophthalmia, etc. H. Gradle (Archives of Ophthalmology, New York, 1887), in systematizing the ocular symptoms dependent on pathological conditions of the nose, finds the following classes : — " 1. Lacrymation without primary lesion of the tear-pass- ages of the eye and due to some chronic abnormality of the nasal passages. " 2. Fullness of the lids and itching, possibly with lacry- mation and more or less pain and with asthenopia especially marked in one eye. Patients with these symptoms aggravated have also a refraction, or muscular, anomaly. " 3. Periodic discomfort (itching of the lids), allied to hay fever or co-existing with conjunctival lesions, at first of the follicular enlargement and finally of a formation of large, flat, yellowish, follicular granules which disappear in the winter. " 4. Photophobia with or without pain in the eyes, these being often blood-shot, with little nasal annoyance, but decided itching. " 5. Injection of the pericorneal vessels, together with varying degrees of the above symptoms, chronic and persistent. " 6. Acute congestion of the lids with irritable nose, ery- sipelatoid in character, subject to recurrence, lasting from two to six days. " 7. Sudden oedema of the lids without congestion, the attack lasting a few hours." In the present treatise we shall not draw such precise 284 DISEASES OF THE EAR, NOSE, AND THROAT. symptomatological lines, but shall confine our consideration of the subject to two classes, — viz. : (1) pathological conditions of the eye dependent on hypertrophies, deformities, or mechanical abnormalities of the nose; (2) pathological conditions of the eye resulting from the passage of morbific material from the nose through the nasal duct or intermediate tissue of the eye. One of the frequent causes of ocular troubles is chronic hyper- trophic rhinitis, especially that form in which the mucous mem- brane is subjected to repeated, sudden engorgement of the blood-vessels from very slight irritation. In these cases we usually have a copious, watery discharge and severe inflamma- tion of the inferior turbinated body, especially marked in the anterior half, associated sometimes with mucous polypi in the middle meatus. The eye symptoms occurring with this con- dition are lacrymation ; photophobia ; burning and smarting of the lids, with deep injection, especially marked at the margin ; and not infrequently ciliary and conjunctival injection. Polypi of the mucous type so situated as to form a wedge between the septum and the inferior turbinal, or situated so as to fill the superior meatus, give rise to persistent ocular lesion. Deflected septum, spurs, large ridges on the septum, and synechia? play an important part in the production of sympa- thetic ocular conditions. Bishop cites a case of amblyopia of the left eye, greatly impaired hearing, tinnitus aurium, and a sensation of fullness in the left ear cured by the removal of an osseous synechia between the left middle turbinated bone and the nasal septum. Polypi in the superior nasal cavities sometimes produce that peculiar facial deformity known as "frog-face," where the nose becomes widened between the eyes and the eyes protrude. Pressure on the upper part of the nasal duct produces epiphora and catarrhal conjunctivitis, which can be effectually cured only by the removal of the obstruction and the restoration of the nose to its normal function. Abnormal development of the ethmoid and sphenoid markedly affects the function of the ocular muscles or the acuteness of vision. Overdevelopment of the ethmoid, espec- DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 285 ially in the anterior part, will sometimes produce entire stenosis of the upper part of the nasal duct, and we have epiphora from pressure. Following this we get blennorrhcea of the lacrymal sac and possibly dacryocystitis. Abnormal development of the posterior portion of the ethmoid may produce widening of the in- terorbital space ; displacement of the origin of the internal recti muscles, with high degrees of astigmatism ; and occasionally divergent strabismus following. Overdevelopment of the sphenoid may, by pressure upon the optic nerve, produce permanent atrophy, limitation of the field of vision, and partial or complete color-blindness. Hypertrophies, polypi, or tumors in the superior nasal sinus may produce temporary blindness or high degrees of amblyopia, which are ameliorated -or cured by the removal of the obstruction. Pathological Conditions of the Eye Resulting from the Pass- age of Morbific Material from the Nose through the Nasal Duct or Intermediate Tissue to the Eye. — The ready means of access of infectious germs of all kinds to the eye from the nose by means of the nasal duct (Fig. 146) renders the eye liable to attack in nasal diseases, such as ozaena, hydrorrhcea, hyper- trophic rhinitis with watery discharge, gonorrhoea, syphilis, diphtheria, etc. The conjunctiva is a very delicate and sensitive membrane, far more so than the Schneiderian mucous membrane, and easily yields to the attack of morbific germs. These germs sometimes gain entrance to the eye by direct migration, but are very frequently forced into the eye by blowing the nose, sneezing, and not infrequently by the use of the Politzer air-bag. The cul-de-sac of the inferior turbinated body (Fig. 146, 4) is the receptacle for the collection of material which is, or becomes, decomposed, and finds its way or is forced into the lacrymal sac and to the conjunctiva, and we have a blennorrhcea, conjunc- tivitis, phlyctenular keratitis, or ulcer of the cornea following, which will not yield to treatment until the origin of the trouble, the nasal affection, has been corrected. In the fall and spring of the year, particularly, the attention of the ophthalmic surgeon is attracted by the number of children who present themselves '266 DISEASES OF THE EAR, NOSE, AND THROAT. with corneal ulcers or phlyctenular troubles, usually attended by nasal affections. There is great congestion of the turbinals, profuse watery discharge, and the formation of crusts on the nostrils, the sores extending down on the upper lip. The eye symptoms are persistent, are attended by lacrymation and by Fig. 146. 1, middle turbinated body turned aside and beld by a hook ; 2, nasal duct and valves ; 3, canal leading to the maxillary and frontal sinuses ; U, inferior turbinated body showing location of the mouth of the nasal duct in the cul-de-sac. increasing photophobia and resist local treatment until the nasal affection is cured. The treatment of nasal affections is fully given in other chapters of this work. The most common ocular affection caused by diseased con- ditions of the nose is disease of the lacrymal apparatus. We have many cases of lacrymal trouble which are in no way influenced by conditions in the nose, but are caused by the passage of germs from the eye through the canaliculi to the lacrymal sac or into the nasal duct. We may have stenosis of DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 287 the canaliculi situated in any place between the puncta and the opening into the lacrymal sac. In this class of cases we have epiphora as an early symptom, with sometimes a contraction or atrophy of the lacrymal sac, but more frequently dilatation and blennorrhcea. When the stenosis is situated in the nasal duct below the sac (Fig. 145, 2) we have abnormal dilatation of the sac and accumulation of muco-purulent secretion. In both cases the permanent symptom is epiphora, and we may have, following this, conjunctivitis, and dacryocystitis. One-half of the above cases have their origin in nasal affections. Hypertrophic rhinitis may cause stenosis of the lower part of the nasal duct, the inflammation extending through the canal to the sac. Atrophic rhinitis with fetid dis- charge is most frequently the cause of lacrymal trouble ; the morbific germs pass through the canal to the sac and remain there the nidus of infection until the disease is established. Empyema of the antrum of Highmore may be the cause of lacrymal disease, as the contents of the antrum may enter the nasal duct directly or purulent secretion from the antrum may pass from the nose through the nasal duct to the sac. Treatment of Lacrymal Diseases. — The first point to be settled, if possible, is the cause of the existing condition. If the disease is traceable directly to pathological conditions exist- ing in the nose, then the nose should receive proper treatment in conjunction with the treatment of the lacrymal apparatus. If the epiphora is due to stenosis in the canaliculi, occlu- sion of the puncta, blepharitis, eversion of the puncta, etc., these conditions must be remedied. When the lacrymal sac is filled with acrid or muco-purulent discharge, this should be evacuated by means of firm pressure by the thumb or finger on the sac, pressing the retained secretion out through the puncta (Fig. 145). The eye should then be thoroughly cleansed with a saturated solution of boric acid, after which the sac should be washed out. In order to introduce a lacrymal syringe it is necessary to enlarge the calibre of the puncta. To do this I introduce the canaliculous knife into the canaliculus (Fig. 147), the cutting-edge being turned toward the eye, and by retracting 288 DISEASES OF THE EAR, NOSE, AND THROAT. the lid with the thumb and drawing the knife out, make a small incision in the punctum perpendicularly to the palpebral fissure large enough to insert the end of the syringe or a small probe. This operation maintains the integrity of the canaliculus, and the pressure of the lids on the wound tends to keep the edges apart and prevent adhesion. For washing the sac I have derived great benefit from the following solution : — B Fl. ext. hyclrastis, Zinci sulpli., . Aquae destil., . q. s. ad ^iss. gr. iv. 5U— M. Fig. 147.— Tear-gland and Drainage. 1, 3, orbital and palpebral portions of lacrynial gland ; 2, fibrous band dividing the gland ; U, 5, orifices and branches of the lacrymal canal ; 6, lacrymal sac. which I inject with the lacrymal syringe every other day, using the solution as hot as the patient can well stand. If a stricture of the canal exist below the sac I insert, if possible, a No. 5 or No. 6 Bowman probe, and follow this with an injection of the above solution. If this or other conserva- tive treatment fail, the stricture must be treated surgically, which course is given in detail in works on the eye. Gould quotes Hamilton in detail in the following cases : — Case I. — Empyema of the antrum and unilateral hyper- trophic rhinitis of the left side, attended with the following eye DISEASES OF THE ACCESSORY CAVITIES OF THE NOSE. 289 symptoms: (1) concentric contraction of the visual fields for all colors, (2) accommodative asthenopia, (3) retinal hyperesthesia, and (4) photophobia with blepharospasm and intra-orbital neu- ralgia. The evacuation of the empyema and its cure were speedily followed by the disappearance of the eye symptoms. Case II. — Ecchondrosis of the triangular cartilage and chronic rhinitis. This case was attended with the following eye symptoms: (1) asthenopia, (2) pain in the eyeball, (3) injection of the eyes when used for close work, (4) blepharospasm, and (5) contraction of the visual fields. These symptoms disap- peared on removal of the growth. Case III — Spine of the bony septum causing chorea. The following eye symptoms were present: (1) asthenopia, (2) sub- jective color-sensations, (3) sneezing, and (4) contraction of the field of vision. These symptoms disappeared on removal of the spine of the septum. Case IV. — Advanced chronic atrophic rhinitis, with middle turbinate hyperplasia. The following eye symptoms were present: (1) asthenopia, (2) lacrymation, (3) pufhness of the lids, and (4) contraction of the visual field. These symptoms were relieved by the treatment of the nasal condition. Case'V. — Syphilitic ozaena. The following eye symptoms were present (Transactions of the Intercollegiate Medical Con- gress of Australasia, 1889, vol. ii, p. 779): (1) asthenopia, (2) lacrymation, (3) pericorneal injection on using eyes, and (4) contraction of the visual fields, which was temporarily removed by the use of amyl-nitrite. These eye symptoms were amelio- rated as the nose improved. Case VI. — Polypi, nasal and naso-pharyngeal, with eye symptoms similar to those recorded. 19 CHAPTER XXVI. DISEASES OF THE NASO-PHARYNX. Nasopharyngeal Catarrh. Synonyms. — Post-nasal catarrh ; rhino-pharyngitis ; retro- nasal catarrh; follicular naso-pharyngeal catarrh. Pathology. — Naso-pharyngeal inflammation may be acute or chronic, but the acute stage rapidly merges into the chronic form, leaving a thickening of the mucous membrane, — a pro- liferation of tissue that gives rise to a roughened and granular appearance of the membrane and increased secretion from the mucous glands. Etiology. — Sudden and extreme changes in meteorological conditions, especially in a low, damp climate are undoubtedly the chief exciting causes of this disease. Inhaled dust is an- other important etiological factor ; but climatic conditions are of prime importance; otherwise, those who live in a dusty atmosphere, but in a warm, high, dry, equable climate, would suffer equally with those under the reverse conditions. This disease is most common in the region of the Great Lakes and, indeed, in many other parts of America. Even in Colorado, the Mecca of consumptives, this disease prevails. But the soil favors this, for it is so light and sandy that the rains percolate through into the subsoil in a few hours, leaving on the surface a fine coat of dry dust, the toy of the winds and the torment of catarrh. I have never experienced elsewhere such dust-clouds as I have seen in Denver. In the Mississippi Valley and the Great Lakes Kegion the barometrical and thermomet- rical changes are rapid and excessive. The thermometer often falls thirty degrees or more in a few hours, and half that much in as many minutes. In hot summer-days, with southerly winds, cold waves sweep down from the northwest, catching the people in thin clothing, chilling the skin, and causing internal con- gestions that naturally attack the respiratory passages. The (290) DISEASES OF THE NASOPHARYNX. 291 dampness of the atmosphere and the prevalence of dust aid in locating the seat of irritation in the most exposed air-cavities. After these sudden attacks of cold waves an influx of patients usually attests the cold-giving nature of the changes. I have found San Francisco no better than Chicago in climatic con- ditions. The fogs of the early morning and the bitterly-cold, penetrating winds of the afternoon, with only a few hours of congenial warmth to lure one to don warm- weather attire, pre- sent the conditions favorable to the production of nasopharyn- geal catarrh. But the reverse of this picture is to be found by a twenty-minute ride across the bay to Oakland. There one may doff his overcoat and bask in the balmy sunshine of summer, while his neighbors a few miles distant shiver in the ocean- winds. But even here we cannot escape the irritating dust that plays hide-and-seek with the cilia of the nose. For catarrhal patients the climate of Los Angeles or San Diego is preferable to that of San Francisco ; but even in these delightful gardens of America there is no escape from dust. The part played by this irritant in the causation of post- nasal catarrh is easily understood when we consider the con- formation, position, and lining of the naso-pharyngeal cavity. Its shape is such as to receive and change the course of the current of air as it strikes the vault and posterior wall of the pharynx, and all the dust-laden air inhaled through the nose must come in contact with this part. The foreign particles not removed by previously impinging on the nasal cilia or mem- brane find lodgment here, and, if sufficient moisture has not been absorbed by contact with the nasal chambers proper, the secretions of the retropharyngeal space are taxed to perform this function. The resulting storage of dust and the drying of the membrane, which is devoid of the acute sensibility charac- teristic of the nose and larynx, and therefore of prompt reflex efforts at dislodgment, tend to excite irritation and consequent inflammation. Other predisposing causes of naso-pharyngeal catarrh are discussed in the first chapter on general considera- tions of ear, nose, and throat diseases. This disease is undoubtedly more prevalent in America 292 DISEASES OF THE EAR, NOSE, AND THROAT. than in European countries. The reasons assigned for its prev- alence in various parts of this country are sufficient to account for this difference. It is not a contagious affection, like epidemic influenza, neither can it be termed hereditary, but its universal presence is certainly suggestive of a predisposing hereditary influence. It is not limited to the frail, but is just as likely to be encountered in the robust. Symptomatology. — In the early history of naso-pharyngeal catarrh the patient notices a sense of irritation in the upper and back part of the throat. This provokes attempts at clearing the throat, or hawking, which is irksome to the patient and disagreeable to his companions. A sense of constriction and a tired or aching feeling is often present, especially while speaking in public. The vocal organs weary easily, and the necessary efforts to clear the throat during a lecture or sermon are weari- some to both speaker and audience. Clergymen are frequent subjects of this complaint. There is almost a universal habit among them of efforts to relieve this irritable condition of the upper throat. Posterior rhinoscopy discloses a thick, tenacious, light- yellow secretion sticking to the posterior wall of the pharynx. On removing this discharge the membrane appears very red and roughened by the formation of granulations. These are round and punctated or irregular and flat, with broad bases suggestive of particles of a filled sponge. Frequently they coalesce, es- pecially at the sides of the throat just behind and below the posterior faucial pillars, and form a welt extending upward and outward in the direction of the Eustachian orifices. These point to the throat deafness so often met with in catarrhal climates. The blood-vessels are often engorged and tortuous and stand out prominently above the surface of the surrounding tissues. The Eustachian prominences are swollen and reddened and the orifices constricted or closed. Extension of the inflam- mation a little farther through the Eustachian openings results in tubal catarrh and impaired hearing, as already described in the ear division. The pharyngeal, or Luschka's, tonsil is some- times hypertrophied, and in children adenoid vegetations may DISEASES OF THE XASO-PHARYNX. 293 so occlude the vault of the pharynx as to preclude nasal respi- ration (Plates II and III). Mouth-breathing and its train of evil consequences result. The faucial pillars are more or less involved, presenting a swollen, infiltrated condition. Diagnosis. — There is little likelihood of confounding this affection with any other. Adenoid vegetations are confined to the young and are easily seen with the rhinoscopic mirror and felt by the finger. The same may be said concerning polypi. Syphilis causes sore throat, but the characteristic erosions and the history, added to the testimony of antisyphilitic remedies, serve to dispel any doubt. Prognosis. — Although it is the practice of charlatans to represent this disease as being dangerous to life and leading to pulmonary consumption, its early history does not confirm such statements. In its early stages it yields readily to proper treat- ment, but after it has existed for a number of years it becomes persistently chronic and intractable to all methods of treatment. However, much relief can be afforded by hygienic measures and proper cleansing and stimulating topical applications. Treatment. — The first object of treatment is perfect clean- liness ; detergents — such as Dobell's and Seller's solutions — should be used in the form of sprays, both through the anterior nares and throat, to dislodge all secretions and crusts that adhere to the naso-pharyngeal walls. If these alkaline, antiseptic sprays, that dissolve the tenacious secretions and dislodge them in ordinary cases, are not sufficient to remove them in this form of catarrh, cotton, twisted upon the curved post-nasal carrier, should be used to wipe out all the discharges. Then stimulating and tonic sprays should be applied with the Davidson or De Vilbiss atomizers. Camphor-menthol in lavolin, 5-per-cent. coarse spray, or a 10-per-cent. solution in the form of a nebula, in the hand-dilator, will afford decided relief. A tonic, antiseptic spray is had in eucalyptus in lavolin, 4 per cent. ; or, as a tonic nebula to be used in the hand-dilator, an excellent preparation consists of oil of cubebs, 25 parts; pure camphor-menthol, 10 parts; and lavolin, 65 parts. However, the latter solution must not be used in the form of a coarse spray. This and a 29-1 DISEASES OF THE EAR, NOSE, AND THROAT. 10-per-cent. solution of camphor-menthol inhaled through the throat and exhaled through the nose act as decided stimulants and tonics. It is my practice to prescribe for home treatment a 3-per-cent. solution of camphor-menthol in lavolin, to be used every morning and night. The patient is instructed to throw a sufficient spray of this preparation into both nostrils and throat to satisfy him that the parts are entirely covered with the medi- cine. The application of this remedy proves very grateful and refreshing to patients, especially to public speakers. Upon being used at bed-time it remains in contact with the mucous mem- brane during the hours of repose, when no efforts are made to clear the nose ; so that its action is continuous over a number of consecutive hours. Excessive tobacco-smoking must be interdicted, and those who continue to smoke must be instructed that the habit of forcing smoke outward through the nose acts as an irritant and aggravates the existing condition. The inhalation of dust; irritating gases, like those from matches, etc. ; exposure to cold and damp and drafts of cold air, especially upon the back of the neck and back of the arms ; and exposure of the feet to cold and wet must be avoided. Animal fibre must be always worn next the skin. Woolen is preferable to silk. Cotton and linen must not be used for underclothing. Consisting, as they do, of vegetable fibre, they favor rapid evaporation of the perspiration (causing chilling of the skin), and contraction of the capillary vessels and resulting internal congestion. The diet must be plain and nutritious, avoiding an excessive use of meats, sweets, and alcoholic stimulants. Atrophic Catarrh of the Naso-pharynx. This disease usually accompanies the same condition of the nose which has already been described, but it may exist inde- pendently of atrophic nasal catarrh. In the early stage of this affection the mucous membrane of the naso-pharyngeal space usually appears dry and shining. Later, crusts are formed similar to those described in ozsena. Sometimes quite large patches of those crusts, which adhere closely to the membrane DISEASES OF THE NASOPHARYNX. 295 and are removed with difficulty, are expelled. They are gen- erally of a dirty-white or greenish color and sometimes brown or even black. The latter color is usually found where patients are exposed to the inhalation of a smoky atmosphere in the neighborhood of factories and hotels and buildings in which soft coal is largely used in furnaces. These crusts sometimes are detached with such great difficulty that the patient is under the necessity of inserting his finger into the vault of the pharynx and detaching them with the finger-nail. The pathology of this disease is the same as for nasal ozsena, to which the reader is referred. The symptoms consist of a sensation of dryness in the throat, which is much more disagreeable than the presence of an hypersecretion. When crusts form, decomposition takes place, imparting a foul odor to the breath. The efforts of the patient at dislodgment of these secretions cause gagging and some- times vomiting, and for this reason they produce gastric dis- turbances. The points of diagnosis are identical with those given for ozaena, under the heading of " Atrophic Nasal Catarrh." The prognosis is unfavorable. This is a persistent, chronic disease, which is not easily amenable to treatment. However, much relief may be afforded until such time as the processes of nutrition can be so improved as to give permanent relief. Treatment. — Antiseptic, alkaline, detergent solutions — such as DobelFs and Seller's — must be used abundantly to dissolve and dislodge the crusts. . When no crusts are present, but merely a pale, dry, shining, mucous membrane, remedies that stimulate the muciparous follicles to secretion must be used. These consist of the eucalyptol, iodine, and cubeb sprays already mentioned. Further treatment for this affection is the same as that laid down for nasal ozsena. Fibrous Polypi of the Naso-pharynx. Fibrous polypi in this locality are of infrequent occurrence (Plate IV). They are not found above the twenty-fifth year and occur more frequently in men than in women. They cause 296 DISEASES OF THE EAR, NOSE, AND THROAT. obstruction to nasal respiration, dyspnoea, epistaxis, and facial disfigurement. Pathology. — These tumors occur singly and are attached by a broad pedicle to the roof of the pharynx. They are dense, smooth, and of a dark-red color. The blood-vessels of the interior are smaller than those of the mucous membrane covering them. Bleeding takes place easily ; so that palpation with the probe causes a sanious discharge. These polypi may develop to such an extent as to invade the throat even to a level with the epiglottis. Etiology. — Their cause remains in obscurity. Symptomatology. — The most prominent symptoms are difficult breathing in consequence of the nasal obstruction, nose- bleeding, stupidity, a nasal intonation of the voice, and difficulty in articulation of speech. Pressure upon the orifices of the Eustachian tubes may cause obstruction to the ventilation of the middle ears, Eustachian salpingitis, and consequent deafness. When these growths assume large proportions they produce sufficient pressure upon the surrounding structures to broaden the base of the nose and increase the width between the eyes, giving the appearance suggestive of the " frog- face." Pressure may be sufficient to cause separation of the nasal bones and absorption of the facial and cranial bones, producing intra- cranial complications. There is generally a copious muco- purulent discharge and difficult deglutition. Diagnosis. — These tumors are differentiated from mucous polypi by their hardness, frequent .bleeding, and their occur- rence only under the twenty-fifth year. They are distinguished from adenoid vegetations in the vault of the pharynx by the soft, spongy, lobulated appearance of the latter and their occurrence only in the very young. The appearance of the two in the rhinoscopic mirror and the sensations imparted to the finger introduced into the naso-pharyngeal space render a differential diagnosis not difficult. Prognosis. — Fibrous polypi pursue a steady growth until, in from three to five years, they prove fatal. If their develop- ment can be repressed by local treatment until the patient DISEASES OF THE NASOPHARYNX. 297 arrives at the age of 25 years, the prospects of recovery are fair. Treatment. — These growths should be removed with the galvano-cautery snare, electrolysis, ecraseur, powerful cutting forceps, or a curette. Before the operation for removal is com- menced the body of the polypus should be secured by a strong thread so as to prevent its dropping into the throat and pro- ducing suffocation. After removal, the attachment of the polypus should be thoroughly cauterized. Fibromucous Polypi of the Naso-pharynx. These tumors are of somewhat rare occurrence. They vary in size from one to three inches (two to eight centimetres). They are smooth, oval, and of a dusky-red color and occasion nasal obstruction and deafness, but no haemorrhage. One serious inconvenience occasioned by them is the inability to blow the nose. Pathology. — Unlike the fibrous growth, which occurs on the under surface of the basilar process, the fibromucous polypi, springing from the connective-tissue fibres and mucous elements, naturally partake of their character. They are dissimilar to the fibrous polypi ; adenoid in appearance, texture, and history ; and do not tend to recur after extirpation. Treatment. — Evulsion should be made with strong forceps through tthe mouth, or the cold- wire or galvano-cautery snare can be used thl cough the nose. After their removal the site of attachment should be cauterized. Malignant Tumors of the Nasopharynx. These tumors are of very rare occurrence. Thej^are at- tended with pain in the throat and back part of the nose, extending to the ear ; catarrhal symptoms, with increased dis- charges from the nose and throat; difficulty in swallowing; and r as they progress, general impaired nutrition. They are likely to be of the sarcomatous type, either pear-shaped or lobulated. Their growth is rapid, and there is a strong tendency to recur- rence after their removal. Only a microscopic examination will 298 DISEASES OF THE EAR, NOSE, AND THROAT. reveal their true nature. They are likely to be mistaken for fibrous polypi, but are less dense, softer to the touch, and present quite a different history. The prognosis is hopeless. Treatment consists in their removal, if possible, with the means already detailed for operations upon fibrous polypi. Supportive and tonic remedies should constitute a part of the treatment. Adenoid Vegetations in the Vault of the Pharynx. Synonyms. — Adenomata ; hypertrophy of the pharyngeal, or Luschka's, tonsil. Pathology. — These growths occur in two varieties. The first consists of spongy, stalactite projections from the vault of the pharynx ; the second of smooth, fibrous tumors of irregular shape. They are very vascular and contain lymph-cells and a follicular structure resembling that of the oral tonsils. Etiology. — This is mostly a disease of childhood and is oftenest seen under the tenth year. Heredity is an important factor. Sometimes several children in the same family are sub- ject to these growths. They are always to be looked for in children with hypertrophic rhinitis and enlarged faucial tonsils. Symptomatology. — The most striking features in a pro- nounced type of this affection are the parted lips, prominent eyeballs, obliteration of the normal lines of expressk/n of the face, and a consequent appearance of listlessj^fess and inferiority (Fig. 148). Mouth-breathing, a ^oii'sy respiration, snoring, and a lack of resonance of <" V e voice are the typical symptoms. There is a characte;'jf f Cic"thickness of speech, or nasal intonation. As Che ::; ce f "said, "He intunes in his nose." Such children are absent-minded and have the appearance of being inattentive, which may be due either to mental dullness or impaired hearing. There is a plentiful, tenacious discharge of a grayish or bloody color. Examination with the finger causes bleeding. There is a history of recurring colds in the head, earache, diminished hearing, noises in the ears, or otorrhcea. There may be press- ure on the Eustachian tube or an extension of the adenoid I " One of the newest and most practical medical books of the \ day." — Haider Hospital Bulletin. " This is the best and most recent work upon this subject we have yet seen, and it gives us pleasure to recommend it to our readers and the profession." — Charlotte Medical Journal. " The lectures afford an interesting course of study, and no medical practitioner will regret having acquired the information so tersely and authoritatively furnished in this compact little book." ■ — Notes on New Remedies. 11 It is .certainly an advantage to the American portion of the medical profession that Prof. Bouchard's well-known lectures on Auto-Intoxication in Disease should be rendered into the English tongue. The subject is one of every-day interest to the practi- tioner, and mauy of the facts alluded to can no longer be ignored." — Medical Age. 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Translated, euitn a Preface, By THOMAS OLIVER, M.A., M.D., F.R.C.P., Professor of Physiology, University of Durham ; Physici»r- to the Royal Infirmary, Newcastle-upon-Tyne ; and Examiner in Physiology, Conjoint Board of England. The Thirty-two Lectures in this volume deal with the toxins, pathogenic processes generally, elimina- tion of poisons, preliminaries to the study of the toxicity of emunctory products, intestinal antisepsis, and of various diseases due to bacillary products. No subject commands a greater interest; none de- mands more serious study. SEAD THE FOUIiOWlfiG Cf*ITICISJV[S. "The work is a most valuable one to every physician. "- Ontario Medical Journal. . " It is indeed a book of great value at the present day . " — Texas Courier- Record of Medicine. OVER. Fig. H8.— Mouth-breather (17 years old). Adenoid vegetations in the vault of the pharynx; hypertrophied oral tonsils; bilateral nasal polypi ; spreading of nasal bones, producing great breadth of nasal arch ; protrusion and wide separation of eyeballs (frog-face) ; suppurative ethmoiditis requir- ing curettement ; and chronic suppuration of both middle ears. DISEASES OF THE NASO-PHARYNX. 299 inflammation through the tube to the ear. The growths are light pink, turning to red on being irritated. They obstruct posterior rhinoscopy, and are often unequally developed on the two sides. The symptoms given are of typical cases ; in many they are not so well defined. Diagnosis. — The symptoms described render this a simple matter. The rhinoscope is not easily used in children, and I rely mostly on the digital examination. Prognosis. — The tendency is to absorption during early adolescence. Treatment. — While it is the practice of some rhinologists to treat adenoids with washes, sprays, caustics, the galvano-cautery, etc., for periods varying from four to fourteen months, I much Fig. 149.— F. U. Greene's Mouth-gag. prefer the one painless operation, lasting but five minutes and insuring a radical cure. The best anaesthetic for this operation is ethyl-bromide. Before administering it the little patient should be calmed into a tranquil state of mind, for if there is great excitement the drug is not so efficacious. The instru- ments are sterilized by boiling or steaming, and the mouth-gag (Fig. 149) is inserted between the molar teeth. It must be care- fully held in place by an assistant until the operation is com- pleted ; otherwise it slips out of place and allows the jaws to close, after which they are with difficulty separated. The pa- tient is held in a sitting posture on an assistant's lap (Fig. 150). An ounce tube of bromide of ethyl is emptied into the air-tight inhaler and administered as in etherization, allowing no air to enter. Anaesthesia is induced in about one minute and lasts 300 DISEASES OF THE EAR, NOSE, AND THROAT. about five minutes. Not more than half an ounce is taken, but the remainder will not keep for subsequent use. The patient quickly recovers consciousness, and after lying down for a few minutes he is ready to be taken home. Fig. 15U.— Position of Child for Adenoid Operation or Intubation ; Mouth-gag Introduced. The instant anaesthesia is complete Gottstein's large or small ring-curette (Fig. 151) is inserted behind the velum and upward near the vomer to engage the central, highest mass first. Then the cutting-surface is passed backward and downward in contact with the posterior pharyngeal wall as far as the growths Fig. 151.— Gottstein's Ring-curette. extend. The same movement is executed on either side wherever there are growths, sweeping them all out by three or four passes of the curette. Finally the finger is inserted to discover if any remain. If so, they may be detached with the finger-nail or the curette. DISEASES OF THE NASOPHARYNX. 301 As soon as all the adenoid tissue is extirpated, the gag is removed and the patient's body is inclined forward, with the face downward. The surgeon loudly commands the patient to " spit it out! " Hence the blood escapes through the nose and mouth and the patient at once begins efforts at expulsion, and the blood is thereby prevented from entering the larynx or the stomach. If the faucial tonsils are hypertrophied, they are removed before the adenoids. This order of operating presents two advantages : the space through which we operate is amplified and there is no bleeding from above to obscure the tonsillotomy. The operator must waste no time, but, if he act promptly and rapidly, there is sufficient time for all this procedure. Haemorrhage lasts but a few minutes and generally ceases by the time full consciousness is restored. This method deprives the operation of the horrors experienced by children whose adenoids are extirpated without anaesthesia ; and neither chil- dren nor parents, who are excluded from the room until the bleeding ceases, retain any revolting memories of the affair or of their doctor. Many cases receive no after-treatment ; but it is better to give a spray of camphor-menthol and lavolin — 3 per cent. — with an atomizer (Fig. 118) for home use three times a day for a w T eek or more. While instances of severe haemorrhage from this operation are reported, I have never witnessed any. In my experience with quite a considerable number, none but satisfactory results have obtained. One needs to take care not to wound the orifices of the Eustachian tubes or to drag a mass of the adenoid tissue down into the throat and leave it hanging there by the pharyngeal membrane intact. I have observed this con- dition after what must have been a hasty and incomplete oper- ation. The finger should not be inserted into the pharyngeal vault while the curette is in action ; but one should not fail to examine immediately after curetting to ascertain if the adven- titious tissue has been completely removed. I have never ob- served any bad effects from ethyl-bromide. It is as safe as ether and far preferable for such short operations. 302 DISEASES OF THE EAR, NOSE, AND THROAT. The operation itself is not difficult, and I have never re- garded it as dangerous. It is a simple curettement in an easily accessible cavity, providing the mouth is kept properly gagged. In ahout seven hundred operations by my assistants and myself with bromide-of-ethyl anaesthesia no accident or haemorrhage of importance has occurred. PART III Diseases of the Pharynx. Plate V. PLATE V. Figure 1. — Male, aet. 21 ; anterior view of extensive osteo-enchondroma of septum, occluding completely left nasal cavity ; mass reduced with dental engine. Figure 2. — Lateral view of above. Figure 3. — Male, set. 24 ; posterior view of asymmetrical nasal cavities of above case ; complete stenosis of the left naris. Figure 4. — Male, set. 44 ; anterior view of deviation of septum to right, causing partial occlusion of cavity. Figure 5. — Lateral view of above, showing concavity of septum anteriorly and a convexity posteriorly, due to abnormal thickness of the septum. Figure 6. — Posterior view of above, showing the thickened septum pressing on left middle and inferior turbinated bodies ; causing asthma. Thickness reduced with surgical engine, passing burr under the mucous membrane ; asthma relieved. Figure 7. — Male, aet. 48 ; relaxation of soft palate, causing symptoms of elongated uvula ; astringents found useless ; amputation of uvula. Figure 8. — Female, set. 22; elongation of uvula, causing cough, expectoration, etc., and general symptoms of phthisis ; amputation ; complete relief. Figure 9. — Female, get. 27 ; position of mouth in forcible separation of jaws during tonsillitis; further examination impossible; diagnosis established by character of paiu, color of tongue, odor of breath, and dysphagia. Figure 10. — Male, aet. 28 ; hypertrophy of the tonsils ; amputation with tonsillotomy Figure 11. — Appearance of tonsils in above case during an attack of tonsillitis. [Note. — Represented as seen by gaslight. By daylight the red color appears much paler.] V. /.- I th Ph 9 CHAPTER XXVII. DISEASES OF THE PHARYNX. Acute Pharyngitis, or Simple Sore Throat. Pathology. — Acute sore throat may be characterized by a simple hyperemia or an active inflammation with round-cell infiltration of the mucous membrane of the pharynx and serous effusion in the submucous tissues. The secretions contain epithelial cells", pus-corpuscles, and micrococci. Etiology. — There is quite a wide divergence of opinion respecting the causes of acute catarrhal inflammation of the throat. There are excellent students who deny the classic theories of taking, or catching, cold. Thorner and Fick com- bat the idea. But what shall we say of the common expe- riences of life among laymen and doctors alike] When individuals possessed of unusual intelligence and powers of observation note that certain phenomena invariably follow given causes, that exposure of certain skin-surfaces, like the back of the neck, to cold draughts of air, is regularly and repeatedly followed closely by symptoms of irritation or inflam- mation of the nasal or pharyngeal mucous membrane, not a few times only, but scores and hundreds of times in a long- experience, shall we say that human testimony is not to be accepted, that the powers of observation are at fault, the reason clouded, and experience a delusion ] Shall testimony of such a positive nature as would receive credence, and upon which a just verdict would be rendered in law, be not accredited equal weight in medicine'? The logic of consecutive circumstances and events is no less forceful here than in other departments of physics. In the case of certain individuals the exposure of the back of the neck for a short time to cold winds is just as certain to be followed by an hyperemia or an actual inflam- mation of the nasal or pharyngeal mucous membrane as the inhalation of the fumes of a lighted match by a person subject 20 (305) 306 DISEASES OF THE EAR, NOSE, AND THROAT. to attacks of hay fever will precipitate a paroxysm of that dis- ease. Chilling of the skin of the chest by exposure to cold winds causes a reflex paresis of the blood-vessels of the bronchi or lungs, resulting in hypersemia and congestion, or inflamma- tion, of the lining mucous membrane. The same condition of the corresponding membrane of the nose or throat is caused in certain sensitive or predisposed persons by the chilling of the feet or back of the head or neck, but not by the impression of cold on the nose or throat directly. These causes and effects follow each other in such quick and logical succession, and are the subjects of such universal observation and experience, that one cannot ignore or resist their force. The theory that these diseases are the result of bacterial infection may be, in some part, true, for these micro-organisms may easily enough act as exciting causes which cannot be resisted by a membrane already weakened by paresis of its vessels caused by the impression of cold ; but cold is by no means held to be the only predisposing or exciting cause of acute catarrhal attacks. Streptococci and other germs have been found in the secretions in abundance, but their precise relations to the disease, cause or product, have not been determined. This affection is an accompaniment or a sequel of the ex- anthemata, improper use of the voice, traumatic or chemical injuries of the throat, iodism, etc. Predisposing causes are heredity, impairment of the digestive and eliminative functions, living in overheated and ill- ventilated rooms, etc. Symptomatology. — The first intimation given of an attack of acute pharyngitis is a sense of discomfort in the region of the throat and more or less stiffness of the muscles concerned in deglutition, or actual pain. The temperature rises in severe attacks, especially in children, several degrees, even as high as 103° or 105° F. In mild attacks there is no fever. The naso- pharynx is frequently involved and the symptoms are propor- tionately extended. There are likely to be headache and symp- toms referable to the ear, such as a feeling of stuffiness, dullness of hearing, and ringing in the ears. Of course, these symp- toms are attributable to an extension of the inflammation to the DISEASES OF THE PHARYNX. 307 Eustachian orifices or tubes. It is not uncommon to see the middle ear involved to the extent of acute otitis and suppuration, with perforation of the membrana tympani. The act of swal- lowing causes pain, to avoid which the head and neck are made to perform certain movements characteristic of painful deglu- tition. The voice sounds muffled and obstructed and its use is avoided on account of the discomfort produced. During the act of swallowing the food is prone to enter the post-nasal space and occasion much discomfort. After the dry stage of inflammation has passed the throat becomes bathed in a sticky mucus. This happens about the second day, and soon after this pus-corpuscles begin to make their appearance. The efforts to clear the throat of these rapidly-accumulating discharges cause so much acute suffering that they are often swallowed, when nausea and vomiting are likely to follow. The breath becomes very foul and the tongue thickly coated, indented, and flabby in severe attacks. Early inspection shows a bright-red color of the membrane covering the fauces and pharynx (Plate VI). At first this is simply hyperaemic, but as exudation of serum takes place there appears a swollen, cedeinatous condition, especially marked in the loose tissue of the palate and uvula. The velum is thickened and its movements restricted and painful. The uvula is swollen to much more than its normal size and feels like a foreign body in the throat, exciting frequent attempts to swallow. The duration of this disease varies from two or three days to a week or longer. The high temperature of the initial stage drops in a day or two and remains nearly normal. It generally develops on examination that the patient has been subject to similar attacks with a suggestiveness of periodicity. They are expected in the fall-, winter-, or spring- time, which points to the probability that there has been a predisposing chronic inflammation that requires treatment to avert future attacks. Diagnosis. — Simple sore throat cannot always be dis- tinguished from the sore throats of measles and scarlet fever until the eruption appears or from tonsillitis until the glands swell. In rheumatic sore throat there is not likely to be so 308 DISEASES OF THE EAR, NOSE, AND THROAT. marked an cedematous condition of the tissues, but more pain, referable to the cervical muscles. Prognosis. — The disease lasts only about a week and is not dangerous unless it extends to the larynx. Treatment. — If seen during the first stage of the attack it can be either averted or greatly ameliorated by the adminis- tration of atropia combined with morphia in the proportion of 3-J--JJ- grain atropia to -J grain of morphia. Even in the second stage of inflammation, when serum and mucus are pouring forth in abundance, the drying effect of these remedies lessens the secretion and the consequent painful efforts to swallow it, while their anodyne properties reduce the suffering to a min- imum. The atropia antagonizes the nauseating, depressing, and constipating effects of the morphia. I have often averted these attacks in patients who had been in the habit of passing through sieges of this disease with such distressing regularity that their experience was not to be ignored. Instead of suffer- ing for a week or more, the symptoms would either disappeai quietly in a few hours or cover a period of only a day or two, and with but little inconvenience. The use of quinine, which is so common among the laity as well as among physicians, leads to serious results in numerous instances. I have known families to buy quinine by the ounce and keep it in the closet ready for daily doses for the slightest ills. Some of the most hopeless cases of deafness I have ever met are those occasioned by the use of quinine. It is less effective and more harmful than other remedies. At the onset of an attack the patient had better go to bed, if the symptoms are severe, and take the tablets mentioned containing the atropia and morphia, or the coryza tablets made for me by Truax, Greene & Company, containing, each, caffeine, -} grain; morphia, y 1 ^ grain ; and atropia, g^ grain. There is seldom any neces- sity for repeating these more than four or six times during the first two days, when the symptoms will often have disappeared. It frequently happens that one or two doses are sufficient. The effects of one dose last about four or six hours, when the patient is directed to take another, providing the symptoms begin i to DISEASES OF THE PHARYNX. 309 revive. He is never allowed to know the nature or the name of this remedy for sufficient beneficent reasons already set forth herein. The bowels should be opened with a saline draught or a laxative pill. The old-fashioned sweats were quite effective, but after leaving the bed the skin is like a sensitive plant and every breath of cool air has a chilling effect ; so that patients are left more liable to take cold after the sweat. Moreover, the excessive flow of perspiration is weakening. The air of the room should be kept moist during the dry stage of the first day or two, and steam-inhalations are grateful. These are best produced by utilizing some vessel having a nozzle, that may be found at hand in every house, like the tea-pots, into which a pint of very hot water is poured. Tincture of benzoin, camphor, 10 drops of pure camphor-menthol, or a few crystals of menthol are added to the steaming water, a napkin is wrapped about the nozzle to protect the lips which are to embrace the tip, and this medicated steam is inhaled into the throat. It must not be too strongly impregnated with the medicaments so as to produce an irritating effect. When both nose and throat are suffering from an attack of acute inflam- mation, I have found that menthol afforded relief, especially during the dry stage, by employing it as follows: A few of the crystals are placed in a teaspoon or saucer and held over a lamp or stove until the crystals melt and produce fumes that penetrate every part of the room. Just enough is used to medicate the atmosphere to the point of comfortable inhalation. The patient closes or covers his eyes to prevent any smarting of the conjunctivae, and is instructed to inhale through both his nose and mouth, if nasal respiration is possible. This causes a free flow of mucous secretion, that bathes and moistens the inflamed membrane and greatly relieves the sense of burning heat and dryness. In order to obtain a continuous effect of ammonium chlo- ride on the blood-vessels, and the soothing effect of Tolu and licorice, I have prescribed with satisfaction a tablet consisting of 310 DISEASES OF THE EAR, NOSE, AND THROAT. R Ammonii chloric! i, gr. ij. Tincturse opii camphoratie, Syrupi scillse compositi, Syrupi Tolutani, aa TTLv. Extracti giycyrrkizse, gr. iiss. — M. This tablet is dissolved slowly in the mouth, and the re- sulting medicated saliva is kept in contact as much as possible with the inflamed membrane. During the dry stage pilocarpine can be used, if it is desired to produce diaphoresis, ^ or % grain two or three times during the day, or enough to produce con- siderable perspiration. Gargles are not very efficient, since they reach only the anterior surface of the fauces and generally pro- duce much discomfort. Potassium chlorate has been a very popular remedy for a long time, but I have never been able to observe any beneficial effect from it, except that of a detergent in the form of a wash. The bromide of potash produces more of a sensation of relief than the chlorate in solution, and if swallowed in 10- or 20-grain doses produces a sedative effect. The glycerite of tannin causes an exudation of serum and relieves the distended blood-vessels, besides contracting the vessels and thus modifying the intensity of the inflammation by a double effect ; but the objection to its use is the necessarily disagreeable method of applying it to the throat with a camel's hair pencil or cotton-applicator. It cannot be sprayed w 7 ith an atomizer without heating it to an uncomfortable temperature. After using it in my private and dispensary practice for many years I must say that it is an effective remedy if thoroughly and gently applied, notwithstanding the recently expressed disap- proval of this remedy by so eminent an authority as Lennox Browne. By applying it several times a day I have seen the inflammation subdued and the attack materially shortened. I have used guaiacol in these cases, but have found different pur- chases to vary considerably in strength. Some samples cause but little burning and smarting when applied pure, while others are very violent in their action and need to be diluted one-half. Patients feel relieved after the applications, particularly in case of high temperature. In some instances in which I used the pure guaiacol the membrane looked immediately after the appli- DISEASES OF THE PHARYNX. 