Glass. Book COPYRIGHT DEPOSIT DISEASES EAR, NOSE, AND THROAT THEIR ACCESSORY CAVITIES SETH SCOTT BISHOP, M.D., D.C.L., LL.D. Professor of Diseases of the Nose, Throat, and Ear in the Illinois Medical College; Professor the Chicago Post-graduate Medical School and Hospital: Surgeon to the Post-graduate Hospital; Consulting Surgeon to the Mary Thompson Hospital, 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; One of the Editors of the Laryngoscope, etc. Second Edition. Thoroughly Revised and Enlarged Illustrated with Ninety=four Colored Lithographs and Two Hundred and Sixteen Additional Illustrations 13 M PHILADELPHIA, NEW YORK, CHICAGO THE F. A. DAVIS COMPANY, PUBLISHERS 1898 1830,8 .843 'rid COPY, 1830. COPYRIGHT, 1898, BY THE F. A. DAVIS COMPANY. [Registered at Stationers' Hall, London, Eng.] OCT 3 11898 & of Co^ Philadelphia, Pa., U. S. A. The Medical Bulletin Printing-House 1916 Cherry Street. N RECOGNITION OF HIS DISTINGUISHED SERVICES ADVANCEMENT OF SURGERY, THIS BOOK IS Affectionately Dedicated TO PROF. NICHOLAS SENN, M.D., Ph.D., LL.D., BV THE AUTHOR. PEEFACE TO THE SECOXD EDITTOX. The early exhaustion of the first edition lias afforded a welcome opportunity to add many desirable improvements in the second. The writer is under deep obligations for the cordial reception and generous criticism of the book by the medical press and profession. Many of the excellent suggestions made by the reviewers, who are largely teachers in this branch, have been acted upon, with the result of in- corporating new subjects and much other new and valuable material. The generally-expressed wish for enlargement and greater detail in the treatment of various diseases has been met, as far as could con- sistently be done. Two new chapters have been written, one on "Re- lated Diseases of the Eye and Xose," and the other on "Life-insurance Affected by Diseases of the Ear, Xose, and Throat."' Illustrated articles on "Direct Laryngoscopy, or Autoscopy"; and on "Pachy- dermia Laryngis,' v etc., have been added. Many new colored drawings and half-tone engravings from photographs of interesting and in- structive cases, specimens, and preparations have been made for this edition. It was the original purpose to condense as much indispensable in- formation as possible in a book of convenient size for students and general practitioners, and it has been found practicable to hold to this method ■ while making the additions of new matter, to the extent of more than 25 per centum, by utilizing to the highest advantage the arts of lithography, engraving, and printing. Instead of devoting the usual large space to descriptive anatomy, this subject is profusely pictured in close association with the diseases treated of, and the many illustrations, together with their accompany- ing explanations, keep the various organs, their surgical relations, and their varying appearances in health and disease always before the eye. It is believed that, with the more extended treatment of the most important subjects and their ample illustrations, this volume will meet with even a more cordial favor among the specialists than the first edition was fortunate enough to enjoy. For valuable services in preparing illustrations for the second edition the writer desires to express -his acknowledgments and thanks VI PKEFACE. to Professor Politzer for his permission to reproduce a number of his artistic colored figures; to Mr. Beady, the medical artist, for colored drawings; to Max Thorner for illustrations of direct laryngoscopy; and to E. C. Talbot and C. W. Baker for photographs. Moved by the kind welcome accorded to the first edition, the writer has earnestly endeavored to make the second issue more fully and satisfactorily meet the requirements of a magnanimous profession. S. S. B. 103 State Street, Chicago, September 15, 1898. PREFACE Frequent requests from medical students and general practi- tioners for a book on diseases of the ear, nose, and throat especially adapted to their needs have prompted the writer to endeavor to meet this demand. This work was designed, first, to help students in preparing for their degree; second, for those progressive practitioners who wish to acquire the proficiency necessary to properly treat those patients who are unable to visit specialists; 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 constitute 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 un- pretentious 