311 cation as if an escharotic had been used. It was covered with a light-gray pellicle, and on the following morning I have found the mucous membrane of this area broken down and ulcerated. There is the same objection to this that can be urged against any remedy that must be applied with a swab or probang. Cocaine for this disease is justly condemned by Ingals. As he observes, the effect is transitory, unless one takes into account the possible after-effects of a contracted drug habit. Thorner has experienced excellent results from salol in 10- or 15-grain doses four to six times a day. It relieves the pain in both pharyngitis and tonsillitis. The application of ice to the throat externally, which can be accomplished with the ice-bag (Fig. 78) and by sucking pieces of ice, if they can be relied upon as being free from disease germs, may modify and abbreviate the inflammation. Antipyrin, phenacetin, and aconite are useful during the fever and painful stage. After a muco-purulent dis- charge has formed, the antiseptic alkaline sprays, followed by the soothing, oleaginous inhalents of salol, etc., are beneficial in cleansing, disinfecting, and protecting the inflamed surfaces. The diet must consist of very nourishing fluids, like the animal broths, beef-tea, barley- and rice- water, milk, etc. The body should be clothed according to the principles laid down in treating of acute rhinitis. One should always dress as warmly as comports with comfort. The strong tendency of this disease to extend to the Eusta- chian tubes and middle ears makes prompt and efficient treat- ment imperative. The most effective measures for preventing or managing these complications are dealt with in the divisions on Eustachian tubal catarrh and acute inflammation of the middle ear. Simple Chronic Pharyngitis. Synonyms. — Chronic sore throat; chronic catarrh of the throat. Pathology. — The condition here is essentially a repetition of the process that eventuates in simple chronic rhinitis. Fre- quently-recurring attacks of congestion and inflammation cause 312 DISEASES OF THE EAR, NOSE, AND THROAT. a loss of tonus of the blood-vessels, which remain permanently dilated. Varicose veins stand out prominently in their tortuous courses, and the membrane remains thickened. The infiltrated tissues (Plate VI) are deprived of the opportunity of returning to their normal condition through the process of absorption because of the interruption to this process occasioned by repeated attacks. Etiology. — Generally, simple chronic pharyngitis is the sequel of acute attacks, but it may result from the abusive use of alcoholic beverages, excessive smoking, indigestion, and torpidity of the liver. Persons exposed to a smoky, dusty atmosphere or irritating gases are especially liable to this form of catarrh. A diseased condition of the nasal membrane predisposes to this affection. Symptomatology. — A sensation of stiffness or a parched feeling is experienced in the throat, which is only temporarily relieved by drinking. The voice is often lowered in pitch and becomes easily fatigued. Viscid masses of mucus are some- times seen clinging to the posterior pharyngeal wall, and efforts to remove them result in explosive, scraping expulsions of the air that add to the existing trouble and set up irritation of the uvula and velum palati. These parts are thus forced into participation in the throat trouble and often are of a deep-red color, swollen, and the uvula is elongated. The resulting con- tact of the uvula with the tongue aggravates the condition already present by provoking a cough and frequent swallowing occasioned by a feeling as if a foreign body were in the throat. Diagnosis. — The conditions already described render the diagnosis a simple matter. It is not likely to be confounded with any other disease. Prognosis. — This affection is annoying, but not danger- ous to life, and the prospect of relief is good if the patient is willing to submit to continuous treatment for a considerable time. Treatment. — After complete cleansing of the pharynx . by the alkaline solutions given in Chapter XVIII Sajous prefers silver-nitrate solution, 40 grains to the ounce. It reduces the DISEASES OF THE PHARYNX. 313 calibre of the blood-vessels and promotes absorption. If silver is used, the strong is preferable to the weak solution. This is applied daily with cotton on a holder, with care not to let it drip or press out into the larynx. I have found patients to experience great relief by using at home — every morning and night at first, and later, when improvement is marked, only at bed-time — a 3-per-cent. solution of camphor-menthol in lavolin. I have prescribed this for hundreds of patients, and they often say, many months afterward, that their improve- ment was so great and gratifying that they have had the pre- scription repeatedly filled, and have obtained the remedy for their friends. This is used with a small hand-atomizer (Fig. 118). For office-treatment, after the cleansing throat douche in coarse spray witli sufficient air-pressure to dislodge and expel all the secretions that may stick to the membrane, I use, for a protective and emollient, benzoinated lavolin ; for antiseptic and stimulant purposes eucalyptus in lavolin, 4 per cent., and pine-needle oil of the same proportions; and, if the membrane become too dry from insufficient secretion of mucus, a 25-per- cent, solution of oil of cubebs in lavolin. This acts as a decided tonic. Pernicious habits must be stopped, and indigestion and torpidity of the liver overcome by proper treatment and hygiene on general principles. Acute Rheumatic Pharyngitis. Synonyms. — Rheumatic sore throat; rheumatic angina. Pathology. — The pathology of this affection is the same as in rheumatism, the discussion of which belongs to the province of general medical works. The uric-acid diathesis is discussed under the heading of "Hay Fever" (page 222). Etiology. — In persons who are subject to attacks of sore throat the acquirement of the rheumatic habit of body is likely to be followed by this type of throat affection. Attacks usually follow exposure to cold and damp. Symptomatology. — Attacks come on suddenly after the 314 DISEASES OF THE EAR, NOSE, AND THROAT. impression of cold, and announce their presence by pain in the throat and great difficulty in swallowing. The pain of deglutition is so acute that the patient refrains from eating or even quenching his thirst. All this time there appears to be an increased secretion and flow of saliva, which necessitates frequent spitting or the alternative of swallowing. This act keeps the sufferer constantly harassed, for the movements of the muscles of deglutition cause exquisite distress, and with each act the head and neck are seen to execute certain move- ments characteristic of attempts to avert the inevitable painful- ness of the act. While the attack lasts the suffering is greater than is usually experienced in simple acute pharyngitis, for the soreness in the rheumatic form is not confined to the mucous membrane of the pharynx alone, but exists in the muscles concerned in the movements of swallowing and even in the superficial muscles of the neck, such as the sterno-cleido-mastoid. These attacks may not last more than a day or two, when other parts, like the muscles of the back or the shoulders, may be attacked. On the other hand, there are patients who are not conscious of ever having had an attack of rheumatism, at least, an acute attack, but who are subject to periodical visita- tions of the typical throat affection at certain seasons of the year, either at the change from winter to spring or in the late fall. The mucous membrane of the palate and pharyngeal wall appears of an intense-red color and has a puffy, swollen look. There is sometimes headache, accompanied with fever of a mild grade. After a few attacks those who are subject to them readily recognize their character. Diagnosis. — The distinguishing features are the suddenness and severity of the attack, the exquisitely-painful deglutition, the soreness of the cervical muscles, the brevity and shifting character of the disease, and the rheumatic history. Prognosis. — This disease is self-limited, so far as its mani- festations in the throat are concerned, for it passes off in about four days, but to return again on exposure. Prompt treatment will avert attacks. Treatment. — Salicylic acid in some form is the most effective DISEASES OF THE PHARYNX. 315 remedy. I prefer a freshly-prepared salicylate of sodium, and generally prescribe it in the following formula : — R Acidi salicylici oiij. Sodii bicarbonatis, 5ij. Elixiris gaultheria?, §ss. Glycerini, 3iij- Aquae, q. s. ad §iv. Misce. Signa : One teaspoonful, in water, every two or four hours. This is given every two hours, at first, until a perceptible improvement is shown or until the physiological effects are manifested : ringing in the ears and slight impairment of hear- ing. Then the doses are stopped or diminished or placed sufficiently far apart to avoid these effects. The latter are simi- lar to those of quinine, and must be avoided as far as possible, so as not to produce hyperemia or congestion of the middle ears or irritation of the auditory nerves. If the salicylate is not well borne, if gastric disturbance and head symptoms indicate unusual susceptibility to this drug, salicin can be advantageously substituted for it. This is best given in pilular form in doses of 5 grains, as detailed for the administration of the salicylate. In my opinion these preparations are preferable to the alkalies, guaiacum, or salol. For the fever and pain an ti pyrin affords the most decided relief. Indeed, this remedy appears to exercise a special influ- ence in quelling this disease, and is superior to phenacetin, acetanilid, etc., not only in reducing temperature, but in trans- scending the limited action of an antipyretic. Potassium bromide, bromidia, or morphia, combined with a proportionate amount of atropia, may be called for to subdue the pain. As an external application, I have found the following liniment efficacious : — R Olei tiglii, 5ij. Chloroformi, 3ij. Aquas ammonii fortioris, 5J. Olei sesanii !|iij. Misce Signa : Apply on cotton. This is used by saturating a layer of lint or cotton, which is applied to the whole anterior and lateral aspects of the neck 316 DISEASES OF THE EAR, NOSE, AND THROAT. and then covered with a thick layer of cotton. The underclothing should always consist of wool. Chronic Rheumatic Sore Throat. Synonym. — Gouty sore throat. Pathology. — This has generally passed under the name of gouty sore throat and is due to the same causes that operate to produce various rheumatic or gouty manifestations in other organs. There is undoubtedly an increased formation and a retention of uric acid in the body, and these processes, together with their resulting morbid phenomena, are discussed at length in the chapter on hay fever (page 222). Symptomatology. — This disease differs from acute rheu- matic sore throat principally in degree. There is not acute suffering except in exacerbations of the disease when it lapses into the acute form. It usually comes on at the same change- able seasons that excite the acute attacks, but may be present in greater or less conspicuousness throughout the year. In this case it is more troublesome during the winter months. There is a sense of discomfort, perhaps ill-defined, but annoying, in and about the throat, often extending to the larynx or even to the trachea. When these lower air-passages are involved, it is often in consequence of cold, damp, chilling winds from the northwest. Pressure over the larynx or the hyoid bone reveals tenderness and soreness of the parts, sug- gestive of perichondritis or periostitis. The patient is conscious of an indefinite sensation described as a constriction or an aching, which is increased by considerable use of the voice. The laryngeal mucous membrane is not generally involved to the extent of producing hoarseness or presenting positive indications of the disease on laryngoscopy. Diagnosis. — This disease must be differentiated from the simple inflammation of the throat and from tuberculosis, syphilis, and cancer. However, the spasmodic, intermittent, and characteristic history of this trouble ought to facilitate the forming of an opinion. The physical appearances are generally negative as compared with the malignant diseases which are DISEASES OF THE PHARYNX. 317 distinguished by visible lesions. In the latter diseases we find the cachexia or constitutional condition indicated by the par- ticular infection in each instance. Prognosis. — If the rheumatic or gouty habit has not existed too long, or is not of too severe a type, the prospect of relief as the result of treatment is good. The disease is not dangerous. Treatment. — The internal medication consists of that just previously described for the acute form, with the addition of a prolonged use of lithium. This remedy should be taken in appreciable doses rather than in the so-called lithia-waters extensively advertised in the newspapers. These waters often contain so little lithia according to the admittedly-correct analyses that one must needs swallow the startling draught of six thousand gallons of water to get an ordinary dose of lithia. The most convenient preparation is a tablet of effervescent citrate of lithia containing 3 grains, made by Wm, R. Warner & Company. I have tried the various preparations, but have found none so satisfactory as this. Two or three of these are dis- solved in a large glass of water — the more water, the better — and taken once or twice a day for months in succession until the rheumatic or gouty habit is overcome. I have known of no serious disturbances following the protracted use of lithia in this form, although I have given it over very protracted periods. A few individuals are susceptible and have symptoms of stran- gury if too much is taken. Others do not use a sufficient quantity of water and have a slight gastric disturbance. The sufferers from this disease, like most other people, drink too little water to dissolve the waste-elements of the body and eliminate them. We flush the sewerage system of a city to increase freedom from infection ; but how much more important is it to flush the sewerage of the body and wash out the waste- products of tissue metamorphosis and prevent infection of the system by the results of decomposition. The success of the water-cures in these diseases lies largely in the amount of water passed through the body, taking up the debris of the tissues, dissolving out the urate of soda from the joints, the liver, and the more alkaline tissues, in which it is stored only to enter the 318 DISEASES OF THE EAR, NOSE, AND THROAT. blood when it becomes sufficiently alkaline in reaction and then to rack the body with pains. The clothing should always be sufficient to keep the person as warm as comports with comfort, and wool is preferable to silk, for it is a more perfect protective against rapid changes of the temperature. Cotton or linen must never be worn next the skin. The bowels must be kept regular. If sensitive spots are detected in the throat or larynx, a 10- per-cent. solution of carbolic acid in glycerin can be applied to the painful area. The local anaesthetic effect of the carbolic acid affords relief without cauterizing the tissues, by the use of this combination. CHAPTER XXVIII. DISEASES OF THE PHARYNX, CONTINUED. Sore Throat of Measles, Scarlet Fever, and Small-pox. measles. The mucous membrane of the throat often participates to a large degree in the eruption of measles, and, although it generally is not severe enough to require special treatment, I have seen it so intensely involved as to necessitate as persistent efforts as the diphtheric throat. In this class of cases the mor- tality amounts to 80 per cent. If the throat is examined about the time the fever appears it is found to be hyperaemic, and this condition increases to a congestion by the third or fourth day of the fever when the eruption is noted. In the membranous form an exudation- occurs that closely resembles the false membrane of diphtheria. If this is removed, an uneven, raw-looking, ulcerating surface is found beneath. The inflammation and exudation cover the soft palate, uvula, tonsils, and posterior pharyngeal wall in severe cases. The swelling of these parts is great, the velum palati is paretic, swallowing is torturesome, and the tongue and general condition are indicative of a grave disease. The ulcer- ative process may extend deeply enough into the tissues to eventuate in abscesses. Instances of Eustachian tubal catarrh and middle-ear complications are numerous. The larynx is often invaded in measles, but generally only to the extent of setting up a catarrhal condition such as com- monly affects the trachea and bronchial tubes ; but, if the diph- theric form of measles affects the larynx, the outlook is a very discouraging one, for four out of five of these cases die. Treatment. — The simple catarrhal sore throat requires treat- ment principally to prevent middle-ear involvement. The meas- ures recommended for acute pharyngitis are sufficient, but the membranous form should be treated with as unremitting thor- (319) 320 DISEASES OF THE EAR, NOSE, AND THROAT. oughness as diphtheria, the treatment for which is indicated here. (See chapter on diphtheria.) SCARLET FEVER. As in measles, so in scarlatina, the pharyngeal mucous membrane is generally concerned, but in the simple form of the disease the throat involvement is not serious. In the severe form the membrane becomes intensely injected and of a dark- red color. Infiltration of the tissues produces swelling that is apparent to the eye on inspection and even the neck may pre- sent a swollen appearance. The glandular bodies with which this region is so richly supplied — the tonsils and the parotid, sub- maxillary, and lateral cervical glands — may all be invaded by an intense phlegmonous inflammation with resulting abscesses. The throat may be inflamed even when the eruption of scarlet fever is absent. As in measles, the swelling and oedema involve the soft palate as well as the pharyngeal walls, and suppuration and abscesses may occur if the necrotic process extend deeply into the submucous tissues. Middle-ear diseases more often result from scarlatina than from measles, and the results are far more disastrous than from measles. Suppura- tion of the tympanic cavities with resulting granulations, polypi, extensive caries, and necrosis, as well as a high degree of deafness, are frequently attributable to scarlet fever. A malignant type of this disease occurs that takes on the form of diphtheria. The throat symptoms do not make their appearance until a week or longer or until the exanthem and fever have disappeared. Then the throat is attacked, the sub- maxillary glands swell, the throat is covered with a diphtheric membrane, a foul discharge takes place, and the breath acquires a fetid odor. The larynx is sometimes invaded, producing the croupy form of scarlatina. The glands at the angle of the jaw may suppurate and the resulting abscesses, breaking outward, leave scars at this point. The diagnosis is aided by the presence ol an epidemic, and doubt is set at rest by the appearance of the eruption. In the membranous form culture-tests for the presence of the Klebs- DISEASES OF THE PHARYNX. 321 Loffler bacilli should be made to determine whether or not we have to deal with true diphtheria, and in the absence of bacte- riological facilities the disease, as far as the throat is concerned, at least, is to be treated on the theory that it is diphtheria. The prognosis in scarlet-fever sore throat, if this is a prom- inent feature of the disease, must be guarded, for the throat affection often causes death. In the simple form it is not danger- ous; but in the severe, or anginose, form about 25 per cent, die, and about 50 per cent, of the diphtheric cases prove fatal. Treatment. — Aside from general treatment, which is prop- erly left to general works on medicine, the throat should receive special attention when it gives promise of becoming seriously involved. In the first stage of the inflammation cold, in the form of an ice-bag (Fig. 78), may modify the intensity of the inflammation and avert or retard the tendency to suppuration. The throat-tablets and other remedies recommended in the treat- ment of acute pharyngitis are more effective than gargles. In the pseudomembranous form, which may prove to be a diph- theric complication, the treatment for diphtheria must be followed. SMALL-POX. . The pustular eruption of small-pox makes its appearance in the throat in many cases, and I have seen it extend forward to the buccal cavity. The amount of the throat eruption corre- sponds to the virulency of the attack. The swelling and inflam- mation may become sufficient to cause pain and difficulty in swallowing. The inflammation extends in many instances to the larynx and trachea, and the resulting oedema has caused suffocation and death. In mild attacks there is no danger ; but invasion of the larynx is a grave complication. Treatment. — The cleansing and disinfecting sprays followed by the protective and emollient and oily preparations given in Chapter XVIII are indicated. If the oedema extend to the larynx, scarification must be resorted to in order to prevent suf- focation, and indeed it may become necessary to intubate or 21 322 DISEASES OF THE EAR, NOSE, AND THROAT. perform tracheotomy. In the diphtheric form resort must be had to the treatment described in the chapter on diphtheria. Follicular Pharyngitis. Synonyms. — Folliculous, or granular, pharyngitis ; clergy- man's sore throat. Pathology. — There are two forms of follicular pharyngitis, — the hypertrophic and the exudative. In the first form the follicles are enlarged and stand out prominently upon the mem- brane, while in the second, or exudative, form there is a secretion of a light color, which may become dried and cheesy in con- sistence and appearance. In the hypertrophic condition the morbid changes are epithelial rather than follicular, but in the exudative form the follicular tubules are distended and their walls thickened, and chalky deposits are sometimes found within the follicles. In the case of public speakers the severe tests to which the vocal organs are put increase the demands on the glandular elements to furnish an extra amount of the lubricating secre- tions. This protracted exercise results in increased blood- supply and deposit of nutrient materials, or an excess of growth of the glandular tissues, and this, together with occlusion of the apertures of the follicles, account for their hypertrophic con- dition. Irritating discharges from the naso-pharynx serve to excite inflammation in the orifices of the follicles, resulting in their constriction or obliteration. Etiology. — It is not a simple matter to account for this disease, for it exists in young children who are not exposed to the irritants to which the disease is usually attributed : excessive use of the voice, the inhalation of dust, gases, smoke, etc. There seems to be an inherent tendency to a proliferation of cells in the mucosa. It is especially prevalent in those having the strumous diathesis. Old age seems quite exempt from this form of throat trouble, but presents the atrophic stage of pharyngitis. Symptomatology. — In the early stage of this disease the patient complains of dryness of the throat or a tickling sen- DISEASES OF THE PHARYNX. 323 sation that occasions frequent efforts to relieve, and a slight, hacking cough. The voice assumes a husky quality and tires after speaking or singing a short time, and while using the voice transitory lancinating or shooting pains occur. The dry stage is followed by a mucous secretion which is often stained with pus or blood. The discharge is usually thick and tensile, and clings to the posterior pharyngeal wall or sticks to the posterior surface of the velum. If it is not too abundant it dries into scales or crusts. The membrane covering the back wall of the pharynx is studded with several spongy, red masses or is sometimes quite covered with them (Plate VI). They are in some instances punctated, appearing like little nipples ; in others they have broad bases, are fiat, and become coalesced in patches. Behind and external to the posterior faucial pillars their union forms a ridge extending upward and outward toward the Eustachian orifices. The blood-vessels are engorged and the veins are abnormally prominent. The tonsils are enlarged in a considerable proportion of these cases and the uvula is relaxed and tickles the tongue (Plate V). The membrane intervening between the follicles may be atrophied and of a grayish-white color that will convey an impression, at first sight, of pus. Diagnosis. — Cohen mentions the presence of ulcerated patches in this affection, which would render one liable to mis- take this for a syphilitic throat, but I do not remember to have encountered this condition. Eliminating the question of ulcers, which must be very rare, there is little likelihood of this being mistaken for syphilis or tuberculosis. Prognosis. — If let alone follicular pharyngitis may be ex- pected to invade the larynx and seriously affect the voice for speaking and ruin it for singing, or it extends to the Eustachian tubes and through them to the middle ears, resulting in hyper- trophic or sclerotic catarrh of these important organs. At last the history of this disease brings us to the fourth stage of throat catarrh, or atrophic inflammation, resembling atrophic rhinitis. Treatment.— The physician does not often enjoy the op- portunity of treating this disease in its early stages, for the S24 DISEASES OF THE EAR, NOSE, AND THROAT. symptoms are not urgent enough to suggest the need of medical services. As in the other inflammatory processes, cleanliness is the first prerequisite. The alkaline and antiseptic washes and the oleaginous sprays discussed in the chapter on those subjects are useful here. After perfectly cleansing the nose and throat, for this is the first step in the treatment, the follicles, two or three at a sitting, should be reduced by the application of chromic acid, London paste, or — better still — the galvano- cautery. If the acid or paste is used, great caution is necessary not to let it drop into the larynx or oesophagus or spread upon the surrounding membrane. The chromic acid is applied in the form of a bead of the crystals fused upon the platinum wire- loop applicator (Fig. 66). The London paste is applied in small particles so that they will adhere like minute spots of plaster on the surfaces of the follicles. The galvano-cautery is the most satisfactory means of erad- icating the tumefied follicles (Figs. 132, 133, and 134). The long electrode is chosen according to its fitness for the particu- lar condition present and applied to the apex or centre of the follicle before the current is turned on. Then the circuit is closed for an instant until the tumefaction is burned so as to de- stroy it to a point a little below the surface of the adjacent mem- brane. On the following day the hypertrophied tissue is seen to have given place to a gray surface that will be cast off as a slough in about a week. By repeating this process a number of times all the enlarged follicles can be dispersed. In the meantime cleansing, soothing, and protective remedies should be applied in the form of sprays, such as a 3-per-cent. solution of camphor-menthol, benzoinated lavolin, and a 4-per-cent. solution of eucalyptol in lavolin. These should be used once or twice a day, preferably at bed-time and on rising in the morning. General treatment is demanded by a uric-acid diathesis to prevent rheumatic or gouty attacks in the throat, and, if the digestion is faulty or the eliminative functions are impaired, remedies must be addressed to these conditions. The local treatment is often aided by tonics and alteratives. diseases of the pharynx. 325 Membranous Sore Throat, Non-diphtheric. Synonym. — Simple membranous sore throat. Pathology. — There occurs occasionally a form of sore throat characterized by an exudate that covers the pharynx and fauces, and extends upward and forward toward the hard palate on its inferior surface, resembling the diphtheric membrane. This is the result of an herpetic eruption in the throat, the blisters of which rupture and cover the membrane with their contents. Etiology. — The cause of this affection is not known, but it is more prevalent during epidemics of diphtheria than at any other times. Symptomatology. — The initiatory symptoms are very like those of diphtheria, except that they are of diminished intensity. There are chills; fever of 101° or 103° F. ; rapid pulse ; dirty, indented tongue ; dry throat, with burning pain ; and difficulty of swallowing. Blisters are often found coincidently on the lips. In the beginning of the attack the membrane of the throat is of a deep-red color dotted with follicles that are inflamed or pustular in character. As these pustules rupture and their con- tents escape over the surrounding surface the appearance of a false membrane is given to such patches. The seat of each ruptured pustule may become an ulcer, and these grouped together present irregular areas of ulceration. Diagnosis. — Simple membranous sore throat may be con- founded with diphtheria, but it is not so grave a disease. Al- though it may be ushered in by symptoms simulating diphtheria and with a high fever, generally all the symptoms are of a milder grade. The simple membrane is much thinner, — indeed, one can almost discern the mucous membrane beyond, — while in diphtheria the false membrane is three or four millimetres thick and closely adherent to the surface beneath. In the simple disease the membrane is easily detached by means of cotton on a carrier, leaving a smooth surface, while detachment of diphtheric membrane reveals raw, uneven, ulcerating tissues exposed to view. Bacteriological examination in diphtheria 326 DISEASES OF THE EAR, NOSE, AND THROAT. shows the presence of the Klebs-Loffler bacillus, which is the germ of this disease, while the tests of the simple form are negative. The sputa and sections of the membrane should be submitted to the culture-tests in this or any other disease in which diphtheria is suspected. It has become an easy matter in large cities like Chicago, where there are laboratories for such purposes and the health department of the city government conducts such experiments. Prognosis. — This disease in itself is not dangerous, but it should not be forgotten that true diphtheria sometimes is en- grafted upon it, especially during epidemics. Treatment. — During the first stage, when the fever is high, guaiacol diluted one-half with glycerin and applied with cotton on a holder mitigates the symptoms, and is indicated on account of its effect in reducing the temperature. It is best not to use it in full strength, for it has sometimes appeared to have a destructive effect on the mucous membrane, and I have found on the day following its application an ulcerated surface cor- responding to the area touched with the pure guaiacol. Hy- drogen dioxide should be sprayed into the throat every few hours, the intervals depending on the rapidity with which the false membrane is formed. But it is not necessary to use it fre- quently if it cause much smarting and burning, for the gravity of the disease does not warrant it. If considerable pain is pro- duced by the H 2 2 , it probably contains too large a proportion of acid and requires dilution. The blue litmus-paper will show this. Ingals prefers the following pigment : Morphias sulphatis, gr. iv ; acidi carbolici, gr. xxx ; glycerini, fgj ; to which he adds 30 grains of tannin when an astringent is required. Inhalations and sprays are more easily applied and cause less discomfort than swabs and pro bangs. I have seen much relief afforded by adding 10 drops of pure camphor-menthol to a pint of hot water for the patient to inhale through the mouth. An ordinary tea-kettle or small tea-pot or coffee-pot can be pressed into service for this purpose. The nozzle is covered with several thicknesses of cloth, not including the opening itself, so as to prevent burning the lips, and the end of the DISEASES OF THE PHARYNX. 327 nozzle is taken between the lips while the steam impregnated with the fumes of the medicine is drawn gently into the throat. This has given good results in other forms of sore throat. Car- bolic acid in glycerin, of 5- or 10-per-cent. strength, will deplete the blood-vessels and anaesthetize the mucous membrane suf- ficiently to relieve pain. Sprays of eucalyptol, camphor-menthol, or salol in 3-per-cent. solutions — after the alkaline antiseptic sprays already given in Chapter XVIII — have a refreshing effect. The general treatment, diet, and hygienic and prophylactic measures appropriate to this disease are the same as those recom- mended in the treatment of coryza and acute pharyngitis. CHAPTER XXIX. DISEASES OF THE PHARYNX, CONTINUED. Diphtheria. Unlike the sore throats of scarlatina, measles, and small- pox, in which a pharyngeal manifestation is not a necessary element of the disease, or in which, if it exist, it is merely incidental to a constitutional malady, in diphtheria we recognize a veritable throat affection with systemic infection. The impor- tance of the disease and the advancements recently made in its pathology and treatment warrant an extended presentation of the subject. Since the discovery of the microbe which causes diphtheria by Klebs, in 1883, the method and nature of the disease have been illuminated by the researches of Lofrler, Roux, Welch, Prudden, and others. Pathology. — In true diphtheria there is always present in the membranous deposits in the throat a micro-organism that is not found in like exudates of other diseases. This microbe is easily differentiated from others and can be isolated and prop- agated in culture-tubes. When animals like guinea-pigs and rabbits are inoculated with this organism the disease which produced the microbe is reproduced in the susceptible animals. Extensive experiments and studies by scientific observers have conclusively demonstrated that this disease is one of local origin with constitutional phenomena depending upon the absorption of a poison generated by the specific micro-organism. The false membrane of diphtheria abounds in these microbes in its superficial layers, but they are not found in the stratum next the mucous surface, and generally not in the mucous membrane itself. The poisonous principle evolved by this microbe is com- parable to the venom of serpents, and in this connection it is instructive to observe that in contrast to this deadly microbe another is found identical with it in biological and morphologi- (328) DISEASES OF THE PHARYNX. 329 cal characteristics, but lacking in the power to destroy the lives of susceptible animals. This has been termed the false, or pseudodiphtheric, bacillus. Concerning the variations in the pathogenic properties and powers of these bacilli, Abbott says, in the Medical Neics for November 17, 1894 : " It was observed that the genuine, virulent diphtheria bacillus was liable to fluctuate in the degree of its pathogenic properties, at times possessing these to such an extent that, when inoculated into guinea-pigs, death resulted in from thirty-six to forty-eight hours, while again the period of inoculation was much longer, Fig. 152.— Diphtheria Bacilli. (After Krieger.) Culture on agar-agar, twenty-four hours old : stained in alkaline methylene-blue magnified 1000 time<. often reaching five or six days, and in not a few cases organisms were obtained from undoubted cases of diphtheria that failed to give more than a temporary local reaction when inoculated into these animals." The micro-organism of diphtheria is named the Klebs- Lofner bacillus (Figs. 152 and 153), after the scientists who have brought to light the germ that causes untold suffering and a vast waste of human life. When this bacillus comes in contact with a mucous membrane or with abraded skin an inflammation is excited. The conditions then are favorable for 330 DISEASES OF THE EAR, NOSE, AND THROAT. the development and propagation of bacilli, — warmth and moisture, — and, while the microbes themselves do not enter into the lymph or blood circulation, their poisonous product does. In this manner an infection of the whole system takes place, — a toxaemia of specific type. This poison introduced into the blood of guinea-pigs and rabbits in minute quantities produces death, and its potency is retained for long intervals in a vacuum. According to Yersin and others, the bacillus itself is not viru- lent, but the poisonous product of the microbe is the material % . -**« l#v it •ts i ^ Fig. 153. — Diphtheria BacHiU. (After Krieger.) Culture ou blood-serum, prepared as Fig. 152 ; magnified 1000 times. The short form 8 resented in this specimen is due to their rapid multiplication. Some of the germs are istinguished by a club shape, which is considered characteristic of this species. that causes paralysis in sheep and dogs, and death in rabbits. A similar bacillus is also found in the mouths of individuals who have never had diphtheria and who have not been exposed to it. To all appearances this is the true Klebs-Lofrler bacillus deprived in some way of its virulency. It may have become modified or attenuated, but whether its poison-producing powers can become revivified is not known. These facts demonstrate that practically two diseases have formerly passed under the name of diphtheria, just as previously to the present century scarlatina and measles were supposed to be identical. DISEASES OF THE PHARYNX. 331 In true diphtheria the infection and toxaemic condition are produced by the Klebs-Lofner bacillus, but in false diphtheria this bacillus is absent or is changed in character, and in its place are found the streptococcus longus, the streptococcus pyogenes (Fig. 154), and the staphylococcus. False diphtheria is a much milder disease than the true form and is far less frequently productive of paralysis. Although these two forms of the disease cannot be differentiated except by bacteriological methods, Baginsky, Virchow, Henoch, Smith, and others recognize the dual character of the disease. In the Fig. 154.— Streptococcus Pyogenes. (After Krieger.) Streptococci and leucocytes of human pus; stained in gentian-violet: magnified 1000 times (Pfeiffer and C. Fraenkel). true form the streptococcus and staphylococcus are often found associated with the Klebs-Lofner bacillus and even the internal organs are invaded by the cocci, where the bacilli of true diph- theria do not penetrate. The cocci have been found in the lungs and kidneys as well as in abscesses of the neck. The bacillus of true diphtheria is possessed of remarkable vitality and may convey the disease after months and even years of latency. D'Espine and others found their potency unim- paired in cultures of sixteen months. Cases are on record in which infection occurred from clothing and other articles after 332 DISEASES OF THE EAR, NOSE, AND THROAT. as many as twenty years, and these are authenticated by ob- servers of undoubted competency and credibility. Diphtheria usually attacks persons under the age of 30 years, but may occur at any period of life. Its relative frequency in the very early years would almost justify the desig- nation of a disease of children. Out of 1512 cases in one statis- tical table I find that 1309 occurred in children under 6 years and only 203 from 6 to 17 years. It has been observed very infrequently in infants under 6 months old ; but at this age the organism appears to be nearly immune against this disease. The period of incubation varies greatly, there being as wide a margin as from one to twenty days. In animals directly inoculated the variation is only from half a day to three days. The sooner the disease makes its presence known, the more virulent the type of attack. When the onset is slow and slug- gish it seems to indicate either the modification or attenuation of the infecting germ or the strong power of resistance of the system. Etiology.— Diphtheria is not a sporadic disease, since it cannot arise in a body independently of any extraneous cause. It can reproduce, but cannot produce, itself. The disease orig- inates in any individual in the following manner : The specific micro-organism known as the Klebs-Lofrler bacillus gains lodg- ment upon the mucous membrane or denuded skin. There it grows and multiplies, and during this development of cultures of the germ a poison is produced that is chemically analogous to the venom of serpents, and the analogy may be extended to include its virulency. The resulting pathological manifestations are a reproduction of the disease whence the infecting germ was derived. An exposure of a susceptible person to the specific microbe for only an instant may be sufficient to insure its recep- tion upon a favorable soil, and so rapid is the process of propa- gation and toxaemia that a few hours — or days, at most — witness the development of this plague of nations. Abbott, in the Medical News for November 17, 1894, speaking of the Klebs-Lofrler bacillus, pithily puts his views in these words : " If this agent is present, diphtheria exists ; if it DISEASES OF THE PHARYNX. 333 is absent, then the local conditions and constitutional manifes- tations must be attributed to some other cause, and the disease is not diphtheria." The vitality of the bacillus, extending over many months or years, seems to insure the enduring nature of this decimator of communities. This is not an exaggerated characterization, for I have been in an epidemic that has literally annihilated family after family of children until the population was dazed by the devastation. Contact of persons with those who are, or have been, suf- fering with diphtheria is not necessary to constitute exposure. Merely the inhalation of a patient's breath, or being in the same room, or being in the presence of one who has been in such a situation and who may carry the infection in his cloth- ing, or handling a book between the leaves of which the germs may have found their way, may result in communicating the disease. The bearing of these facts upon the use of library books and the antiquated form of kissing the bible in courts and societies is too apparent to need elucidation. These germs naturally harbor where millers, moths, and molds thrive most. Dark, damp, badly-ventilated, and filthy places seem to be their appropriate habitat. It is commonly believed that the sewers of a city are the conveyors and dis- tributors of this poison to the people. Unless the sewer-traps are perfect and the sewers abundantly flushed, it is evident how the houses along the line of a sewer-system may become, one after another, the recipients of a poison entering farther up the stream. These microscopical germs are disseminated by vapors and winds and penetrate our homes with escaping sewer-gas. This view is substantiated by the fact that the death-rate from diph- theria is twice as great in cities as in rural districts, according to our vital statistics. The subtile nature of this microbe and its fondness for its victims and its vitality and power of propagation are suggestive of the multitudinous ways of infection and of the necessity of unceasing vigilance to escape it. One never knows when a child in school or in a public conveyance may not be sitting beside a diphtheric individual, and it seems as though no argument is 334 DISEASES OF THE EAR, NOSE, AND THROAT. needed to show the absolutely dangerous character of the uni- versal habit of kissing children, who, in fact, are much more susceptible to this deadly disease than the adults who expose them. Surgeons have contracted diphtheria and many have lost their lives by having a particle of the membrane or discharges from a patient's throat coughed into their eyes or upon their lips or by receiving it upon an abraded skin surface. When making examinations of the throat they have forgotten either to wear protecting glasses over their eyes or to keep to one side of the line of the column of air expelled by coughing. The lower animals are subject to attacks of diphtheria. Pigeons, turkeys, and cats have communicated it to the human family in various authenticated instances. Hence the unappre- ciated danger of allowing children to pet and caress sick cats is apparent. Rabbits and guinea-pigs are susceptible to the diph- theric virus, and cows' milk has been known to convey this disease, as it does scarlatina. Symptomatology. — There is a very wide margin of varieties in both the local and systemic manifestations of diphtheria. The disease may appear in a very mild form or there may be a severe throat imfiammation with distressing local evidences and alarming and fatal constitutional involvement. The period of incubation is generally from two days to a week, and is charac- terized by sensations of chilliness, waves of heat, headache, weari- ness or sleepiness, and depression of spirits. Following these premonitory symptoms are more pronounced ones announcing a serious disturbance of the digestive and circulatory systems. Loss of appetite, nausea, vomiting, and diarrhoea occur, accom- panied by thirst and increase in the force and frequency of the heart's action. Heat and dryness of the throat, stiffness or sore- ness in the muscles concerned in the act of swallowing, which is painful ; and tenderness on pressure under the angle of the jaw indicate the localization of the pathological process in the throat. The temperature rises to 101° F. in the first stage and sometimes as high as 104° F. Adults are more likely to com- plain of headache and backache than children. An erythem- DISEASES OF THE PHARYNX. 335 atous eruption occasionally appears during the first stage. Inspection of the throat within the first few hours of the seizure reveals a reddened, swollen condition of the mucous membrane of the soft palate and tonsils. All the symptoms are not present in all the cases. One must expect to find some of these lacking, and a description that will accurately fit one case may vary widely of the mark if applied to the next. But we would best consider typical cases. The second stage is that in which the false membrane is formed and the presence and proliferating powers of the diph- theria bacillus are demonstrated. The first appearance of this disease-label — which is usually within the first day or two of the onset — is a thick, yellow secretion, which can be seen covering the tonsils. A little later a yellowish-gray or a dirty, grayish- w 7 hite, false membrane is seen to have made its appearance in the fauces and pharynx, increasing in thickness and extent until little can be seen but this background to a painful picture. If pieces of this adventitious tissue are detached from the mucous membrane, to which it is closely adherent, the latter is seen to appear rough, raw, granular, and bleeding. All the group of glands in the vicinity of the throat become indurated and sensitive. The high temperature usually falls after the full develop- ment of the exudate in the pharynx, and may reach the normal on the fourth or fifth day. Decomposition of the secretions of the throat causes an offensive breath, which may often be ob- served the instant one enters the patient's room. The profound impression of the diphtheric virus on the circulatory system is evident from the feebleness of the pulse, which is compressible and abnormally rapid or slow. The kidneys participate in the general systemic disturbance, although the diphtheria bacillus itself does not penetrate to them; and the urine is decreased, high-colored, and rich in urea, and often in albumin also. About the third or fourth day there may occur an extension downward of the disease into the larynx with unmistakable signs of a serious complication. The respiration is harsh and embarrassed and a dry cough reveals the hoarseness of the 336 DISEASES OF THE EAR, NOSE, AND THROAT. voice. Increasing constriction of the laryngeal cavity and narrowing of the air-tnbe from the pharynx to the trachea is evidenced by distressing dyspnoea, blueness of the lips and finger-nails, pufflness of the face, and increasing dullness of the intellect until unconsciousness and fatal coma come to the sufferer's final relief. Other complications result from an extension of the disease to the nasal cavities, followed by a thin, yellow or dark, foul dis- charge from the nose, excoriating the skin about the nostrils and on the upper lip. The invasion of the nasal ducts may lead to involvement of the eyes, or extension to the Eustachian tubes may presage invasion of the middle ears with the train of con- sequences following in the wake of a suppurative middle-ear inflammation of a diphtheroid type. The third stage results in resolution or death. This period of the disease begins at about the end of a week, when all the racking symptoms may gradually melt away with the loosening and exfoliation of the false membrane. The general condition shows a refreshing improvement, — a sunshine of calm succeed- ing a physical storm. The fever is gone, the pulse drops to the normal rate, painful swallowing disappears, desire for food returns, the kidneys and skin perform their functions naturally, and all but the strength may now return to par. Unless a relapse occurs, or the heart has been too pro- foundly implicated so as to incur the liability of syncope, or diphtheric paralysis follow the attack, the patient pursues a normal course to complete recovery. In case the infection is of an intensely virulent type and finds the powers of resistance weakened, the system yields to the irresistible invasion of the virus and succumbs to coma and death. This is the natural history of a typical attack of diphtheria uninfluenced by the efforts of man to avert or modify its progress. Between this type and simple membranous sore throat there are great variations in the virulency of the infection and its mani- festations. Diagnosis. — Simple membranous sore throat and ulcerative DISEASES OF THE PHARYNX. 337 tonsillitis are the most likely to confuse the practitioner in differ- entiating between diphtheria and other pharyngeal affections ; but the exudative form of sore throat in measles and scarlet fever also closely resembles true diphtheria. The presence of a diphtheric epidemic, the rapid development of the symptoms, and the closely adherent, leathery membrane are definite diag- nostic features. The membrane of the other diseases is thin and easily wiped off with cotton, leaving generally a smooth membrane beneath, instead of a rough, ulcerating, or bleeding surface. The absence of the skin-signs of measles, scarlatina, and erysipelas aid in excluding those diseases, although very exceptionally an erythematous rash occurs in the first hours of diphtheria. From throat inspection alone it is impossible to distinguish between diphtheria and'other forms of pharyngitis before either a false membrane forms or an eruption appears, so that it is then necessary to be conservative in expressing an opinion, and to treat the case as though it were expected to eventuate in diphtheria. A positive diagnosis is possible if a bacteriological exami- nation prove the presence of the Klebs-Loffler bacillus. Other microbes may be present and embarrass the results of treatment, but the nature of the infection is established. It must not be forgotten, however, that another micro-organism identical with the Klebs-Loffler bacillus, to all appearances, is sometimes found, but differing from it in that it produces a milder affec- tion. The disease characterized by this microbe should be termed " diphtheroid," analogously to the formation of the term " typhoid " from typhus. As soon as any symptoms exist to excite a reasonable doubt as to the possibility of the disease being diphtheria, the secretions, and especially any available false membrane from the throat, should be secured in a perfectly- clean, sterilized test-tube and submitted to the microscope and culture-test by a competent bacteriologist whenever it is possible to do so. Where it is not practicable, the treatment should be conducted on antidiphtheric principles until a positive diagnosis can be rendered. 22 338 DISEASES OF THE EAR, NOSE, AND THROAT. Prognosis. — This is one of the most fatal of the diseases that afflict humanity; but, in view of all the evidence adduced during the past year, it is evident that the death-rate has been reduced since the introduction of serum therapy. Notwith- standing this, the physician should always recognize the possi- bility of a fatal termination even under the most favorable circumstances for treatment. If the infection is of a mild type and the resisting-powers of the patient are strong, the chances of recovery are good. The majority of such cases get well ; but one cannot tell when such a case may take on a virulent form of the disease that rapidly leads to collapse. Patients often succumb in a day or two after the seizure, and the majority of fatal cases die by the fifth day. In very young children, at the age when tenacity upon life is feeble, this disease rages with a fearful mortality. Signs of the gravity of an attack are invasions of the nose, ears, larynx, and trachea ; haemorrhages ; purpuric eruption; suppression of the urine; vom- iting, and diarrhoea. In laryngeal stenosis without intubation or tracheotomy the death-rate reaches the appalling figure of 95 per cent. A large number of sudden deaths are attributed to heart-failure. CHAPTER XXX. DISEASES OF THE PHARYNX, CONTINUED. Diphtheria, Continued. Treatment. — Since diphtheria is primarily a local disease with secondary constitutional infection, in this respect com- parable to syphilis, we will take up the consideration of medic- inal treatment in the logical order suggested by the sequence of the phenomena that constitute its history: (1) local and (2) constitutional treatment, — both the classic method and the modern serum therapy. But coincidently with the beginning of treatment certain preliminary precautions must be observed for the conduct of any given case to a successful issue, and also for the protection of other members of the family and the community. In addition to observing the patient's pulse, temperature, and respiration, and other physical signs and symptoms, the throat and nose should be examined in such a way as to avoid the possibility of the physician himself becoming infected. In- stead of occupying a position immediately in front of the pa- tient while inspecting the throat he should be at one side and on the alert to dodge any of the discharges from the throat that may be expelled by a sudden, explosive cough. Otherwise a lodgment of the venomous secretion or a particle of false mem- brane in the doctor's eye or on his lips may cost him his life. Moreover, cases have occurred in which the expulsion of the virus has resulted in its Ian dins: in the examiner's beard or on his clothing, and the communication of the disease with deadly effect to members of his own family or to other patients. The practice of holding a small pane of window-glass between the patient's mouth and the physician's face is an excellent one. The medical attendant of a diphtheric case would best re- move his coat and vest and wear an operating-gown reaching from his neck to his feet, or, in lieu of this, a sheet pinned about his neck and enveloping the person to the feet. After the (339) 340 DISEASES OF THE EAR, NOSE, AND THROAT. examination, his hands, face, and beard should be washed with a solution of bichloride of mercury, 1 to 10,000. The instruments used should be boiled over a very hot fire in a solution of car- bonate of sodium — an ounce to the pint of water — to disinfect them. All utensils, handkerchiefs, napkins, etc., used by the patient must be treated in the same manner. Assuming that the examination reveals the presence of diphtheria, or even a condition that excites a suspicion of that disease, the patient must at once be isolated from all except the medical attendant and the nurse. If possible, one or two rooms should be selected away from any cellar or basement, above the ground-floor and so situated as to admit the sunlight and an abundance of fresh air. All carpets, rugs, window-curtains, pictures, draperies, upholstered furniture and unnecessary arti- cles must be removed before the patient is admitted into this room. Without exposing the sick one to draughts of air, free ventilation should be effected from the tops, not the lower parts, of windows. The temperature should be kept uniformly at 70° to 74° F. The body-clothing must be such that children cannot expose themselves to cold at night, and this rule should be observed also at all times, with children especially, who ought to wear union-suits by day and night-drawers at night. These consist (the first) of woolen shirt and drawers in one piece and (the second) of cotton-flannel or cotton suits made in the same way. The woolen suits are to be used in winter and the cotton-flannel for cool and the cotton for hot weather. The drinking-water must be pure. If there is reason for the slight- est suspicion of the purity of the water it should be boiled for fifteen minutes and then chilled, not by placing possibly-infected ice in it, but by setting it covered in a cold, pure atmosphere in winter or surrounding it with ice in hot weather. Pure water made cold by this means is safer than the ice sucked as recom- mended by many writers, since freezing does not destroy disease germs. The drainage of the house should be inspected to ascertain if cess-pools, stagnation, or faulty sewer connections are respon- sible for the sickness. All communication between the outside DISEASES OF THE PHARYNX. 341 world and the patient must be forbidden, except through the physician and the nurse. In order that the contaminated air of the sick-room may not infect the adjoining apartments, a sheet should be saturated with a 5-per-cent. solution of carbolic acid and hung over the door-way of the chamber. A valuable anti- septic procedure is to have the bedstead, floor, and walls washed daily with a solution of mercuric bichloride, 1 to 10,000. One to 20,000 parts of water will destroy bacteria in ten minutes. The physician's duties do not end with giving instructions. He, himself, must often insist on their observation and person- ally superintend or execute his own orders if he would save his patient's life. As an illustration of the indifference of the aver- age family to the commonest sanitary regulations I will adduce a single instance: Upon being called to see a girl of 17 years, I found sufficient clinical evidence to warrant pronouncing her ailment diphtheria. She was lying in a bed in a large, but dark, damp, and apparently musty room. On inquiry it de- veloped that her brother and father had died of the disease in the same room and in the identical bed. I immediately asked to be shown the rooms on the floor above, and selected two adjoining apartments extending the width of the house, so that windows admitted sunlight and air on opposite sides. I directed all the contents of these rooms to be removed, excepting nothing but a bed, a table without a spread, and a chair without up- holstering. Promise was exacted that the patient would be removed to these chambers without delay. On the following day I found the patient where I had left her, and worse. Xo time was lost in informing the family that I would at once withdraw from the case, and that I would not make another visit or prescribe for the patient at the present one unless they imme- diately removed her to the selected apartments. They had decided that it would inconvenience them to do so, but lost no time in complying with my demands. Thorough antiseptic measures were adopted, such as had not been employed in the cases of the brother and father. Another younger child, a sister of the patient, soon was suffering from the same disease. She was subjected to the same rigid hygienic measures. Both 342 DISEASES OF THE EAR, NOSE, AND THROAT. children recovered. One had abscesses of the neck, but no permanent bad results further than scars indicating the points of incision. Father and son died in the same room, in the same bed, with the surrounding conditions described. The two sisters recovered under conditions made as favorable as possible. Had they been kept in the dark, damp, musty, infected atmos- phere of the double-death chamber, I predicted that the under- taker would soon follow my footsteps. Measures that seem imperative and even harsh may sometimes be absolutely neces- sary to the patient's welfare and the doctor's conscience and reputation. It is a great advantage to have a skilled nurse to faithfully and intelligently execute the physician's directions. She will best carry out all the modern methods of care of the sick as perfected in our great hospitals. She will be prepared — as no untaught person can be — to observe the aseptic and antiseptic teachings of advanced medicine. Nothing that leaves the diph- theric patient, and that is capable of bearing infectious material, should escape a most thorough system of sterilization. Instead of napkins or handkerchiefs, cloths should be used to receive the matters expectorated, or discharges from the nose, etc., and these should be burned with the most scrupulous care that not a rag is left. The importance of this and the disinfection of sputa is plain enough when we reflect that flies are attracted to such refuse, after visiting which they cultivate the acquaintance of your susceptible nose, lips, and eyes, or any point of skin denuded of its epidermis, and there inoculate your infectious point. Cats prowl around the backyard, into which cloths soiled by the diphtheric discharges are thrown. These cats contract the disease and distribute it throughout the neighbor- hood. Dame Nature, in an angry mood, seems to have exercised all her cunning and ingenuity to devise unsuspected ways and intricate and invisible means for the prolific production and wide dissemination of the germs of this fatal plague of the throat. Such considerations led J. Lewis Smith to say : " The day will probably never come when we can say of diphtheria, as we can of small-pox, that it is virtually suppressed." DISEASES OF THE PHARYNX. 343 The sputa should be disinfected, before removal from the patient's chamber, by pouring over it enough of a solution of bichloride of mercury — 1 to 1000 — to entirely cover the dis- charges. This should remain in the receptacle at least a half- hour and be agitated several times to bring all portions of the ejecta into contact with the disinfectant. Deodorizing and dis- infecting medicaments are volatilized in the room, much to the patient's comfort. I have observed excellent effects from melting menthol crystals in a teaspoon over a flame until the air was comfortably impregnated with the fumes. When the nose was involved I have taken the hot steaming liquid to the bedside and held it where I could blow the fumes over the bed toward the patient's face so that he would inhale a considerable quantity of them through both the nose and throat. His eyes are kept closed, and if not too great heat is used so as to make the fumes too dense, without any irritating effects, his nose and throat are benefited. If the throat is entirely covered by a thick mem- brane, of course no fumes reach the mucous coat beneath. J. Lewis Smith uses as a prophylactic the fumes of the following prescription : ly Olei eucalypti, acidi carbolici, aa 5j ; tere- binthinse, S viij . " Add 2 tablespoonfuls of this mixture to 1 quart of water and allow it to simmer constantly near the patient in a vessel witli a broad surface, as a tin or zinc wash- basin, a vessel with a broad surface being needed so that it will not take fire. The vapor produced is strong and penetrating, but not unpleasant." Pynchon uses parching or burning coffee as a deodorizer. Local Treatment. — There are remedies that exert a solvent action on the false membrane when the latter is macerated in them for a considerable time, and this fact has led to their use as gargles and local applications by means of swabs and sprays. Some of these remedies have too slow and feeble an effect to be of efficient use in the throat. Others exert a decided and per- ceptible influence in dissolving the exudate both without and within the body. Such, for example, is sulphocalcin, to which my attention was first attracted by William C. Wile several years ago, at a meeting of the Mississippi Valley Medical 344 DISEASES OF THE EAR, NOSE, AND THROAT. Association, to which he reported a large series of diphtheric cases in which unusual success had attended the topical applica- tion of this remedy. I then introduced it into my practice, and am able to confirm Wile's statement of the solvent properties of this preparation. In a letter recently received from the doctor he re-affirms his previous statements, and says his experience during the intervening years has been as satisfactory in the use of the drug as his first reports indicated. My method of employing the liquid is as follows : Absorb- ent cotton is twisted firmly on a long cotton-carrier curved at the roughened end so that it is impossible for the pledget to drop off into the throat. This is dipped into the fluid and pressed against the side of the small container, which should have a wide mouth. After pressing out all the surplus so that none will squeeze out and run down into the larynx, the medi- cated cotton is brought into contact with all the surfaces of the false membrane, making sure that the latter is wet with the sulphocalcin. The cotton is then burned. This treatment is repeated as often as is necessary to keep the membrane dissolved and the throat clear of it. At first it has sometimes been neces- sary to have the nurse apply it every fifteen minutes, lengthening the time between the treatments, as the membrane becomes less rapidly formed, to a half-hour, an hour, or two or four hours. When no false membrane re-appears the remedy is discontinued. The solvent effects of this treatment are so apparent that I wonder at its not having come into more general use. Its disa- greeable odor is an unfortunate feature. In the British Medical Journal of recent date Lennox Browne speaks of sulphurous acid as being an efficient germi- cide that acts systemically as well as locally with good results. I have often applied the sulphocalcin pure, and always do when the false membrane is thick enough to prevent the remedy from coming into actual contact with the mucous surface ; but, when the exudate is reduced to such a state of thinness as to allow the drug to penetrate to the mucous membrane beneath, it is necessary to dilute it with water until the smarting and burning otherwise produced is reduced to the point of DISEASES OF THE PHARYNX. 345 toleration. But, the stronger it can be borne, the better the results. Dioxide of hydrogen (peroxide, H 2 2 ) nas Proven very effective when it could be used in full strength with an atomizer. I have used large quantities of it during the past few years with great satisfaction. It is one of the best of disinfectants and antiseptics. When a spray of the fifteen-volume strength is made to copiously cover the false membrane it immediately begins to foam. As it comes in contact with pus-corpuscles they are decomposed and oxygen is liberated to destroy the micro-organisms present. The mechanical effect of the process of effervescence appears to make the false membrane more friable, to loosen it, and to aid in its removal. It is best to spray an abundance of the fresh preparation into the throat while the tongue is depressed, so as to reach every part of the pharynx. Then the patient, if old enough, is directed to hold it in the throat and gargle it so that contact is prolonged. Gag- ging should be avoided for fear of producing vomiting and the loss of much-needed food. The tongue-depressor must not be carried far enough back on the base of the tongue to cause retching. This treatment has proven very effective in my experience, and is repeated every half-hour, or every one, two, or four hours, as the conditions demand. Pynchon adds 1 grain of mercuric bichloride to 4 ounces of the dioxide to increase its germicidal action. It is of prime importance that the hydrogen dioxide be strictly pure, fresh, and just opened, and not allowed to be exposed to the air, heat, or light. If the pure dioxide cause too much smarting, it can be diluted. For some years before sulphocalcin and dioxide of hydro- gen were introduced I used lactic acid in a steam-atomizer. It appeared to have a beneficial action in softening and loosening- the false membrane. It is a favorite remedy with Lennox Browne, who applies it pure once or twice a day and has the nurse make applications of a dilution, 1 to 6, every two or three hours. It is to be pressed into the false membrane with a cotton swab. This cotton-applicator should always be used instead of a brush, for the latter is sometimes laid aside and 346 DISEASES OF THE EAR, NOSE, AND THROAT. forgotten only to be used at some future time and add more sorrow and deaths to the account of diphtheria. Such instances are on record. When pieces of the diphtheric membrane are macerated in pure lactic acid outside the body it becomes "-soft, translucent, and jelly-like." There is one objection to all applications that must be made with swab, brush, probang, etc. In the case of fighting, struggling children they probably do more harm than good by exhausting the little patient's strength. I have used the purple, or blue, pyoktanin, but am not satisfied of its value. From my experience with a 10-per-cent. solution of carbolic acid in glycerin in other diseases I am led to believe that its germicidal and local-aneesthetic effects would be valuable here. Lime-water irrigations and sprays have but little effect on the false membrane, but the direct fumes of slaking lime are beneficial, as even steam alone tends to soften and loosen the membrane. The lime-water makes the mem- brane more friable, but not thinner. I could never see any satisfactory results from potassium chlorate except simply as a cleansing solution. Salicylic acid is highly recommended by some Europeans, but is not in favor with Americans as a local remedy. I have no experience with it in diphtheria, but the results of trials with it for similar purposes in other diseases are not re-assuring. Insufflations of powdered sulphur are much used by the laity, but I have seen no benefit, though much misery, from them. Tearing off the pseudomembrane and cauterizing the mu- cous membrane is to be deprecated. Its forcible removal is justifiable only when it amounts to an actual obstruction to respiration. It should be borne in mind that the bacilli are not in the layer next the mucous membrane, but in the super- ficial layers. Generally they are not found to have penetrated to the mucous membrane, — a fact that seems to have been lost sight of by those physicians who aim to penetrate the deeper layer of the false membrane in order to inject remedies into the mucous tissues beneath, which opens up an avenue for the penetration of germs to the blood- and lymphatic vessels. DISEASES OF THE PHARYNX. 347 J. Lewis Smith reports excellent results from the following prescription for topical application : — R Acidi carbolici, gtt. x. Liq. ferri subsulpliatis, fSiij- Glycerin! . . . fgj. Aquae purae, f 3ij. Loffler (Deatsch. med. Woch., October 18, 1894) gave to the Budapest Congress his formula for toluol for the local treat- ment of diphtheria. It consists of alcohol, turpentine, and 2- per-cent. phenol (proportions not given). Since then he has used the following formula : Alcohol, 60 volumes ; toluol, 36 ; liq. ferri chloridi, 4. In 71 cases in private practice he had no deaths; adding 30 cases in hospital with 5 deaths, makes a mortality of 4.9 per cent. The local applications of toluol " should be begun early, should be thorough, and should be repeated every three or four hours until the temperature sinks to normal, which usually occurs in from twenty-four to forty-eight hours. Afterward three times daily and continued as long as any membrane is present." Loffler claims that if this application is used often enough and thoroughly the disease does not spread and has not invaded the nose or larynx in any case so treated. Intense pain followed the application, so " 20 volumes of menthol were added, making: menthol, 20 volumes ; toluol, 36 ; absolute alcohol, 60 ; liq. ferri chloridi, 4." When the nose is invaded, a spray of dioxide of hydrogen, 1 part in 5 or 10, if it smarts, or Seiler's alkaline antiseptic solution, the formula for which is given in Chapter XVIII, should be sprayed into the nose until it is cleansed. Then the nares are cleared by blowing or by cotton on the small carrier (Fig. 9), and aristol is insufflated by means of the small powder- blower (Fig. 32). Cold applied continuously to the throat with ice-bags (Fig. 78) retards and modifies the intensity of the inflammatory action of the first stage, but, after the false membrane begins sepa- rating, continuous heat is indicated. The hot applications may 348 DISEASES OF THE EAR, NOSE, AND THROAT. be better borne than ice in the first stage, and if cold appear to produce discomfort and irritation the heat should be substituted. Water as hot as can be comfortably borne may be used in the same rubber bags. Acids retard the proliferation of micro-organisms, and for that reason lemon-water and cold water acidulated with the acid phosphate or dilute sulphuric acid are of service and grateful to the patient. If the sulphuric acid is used it must be taken through a glass tube and must not be allowed to come in con- tact with the teeth on account of its deleterious action on the enamel. Frozen milk and beef-tea cool the throat, quench the thirst, and support the strength. Barley- and rice- water are to be recommended in the same way and for the same reasons. Internal Treatment. — The patient should be persuaded to take milk in preference to water for quenching the thirst and for the sake of maintaining the strength. Insistence may need to be resorted to for the sufferer's good. When the strength begins to wane alcoholic stimulants are necessary to bridge over the period of exhaustion and consequent collapse. Whisky, sherry-wine, or diluted alcohol in emergencies are mostly to be preferred. Stimulation and alimentation by enemata may be required when swallowing is impossible or the stomach rejects everything. Preparations of predigested foods, peptonized meat, etc., can be injected into the bowel per rectum through a large catheter extending well up toward the sigmoid flexure. Tonics are indispensable in severe cases. Quinine and iron are the favorites of most physicians unless heart-failure is im- pending, when strychnine is employed. Tincture of the chlo- ride of iron is given in large doses every two hours, proportioned to the patient's age. It is best combined with glycerin, as, for example, in Billington's formula : ty, Tincturas ferri chloridi, f3j ; glycerini, aquas, aa fgj. Mercury in the form of the bi- chloride and the mild chloride has for a long time been in high repute with the profession both in Europe and America. The corrosive sublimate is used in solution — 1 to 10,000 — locally, and considerable doses in the form of pills, etc., are also given internally. The calomel is administered internally and by " DISEASES OF THE PHARYNX. 349 sublimation. Internally it is given in doses of i to 3 grains every two hours until the bowels move freely, and then the doses are placed at sufficient intervals to not weaken the patient by catharsis. When the membrane is discharged, the calomel is discontinued. I. N. Love uses sodium benzoate in doses of 5 to 15 grains. Guttmann and others claim good results from pilocarpine, but its depressant action on the heart and the bron- chorrhcea it produces render its efficacy at least questionable in a disease with a natural tendency to heart-failure and respiratory obstruction. In case of enfeebled heart-action full doses of strychnia are indicated. Treatment for laryngeal invasion will be found in the division on the larynx. Apartments occupied by diphtheric patients must always be thoroughly fumigated with sulphur as soon as recovery takes place. Dry fumigation is not sufficient. In order to effectually destroy disease germs the air must be kept moist during the process of fumigation. Paralysis of the larynx, pharynx, velum palati, and lower extremities and loss of the tendon reflexes are sequels of diph- theria. Strychnine in large doses, especially subcutaneously injected ; central galvanization ; and local faradization have given the best results in overcoming these paralyses. The antitoxin, or blood-serum, therapy, already mentioned, is considered in the following chapter. Intubation is treated of under a separate heading. CHAPTER XXXI. DISEASES OP THE PHARYNX, CONTINUED. Diphtheria, Continued, serum therapy in diphtheria. Behring, Kitasato, Roux, Ehrlich, Martin, and others have found, as a result of their experiments, that if the blood-serum of animals that have been deprived of susceptibility to a disease be injected into other animals, it deprives the latter, in turn, of susceptibility to that disease, and modifies or aborts the disease if it is already present. Rabbits and guinea-pigs are employed in these experiments. If the serum from one of these animals previously immunified against diphtheria or tetanus be injected into another susceptible one, the latter is protected from the given disease for a time. The method of procedure in these experiments is, briefly, as follows : Enough of the poisonous product of the disease is injected into an animal to sicken it, but not to cause death. Small hypodermatic injections of diphtheria cultures and toxins are given at first and gradually they are increased as the toler- ance of the animal increases. As this process proceeds the blood of the injected animal acquires gradually increasing im- munifying powers. The injections are followed by local tume- faction and fever. At intervals a quantity of blood is taken for the purpose of experimental tests on other animals to determine its efficacy. After the latter is shown to be sufficient, a large amount of blood is taken from the animal, placed in vessels on ice to produce coagulation, and the separated serum, mixed with i of 1 per cent, of carbolic acid, constitutes the serum remedy. On account of their susceptibility and size, goats and horses are employed to obtain this serum in large quantities. An enormous amount of this is produced in Germany. Behring says : " The works can now supply one hundred thousand doses (350) DISEASES OF THE PHARYNX. 351 a month, which barely keeps pace with the demand from Europe and America." The benefit to be derived from the antitoxin injection de- pends largely upon the time in the history of the disease at which the remedy is employed. If three or four days or a longer time has elapsed, so that the disease has invaded the larynx or bronchial tubes, and the profound toxic effects of the diphtheric poison are manifested in the heart, nothing may save. If the building is nearly consumed by fire, water cannot save it. However, the patient should always be given the benefit of a doubt and the remedy that promises the most hope must be used. The German physicians report a large saving of life by the use of the serum therapy. Roux, of Paris, claims similar results. It is asserted that the serum itself is harmless, and some deaths that have followed immediately upon the injections may have been due to other causes, such as the syringe penetrating a vein and injecting air, or heart-failure, etc. Other deaths may have been caused by the accidental introduction of some other ma- terial of a septic nature. The varying results apparent in the statistics of different observers and hospitals are likely affected to a considerable extent by a difference in the virulence of the several epidemics and of different cases in the same epidemic. In reviewing the subject of blood-serum therapy, or anti- toxin treatment, with a view to fix its present status and to place a just and impartial estimate upon its actual value in diphtheria, I have investigated the current literature on the question down to the present time. I shall offer the evidence on both sides, and the reader would best assume a judicial atti- tude and decide according to the law and the evidence as they are presented by the several able advocates. The serum injections are made in the loose subcutaneous tissue, generally below the axilla or between the shoulder-blades, after preparing the skin by washing with soap and a bichloride solution, 1 to 1000. The antitoxin of Behring comes in her- metically-sealed flasks or vials bearing labels that indicate the doses contained. Each vial contains one dose, as follows: No. 1, 352 DISEASES OF THE EAR, NOSE, AND THROAT. 600 immunizing units, to be used on the first or second day oi the attack ; Xo. 2, 1000 units, for serious cases on first or second day or in mild cases of longer duration ; Xo. 3, 1500 units, for adults or severe cases in children. If one injection does not prove effective, it is repeated after twenty-four hours. As a prophylactic, smaller doses are given. For children, 100 to 200 units are sufficient. The length of time this dose affords immunity is not definitely known, but it is safest not to allow more than three weeks to elapse with a child still exposed to the disease without a repetition of the protective dose. An extended treatment of this subject may be found in an excellent monograph entitled " Blood-serum Therapy and Antitoxins," by G. E. Krieger, Chicago. We will now consider the results of the blood-serum therapy. Behring (Deutsch. med. WocJi., January 10, 1895) an- nounces that the dose of 60 units, at first considered sufficient, is too small for some cases, and that 150 units had better be given in all cases. Even this dose is not always sufficient when the infection is virulent and the period of incubation nearly over. In such cases a full dose of Xo. 1 (600 units) may not be sufficient to prevent the development of the disease. An attack following the injection is usually mild. In 10,000 cases immu- nized only 10 contracted diphtheria. The antitoxin is excreted by the kidneys, and immunity depending on it ceases when all is eliminated. The larger the total dose, the longer the immu- nity, and smaller doses at intervals are more serviceable than one large dose. For the first time Professor Behring has replied to the critics of antitoxin, and supports the efficacy of this discovery by innumerable statistics (Deutsch. med. Wbch., 1895, Xo. 38). He claims that even statistics do not do it justice, as it is used in perhaps the more desperate cases, and the mortality percentage is, therefore, higher than it should be in proportion. But, even allowing for countless errors, the percentage is a great gain over the past. The mortality in Berlin in 1895 sank to 15 per cent., two-thirds less than it had averaged during the seventeen vears DISEASES OF THE PHARYNX. 353 preceding, while the character of the diphtheria was more seri- ous than at any time since 1886. Of 10,312 cases, 5833 were treated with serum, with a loss of 9.6 per cent., while 3479 cases treated without it showed a mortality of 14.7 per cent. The percentage fell to 10.3 per cent, in the Contagious Disease Institute, where the serum was exclusively used. He asserts that the question now is : Shall it be used to secure immunity ] For this purpose he recommends one-half of a regular dose. Improved methods have enabled the dose to be concentrated from o cubic centimetres into 1 cubic centi- metre. He regrets that the specific for tuberculosis is not yet all that was hoped for it, but congratulates Ransom on his cholera serum and Knorr on his for tetanus. (Centralblatt filr Chirurgie, January 11.) " Professor Behring delivered a recent address on this sub- ject in which he replied to the swarms of critics who have been attacking him the past year or so. He maintained that sta- tistics prove the efficacy of the serum, and that the 60,000 deaths from diphtheria which the German empire has averaged each year will be found to be reduced to 40,000, and a more general use of the serum would reduce this to one-third. Throughout the city of Berlin the fatality in diphtheria amounted to 30 per cent., but in the Contagious Hospital, where serum was promptly used, the mortality was only 20 per cent. In the same time in 1895 it was only 10.3 per cent. The mortality in the hospitals had always been much greater than outside here- tofore. Last year the percentage of mortality in diphtheria cases in Berlin fell to 15 per cent. During this period the dis- ease was not a mild form, but averaged more morbid symptoms than at any time since 1886. During the first three months of 1894, when the serum was not to be had, there were 363 deaths per 1000, while the last three months, when everybody could get the serum, there were 198 deaths per 1000." {Journal of the American Medical Association, February 8, 1896.) " Kossel, speaking for Koch and of the results obtained in the Institute for Infectious Diseases at Berlin, declares that no uncomplicated case that was treated in the first or second stage 23 354 DISEASES OF THE EAR, NOSE, AND THROAT. of the disease was lost, and that the mortality of all cases was reduced to 16 per cent." (Sajous' "Annual of the Universal Medical Sciences.") Kossel (Deatsch. med. Woch., October 25, 1894) with cow- serum reports 117 cases of diphtheria with 13 deaths, or 11.1 per cent. Kossel concludes " that one cannot expect to cure every case of diphtheria with serum, but that with a sufficient dose recovery will follow with certainty in all cases of fresh, un- complicated diphtheria. The prognosis is also much better, even in the later stages of the disease, than without the serum treatment." The use of antitoxin is highly extolled by the French. M. Monod claims that its use has decreased the mortality from diphtheria 6b per cent., and it is claimed that by its use 15,000 lives in France have been saved. "In the Hopital Trousseau (Med. Press, January 9, 1895), during October and November, 1894, 302 children were ad- mitted to the ' doubtful wards,' and were at once injected with 20 cubic centimetres of serum. Later, 53 were recognized as not diphtheria, and remained in these wards until recovery, none contracting diphtheria. Two hundred and forty-nine children were admitted to the diphtheria wards, and at the expiration of Moisard's term 18 were still under treatment. Of the remain- ing 231, 34 died, or a mortality of 14.7 per cent. As sequels of the serum therapy there were, in all, 14 cases of urticaria, 9 of scarlatiniform erythema, 9 of polymorphous erythema, and 1 of purpura." "In. the Hopital des Enfants Malades, Paris, there was a reduction of mortality by serum therapy in 448 cases to 24.33 percent, as against 51.71 per cent, for 3971 cases occurring from 1890 to 1894. In no case was there any untoward result that could be ascribed to the treatment except slight urticaria. The beneficial effects of the serum were a marked improvement in the general condition ; a cessation of the growth of membrane within twenty-four hours, and disappearance of the membrane after thirty-six to seventy-two hours, with rarely a longer per- sistence ; a return of the temperature to normal ; a diminution DISEASES OF THE PHARYNX. 355 of the amount and frequency of albuminuria ; and the appear- ance, less often, of such diphtheric sequelae as paralyses," etc. (American Year-book, 1896.) " Kitasato, of Tokio, has collected from reliable sources 26,521 cases of diphtheria in Japan previous to serotherapy, with 14,996 deaths (56 per cent.) ; while of 353 cases treated here from November, 1894, to November 25, 1895, there were only 31 deaths (8.78 per cent.). There is reason to believe that the mortality can be lowered if the treatment could be commenced early in the course of the disease. Thus, in 110 cases in which injections were made within forty-eight hours after the invasion all ended in recovery. On the other hand, of 33 cases treated after the eighth day of the disease 11 were lost. Some of the patients were brought into the institute in a moribund condition ; 6 children died within five hours after ad- mission; 6 more within ten hours; altogether 21 cases (two- thirds of the total mortality) were lost within the first twenty- four hours. As to the effects of the serum on the course of the disease, the points to be noted are: 1. The fall of temperature; in many places the defervescence was almost critical, and it takes place usually at the end of twenty-four to forty-eight hours. 2. The separation of the false membrane, which takes place, as a rule, after the return of the temperature toward the normal. Very large casts of the trachea and larger bronchi have been coughed up. 3. Urticaria-like eruptions were observed in very many cases, being, in some, quite severe and annoying. They, however, disappeared in a few days without any treatment. 4. In 4 cases marked albuminuria was observed at the time of admission. In these cases albumin disappeared from the urine in the course of the treatment. Pyrexia was accompanied by albumin in the urine, but there was no reason to believe that any renal trouble was caused by the injections. 5. Five cases developed paresis of the soft palate. Microscopic as well as culture examinations were made in every case, and Dr. Kita- sato's report only deals with those cases in which Loffler's bacilli were demonstrated to be present." {Journal of the American Medical Association, May 9, 1896.) 356 DISEASES OF THE EAR, NOSE, AND THROAT. H. Gradle writes as follows, January 26, 1896 : " Of a total of 3311 cases collected by Behring from the health reports in Berlin, in 1895, since the general use of antitoxin, 16 per cent, died, while according to previous experiences in the same places and by the same observers the mortality had been from 31 to 36 per cent. The death-rate is not the same in different cities and among different classes of the population, but, what- ever it has previously been, it was always diminished by the new treatment. There is not a single record of any observer who has seen a sufficient number of patients to draw statistical inferences but what confirms the life-saving effects of the anti- toxin treatment. No such evidence has ever been brought forward to prove the efficacy of any other treatment in diph- theria, and those physicians who speak boastfully of their time- honored remedies in their own hands cannot adduce the testi- mony of others in favor of their pet medicines, as no two text-books formerly agreed on the treatment of diphtheria. " Does the use of antitoxin involve any danger % A few deaths have been reported as occurring soon after the use of the remedy. But no observer who is familiar with the treacherous nature of the disease and the sudden heart-failure which some- times occurs even in the mildest forms of the diphtheria can be convinced that antitoxin is responsible for these deaths. It was simply used too late to prevent them. An unpleasantness, but not a real danger, which has, however, been observed in about 5 per cent, of the cases treated, is a slight feverish disturb- ance, sometimes with pains in the joints or a rash on the skin. This incident, which has never proved serious, is insignificant in proportion to the positive danger of the disease which the treatment reduces. " The prevention of diphtheria by means of antitoxin given after exposure to the disease, but before it has broken out, has likewise proved an unqualified success. Observations in chil- dren's hospitals and orphan-asylums, particularly in New York City, have shown this. Epidemics which in former times could be checked in such institutions with difficulty, and only by per- sistent quarantine of all the inmates, have been stopped promptly ,tly DISEASES OF THE PHARYNX. 357 within the last year by the preventive use of antitoxin. The experiences of the physicians acting for the Chicago Board of Health have also confirmed the utility of the preventive treat- ment in checking the spread of the disease in crowded tenement- houses." (They confirm these reports at the present time, January, 1897.) Karlinski (Wien. med. Woch., February 16, 1895), as a result of a careful series of experiments on his own person, concludes that the diphtheric-heilserum influences in no way the metabolism of a healthy organism, and that the albuminuria in diphtheric cases treated with antitoxin should be ascribed to the disease rather than to the remedy." Foster {Medical News, February 2, 1895) says: "Of 2740 cases, including those requiring tracheotomy and intubation, treated with antitoxin, 509 died, — 18.51 per cent. Of 4445 cases not treated with antitoxin 2017 died, — -15.36 per cent. All the cases recovered when the antitoxin was injected on the first day of the disease ; 2.83 per cent, died when the injections were begun on the second day ; 9.99 per cent, when the first treatment was on the third day ; 20 per cent, died when the first treatment was on the fourth day ; 33.33 per cent, when the injections were begun on the fifth day; 841, or 38 per cent., when they were begun after the fifth day." Edwin Rosenthal (Transactions of the Philadelphia County Medical Society, January, 1896) says: " The antitoxin serum is used as a curative or immunizing agent by subcutaneous injec- tion into the tissues of the body. The parts chosen w r ere in the back between the scapulae, on either side of the vertebral column, though other parts of the body, as the loins, groins, or the side of the chest, have been selected. " The parts were cleansed with alcohol soaked on sub- limate cotton or gauze, the injection was made at one time with a suitable syringe, and after injection the parts were soaked with iodoform collodion. " The quantity injected depended upon the severity of the case and the day of the disease when the injection was made. If in the first two days and the disease mild, 600 units were 358 DISEASES OF THE EAR, NOSE, AND THROAT. injected. If, however, the case were more severe, as in the laryngeal variety, or after two days, 1000 or 1500 units were injected. These injections were repeated, if necessary, in twelve to twenty-four hours. After injection, if the pulse and temper- ature declined, no more antitoxin was given ; but, if the symp- toms continued or became more urgent, larger quantities of the serum were injected until the characteristic decline took place." Rosenthal chose his dosage in units for the reason that so many different antitoxins were sold. He had used Behring's, Aronson's, Gibier's, Roux's, Solis-Cohen's, and Mulford's, and each variety represented a different strength, 1 cubic centimetre (about 15 drops) representing 60, 100, or 150 units ; it was, therefore, easy to use the required dosage if the strength of the antitoxin were known. For instance, an injection of 1000 units of Mulford's antitoxin would require 10 cubic centimetres at a dose, and so on. A total of 222 cases with 13 deaths showed a mortality of 5J-g- per cent. Of the 84 laryngeal cases, 12 died; 31 were intubated, with 5 deaths. Rosenthal's conclusions were : " Antitoxin is a specific in diphtheria; but, while acting specifically, it is not a cure-all, and other treatment must be pursued as indicated by the special case. The earlier the antitoxin was used, the more certain was its success." R. H. Babcock, in the President's Address before the Tri- State Medical Society, in Chicago, April 7, 1896, spoke as fol- lows : " The crowning achievement in this line of work has come through the chemistry of bacteriology. Nuttall conclu- sively demonstrated in 1888 the power possessed by the blood- serum of combating the poisonous products of bacterial growth, but to Behring and Kitasato, in 1891, belonged the credit of having found a practical means of utilizing antitoxins in the treatment of disease." To those who decry the -antitoxin treat- ment of diphtheria as dangerous and its advantages as not yet proven, Babcock commended the criticism by Welch in the Johns Hophins Bulletin of October, 1895. Welch's analysis of cases treated and published up to that time, in the opinion of DISEASES OF THE PHARYNX. 359 Babcock, " sets at rest all doubt concerning the great reduc- tion in mortality accomplished by this treatment, and renders the physician culpable who refuses this remedy to his patients." Rosa Engelmann, of the Chicago Health Department, in detailing the results of her experience with antitoxin says : " Seven deaths in 103 cases, or 6.97 per cent., is a very low death-rate, especially if one consider that 50 of the 103 cases, or almost 50 per cent., were croup, — the most dangerous form of diphtheria. Doubling this death-rate to 14 per cent, for the laryngeal cases still leaves a remarkably low mortality. This brilliant record is due to the fact that 91 of the 103 cases were injected within the first three days." {Medical Standard, March, 1896.) Hare (Therapeutic Gazette, January 15, 1895) indorses serum therapy, but emphasizes the necessity of not omitting other treatment. " Three tilings are important to know when using antitoxin : 1. That a single dose of antitoxin is not always sufficient to counteract the poisonous infection. 2. While it may counteract the results of the Loffler bacilli, it does not pre- vent its continued growth at the site of infection, — throat, nose, etc., — and the patient may still be dangerous to infect others even after all the usual traces have disappeared. 3. It does not combat other infection, as the streptococcus or the like ; it may prevent it if used early enough ; but other treatment must be used in conjunction to make a favorable result." (Charlotte Medical Journal, February, 1896.) The majority of the members of the American Pediatric Society, at its meeting in May, 1896, were of the opinion that the effects of the serum therapy in diphtheria justified an ex- tensive trial. The same opinion prevailed in the Association of American Physicians. John Winters Brannon, physician to the Willard Parker Hospital, New York (International Medical Magazine, January, 1896), says: "I must admit that I am as yet unable to range myself either among the enthusiastic advocates of diphtheria antitoxin or with those who unqualifiedly condemn it. Perhaps, if I touch upon some of the clinical features of diphtheria as 360 DISEASES OF THE EAR, NOSE, AND THROAT. modified by the administration of antitoxin in the Willard Parker Hospital, the reasons for my position may become apparent. Ci Among the favorable results claimed to follow upon the injection of antitoxic serum are a prompt improvement in the general condition of the patient, a strengthening of the action of the heart, a fall of the temperature, a rapid disappearance or 4 melting away' of the membrane in the throat, and marked re- lief of laryngeal stenosis. I have already said that I believed that antitoxin often had a favorable effect upon the laryngeal symptoms, and I am inclined to think that this is especially true of the intubated cases, which seem to do better under anti- toxin than without it. On the other hand, I have failed to note any effect, favorable or otherwise, upon either the pulse or the temperature, nor have I ever seen any 'melting away' of the membrane which is not also observed in cases which have not received antitoxin. There is a case now in the wards in which the membrane has persisted for three weeks, although antitoxin was given on the third day of the disease. The general con- dition has also usually remained unaffected, except as it might be influenced by the relief of laryngeal stenosis referred to above. " Now as to the alleged untoward effects of antitoxin. It has been said to cause nephritis, or, at least, albuminuria, and to favor post-diphtheric paralysis, or dissolve the red cells of the blood, and to set up septicaemia in some manner as yet unex- plained. In regard to all these clinical phenomena, I can only say that I have failed to observe them, though I have looked for them day by day, particularly during the past eight months. Cases have shown albuminuria as in previous years, and, in the opinion of one of the resident staff, rather more than formerly, but casts or other evidence of nephritis have been absent. Suppression of the urine occurs, but not with unusual frequency. With the exception of simple regurgitation due to temporary paresis of the palatal muscles, I should say that post-diphtheric paralysis has been noteworthy by its absence during the present year. With regard to the destruction of the red cells of the DISEASES OF THE PHARYNX. 361 blood or the occurrence of septicaemia, I have seen nothing which would lead me to attribute either of these morbid proc- esses to the administration of antitoxin rather than to the diph- theric poison itself. Among the hundreds of cases treated this year in the hospital, there is but one in which, in my opinion, antitoxin may have contributed to the fatal termination. In the case in question, a severe one at the outset, a synovial in- flammation developed in several joints some ten days after the injection of serum, coincidently with an urticarial eruption cover- ing the legs and trunk. The fluid in the joints became puru- lent and the signs of broncho-pneumonia were found in the lungs. After a protracted illness the child died, and, on autopsy, in addition to the pus in the joints and the pulmonary consoli- dation, there was found marked fatty degeneration of the heart and kidneys. This case would probably have died from other complications, but we cannot but associate the joint process with the giving of antitoxin." In the Journal of the American Medical Association for February 9, 1895, B. Becker quotes as follows: " Koerte says: 4 Bacteriologists say that antitoxin, if early used, will almost surely cure the genuine diphtheria. They wish those cases ex- cluded which are complicated by the presence of other bacteria or cocci. In regard to this, I must say that we, as practi- tioners, when we talk about cure and treatment of diphtheria, must keep in view the clinical symptoms and appearance of the disease, and that under this well-known and fully-characterized picture also those cases belong which are described as mixed infections. Every physician will declare such a case a severe one of diphtheria. From this point of view it is at this time not probable yet that antitoxin will cure all cases of diphtheria, in a broader sense. Also the assertion that in an early and sufficient use of the serum all cases of genuine diphtheria can be cured is not proved yet. There is the possibility that in various epidemics those cases of mixed infection are so frequent that they may make a limit for the use of the serum. In spite of the rather favorable results which I have related, a longer continued observation at the bedside only can bring a decision 362 DISEASES OF THE EAR, NOSE, AND THROAT. as to the value of the antitoxin.' " {Berlin. Jclin. Wocliensclirift.) A discussion of the antitoxin was brought up at the Med- ical Association of Munich, after the hearing of reports of cases by Bucher, von Ranke, Seitz, and Emmerich. The following resolution was unanimously adopted by the association : — "1. To give a positive opinion about the value of Behring's serum is not possible at this time, especially on account of the differences of diphtheria in regard to appearance and severity of the disease ; only a longer and closer observation can have a positive effect. It must be recommended, therefore, not to expect an absolute panacea, which suggestion should be given to the public also. " 2. Our experiences with the antitoxin are of such a kind that we consider it worthy of further investigations and trials, especially in clinical and polyclinical institutions, as those places are the most fit for such experiments." {Munchener medic. Wocliensclirift. ) The opposition to the serum therapy finds an advocate in Lennox Browne ("Diphtheria and its Associates," 1895), who claims as a result of his experience with the antitoxin " A greater number of children have been found liable to attacks of cyanosis and fainting, with a correspondingly-increased demand for nervines and stimulants. Complete recovery is, for the most part, delayed, and an unexpected fatal result at a late period is more frequent. When drawing attention at a meeting of the Clinical Society, last December, to an increased liability to the most grave complications of diphtheria — viz., anuria, nephritis, and cardiac failure — under the use of serum we took occasion to express a hope that further experience might prove that the dis- advantages of serum would be more than outweighed by its benefits." In 1000 cases with 284 deaths as compared with the earlier methods of treatment, he says : " The actual mortality was the same, — namely, 27. It was 27.10 on the whole number — 1163 — treated during the year 1894 at the hospital whence our comparisons were made." " The foregoing observations as to the effects of serum treatment will, we trust, have made it clear that the injection of DISEASES OF THE PHARYNX. 363 antitoxic serum into a patient attacked by diphtheria is not altogether free from an added danger, notwithstanding that the amount of active principle administered can be measured only by million ths ; and we have seen that the power of this serum to do good and, per contra, its capacity for inflicting injury is in proportion to the duration of the disease, — in other words, to the degree of the toxaemia. " As a corollary, we might be able to pronounce that the power of antitoxic serum to act as a prophylactic against a pos- sible attack of diphtheria is in proportion to the rigor and healthy blood condition of the individual in whom it is em- ployed ; but the very minute dose administered for this purpose is evidently capable of being soon broken up by cellular action in the healthy. " We can, therefore, understand the general admission as to the evanescent character of the immunity so obtained. Moreover, reports of cases are not wanting in which noxious and even fatal results have followed the use of serum when employed as a prophylactic. " On all these grounds, therefore, we do not feel justified in recommending serum for this purpose. More real methods of preventing the spread of diphtheria are to be found in im- proved sanitation, in prophylactic surgical treatment already detailed, and in efficient isolation and disinfection." Kassowitz (Wien. med. WocJi., Xos. 5 to 8, 1895) opposes serum therapy for the reasons that ' ; Attempted immunization toward diphtheria has failed repeatedly ; relapses have occurred in children treated in the first attack with antitoxin ; injection on the first or second day has not always averted a fatal issue, death in some cases occurring as a result of the diphtheric toxin ; post-diphtheric sequels seem as frequent as formerly ; the anti- toxin has no sudden antipyretic action ; the membrane does not seem to be loosened earlier or its formation checked ; and the total mortality for diphtheria in Berlin has not been lowered. " Hagenbach ( CorrespMatt fur Schweizer Aer., January 1, 1895) used Behring's heilserum in a severe case of diphtheria 364 DISEASES OF THE EAR, NOSE, AND THROAT. with the following results : " Three days after the injection petechias broke out on the neck and spread over the whole body, vomiting- set in on the seventh day, and death occurred on the tenth. The autopsy showed hsemorrhagic gastro-enteritis, a high degree of fatty degeneration of the heart, and parenchyma- tous nephritis." Winters {Medical Record, April 20, 1895) opposes the serum treatment, declaring that, during an experience of three months in the Willard Parker Hospital with one hundred and fifty-four cases treated by it, " In not a single case has there been the least evidence that the formation of the pseudomem- brane was checked, that the exfoliation of the pseudomembrane was hastened, or that the throat was free from the membrane earlier than in the cases that have not been treated by antitoxin. In not a single septic case has the antitoxin made the least impression on the symptoms. The toxeemia has not in one instance been relieved or lessened. There has been no indi- cation, in the character or frequency of the pulse or in the general condition of the patient, that a specific for the toxaemia had been administered. The antitoxin is, therefore, opposed, first, because it does not neutralize the toxaemia nor favorably influence any of the clinical manifestations of diphtheria, and, second, on account of its immediate danger to life through its influence on the kidneys and on the nervous system, and, re- motely, through its influence on the blood." Strueh (Journal of the American Medical Association, May 16, 1896) opposes antitoxin therapy and cites the unreliable character of statistical information, instancing the variations in mortality in the Children's Hospital at Basel. In 1876 the death-rate was 34 per cent.; in 1886 it was only 6 per cent. " Had they used any new remedy during the latter year the decrease in the mortality would undoubtedly have been ascribed to the new treatment." Ewing finds that " the antitoxin caused a diminution of the red blood-corpuscles and extensive changes in the leuco- cytes. These changes are likely to lead to obstructions in the capillary circulation, to changes in the kidneys, to necrotic foci DISEASES OF THE PHARYNX. 