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 read}' reference. Several subjects are treated in greater detail than characterizes the work as a whole, for the following reasons: Xo book, equivalent to this, is now available containing the latest developments concern- ing diphtheria, the blood-serum therapy, the medical and surgical management of mastoid diseases, the related diseases of the eye and nose, the most successful treatment of hay fever, the improved com- pressed-air instruments, vaporizing apparatus, inhalents, etc. There- fore these subjects are given especial prominence. The opinions and experiences of a large number of eminent authorities are presented on the subjects of diphtheria, antitoxin therapy, and hay fever. Like works on general medicine and surgery, little space is de- voted to the anatomy of the various organs. It is assumed that the reader either has a fair understanding of anatomy or 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 the study of middle-ear diseases. (vii) Ylll PKEFACE. The writer lias freely consulted many books and journals, and desires to fully and frankly acknowledge Ms very great indebtedness to them. Chiefly among these are the works of Politzer (Dodd's translation), Sajons, Burnett, Gruber, Koosa, Browne, Mackenzie, Ingals, Bosworth, Tnttle, the American Year-book, etc. For generous contributions of valuable figures and plates I am under deep obligations to Politzer, Sajons; Trnax, Greene & Company; Holmes, and Krieger; and, for photographing, to F. A. Place. I am indebted, also, to my assistant, C. L. Enslee, for the laborious task of preparing the statistical table of 15,300 cases from any clinical record- books. It remains to express my sincere appreciation of the cordial 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 Street, Chicago, February 7, 1897. CONTEXTS. PART I. DISEASES OE THE EAR. CHAPTER I. PAGE A General Consideration of Diseases of the Ear. Xose. and Throat Based ox a Study of Twenty-one Thousand Cases 3 CHAPTER II. Examination of Patients 13 Instruments and apparatus. Tests for hearing. Recording cases. CHAPTER III. Compressed-Air Appliances and their Uses 29 Accurate methods of treatment with compressed air. High- and low- pressure devices. How to use high pressure safely. The advantages of improved air-condensers over rubber bags. De- tails of treatment with air- meters, or regulators. CHAPTER IV. Methods of Producing and Using Compressed Air 36 The most useful devices for hand- and water- power pressure. Politzerization. Catheterization. Auscultation. CHAPTER V. Diseases of the External Ear 47 Frost-bite. Eczema. Lupus. Gangrene. Carcinoma. Perichon- dritis. Hsematoma. Cystoma. Intertrigo. Herpes. Pemphigus. Syphilis. Deformities of the auricle. Hypertrophied auricle. Scroll-ear and associated deformities. CHAPTER VI. Diseases of the External Auditory Canal 5Q Inspissated and impacted cerumen. Diffuse inflammation of the external meatus. Furunculosis. Parasitic inflammation, or otomycosis. Exostoses. Imperforate meatus. Foreign bodies in the meatus. CHAPTER VII. Diseases of the Middle Ear G7 Injuries of the drum-head. Inflammation of the drum-head. Eu- stachian tubal catarrh, or salpingitis. Acute inflammation of the middle ear. (ix) X CONTEXTS. CHAPTER VIII. PAGE Diseases of the Middle Ear, Continued 78 Acute suppurative inflammation of the middle ear. Chronic non- suppurative inflammation of the middle ear. Hypertrophic, or secretive, catarrh of the middle ear. CHAPTER IX. Diseases of the Middle Ear, Continued 90 Sclerosis, or the adhesive inflammation of the middle ear. CHAPTER X. Diseases of the Middle Ear, Continued 104 Operative treatment of tympanic sclerosis. Mobilization of the ossicles. Incision of the posterior fold of the drum-head. Mul- tiple incisions of the drum-head. Excision of areas of the drum- head. Division of the tensor tympani. Excision of the membrana tympani and ossicles. Operation for excision of the ossicles. Mobilization of the stirrup. Stapedectomy. CHAPTER XL Diseases of the Middle Ear, Continued 116 Chronic suppurative inflammation of the middle ear. Aspiration of the tympanic cavity. CHAPTER XII. Diseases of the Middle Ear, Concluded 127 Sequels of middle-ear inflammation. Granulations. Polypi. Caries and necrosis of the tympanic cavity. Necrosis of the ossicles. Adhesions, cicatrices, and perforations of the membrana tym- pani. Artificial drum-heads. Deafness following