365 in the liver, to pneumonia areas in the lungs, to obstructions of the cerebral circulation, and possibly to convulsions." Several deaths have been directly attributed to antitoxin injections. One reported recently well illustrates these deplor- able experiences. James L. Taylor writes to the Journal of the American Medical Association as follows (April 4, 1896): "A most unfortunate and distressing accident occurred in the practice of Dr. S. S. Halderman, of Portsmouth, Ohio, on March 22, in connection with the use of antitoxin. A mild form of diphtheria was prevailing in the family of Mr. George Kricker, cashier of the Central Savings-Bank, and the doctor administered the usual dose of antitoxin, as a prophylactic, to a little boy, 5 years old, in whom the disease had not yet appeared. The child, which had seemed to be in perfect health up to this time, was asleep when the injection was given, and in five minutes was a corpse. The doctor had withdrawn to another room to refill his syringe for use on another child when the mother noticed the boy's lips puffing up, and called to him that something was wrong with Willie. By the time the doctor reached the child, breathing had ceased. The killing fluid, which thus acted with far more rapidity than a fatal dose of morphia, arsenic, or strychnia given per mouth would have done, seems to have caused death by paralyzing the heart. At least, that is the cause assigned in the death-certificate. The serum was Behring's fresh, injected beneath the scapula and in the usual way. The doctor, one of the first to introduce antitoxin into medical practice in Ports- mouth, was an enthusiastic advocate of serum therapy, and presumably used all the precautions which skill and experience can suggest. This terrible accident, therefore, can have but one meaning. It furnishes absolute proof of the inherent danger of antitoxin as a therapeutic agent." In a private letter of July 9, 1896, from Edwin Klebs, formerly of Germany, now Professor of Pathology in the Chicago Post-Graduate Medical School, he says : " The good effect (of serum therapy) in the first two days of diphtheria seems to be doubtless." Referring to the Atlanta meeting of the American Medical Association, he continues : " I remarked 366 DISEASES OF THE EAR, NOSE, AND THROAT. the dangerous effects in some rare cases, as that of Professor Langerhans. Now. the papers bring the notice that the death occurred by the introduction of stomach-contents in the bronchi. I do not know if that is acceptable, possibly post-mortal. I wished to point out the problem to get the antitoxin substances in a purer form, so that all possibility of infection may be avoided." In his discussion at the meeting referred to, Pro- fessor Klebs said : " Now I come to a point that seems to me to be of the highest importance, — the danger of antitoxin. I wish that point would be illustrated in a more extensive manner by publishing all cases in which the injection was shortly followed by death. We have such cases, but a part of them seems to be on account of the disease. But if in one case alone the patient has been killed by antitoxin, we have a great interest to find out the true cause of the death. Such a case is that of Pro- fessor Langerhans, in Berlin. After a girl in the house became diphtheric, he thought he would, if possible, prevent the spreading of the disease to his own children, but after the injection the first child died immediately. So it is possible that death may occur after the most cautious injection of antitoxin, — a fact that gives a high responsibility to every physician using this remedy. We must search, therefore, to find out what may have been the cause of such fatal accident. " In this case it is reported that the body of the dead child was quite normal, well nourished. There was no introduction of air into the blood. The danger of introducing air is, by the way, not so great as often accepted. One can inject some centi- metres of air in the blood-vessels of a rabbit without any bad effect, as the air is resorbed in a very short time. It will be better to inject the fluid in children into the muscles far distant from the lungs, — the dorsal or gluteal region. Then it is con- venient to push the needle alone in first and see if bleeding fol- lows or not. If not, one may inject without fear, but always slowly, under no high pressure. If these precautions are fol- lowed, I think that no danger can be feared from the injection. " I think it is not probable that the antitoxic serum itself con- tains such a formidable heart-poison, as very great quantities of DISEASES OF THE PHARYNX. 367 it injected into the peritoneal cavity of animals prove harmless Much more probable it seems to me, that in this and other simi- lar cases observed in Brooklyn, N. Y., an accidental pollution of the antitoxin has combined with intra-venous injection to produce the fatal effect. " The sure disinfection of serum is a very difficult matter. Twice I have found microbes in tubercle serum. On the other side, the best antiseptics — as mercury bichloride, phenol, and kresol — make coagulations in the serum. Therefore, one must search for other disinfectants that will not coagulate albumin- ous matters. I note that chinosol is proclaimed as such by Emmerich ; its antiseptic action is forty times stronger than carbolic acid and does not coagulate albumin. I have proved it a very good disinfectant for external and internal use, and I would recommend it for the disinfection of serum. Certainly we must demand from the manufacturers of antitoxic serum that they must prepare the serum in an absolutely-pure man- ner, excluding totally the possibility of accidental pollution. It is not a good manner to dispense it in colored bottles. It can be protected against the light by dark coverings. " I am sure that all these precautions can be executed and will be executed in this land, in which I have seen as good bacteriologic work as anywhere in Europe." In the case of the sudden death of Professor Langerhans' child, the official report says "that previous to the fatal injection the child had taken dinner, followed shortly afterward by some milk and cake. Death took place during a severe fit of cough- ing, and the necropsy showed that the trachea and bronchi were entirely filled with a gray substance, which was proved by micro- scopic examination to consist of particles of food, a good deal of the same being still present in the stomach. The uvula was swol- len. The medical experts declare, therefore, that the child died from suffocation. They are of the opinion that the boy vomited after the injection, and that, being in a fainting state from the pain of the injection, he was not able to get rid of the vomited matter, but drew it into the larynx in the act of inspiration. They did not find any embolus of air in the pulmonary artery, as was 368 DISEASES OF THE EAR, NOSE, AND THROAT. suggested, nor was there any confirmation of the opinion that death had occurred by syncope. According to the statement of the Control Office, the serum was of normal quality." {Journal of the American Medical Association, July 11, 1896.) Reports of health commissioners of various cities give the results of the serum therapy as follow : In New York City the death-rate was reduced by antitoxin from an average of 33.93 to 21.16 per cent.; Indianapolis, from 26.29 to 13.36 per cent.; St. Louis, in 1894, with no antitoxin the death-rate was 28.2 per cent., and in 1895 the death-rate among those treated with antitoxin was 8.4 per cent. The Chicago Health Department reports (May, 1896) a reduction from 52 to 9 per cent. ; Boston, from 50 to 16. The Kaiser and Kaiserin Hospital, of Berlin, reports a reduction from 50 to 10 per cent., and the Willard Parker Hospital shows a mortality of only 10 per cent, under serum therapy (Neio York Medical Journal, February 15, 1896). In the Boston City Hospital the reduction in the death-rate was from 42 to 17 per cent. In the Johns Hopkins Hospital Bulle- tin W. H. Welch shows that, in 814 cases in which the serum was used before the third day, the percentage of deaths was only 5.5 per cent. Regarding the present status of medical opinion, an edi- torial in OaillarcVs Medical Journal for June, 1896, says : "The present status of the question undoubtedly justifies the early use in moderate quantities of a good preparation of antitoxin. We are not prepared to say the failure to use it under such con- ditions would be as easy to explain or to justify. The records of the last eighteen months have shown, throughout the whole civilized world, such a material decrease in the percentage of deaths from diphtheria where antitoxin has been used that the evidence of its value cannot be neglected, however much it may be questioned. Only last week one of the best-known prac- titioners in New York City, who has given special attention to this subject, both in this country and abroad, made a most bitter attack upon antitoxin as a therapeutic agent, the same writer having taken the same stand early in the days of antitoxin therapeusis. There were several others at this meeting who DISEASES OF THE PHARYNX. 369 gave their support to the speaker's views, and the question, therefore, becomes again one for earnest consideration and discussion." In an article published in June, 1896, J. M. French, in reviewing the first year of the antitoxin treatment, maintains that the harmless character of the serum has been demonstrated in more than 100,000 injections. " Taking all cases reported together, the practical result of the first year's use of antitoxin, so far as can be judged at the present time, has been to lessen the death-rate from diphtheria, in cases where it has been used, nearly or quite one-half, thus proving itself beyond all doubt to be the most successful of any known treatment for this dread disease. It is confidently pre- dicted that the results will be even more favorable the second year, owing to improvements in the methods of preparing, pre- serving, and administering the serum. There is also every reason to anticipate that the same success which now attends the treatment of diphtheria by the serum method will soon be attained in the cases of a number of other specific diseases." {Medical and Surgical Reporter.) The opinions and practice of Chicago general physicians are fairly represented by the following extracts from communi- cations to the editor of the North American Practitioner, J. H. Hollister, and published in April, 1896 : — H. M. Lyman : " I have seen no cases of diphtheria since the intro- duction of the antitoxin treatment of the disease, but, whatever may be concluded regarding the antitoxin treatment, there are certain measures that should never be neglected in the management of diphtheria : 1. The maintenance of general and local cleanliness by means of gargles, injec- tions, vapors, and sprays, so far as they can be used without risk of exhausting the patient, or terrifying him if a } T oung child. 2. The sus- tentation of strength by the frequent administration of milk, broth, eggs, and alcohol. 3. The encouragement of renal and intestinal elimination by the use of mercurials in small and frequent closes. 4. The avoidance of all drugs that are disagreeable and irritating, such as the tincture of the sesquichloride of iron, quinine, etc. "During the period of convalescence, especial^ if the patient has passed the period of infancy and early childhood, the treatment may be conducted in accordance with general principles. The occurrence of 24 370 DISEASES OF THE EAR, NOSE, AND THROAT. paralysis calls for special treatment of the neural inflammation by which it is caused." Wm. E. Quine : " Local Treatment. — None except poultices, which are recommended when there is much swelling of the lymphatics. I dis- approve strongly of the use of the brush and probang, and have come to regard the atomizer with indifference. " Internal. — In ordinary pharyngeal diphtheria my routine treat- ment consists of the administration of the tincture of iron, — 1 drachm in an ounce of a mixture of glycerin and syrup. Of this a teaspoonful is given for a dose, and never less than half a teaspoonful, even to an infant, every two hours or every hour, according to the severity of the case. The medicine is given undiluted, and no drink is permitted imme- diate^ after it. The object is to have it adhere to the affected parts. In case vomiting occurs, ^ or J minim of carbolic acid is added to each dose; and if vomiting persist, which is rarely the case, the treatment is stoutly maintained, nevertheless. Corrosive sublimate, chlorate of po- tassium, whisky, and quinine are not, in my opinion, important additions to the treatment. Laxatives are given as required. Recumbency is enjoined. Feeding is attended to with urgent insistence. " Antitoxin. — My experience has been limited to its use in eighteen cases of nasal and laryngeal involvement. In such cases I employ it at once, — ' Behring's No. 2.' I have not witnessed a failure, and have not seen any harmful result beyond the appearance of a transitory erup- tion on the skin in two or three cases, and the occurrence of transitory albuminuria in a like manner ; but, nevertheless, my respect for the observations of others, recorded and unrecorded, in relation to untoward events which must be ascribed directly to the influence of the antitoxin, holds me to a preference for the iron mixture in cases of uncomplicated pharyngeal diphtheria. " Formerly I regarded the atomizer as an important aid to treat- ment, especially of diphtheria of the larynx, and antiseptic injections, such as a weak sublimate solution, repeated every two or four hours, as indispensable to the efficient treatment of nasal diphtheria; but for t-he past year or so I have been falling away from these measures and relying on the antitoxin." J. A. Robison : " Prior to the introduction of the antitoxin treat- ment it was trul3 r said: 'there is no specific treatment for diphtheria.' But my experience recently in the use of antitoxin in five cases of true diphtheria has converted me to the belief that it is a specific. Antitoxin, in nry -opinion, is the prince of remedies. Yet there are cases in which I would not cease to emplo}^ the older methods of treatment." Frank Billings : " General Treatment. — The temperature of the patient to be controlled by frequent bathing with water. The bowels should be freely evacuated in the first twentj^-four hours by the use of calomel combined with sodium bicarbonate, in doses graded to the age of DISEASES OF THE PHARYNX. 371 the patient. Strychnia sulphate, in doses graded to suit the age of the patient, from the beginning to the end of the disease, as a general and as a cardiac tonic. Alcohol, in the form of sherry-wine, whisky, brandy, or rum to be used only in cases of great toxaemia, in frequently-repeated small doses, when used at all. In the great majority of cases it is not necessarj 7 , and I think it should be reserved as a final antitoxin. A diet fluid in form of milk, milk and egg, animal broths, gruels, koumiss, matzoon, or any modified milk. "Local Treatment. — The following plan gives me great satisfaction : A thorough cleansing of the pharynx and naso-pharynx with a solution of H 2 2 : for the pharynx diluted two or three times, for the nose and naso-pharynx five or six times ; by having the patient gargle or by spraying the pharj-nx, and b} r syringing the naso-pharj'nx through the nose. I believe in applying treatment through the nose as well as upon the pharynx in all forms of throat diphtheria. After cleansing with H 2 2 I use R Hydrarg. chlorid. corrosivi, . . . gr. T ^ to -£-§. Sacchari albi gr. iii to v. Misce ; triturate. Ft. chart, no. j. Signa : Apply dry upon the tongue every hour. " This does very well with all patients, and with children is taken readil} 7 ; it is applied directly to the pharynx and is also an efficient con- stitutional remedy and laxative. It is to be withdrawn if diarrhoea or bloody-mucous stools occur. " To the nose, after cleansing, appty with a syringe a solution of corrosive sublimate in water, 1 to 10,000, every two hours. " A steam-spray should be kept playing almost constantly over the head of the patient. R Acidi carbolici, 3j- Zinci snlphocarbolatis, 3j. Glycerini, gj. Aquae, q. s. ad ^iv. Misce. Signa : To be used in the steam-spray atomizer ; or R Glycerini, gj. Aquae calcis, 3iij. Misce. Signa : Use in the steam-atomizer. " These solutions remain suspended in the air quite a time, and seem to afford the patient much relief. " In case corrosive sublimate cannot be borne, I consider tr. ferri chloridi, 5U ; glycerini, §j ; aquae, giijj may be used in place of it; 3j every hour. 372 DISEASES OF THE EAR, NOSE, AND THROAT. " I consider antitoxin of great benefit in all cases, — greatest when used early in the disease. A maximum dose should be used in all cases and should be repeated within twelve hours. I would not hesitate to use it in a case, no matter what the complication. I believe, however, in carrying out a thoroughh T -planned local and general treatment, even when the antitoxin is used." A critical review of the great mass of evidence accumu- lated, both favorable and unfavorable, to the blood-serum therapy, a small fraction of which is here presented, forces the conclusion that the preponderance of evidence justifies the ver- dict that diphtheria antitoxin, administered early and in sufficient doses, — the first or second or not later than the third day of the disease, — has the power to prevent a fatal issue. Given later it may modify the intensity of the toxaemia if a multiple of the ordinary dose is given. Mixed infection, and invasion of the larynx demanding intubation or tracheotomy, lessen the chances of recovery. While the serum is a powerful remedy and may be capable of doing harm, the disease itself is so virulent that, in view of the great weight of testimony and statistics in favor of the anti- toxin, the physician should not fail to avail himself of this addition to thorough local and general treatment. CHAPTER XXXII. DISEASES OF THE PHARYNX, CONTINUED. Tonsillitis. Synonyms. — Quinsy ; amygdalitis ; phlegmonous sore throat ; angina tonsillaris ; ulcerative tonsillitis ; suppurative tonsillitis; abscess of the tonsil. Pathology. — This is an acute inflammation of one or both tonsils. There are three principal varieties: (1) simple catarrh, (2) ulcerative tonsillitis, and (3) abscess of the tonsil. Some authorities distinguish five varieties of this disease, but practically they are all variations of three types of inflam- mation. The inflammatory action may be of a mild catarrhal character and limited to the mucous membrane, or it may eventuate in superficial ulceration, or it extends to the sub- mucous tissues, with infiltration of the whole gland and the peritonsillar connective tissue. In the second and third forms the lacunae,, or crypts that indent the surface of the tonsil, are filled with micrococci, pus, and epithelium. Tonsillitis is most frequent in persons between the ages of 15 and 30 years, and especially among those of a rheumatic habit and with hypertrophied tonsils. The inflammation usually involves to a greater or less degree the pillars of the fauces and the uvula. They are red and swollen and the uvula elongated and troublesome (Plate V). The attack may termi- nate in resolution, ulceration, abscess, or hypertrophy. In the case of an abscess it may rupture near the superior and anterior portion of the tonsil in the vicinity of the arch of the palate. The orifices of the crypts may become obstructed, with the result of distending these cavities with the pent-up secretions. With regard to the bacteriology of tonsillitis, it cannot be said, at the present time, that the various forms of tonsillitis are caused by any special organism, although they may be traced to a microbic infection. A. Veillon {Archives de Medecine, March, (373) 374 DISEASES OF THE EAR, NOSE, AND THROAT. 1894) concludes that " pathogenic microbes may be found in all forms of non-diphtheric tonsillitis. The streptococcus pyogenes virulens was present in the twenty-four cases examined, and was usually associated with the less virulent pneumococci and some- times with staphylococci. The streptococcus appears to play the most important role in all cases. The different kinds of tonsil- litis are of the same nature. The clinical and anatomical differ- ences depend upon (1) whether the organisms affect the surface of the mucous membrane, its deeper layers, or the subjacent cellular tissue, and (2) the virulence of the microbes and the resistance of the subject." Etiology. — While tonsillitis is not usually met with in persons younger than 15 or older than 30 years, I have seen it above the fiftieth year. No age is absolutely exempt. Rheu- matism is an important factor in the production of this disease. A close relationship is often observable between attacks of tonsil- litis and rheumatism, one following or preceding the other — one subsiding as the other develops. Cold, damp, foggy, or change- able weather is a predisposing cause ; the presence of hyper- trophy and the history of previous attacks presage future ones. Unusual exposure is a frequent excitant of this as it is of other inflammations. The crypts are often found filled with caseous masses that excite inflammatory action. These cheesy plugs undergo decomposition and become acrid, irritating, and foul- smelling. Symptomatology. — Premonitory symptoms are : a heavy feeling akin to exhaustion, followed by a sense of feverishness, headache, and pain in the back and legs. Chilliness may be present during the first few hours and the temperature may rise to 103° or 105° F. by the second day. If the fever is very high it indicates that the deeper structures are likely to become the seat of an abscess. As the disease progresses, the tonsil becomes swollen and obstructive to deglutition; sensations as if a foreign body were in the throat, together with increased secretion of mucus, occasion frequent efforts to free the throat by swallow- ing, which becomes more and more difficult. All the surround- ing tissues now participate in the inflammation in the severe DISEASES OF THE PHARYNX. 375 type so that the velum and uvula are red, thickened, and sensi- tive. The elongation of the uvula to the extent that it hangs upon the tongue (Plate V) adds to the excitants of painful deglutition. When the inflammatory action extends to the orifices of the Eustachian tuhes and to the pharyngeal tonsil, impaired hearing, ringing, and even pain in the ears ensue. These symptoms represent the crisis of the simple catarrhal form of a severe character, and now begins an abatement of the inflammation, subsidence of the pain, swelling, difficult swallow- ing, and the membrane begins to assume a more natural color. In the second, or ulcerative, form, instead of an ameliora- tion of all the symptoms at the crisis of the inflammation, the mucous membrane softens and breaks down in spots. The surface of the gland is dotted with small, yellowish-gray points (Plate V) that coalesce and form irregular ulcers covered with a muco-purulent discharge. I have known physicians to mis- take this coating of the ulcers for a diphtheric exudate, but the deposit can be seen at first as limited to the orifices of the lacunae, and there is a wide difference between the two, even in macroscopic appearances. When the inflammation extends to the deeper structures speech is seriously interfered with, and it is difficult to articulate with sufficient clearness to be understood. The mouth cannot be opened on account of the pain and tumefaction about the angle of the jaw, and it may be well-nigh impossible to examine the pharynx, even with the aid of the forehead-mirror and tongue-depressor (Plate V). In this stage cold sweats and sleeplessness are sometimes experienced. Liquids regurgitate into the nose or find their way into the larynx, occasioning most violent fits of coughing and strangling. The cervical muscles sometimes become sore and tender on pressure. The continuous exertions necessary to clear the throat of secretions, which are not swallowed, but allowed to slaver from the mouth, serve to increase the distress. When the uvula can be seen, it is found clinging to the affected tonsil. While the secretion of saliva is increased, the urine is diminished in quantity and of high color. The breath becomes freighted with a fetid odor and the tongue 37b" DISEASES OF THE EAR, NOSE, AND THROAT. is furred with a yellowish-gray coat. The bowels are generally constipated. Mild attacks of tonsillitis may not extend beyond a week, but the severe form, which terminates in an abscess, is a tedious type. In the course of a week or ten days a chill denotes the formation of pus, and a little later, if the abscess is not opened, it breaks, usually in the throat, However, it may rupture externally at the angle of the jaw, or burrow underneath the cervical muscles, forming an abscess of the neck, or it may gravitate to the thoracic cavity. Diagnosis. — The characteristic symptoms described render a diagnosis comparatively easy. There is not much likelihood of confounding this disease with any other except diphtheria. In the latter disease the tonsils are not always swollen, and the false membrane is thick, leathery, and of much lighter color generally. Yet it must not be forgotten that the Klebs-Lofrler bacillus is sometimes found in the throat when there is no false membrane ; so that in suspicious cases a bacteriological exam- ination should be made. In the sore throat of measles and scarlet fever the distinguishing rash, the ease of opening the mouth, and the comparatively little enlargement of the tonsils clear up any doubt. Syphilitic sore throat does not present the intense group of symptoms of severe tonsillitis, and can be differentiated from the mild catarrhal form, in that fever and pain are generally absent and the difficulty of swallowing is not so prominent a symptom. Patches of redness, instead of the bright, diffused, red glow of acute tonsillitis, characterize the early stages of syphilis, while the secondary stage is mani- fest in the mucous patches and skin eruptions, and the tertiary stage in the deep ulcerations and an unmistakable history. Prognosis. — Simple catarrhal- tonsillitis usually terminates in resolution, running a course of about a week. It is often preceded or followed by a rheumatic attack of other structures, and may end in tonsillar hypertrophy. Ulcerative tonsillitis also tends toward recovery, but the possibility of invasion of other parts, such as the Eustachian tube and tympanic cavity, emphasizes the necessity for efficient treatment. Occasional ""' DISEASES OF THE PHARYNX. 377 deaths have occurred from tonsillar abscess breaking into the larynx or causing laryngeal oedema. The occurrence of an abscess lengthens the attack to two or three weeks and some- times longer. Local Treatment — Local applications of glycerin of tannin have proven effective in the simple catarrhal tonsillitis. I am aware of the opposition to this treatment by high authority (Lennox Browne), but I cannot ignore years of actual satis- factory experience with it. I have made it a practice to apply this remedy with a very soft, bushy camel's hair pencil every two or four hours. If there is considerable pain, a 10-per-cent. solution of carbolic acid in glycerin will afford a local anaes- thetic effect, besides depleting the vessels and acting as an anti- septic. I have found local applications of guaiacol useful. It appears to shorten the attack. If the pure drug is painful, it can be diluted one-half with glycerin. Gargles of alum-water and potassium bromide in 4-per-cent. solutions are grateful in some cases. Much refreshing relief is experienced after copi- ously spraying the throat with benzoinated lavolin or a 3-per- cent, solution of camphor-menthol (Figs. 118 and 119). The author's throat tablets have given excellent satisfaction. Each tablet contains & Amnion ii chloridi, Tincturae opii camplioratoe, Syrupi scillse compositi, Syrupi Tolutani, . Extvacti glycyrrhizse, . ;•■• '.]■ aa ITlv. . gr. iiss. These are allowed to melt slowly in the mouth, so as to prolong the contact of the remedies as much as possible with the inflamed membrane. Ulcerative tonsillitis should be treated with alkaline dis- infectant and antiseptic topical applications. Frequent sprays of hydrogen dioxide (peroxide), Dobell's and Seller's solutions, glycothymolin, listerin, paste urin, borolyptol, etc., will cleanse and disinfect the glands, after which a covering of aristol should be given with the powder-blower (Fig. 32). If an abscess is indicated by the severity of the symptoms, 378 DISEASES OF THE EAR, NOSE, AND THROAT. local cold should be used early by means of an ice-bag (Fig. 78) directly over the tonsil. As soon as the abscess can be discerned it should be opened instead of waiting for nature to accomplish this. Several days of extreme wretchedness will be spared the sufferer by this means. The knife should have a handle sufficiently long to not hamper one in his movements. The cutting-edge must be kept toward the median line so as to avoid wounding the internal carotid artery, which might occur by a sudden movement of the patient if the cutting edge were directed toward the artery. The abscess usually points near the arch of the anterior faucial pillar. For phlegmonous tonsillitis Gouguenheim {Lyon Medical, 1894) recommends Leiter's coil around the throat, leeches to the angle of the jaw, 20- to 33-per-cent. cocaine painted in the pharynx, irrigations with warm boric-acid solution, and salol or naphthol internally for an intestinal antiseptic. Tonsils that are subject to recurring attacks of inflamma- tion should be guillotined (see division on tonsillotomy). Constitut'umal Treatment. — When the pain is severe and swallowing difficult, I have seen the most gratifying relief attend the administration of a combination of morphia with atropia in the proportion of \ grain of morphia to ¥ ^ grain of atropia. This remedy relieves pain and irritability, dries up the excessive secretions that constantly excite efforts to swallow, and modifies the intensity of the inflammatory process. Patients to whom I have administered this for the first time, and who have been in the habit of passing through similar attacks for years, have remarked with unfeigned gratitude that they had never before received sucli relief from suffering during a siege of their malady. A laxative should be given at the onset of the attack, so as to open the bowels freely. Aconite enjoys quite a repu- tation in this disease, given in doses of 2 or 3 drops every half-hour. Potassium bromide, mentioned in connection with local treatment, has a beneficial sedative effect if some of it is swallowed after gargling with it, so that 10 grains every two or three hours are taken. The rheumatic character of this affection calls for such • DISEASES OF THE PHARYNX. 379 remedies as salicylic acid and antipyrin. If there is no reason why salicylate of sodium should not be given, it is to be pre- ferred. When it is well borne I give 10 grains every two hours until the symptoms become ameliorated or slight physiological effects are produced. A freshly-prepared solution should be used, for example, as follows : — & Acicli salicylici, 3iij- Sodii bicaruonatis, 3ij. Elixiris gaultheriae, ^ss. Glycerini, 3iij. Aquse, q. s. ad 3iv. Misce. Signa : One teaspoonful, iu water, every two hours. If salicylate of soda disagree with the stomach or cause ringing in the ears, salicin should be substituted in pilular form, 5 grains to be taken every two or four hours. Antipyrin in doses of 5 or 10 grains every three or four hours not only relieves pain, but possesses especial efficacy in rheumatic affections. Hypertrophy of the Tonsils. Synonyms. — Enlarged tonsils ; chronic tonsillitis ; follicular tonsillitis. Pathology. — Hypertrophy of the tonsils is a true hyper- plasia, according to Virchow, in which all the glandular ele- ments participate in the proliferous process. The increase and induration of the connective tissue is manifest in some tonsils at the time of excision, by the resistance to the passage of the guillotine through them, but in most instances they are yielding and sponge-like. The crypts are expanded and the walls tume- fied. Instead of a tenacious mucus filling the cavities there are often cheesy masses of a light-yellow color sometimes mixed with calcareous concretions. There is an increase in size and usually in number of the follicles surrounding the depressions. Norris Wolfenden {Journal of Laryngology, etc., August 18, 1894) reports the results of studies in follicular tonsillitis as follows : " Follicular tonsillitis is a desquamative process in the crypts of the tonsils, the follicles taking no part in the process 380 DISEASES OF THE EAR, NOSE, AND THROAT. and only exhibiting a secondary hypertrophy, as recently main- tained by Sokolowski and others. There are other forms of infective tonsillitis associated with the exudation of fibrin, the presence of streptococci, staphylococci, and pneumococci." In the follicular, or lacunar, tonsillitis the pseudomembrane shows staphylococci and streptococci and the pseudodiphtheric bacillus. It cannot always be distinguished from diphtheria except by bacteriological examinations. Kriickmann (Virchow's Arcliiv) confirms Hanau and other observers in the view that the tonsils are the portal of entrance for tubercle bacilli in cases of tuberculosis of the cervical lymphatic glands. Etiology. — Hypertrophied tonsils are found in the very young so often that they may be spoken of as being congenital, but in many instances they develop about the age of puberty. The largest number of cases are seen between the ages of 10 and 20 years, the next largest under the tenth year, and those occurring between 20 and 30 years are next in frequency. After the thirtieth or fortieth year tonsillar hypertrophy is rather infrequent, for their growth ceases and the process of atrophy sets in about the thirty-fifth year. Nearly twice as many males are affected as females. The rheumatic habit ; living in a damp, cold atmosphere ; recurring attacks of inflammation, the throat complications of the eruptive diseases, diphtheria, syphilis, and the strumous diathesis are all productive of those conditions that predispose to an increase in the volume of these glands. After the thirty- fifth year I do not advise the removal of the tonsils unless there is some special reason for it, since their gradual diminution in size and tendency to inflame dates from about this period of life. Symptomatology . — The appearance of a child with enlarged tonsils often presents a picture which suggests at once the nature of the trouble. Previously to an examination of the throat one is often able to predict the condition to be found. The under jaw drops, the mouth remains continuously open, the eyelids droop, and the face is expressionless and suggestive of a dull intellect. During sleep the respiration is noisy and of a snoring character. DISEASES OF THE PHARYNX. 381 Associated with hypertrophied tonsils in a large proportion of children so affected will be found an enlargement of Luschka's tonsil, or adenoid vegetations in the vault of the pharynx. In these associated diseases with obstruction to the current of air through the nose by adenoids and the backward projection of the oral tonsils, and to the passage of air through the mouth by the blocking up of the fauces with the oral tonsils, the aeration of the blood is seriously interfered with. The effects on the voice are readily apparent. The resonance of the nasal cavities is so diminished that speech has a thick, unnatural nasal quality, and the articulation of words is impeded and difficult (Fig. 148). The tonsils are situated in such close relationship to the Eustachian orifices that any disease of the gland threatens im- pairment of the integrity of the Eustachian tubes and middle ears. While the tonsils are not so situated as to produce actual pressure upon the tube-mouths, as was formerly supposed, any inflammatory action affecting the gland readily extends by con- tinuity to the tubal membrane. The large number of patients with hypertrophied tonsils suffering from middle-ear diseases is suggestively significant. Mackenzie and others speak of defective smell and taste in tonsillar hypertrophies. Great embarrassment of the respiration may interfere seri- ously with the general health, and in very young persons, or those with a tendency to rickets, the chest-walls may become deformed, resulting in pigeon-breast, or a pyriform deformity. Inspection of the throat reveals the tonsils tumefied (Plate V) and in some instances so enormously enlarged as to lie in contact with each other and to cut off a view of the posterior wall of the pharynx. They are generally very red, soft, and yielding, and can be crowded through the fenestra of a tonsillo- tome so small that it would seem impossible. Diagnosis. — A view of the pharynx under good illumina- tion is sufficient to establish the diagnosis. There is a possi- bility of mistaking an enlarged tonsil for a pharyngeal abscess, but the chances are remote. The location of the tonsil and, if necessary, palpation with one finger on the tonsil and another 382 DISEASES OF THE EAR, NOSE, AND THROAT. over its base under the angle of the jaw, would distinguish the location and character of the tumor. Prognosis. — Probably the vast majority of hypertrophied tonsils are never removed or even treated, yet it is the exception to see them after the thirtieth or fortieth year. This means that there is a natural reduction to the normal size after adolescence or middle life. However, there are many individuals with im- paired hearing that is attributable either directly or indirectly to the presence of tonsils that have been subject to repeated attacks of inflammation. In adult life I rarely advise their removal unless they are provocative of some disturbance, for in many they occasion no inconvenience. But I have seen persons in middle life who were subject to so much suffering from attacks of quinsy that they sought relief by excision. It must not be forgotten that the lacunae of the tonsils, from twelve to eighteen in number for each gland, offer nides for the reception and culture of micrococci that may give rise to more serious trouble. These depressions are sometimes very deep, plunging down into the parenchyma of the gland, and form an ideal nest for the development of micro-organisms. There are warmth, moisture, decomposing secretions, and a harbor from the cur- rents of air or friction of fluids and food that might otherwise dislodge them. Treatment — Iodine internally, astringents to the surface of the tonsil, and injections of various drugs into the body of the gland are recommended for its reduction, but they are all inane makeshifts that worry the patient without benefit to any one but the doctor. The tonsil should be removed in its entirety. My aim has always been to cut it clean off at the base so as to get below the bottoms of the crypts and leave a smooth surface for the stump. Tonsillotomy. — Before operating for excision of the tonsil the throat should be sprayed with an antiseptic wash, such as dioxide of hydrogen or mercuric bichloride, — 1 to 10,000, — to remove or destroy any microbes that may be present. I rarely paint the parts with cocaine, for the reason that it is not a very painful operation. The gland is not freely supplied with nerves DISEASES OF THE PHARYNX. 383 of sensation. But in very finical individuals it may be neces- sary to employ a weak solution for the purpose of a placebo. Occasionally I have been obliged to use the bromide of ethyl, removing both tonsils and adenoids during one anaesthesia. The patient, if a young child, is seated on the lap of an assistant or a nurse. One arm of the latter pinions the arms of the child, and with the other hand the patient's head is held back against the nurse's shoulder by pressure on its forehead. A convenient method is to infold the child in a sheet, which is made to fix immovably the arms and legs (Fig. 150). Now the tonsillotome (Fig. 155) is introduced into the mouth like a Fig. 155.— The Author's Tonsillotome, with Excised Tonsil. tongue-depressor, then slipped to one side with a turn that causes the ring of the opening to surround the tonsil. Suf- ficient pressure is then brought to bear to cause it to embrace the tonsil at its base. An assistant should press with his thumb or finger upon the side of the neck just over the base of the gland so as to prevent it from receding from the instrument. This counter-pressure need not be great, but simply sufficient for support. As the instrument is pressed into position, the operator's thumb drives the blade through the gland until the 384 DISEASES OF THE EAR, NOSE, AND THROAT. cutting-edge of the guillotine rests between the ring-plates. This act completely severs the tonsil and secures it between the bevel of the knife and the upper ring-plate. Care must always be taken to cut the tonsil clear through before withdrawing the instrument. Tonsillotomes. — Any physician who has had a considerable experience in tonsillotomy with the various tonsillotomes will not be likely to deny that these instruments are generally too complicated. They are armed with needles, barbs, or sharp- toothed forceps for piercing the tonsil and dragging it through the fenestra before any cutting is done by the blades. A tonsil- lotome constructed after the pattern I have made renders the barbs unnecessary. It reduces the painfulness of the operation by one-half; it divests the procedure of any danger of an accident to the operator or patient; it makes a skillful and easy operation possible with a minimum amount of experience ; it resembles a large, folding tongue-depressor so closely that children usually offer no opposition to its introduction for the removal of the first tonsil ; and it combines strength and compactness with simplicity of construction. It is made on the principle of a guillotine, the blade of which is propelled by the thumb of the same hand that grasps the handle. The latter is set at such an angle to the shaft as will permit the most perfect co-ordinate action of the muscles of the hand and arm of the operator. All the work may be done with one hand. This advantage is not a small one, for two reasons : the powers of co-ordination and antagonism of muscles are far more perfectly under control in operating an instrument which requires but one hand than they are when both hands must co-operate, and one hand of the operator is left free to hold the head of the patient, if necessary, as the dentist does in extracting a tooth. The advantages of a tonsillotome that can be operated entirely by one hand are about the same as in a tooth-forceps which does not require two hands to manipulate. I have had two sizes manufactured, the smaller having a fenestra of the calibre ordinarily found in such instru- ments, the other supplied with an aperture larger than the largest Mackenzie tonsillotome, while it is so compactly con ;on- DISEASES OF THE PHARYNX. 385 stmcted as to require less space in which to operate. I have used the larger size to extirpate enormously hypertrophied ton- sils in children as young as 2J years, where it was impossible to insert the Mackenzie instrument of the necessary size. The smaller one is sufficient for the majority of cases, but the fen- estra is not capacious enough to admit the bases of the extraor- dinary glands we occasionally see. It is advisable to remove the whole tonsil, and, as the tops only of the largest tonsils can be severed with the smaller instruments, it may be better to have the larger size, if but one is to be kept. The blade is so protected as to make it impossible to wound the ascending pharyngeal or the internal carotid artery. The shaft that propels the blade is of such a width as to make the use of a gag unnecessary, for it protects the finger of the oper- ator from the patient's teeth, if it is placed in the mouth to ascertain when the fenestra is in such a position as to embrace the whole tonsil, as it is necessary for one to do when operating in children with other tonsillotomes. Since I have used this guillotine I have not had my finger bitten, while it was not an uncommon occurrence, before, to come off second best so far as pain was concerned. With the shank wide enough to afford protection, it is unnecessary to introduce the finger into the mouth, for the teeth and lips cannot close enough to prevent the operator from seeing plainly the field of operation. There is no working in the dark or fear of damaging structures one does not wish to attack. The handle is firmly fixed to the shank with a hinge-joint and self-acting spring-lock; so that the fenestra can be pressed down about the base of the gland with any degree of power required. This feature dispenses with any necessity for hooks, forceps, needles, or barbs for spearing the tonsil. The latter, being a soft, fleshy mass, adapts itself to the shape of the fenestra and protrudes through it the instant its base is pressed around. The pain of spearing or tearing the tonsil by toothed or barbed accessories, designed to drag the gland through the fenestra before the blade cuts, excites the most vigorous strug- gling and resistance on the part of a child. Even when the 25 386 DISEASES OF THE EAR, NOSE, AND THROAT. utmost care has been exercised, the barbs have pierced the soft palate or the surgeon's finger, instead of the tonsil. Moreover, the gland always comes out with this instrument, the same as though barbs were used. There is another important advantage in having the handle attached to the shank with a hinge pro- vided with an automatic lock, for the cutting extremity of the instrument cannot be thrown out of your control by a disturb- ance of the coaptation of its parts. The last time I operated with a Mackenzie tonsillotome the child jumped just as I was placing the fenestra about the tonsil. The shank revolved upon the handle, leaving the latter in my hand, while the cutting-end was entirely displaced and removed from the vicinity of the gland. It is impossible for this improved tonsillotome to play such a trick. The handle contains a concealed spring-lock operated by a convenient thumb-plate. When this is moved downward, the hinge-joint is unlocked and the instrument folds upon itself like a pocket-knife, occupying the space of about one and one-fourth inches in width and thickness by six and one-half inches in length. Another pertinent point, that should not be neglected in this age of antisepsis, is the provision for cleansing and disinfecting the three pieces of which the instrument consists. By raising the proximate end of the hori- zontal top spring of the shaft and swinging it 90 degrees to either side it becomes disengaged from its lock and liberates the blade from the shank. This arrangement makes it as simple as possible for taking apart, sterilizing, and putting together again. In amputating the apex of a relaxed and elongated uvula the blade is inverted. It is claimed by some operators that the remnant of the tonsil will become atrophied if the apex only is clipped, but I have never been able to find a good reason for half-doing the operation. I have never seen any but healthful results from ridding the throat of the whole trouble at once. There are cases in which one may be in doubt as to whether the gland ought to come out or not, because there is but slight hypertrophy, and the appearance of the throat does not seem to warrant surgical interference. But those same glands may be honey-combed with deep, slit-like crypts that are DISEASES OF THE PHARYNX. 387 packed with inspissated, decomposing, irritating, caseous secre- tions that start the attacks of sore throat that make the patient's life a burden. It is a good rule never to part with the patient until one is sure that all oozing of blood has ceased. I have seen only one case of very severe haemorrhage, but as a number of such in- stances are on record we must always be alert for them. In the case of a student at the Illinois Medical College, a young man of 24 years, I had my first experience with profuse haemorrhage from this procedure. After I had operated on a number of children during the clinic and had sent them to the treatment- room to wait until all signs of bleeding ceased, the student re- quested me to operate on one of his tonsils. On examination I found it only slightly hypertrophied, and remarked that I did not generally remove glands so little enlarged. However, he insisted that he had suffered all his life from recurring attacks of inflammation, and was anxious to part company with the cause of them. Thereupon I excised it, but was struck with the very unusual amount of resistance offered to the cutting-blade. It seemed like forcing it through creaking leather. As the student left the operating-chair I proceeded with my remarks to the class as follows : " The haemorrhage has entirely ceased in all the children and they can now go to their homes. I have removed a large number of tonsils in my various clinics and in private practice without seeing a case of persistent haem- orrhage. I have never had to use anything to stop the bleed- ing. It generally ceases within five or ten minutes sponta- neously. But in case of severe haemorrhage, what would you do ] Excellent remedies are to be had in a saturated solution of tannic acid in water ; an ice-cold gargle ; pieces of ice held in the back of the mouth in contact with the bleeding surface ; ice applied to the neck over the tonsil ; powdered alum rubbed into the tissues ; a strong solution of iron persulphate applied on cotton or with the finger ; 2 drachms of gallic acid with 6 ; drachms of tannic acid to the ounce of water ; pressure by for- ceps both externally and internally upon the tonsil, and firm compression of the common carotid artery. This compression 388 DISEASES OF THE EAR, NOSE, AND THROAT. reduces the supply of blood to the tonsil-stump and encourages faintness, and with fainting the haemorrhage will probably cease. " There is more bleeding in this young man's case than I have ever seen. It does not diminish. In fact, there is a con- stant stream of blood flowing into the basin. It looks as though we were to have our first experience with a persistent tonsillar haemorrhage. I will send for ice, and exert firm, deep com- pression on the common carotid. The pallor of countenance and the beads of perspiration show the effect of the loss of blood. The profuse haemorrhage is probably due to the fact that the recurring attacks of inflammation during the past years have left the gland in an indurated, fibrous condition, which prevents collapse of the blood-vessels. There is no history of an hemorrhagic diathesis. We will deprive the vessels of their blood-supply until coagula form and plug their open mouths, and keep him in a sitting posture to assist in this and to pro- mote faintness. We will not allow him to gargle fluids for fear of washing away any clots that may form, but give pellets of ice instead. "It is now forty minutes since the tonsillotomy and all haemorrhage has ceased. The young man's room-mate will keep watch over him and inform us if there should be any re- turn of the trouble, although I do not anticipate it if he remain perfectly quiet in bed the remainder of the day. He complains of feeling faint. " This incident illustrates the necessity of always being pre- pared for emergencies. The most successful soldier, lawyer, or doctor is the one whom you can never surprise." The young man had no further haemorrhage and made an excellent recovery. After these operations patients are given a spray of camphor-menthol in lavolin, 3 per cent., for use at home four or six times a day until all soreness ceases. H. W. Loeb removes the tonsil with the hot snare. He believes that by removing only a small portion a cure through cicatricial contraction is effected. Jonathan Wright has devised a galvano-cautery instrument fashioned after the guillotine tonsillotome. CHAPTER XXXIII. DISEASES OF THE PHARYNX, CONTINUED. Mycosis of the Pharynx. Synonym. — Pharyngomycosis. Pathology. — This is a very rare parasitic disease of the superior pharyngeal space, including the tonsils. Small, white or yellow growths appear, projecting above the mucous mem- brane, instead of occupying a recessive position, as is the case with tonsillar concretions. They may invade the lacunae, but are not confined to them. They spread upon the soft palate, the pharyngeal membrane, and base of the tongue. As I have seen it, the growth is not soft like the cholesteatoma of the tonsil, but tough and somewhat difficult to remove in its en- tirety. It has, in some instances, a fungoid appearance, and penetrates the mucosa to such a depth as to prevent its removal with a probe. Etiology. — The cause of this disease is obscure, but the microscope reveals the leptothrix buccalis, which finds a habitat in carious teeth. Symptomatology. — No conspicuous symptoms are produced by this disease, but patients discover the growths accidentally and apply to have them removed. Diagnosis. — The diagnosis is easily made, since the symp- toms of inflammation characterizing pharyngitis, tonsillitis, etc., are wanting. It is distinguished from tonsillar concretions by the prominence of the growths and their location without the lacunae. Prognosis. — The tendency is not toward a spontaneous cure. The disease is very pertinacious and, like the regenera- tion of the drum-head, these growths often reproduce themselves as fast as they are removed. Treatment. — If caries of the teeth is found it must receive attention. Delavan uses the curette and follows this with the (389) 390 DISEASES OF THE EAR, NOSE, AND THROAT. galvano-cautery. After removing the fungi the membrane should be sprayed with undiluted hydrogen dioxide or mercuric bichloride, 1 to 10,000. Each growth should be treated as has already been recommended for enlarged pharyngeal follicles, using cocaine and then cauterizing half a dozen points at one sitting. In a monograph on pharyngomycosis leptothricia benigna, published in the New Yorker medizinische Presse, December, 1886, Max Toeplitz reviews the literature of the subject. Carbolic acid, sesquichloride of iron, and the sublimate solution, 1 to 2000, are recommended. Toeplitz uses the curette and galvano-cautery. Homer M. Thomas reports success from the galvano-cautery. Concretions in the Tonsil. Pathology. — The crypts of the tonsil are sometimes filled with an accumulation of dried secretions that consist mostly of carbonate and 'phosphate of lime in the hard variety, and of a cholesteatomatous mass in the soft deposits. The latter consist of cholesterin, epithelial cells, pus-corpuscles and micro-organ- isms. The hard concretions are called chalky or cretaceous concretions or calculi, and the soft ones cheesy or caseous deposits. These conditions are comparable to certain diseases of the ear that have been considered : cretaceous deposits in the drum- head and cholesteatoma of the tympanic and mastoid cavities. Etiology. — Tonsillar deposits are due to an inflammation of the walls of the lacunae. Symptomatology. — The symptoms are not of a troublesome nature. A sensation of irritation or fullness, especially when swallowing, may be the only unusual thing to be noticed. The deposit can generally be seen as a cheese-like point, and several will likely be found by a careful examination. Sometimes they will be overlooked unless hunted for by a blunt-pointed probe to depress and bring forward the mouth of each opening. The difference in the consistence of the masses is readily detected by the sensation imparted through the probe. Patients often observe these concretions in their sputa, with which they have been expelled in the form of little, yellowish balls. Their pres- Fig. 156.— Adhesion of Soft Palate to the Posterior Wall of the Pharynx. The Resulting Diaphragm is Perforated Behind the Uvula. (The Author's Case.) DISEASES OF THE PHARYNX. 391 ence is a menace to the health of the gland, for they degenerate into irritating excitants of inflammatory processes. Treatment. — With the tongue depressed these concretions are removed without much difficulty by the curette (Fig. 75). If they are reproduced the crypts should be treated to the hot electrode or some other cautery. Non-malignant Tumors of the Pharynx. Tumors of the pharynx are not of frequent occurrence. I have seen many papillomata springing from the velum palati and uvula, varying in length from five to ten millimetres, but of pretty uniform diameter, this being about one-half their length. Fibroid and fatty tumors are rarely found, but such cases are recorded. They take their origin from the mucous or sub- mucous tissue, from the lymphatic glands, or from the perios- teum of the base of the skull or vertebrae. Symptomatology. — A papilloma occasions no discomfort. The patient is not aware of its presence until informed by the examiner. If the growth attain a considerable size it embar- rasses respiration and swallowing, or, if it reach to the epiglottis, it provokes a cough. Treatment. — If papillomata give trouble they are easily removed by the snare or galvano-cautery. Other tumors must be treated similarly according to the exigency of each case. Adhesions of the Soft Palate to the Pharyngeal Walls. Adhesions of the soft palate to the posterior wall of the pharynx sometimes occur, as shown in Fig. 156 and Plate VI. In my case, shown in Fig. 156, the young lady's throat is divided into a superior and inferior portion by an adventitious mem- brane consisting of extensive adhesions between the posterior columns and arch of the palate, on the one hand, and the lateral and posterior pharyngeal walls, on the other. An oval aperture is seen behind the uvula, through which nasal res- piration takes place. The only inconvenience suffered is the 392 DISEASES OF THE EAR, NOSE, AND THROAT. lodgment of particles of food behind the new membrane. This aponeurosis, or pharyngeal diaphragm, is the result of the throat affection attending scarlatina which she had when a small child. Uyulitis. Inflammation of the uvula is sometimes more intense than the inflammatory action affecting the remainder of the pharynx. The swelling, oedema, and elongation of the uvula then consti- tute the conspicuous features of the disease. It increases to several times its normal proportions and hangs pendent upon the tongue, down toward the larynx. In this condition it gives rise to frequent swallowing and coughing. Treatment. — If the uvula is much elongated (Plate V) it should be clipped, with care that not enough be amputated to leave it too much abbreviated when swelling recedes and con- traction takes place. I have known it to be completely removed by mistake, probably on account of the operator's poor sight, and the articulation of words Was perceptibly defective. On the other hand, I have known syphilis to destroy it without producing this effect. Malformations of the Uvula. There has recently been some discussion in the medical journals relative to a deformity of the uvula known as " bifur- cated" or " double" uvula, conveying the impression that it is a very rare anomaly. I have seen quite a considerable number of such instances and do not regard them as extremely rare or of clinical importance. The journal writers have advocated imme- diate amputation of the supernumerary appendage, but as I have never been able to elicit any information that they were the cause of suffering or trouble of any kind, and, as the owners of this extra appendage were entirely innocent of a suspicion that there was an unusual condition of their throats, I have never deprived them of this heritage. Papillary growths on the uvula are occasionally found, and should be removed if they cause irritation. Plate VI PLATE VI. Figure 1. — Male, set. 23; acute pharyngitis. Figure 2. — Male, set. 44 ; simple chronic pharyngitis. Figure 3. — Male, set. 21 ; follicular pharyngitis ; galvano-cautery to follicles. Figure 4. — Male, set. 67 ; atrophic, or dry, pharyngitis. Figure 5. — Normal appearance of pharynx, uvula, and palatal folds. e, Soft palate. o, Posterior pillar. /, Uvula. p, Anterior pillar. n, Posterior wall of pharynx. Figure 6. — Male, set. 23 ; tuberculosis of pharynx. Figure 7. — Male, set. 28 ; retropharyngeal abscess. Figure 8. — Male, set. 29 ; syphilitic ulceration of pharynx and soft palate ; mercury and iodide of potassium ; local applications of iodoform and morphia ; afterward cauterized with mitigated stick. Figure 9. — Male, set. 20 ; adhesion of soft palate to posterior wall of pharynx, following syphilitic ulcerations ; perforation of soft palate, enabling patient to breathe through the nose . [Note.— Represented as seen by gaslight. By daylight the red color appears much paler.] Plate F. Syous, Pmvt Burk&M c reir,Q e Lith.Ph* a diseases of the pharynx. 393 Tuberculosis of the Pharynx. Tubercular invasion of the throat is of infrequent occur- rence. Pathology. — A granular condition of the mucous membrane of the pharynx, with areas of a gray color, precedes the break- ing down of the epithelial layer that ushers in the stage of ulceration. The ulcers are superficial, of irregular forms, and ill-defined. Like a granulating wound, they respond to the touch by bleeding. Etiology. — The throat invasion is generally secondary to the same affection of other organs. Symptomatology. — The cough, constantly-elevated tempera- ture and accelerated pulse, loss of appetite and the characteristic expression of countenance, pallor of skin, and habit of body point toward the invasion of the great white plague. If the lungs are involved there will be expectoration, with cough ; if not, the cough may be, at first, dry and hacking. The most conspicuous and distressing symptom is pain, especially during movements of the muscles concerned in deglutition and speech. The proper nourishment of the patient is interfered with by the difficulty and pain experienced in swallowing. He will refrain from taking food as long as possible, in order to escape the torture of eating. Inspection reveals the granular, or ragged, ulcerated condition of the mucous membrane already described (Plate VI). Diagnosis. — Tubercular throat must be distinguished from syphilitic ulceration. The history of syphilis and the family history of tuberculosis must be sought. The latter disease is usually one of adult life, while syphilis, especially the congenital form, may occur in children. Syphilis is not attended by fever, and generally not by pain or difficult swallowing. Its ulcers are clearly denned, with red areola and clean-cut borders pos- sibly undermined. The ulcers of tuberculosis are shallow, ragged, and pale. They differ from scrofulous ulcers in that the latter are deep, with well-marked borders, and pain, fever, and cough are generally absent, while the muscles of phonation and deglutition cause little or no pain by their movements. The 394 DISEASES OF THE EAR, NOSE, AND THROAT. scrofulous affection occurs mostly in children in whom there are no evidences of tuberculosis. Prognosis. — This is an acute affection that proves quickly fatal from exhaustion. The average duration varies from six weeks to six months, but it may be prolonged much beyond the latter time. Treatment. — For the relief of the most prominent symptom, pain, Sajous strongly recommends the application of a 10-per- cent, solution of cocaine, after cleansing the ulcers with a borax solution of 1 per cent, in the form of a spray (" Diseases of the Nose and Throat," 1892). He deprecates cauterization with silver as more hurtful than beneficial. Steam-inhalations of hot infusions of opium, belladonna, hyoscyamus, and conium pro- duce a soothing, sedative effect and render swallowing less painful. A solution of creasote and menthol in lavolin, in the proportion of 2 per cent, of creasote to 10 per cent, of menthol, makes an excellent topical remedy. Iodoform insufflations have proven beneficial, but aristol is preferable. It is devoid of a disgusting odor and taste, is slightly anaesthetic, and adheres to the surfaces of the ulcers better than any other powder. Before applying any of these local remedies the discharges covering the ulcerated surfaces must be washed off by such an alkaline spray as Dobell's or Seller's. A solution of sodium bicar- bonate, 3 grains to the ounce, is also useful for this purpose. The cauterization of tuberculous ulcers by acetic acid, as practiced by Krause, is probably productive of more benefit than any other method. The ulcers are treated similarly to lupus. After cleansing and cocainizing them the acid is rubbed in by means of a cotton pledget, using a solution of 20- to 40-per- cent, strength, to begin with, and increasing the strength rap- idly to 80 and 100 per cent. As fast as the eschars become detached, which they do in a few days, the treatments are repeated, until the process of cicatrization is seen to begin. If the tubercular granulations are covered with mucous membrane, the latter must be incised to give the acid access to the lesions beneath. Heryng uses sharp curettes to scrape away projecting masses of tumefied tissues. DISEASES OF THE PHARYNX. 395 Cicatrization sometimes follows this method, but close watch must be kept for renewed breaking out of the disease in either the cicatrices or at new points. J. Solis-Cohen condemns galvano-cauterization as injurious "except under the most skillful manipulation." Ingals uses either the following spray or morphine troches : — R MorphisB sulphatis gr. iv. Acidi tannici, Acidi carbolici, aa gr. xxx. Glycerini, Aquse dest., aa f ^ss. Tuberculin and tuberculocidin have not fulfilled the expecta- tions of the profession. The former has proven positively harm- ful, and since patients do as well under other forms of treatment as with the use of the latter, their employment is not recom- mended. Creasote has been largely used internally and applied locally in recent years, and, while undoubted benefit has accrued from its use in the hands of eminent practitioners, there are some who discourage its employment. However, in a disease so intractable, and discouraging to both patient and physician, as this must be admitted to be, whatever has proven beyond cavil and reasonable doubt to have been helpful in treatment is worthy of trial. Great caution is necessary in its administration to patients who have high temperature or haemorrhages. It is given in doses of 1 to 10 minims or more three times a day, preferably in milk, as recommended by Glasgow. It can be given at any time with reference to meals, but is best taken before meals if well borne, since it then exercises a preservative influence upon ingested food against the process of decompo- sition. The effect of this upon the promotion of nutrition is apparent. Creasote is readily taken in the form of capsules, or it may be combined with alcoholic or tonic preparations, as used by Cohen. The feeding of this class of patients is an important subject. When the high temperature does not forbid much animal food, 396 DISEASES OF THE EAR, NOSE, AND THROAT. as much should be consumed as is consistent with good digestion. Milk, cream, codliver-oil, eggs, and vinous stimulants support the strength, improve nutrition, and prolong life. Added to these, the vegetable bitter tonics, iron, and quinine act as valu- able aids to enrich the blood and increase the general tone of the body. An out-door life in a high, dry, sunshiny, warm climate with equable temperature is conducive to the improvement of these patients, especially when combined with proper protection of the body by woolen underwear and a healthful employment of the mind and body in a cheerful or useful occupation. The most favorable climates are those of Southern California, Ari- zona, and New Mexico. Robert Levy says of Colorado : " I cannot add that our Colorado climate, so beneficial to pulmonary and, at times, to laryngeal phthisis, has any remedial influence upon pharyngeal tuberculosis. Miliary tuberculosis, with which tubercular ulceration of the pharynx is often associated, pre- sents'no encouragement in any climate, but in our high altitude it is my conviction that cases so afflicted decline very rapidly. The climate can only be of value in such cases as present no evidences of miliary tuberculosis or advanced disease, either local or constitutional." {Denver Medical Times, June, 1896.) Syphilis of the Pharynx. Although the throat is subject to the manifestations of syphilis in the three stages of that disease, the primary lesion is not often observed in this locality. The history of chancre in the pharynx is similar to that of the same ulcer in other localities, with a duration of about six weeks. The secondary lesions are of frequent occurrence and the characteristic mucous patches are readily recognized. The tertiary stage is repre- sented by the presence of gummata or eroding ulcers. The congenital form generally shows itself about five or six weeks after birth by the appearance of secondary lesions, and the tertiary stage at any time preceding the fifteenth or sixteenth year. Pathology. — Chancres are generally found on one tonsil, Fig. 157.— Destruction of Velum Palati. DISEASES OF THE PHARYNX. 397 while the secondary and tertiary lesions show a special predi- lection for the soft palate. The syphilitic eruptions of the throat are similar to those occurring in other parts of the economy and are often coincident with them. In the early stage papular ele- vations make their appearance, the epithelial covering of which becomes eroded ; or erythematous patches occur in the form of a blush or mere hyperemia of transitory duration ; or the epi- thelium of these areas becomes exfoliated, leaving a denuded, pus-secreting mucous membrane beneath. These mucous patches now assume an ashy-gray color, with a rough, granular surface. They are eruptions of the secondary period of syphilis and extend their boundaries so as to invade a large territory in a comparatively brief period. They are surrounded by a red areola and a well-defined border, and there is a copious, yellow, purulent, nasty discharge from them. In the tertiary stage the ulcers are deeper than the mucous patches of the secondary period. The infiltration extends to the whole depth of the membrane and results in irregular thick- ening and induration in the form of nodules or gummata. If these are incised in the early stage they exude a glairy fluid. In time they degenerate into a caseous mass, which becomes sur- rounded by dense connective tissue. They are closely analogous to tubercle, but differ from the latter in their greater tendency to the formation of connective tissue. The increased proliferation of connective tissue produces pressure on the blood-vessels that supply the gummata with nutrition, thus cutting off their own nutrient sources. Breaking down and softening follow in each gumma, presenting a yellow spot which is soon the seat of an ulcer. The mucous patches of the secondary stage are superficial and may end in resolution with contraction of the tissues as the cicatrix forms. The tertiary ulcers may occur in any part of the pharynx. They extend rapidly and deeply, perforating the pillars of the fauces or the velum (Plate VI) in a few days, and gradually eating away the whole velum, uvula, and faucial columns, as illustrated by one of my cases in Fig. 157. Etiology. — The specific virus of syphilis is yet one of the 398 DISEASES OF THE EAR, NOSE, AND THROAT. unknown quantities in medicine notwithstanding the fact that a considerable percentage of humanity are, or have been for many generations, infected by it. The occurrence of the pri- mary lesion in the mouth or pharynx is generally in conse- quence of kissing or of using utensils not thoroughly cleansed after having been used by syphilitics. They may also result from certain practices of sexual perverts. The secondary stage of syphilis is quite generally accompanied by throat lesions, and next to the genital organs the throat is the most frequently affected. Tertiary manifestations may crop out in the pharynx a quarter of a century after the appearance of the initial sore, but the average interval is about seven years (" the perfect number " %). Symptomatology. — The primary lesions of the throat are attended with so slight a disturbance that they are altogether likely to be overlooked. The submaxillary lymphatic glands may be enlarged and tender to the touch. Inspection discloses a red, or perhaps a gray, denuded spot with prominent edges. It generally disappears spontaneously. As already remarked, the initial lesions are mostly found on the tonsil. Fournier {Bull. Med., Nos. 9 and 10, 1895) "recognized syphilitic ulcer of the tonsil in 40 per cent, of his cases of ulcers of the mouth. The sore is generally single, and sometimes covers the whole tonsil, occasionally extending to the pillars of the fauces and to the base of the tongue. The erosive form is the most common. The symptoms are trifling, but the ulcer- ative form causes pain and difficult swallowing ; the ulcers are brown, gray, or yellow and the tonsil is indurated." Occasion- ally there is some systemic disturbance. Secondary symptoms manifest themselves as an erythema or as mucous patches on one or both sides of the throat. The erythematous eruption occurs either in blotches, suggestive of the roseola, or it may appear as a diffused redness spreading over the whole pharynx. This stage is attended with the usual symptoms of simple sore throat. After a few days, distinct patches are clearly made out on the anterior columns or on the velum and other parts of the throat or mouth. The sides of DISEASES OF THE PHARYNX. 399 the tongue near its base are especially liable to suffer. At first these mucous patches appear as slight, rounded elevations of a dark- red color. Their centres soften and break down, leaving a characteristic, slightly-cup-shaped excavation, which later as- sumes a gray color. In this stage swallowing is attended with pain. The tertiary lesions generally begin by attacking one tonsil and the adjacent faucial pillars. The nodular and gummatous points begin to show signs of breaking down, then the epithelial layer covering them grows thin, revealing a yellow spot under- neath. Finally the epithelium is exfoliated, exposing an ulcer- ating process which penetrates the mucosa deeply, leaving an accentuated cup-shaped depression surrounded by uneven, but prominent, ragged edges. These ulcers are rapidly destructive to the soft tissues, and do not seem to be retarded in their erosive action by cartilage or bone. I have seen them perforate the soft palate in a few days, and for a time no treatment would stay their progress or appear to produce any impression what- ever. The whole soft palate is sometimes destroyed, as I have seen in a series of cases (Fig. 157). Cicatricial contractions have the effect of narrowing the lumen of the throat, and adhesions may encroach seriously upon the upper part of the pharynx or even shut it off from the lower part by adhesions of the soft palate to the posterior pharyngeal wall (Plate VI) similarly to the condition shown in Fig. 156. It is somewhat remarkable to observe the trivial character of the subjective symptoms as compared with the extensive gnawing away of the structures of the throat. I have seen this corrosive process plowing through the faucial columns and the velum, leaving perforations, eating away their borders until several small apertures united into one large hole, destroying one of the supporting shreds of the velum, and allowing the ragged remnant to drop, and hang as a pendant, swaying and fluttering with the currents of air. Patients subject to these erosions sometimes appear to experience less inconvenience from them than others suffer from a common cold. But in other individuals much pain attends the process, and swallowing 400 DISEASES OF THE EAR, NOSE, AND THROAT. causes a distressing effort. Solids must be eschewed and the diet confined to liquids until amelioration of the condition can be effected. Diagnosis. — This disease may be mistaken for tuberculosis, and in the early stage may be confounded with a simple catarrhal inflammation of the mucous membrane. But the latter yields readily to treatment, while the syphilitic disease progresses unin- fluenced by any other than specific treatment. In tuberculosis serious constitutional disturbances are present, such as are not accompaniments of syphilis : fever emaciation, etc. The areas of hyperemia that later become the seat of ulceration are paler and softer in tuberculosis than in syphilis. The ulcers of syphilis have more regular, clearly defined borders and are deeper than in tuberculosis. The pain of the latter disease, especially in swallowing, causes great suffering, while it is not a prominent symptom of syphilis and may be absent altogether. The patient improves and gains in weight on specific treatment in syphilis, but grows worse in tuberculosis. The presence of pulmonary tubercular lesions will aid in clearing up the diagnosis. Prognosis. — The primary sore disappears in about six weeks. The secondary lesion is about that time in coming on after infection and lasts approximately the same length of time when left to nature. The third stage is far more serious, for, while the primary and secondary periods may not menace health or life, the tertiary form invades all tissues with a wanton de- struction that is, at times, appalling. Important structures are not immune. A large blood-vessel may be opened and cause a fatal haemorrhage. Contractions of cicatricial tissues may constrict the throat and seriously interfere with breathing, swallowing, and speaking. Treatment. — Cleansing solutions should be used on the ulcerating surfaces before local applications will be of any avail. For this purpose I have had satisfactory results from the alka- line antiseptic solutions of Dobell and Seiler, in the form of a coarse spray with sufficient force to the stream to dislodge and wash away all the dirty secretions. These are good, cleansing, DISEASES OF THE PHARYNX. 401 soothing sprays for the primary lesions and the erythema also. Then I touch the denuded surface with tincture of iodine, pure, by means of a small cotton pledget twisted hard upon the silver applicator. When the iodized cotton is pressed upon the ulcer- ating part, not enough of the tincture should be left to run down over the healthy membrane. This treatment is usually followed by a drying up of the discharges and the institution of a healthy granulating process. If the throat is exceedingly painful, especially upon swal- lowing, one is justified in painting it with a 4-per-cent. solution of cocaine just before meals, to insure sufficient ingestion of food to support the strength. After cleansing and drying the ulcers with absorbent cotton, I cover them with a coating of aristol by means of a small powder-blower (Fig. 32). The antiseptic and slightly anaesthetic effects of aristol, besides its power of pro- moting granulation formation, have seemed to me to transcend the properties of any other single remedy. Sajous cleanses with a solution of potassium permanganate, and uses zinc sulphate or lead acetate, in a 5-grain solution, for their astrin- gent effect, or 5 minims of the tincture of the chloride of iron in a drachm of glycerin. Mackenzie used 20 grains of the zinc chloride to the ounce for the erythema and tincture of iodine for the mucous patches. If the ulcers were indolent he pre- ferred copper sulphate, 15 grains to the ounce. In the secondary and tertiary periods I employ mercury and potassium iodide, the mixed treatment, and tonics, with whatever general treatment the condition of each patient suggests. Cancer of the Pharynx. Synonym. — Carcinoma of the pharynx. Pathology. — Cancer of the superior portion of the pharynx is generally of the scirrhous form, and presents, in its early history, an indurated mass not clearly defined in its circum- ference. At first the mucous membrane covering it may not show any visible changes. The growth may extend to include the soft palate and pharyngeal vault. As the epithelium breaks down and ulceration of the surface of the tumor begins, a fetid 26 402 DISEASES OF THE EAR, NOSE, AND THROAT. exudate bathes the surface, which assumes a red or light- greenish appearance. Large, pedunculated granulations are sometimes to be seen, during this carious process, springing from the floor of the ulcer. The submaxillary lymphatic glands be- come infiltrated early in the attack. When the cancer is situated in the lower part of the pharynx, or the pharyngo-laryngeal cavity, it generally takes on the character of epithelioma. Its most usual site is a little below the arytenoid cartilage. Instead of the red or light- greenish surface of ulcerating scirrhus, this variety presents a gray surface inclosed by the very red, tumefied, mucous mem- brane. The disease spreads until it circumscribes the passage. Etiology. — Heredity is the only known cause of this disease. Symptomatology. — Inspection reveals the presence of a tumor or an ulcerating surface. The symptoms are character- istic of a lesion obstructive to respiration and deglutition. Pho- nation is interfered with, the speech is thick, and there is a foul-smelling, frothy expectoration. Swallowing is painful, but the suffering is not limited to this act, being constant and some- times extending to the Eustachian tubes and ears. Diagnosis. — This is not obscure. It is possible to mistake this for a syphilitic lesion, but the use of mercury and potassium iodide will remove all doubt. In a case recently under my observation the attending physician was not able to reach a conclusion. I suggested that a mixed treatment would soon result in recovery, which in a few weeks followed, demonstrating the specific nature of the lesion. Prognosis. — Sooner or later death closes the scene. Treatment. — In the nature of the case only palliative meas- ures are proper. If death is impending by obstruction to respira- tion, intubation or tracheotomy may prolong life. Nourishment may be administered by the oesophageal tube or by enemata, when swallowing is obstructed. Cocaine, morphine, and seda- tive sprays afford temporary relief only. Thomas Hubbard reports, in the Journal of the American Medical Association, June 13, 1896, a case of squamous epithe- DISEASES OF THE PHARYNX. 403 lioma of the velum palati cured by injections of caustic potash by a curved platinum needle. Injections were repeated wherever proliferating epithelial growths were seen. Cicatrization was rapid as well as the general improvement. The case remained cured after two years. CHAPTER XXXIV. DISEASES OF THE PHARYNX, CONCLUDED. Retropharyngeal Abscess. Etiology. — Abscess in the posterior pharyngeal wall may result from acute inflammation of the pharynx or of the sub- mucous tissue and glands ; from a middle-ear suppuration in consequence of the pus breaking through the anterior wall of the tympanic cavity or through the semicanal for the tensor tympani muscle, and from a disease of the vertebrae. It is more likely to occur in the strumous or syphilitic, and may be a sequel of the eruptive fevers or diphtheria. Traumatism resulting from the swallowing of fish-bones, the impact of a lead-pencil, etc., or scalding liquids and destructive chemicals may give rise to retropharyngeal abscess. Symptomatology. — If the abscess is located in the upper and back part of the pharynx there is a sensation of fullness accompanied by obstruction to nasal respiration with nasal voice. The tumor may be seen in this locality with the rhinoscopic mirror, and if it is not too high it may become visible by using the palate-elevator (Plate VI). On passing the finger into the vault of the pharynx it meets with a resistance which may be mistaken for adenoid vegetations. When it is posterior to the base of the tongue it can be brought into view by the use of the tongue-depressor. If the swelling is behind the glottis and attains a large size it is liable to press on the epiglottis and embarrass its functions. The swallowing of foods and liquids is so interfered with as to cause their entrance into the larynx. Dyspnoea of such a serious degree as to endanger the patient's life may result from an abscess in this region. Occasionally the tumefaction increases to such a size as to be visible by means of a swelling in the side of the neck. The inflammatory process may extend to the cervical glands, producing induration, pain, and tenderness. (404) DISEASES OF THE PHARYNX. 405 The head assumes a position suggestive of torticollis, being held fixedly to one side with the face upturned and everted. The general condition is one indicative of a severe illness. The temperature is often somewhat elevated, and thirst adds to the general discomfort. Like tonsillar abscess, rupture takes place usually into the throat. The evacuation of pus may fill the larynx and cause strangulation, or, if relief is not obtained early enough by incision or rupture, a dangerous or fatal oedema of the larynx may occur, or the pus may burrow among the cervical muscles and produce an abscess of the neck, or it gravitates to the thoracic cavity. Inspection shows a bulging of the mucous membrane at the seat of the swelling. The tumefaction and the contiguous structures present a dark, dusky-red hue, including the uvula and soft palate. Fluctuation can be felt by pressure with the finger over the bulging surface. Diagnosis. — Retropharyngeal abscess may be confounded with other inflammatory affections of the throat, but the absence of cough, pseudomembrane, vocal changes, and ulcerative con- ditions of the mucous membrane, taken together with the pres- ence of obstruction to respiration and deglutition, the unnatural fixation of the cervical muscles and twisting of the neck, the presence of bulging and fluctuation in the walls of the pharynx proper are decisive diagnostic features. Treatment. — If seen early, the ice-bag (Fig. 78) should be applied to discourage pus formation. As soon as fluctuation can be made out the abscess should be punctured with bistoury or trochar, making an opening sufficient to evacuate the cavity, but not large enough to cause a profuse gush of the contents to overwhelm the patient by filling the larynx and causing strangulation. MacCov recommends that the incision be made high enough in the swelling to necessitate pressure on the tumor to empty it, so as to avoid too great and continual flow of pus. The incision should be so made in a vertical direction as to leave a small wound so as not to favor the entrance of food into it during the act of swallowing. The internal carotid artery must be avoided by cutting toward the median line. 406 DISEASES OF THE EAR, NOSE, AND THROAT. Cocaine should be painted, in a 4-per-cent. solution, over the part to be entered, before the operation. A trochar can be used instead of a knife, but care is necessary to prevent it suddenly plunging beyond the abscess, as the wall yields, and injuring the parts beneath. The vertebrae are easily damaged by such an accident. The instant the abscess is opened the patient's head should be thrown forward to avoid the flowing of pus and blood into the larynx. The part of the knife-blade that is not to enter the tissues is protected by twisting cotton firmly around it as is done on the cotton-carriers. The blood is likely to be found impoverished and calling for iron and a nutritious diet. Alteratives containing iodine and the bitter tonics are useful. The throat should receive proper attention until the wound heals, and any abnormality present should be corrected. Neuroses of the Pharynx. There are two varieties of neuroses affecting the pharynx, — one of sensation, the other of motion. neuroses of sensation. These affections are of four kinds : hyperesthesia, anaes- thesia, paraesthesia, and neuralgia. Hyperesthesia. — The upper portion of the pharynx is liable to increased sensitiveness in persons subject to frequently recurring attacks of inflammation, and in the hysterical. No other abnormality may be discernible in the individual aside from the exquisitely sensitive throat. Treatment. — If any inflammatory condition appear on ex- amination, this must be combated by such remedies as "have been mentioned for pharyngitis, etc. If the condition give considerable discomfort one may be justified in applying cocaine in a 4-per-cent. solution, without the patient's knowledge of the nature of the remedy. A 10-per-cent. solution of carbolic acid in glycerin obtunds the sensibilities of the nerve-ends, and does not present any of the objections applicable to cocaine. The membrane can be protected by an emollient and slightly DISEASES OF THE PHARYNX. 407 auaesthetic spray consisting of camphor-menthol in lavolin. It is best to begin with a 3-per-cent. solution of this, giving the patient directions to use it in an atomizer for home treatment, and increase to a 10-per-cent. solution in office treatment, which can readily be done if the stronger preparation is employed in the dilator, or nebulizer (Figs. 18 and 120), at first, and after- ward in a coarser spray (Fig. 116). Aristol is preferable to most other powders, for its local anaesthetic and adherent qualities. Aconite in glycerin, a salol- or antipyrin- spray or guaiacol applications diluted with glyc- erin at first, pure afterward, are indicated if a rheumatic or gouty condition exist. Added to these, sodium salicylate, sal- icin, antipyrin, and lithium are effective in ridding the system of the uricacidsemia that may lie at the root of the trouble. If the case is of an hysterical nature, sedatives and tonics are required : valerian, the bromides, strychnia, arsenic, iron, etc. Anaesthesia. — Loss of sensation is of less import than its exaltation, since it is not accompanied with like suffering. It is sometimes a sequel of diphtheria or insanity. Nerve-tonics, such as are mentioned above, and galvanization are indicated. Parcesihesia. — Patients sometimes experience the sensation as if some foreign body were in the throat, when it is impossible to make out either the presence of one or any evidence that one may have at any time found lodgment. Indeed, no abnormal condition whatever of the pharynx is discernible. This condi- tion obtains in hysterical individuals, and it is difficult to satisfy them that they are mistaken. This manifestation is purely of a neurotic character and must be treated accordingly. Treatment. — Such methods as are recommended for hyper- sesthesia are appropriate here, — nerve-stimulants, tonics, or seda- tives as the particular features of the case may demand. Neuralgia. — While painful sensations in the pharynx are sometimes attributable to inflamed follicles, uric-acid irritation and various local lesions, there is a class of cases in which pain is experienced without the presence of any visible morbid process to account for it. This occurs in hysteria and is very difficult to influence. 408 DISEASES OF THE EAR, NOSE, AND THROAT. Treatment. — If any local lesion can be discovered it must be treated according to the principles already laid down, but when the pain is purely neurotic, topical applications to the sensitive or painful spot, if it can be located, and nervines, sedatives, and tonics, as set forth in treating of hyperesthesia, must be brought into requisition. NEUROSES OF MOTION. Two kinds of neuroses of motion are met with : spasms and paralysis. Spasms. — Spasmodic contractions of the pharyngeal mus- cles may be excited by any local irritant : traumatic, such as harsh particles of food ; or idiopathic, such as inflamed follicles ; or the affection may be purely neurotic, such, for example is globus hystericus. The levator palati muscle is occasionally subject to choreic attacks, in which the soft palate is thrown against the wall of the pharynx with more or less regular con- tractions and relaxations, accompanied by objective smacking or crackling sounds. These spasms may be associated with serious and grave neuroses, as well as with inflammatory con- ditions of the soft palate. Central nervous lesions and hydro- phobia are characterized by this symptom. Treatment. — If pharyngeal spasm can be traced to inflam- mation of the velum or oedema of the uvula, the proper treat- ment already outlined for these conditions will afford relief. Anomalous conditions of the nasal cavity must be searched for, and inflamed follicles in the pharynx that might provoke the attacks. Any local diseased condition must be corrected. When the contractions are dependent upon other maladies the treatment must naturally be addressed to the initial affection, such as brain-tumors and hydrophobia, for the spasms constitute a symptom only of such diseases. Diffusive nerve-stimulants, tonics, and hygienic and dietetic measures appropriate to each case will be suggested by the conditions present. Paralysis of the Pharynx. — Paralysis of the muscles of the pharynx results from diphtheria, syphilis, some central nervous lesion, or the fatal fevers. All the pharyngeal con- DISEASES OF THE PHARYNX. 409 strictor muscles may be involved or the disease may affect only one, or the muscles of one side alone are sometimes involved. There may be paralysis of one-half and paresis only of the opposite half of the pharynx. Swallowing and speech are more or less impaired, according to the extent of the paralysis. Food, and especially liquids, regurgitate into the posterior nares or enter the larynx. The latter accident is the more likely to occur when the epiglottis is included in the paralytic condition. Treatment. — The therapeutic measures will be determined by the nature of the lesion on which the paralysis depends. If it is a sequel of diphtheria, strychnia and arsenic are indicated. Excellent results have been reported during the past year (1896) from the subcutaneous injections of strychnine. In ad- dition to tonics I prefer for such conditions a current from the primary coil of a faradic battery, which, as the galvanometer demonstrates, possesses galvanic properties. This will cause contractions of the muscles if the disease has its origin in the nervous centres, but in case of atrophy of the muscles they do not respond to the current, The condition in the latter case is unpromising. In addition to electric treatment three or four times a week, general tonic remedies are usually called for. Burns and Scalds of the Pharynx. The pharynx is the seat of injury from inhaling very hot steam, air, or smoke, especially in burning buildings. Firemen are particularly subject to these accidents. Children sometimes inhale steam from a tea- pot or kettle or pour hot liquids down their throats. Patients and nurses by mistake give escharotic fluids instead of the correct internal medicine. I have had patients whose throats w r ere severely burned by aqua ammonia and carbolic acid in strong solutions that were administered by mistake from bottles standing beside those containing the proper remedies. Symptomatology. — Immediately after these accidents the mucous membrane of the throat is of a gray color, produced by 410 DISEASES OF THE EAR, NOSE, AND THROAT. the destructive agent. Inflammation follows, with more or less suppuration and sloughing of the tissues. Diagnosis. — This is usually made by the patient or his friends before the arrival of the physician. Prognosis. — Persons caught in burning buildings and fire- men are often so seriously burned by inhaling heat, hot smoke, and sometimes steam that recovery is impossible. There may be such an extensive breaking down of the tissues in the throat as to leave a stenosis if recovery take place. Treatment. — Ice-bags (Fig. 78), cool drinks, or, better still, pellets of pure ice in the mouth afford some relief and tend to modify the severity of the inflammation. Nourishment may have to be given for a time per rectum. When the larynx is involved to the extent of impending suffocation, tracheotomy must be performed at once. Foreign Bodies in the Pharynx. It is not uncommon to find fish-bones, pins, needles, and bristles, among sharp-pointed articles, lodged in the walls of the pharynx. As the constrictor muscles contract about them, they are forced into the soft tissues, until in some instances they escape detection on first looking into the throat. I have found such bodies as sections of juniper-leaves, etc., so imbedded as to be extracted with the greatest difficulty. This is especially true when they have remained for a number of days in the throat exciting continued efforts at swallowing and setting up an intense congestion of all the surrounding structures. Besides articles of a sharp, piercing nature that penetrate the tissues, bodies like unmasticated boluses of food and coins occasionally slip into the gullet and threaten strangulation. S//mj)tomatoIogg. — Sharp bodies are generally arrested in their progress by being caught in the lateral walls of the pharynx, where they will be found projecting from the tissues which they have penetrated. Small bodies are likely to lodge on one side of the epiglottis in the pyriform sinus. The large boluses of food, coins, etc., are arrested at a point just posterior to the larynx or a little superior to it, and are very liable to DISEASES OF THE PHARYNX. 411 catch upon the epiglottis and force it downward. Little bodies often drop into the pyriform sinus or the glosso-epiglottic fossa. The symptoms produced by foreign bodies in the throat are sometimes very distressing, and even dangerous. If the epiglottis is forced downward so as to close the entrance to the larynx the patient may suffocate before relief arrives. When sharp articles stick in the throat they produce a pricking sensa- tion, which increases during the act of swallowing. Pebbles, buttons, and the like may remain secreted in the pyriform sinuses for a considerable time without giving rise to serious inconvenience. It often happens that when crusts of bread and other hard substances are swallowed they scratch the mucous membrane of Fig. 158.— Mackenzie's Lateral Throat-forceps. the throat, and this abrasion, giving rise to irritation, produces the impression in the mind of the patient that a foreign body is present. I have known them to insist strenuously upon the presence of some substance ; but an application of a 4-per-cent. solution of cocaine to the irritated area removes it apparently. There is also a similar sensation due to a point of irritation which may be found to exist in an inflamed follicle. Certain susceptible individuals occasionally believe they are afflicted with a foreign substance in the throat when the trouble is purely a nervous one, — globus hystericus. Treatment. — Sometimes foreign bodies can be seen by de- pressing the tongue, but generally the laryngeal mirror is nec- essary. Remembering what has been said about the points of lodgment of the various kinds of bodies, and ascertaining, if 412 DISEASES OF THE EAR, NOSE, AND THROAT. possible, from the patient what the object was most likely to have been, the search is much facilitated. Sometimes it is best to insert the finger to locate the body, and it may be possible to extract it during this examination. Long, curved forceps are best adapted to this use (Fig. 158). One should be careful to not wound the adjacent tissues in the effort to grasp the foreign body. In extreme cases it may become necessary to open the trachea in order that respiration may proceed until the body can be rescued. A bolus of food may be forced down into the oesophagus if it cannot be extracted. Considerable irritation or inflammation follows these accidents. PART IV. Diseases of the Larynx. Plate VII PLATE VII. ANATOMY OF THE LARYNX. a. Thyroid cartilage. b, Cricoid cartilage. e, Arytenoid cartilage. d, Cartilage of Santorini. e, Cricothyroid membrane. /, Vocal band. g, Arytenoidens muscle. A, Lateral cricoarytenoid muscle. i, Posterior cricoarytenoid muscle. j. Epiglottis. A;, Vocal process. Figs. 1 to 9. ra, Cartilage of Wrisberg. n, Aryteno-epiglottic fold. o 1 , Upper fasciculus of thyro-arytenoid muscle. o a , Middle fasciculus of thyro-arytenoid muscle. o 3 , Lower fasciculus of thyro-arytenoid muscle. p, Ventricle of the larynx. q, Laryngeal sac. r, Ventricular band. s, Superior aryteno-epiglottic muscle. t, P, Two fasciculi of thyrocricoid muscle. u, Superior thyro-arytenoid ligament. Fig. 1. posterior view. ABDUCTION AND ADDUCTION. Fig. 2. Vocal bands abducted by contraction of posterior crico- arytenoids (arytenoideus cut off). Fig. 4. LATERAL, VIEW. Section of larynx showing the relation of adductor and abductor muscles. Fig. 3. posterior view. Vocal bands adducted par- tially by contraction of lateral cricoarytenoids (arytenoi- deus not having acted) . Fig. 5. HORIZONTAL SECTION OF LARYNGEAL FRAME-WORK, ABOVE VOCAL BANDS. Vocal bands in abduction. Vocal bands in partial adduction. EXTENSION AND RELAXATION. Fig. 6. lateral section. Relaxation of vocal band through contraction of thyro- arytenoids and relaxation of thyrocricoids. Fig. 7. lateral section. Interior of larynx. Flaps raised to show laryngeal sac, and the relation of muscles with the mucous membrane. Fig. 9. anterior section. Interior of larynx and rela- tion of muscles. Fig. 8. lateral section. Extension of vocal band by elevation of the cricoid carti- lage through contraction of the thyrocricoid muscles and relaxation of the thyroaryt- enoids. Fig. 10. innervation of the larynx. Posterior section of neck and upper part of chest, showing the course of the pneumogastric nerves, their branches, and their relations. Lateral half of trachea and quarter of larynx cut off. A 1 , Pneumogastric nerve. JB l , Superior laryngeal. Right recurrent laryngeal. Right lung. Left recurrent laryngeal. Branch of superior laryn- geal. (Esophagus. Aorta. Pulmonary artery. Trachea. (upper), Internal jugular vein cut off. (lower), Bronchi. Arytenoid cartilage. Subclavian artery. Common carotid "artery. External carotid artery. Internal carotid artery. Base of cranium. (upper), First cervical vertebra. (lower), Arytenoideus muscle. Pharynx cut oil' from up- per attachments. p:piglottis. BLyoid bone. Thyroid cartilage. Cricoid cartilage. s, Thyroid gland. u, Thyrocricoid muscle. v, Cervical vertebrae. x, y, Muscles of neck. z, Innominate artery. Fig. 11. arteries and veins of the anterior portion of the neck. Vessels of the neck, show- ing those in danger of being- severed in making artificial opening into the larynx and trachea, and their connec- tions. a, Trachea. b, Cricoid cartilage. c, Thyroid cartilage. d, Thyroid gland. e, Cricothyroid membrane. /, Thyrohyoid membrane. g, Hyoid bone. h, Aorta. i, Innominate artery. j, Common carotid artery. k, Superior thyroid artery. I, Anterior jugular vein. m, Cricothyroid artery. n, Internal jugular vein. o, Thyroid plexus. p, Right inferior jugular vein. q, Left inferior jugular vein. r, Cricothyroid vein, s, Superior thyroid vein. t, Middle thyroid vein. w, External jugular vein. v, Subclavian vein. x, Right and left innominate vein. y, Superior vena cava. Plate ¥11 E. Sajous, Pinx.it. Burl< & M c Fetndge. Lith. Phila CHAPTER XXXV. DISEASES OF THE LARYNX. Laryngoscopy and Instruments. Examination of the interior of the larynx, commonly tiled laryngoscopy, is made by means of a light reflected into Le larynx through the medium of two mirrors. The first, or forehead-, mirror is illustrated in Fig. 4, and is used in the same manner as in otoscopy and rhinoscopy, already described. The second mirror, sometimes dignified by the name of laryngo- scope, consists of a circular plane-glass mirror inclosed in a metallic frame, to which is attached a wire handle set at an angle of 120 degrees to the plane of the mirror (Fig. 112). It is made in several sizes, but those most commonly employed vary from one inch (twenty-five millimetres) to one-half inch (twelve millimetres) in diameter. The most perfect view is ob- tained by using as large a mirror as the proportions of the throat will permit without contact between mirror and mucous membrane. The sizes are numbered according to their diame- ters, No. 1 being one inch (twenty-five millimetres) wide, and the others graded by one-eighth-inch (three millimetres) varia- tions down to one-half inch (twelve millimetres), and numbered accordingly. In the capacious throats of adults the largest size is to be used, while in children the smaller ones are necessary. For the purposes of illumination there are various devices for projecting the rays of light upon the laryngeal mirror. Fig. 159 shows an ingenious device of Allen DeVilbiss, which is a modification of Mackenzie's light-concentrator. It is simpler in construction than Tobold's apparatus, although it is similar to it. It is provided with two mirrors, one plain and the other concave, both of which are attached to a stationary mirror-bar by means of ball-and-socket joints, so arranged that they may be easily changed to any position on the bar and inclined at any angle. (415) 416 DISEASES OF THE EAR, NOSE, AND THROAT. The plane mirror enables the physician to show his patient the condition of the affected parts, and, if needing treatment, explain its necessity. "By this method patients may see the extent and nature of their diseases and receive treatment when they might otherwise consider it of but little importance, nol demanding medical assistance." If deemed advisable, the pa- tient may be shown, from time to time, the changing condition of his disease, and thus be kept interested in its treatment. By this device the patient can see to keep himself " in light," thus Fig. 159.— DeVilbiss Illumikatok. relieving the physician from the necessity of frequently adjust- ing the mirror. This laryngoscope can be adjusted to a student's lamp, and may be raised or lowered by means of a single set-screw. Figs. 1, 2, and 5 show other adjustable lamps. Assuming that we have proper illumination, the examina- tion proceeds as follows: The patient and examiner being in the relative positions illustrated in Fig. 159, with the patient's mouth open, the tip of his tongue is taken between the phy- sician's thumb and index finger, protected from actual contact with the tongue by a napkin or thin towel, and the tongue is DISEASES OF THE LARYNX. 417 held protruded from the mouth. The patient should not make an effort to force the tongue forward nor to retract it, but should let it lie passively in the surgeon's control. This is necessary in order to raise the epiglottis and expose the aperture of the larynx. This is effected by traction on the glosso-epiglottic ligament, which happens in the drawing forward of the tongue. Unless the examiner is careful in this act he will wound the fraenum on the sharp edges of the lower incisor teeth. It is advantageous to instruct the patient to assist in his examination by holding his tongue himself, using the hand opposite to the one used by the examiner, so as not to be in the way of the laryngeal mirror as it is introduced. The light is now focused on the uvula, and the front of the laryngeal mirror is exposed for only an instant over the flame to warm it. This must be done in order to prevent the moisture of the breath from condensing upon the glass and blurring the laryngeal image. After a second of warming the mirror is touched to the surgeon's cheek, or a sensitive part of his hand, to determine if the heat is sufficient to avoid conden- sation. If the flame is very hot, or if the mirror is exposed to it during too long an interval, the silver, or other backing of the glass, is fused, and the instrument destroyed. Glass being a poor conductor of heat, there is less danger of melting the coating of the back if the glass itself is held next the source of heat. The laryngeal mirror now being ready for introduction, it is held like a pencil, and without loss of time, which would al- low the mirror to cool, it is carried into the throat in such a way as to avoid contact with the tongue and surrounding parts, so as not to cause nausea and retching. The back of the mirror is made to impinge upon the anterior surface of the uvula and to carry the latter upward and backward. The mirror is then turned so as to reflect the rays of light from the forehead-mirror into the cavity of the larynx, when an image of the interior of the larynx and the superior portion of the trachea will come into view. The patient should be told that no pain will be caused, and that he should remain perfectly passive and breathe •±18 DISEASES OF THE EAR, NOSE, AND THROAT. quietly. If he is able to accommodate himself to the situation, an opportunity is given to study the vocal cords, which are seen in an abducted relation, of a white color, about three-fourths of an inch (two centimetres) long, and diverging from the upper to the lower ends, as seen in the reflected image. If the subject is caused to utter the broad, open sound represented by the syllable " ah," as used by vocalists in devel- oping their voices, the vocal bands approximate each other and become parallel, with only a narrow slit preventing contact be- tween them. As seen before vocalization, the vocal bands are concealed largely from view by the ventricular bands, only their borders being then visible. One should not forget that he is not looking directly at the contents of the larynx, but at an image of them in a mirror, which, of course, reverses the picture to the observer; or, in other words, the examiner sees the picture as he would if his eye were behind and above the larynx, — the position occupied by the mirror. The epiglottis appears in the upper section of the mirror as a yellowish-pink valve, showing on its surface a map of minute blood-vessels. Its outline is suggestive of a Cupid's bow, with the convex surface directed upward. Just below this bow is seen the anterior commissure of the vocal cords, which is narrower than the posterior commissure, as shown in the lower part of the image. The right vocal band appears in the left field of the image and the left is reflected in the right side of the picture. From the right and left termini of the bow-shaped borders of the epiglottis spring the aryepi- glottic folds, curving gracefully inward to meet each other in the form of a horseshoe, and completing the superior boundary of the opening into the larynx by their union in the arytenoid commissure (Plate VIII). On either side of the junction of the ary epiglottic folds is a nodular eminence called the cartilage of Santorini, and immediately to the outside of these knobs, on either side and slightly elevated above them, is a bulbous-appear- ing prominence, — the cartilage of Wrisberg. These eminences are more of a redder hue than the epiglottis. Below them are seen the ventricular bands, which spring from an area corre- DISEASES OF THE LARYNX. 419 sponding to the junction of the cartilages of Santorini and Wrisberg. The junction of the ventricular bands in front, their an- terior commissure, is concealed by an eminence, — the cushion of the epiglottis. The vocal bands or cords appear below the ven- tricular bands, extending from below the cushion of the epiglot- tis to points just inferior to the cartilages of Santorini. Between the ventricular band and vocal cord is a dark aperture termed the ventricle of the larynx. Beyond all these structures appear the rings of the trachea. From three to six are usually in sight, and sometimes a view of the whole length of the trachea to the branch of the right bronchus is obtained. For the anatomy of the larynx see Plate VII. Difficulties of Laryngoscopy. Laryngoscopic examinations are not without considerable obstacles in many instances. Although there are individuals with capacious throats devoid of sensitiveness, who readily co- operate so as to afford a broad-gauge view of the interior of the larynx and trachea, there are far more frequently persons who have little or no control of their muscles, and who retch and gag, and even vomit, when an attempt is made at laryngoscopy. In such cases it may become necessary to inure the throat to the presence of foreign bodies by the practice, on the part of the patient, of inserting smooth, blunt articles, such as spoon-handles and the like, daily at home. In this manner a tolerance of in- struments may be cultivated to such a degree as to render successful subsequent attempts at an examination. When repeated efforts fail on account of hypersensitiveness of the throat, it is necessary to bring to our aid a 4-per-cent. solution of cocaine. This is painted over the base of the tongue and the soft palate, and in a few minutes the sensibilities of the nerves are so benumbed as to permit of a thorough inspection with the mirror. Another instance in which it may become necessary to em- ploy cocaine is when the epiglottis is pendent to the degree of obstructing the rays of light and preventing their penetrating 420 DISEASES OF THE EAR, NOSE, AND THROAT. the laryngeal cavity. In this condition the epiglottis must be raised and pressed forward out of the field of vision by a curved probe ; but in order to do so without producing pain and gagging the epiglottis must be treated to the cocaine solution. The tongue is often forced upward and shuts off the view if the mirror come in contact with it and produce gagging. The patient is told not to strain, and the tongue is not drawn forcibly forward. If then the arching of the tongue does not recede, the tongue-depressor must be employed. If the mirror is held by the right hand, the tongue-depressor is held by the left in such a way that the instrument intervenes between the thumb and the tongue and the first finger rests under the tip of the tongue. The depressor must not be carried far enough backward to provoke nausea and retching. When the tonsils are enlarged they so encroach upon the lumen of the cavity as to interfere with a satisfactory laryngo- scopy. A small mirror must be resorted to ; but tonsils sufficiently hypertrophied to embarrass an examination of the larynx ought to be clipped. CHAPTER XXXVI. DISEASES OF THE LARYNX, CONTINUED. Acute Laryngitis. Synonyms. — Acute catarrh of the larynx; spurious croup. Pathology. — Acute inflammation of the mucous membrane lining the laryngeal cavity is characterized by an engorgement of the blood-vessels, — an hyperemia, — accompanied, at first, by dryness of the membrane and afterward by an exudation of serum upon the mucosa, mixed with undeveloped epithelial cells and white corpuscles. The thin, translucent secretion soon gives place to a more copious secretion of a thick, opales- cent, mucoid character, studded with desquamated epithelium, pus-corpuscles, and traces of blood. Points of denudation of the mucous membrane are generally present, but the submucosa is rarely invaded by ulceration in this affection. Etiology. — Exposure to cold is the most common cause of this inflammation. Sudden changes from warm, ill- ventilated apartments to a cold, damp, or windy atmosphere when the subject is in a perspiration or insufficiently clad are frequently followed by laryngitis. This is most commonly seen during the changes of the seasons from fall to winter and from winter to spring. The inhalation of irritating gases such as are often generated in laboratories may excite a catarrhal condition of the larynx. Dust of certain kinds is a causative factor. Per- sons riding over the alkali deserts or plains of the western part of the United States are sufferers from rhinitis, laryngitis, and conjunctivitis occasioned by the irritating effects of the great quantities of alkali-dust in those regions. Overtaxing the voice and its improper use by singers and speakers bring on an acute laryngitis. Instances of this affection are very common during the political campaigns, when stump-speakers are driven from the field by the inordinate use of their vocal organs. Fire- men — who shout in the heat and smoke of burning buildings, (421) 422 DISEASES OF THE EAR, NOSE, AND THROAT. and who often inhale much of the hot air, steam, and smoke — are subject to this disease. The uric-acid diathesis, rheumatic and gouty conditions, and the eruptive diseases stand in a causative relation to acute laryngitis. Symptomatology. — The premonitory symptoms of acute laryngitis may be so vague and trivial as to scarcely arrest the attention of the subject. A slight feeling of dryness, as though the air inhaled was devoid of moisture and, therefore, irritating, is generally the first unusual condition noticed. This is likely to be followed by a scratching or tickling sensation that excites efforts to relieve it by clearing the throat or coughing, which, instead of relieving the irritation, only adds to the feeling of roughness. A sense of constriction or of soreness soon follows, but palpation of the larynx seldom develops tenderness. As the attack progresses and the vocal cords become involved, there occurs a change in the quality, or timbre, of the voice. It takes on a husky, or hoarse, character, which has the effect of apparently lowering its pitch. About this time discomfort in swallowing occurs, amounting to a very painful effort. This is especially the case in the rheumatic form of the disease, and with the accentuated painfullness of deglutition may come a complete loss of voice, so that the only speech possible to the patient is a forced whisper. Cough is not necessarily a symp- tom of acute laryngitis, but is frequently present. Its hoarse character is indicative of the situation of the causative lesion in the larynx. Auscultation of the larynx will result in demon- strating the presence of mucous rales. These are not heard during the initiatory stage, in which the mucous membrane is dryer than it is in the normal state ; but later, as the serous exudate and mucus bathe the walls of the larynx, the passage of air through these fluids gives rise to easily-detected rales. The expectoration is characterized by the presence of the secre- tions just mentioned, and later in the disease by the presence of pus, possibly streaked with blood. The presence of blood, however, is generally an accidental and unusual feature, being the result of a very violent fit of coughing or, perhaps, of vomiting. DISEASES OF THE LARYNX. 423 This disease does not usually give rise to very serious gen- eral disturbances of the system in adults, but it often presents alarming symptoms in children. As all diseases produce a more profound impression during the early years of life than in adults, so acute laryngitis may evoke such violent symptoms as to fill the patient and friends with terror. The temperature rises ; the pulse becomes accelerated, bounding, and hard, and the tongue is heavily coated. Even when the little patient appears during the day to have no serious sickness, he may awaken at night with a suffocative attack out of all proportion to the apparent cause. The respiration is embarrassed and the respiratory effort is marked by an audible, stridulous sound. The cough reveals a changed voice, hoarse and husky, and the diminished oxygenation of the blood and the frantic efforts to overcome the obstruction to breathing bring on a swollen and congested appearance of the face. These attacks are sometimes called stridulous laryngitis, and they are probably occasioned by the drying of accumulated discharges in the glottis. The child breathes through his open mouth, with the result that the air entering the larynx and lungs is not moistened by the secretions of the nose, as it is in normal respiration. Consequently the dry air causes rapid evaporation of the water of the laryngeal secretions, with the effect of causing them to dry upon the vocal cords until they offer a positive obstacle to the current of inspired air. When the obstruction has existed long enough to cause actual distress the patient awakens in a frightful state of impending strangulation. Soon, however, the active efforts of the patient to dislodge the inspissated secretions relieve the stenosis and restore free respiration, when calm succeeds the storm. The attacks described here have been attributed by some authors to a spasm of the adductors of the vocal bands. This spasmodic contraction may play a role as a complication, but the mechanical explanation is reasonable ; all the elements requisite to the production of such attacks are present ; and it so conforms to our experience with similar conditions in other situations as not to necessitate an exercise of the imagination to account for all the phenomena observed. 424 DISEASES OF THE EAR, NOSE, AND THROAT. Inspection of the larynx during an attack of acute inflam- mation reveals a mucous lining of a bright-red color (Plate VIII). The congested condition may be limited to various portions of the membrane, but usually it is diffused over the whole surface. There is a tumefied condition in severe forms of inflammation, and the ventricular bands may be so swollen as to override the true vocal bands and nearly occlude them from view. Then they are seen as slight, reddened lines below the ventricular bands. Ulcerations are not frequently seen, but small spots of the membrane denuded of its epithelium may be present. The epiglottis may participate in the inflammation, as shown in Plate VIII, or it may not be involved. (Edema occurring in the course of laryngitis constitutes a grave complication, since it may give rise to fatal stenosis. Diagnosis. — In adults no serious difficulty to a diagnosis presents, in view of all the symptoms related. It is not likely to be confounded with diphtheria except in children, when it may be mistaken for true croup. In case of doubt, an exam- ination of the fauces will likely reveal false membrane if diph- theria is present. A laryngoscopic examination should be had if obtainable. The secretions should be subjected to bacterio- logical examinations if there is reason to suspect diphtheria. However, this disease does not run such a course as does diph- theria and it is not attended with the symptoms of profound sickness comparable to those of diphtheria. Prognosis. — This disease is of short duration and yields readily to proper treatment. Treatment. — Local remedies are useful as detergents, astrin- gents, anaesthetics, protectives, and tonics. A spray of a mild alkaline solution with antiseptic properties, such as Seller's, will dissolve and wash away the discharges, and, besides leaving the mucous membrane clear and free for the application of other medicaments, the effect is a very agreeable and soothing one. In the dry stage I have found menthol very efficient when in- haled in several different ways. If no atomizer is at hand, the crystals can be fused in a teaspoon over a lamp or stove until the atmosphere of a small room is comfortably impregnated DISEASES OF THE LARYNX. 425 with the volatile fumes. The patient is directed to keep his eyes closed to prevent any smarting, and, unless his nostrils par- ticipate in the inflammation, he is instructed to breathe through the mouth. The inhalation starts a refreshing flow of mucus to bathe the parched membrane of the dry stage. Another excellent treatment consists in putting 10 drops of pure cam- phor-menthol into a half-pint of hot water contained in a tea- pot or kettle, wrapping a napkin around the nozzle to prevent burning the lips, and then inhaling this medicated steam through the mouth with the lips embracing the protected tube. The hot, moist steam has an excellent effect, in addition to the action of the camphor-menthol in contracting the capillary blood- vessels and producing a slightly anaesthetic and antiseptic effect. Cocaine and silver nitrate are recommended by some writers and are used much oftener than they ought to be. They are to be avoided in acute laryngitis. I have found my throat-tablets useful, and they can be given freely, without producing any unpleasant consequences, except, perhaps, nausea. Each tablet contains 2 grains of ammonium chloride and 5 minims each of paregoric, compound syrup of squills, and syrup of Tolu, with 2J grains of extract of licorice. These are held in the mouth and allowed to dis- solve slowly and trickle down the throat. Besides the desirable action of the ingredients of this tablet on the mucous mem- brane of the throat, the licorice generally produces a laxative effect on the bowels. J. D. Arnold recommends, in the case of superficial erosions, the use of cocaine, followed by painting the laryngeal mucous membrane with a 1- or 2-per-cent. solution of chromic acid. He employs the cocaine not for the purpose of anaesthesia, for this strength of chromic-acid solution is not painful, but to contract and deplete the blood-vessels, in which condition the action of the acid is more beneficial. If the inflammation is of a severe grade, the ice-bag (Fig. 78) is indicated. Leeches to the neck are sometimes employed, but cold is preferable. General treatment consists, first, in putting the patient in 426 DISEASES OF THE EAR, NOSE, AND THROAT. such a condition as is favorable to successful treatment. He need not necessarily be put to bed, but lie had best remain in-doors for a few days, where the temperature is uniform and where he will not be exposed to those conditions that brought on the attack. In the dry, or first, stage, -J- or even J grain of pilocarpine is useful to stimulate the sudoriferous and salivary glands to activity. This is a substitute for the old-fashioned, dismal sweats that loom up in our memory of boyhood. Quinine — that much-abused remedy, given for almost every ill that afflicts our race — is of little or no use here, as far as my expe- rience goes. One or two doses of morphia, ^ grain, combined with atropia, g^ 7 grain, and caffeine, ^ grain, have often ap- peared to greatly ameliorate, and even shorten, the attacks materially. Irritants — tobacco-smoke, alcoholic liquors, etc. — must be forbidden. If cedema be found, the tissues affected must be scarified, to let out the contents. Should the tumefaction and stenosis be so great as to seriously embarrass respiration or threaten suffoca- tion, tracheotomy must be performed. The rheumatic type of acute laryngitis is attended with considerable pain and difficult deglutition, that require promptly- acting remedies. Ten-grain doses of salicylate of sodium every two hours should be given until either the symptoms begin to show signs of relief or the physiological action of the drug begins to manifest itself in stuffiness in the ears, diminished hearing, ringing noises in the ears, or gastric disturbances. Then the doses should be placed at greater intervals or discon- tinued until these transitory symptoms abate, and renewed again in smaller doses until after complete recovery. A fresh prepara- tion should always be made, like the formula given in the article on the treatment of rheumatic pharyngitis. If the sodium salicylate disagree with the stomach or produce serious aural symptoms, and more especially if the patieiit already has an affection of the ear, the salicin should be substituted for the salicylate. I have seen 10 grains of salicin, taken every two hours, produce prompt relief before the expiration of a day. This effect is hastened if the same doses of effervescing citrate DISEASES OF THE LARYXX. 427 of lithia are taken three or four times a day. Antipyrin is often beneficial in this disease. Climate has a definite effect on the rheumatic form of laryngitis. I have known a patient suffering from it during a season of cold, humid, windy weather that prevailed along the Great Lakes Region, to go south, into a genial, warm, sunshiny climate, and recover from the attack, without medicine, after two days of life in the sunshine, so magic in their effects are climatic conditions. CHAPTER XXXVII. DISEASES OF THE LARYNX, CONTINUED. Croup. ^m- Synonyms. — Pseudomembranous croup; idiopathic mem- branous croup. Pathology. — The question of the identity or duality of croup and diphtheria is still a mooted one. Excellent author- ities differ on this subject. So scholarly an author as Sir Mor- ell Mackenzie believed the two to be identical. Both diseases affect the mucous membrane, with the result of producing a false membrane. Both diseases attack the same organ, — i.e., the larynx. Both obstruct respiration. In these three particu- lars there is a close similarity in the two diseases, but the author is not prepared to admit their identity. Croup is pri- marily an affection of the larynx ; diphtheria is generally at first an affection of the pharynx, although it may, in a certain percentage of cases, develop primarily in the larynx. " In one hundred and fifty-one diphtheric cases the membrane was lim- ited to the larynx only once. In eighty-eight the membrane appeared first in the larynx or simultaneously with that of the pharynx " (Northrup). Croup is more frequent in the country, while diphtheria is more prevalent in cities. In the opinion of the author, the wide difference between the unicists and dualists can be harmonized by recognizing what certainly appears to be pathologically and clinically true : that there are two varieties of membranous croup, the one diphtheric, the other non-diphtheric. " Out of two hundred and eighty-six cases of membranous croup 80 per cent, were diphtheric and 14 per cent, were certainly not diphtheric" {Medical Record, September 15, 1894). True croup is an idiopathic disease ; diphtheria does not arise spontaneously, independently, in isolated instances without inoculation or infection, directly or indirectly, from a previously (428) DISEASES OF THE LARYNX. 429 existing case of the disease, as croup does. The latter is not a contagious, inoculable disease ; diphtheria is pre-eminently so. Croup does not infect the whole system with a profoundly- depressing and exhausting poison, causing paralytic sequels, as the diphtheria toxin evolved by the Klebs-Loffler bacillus does. The clinical pictures of the two diseases are similar in their mechanical effects upon the respiration and consequent deoxy- genation of the blood, but from that point their histories are not parallel. Their divergencies are apparent to one who has had much experience in their treatment. He must recognize that we have a laryngeal diphtheria, on the one hand, and a true croup, on the other. This is a disease of childhood, and occurs most frequently about the second year, and from that to the tenth year. Croup is an inflammation of the mucous membrane, mostly confined to that part of the larynx superior to the vocal bands, but it may extend to the trachea. It is attended with the formation of an exudate, or inflammatory lymph, that is de- posited in the form of a fibrinous membrane on the epiglottis, the ventricular bands, and to a greater or less extent upon the vocal cords. This false membrane does not penetrate the epithe- lial layer to the submucosa as the diphtheric membrane does, but it can be peeled off without tearing the mucous membrane or leaving a rough, raw, and bleeding or ulcerating surface. If the inflammation extend to the submucosa the laryngeal muscles become involved, resulting in spasms or paralysis. Etiology. — This disease may arise primarily, without any discoverable exciting cause, or it may occasionally be secondary to injuries, various irritants, scarlet fever, measles, small-pox, etc. Cold and moisture, especially combined with strong winds, may give rise to attacks. I have not observed that the previous condition of health exerted much influence for or against the production of croup. Healthy-appearing children seemed to be as easily subject to it as those who were badly nourished. The author has had a considerable opportunity to study these subjects in his practice in connection with the children's de- partments of the South-Side and of the West-Side Free Dis- •430 DISEASES OF THE EAR, NOSE, AND THROAT. pensaries, and, while the children that most easily succumbed to diphtheria and other diseases were the feeble and strumous, he has seen the fat and rosy children as often attacked by croup as those with impoverished systems. The chilling of children by exposing them to draughts of cold air ; the unpardonable practice of leaving their thighs bare and exposed to cold, as is the almost universal custom ; the carrying or wheeling of infants bare-headed in the cold ; allow- ing children improperly clad to sit about in the open air in chilly weather, and to run about the house morning and night in their bare feet in cold weather, and similar practices that encourage the shocking of the skin by cold and disturbing the balance in the circulation of the blood are all prolific causes of croup. Symptomatology. — The first thing that may be noticed is the hoarseness of the child's voice. Before any fever or sub- jective symptoms develop the parents may notice the sudden change in quality of the voice, but some indisposition may show for several days before the attack. Next, a slight cough ap- pears that accentuates the coarse timbre of the voice. Its pitch sounds much lower than normal. Soon there are signs of fever and complaints of not feeling well. If the little one is old enough to describe sensations, headache may be spoken of. The symptoms often develop with surprising suddenness. The child may appear well during the afternoon, and by 7 o'clock in the evening the voice changes to a hoarse quality, which may be overlooked by the untutored or careless, until, two or three hours later, coughing and difficulty of breathing alarm them to the point of summoning medical assistance. With each inspiration now is heard the well-known crowing sound of croup. The temperature rises to about 103° F. as the night wears wearily on and the obstruction to respiration in- creases with the increasing false membrane. The true inflam- matory character of the disease is apparent. The pulse is accelerated, bounding, and hard; the tongue coated; the skin hot and dry ; the face red and puffed ; and the secretions are checked. Unless relief is obtained by expulsion of some of the DISEASES OF THE LARYNX. 431 obstructing membrane the difficulty of breathing increases until the labor necessitated in aerating the lungs is pitiful in the extreme. The sound of the prolonged crowing inspiration and the lengthened expiration indicate the extreme narrowing of the chink between the vocal bands. As the blood becomes poisoned by the lack of oxygen the little one's face, flushed at first with a beauteous glow, takes on a bluish tinge that darkens as the world grows dark to the little sufferer, until, at last, a cyanotic hue announces the approach of death. If portions of the false membrane are expelled, more or less relief is obtained, and a respite experienced until more mem- brane is formed to take its place, when dyspnoea again ensues. Often the worst is over in twenty-four or forty-eight hours, but in other cases the duration may be five or six days. Diagnosis. — Membranous croup may be mistaken for laryn- geal diphtheria, acute laryngitis, or laryngismus stridulus. It may be difficult sometimes to distinguish croup from diphtheria. In croup the constitutional disturbance is less pro- found than in diphtheria. Obstruction to breathing is really the principal symptom of croup. Slight catarrhal symptoms and indisposition may exist for several days before the attack of croup, but the diphtheric attack is sudden and accompanied with severer symptoms. Croup is neither infectious nor con- tagious ; diphtheria is both. In nearly every case of diphtheria there is a false membrane in the pharynx, but this is not true of croup. The difficult breathing of croup appears suddenly, while that of diphtheria is more gradual and lacks the spasm of croup. No other member of the family or community catches croup ; diphtheria spreads to others, and has paralysis as a sequel, while croup has not. In case of doubt a bacteriological examination should be made. Acute laryngitis resembles croup in some respects, but it is 'attended by more pain in the larynx, less difficulty in respiration, and by no formation of false membrane. Croup is a disease of childhood, while laryngitis is generally confined to later years. The peculiar crowing sound of croup does not occur in laryn- gitis. The cough of the two diseases differs, that of croup •132 DISEASES OF THE EAR, NOSE, AND THROAT. having a deeper hoarseness and not being so short and hacking as in laryngitis. Laryngismus stridulus does not present the symptoms of sickness like croup. There is no fever and the labored respi- ration comes on quickly and subsides in a few minutes. The voice remains normal between the attacks. Prognosis. — Membranous croup is a very fatal disease. Statistics show that considerably more than half of the cases die, — 60 or 70 per cent. Since the introduction of intubation of the larynx by O'Dwyer the death-rate has materially improved. In a collective investigation by Ranke (MilncJiener med. Woch., No. 44, 1893), concerning intubation in Germany, he reports 1445 cases intubated for croup, with 553 recoveries, or 38 per cent. O'Dwyer (New York Medical Journal, March 10, 1894) claims that the " mortality of laryngeal diphtheria without treat- ment is 90 per cent., which can be reduced to from 27 per cent, to 47 per cent." Attacks of great severity may progress rapidly to a fatal termination, the end being induced by a spasm of the glottis occurring in a few hours from the seizure. In others the larynx gradually fills with the false membrane, depriving the lungs of air until carbonic-acid poisoning, coma, and death occur. Treatment. — A patient with croup should be kept in a moist atmosphere. I have made it a rule to put the child in a room containing a stove, when it is possible. Then, large vessels, like dish-pans or boilers, should be placed on the stove and just enough water poured in them to cover their bottoms and keep them from burning. A hot fire is kept up and in this way the atmosphere of the room is maintained saturated with steam, and at a temperature of 76° or 80° F. If there is paper on the walls, it will, of course, be spoiled. Unslaked lime is sent for, a bushel or more. A lump as large as a man's head is placed in a wooden bucket containing about two quarts of hot water. As chemical combination takes place an abundance of steam is generated which is conducted to the patient's head by a tent-shaped arrangement of a sheet. DISEASES OF THE LARYNX. 433 In the first, or catarrhal, stage counter-irritation is useful over the larynx by means of poultices of flaxseed-meal with mustard. The ice-bag (Fig. 78) may modify the intensity ot the inflammation. Gottstein advises not only these, but the use of leeches on the upper part of the sternum. Glasgow uses a spray of hydrogen dioxide thrown directly into the larynx. He believes the mechanical effect of the effer- vescence produced is to detach the false membrane and facili- tate its expulsion. For the purpose of increasing the secretion of mucus, which has a similar effect, menthol crystals may be employed by fusing a few in a teaspoon over a flame until the air is comfortably impregnated with the fumes. Inhalations of vinegar are highly recommended by some writers. Calomel, both internally and externally, has proved a valu- able remedy. It is believed to be potent in preventing the formation of an exudate. It increases the secretions, which action in itself contributes to the casting off of the false mem- brane. J. Dundas Grant reports favorable results from 1 -grain doses every four or six hours. With each dose he combines 3 to 5 drops of wine of ipecacuanha and 3 to 5 grains of bromide of potassium. I have for a long time been satisfied that calomel was efficacious, and have employed it in smaller doses more frequently administered, | grain every two hours, until the bowels were considerably relaxed. I use the sodium bromide in preference to the potassium because it contains a larger per- centage of bromine and is not so vitiating to the blood. Fruitnight, in the Archives of Pediatrics for June, 1895, calls attention to the value of calomel fumigations in croup, whether looked upon as simple or specifically diphtheric. This treatment was originally suggested some years ago by Corbin, of Brooklyn, and later recommended by Dillon Brown. It should be used when there are symptoms of serious laryngeal involvement. " The amount of mercurial salt to be vaporized varies from 5 to 20 grains, repeated at intervals varying from one-half to two or three hours, according to the severity of the symptoms; in the average cases 15 grains hourly. The patient is to be kept in the vapor-saturated atmosphere, within a tent, 28 434 DISEASES OF THE EAR, NOSE, AND THROAT. for a period varying from ten minutes to one-half hour. In one hundred cases thus treated no case has been subject to dele- terious results. In one case only did slight ptyalism occur. Salivation, diarrhoea, depression, prostration, and anaemia must be prevented by watchfulness and proper treatment." (Year- book.) Emetics play an important role in the urgent stage of croup. When the larynx is filling to the degree of threatening suffo- cation a prompt emesis will often loosen the false membrane and effect its expulsion. To accomplish this I have most often used turpeth mineral (yellow sulphate of mercury) and with the most gratifying results. One or two doses will produce vomiting in a few minutes and afford marked relief. Ipecac, alum, and sulphate of copper are efficient. I have never tried the last of these three. One should guard against the tendency of parents or nurses, or wise and more meddlesome neighbors, to overdose children with emetics, on account of the exhaustion and the irritability of the stomach which they produce. When these measures fail, intubation or tracheotomy must be done. Children who are recovering from this disease have very sensitive throats and must be protected against cold air and draughts. They should be clothed throughout in woolen gar- ments, and kept in-doors until a normal condition of the larynx is re-established. Sprays of cubebs, camphor-menthol, lavolin, pine-needle oil, pine-tar, etc., will assist materially in a complete restoration of the mucous membrane to a state of health. CHAPTER XXXVIII. DISEASES OF THE LARYNX, CONTINUED. Intubation of the Larynx. To Joseph O'Dwyer, of New York, is due the credit of introducing the operation of intubation, which is now so com- monly performed. Bouchut, of Paris, demonstrated in 1858 that the operation was practicable, but no practical results followed his discovery until O'Dwyer, without knowledge of Bouchut's work, showed actual recoveries due to it. The instruments for this procedure are a set of tubes' of Fig. 160.— O'Dwyer's Intubation-tubes. Fig. 161.— Scale. varying calibre, with a scale for measuring the tube, to assist in selecting the proper size; a mouth-gag (Fig. 149); an introducer; an extractor, and a protector for the surgeon's finger. The tube (Fig. 160) is constructed with a flaring top that rests upon the ventricular bands. On one side of the flange is an aperture through which a loop of thread sixteen inches long is passed before introduction, in order that, if the tube accident- ally pass into the oesophagus, instead of the larynx, it can be withdrawn. The obstruction of the tube with particles of membrane may also render it necessary to draw the tube out (435) 436 DISEASES OF THE EAR, NOSE, AND THROAT. ilk by the thread. It is safest to employ a strand of braided sill or linen thread, being certain that it contains no inequalities to catch in the fenestra. The scale (Fig. 161) is used to determine the size of the tube to be employed, according to the age of the patient. Fig. 162.— O'Dwybr's Introducer, with Tube Attached. The introducer (Fig. 162) is screwed into the obturator of the tube, as shown in the illustration, and, when the tube is inserted into the larynx, pressure on the button of the intro- ducer separates the obturator from the tube, leaving the latter in the larynx while the obturator is withdrawn. The extractor (Fig. 163) is so constructed that, when the Fig. 163.— O'Dwyer's Extractor. blades at the curved extremity are introduced into the mouth the tube, pressure on the lever will separate the forcep-blades. These are roughened so that they obtain a grip that insures the extraction of the tube when they are withdrawn. In addition to these instruments, one needs a protector DISEASES OF THE LARYNX. 437 against being bitten during the operation. J. E. Rhodes (Jour- nal of the American Medical Association, January 15, 1895) has " devised a protector. It consists of a rubber glove that covers the hand from the wrist to a little beyond the metacarpo- phalangeal joints. On the index finger the terminal phalanx only is left uncovered." In order to prevent infection through the coughing of a patient while the operator occupies a position before his mouth, it is altogether safest to protect the eyes with glasses and the mouth and nose with a respirator or kerchief. The operation is a very brief one, not extending over ten seconds. The quicker it is accomplished, the less it interferes with respiration, and, therefore, with aeration of the blood. One should acquire not only extreme dexterity, but gentleness, in order not to do unnecessary damage to the delicate structures encroached upon. With proper skill one need inflict no injury or seriously interrupt breathing. In selecting the tubes it should be remembered that the smallest is intended for chil- dren younger than 2 years, the next for those between 2 and 4, the third smaller for those between 4 and 6, the fourth for those from 6 to 8, and the largest for those over 8 years of age. After the tube of proper size, according to the age of the child, as indicated on the scale, has been chosen, it is attached to the introducer by screwing the latter into the obturator con- tained within the tube, with the short side of the tube toward the handle, as shown. The latter is threaded as already de- scribed, and the instrument laid within easy reach of the right hand. Now, the child should be placed upon the lap of the nurse or assistant and held as shown in Fig. 150, illustrating the operation for removing adenoid vegetations from the vault of the pharynx. A strong sheet is wrapped and fastened about the child, so as to prevent any freedom of movements of its arms and legs, the latter being held between the nurse's knees. The nurse passes her left arm around the child's left side and over its arm, crosses the little one's wrists, and holds its right hand with her left and its left hand with her right, thus making it impossible for the child to interfere with the surgeon's work. i 438 DISEASES OF THE EAR, NOSE, AND THROAT. One assistant places the mouth-gag, as shown in the figure referred to, with the gag resting between the molar teeth of the left side. He must attend assiduously to the holding of the gag in place and keeping the child's head, thrown a little backward on the nurse's shoulder, immovably fixed. If these directions are efficiently followed there can be no kicking, sliding down, snatching of the instrument, or dislocation of the gag. The introducer, with tube and obturator attached and previously warmed, is then taken, the thread loop is passed over the left little finger, and the left index finger, being oiled, is carried into the pharynx until its tip rests behind the epiglottis and holds it upward. Now the end of the tube is made to follow the course taken by the tip of the inserted finger until it rests directly beneath it. The tip of the finger readily recog- nizes the epiglottis and the opening between the arytenoid cartilages. The instant the end of the tube rests beneath the tip of the finger in the median line, the handle of the introducer is brought upward so as to pass the tube from this point straight downward into the larynx. Unless this direction is followed at this particular step of the operation the tube will pass back of the larynx into the oesophagus. The tube once in the larynx, the thumb pushes the slide and the tube is released, the intro- ducer withdrawn, and the finger still in the throat presses the tube down into proper position. The surgeon should not neglect the use of a finger-guard and some protector for his mouth and nose during the intro- duction of the tube. A bite of the child or the ejection of a diphtheric discharge may cost the operator his life or communi- cate the disease to others. Before introducing the tube it should be examined to see if the instrument work easily, if the tube is readily released, and if it will remain safely in position while it is being intro- duced. The larger the tube that can be used, the freer the respiration and the discharge of particles of membrane will be through it. The thread is best not removed from the tube directly after the insertion, for an increase in the embarrassment of the respi- - DISEASES OF THE LARYNX. 439 ration may occur, indicating that either false membrane has been pushed along below the tube to block up its lower opening or that the lumen of the tube is obstructed by the presence of false membrane or secretions in it. In either condition the tube must be removed forthwith. So the thread loop is secured by attach- ing another thread to it and passing it around the child's neck. As soon as it becomes apparent that the operation has fulfilled its purpose by affording freedom of breathing, the gag is re- introduced, the thread is cut, the finger-tip placed on the end of the tube to prevent its dislodgment, and the thread loop is with- drawn, leaving the tube in position. If the operation has been successful, the patient, relieved of the horror of impending suffocation, now drops into a peaceful slumber, which must be encouraged, in order that nature may recuperate its waning strength and fortify its resisting-powers. Pellets of ice may now be allowed the patient to suck for quenching the thirst and to teach swallowing with .the tube in place. Later a few drops of cold milk are given for the same purposes. Should the first attempt to introduce the tube fail, the child must not be exhausted by too immediate an attempt for the second trial. A little rest is always best, unless the dyspnoea is exceedingly urgent. If the intubation fail or is followed by no relief, tracheotomy is the last resort. The physician should always be prepared for this emergency by having the trache- otomy instruments at hand. A bottle of nitrite of amyl should be provided, for, in case of threatened collapse, the inhalation of a few drops of it may resuscitate the little patient. To remove the tube the patient is prepared the same as for its introduction. The extractor is carried down, under the guidance of the tip of the protected left index finger, until it is slipped into the opening of the tube, when the lever is pressed upon by the thumb, the forcep-blades expanded to engage the tube, and the instrument is withdrawn with the tube attached. One must not forget to keep up the pressure that holds the tube attached to the extractor, or the tube might drop back into 440 DISEASES OF THE EAR, NOSE, AND THROAT. the throat. Removal of the tube may be necessary to clear it of obstructions or to ascertain when the patient no longer re- quires it. Should it be necessary to re-introduce it, a second tube had best be at hand already attached to the introducer, so that, if great dyspnoea occur before one has had time to clean and thread the tube removed, the other one can be inserted without delay. In case no other tube is at hand Northrup advises to " thrust the obturator into the tube and take two turns of thread of any kind around the neck of the tube, gathering the two ends in the right hand as it grasps the handle. In this way the thread holds the tube to the obturator during the insertion, and when it is in the larynx unwinds from the shaft and is drawn away." After the tube lias been in the trachea for a quarter of an hour, and there are no indications that it will have to be re- moved, the loop of thread is cut, and, with the finger in the pharynx and resting on the end of the tube the same as on its introduction, the string is withdrawn. Care must be taken not to disturb the tube in doing so. While the thread is in the mouth it excites nausea and gagging. The tube is allowed to remain in the larynx for several days, sometimes five or six, but, as soon as it becomes ap- parent that the disease has progressed so favorably as to render its presence there unnecessary, it is extracted. Sometimes it is coughed out. In the course of three or four hours after intubation the larynx becomes accustomed to the presence of the tube ; but if fluids are administered in a sitting posture they are almost cer- tain to enter the larynx and excite violent coughing, which may expel the tube, or they may enter the lungs and cause pneu- monia. The safest way to feed these patients is that proposed by Frank Cary, of Chicago, as follows : The patient is placed upon his back, with his feet elevated so that the axis of the body rests at an angle of forty-five degrees with the plane of the floor. The fluids are given through a tube or nursing-bottle in this position ; then they do not gain entrance into the trachea. Solids do not enter the trachea. Custards, corn-starch, thick DISEASES OF THE LARYNX. 441 gruels, etc., are quite readily taken, and many children soon learn to eat and drink with the tube in position. Intubation is to be preferred to tracheotomy in children under 5 years, particularly with an abundance of adipose tissue overlying the trachea. Parents more readily consent to this procedure than to an operation that involves the use of the knife. Intubation produces less shock than tracheotomy, and the air is better prepared for contact with the mucous mem- brane below the trachea after intubation than when it enters directly through a tracheotomy-tube. No anaesthesia is required for intubation, but it is generally necessary in tracheotomy, although I have operated without an anaesthetic in case of emergency. I have seen cases requiring tracheotomy in which the time necessary to produce anaesthesia could not be sacrificed, and, indeed, the carbonic-acid poisoning produced a sufficient anaesthesia. There are instances in which intubation fails because the tube cannot be retained in position, or sufficient nourishment cannot be taken to support the waning strength, or the tube becomes so clogged that it has to be removed repeatedly. In these cases tracheotomy will have to be brought to our aid. Intubation is not difficult for the laryngologist, but one needs considerable practice in order to be reasonably sure of success. The best means of acquiring dexterity is to introduce a tube frequently into the larynx of a cadaver. In the absence of conveniences for this, the tube should be many times introduced and extracted by means of substituting a hand, preferably that of another, for the larynx. The tube should be placed com- pletely out of sight in the hand while its mouth is sought for with the extractor. But it should not be forgotten that the passive hand differs somewhat from an obstreperous, struggling child. Intubation requires two assistants, and, if possible, one of these should be able to remove the tube or to introduce it if it is necessary to remove it or if it is coughed up. So in case of intubation it is important that skilled assistance be at hand for these emergencies. Tracheotomy is easier to perform, and can be done in ex- 442 DISEASES OF THE EAR, NOSE, AND THROAT. tremities without skilled assistants. If the tube become clogged the nurse can prevent suffocation by removing it and maintain- ing the opening free until the surgeon arrives. In these respects tracheotomy presents advantages over intubation. In cities Fig. 164.— Roswell Park's Aluminium Tracheal Tube. where skilled laryngologists are within quickly-calling distances intubation possesses superior merits. In the country, with all its unavoidable disadvantages, tracheotomy is hardly likely to be superseded. Tracheotomy. The instruments necessary for this operation are a small knife, double retractors (Fig. 88), haemostatic forceps, tracheal Fig. 165.— Hard-Rubber Tracheal Tubes. forceps, a tenaculum, a grooved director, a flexible catheter, and tracheotomy-tubes of various sizes (Figs. 164 and 165). The average size, up to 3 years, is one-fourth inch (six milli- metres). Other convenient articles should be at hand, if DISEASES OF THE LARYNX. 443 circumstances permit of their being supplied : sharp-pointed forceps, an aneurism-needle, thread, absorbent gauze, and tapes. An anaesthetic should be given unless the requisite time would endanger life, or the diminution of the amount of oxygen reaching the lungs would add to a danger already imminent, or unless the sensibilities are sufficiently obtunded by carbonic-acid poisoning of the blood. In this operation chloroform is to be given the preference over ether, on account of the effect of ether in exciting glottic spasm and increasing the difficulty of respiration. The high operation, in which the trachea is entered above the isthmus of the thyroid gland, is generally to be preferred to the low one, in which the incision is made below the isthmus, since in the high operation there are fewer and smaller blood- vessels to encounter (Plate VII). Another advantage gained in the high operation lies in the more superficial position of the trachea. The position of the patient during the operation is upon the back, with the head thrown backward by means of a narrow support under the back of the neck, to force upward promi- nently the anterior surface of the neck. If the operation is done without anaesthesia, the head, hands, and legs must be held by assistants. The incision is made in the median line, over the cricoid cartilage, for the high operation, extending an inch or more above and below the cartilage. The superficial anterior jugular vein may be met with at this point, and requires to be drawn out of the way or doubly ligated and divided ; but, if there is need for great haste, it can be secured by haemostatic forceps until after the trachea is opened. The superficial fascia is opened, the grooved director inserted, and the incision is com- pleted, after which the deep fascia is similarly incised. The knife-handle is used to separate the sternohyoid and the sterno- thyroid muscles ; the double retractors (Fig. 88) are now inserted to keep the wound open and to check haemorrhage by their pressure on its sides. The rings of the trachea can easily be felt, and the isthmus of the thyroid gland may protrude 444 DISEASES OF THE EAR, NOSE, AND THROAT. sufficiently to necessitate its being drawn down out of the way. A transverse incision is now made, about one-half inch (one centimetre) long, over the superior border of the cricoid carti- lage, penetrating the superficial layer of the deep cervical fascia. The grooved director is then introduced, passing from above downward between the cricoid cartilage and the deep layer of the deep cervical fascia. The two layers of fascia with the intervening veins and thyroid isthmus are drawn downward, exposing the upper rings of the trachea. These are fixed by the tenaculum and divided by an incision about one-half inch in length, according to the age of the patient. Great care must be taken that the knife does not penetrate the posterior wall of the trachea and the oesophagus. Equal forethought should insure that the false membrane is penetrated, so that the tra- cheal tube shall not be inserted between the membrane and the wall of the trachea, thus blocking up its opening. Equal care must be used to avoid the entrance of blood into the trachea and lungs. Coughing generally occurs when the trachea is opened, so that the secretions and portions of the false mem- brane are expelled. In case of diphtheria it is evident how necessary it is for the physician to be on the alert to dodge the bombardment of poisonous discharges. The trachea being opened, a dilator is employed by many surgeons until the haemorrhage ceases and free respiration is established. Sponging must be rapid ; the opening must be maintained free from discharges ; all false membrane within reach of the tracheal forceps must be extracted, and, finally, the tracheal tube is introduced and secured by tapes passing around the neck and tied on one side. As large a tube as the trachea will admit should be used. The patient must be closely watched and, if necessary, artificial respiration must be performed ; clog- ging of the tube and interference with it must be prevented. All the tissues about the wound should be cleansed with a solution of bichloride of mercury, 1 to 5000, and a divided piece of gauze, smeared with carbolized vaselin, should be interposed between the collar of the tube and the surface of the wound. DISEASES OF THE LARYNX. 445 The low operation is performed similarly to the one already described, except that the incision begins at the cricoid carti- lage and ends about one-half inch above the sternum. The trachea lies deeper here ; the blood-vessels are larger and more numerous and the thyroid isthmus is in the way. It is a more difficult procedure. After tracheotomy the tube is best protected by a layer of bichloride gauze kept loosely above and about the tube, without impeding the currents of air. As rapidly as it is soiled this protector should be removed. The air of the apartment is kept at a uniform temperature of 76° to 80° F., and impregnated with moisture to prevent irritation of the mucous membrane of the deeper air-passages. During the first day the inner tube must be removed frequently for cleaning with a 5-per-cent. solu- tion of carbolic acid, and to make certain that there is no obstruction. Sections of the false membrane may block up the lower end of the large, or outer, tube and require removing with the tracheal forceps. In such an emergency the cannula has to be removed. The nurse should always be instructed as to the possibility of such an accident, and that she must at once cut the tapes, remove the tube, cleanse and free the opening, and maintain its patency until the surgeon can be summoned. In two or three days the tube should be closed momentarily to determine if respiration is normal without it ; if so, it can be dispensed with and the wound closed. CHAPTER XXXIX. DISEASES OF THE LARYNX, CONTINUED. Chronic Laryngitis. Synonym. — Chronic catarrh of the larynx. Explanatory Note. — Before entering upon a consideration of this subject it is pertinent to explain why there is no separate article in this book, as is customary, on subacute inflammation of the larynx. There are many varying degrees of inflammation of the mucous membrane. During the same attack of acute inflammation the process exhibits different degrees of intensity, but the tendency of our times has been too much toward useless and confusing refinements and multiplication of pathological conditions into entities, when they were really but modifications of the same disease, like shades of the same color or variations of the same malady. Formerly the mild grade of acute inflam- mation of the middle ear was described separately as a subacute inflammation, although it is not a different disease ; but the lead- ing books on otology now discard this adventitious distinction, and laryngologists should lend encouragement to a sensible simplification of a terminology which is encumbered with un- warranted parasites of nomenclature. So we will not attempt to multiply the varying grades of intensity of an acute inflam- mation into separate diseases. Pathology. — When acute laryngitis is neglected it naturally terminates in a chronic inflammation, which leaves the mucous membrane thickened and the small blood-vessels engorged and tortuous. There is an increase in connective-tissue formation, the encroachment of which on the epithelial layer produces the superficial erosions occurring in this disease. The posterior por- tion of the cavity only may be involved, or the inflammatory process may extend to every part of the larynx, not excepting the muscles. When the latter become indurated the mechanism of pitch-production is so interfered with as to render its changes (446) DISEASES OF THE LARYNX. 447 very difficult. If the mucous membrane covering the vocal cords is thickened, the result is an alteration in the timbre or quality of the voice, which assumes a hoarse sound. Etiology. — As chronic rhinitis is the direct result of re- peated or neglected attacks of acute nasal catarrh, so chronic laryngitis may be a sequel of recurring or neglected attacks of acute catarrh of the larynx. But this disease is not always a heritage of an acute attack. It often arises cle novo. Many pa- tients who are afflicted with chronic hypertrophic rhinitis present a chronic laryngitis as a complication or result of the nasal hy- pertrophy. This is easily understood when we take into con- sideration the continuity of mucous membrane of the larynx, pharynx, and nasal cavities. In addition to this direct cause is another which illustrates the importance of prompt and efficient treatment of nasal anomalies. The discharges from the nose and naso-pharynx constantly find their way either directly into the larynx by dripping into the cavity, or they gravitate down to the immediate vicinity of the portal of the larynx, where they cause direct irritation by their presence, and indirect irrita- tion by exciting efforts to dislodge them, with a hacking cough. Bosworth lays stress upon this source of chronic laryngitis. Another causative relation of hypertrophic rhinitis to this disease lies in the forced mouth-breathing in consequence of nasal stenosis. The air then reaches the larynx without the processes of purifying, warming, and moistening having been applied to it as they are by the nasal passages in a normal condition. Excessive use of the voice, especially when it is taxed beyond its natural or acquired compass, sets up an hyperemia and congestion that finally terminate in a chronic inflammation. Ambitious, but ill-trained singers, the periodical orators of polit- ical campaigns, hucksters, intensely-emotional revivalists, etc., are frequent sufferers. Inactivity of the liver, and dyspepsia, alco- holic excesses, and atmospheric irritants are prolific producers of this disease. Symptomatology. — The most marked symptoms are devel- oped when attempts are made to use the voice. While it is at 448 DISEASES OF THE EAR, NOSE, AND THROAT. rest there may be very little to call the patient's attention to the fact that he has a larynx. In other instances there is a sensa- tion of dryness or a slight irritation that excites a hemming or a little cough. But when the patient begins to call the vocal organs into activity the trouble begins. A tickling sensation is experienced that produces an irresistible desire to cough. Burning and prickling pains are felt in the larynx, which one endeavors to relieve by clearing the throat. In the midst of a sentence a cutting pain shoots through the organ, that may be described as a feeling as though the vocal cord were splitting or tearing. The sentence, or even the word, is cut short, and for an instant the speaker is unable to proceed until he clears the throat or takes a drink ; hence arises the habit of many speak- ers of providing themselves with a glass or a pitcher of water before beginning a discourse. The voice shows the most marked effect of this disease, but there are great variations in different patients, and pecul- iarities distinguishing certain cases. When a speaker, for ex- ample, begins an address, his voice may be husky and cracked in quality, while, after proceeding for a short time, the normal timbre may be restored. Singers experience the same pecul- iarity. This is probably due to the increased secretion stimu- lated by a quickened circulation, as well as to improved inner- vation resulting from the intensity of will-impulse. Another characteristic is the natural quality observed in the customary tones and the breaking of this quality on straining the voice, and even a condition of complete aphonia, or loss of voice. The secretions are not copious from uncomplicated chronic laryngitis. They are generally tenacious and of a gray color, but if ulcerations are present they assume a yellow hue. As in the acute inflammation, there is rarely any blood in the expecto- rations, unless an unusually violent effort at coughing has ruptured the vessels. Inspection with the laryngeal mirror shows an hypersemic condition of the mucous membrane (Plate VIII). As the figures illustrate, the small blood-vessels of the epiglottis are engorged and conspicuous. The vocal cords are sometimes red, DISEASES OF THE LARYNX. 449 one or both ; at other times they do not participate in the in- flammatory process. One cord may be affected, while the other remains of normal appearance, or parts only of the cords may show an injected condition of their blood-vessels. These parts are the lateral attached borders of the vocal bands. The con- dition of the membrane varies, according to the amount of secretions present, from absolute dryness to a general covering of the whole interior with secretions. Like similar conditions of the mucous membrane in other localities, a gradual thicken- ing of the mucosa and submucous tissues results from inflam- mation of long duration, and the vocal cords may be affected by this hyperplasia to the extent of granulation formation, or trachoma. The presence of these excrescences materially em- barrasses the vibration of the cords and changes the character of the notes produced. The chronic thickening of the mucosa and the subjacent tissues diminishes the mobility of the larynx, just as we have seen that the increased thickness of the drum-head and of the tissues entering into the construction of the joints of the ossicles and the attachment of the stirrup to the oval window diminishes or destroys their mobility. For example of impeded movements due to hypertrophy : when the interarytenoid fold becomes thickened the arytenoid cartilages cannot approximate each other normally, which is equivalent to saying that the vocal bands cannot do the same thing. Great swelling of the ven- tricular bands obliterates the ventricles and deranges the actions of the vocal cords. One cord becomes paretic and the opposite cord must do vicarious service, which it does by taking the place, almost literally, of its fellow, by moving across the median line to approximate its useless mate. The gap is then closed up, to a degree, and voice-production is made possible. Ulcerations of a shallow kind are occasionally to be seen, generally in the interval between the arytenoid cartilages. Diagnosis. — Chronic laryngitis is likely to be confounded with laryngeal oedema, paralysis, and cancer, or syphilitic and tubercular laryngitis. In oedema the swelling of the mucosa is out. of all proportion to the thickening of chronic inflammation, 29 450 DISEASES OF THE EAR, NOSE, AND THROAT. and, although there may be redness, there is generally a pale, puffy, and water-soaked appearance, and the disease is of short duration. In paralysis neither swelling nor congestion is present. In the catarrhal condition hoarseness is generally more apparent in the morning hours, while the change in char- acter of the voice in paralysis is constant, but less noticeable immediately after a night's rest. Paresis in the catarrhal con- dition more often affects one vocal band than both, according to Ziemssen ; and the absence of mobility is much greater in paralysis. In catarrh the use of the voice often has the effect of clearing it of its cracked quality, while in paralysis fatigue and vocal exercise impair its quality. Tubercular laryngitis presents a very different history from that of the simple catarrhal disease. The general condition of the patient and the presence of a tubercular condition of the lungs assist materially in making a differential diagnosis. The impaired nutrition and strength, the temperature and pulse, the night-sweats, and painful and difficult swallowing are character- istic of tuberculosis, but not of chronic laryngitis. The intra- laryngeal pictures show certain differences in the two diseases. While redness is a symptom of catarrhal inflammation, the membrane in tuberculosis of the larynx may present a bloodless appearance, especially in the initiatory stage of the disease. Erosions, rare in simple catarrh, are characteristic of the tuber- cular affection. In laryngitis of the simple type, even when the erosions are found, they are superficial points of exfoliation of the epithelium ; but in tuberculosis they may extend deeply into the membrane and be distributed over a wide area (Plate VIII), affecting the epiglottis, the posterior commissure, the ventricular bands and the vocal cords. The polypoid con- formation of the arytenoid cartilages produced by the great thickening in advanced cases is well illustrated in the plate to which reference is made. This swelling extends to the aryepi- glottic folds and appears dense instead of cedematous, although the paleness of the membrane may be suggestive of a case of oedema. Syphilis of the larynx (Plate VIII) may closely simulate DISEASES OF THE LARYNX. 451 a simple catarrh, but a syphilitic history or the presence of ulcers or their scars, and deformities due to the contraction of old cicatrices are valuable aids to diagnosis. The effects of the administration of specific remedies in experimental diagnosis are determinative in syphilis. In both tuberculosis and syphilis of the larynx character- istic lesions in the pharynx may help greatly in arriving at a correct conclusion. Chronic laryngitis may be with difficulty distinguished from a malignant disease, at first, but the histories of the two con- ditions vary. In the early stage of malignant disease the red, tumefied appearance is limited to a certain area instead of being- diffused over a large surface. As the neoplasm increases in size it changes the contour of the parts as simple catarrh does not, and difficult and painful swallowing, together with loss of voice, are marked symptoms of malignant disease. As deep ulceration in the latter condition takes place the pain is more pronounced and continuous than is met with in simple chronic laryngitis. Prognosis. — If the disease has not existed too long, and proper treatment and hygienic conditions can be had, the out- look is favorable. But if thickening of the tissues is great and extends to the laryngeal muscles, the difficulties to overcome are considerable. This trouble is usually protracted and extends over many years, in some cases, and, after treatment has accom- plished all it will, the voice may still retain a coarse, unpleasant quality. Treatment. — The topical application of remedies is easily accomplished with the improved apparatus of our day. Com- pressed air and sprays can be made to apply medicaments to the interior of the larynx with ease and efficiency. Useful devices are shown in Chapter XVIII for both office and home treat- ment. Improved appliances for compressing air, both by hand and hydraulic power, are described in Chapter IV. Various medicated sprays — as recommended by Lennox Browne, E. L. Shurly, Charles E. Sajous, and others — will cleanse and disinfect the larynx, as well as produce astringent, 452 DISEASES OF THE EAR, NOSE, AND THROAT. sedative, stimulant, or tonic effects. It is claimed by Roe and Cohen that sprays thrown into the throat are largely condensed in the pharynx, but it can be easily demonstrated upon one's own larynx that the remedy can be made to medicate that organ also. If the spray is thrown through a long tube with a prop- erly-curved extremity (Figs. 116 and 117) for directing the current downward and a little forward from a position similar to that occupied by the laryngeal mirror in situ, the spray enters directly into the larynx. When the dilator is used with the lips closed over the mouth-tube and the patient inhaling through the instrument, the medicinal vapor not only reaches the laryn- geal cavity, but the bronchi and lungs also. In former years I used the complete steam-atomizer of Codman & ShurtlefT, but, as I could discover no compensating advantage of the steam method over the improved apparatus referred to, and as Fig. 166.— Cohen's Sponge- or Cotton- holding Forceps. ?at- the latter requires far less time and trouble in giving trea ments, I have for a considerable time preferred the instruments described. For the application of pigments to the laryngeal membrane special camel's hair brushes, sponges, and cotton are used. I prefer the cotton, either twisted firmly on a holder or used with Cohen's laryngeal cotton-forceps (Fig. 166). The bristles of the brush sometimes become detached and stick in the larynx, like the voice of iEneas. This is not amusing to the patient. Applicators for caustics are specially constructed, but, with a minute cotton-tip twisted very firmly on a carrier, escharotics can be conveniently applied. Counter-irritants, like mustard and tincture of iodine, are sometimes serviceable. They should be applied directly over the larynx and at its sides. It is exceedingly important that DISEASES OF THE LARYNX. 453 the cause of the trouble be removed, and this will generally be found to lie in inordinate and improper exertion of the voice. In such cases absolute rest must be enjoined. When the cough is very troublesome the compound spirit of chloroform or Hoff- mann's anodyne will relieve the irritation. The inhalation of camphor-menthol from the pocket-inhaler (Fig. 128) allays the tickling. When the thickening is considerable, sprays of eucalyptol, 4 per cent.; camphor-menthol, 3 per cent.; or oil of cubebs, 4 per cent., in lavolin should be used once or twice a day. Alum, in a 2-per-cent. solution ; zinc sulphate, 1 per cent. ; or silver nitrate may be used according to the indications in each case. When much irritability exists, with a hacking cough and co- pious secretions and expectoration, inhalations of a 10-per-cent. solution of camphor-menthol in lavolin are effective. These should be taken through the nebulizer, and not in the form of a coarse spray. If erosions are discovered the dioxide of hydrogen, diluted one-half with water, at first, should be sprayed upon the ulcers; then aristol should be sprinkled over them. Iodoform is pre- ferred by some, tannin and alum by others. Chromic acid, 5 or 10 grains to the ounce, and silver nitrate have able advocates. Atrophic Laryngitis. This requires stimulating applications. The lavolin-sprays containing remedies already given are useful, — viz., eucalyptol, oil of cubebs, benzoinated lavolin, menthol, terebene, salol, oil of tar, etc. Shurly recommends iodine internally in the form of hydriodic acid, in drachm doses, three times a day, or iodide of potassium or ammonium. Much relief is afforded by my am- monium-chloride tablets, the formula of which will be found under " Treatment" of "Acute Laryngitis." Two or three can be used in the course of an hour, allowing them to dissolve slowly in the mouth, so that the medicated saliva will trickle down and remain in contact with the mucous membrane about the entrance to the larynx as long as possible. 454 diseases of the ear, nose, and throat. Suppurative Laryngitis. Synonyms. — Phlegmonous laryngitis; purulent laryngitis; diffuse abscess of the larynx. Pathology. — This is an inflammation of the submucous tis sues of the larynx, with infiltration of the areolar tissue and suppuration, ending in the formation of abscesses. The area most frequently involved is the superior part of the larynx contiguous to the epiglottis. Etiology. — Suppurative inflammation of the larynx may be idiopathic, or it may arise secondarily by extension from the pharynx. It may originate in perichondritis secondary to syphilitic infection or other wasting disease. Symptomatology. — Difficult respiration and impairment or suppression of the voice are the most prominent symptoms. There is a choking or stifling sensation, as though a foreign substance had gained entrance into the larynx, accompanied by increasing pains. Some difficulty in deglutition appears ; all the symptoms become exaggerated; the breathing is strident, the voice feeble and cracked, the face puffed and purple, and suffocation seems imminent. Frequent attempts are made to free the throat by hemming rather than by coughing. Laryn- goscopy reveals the inflamed, tumefied mucous membrane ob- structing the air-current. Circumscribed swelling may be seen in the region of the aryteno-epiglottic folds. Diagnosis. — Inspection discloses the differences between this disease and the presence of foreign bodies, diphtheria, croup, tumors, pharyngeal abscess, and spasmodic croup. The dyspnoea of this disease appears more gradually than that occa- sioned by the presence of foreign bodies or laryngismus strid- ulus, in which the obstruction to breathing occurs suddenly. The history of a tumor does not present the characteristics of an inflammation. Prognosis. — Suppurative laryngitis is a rapidly-fatal disease. It kills about three out of four of its victims. Death is caused by strangulation or inanition. Treatment. — If the patient is seen at the onset of the at- ; DISEASES OF THE LARYNX. 455 tack, cold, in the form of ice-bags (Fig. 78), should be constantly applied over the larynx. Pellets of ice may be sucked so as to produce the effect of cold internally as well as externally. Leeches may be applied over the upper portion of the sternum, but in this disease there is one objection to them that may not have weight in other diseases of the larynx, — i.e., the patient soon becomes exhausted from the lack of nourishment, owing to the impossibility of swallowing sufficient food, and bleeding only adds to his weakness. The air should be kept moist the same as in croup. (Edematous tissue and abscesses must be evacuated by scarification. Supportive and stimulant treatment must be combined with nutritious enemata to meet the inevi- table failure of strength. Suffocation must be prevented by tracheotomy or intubation. Abscess of the Larynx. The physical conditions in this disease coincide so closely with those just described under the heading of " Suppurative Laryngitis," in which abscesses occur, that a separate description would be tantamount to tautology. The treatment is the same as for abscesses occurring in suppurative laryngitis. Granulations of the Vocal Cords. As a result of chronic laryngitis of long duration, a rough- ened condition of the vocal bands is found, to which the name " chorditis tuberosa " is sometimes applied. There is a prolif- eration of connective tissue, productive of inequalities that are apparent in the laryngoscopic image. This condition obtains most frequently in public speakers and singers and is sometimes quite intractable to treatment. Treatment. — The remedies recommended for chronic laryn- gitis are applicable here. Charles E. Sajous advises applying chromic acid to the cocainized hypertrophies. This is best accomplished by fusing the acid on the applicator (Fig. 66), bent to the proper curve. Only a few of the prominent points should be touched at each treatment. 456 DISEASES OF THE EAR, NOSE, AND THROAT. QEdexMA of the Larynx. .. Synonyms. — (Edematous laryngitis ; purulent laryngitis ; oedema glottidis. Pathology. — The loose attachment of the mucous mem- brane to the walls of the larynx favors infiltration and separation of the mucosa from the cartilages (Plate VIII). The changes that take place in acute cedematous inflammation occur so rap- idly as to preclude their study, the disease proving rapidly fatal in many cases. In this form the infiltration consists of serum, but in the more protracted attacks it consists of a mixture of serum and pus, with effusion of blood, in occasional instances. The epiglottis is sometimes involved to the extent of becoming greatly enlarged. The loose areolar tissue of the aryepiglottic folds is probably more copiously engorged with the fluid exu- date than any other portion of the larynx, and the ventricular bands suffer nearly as much. The true vocal bands may escape altogether or participate to the degree of slight swelling. The laryngeal muscles may present a water-soaked appearance if a post-mortem examination is made, after death due to this disease. Associated with oedema of the larynx may be a similar infiltra- tion of the pharynx and even of the neck. Etiology. — Most cases of laryngeal oedema occur between the ages of 20 and 35 years, and are nearly three times as frequent in men as in women. It may be idiopathic or symp- tomatic. Nearly three times as many cases are secondary as are primary in character, — that is, most cases are consecutive to some other affection, such as Bright's disease, that gives rise to a dropsical condition of lax tissues. When oedema of the pharynx invades the adjacent laryngeal tissues, the latter is termed " con- tiguous oedema " ; and when laryngeal oedema is secondary to some other disease of the larynx it is designated as consecutive. Any cause that operates to produce an inflammation of the laryngeal mucosa or submucosa may be a cause of oedema. Exposures to cold or impure air containing irritating particles or gases, injuries, scalds, corroding chemicals, and certain dis- eases cause or predispose to this disease. Such affections as DISEASES OF THE LARYNX. 457 Bright's disease, syphilis, tuberculosis, and typhoid and the eruptive fevers. Symptomatology. — The prominent and most distressing symptom is the difficulty of respiration. There is a sensation as if a foreign body had gained entrance into the throat, and difficulty of swallowing adds to the suffering. As the swelling and consequent stenosis of the larynx progresses, the labor of breathing becomes more arduous, until the patient is threatened with impending suffocation. As the lumen of the larynx is encroached upon, and the pressure of the tumefied tissues increases, the voice becomes feeble and finally disappears. Frequent efforts are made to clear the throat of the ob- struction, but they are not of the character of a cough. There is but little expectoration, and this consists of mucus. The suf- fering occasioned by this disease is intense, not only of the pa- tient, but of his helpless friends. He cannot lie down, but sits with his body and head thrown forward, unable to speak, but exerting every muscle to draw in enough air to support life. He calls to the by-standers for help, has them support his arms and shoulders, one attendant on either side, while he seeks the open window for air. The noise of inspiration is harsh and indicative of the extreme narrowing of the glottis. Moments of relaxation and relief may occur, only to be followed by the paroxysm that threatens immediate suffocation. As the sufferer gasps for air with open mouth and horror-stricken eyes, his face puffed and purple, his whole frame convulsed with an agoniz- ing struggle for life, the surgeon or death soon comes to his relief and closes the scene. Inspection, when it is possible, reveals the epiglottis red and swollen to enormous proportions, and it may cut off a view of the laryngeal cavity. The enlargement becomes so excessive as to amount to a deformity. The aryepiglottic folds are seen to be tumefied even to the point of medial contact with each other over the laryngeal opening during inspiration. When inspection is impossible, a quick, but gentle, palpa- tion with the finger, not interrupting respiration to a dangerous degree, may enlighten the examiner as to the condition present. 458 DISEASES OF THE EAR, NOSE, AND THROAT. The roll-like character of the epiglottis and the spongy feeling of the aryepiglottic folds are characteristic. Diagnosis. — (Edema of the larynx may be mistaken for the presence of foreign bodies, polypus, retropharyngeal abscess, acute laryngitis, or pulmonary emphysema. The symptoms and the conditions presented on examination are sufficient to mark the differences. Diphtheria of the larynx can be detected by the discharge of shreds of the false membrane and the latter is generally found in the pharynx also. Prognosis. — About one-half of all cases of this disease terminate fatally. Acute laryngeal oedema has an average dura- tion of about a week. Cases arising in the course of pharyn- geal oedema generally pursue a favorable course, but those re- sulting from aneurism of the aorta or of other important vessels of the neck prove fatal. The same is true of oedema arising from an extension of the disease from the external areolar tissue. Tubercular oedema is unfavorable, but the syphilitic type is amen- able to treatment. The prognosis should always be guarded. Treatment — Scarification is the classic remedy, but there are other means of relief that have come into use in later years. Pilocarpine depletes the blood-vessels of their serum and is in- dicated here to drain the water-soaked tissues. It can be given in doses of \ or J grain until free salivation and diaphoresis are produced. Enough to cause heart-depression should not be administered. In violent acute cases the blanching, shrinking, and anaes- thetic effects of cocaine would appear to be indicated. I have never tried it in this condition, nor have I seen it mentioned in this connection, but for prompt action and immediate relief from impending suffocation its physiological action suggests its use. Unless a speedy change for the better takes place, scarification, intubation, or tracheotomy should be done. When oedema has become chronic, its treatment is much like that of chronic laryngitis, with the addition of scarification. Dilatation by Schrotter's method with hard-rubber tubes has proved useful, and the intubation-tubes, promise good results. In severe cases tracheotomy may become imperative. CHAPTER XL. - DISEASES OF THE LARYNX, CONTINUE©. Neuroses, spasmodic croup. Synonyms. — Spasm of the larynx ; spasm of the glottis ; laryngismus stridulus. Pathology. — According to Marshall Hall, this is a reflex nervous disease, the exciting cause of which may be located in remote organs, — for example, in the teeth, the intestinal tract, or at a point of pressure on the recurrent laryngeal nerve. It is believed by some authorities to be of purely cerebral origin. Etiology. — This is, for the most part, a disease of childhood, although it occasionally occurs in adult life. It may be brought on by the accidental entrance of liquid or foods or any foreign body into the larynx. Dentition is a common cause, and mental emotion may give rise to attacks. Symptomatology. — The closure of the glottis may be com- plete or incomplete. In the former case there is entire arrest of respiration temporarily. The child is taken with a sudden convulsion; the eyes are rolled ; the hands and feet are cramped, and even opisthotonos may supervene. All at once a spasmodic inspiratory movement occurs, announcing the cessation of the spasm. When the glottis is incompletely closed, the air passes through it with a harsh, croupy sound, which resembles closely the crowing of croup or the whoop of whooping-cough. During these distressing attacks the face becomes flushed, congested, or livid, according to the severity of the attack, and the veins of the neck are distended. In extreme cases the spasm does not relax and the child dies in convulsions. These attacks may follow each other rapidly, or one only may occur at long intervals, and the child appears in excellent health between the attacks. They occur usually at night, (459) 460 DISEASES OF THE EAR, NOSE, AND THROAT. waking the child out of a sound sleep. They are not accom- panied by fever or cough, but there is copious perspiration. Children under 2 years of age are most frequently subject to this disease, and boys are attacked more often than girls. Those whose systems are impoverished are the most likely to suffer. Diagnosis. — Spasmodic croup does not closely resemble any other disease except true croup, from which it can be differ- entiated by the absence of fever and false membrane and by the presence of good health as soon as the transitory paroxysm yields and normal respiration succeeds. Prognosis. — When the attacks do not show a high degree of intensity of the spasmodic contraction, and when they do not last long or do not occur at short intervals, the prognosis is usually favorable. But when the closure of the glottis is com- plete the child may die of strangulation before help can be summoned. The more frequently the paroxysms occur, the more danger there is to life. If the spasms are owing to cere- bral disease the prognosis is grave. Treatment — For immediate relief a few drops of amyl- nitrite, ethyl-bromide, chloroform, or ether may be inhaled, if any air is inspired. If not, dashing cold water in the face, slapping the back of the shoulders, applying ice to the back of the neck, tickling the throat, or introducing the finger to cause vomiting may succeed in aborting the attack. While the finger is in the throat it should be used to learn whether the epiglottis is impacted in the aperture of the larynx, and, if it is, the tip of the finger should be hooked under the epiglottis and made to raise it into position. Drawing the tongue out of the mouth also raises the epiglottis. A hot mustard bath may relax the spasm. Hypodermatic injections of apomorphine, in very minute doses, or a dose of turpeth mineral, 1 or 2 grains, may excite vomiting and end the paroxysm. Powdered alum in teaspoon- ful doses is a harmless and efficient emetic. The cause of the attacks must be ascertained and prophy- lactic measures adopted. Laryngitis, indigestion, troublesome teeth, or irritation of the genital organs, especially of the pre- DISEASES OF THE LARYNX. 461 puce, may bear a causative relation to this disease. As a rule, general tonics, nervous sedatives, and an especially nutritious diet are indicated. ANOMALIES OF SENSATION. Hyperesthesia, neuralgia, and parse sthesia of the larynx are most commonly met with in singers and public speakers who strain their vocal organs. Pathology. — Congestion of the laryngeal mucous mem- brane is often present, but inspection may not reveal any appar- ent structural change ; this is true when the affection is purely of a neurotic character. Etiology. — Excessive use of the voice after faulty methods, overindulgence in alcoholic beverages, excessive smoking, varicose veins and hypertrophied glands at the base of the tongue, and inflammatory affections of the larynx occasion hy- peresthesia. The causes of paresthesia are quite numerous and sometimes obscure. Anything that produces a depressed condition of the nervous system may be said to predispose to this nervous anomaly. Foreign bodies in the larynx and inflam- matory conditions of the mucous membrane cause it. To these causes, and to the uric-acid diathesis, neuralgia is due. Symptomatology . — The laryngeal mucous membrane is of- ten exquisitely sensitive in hyperesthesia, so that dusty or cold air, the fumes of a match, smoke, etc., provoke fits of coughing. There is usually a sensation of dryness, or scratching, or tick- ling in the larynx that excites hemming or slight coughing to give relief. Neuralgia here, as elsewhere, is not constant. Fu- gitive pains and sensations of soreness of a transitory nature are present. In paresthesia there are unusual sensations, generally of a foreign body in the larynx. Patients sometimes can scarcely be convinced that the impression is not produced by a foreign substance. This is called globus hystericus. Diagnosis. — There is not much difficulty in deciding upon the nervous nature of these affections, since examination gener- ally fails to discover any physical signs. The symptoms are quite characteristic. •162 DISEASES OF THE EAR, NOSE, AND THROAT. Prognosis. — These troubles are rather annoying than serious. They are persistent, but amenable to treatment. Treatment. — If any irritation is found, the throat- tablets — containing ammonium chloride, 2 grains ; camphorated tincture of opium, compound syrup of squills, and syrup of Tolu, each 5 minims ; and extract of licorice, 2J grains — may allay the ir- ritation and cough. Inhalations of oil of cubebs, carbolic acid, salol, and eucalyptus in lavolin, as described under the heading of " Sprays and Inhalents," are beneficial. When hypertrophied glands and varicose reins are found in the pharynx, and espe- cially about the base of the tongue, they are to be eradicated by means of the cautery. The bromides and other nervous seda- tives and nervous stimulants, like valerianate of ammonia, are demanded in certain cases General tonic treatment is often necessary, combined with a fattening regimen. NERVOUS APHONIA. Synonyms. — Hysterical aphonia; hysterical paralysis of the vocal cords; functional aphonia. Pathology. — This is a functional bilateral paresis of the lateral cricoarytenoid muscles, interfering with the normal ref- lations of the vocal cords during attempted phonation. They cannot be properly approximated. It is not due to any organic lesion, but to a temporary loss of the power of muscular co-ordination or of innervation. Etiology. — This affection is a symptom of hysteria and de- bilitating diseases. It occurs most frequently in unmarried women, and is especially marked between puberty and the establishment of the menopause. Symptomatology. — A peculiarity of this disease is that the patient may not be able to utter the common conversational tone, but may cough or laugh audibly, which does not occur in complete paralysis. The onset is sudden, like that of spasmodic croup, and the patient cannot attribute it to any cause ; or it may follow upon an intense mental impression. Even whisper- ing is sometimes out of the question. The attacks are irregu- lar, appearing one day and disappearing the next, without any DISEASES OF THE LARYNX. 463 premonitory signs or symptoms. The impression of cold often develops the symptoms, and this fact may account for patients, exposed to draughts of air at night, losing their voices between the hours of retiring and arising. Inspection during phonation shows the effect of the loss of power of the adductors. The vocal cords cannot be brought into close relationship (Plate VIII). Efforts to approximate them may cause a spasmodic approaching of the cords, followed immediately by their wide separation. Unless a catarrhal con- dition exists, the larynx is pale and presents no inflammatory appearances. Diagnosis. — The history, symptoms, and appearances de- scribed render the diagnosis easy. Prognosis. — This is favorable, although there is a liability of the attacks to return. This is the kind of trouble in which the various sorts of "mind-cures" are effective. The mental im- pression made by simply introducing any indifferent instrument, such as a laryngeal mirror, into the throat may restore the voice. In other cases actual treatment must be pursued for a considerable time to effect a cure. Treatment. — Strychnine, beginning with -^ grain and in- creased gradually until its physiological effects are produced, and electricity are efficient remedies. Sir Morell Mackenzie de- vised a laryngeal electrode for this purpose, by means of which one electrode is applied within and the other without the larynx. The galvano-faradic current is preferable. If the muscles have not become atrophied this treatment is speedily beneficial. The elixir of the valerianate of ammonia, combined with quinine, if a tonic effect is desired in addition to that of a diffu- sive nervous stimulant, meets the indication admirably. Zinc valerianate in 1 -grain doses every four hours is recommended by Sajous, as well as coca-wine. PARALYSIS. The laryngeal muscles may be paralyzed singly or in pairs, or several muscles may be affected simultaneously. The paral- ysis may be unilateral or bilateral, affecting only one side or 464 DISEASES OF THE EAR, NOSE, AND THROAT. both. Anaesthesia of the laryngeal mucous membrane may ex- ist as a complication. The paralysis may be of central origin, the disease being located in that part of the brain in which the laryngeal nerves have their origin, or it may be due to a disease in the course of the nerve-trunk. On the other hand, the lesion may be of a local character, the muscles being affected either primarily, or secondarily to some debilitating systemic malady. Pathology. — Cerebral causes of paralysis of the laryngeal muscles are : the gummata of syphilis, apoplexy, multiple scle- rosis, tumors, etc. Diphtheria is one of the most frequent causes, aneurisms in the neck, tumors, progressive bulbar paralysis, hy- pertrophied glands, etc., are among the causes. The recurrent laryngeal nerve is subject to pressure from aneurism of the arch of the aorta, the left carotid, or the subclavian artery. Aneurism of the carotid, the subclavian, or the innominate artery on the right side may produce the same effect. These conditions re- sult in unilateral paralysis, in which the epiglottis cannot be completely closed and there is loss of power to extend the vocal cord. , When an aneurism or other tumor is large enough to occasion pressure on both recurrent laryngeal nerves bilateral paralysis results. The laryngeal muscles may become the seat of disease which, independently of any affection of the nerves, may im- pair or destroy their function. An extension of the inflamma- tory action from the mucous surfaces to the muscular tissue, with exudation and swelling, may produce a paretic condition of a transitory nature. Degenerative changes, such as atrophy of the muscular tissues, may occur to such an extent as to eventuate in muscular paralysis. Etiology. — Certain drugs and chemicals cause laryngeal motor paralysis, such as the following: Belladonna, opium, phosphorus, arsenic, mercury, lead, and alcohol. Such diseases as diphtheria, rheumatism, syphilis, anaemia, and inflammation of the adjacent areolar tissue and glands are causative conditions. When paralysis of the muscles of abduction — the posterior cricoarytenoid — occurs, the vocal cords lie in such constantly close relation to each other as to present a serious obstruction DISEASES OF THE LARYNX. 465 to respiration (Plate VIII). The breathing is noisy and labored, and suffocation is imminent. The voice is not affected because of the action of the arytenoideus muscle in approximating the vocal bands. When unilateral paralysis of the posterior crico- arytenoid muscle takes place there is no dyspnoea except on great exertion (Plate VIII). When both sides are affected it may be due to brain disease in the region of the fourth ventricle or in the medulla affecting the pneumogastric and spinal accessory nerves. Paralysis of the muscles of adduction — the lateral crico- arytenoid — results in the vocal cords remaining in a condition of abduction, or separation from each other as far as possible. This occurs most frequently in hysteria and leaves no vestige of the voice. If this paralysis is unilateral, whispering may be possible. When paralysis of the arytenoideus muscle happens the voice is very feeble or altogether lost. A triangular space be- tween the vocal cords, behind the vocal processes, remains dur- ing phonation in consequence of the loss of contractility of this muscle. Paralysis of the muscles of tension — the thyrocricoid and the thyro-arytenoid muscles — is not infrequent. Paralysis of the thyrocricoid muscles leaves the vocal cords relaxed and uneven. They may be seen in contact with each other at irregular inter- vals and moving unnaturally, — depressed and elevated in the currents of air. The timbre of the voice is changed to a hoarse, monotonous quality. The respiration may be more or less em- barrassed. Paralysis of the thyro-arytenoid muscles prevents approximation of the vocal bands, especially at their centres, so that an elliptical aperture remains between them (Plate VIII). The voice is feeble, easily wearied, high-pitched, and husky. Inordinate use of the voice is the most frequent cause of this form of paralysis. All three forms of paralysis already described sometimes co-exist, — paralysis of abduction, adduction, and relaxation. This condition results in total suppression of the voice. The vocal bands remain passively half-way between abduction and 30 466 DISEASES OF THE EAK, NOSE, AND THROAT. adduction, or in the cadaveric position. The usual causes are aneurism of the arch of the aorta, goitre, or disease of the oesophagus. If a brain disease were the cause, there would be loss of sensation and an erect epiglottis, indicative of paralysis of the superior laryngeal nerve. There may be unilateral paralysis of abduction, adduction, and relaxation, in which case but one vocal band assumes the cadaveric position (Plate VIII). In this form of paralysis the opposite and unaffected vocal cord may perform vicarious function, so that the voice is but little roughened in quality ; but, unless the power exists to draw the healthy cord beyond the median line to approximate its para- lyzed fellow, the voice is seriously affected or destroyed. The effort of speaking soon tires the patient, and exertion causes labored respiration. Treatment. — The wide variation in the nature of the causes of laryngeal paralysis renders it impracticable, in a work of such an elementary character as this, to deal in detail with all of them. Lesions of the nervous centres, of the circulatory system, of the apex of the lungs (especially of the right, a disease of which may cause pressure on the recurrent laryngeal nerve), enlargement of the glands of the neck, inflammation of the surrounding tissues and of the laryngeal mucous membrane, tumors, and rheumatic and syphilitic conditions call for treat- ment adapted to each disease. Drug and chemical poisoning must be met with antidotes, restorative measures, and removal of the cause. Strychnia, internally and hypodermatically, to the degree of producing its physiological effects, is valuable. The faradic current, applied to the interior and exterior of the larynx by the special laryngeal electrode, is efficacious. If the mucous membrane of the larynx is sensitive it may have to be cocain- ized to admit of the application of the negative pole to the interior of the cavity. The current is applied by means of the kid-covered electrode, the tip of which must be moistened. By the aid of the laryngeal mirror this electrode is carried to the points that require the current, while the positive pole is applied to the front or sides of the exterior of the larynx. Compound DISEASES OF THE LARYNX. 467 electrodes are made so that both poles may be applied within the larynx. Their use is attended with more difficulty than presents in the introduction of the single electrode. The current is turned on for a few seconds at a time, and repeated frequently during a treatment, which is given on alternate days. General tonic treatment and appropriate hygienic measures must be employed, according to the necessities of each case. CHAPTER XLI. EASES OF THE LARYNX, CONTINUED. Tuberculosis of the Larynx. This is one of the most common of laryngeal affections and generally proves fatal. It is seldom a primary disease, but usually is associated with the same condition in other organs, and in such cases is a secondary affection. Pathology. — The pathogenic principle of tuberculosis con- sists in a micro-organism, — the tubercle bacillus, — which gains entrance into the laryngeal tissues by becoming engrafted upon an area of mucous membrane denuded of its epithelium. Within a few weeks after the development of primary laryn- geal tuberculosis the lungs are invaded by the infection; so that we witness an intimate reciprocal relation between the various sections of the air-passages : laryngeal tuberculosis is most often a sequel of pulmonary tuberculosis, and consumption of the lungs may develop as a secondary manifestation of tubercular infection of the larynx. The first changes observable in the larynx are : an unnat- ural paleness and tumefaction of the epiglottis, succeeded by a superficial, ragged-edged ulceration on the posterior surface of the epiglottis, as seen in the mirror (Plate VIII). Multiple ulcers soon form in other parts of the respiratory tract, extend- ing below to involve the trachea, on the one hand, and upward into the pharynx, on the other. The ulcerative process may destroy the epiglottis. In acute tuberculosis of the larynx the development and course of the disease are often so rapid as to result fatally in the space of only a few weeks. This is known as miliary tuber- culosis. These areas of miliary tubercle are easily made to bleed by pressing upon them. The mucosa and submucosa become infiltrated, sometimes involving the mucous glands, and, as the disease advances, caseous degeneration occurs in (468) Plate VIII PLATE VIII. LARYNGOSCOPICAL APPEARANCE OF THE LARYNX, NORMAL AND DISEASED.* f, m, Fig. 1. — In Abduction. Epiglottis. Ventricular baud. Vocal band. Trachea. Cartilage of Wrisberg. Cartilage of Santorini. Interarytenoid commissure. Fig. 2. — In Partial Adduction. Omega-shaped epiglottis concealing an- terior portion of larynx. Fig. 3. — In Complete Adduction. Depressed epiglottis concealing two- thirds of larynx. h 9, w, y, Fig. 4. — Child's Larynx. Glosso-epiglottic fold. Palato-epiglottic fold. Epiglottis. Pyiiform sinus. Interarytenoid commissure. (Esophagus. Posterior wall of pharynx. Fig. 5. — Acute Laryngitis. Female, set. 25 ; opera-singer. Fig. 6. — Acute Laryngitis. Female, set. 47. Infiltration ; threaten- ing oedema. Fig. 7. — Acute Laryngitis. Female, aet. 24. Accidental deglutition of aq. ammoniae. Spontaneous resolution. Fig. 8. — (Edema of Larynx. Complete closure of the glottis. Fig. 9. — Chronic Laryngitis. Female, aet. 36 ; opera-singer. Fig. 10 — Chronic Laryngitis Complicated with Paralysis of the Arytenoideus. Male, aet. 28. Fig. 11. — Papilloma of Larynx. Mule, aet. 22; stone-cutter. Removed with forceps and cauterized base with galvano-cautery. Fig. 12. — Papilloma of Larynx. Female, aet. 5. Tracheotomy. Extir- pation with forceps and snare. Fig. 13.— Fibroma of Left Vocal Band. Male, aet. 63. Removed with forceps. Fig. 14. — Fibroma of Bight Vocal Band From Mackenzie. Fig. 15. — Abductor Paralysis, Bight Side During Inspiration. Female, aet. 48. Strychnia and iodide of potassium. Electricity. Fig. 16. — Paralysis of Abduction, Adduc- tion, and Bdaxation of Bight Side Band in Cadaveric Position. Shoivn in Attempted Phonation. Female, aet. 61. Due to pressure o: goitre upon right recurrent. Fig. 17. — Paralysis of Thyro-arytenoid Muscles. Female, aet. 35 ; singer. Rest and elec- tricity. Fig. 18. — Bilateral Abductor Paralysis of Seven Tears' Standing. Male, aet. 47. Treatment proved use- less. Fig. 19. — Tubercular Laryngitis, Female, aet. 24. Fig. 20. — Tubercular Laryngitis. Male, aet. 50. Fig. 21. — Tubercular Laryngitis. Male, set. 27. Fig. 22. — Syphilitic Laryngitis. Male, aet. 24. Fig. 23. — Syphilitic Laryngitis. Female, aet. 27. Fig. 24. — Cancer of the Larynx. Epithelioma of left ventricular band. From Mackenzie. Represented as seen by gaslight. By daylight the red color appears much paler. ; \.Sajous.?inx!t Burk & M c Fetnelqe, lith Phiia DISEASES OF THE LARYXX. 469 the tubercles and adjacent tissues. In the acute form of the disease the membrane is seen to be congested, instead of pale, as is characteristic of the chronic form. A peculiarity of this disease is that it may stop short at the vocal cords, in its downward course from the pharynx and through the larynx, and leave the cords unaffected, although the ventricular bands are involved even to the extent of so great tumefaction as to completely hide the vocal cords. Some- times the latter become thickened to such a degree as to threaten suffocation. The processes of infiltration, caseation of the tu- bercles, fatty degeneration of the mucous glands, and breaking down and melting away of the mucous membrane over these tubercular areas proceed until the whole of the interior of the larynx may become involved. The destruction continues until the cartilage itself becomes ulcerated, necrosed, and disinte- grated. As seen in Plate VIII, the cartilages are thickened until the indentations separating the cartilages of Santorini and Wrisberg are obliterated. The resulting tumefaction appears in the shape of a pear. Etiology. — Tuberculosis of the larynx is usually consequent upon a pre-existing pulmonary consumption, although a primary lesion may occur in the larynx, as a result of the reception of the tubercle bacillus at a point on the mucous membrane where desquamation of the epithelium has occurred. Catarrhal affec- tions, exposure to cold and wet and to an irritating atmosphere are predisposing causes. In pulmonary phthisis the lodgment of the tuberculous sputa from the lungs, as must occur in the larynx during expectoration, naturally tends to produce sec- ondary points of inoculation. Heredity is not emphasized as strongly as it was in former years, but inherited tendencies and weakness and a positive predisposition to tuberculosis cannot be denied, in the light of actual clinical experience. Symptomatology. — The visible pathological conditions al- ready detailed need not be repeated. The sensations of the patient are very positive in their character. Pain is often a conspicuous symptom, especially during the act of swallowing. 470 DISEASES OF THE EAR, NOSE, AND THROAT. The voice shows early the presence of a laryngeal trouble, and the hoarseness and feebleness may progress until no sound can be uttered. When the posterior surface of the larynx is ulcerated the pain produced by swallowing may be excruciating. Some- times the pain reaches to the ears, indicating ulceration of the pharyngo-epiglottic folds. Difficult respiration is not a common symptom, but may result from great swelling of the vocal cords, abscesses, or the presence of detached pieces of necrotic cartilages or of tumors. One of the most common features of this disease is cough. Patients complain of sensations of irritation, at first, described as a tickling in the throat or larynx. At this early stage the cough is of a hacking character and without expectoration. When ulceration takes place or abscesses form, or when pulmo- nary tuberculosis is progressing, the cough is attended with expectoration. Diagnosis. — Generally an examination of the lungs will reveal the seat of the primary source of infection. As laryngeal tuberculosis may be associated with the same disease of the pharynx, inspection of the latter may disclose the nature of the malady. The laryngoscopic examination may bring to light the patches of miliary tubercle, but these tubercles cannot always be distinguished from hypertrophied racemose glands. In the early stages this disease is likely to be confounded with simple catarrh, but, as the latter yields readily to treatment and presents no symptoms of gravity parallel with those of local- ized or general tuberculosis, in view of the history of the case, habit of body, probable involvement of the lungs, joints, or other structures, and the laryngeal appearances, one should scarcely err. Prognosis. — Occasionally a case recovers ; nearly all die. Acute tuberculosis of the larynx kills in a few weeks or months. In the secondary laryngeal tuberculosis consecutive to pulmo- nary consumption and characterized by caseation with acute symptoms, the disease proves fatal in from six to eighteen months. These cases may pursue a more chronic course and DISEASES OF THE LARYNX. 471 last from two to four years or longer. It is a difficult matter to cause a tuberculous ulcer to heal, and, if it does, it usually breaks out again. From 10 to 40 per cent, of all patients with pulmonary tuberculosis have this laryngeal complication, which shortens the duration of their life. Treatment. — The treatment given in detail for tuberculosis of the pharynx is just as applicable here, and to avoid unneces- sary repetition the reader is referred to that article for those remedies that are not given here. Lennox Browne {Journal of Laryngology, etc.) maintains that curettement is not absolutely necessary in this disease. Menthol, or menthol with iodol, in spray is best in the pre- ulcerative stage. For pain he uses the ethereal solution of aris- tol in a spray. Morphia insufflations are used in hopeless cases only, but codeia largely, and cocaine before manipulations and in advanced dysphagia. Sprays are better that insufflations of powders. Excepting for relief of acute dysphagia, he prefers applications of the tincture-of-benzoin compound, tincture-of- camphor compound, and tincture of belladonna mixed with yelk of egg just before food. He employs lactic acid rubbed in with considerable force, but not employed previously to ulceration. The lactic acid is useless unless preceded by curettement once to about every four or six applications of the acid. He curettes for the removal of hyperplasia and to clear away the necrotic matter when the ulcers are large, and for converting all the ulcers into one. Desire recommends exalgin twice a day in doses of 4 grains as effective in relieving the difficulty of swallowing and pain. Wolfenden recommends feeding the patient while lying on his stomach while his head depends over the end of the couch, which is elevated so as to bring his feet higher than his head. He then takes liquid nourishment through a tube from the dish placed below his head. When abscesses, growths, etc., produce so great obstruction to respiration as to threaten suffocation, tracheotomy must be done as a last resort. 472 diseases of the ear, nose, and throat. Syphilis of the Larynx. Pathology. — Syphilis of the larynx belongs almost always to the secondary or tertiary stage. It is first manifested by the appearance of a deep blush of congestion of the laryngeal mu- cous membrane, characterized by dryness. A little later the mucosa becomes swollen by serous infiltration, and this stage is soon followed by shallow, ulcerating patches (Plate VIII). The changes that take place in the larynx are similar to those de- scribed in the pharynx, but the results may be far more serious, owing to the diminished calibre of the larynx, which renders tumefaction and cicatricial contraction grave affairs. Mucous patches are likely to be found associated with the same lesions of the pharynx, and occur from three weeks to about three months or longer, following the initial sore. They are not found below the vocal cords, where there are no papillae. When the papillae are attacked they appear as small, red excrescences, swelling to the calibre of a small pea and obstructing respiration. From a rosy-red color they change to an ashy-gray surrounded by a zone of red. They may disappear by the process of ab- sorption or ulceration. A sudden infiltration of the mucous and submucous tissues is an occasional occurrence, and in this situation is of serious import, since the resulting oedema may impede respiration to the point of strangulation. The tertiary stage is characterized by the presence of gum- mata, which become the seat of ulceration. When the erosions penetrate deeply into the sub mucosa the invasion of the blood- vessels gives rise to haemorrhages. Following these deep ulcera- tions are found white, corrugated, contracting cicatrices that lessen the lumen of the cavity by their contractions. Adhesions of adjoining denuded tissues produce the same effect sometimes in a very short space of time. In this manner gross and ob- structive deformities of the epiglottis, ventricular bands, and vocal cords give rise to a dangerous stenosis of the larynx. In the later stages of tertiary syphilis the laryngeal mus- cles and cartilages are invaded, with the result of producing paralysis, as well as ankylosis and destruction of the cartilages. DISEASES OF THE LARYNX. 473 Etiology. — Syphilis of the larynx is most often a tertiary lesion, occurring from three years to a much longer period after the initial ulcer. If it exist as a secondary manifestation, it follows the primary infection in a few weeks or months, the margin of the incubatory period in syphilis being very broad. These syphilitic invasions of the larynx are very rarely primary, and they are more frequent in men than in women. Symptomatology . — As will be seen from the description of the pathological appearances in laryngoscopy, the first stage of syphilitic laryngitis closely resembles acute laryngitis of the simple variety. It may be impossible to distinguish early be- tween the two unless a specific history can be obtained. But in the syphilitic form of congestion or inflammation the rosy hue of the mucous membrane assumes a comparatively mottled ar- rangement, which is quite characteristic of this affection. These patches of redness are likely to be elevated above the surround- ing surface and to show early evidences of beginning erosions of a superficial kind. In this period sensations of soreness, difficulty of swallowing, and pain appear. The voice begins to change in quality ; the pitch is lowered, and a coarse timbre is imparted to it. A slight cough makes its appearance, occasion- ing little inconvenience, and accompanied by a muco-purulent expectoration. Inspection shows the picture already described, resembling a simple laryngitis. The vocal cords may be involved sufficiently to show a congested condition (Plate VIII), which may be bi- lateral when one side of the larynx is involved to a greater ex- tent than the other. Mucous patches are most frequently found on the epiglottis, in the interarytenoid space, and on the ven- tricular bands. They do not differ in appearances from those described as occurring in the pharynx. Papillomata are occa- sionally present, and can be seen as little, wart-like excrescences, or they may assume the appearance of yellowish pimples, nearly as large as a small pea. The mucous patches may disappear in a couple of weeks, when subjected to treatment, and leave a blushing area that gradually fades from sight. The condylomata may become absorbed or ulcerate away. 474 DISEASES OF THE EAR, NOSE, AND THROAT. In the tertiary stage the epiglottis is most likely to be first invaded by the destructive process, ulcerations generally break- ing out on the surface next the tongue or on its border. From this region they spread to the laryngeal cavity, differing from the erosions of the secondary stage in their invasion of the deeper layers of the mucous membrane, in the roughened sur- faces due to granulation formation, or to the papillomata. The ulcers of the secondary stage are superficial patches ; the ulcers of the tertiary period are deep-seated and destructive. Symmetrical bilateral lesions are characteristic of syphilis. When an ulcer forms on one side of the larynx one may confi- dently expect to soon find its fellow situated in a corresponding area of the opposite side. The irregular, ulcerating surfaces are surrounded by a dark-red zone, and are bathed in a purulent secretion, which is expectorated in abundance and imparts a foul stench to the breath. The cartilages break down and are thrown off in the expectoration. The epiglottis may disappear, and the particles of necrosed walls of the larynx may drop down into the chink of the glottis and threaten suffocation. When the deep erosions attack the walls of the blood-vessels and destroy their coats, haemorrhages of a serious degree may take place. Deformities due to swellings, cicatricial contractions, expul- sion of parts of the cartilages, and muscular paralysis occur in the tertiary stage. Stenosis and consequent embarrassment of the respiration may then endanger life. Diagnosis. — This disease may be mistaken for tuberculosis, and in the early stage may be confounded with a simple catarrhal inflammation of the mucous membrane. But the latter yields readily to treatment, while the syphilitic disease progresses unin- fluenced by any other than specific treatment. In tuberculosis serious constitutional disturbances are present, such as are not accompaniments of syphilis : fever, emaciation, etc. The areas of hyperaemia that later become the seat of ulceration are paler and softer in tuberculosis than in syphilis. The ulcers of syphilis have more regular, clearly denned borders, and are deeper than in tuberculosis. The pain DISEASES OF THE LARYNX. 475 of the latter disease, especially in swallowing, causes great suf- fering, while it is not a prominent symptom of syphilis and may be absent altogether. The patient improves and gains in weight on specific treatment in syphilis, but grows worse in tuberculosis. The presence of pulmonary tubercular lesions will aid in clearing up the diagnosis. Prognosis. — This disease yields most brilliant results except in extreme cases of the tertiary type, in which great deformities and loss of structure and function occur. Treatment — Constitutional remedies alone will often dis- sipate laryngeal syphilitic lesions without the introduction of local treatment. This disease, therefore, requires less mechanical skill in its management than tuberculosis and other affections of the larynx. In the early stages mercurials are indicated, while in the later periods the iodides are called for, or the mixture of the two, which is often more efficacious than the iodides alone. The use of the voice, alcoholic stimulants, and tobacco must be interdicted, and in the secondary manifestation T a g grain, or even more, of the bichloride of mercury may be given thrice daily. If the green iodide is employed, -J grain may be used. Inunctions of mercurial ointment may be resorted to if the stomach reject internal treatment, a drachm being rubbed into the skin. In ulcerations a spray of carbolic acid and iodine in lavolin, 4-per-cent. solution, is useful when thrown into the larynx so as to bathe the ulcerated surfaces. This has mildly anaesthetic and alterative effects and answers the purpose of a detergent and protective. In the tertiary stage the mixed treatment has given the best results. I have generally prescribed the mercuric bichloride, jig grain, and the potassium iodide, 5 or 10 grains, to be taken three or four times a day in 1 drachm of syrup of sarsapanlla. The doses are increased in size as tolerance will permit, care being taken that the stomach is not deranged by them. The ulcerations may require local treatment, such as has already been given under the heading of " Syphilis of the Pharynx." J. Solis- Cohen's favorite topical application consists of cupric sulphate in crystals or in solution, or chromic acid, 1 part in 4 or 10 parts 416 DISEASES OF THE EAR, NOSE, AND THROAT. of water. Norval H. Pierce has found the following formula beneficial to syphilitic ulcers: Iodoform, 1 part; sulphuric ether, 10 parts; and albolene, 50 to 100 parts, in the form of a spray. Paralyses usually yield to the constitutional treatment, but it may be advisable to employ electricity and strychnia. Contractions and tumefactions may occur sufficiently to cause strictures and stenosis of the larynx. If the interference with respiration is considerable, the aponeurotic membrane and other adventitious tissue must be incised or removed (Fig. 167), or they can be divided and destroyed by means of the galvano- cautery. When extreme stenosis threatens suffocation, intu- bation or tracheotomy must be performed. Since the cicatricial tissue of syphilitic origin is little susceptible of dilatation, a tube may have to be worn permanently after tracheotomy. Schrotter has devised laryngeal dilators to be inserted at first by the surgeon and later by the patient. These are left in position as long as the patient can endure them, using sizes of increasing calibre. They are used daily to increase the lumen of the laryngeal aperture, taking from six to eighteen months to effect a permanent dilatation. CHAPTER XLI1. DISEASES OF THE LARYNX, CONCLUDED. Tumors. For convenience of description, tumors of the larynx are considered under two main headings, — " Innocent " and "Malignant " tumors. Innocent Tumors. Benign, or non-malignant, tumors of the larynx arise as the result of various kinds of irritation, — such as inordinate use of the voice, great exposure to cold and wet weather, inhala- tion of air containing much dust, especially of a metallic nature, etc. PAPILLOMATA. Among all the tumors arising in the larynx none are so frequently found as these (Plate VIII). They present widely differing variations in size and physical appearances. They may be of a light- or dark- red color, the size of a bean or less, sessile and rough, single or numerous. Others resemble gray warts, springing from a vocal cord like little cones. These are most common in adult life. Children are often subject to laryn- geal papillomata which assume a multiple form comparable to the raspberry or cauliflower. They are rapidly regenerated after their removal. Indeed, all these varieties may recur, but they may be very slow in recurring, or they may not be repro- duced at all. FIBROMATA. These growths are generally found on the vocal cords (Plate VIII). They may be attached by pedicles, are usually solitary, smooth, and of a gray or deep-red color. Fibrous tumors are more often hard than soft, and grow to about the size of a common pea. Their removal is followed by more sat- isfactory results than obtain after operations on other tumors, for they seldom re-appear. (477) 478 DISEASES OF THE EAR, NOSE, AND THROAT. Other very rare specimens of growths may be found in the larynx. Polypoid excrescences, such as mucous polypi, or myxomata, sometimes make their appearance about the anterior commissure. They are attached by peduncles, and have a pale or red, smooth surface. Occasionally the epiglottis is the seat of a cystic tumor which presents a regular, rounded surface. Symptomatology. — The symptoms are those characteristic of obstruction to respiration, phonation, and deglutition. Res- piration is not interfered with in the early history of a laryngeal growth unless it is located in close proximity to the vocal bands or unless it is of rapid growth, so as to attain a large size and materially encroach upon the lumen of the respiratory space. With the increase in the bulk of the tumor, difficulty in respi- ration increases until it may end in asphyxia, unless relief is afforded. The voice may not be impaired if the tumor is situ- ated sufficiently above the vocal cords to prevent any embarrass- ment of their vibrations. Should the growth be located on one of the vocal cords it acts like a damper, impeding the move- ments of the cord in response to the column of air, and, if it rest between the cords, it prevents their approximation and not only causes dysphonia, or difficulty in the production of the voice, but it changes its quality and interferes with respiration. The vocal bands then cannot be normally approximated, and the breathing-space between the cords is lessened in degree, according to the size and shape of the growth. Difficulty in swallowing occurs as a result of the location of the tumor where it prevents closure and perfect coaptation of the epiglottis over the entrance to the larynx. If it is seated upon the pos- terior surface of the epiglottis, as it presents in the laryngeal mirror, the same effect may be produced, Cough may or may not be a symptom, but it may be present as a result of the inability to evacuate easily the accumulations of mucus, which then act like a foreign body, or in case the tumor is of such a kind as to vibrate in the currents of air and thus produce a tickling or cough-provoking irritation. Patients with benign tumors seldom complain of suffering pain. Treatment. — There are numerous methods for the removal DISEASES OF THE LARYNX. 479 of tumors of the larynx. Forceps, knives, and curettes (Fig. 167) have been devised for this purpose. Snares, the galvano- cautery, and caustics are in general use to effect the same results. When the growths have not attained a considerable size and are not easily engaged in an instrument, chemical caustics are applicable. Before any operative procedure the interior of the larynx should be anaesthetized with a 20-per-cent. solution of cocaine. Chromic acid, preferred by Jarvis, is fused into a bead of proper size and shape on the flexible applicator (Fig. 66) and accurately applied to the surface of the growth. Silver Fig. 167.— Tobold's Set of Six Forceps, Knives, etc. nitrate can be similarly employed, fused in the same manner on the platinum-wire loop of the applicator. In making applications of caustics, or in manipulating any instruments in the larynx, the operation is carried out by means of the laryngeal mirror, so that every movement and the rela- tions of all the parts can be closely watched. It must not be forgotten that the movements of the instruments in the larynx are directly opposite to the movements as seen in the mirror, everything being reversed. The utmost care must be exercised, or injury will be inflicted on the surrounding tissues that will be, perhaps, far more serious than the original trouble. Lennox Browne prefers the snare for the removal of growths. Dundas Grant has devised guarded cutting-forceps that take as 480 DISEASES OF THE EAR, NOSE, AND THROAT. firm a grip upon the tumor as Mackenzie's instruments. Much care must be exercised that a tumor once severed from its at- tachment does not drop back into the larynx as it is being removed. Evulsion of laryngeal tumors is preferred by some operators. For this purpose the strong forceps of Mackenzie afford a firm grip upon the growths (Figs. 158 and 168). These instruments are used without great difficulty if the larynx is properly anaesthetized. This is accomplished if the cocaine solution is applied two or three times at intervals of five min- utes. The benumbing effect of cocaine in the larynx is very transitory, not extending over ten minutes, so that operative measures must not be prolonged without renewed anaesthesia. Fig. 168.— Mackenzie's Anteroposterior Laryngeal Forceps. When operating in the larynx, one ought always to have his tracheotomy instruments at hand, for instances have occurred in which spasm of the glottis has immediately followed the pro- cedure, necessitating opening the larynx to prevent a fatal suffocation. Ephraim Cutter was the first to perform laryngotomy for the removal of a laryngeal tumor. This must sometimes be done when the growth cannot be extracted in the usual way. An incision is made into the angle of the thyroid cartilage, the tumor removed, and the wound closed. Malignant Tumors. Malignant growths of the larynx may be classed as epi- theliomata and sarcomata. DISEASES OF THE LARYNX. 481 E1MTHELIOMATA. These are commonly known as cancers, and are, by far, the most frequent of malignant growths in this locality. Bos- worth reported, as a result of a collective investigation of the subject, that, out of three hundred and thirty-four published cases of malignant growths, two hundred and four were cancers and one hundred and thirty were sarcomata. There is considerable variation in the nomenclature of this subject. Browne treats of cancer under two headings : " Epithe- lioma " and " Alveolar Epithelioma " (adenoid, scirrhous, or encephaloid cancer). These growths may occur as primary diseases of the larynx or they may result from an extension to this organ from adjacent tissues. Heredity is an important etio- logical factor, and any occupation or habit that excites constant irritation of the tissues, according to Virchow, may result in converting an innocent neoplasm into a malignant growth. They usually occur after the fortieth year. Symptomatology. — The effect upon speech and articulation will depend upon the situation of the tumor. If it belong to the intrinsic form, — that is, if it attack the subglottic space, the vocal cords, the ventricles, or the ventricular bands, — the voice is more or less seriously affected. Should the growth be limited to the arytenoid cartilages, the sinus pyriformis, the ary- epiglottic folds, or the epiglottis, thus constituting an extrinsic laryngeal neoplasm, the voice may not be markedly changed. When infiltration extends to include the laryngeal muscles, in- terfering with their functions, the voice is altered according to the muscles affected. Hoarseness may exist from near the beginning of the growth. In the intrinsic form not only the voice, but respiration, is embarrassed. Cough may not be present until ulceration has occurred, when a purulent expectoration occurs. In deep erosions, necrotic tissue stained with blood and characterized by a very offensive odor appears in the sputa. In the final periods of the disease difficult deglutition is present, especially in the extrinsic variety of tumor. 31 482 DISEASES OF THE EAR, NOSE, AND THROAT. Pain, the label of malignant growths, is an invariable symptom. It is likely to radiate through the neck into the pharynx, and, as occurs in tuberculosis of the larynx, it extends to the ear. So constant and conspicuous a symptom is the in- volvement of the ear in pain that von Ziemssen considered it pathognomonic of laryngeal cancer. The general, appearance of the patient after a long duration of the disease corresponds to the condition called by that classic alliterative term " cancer- ous cachexia." Inspection shows the location of the growth. At an early date only a thickened or nodular condition of the mucosa may appear, of a gray or deep-red color. When the epithelium is desquamated and the ulcerative process is established, a gran- ular proliferation of tissues springs up about the border of the erosion. Fungoid growths are seen sprouting from the surface of the ulcer, only to succumb to the necrotic process later. Prognosis. — According to Mackenzie, the average duration of the encephaloid cancer of the larynx is three years. Browne gives twelve months as the limit of life after removal of epithe- lioma. The results of tracheotomy are more favorable than those of thyrectomy or thyrotomy. No operation cures ; starva- tion, haemorrhage, or asphyxia ends life. Treatment. — The question of cure does not, at the present day, enter into the subject. Life may be prolonged and rendered less torturesome. From a humanitarian point of view, if it were justifiable under any hopeless circumstances to relieve a fellow-being of his misery and despair by the merciful pro- duction of euthanasia, cancer of the larynx is the case. Death constantly stares his victim in the face, and, what is worse, like the burning coal in the eye of Cyclops, pain, in all its variations and refinements of torture, converts the patient's world into a chamber of horrors. No words can depict the agonies of these coughing, choking, strangling sufferers. Local anaesthetics and anodynes must be added to deter- gents and antiseptics. Sprays of cocaine and morphia in ethereal solutions are indicated for the alleviation of pain. Aristol and iodoform may be used in the same manner. DISEASES OF THE LARYNX. 483 Chloroform and belladonna liniment may be employed for external applications. Steam-inhalations containing conium and benzoin may prove grateful. One should bear in mind that there is always a possibility of a syphilitic taint, which would yield to specific treatment, and a trial of the effects of sodium or potassium iodide should be made. Operative measures may relieve the immediate suffering from impending suffocation, and may prolong life for several months. In October, 1895, Roswell Park reported a case of total extirpation of the larynx for epithelioma. Fourteen weeks after the operation the patient presented himself at the clinic "the picture of health." Operations within the larynx are deprecated by some authorities : Browne and Newman. Gal- vano-cauterization produces only temporary benefit. Trache- otomy offers the greatest promise of relief from suffocation and may prolong life from two to four years. SARCOMATA. These are very rare tumors of rapid growth, and attain to a large size. Their appearances differ widely, sometimes resem- bling fibromata or papillomata. Only a microscopical exami- nation can give a positive diagnosis. They do not kill as soon as epithelioma does, but are destructive of life sooner or later. They should be removed by some of the methods already described for the extirpation of other tumors. Max Toeplitz reports a case of chondrosarcoma cured by intra-laryngeal operation {Transactions of the International Medical Congress, 1890). Foreign Bodies in the Larynx. During inspiration while eating or in the act of laughing foreign bodies are drawn into the larynx, where they find lodgment. Symptomatology. — The presence of any foreign body in the larynx excites most violent coughing and symptoms of strangu- lation. If the body is of such a size and contour as not to completely fill up the lumen of the canal, breathing may pro- 484 DISEASES OF THE EAR, NOSE, AND THROAT. ceed until the reflex spasmodic efforts at dislodgment succeed in expelling the body. When the entrance to the larynx or the glottis is completely obstructed, suffocation may take place before relief can be obtained, the patient dying in a few minutes. Boluses of meat and other soft substances that apply themselves closely to the inequalities of the cavity are the most common causes of death from foreign bodies. But rough bodies may set up such an inflammation before their extraction that cedema of the larynx or pneumonia may result. If the body is coughed up, considerable soreness and pain may be experienced for a few days afterward. Small foreign particles sometimes remain for a long time in the larynx before being thrown out by coughing or sneezing. They may give rise to an irritation that leads to serious lesion of the mucosa. Treatment. — The finger can sometimes be made to reach and dislodge the body if it is lodged in the vicinity of the entrance to the larynx. A common remedy is to slap the patient on the back of the shoulders just as he makes an expi- ratory effort. Gravity may be brought into play in case of a foreign body with some material weight. The patient may be held with the feet upward and the head pendent while expulsive efforts are made by the patient. Sharp-pointed articles penetrate the walls of the larynx sufficiently to arrest their onward progress, and the coughing, retching, and gagging serve to force them farther into the tissues. All the sensitive area should be treated to a 20-per- cent, solution of cocaine, and by the aid of a mirror the object should be located. Then the laryngeal forceps of Tobold (Fig. 167) or Mackenzie (Figs. 158 and 168) may be made to grasp and extract the offending invader. If failure attend the attempt to extract the foreign sub- stance, and strangulation is impending, tracheotomy must be done without delay. If proper instruments are not at command, a pocket-knife will do, and retracting hooks can be improvised with safety-pins, hair-pins, or the like until sufficient conveniences can be supplied. INDEX. Abbott, 329, 332 Abbreviations, 4 Abscess, cerebral and cerebellar, 117, 138, 139, 141 metastatic, 138 of brain, 117, 138, 139, 141 of larynx, 454, 455 of neck, 134, 145, 166 of nose, 271 retropharyngeal, 145, 166, 404 subdural, 137 Accessory cavities of the nose, diseases of, 276 Acoumeter, 22 Acute otitis externa, 53 Acute otitis media, 68 appearances of membrana tvmpani, 69, 70 grip as a cause, 68 leech, artificial, 71 leeches, 71 naso-pharynx, 68 paracentesis membranse tympani, 72 relief of pain, 71, 72 treatment, 70 Acute purulent otitis media, 74 grip as a cause, 68 influenza as a cause, 68 membrana tvmpani, appearance of, 74, 77 * micro-organisms, 74 treatment, 76 Adenoid hypertrophy of vault of pharynx, 298 ear complications, 298 Adenomata of pharynx, 298 Adjustable light, 13, 14 Age, influence of, in diseases, 3 Agnew, 169 Air, compressed, and apparatus, 24-39 Alkaline sprays, 202 Amblyopia from nasal disease, 284 Anaesthesia, local, in nasal surgery, 248 of pharynx, 407 Anaesthetics, general, 139, 150, 299 Angina, catarrhalis acuta, 305 rheumatic, 313, 316 Anomalies, of auricle, 46 of external meatus auditorius, 48 of sensation in larynx, 461 Anosmia, 268 Antiseptic sprays, 198, 202 Antrum, aditus ad, 144 mastoid, 157, 160, 162 of Highmore, 276 Aphonia, 462 Applicator, caustic, 124 Aquseductus Fallopii, 103, 156, 158 Arnold, J. D., 425 Arrangement of instruments, 12 Artificial drum-heads, 127 Aspergilli in the ear, 56 Aspirator for the ear, 121 Asthenopia from nasal disease, 283 Asthma, 232 from nasal disease, 244, 261, 270 Astigmatism from nasal disease, 285 Asymmetry of nasal bones, 243 Atmospheric causes of disease, 8-11, 290 Atomizers, 194 Atresia, of external auditory meatus, 48, 58 nasal, 273 Auditory canal, 50 acute inflammation, 53 boils of, 54 bony growths, 58 cerumen, 50 chronic inflammation, 53 exostoses, 58 foreign bodies, 59 furuncles, 54 hyperostosis, 58 imperforate, 58 malignant disease, 42 narrowing, 59 neoplastic closure, 58 parasitic inflammation, 56 sequestra, 132 Auditory nerve, 172 Aural, fungi. 56 vertigo, 51, 168, 170, 171, 178 Auricle, benign tumors of, 44 cutaneous diseases, 40 cystoma, 45 deformities, 46, 47 eczema, 40 epithelioma, 42 frost-bite, 40 gangrene, 42, 43 hgematorua, 44 herpes, 45 hypertrophy, 46 inflammatory affections, 40, 44 intertrigo, 45 lupus, 41 malignant disease, 42 othematoma, 44 pemphigus, 45 perichondritis, 44 (485) 486 INDEX. Auricle, scroll-deformity, 48 syphilis, 45 wounds and injuries, 49, 59 Auscultation-tube and method of using, 39 Automatic tuning-fork, 20 Autophony. 69, 82 Babcock, K. H., 358 Baa. ice-, 147 Baginsky, 331 Baldness not a cause of disease, 10 Bandage, net, 165 Barclay, Robert, 110 Becker, B., 361 Behring, 350, 352, 353 Bertillon, 225 Bezold, 74, 128, 129 Billings, Frank, 370 Bing's hearing-test, 21 Blake, Clarence J., 105, 111 Bleeding, local, in acute otitis media, 71 Blindness from sphenoid disease, 285 Boils in the external ear, 54 Bone, turbinated, inferior, 37, 286 middle, 37, 286 superior, 37 Bone-conduction, 19-21 in chronic aural catarrh, 91 Bostock, 215 Bosworth, Francke H., 240, 447 Bouchut, 435 Bougies, Eustachian, 67 Boxing the ears, 45, 62 Bracket, adjustable lamp-. 15 Brain-abscess, 117, 138, 139, 141 Brannon, John Winters, 359 Braun, 253 Broadbent, 225 Brown, Dillon, 433 Brown. Moreau E., 241, 254 Browne, J. Lennox, 310, 344, 345, 362, 471, 479, 481-483 Brown-Sequard. on hsematoma, 44 Burnett, Charles H., 56, 105 Burns and scalds of the pharynx, 409 Caisson, effect on ear, 28 Calcareous degeneration of the middle ear, 86, 87, 126 Camphor-menthol, 198 inhaler, 201, 237 Canal, external auditory, 50, 103 Fallopian, 103. 156, 158 glands, 103 imperforate, 58 section of, 103 Canal is tensoris tympani, 65 Cancer of pharynx, 401 Carcinoma, of nose, 262 pharynx, 401 Caries and necrosis from middle-ear dis- eases, 116. 117, 124, 132 ' Carotid artery, rupture of, in suppuration of middle ear, 133 canal, 135, 159 Cary, Frank, 440 Ca-sselberry, William E., 239 Catarrh, chronic, of middle ear, 79, 86 exudatiye, 79 hypertrophic, of the nose, 243 of the middle ear, sero-mucous, 79 Catarrh, heredity of, 292 Catarrh, neryous, 214 Catarrhal otitis media, acute, 68 Catheter, Eustachian, 36 in chronic aural catarrh, 84 method of using, 30, 37, 38 Causes of disease, atmospheric, 8-11, 290 Caustic, applicator, 124 chemical, 123 for nose and throat, 246 Cautery, electric, 245 Canities, accessory, of nose, 276 ! Cerebellar abscess, 138, 141 I Cerebral abscess, 138, 140 Cerumen, impacted and inspissated, 50 Chapman, J., 241 Charcot, 176 Cheatham, William, 241 Chiari, 253 Cholesteatoma, of mastoid, 128 of middle ear, 114, 128 Stacke's operation, 161 Chondromata, nasal, 259 Chorda tympani nerye, 102 Chorditis tuberosa, 455 Chorea, of pharynx, 408 reflex, from nasal disease, 289 Chronic catarrh of the middle ear, 79, 86 adhesiye inflammation, 86 age. 88 alcohol, effects of, 82, 88 ankylosis of ossicles, 86. 87, 93, 95 atrophic stage, 81, 86, 92 auditory hallucinations, 174 auto-aspiration in, 84 autophony, 82 calcareous degeneration, 86, 87, 126 climatic conditions, 82, 85, 89, 290 deafness, 86, 90, 91 differential diagnosis, 82, 92 electricity, 99 Eustachian, catheter, 84 tube, 82 excision of membrana tympani and ossicula, 105 exudation, 79 foreshortening of handle of mal- let, 80, 92 frequency of, 7, 8 heredity, 88 hygienic surroundings, 8-10 INDEX 487 Chronic catarrh of the middle ear. hyper- emia, 79 hypertrophic, 79 injection of liquids, 96, 97 injection of vapors. 97 load noises, effects of. 90 ossicles in. B6 otalgia, 81 pain in ear, Bl, 89 paracentesis, -4 paracusis. 91 partial excision of membrana tynipani. 104 peculiar modifications of hearing, 90. 91 pneumatic tests. -1. 92 proliferation. B6 removal, of membrana tympani and ossicles. 105 staphs. Ill retraction of membrana tympani, BO, 9-2 sclerosis. 86 secretive. 79 sensations of discomfort. -1. 82, 89, 90 statistics, 4-7 tenotomy of tensor tympani. 105 tinnitus annum. B8, -9 tobacco, effects. B8, 175 uric acid. B8 vertigo. 90. 94 purulent otitis media. 112 antiseptic, powders, 118. 119 solutions, 117, 120 appearances of membrana tym- pani. 112 caries and necrosis, of adjacent tissues. 114. 116. 124. 132 of ossicles. 113. 125 caries of carotid canal. 133 cause of intra-cranial lesions. 117. 133 cerebral abscess from. 117. 133 cholesteatoma. 114. 128 excision of drum-head and os- sicles. 111. 121. 125 exfoliation of cochlea, 133 facial paralysis. 116. 129. 177 granulations. 115. 122 mastoid complications. 114 meningitis. 117. 133. 136 metastasis. 138 paralysis, facial. 116. 129 perforation of the membrana flaccida. 113 phlebitis of lateral sinus and jug- ular vein. 133-141 polypi. 116, 122 pyaemia. 117, 133 rupture of carotid artery. 133 seat of intra-cranial lesions, 117, 133 Chronic purulent otitis media, sequela?, 117. 122 symptoms. 115 of brain-abscess, 138 of sinus-thrombosis. 141 thrombosis of lateral sinus and jugular veins, 141, 142 treatment. 117 Chronicity of diseases. 9 Circumscribed otitis externa. 54 Cirrhotic rhinitis. 252 Clark. Sir Andrew. 242 Classification, of diseases. 4-6 of occupation, sex. etc.. 3 Climatic causes of disease. 10. 11. 290 Clinical records. 3. 23 Clothing. 210, 294, 318 Cocaine. 247 Cochlea. 135 exfoliation. 133 Cohen. J. Solis-, 323. 395. 452. 475 Cold, catching. 305 Cold in the head. 208 Compressed air. 24-31 apparatus. 32-39 meter. 25 Congenital deafness. 181 Conjunctivitis from nasal disease. 283. 285 Conklin. 223 Corbin. 433 Corneal inflammation from nasal disease, 2-3. 2-5 Coryza, 208 tablets. 207. 308 Cotton-carrier. 17 Cozzolino. Ill Croup. 428 intubation. 435 laryngismus stridulus. 431. 432 membranous, idiopathic. 42^ spasm of the glottis. 429 spasmodic. 459 spurious. 421 tracheotomy. 442 choice of operation, 443 treatment. 432 Curettes. 134. 152 Curtis. H. H.. 241 Cut-off. compressed air, 26 Cutter. Ephraim, 480 Cystoma, of auricle, 45 larynx, 47^ Daervocvstitis from nasal disease, 287 Daly, W. H.. 241. 277 Darwin. 229 Davey. James E.. 133. 241 Davis. Nathan Smith. 223. 237 D*Espine. 331 De Lamalleree. 242 DeVilbiss. Allen. 140 Deaf -mutism. 181 488 INDEX. Deafness, causes of, 65, 69, 82, 90, 115, 177, 178, 180, 292 congenital, 181 following suppuration of middle ear, 127 hereditary, 182 hysterical, 177 Deformities, of auricle, 46 of nasal cavities, 270, 273 Delavan, D. B., 272, 389 Delstanche, Charles, 85, 96, 117 Dench, Edward B., 130 Desire, 471 Dilators, for nose, 213 for ear tr< Dionisio, 254 Diphtheria, 328 age of patients, 332 bacillus, 329, 330 diagnosis, 336 diphtheric exudate, 328, 335 diphtheroid, 331, 337 effect, on ear, 336 eye, 336 incubative period, 332, 334 intubation, 435 microbe, 328 modes of propagation, 333, 334 of the nose and naso-pharynx, 336 prophylaxis, 340, 352-354, 356 pseudodiphtheria, 331, 337 symptoms, 334 treatment, 339 antitoxin, 350 hygienic, 340 internal, 348 local, 343 serum therapy, 350 tracheotomy, 442 vitality of Klebs-Loffler bacillus, 331, 333 Dobell's solution, 202 Double hearing, 173 Double retractors, 153 Douche, nasal, 195, 254 Drum-head. See Membrana tympani. Ducts emptying into nasal meatuses, 282, 286 Dysphonia, 478 Ear, electrodes, 131 internal, 168 malformations, 46, 48 middle, 62, 65, 92, 103 ' noises, subjective, 51, 69, 82, 88, 174 relation of nose to, 64 , Ear-cough, 51 Ear disease, brain-abscess, 117 from disorders of nervous system, 172, 173, 177, 178 from exanthemata, 68 from grippe, 68 from influenza, 68 Ear disease, from intra-cranial growths, 179 from leucocythsemia, 171 from meningitis, 178 from syphilis, 172 Ear- fungi, or mold, 56 Ebstein, 223 Ecchondrosis, nasal cavities, 243, 259 Eczema of auricle, 40 Ehrlich, 350 Electricity in aural diseases, 99, 130 Electrodes, ear-, 131 Emphysema from Eustachian catheter, 39 Empyema, of antrum of Highmore, 276 of frontal sinuses, 280 of maxillary sinuses, 276 Engelmann, Eosa, 359 Enslee, Charles L., 3 Epiphora from nasal disease, 285, 287 Epistaxis, 255 plugging nares, 256 Epithelioma, of ear, 42 of larynx, 481, 483 of nose, 262 of pharynx, 402 Erectile tuniors of nasal cavities, 259 Ethmoid sinuses, diseases of, 278 osteoma, 279 polypi, 279 Eustachian, catheter, 36 emphysema from use of, 39 method of using, 37 salpingitis, 64 tube, 64, 65, 135 canalis tensoris tympani, 65 cartilage of, 65 fossa of Kosenmiiller, 37 isthmus, 65 membranous part, 65 orifice, 37, 65 patency, 67 stenosis, 67 Ewing, 364 Examination of patients, 12, 189, 415 Exanthemata, effect on ear, 9 Excision, of membrana tympani and os- sicula, 105, 107, 111, 121 partial, of membrana tympani, 103 Exostoses, of auditory canal, 58 of nasal cavities, 260 External ear, 40 auricle, 40 Exudative catarrh of middle ear, 79 Eye diseases from diseases of the nose, 282 Facial expression in diseases of the nose and throat, 298 Facial paralysis, 116, 129, 163, 177 Faith, Thomas, 39 Fallopian canal, 103, 156, 158 False hearing, 91, 173 Farcy, 266 INDEX. 489 Fatality of chronic suppuration of the middle ear, 112, 133, 138, 141 Faulkner, 240 Fenestra, oval is, 162 rotunda, 113 Fibroids, of larynx, 477 of nasal cavities, 258 Floor of the tympanum, 103 Folds of membrana tympani, 18 Foreign bodies in ear, 59 in larynx, 483 in nose, 273 in pharynx, 410 Fork, automatic tuning-, 20 Fossa of Rosenmuller, 37 Foster, 357 Fournier, 398 Fracture, of base of skull, 180 of nose, 272 French, J. M., 272, 369 Frequency of disease, relative, 3, 7, 8 Frontal sinuses, diseases of, 280 transillumination, 281 Frost-bite of auricle, 40 Fruitnight, 433 Fungi, aural, 56 Furuncles, of ear, 54 of nose. 267 Galton's whistle, 21, 22 Galvano-cautery, 245 Ganglion, sphenopalatine. 216 Gelle, 111 Gelle's hearing-test, 21 General considerations, 3 Glanders. 266 Glasgow. W. C. 240, 395, 433 Gleason, on sclerosis, 110 Glenoid fossa, 157 Globus hystericus, 408, 411 Glottis, spasm of, 459 Gluck, I., 241 Gonorrhoea, nasal, eye symptoms, 285 Gottstein, 433 Gouges, 151 Gouguenheim, 242, 378 Gould, 288 Gout, as a cause of hay fever, 222 effect on the ear, 88 Gouty sore throat, 313, 316 Gradle, Henrv. 124, 241, 283, 356 Grant, J. Dundas. 97, 433, 479 Granulations, in suppuration of the middle ear. 115, 122 of vocal cords. 455 Gray. L. C. 227 Greene, 105 Greene's mouth-gag, 299 Grippe, 203 cause of otitis media, 68, 206 effect on ear, 90, 206 Gruber, Josef, 24, 170 Gummata, of larynx, 472 of pharynx, 397 Gunn, Moses, 277 Guttmann, 349 Guye, 176 Hematoma, of auricle, 44 of nose, 271 Haemorrhage, of internal ear, 170, 180 nasal, 255 Hagenbach, 363 Haig, Alexander, 222, 223, 225-227, 238 Haight, Allen T., 282 Hall. Marshall, 459 Hallucinations, auditory, 174 Hamilton, 288 Hanau, 380 Hardie, T. Melville, 241 Hare, 359 Hartmann's, inflation experiments, 29 tuning-forks, 19, 20 Hay fever, 214 etiology, 229 gout. 235 medical opinions, 239 nasal disease in, 219 neurosis. 216 symptomatology, 231 treatment, 234 uric acid, 222 Head-mirror, 13 Hearing, double and false, 173 instruments, 184 tests of, 18 Henoch, 331 Hereditary deafness, 88, 182 Herpes of auricle, 45 Heryng, 281, 394 Higiimore. antrum of, 276 Hollister, J. H., 369 Holmes, C. R., 156-164 Hooks, double mastoid, 153 Horsier. 140 Hubbard, Thomas, 402 Hutchinson, 171 Hydrorrhea, 211, 231 Hyperaudition, 173 Hyperesthesia acoustica, 173 Hyperesthesia, of larynx, 461 of nose, 231 of pharynx, 406 Hyperostosis in auditory canal, 58 Hyperplasia, nasal cavities, 243 Hypertrophy of auricle, 46 Hypertrophies, nasal cavities, 243 posterior, surgery of, 299 Hysterical, deafness, 177 aphonia, 462 Ice-bag, 147 Incision of membrana tympani, 101-103 490 INDEX. Incus. 102, 103, 132, 135 articulation, 102, 103 Inflation of tympana, 26, 27, 36 Politzer's method, 28, 29, 35 Valsalva's method, 29 Inllators, 29, 36 Influence, of age on diseases, 3, 5, 7 of occupation, 3, 5, 7 of sex, 3, 5, 7 Influenza, 203 cause of otitis media, 68, 206 effect on ear, 90, 206 Ingals, E. Fletcher, 241, 311, 326, 395 Inhalents, 198 Inhalers, 201, 237 Instruments, ear, 107, 123 hearing-, 184 Insufflators, 32, 118 Internal ear, 168, 180 anaemia, 168 aural vertigo, 90, 137, 138, 141, 168, 170, 171, 178 concussion of labyrinth, 180 fracture at base of skull, 180 haemorrhage, 170, 180 hyperaemia, 168 hyperaesthesia acoustica, 173 hysterical deafness, 177 leucocythaemic deafness, 171 Meniere's disease, 170 new growths, 179 panotitis, 169 primary acute labyrinthitis, 168 suppurative exfoliation, 133 syphilis, 171 Intertrigo of auricle, 45 Intubation of larynx, 435 Jack, Frederick L., 105 Jackson, 171 Jackson, A. Reeves, 227 Jarvis, 479 Jewell, J. S., 234 Joal, 229 Jones, 121 Jones, Bence, 235 Jugular, fossa, 103 vein, phlebitis of, 141 thrombosis of, 141 Karlinski, 357 Kassowitz, 363 Keratitis from nasal disease, 285 Kinnear, B. O., 241 Kitasato, 350, 355 Kitchen, 241 Klebs, Edwin Theodore, 328, 365 Knife in septum deformities, 251 Knight, C. H., 240 Koch, 353 Koerte, 361 Korner. 139 Koeeel, 353, 354 Kramer, 182 Krause, 394 Krieger, George E., 352 Kruckmann, 380 Kuh, Edwin J., 240 Labyrinth, concussion, 180 injuries, 180 Labyrinthitis, primary acute, 168 Lacrymal canal, affection of, from nasal disease, 287 Lacrymation from nasal disease, 284, 287 Laker, 254 Lang, 237 Langerhans, 366, 367 Laryngeal, paralysis, 463 spasm, 459 Laryngismus stridulus, 459 Laryngitis, acute, 421 symptoms, 422 treatment, 424 atrophic, 453 catarrhal, 421 chronic, 446 treatment, 451 cedematous, 456 phlegmonous, 454 purulent, 456 rheumatic, 426 simple, 421 spasmodic, 423 stridulous, 423 suppurative, 454 syphilitic, 472 Laryngoscopic image, 418 . Laryngoscopy, difficulties of, 415, 419 Larynx, abscess of, 454, 455 acute catarrh of, 421 anomalies of sensation, 461 chronic catarrh of, 446 examination, 415 foreign bodies in, 483 treatment, '484 laryngotomy, 480 tracheotomy, 442 growths in, 477, 480 cystomata, 478 epitheliomata, 481 fibromata, -477 mucous polypi, 478 myxomata, 478 papillomata, 477 polypi, 478 sarcomata, 483 intubation of, 435 neuroses of, 459 aphonia, 462 hyperaesthesia, 461 neuralgia, 461 paralysis, 463 spasm of glottis, 459 stenosis, 457, 474, 476 I! INDEX. 491 Larynx, syphilis, 472 tuberculosis, 468 tumors, 477, 480 vocal bands, 419 Lateral sinus, 133 phlebitis of, 133, 141 thrombosis of, 141 Lavolin, 127 Leeches, 71 Lees, D. B.. 242 Leflaive, 224 Leukaemia, effect on ear, 171 Lever, 223 Levy. Robert, 396 Light for examination, 13-15 Light-condenser, 13 Linea temporalis, 157 Loeb. Hanau W., 249, 388 Loffler, 328, 347 Love. I. N., 349 Lucoe, 95, 96, 128 Lupus, of the ear, 41 of the nasal cavities, 266 Luschka, tonsil of, 292, 298 MacBride, P., 121, 242 MacCoy, Alexander W., 405 MaceAven, 139 Mackenzie, John Noland, 241 Mackenzie, Sir Morell, 401, 428, 463, 482 Maggots in the nose, 275 Malformations of the ear, 46, 48 Malignant disease from suppuration of the middle ear, 41, 42 Malignant neoplasms, in nasal cavities. 261, 262 Malleus, 63, 102, 103, 132, 135 fracture of, 100 ligaments, 63 Marcy. 224 Martin. 350 Massage, otoscope, 14, 16, 92, 94 treatment, 14-17, 95 Mastoid, antrum. 157, 160, 162 cells, 135 curettes, 152 disease in acute otitis media, 144 guide. 152 hooks, 153 inflammation. 143 cholesteatoma, 128 complications of, 143, 166 instruments for operation, 150 operative treatment, 149, 155 primary, 143 sclerosis, 144 operations, 155 haemorrhage in, 156, 159 portion, temporal bone, 157-160, 164 Maxillary sinus, 276 Mays, Thomas J., 223 Meatus, external auditory. 50 internal auditory, 143, 156 Membrana flaccida, perforations of, 113 Membrana tympani. 17, 18, 63, 102, 135 atrophy of, 81, 92 chorda tympani, 102 folds, 18, 102 granulations, 115 haemorrhage, 62, 63 hyperaemia, 62 inflammation, 62 adhesions, 86, 92, 125, 127 injuries, 62 inspection, 16 massage of, 14-17, 95 membrana, flaccida, 18, 63 propria, 18, 63 paracentesis of, 72, 84, 101 perforation, 68, 74, 112-114, 126 pockets, or pouches, 63 polypi, 116 position of ruptures, 113 Prussak's fibres, 18 space, 63 retraction of, 66, 80, 92 rupture of, 62, 74, 180 shape, 17 Shrapnell's membrane, 17, 63 thickening of, 81, 92 topographical relations, 103 topography, of outer surface, 17 of inner surface, 102 umbo, 17 Membranous sore throat, 325 Meningitis, 136 effect on ear, 178 Metastasis in suppuration of the middle ear, 138 Meter, air-, 25 Michael's inflation experiments. 30 Middle ear. 62. 103, 135 chronic catarrh of, 79, 86 gouty and rheumatic diathesis, 88 instruments. 107. 123 Migraine, 223 Mirror, forehead-, 14 -holder. 14 throat, 192 Moisard. 354 Monod. 354 Moos, 143, 170, 178 Mouth-breathing, 293, 298, 380, 447 Murcliison, 222 Mutes, deaf-, 181 Mycomyringitis, 56 Mycosis, of ear, 56 of pharynx, 389 Myringitis, 62, 69 parasitica, 56 Myxomata, of larynx, 478 nasal, 257 Nares, posterior, plugging in epistaxis, 256 Nasal adenomata, 298 492 INDEX. Nasal, atresia, 273 carcinomata, 262 cavities, abscess of septum nasi, 271 adenoma, 298 anosmia, 268 blood-tumors, 271 bony occlusion, 243 chondromata, 259 cold in head, 208 cystic polypi, 258 deformities, 270 deviation of the septum, 270 ecchondrosis, 259 erectile tumors, 259 exostosis, 260 eye diseases from nasal affections, 282 fibrous polypi, 258 foreign bodies, 273 furuncles, 267 glanders, 266 hyperplasias, 243 hypertrophies, 243 lupus, 266 maggots, 275 malignant neoplasms, 261, 262 mucous polypi, 257 osteomata, 260 papillomata, 258 parosmia, 269 perforations of septum, 271 polypi, 257, 258 rhinoliths, 261 sarcomata, 261 sense of smell, 268 supporter for nose, 265 synechia, 243 syphilis, 263 tuberculosis, 263 disease in hay fever, 219 douche, 195, 254 cause of inflammation of the middle ear, 68 haemorrhage, 255 myxoma, 257 polypi, 257 reflex neuroses, 216 specula, 190 stenosis, 208 Naso-pharyngeal diphtheria, 336 Naso-pharynx, 290 climate, effect of, 290 Eustachian tube, 65 fossa of Rosenmuller, 37 tonsil of Luschka, 292, 298 diseases of, in otitis media, 68 atrophic catarrh, 294 diphtheria, 336 examination, 193 facial expression, 298 follicular catarrh, 290 polypi, fibroin ucous, 297 fibrous, 295 Naso-pharynx, diseases of, tumors, 297 voice, 298 Neck-abscess, 145, 166 Necrosis of adjacent structures in middle- ear disease, 132 Neoplasms, of larynx, 477 of nose, benign, 257 malignant, 261 Nerve, auditory, 172, 180 facial, 129, 177 olfactory, 268, 269, 273 Nervous catarrh, 214, 231 Net bandage, 165 Neuralgia, of larynx, 461 of pharynx, 407 Neuroses, nasal reflex, 216 of ear, 173 of larynx, 459 of nose, asthmatic, 232, 244, 261, 270 chorea, 289 eye disease, 283 hypersesthesia, 216 migraine, 223 reflexes in the eye, 231 respiratory, 232 treatment, 234 of olfaction, 268, 271 anosmia, 268 parosmia, 269 of pharynx, 406, 408 Neurotic character of hay fever, 216 Newman, 483 Noises in the ear, 65, 69, 82, 88, 174 Northrup, 428, 440 Nose, 189 diseases of, abscess of septum, 271 accessory sinuses, 276 affecting the eye, 282 animate foreign bodies in, 275 anosmia, 268 asthma, 244, 261, 270 carcinoma, 262 deformities, 270, 273 diphtheria, 336 epistaxis, 255 examination, 189 foreign bodies, 273 furunculosis, 267 glanders, 266 haematoma, 271 lupus, 266 maggots, 275 nose-bleeding, 255 ocular symptoms, 282 ozsena, 252 parosmia, 269 polypi, 257 rhinitis, acute, 208 chronic, hypertrophic, 243 simple, 210 rhinoliths, 261 sarcomata, 261 septal perforations, 271 INDEX. 493 Nose, diseases of, sprays, 198 supporter for bridge and tip, 265 syphilis, 263 tuberculosis, 263 ducts, 282, 286 examination and instruments, 189 fractures, 272 hematoma, 271 pathological conditions affecting the eye, 282 relation to the ear, 64 Nose-bleeding, 255 Nuttall, 358 Occlusion of nasal cavities, 243 Occupations, influence of, 3, 5 classified, 3 O'Dwyer, Joseph, 432, 435 OSdema, of eyelids from nasal disease, 283 glottidis, 456 Olfaction, neuroses of, 268, 269 Olfactory nerve, 268, 269, 273 Ophthalmia, gonorrhoeal, from nose, 285 Optic nerve, compression of, from sphenoid disease, 285 Ossicles, auditory, 102, 103, 132, 135 articulation, 102. 103 caries of, 113, 116, 125 chronic aural catarrh, 86, 92, 95, 100, 105, 107 excision of, 105, 125 hook, 108 incudo-stapedial articulation, 102, 103 vibrator, 100 Osteomata, nasal cavities, 260 Othematoma of auricle, 44 Otitis, externa, acuta, 53 chronica, 53 circumscripta, 54 diffusa, 53 parasitica, 56 media, acuta, 68 from nasal douche, 254 paracentesis, 72 chronica, 79, 86 purulenta, acuta, 74 chronica, 112 Otomycosis, 56 Otorrhoea, chronic, 112 Otoscope, massage, 14, 16 Ozena, 252 cause of eye diseases, 285 Palate, 37 Panotitis, 169 Papillomata, of larynx, 477 of nasal cavities, 258 Paracentesis membrane tvmpani, 72, 84, 101 Paracusis, duplicata, 173 Willisii, 174 Paresthesia, of larynx, 461 pharynx, 407 Paralysis, of auditory nerve, 177 facial nerve, 116, 129, 177 larynx, 463 pharynx, 408 Parasitic otitis externa, 56 Park, Koswell, 483 Parosmia, 269 Peiper, 225 Pemphigus of auricle, 45 Perforation of membrana tympani, 68, 74, 112-114, 126 Perichondritis of auricle, 44 Periosteum separator, 153 Pharyngeal tonsil, 292, 298 Pharyngitis, acute, 305 effect on ear, 307 treatment, 308 chronic, 311 follicular, 322 herpetica, 325 in measles, 319 membranous, simple, 325 rheumatic, 313, 316 scarlatina, 320 small-pox, 321 syphilitic, 396 tubercular, 393 Pharyngomycosis, 389 Pharynx, 37, 305 acute inflammation, 305 burns and scalds, 409 diphtheria, 328 effects of nasal disease on, 322 foreign bodies, 410 herpes, 325 malignant disease, 401 morbid growths, 391 innocent growths, 391 fibroma, 391 papilloma, 391, 392 malignant growths, cancer, 401 carcinoma, 401 epithelioma, 401 sarcoma, 297 neuroses, 406 of motion, 408 of sensation, 406 parasitic disease, 389 uvula, inflammation, 392 malformations, 392 Phlebitis of sinuses, 141 Phlegmonous inflammation of antrum of Highmore, 276 Phlyctenular disease from rhinitis, 283 Phonograph, 98 Photophobia from nasal disease, 283 Pierce, Norval H., 253, 476 Politzer, Adam, 24, 28, 29, 35, 88, 170, 172, 178 Pollen as a cause of hay fever, 229 Polypi, aural, 122 494 INDEX. Polypi, cystic, nasal, 258 mucous, of larynx, 478 nasal, 257 naso-pliarynx, 295, 297 Pomeroy, O. D., 105 Post-nasal catarrh, 290 Powders, antiseptic, 118 Powder-blowers, 54, 118 Prognosis in ear diseases, 7, 8 Prophylaxis of acute rhinitis, 210 Prudden, 328 Prussak's space, 63 Pseudomembranous croup, 428 Psychic influence in hay fever, 215 Pulling. the ears, 45 Purulent otitis media, acute, 74 chronic, 112 pyaemia in, 117 Pynchon, Edwin, 11, 343, 345 Quain, 236 Quine, William E., 370 Quinquaud, 223 Quinsy, 373 Randall, 45 Ranke, 432 Records of cases, 3, 23 Relative frequency of diseases, 3, 7, 8 Resection of drum-head, 103, 104 Reservoirs, air-, 32-35 Retractors for mastoid operations, 153 Retropharyngeal abscess, 145, 166, 404 Rheumatic sore throat, 313, 316, 426 Rheumatism and gout, effects on ear, 88 Rhinitis, acuta, 208 clothing, 210 complications, 209 atrophica, 252 cirrhotica, 252 hypertrophica, 243 simple chronic, 210 Rhinoliths, 261 Rhinoscopic instruments, 189, 192 Rhinoscopy, 193 Rhodes, J. E., 437 Richey, S. O., 88, 97, 133 Rinne's test for hearing, 21 Robinson, Beverly, 241 Robison, John A., 370 Roe, John O., 240. 452 Roof of tympanum, 103, 143 Rosenmiiller's fossa, 37 Rosenthal, Edwin, 357 Roux, 328, 350, 351 Sajous, Charles E., 241, 354, 394, 401, 455, 463 Sarcoma, of larynx, 483 of nose, 261, 297 Saw in nasal deformities, 251 Scarlatina, pharynx in, 320 Scheibe, 144 Schrotter, 476 Schwartze, 155, 169, 178 Sclerosis, of mastoid, 144 middle ear, 86 Scroll-ear, 48 Sea-bathing, effect on ear, Seiler, Carl, 202, 242 Seiss, Ralph W., 240, 249, 68 250 Septum, nasi, diseases and deformities, 270 knife, 251 perforation, 211, 271 Sequels of middle-ear suppuration, 122 Sequestra from ear. 132, 134 Serous otitis media, 79 Sex, influence, in disease, 3 Sexton, Samuel, 105, 131 Sherrington, 224 Shrapnell's membrane, 18 Shurley, E. L., 239, 453 Sinus, inferior petrosal, 143 lateral 133 Sinuses, accessory, of nose, 276 ethmoid, 278 frontal, 280 maxillary, 276 sphenoid, 279 Sinus-phlebitis and sinus-thrombosis, 141 Small-pox, throat in, 321 Smell, sense of, 268, 269 Smith, J. Lewis, 331, 342, 343, 347 Snare, ear, 122 Sokolowski, 380 Solutions, antiseptic, 202 Sore throat, acute, 305 chronic, 311 clergymen's, 322 common membranous, 325 gouty, 313, 316 granular, 322 measles, 319 rheumatic, 313, 316 scarlet fever, 320 small-pox, 321 Spasmodic croup, 459 Spasms of pharynx, 408 Specula, aural, 14, 15 Siegle's pneumatic, 94 nasal, 190 Speech in testing the hearing, 22 Sphenoid sinuses, 279 diseases of, effect on eye, 279, 285 tumors, 280 Sphenopalatine ganglion, 216 Sprays, 198 for ear, 29, 30, 85 Spurious croup, 421 Stacke's operation, 161 Stapes, 87, 103, 132, 135 mobilization of, 106, 110 removal of, 111 Statistics, 1 Stenosis of Eustachian tube, 30, 67 IXDEX. 495 Stenosis, of larynx, 457, 474, 476 of nasal cavities, 208, 232, 244, 253, 298 Strabismus from nasal disease, 285 Stridulous laryngitis, 423 Straeh, 364 Synechia of nasal cavities, 243 Syphilis, of auricle. 45 internal ear. 171 larynx. 472 nasal cavities. 263 pharynx, 396 Syphilitic stenosis of larynx. 476 Syringes, 52 Tables, statistical, 3 Talbot, E. S., 46 Tamponing posterior nares, 256 Taylor. James L., 365 Tegmen. mastoidenm, 143, 160 tvmpani. 103, 143, 160 Temporal bone, 156-160, 164 caries of. 132 Tensor tvmpani. 65 tendon of, 63 tenotomy of, 105 Tests of hearing, 18 acoumeter. 22, 23 Bing's test. 21 expressions for. ID Gabon's whistle. 21. 22 Gelle's test. 21 Rhine's test. 21 speech. 22 tuning-forks, automatic, 20 Hartmann's. 20 Weber's method. 20 whispers, 23 Thorner. Max, 305. 311 Thrombosis of sinuses, 141 and jugulars, 142 Tinnitus aurium, 65. 69, 82, 88, 128, 174 Toeplitz. Max. 133. 172. 483 Tongue-depressor, 191 Tonsil, calculi. 390 hypertrophy, of aural, 379 pharyngeal. 292. 298 mycosis, 389 of* Luschka, 292. 298 pharyngeal, 292, 298 syphilis. 396 tuberculosis. 393 Tonsillitis, acute. 373 treatment. 377 Tonsillotome. 383 Tonsillotomy. 382 Tonsils, acute inflammation, 373 chronic inflammation, 379 adenoids in vault of pharynx, 298 aural symptoms from, 381 treatment. EJ82 anaesthetics, 383 Tonsils, chronic inflammation, treatment, haemorrhage from tonsil- lotomy, 387 hot snare, 388 tonsillotome, 383 tonsillotomy, 382 Wright's electric amygdalo- tome. 388 hypertrophied, 379 lacunae of, 382 large. 379 parasites in, 389 varieties of inflammation, 373, 380 Toynbee's auscultation-tube, 39 Tracheotomy. 442 choice of operation. 443 high operation, 443 ■low operation, 445 Trachoma of vocal cords, 455 Transfixion needles in nasal hypertro- phies, 250 Tuberculin in tuberculosis, 395 Tuberculocidin in tuberculosis. 395 Tuberculosis, effect, dii ear, 115 nasal cavities. 263 larynx, 468 pharynx, 393 Tumors of antrum. 277 auricle, 44 larynx. 477 nasal cavities, 261, 271. 297 pharynx, 391 Tuning-fork, automatic. 20 Turbinated bodies, 37 Tvmpanic cavity, 65, 103 floor of, 103 inner wall, 103 mucous membrane, 117 outer wall, 65, 102 Tympanum. See Tvmpanic cavity. Tyrrell. Shawe, 224 Umbo of membrana tvmpani, 17 Uterine reflex neuroses of larynx, 462 Uvula, 392 Uvulitis. 392 Valsalva's inflation. 29. 98 Vapors, use of. iu ear. 32-34 Variola, pharynx in, 321 Vegetable parasites in ear, 56 Veilon, A., 373 Velum palati, 37, 397 Vertigo. 90. 137, 138, 141, 168, 170, 171, 178 Vestibule, 156, 158 Vibrator, ossicle. 100 Virchow, Rudolph, 331, 379, 481 Visual field, contraction from nasal dis- ease, 289 Vocal cords, granulations of, 455 trachoma, 455 i Voice in nasal disease, 211, 298 4 * 7 ^- ,0o