suppuration. Tinnitus in purulent inflammation. Cholesteatoma. Facial- nerve paresis and paralysis. Carious processes in the temporal bone. CHAPTER XIII. Extension of Ear Diseases to the Cranial Cavity 143 Meningitis. Extradural abscess. Cerebral abscess. Cerebellar ab- scess. Operations for brain-abscesses. Sinus-phlebitis and sinus- thrombosis. CHAPTER XIV. Diseases of the Mastoid Process 149 Medical treatment. Indications and preparations for mastoid operations. Preparation of patient. Instruments required. Preparation of instruments. CHAPTER XV. The Mastoid Operations 162 The Schwartze operation. The radical tympano-mastoid, or Stacke, operation. The modified mastoid operation. Abscess of the neck from middle-ear and mastoid suppuration. CONTEXTS. XI CHAPTER XVI. PAGE Diseases of the Internal Ear 183 Hyperaemia and anaemia of the labyrinth. Inflammation of the labyrinth. Panotitis. Haemorrhage into the labyrinth. Meni- ere's disease. Leucocythaemie deafness. Syphilis of the laby- rinth. Diseases of the auditory nerve. Neuroses of the per- ceptive apparatus. Hyperaudition. Hyperesthesia. Paracusis. Paracusis Willisii. Subjective sounds, or tinnitus aurium. Nervous tinnitus. Spasmodic noises. Paresis and paralysis of the auditory nerve. Cerebral causes of deafness. Xew growths of the internal ear. CHAPTER XVII. Diseases of the Internal Ear, Concluded 191 Injuries of the labyrinth. Deaf-mutism. Education of the deaf. Hearing-instruments. PAET II. DISEASES OF THE XOSE. CHAPTER XVIII. Examination and Instruments 205 Examination of patients. Instruments. Atomizers. Vaporizers. Sprays. Inhalents. Inhalers. CHAPTER XIX. Diseases of the X'asal Cavities 219 Acute rhinitis, or eoryza. Influenza. Simple chronic rhinitis. Chronic nasal catarrh. CHAPTER XX. Diseases of the Nasal Cavities. Continued 229 Hay fever. The neurotic theory. Uric acid as a cause of hay fever. Predisposing and aggravating causes. CHAPTER XXI. Diseases of the Nasal Cavities, Continued 244 Hay fever, continued. Symptomatology. Diagnosis. Prognosis. Abortive treatment. Local self-treatment. Preventive treat- ment. Hygienic measures. Symposium of medical opinions. CHAPTER XXII. Diseases of the Nasal Cavities. Continued 255 Hypertrophic rhinitis. Electric-cautery apparatus. Surgical dv- namomotors. Operations for hypertrophies. Atrophic rhinitis, or dry catarrh. Ozena. Xll CONTENTS. CHAPTER XXIII. PAGE Diseases of the Nasal Cavities, Continued 272 Epistaxis, or nose-bleeding. Mucous polypi. Fibrous polypi. Cys- tic polypi. Papillomata. Erectile tumors. Chondromata. Osteo- mata. Exostoses. Rhinoliths. Sarcomata. Carcinomata. CHAPTER XXIV. Diseases of the Nasal Cavities, Concluded 280 Tuberculosis of the nose. Syphilis of the nose. Lupus of the nose. Glanders. Furunculosis. 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. Congenital deformities of the nose. Foreign bodies in the nose. Animate objects in the nose. CHAPTER XXV. Diseases of the Accessory Cavities of the Nose 297 Inflammation of the antrum of Highmore, or maxillary sinus. Ethmoid diseases. Sphenoid diseases. Diseases of the frontal sinuses. CHAPTER XXVI. Related Diseases of the Eye and Nose 307 Diseases of the eye caused by nasal affections. Ocular reflexes from nasal diseases. Nasal diseases due to ocular anomalies. CHAPTER NXVII. Diseases of the Naso-pharyngeal Cavity 317 Naso-pharyngeal catarrh. Atrophic catarrh of the naso-pharynx. Fibrous 'polypi of the naso-pharynx. Fibromucous polypi of the naso-pharynx. Malignant tumors. Adenoid vegetations in the vault of the pharynx. PAET III. DISEASES OF THE PHARYNX. CHAPTER XXVIII. Diseases of the Pharynx 335 Acute pharyngitis, or simple sore throat. Simple chronic pharyn- gitis. Acute rheumatic pharyngitis. Chronic rheumatic sore throat. CHAPTER XXIX. Diseases of the Pharynx, Continued 347 Sore throat of measles, scarlet fever, and small-pox. Follicular pharyngitis. Membranous sore throat, non-diphtheric. CONTENTS. Xlll CHAPTER XXX. PAGE Diseases of the Pharynx, Continued 355 Diphtheria. Pathology. Etiology. Symptomatology. Diagnosis. Prognosis. CHAPTER XXXI. Diseases of the Pharynx, Continued 365 Diphtheria, continued. Treatment. Examination of diphtheric patients. Isolation. Local and constitutional treatment. CHAPTER XXXII. Diseases of the Pharynx, Continued 375 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 XXXIII. Diseases of the Pharynx, Continued 399 Tonsillitis. Phlegmonous tonsillitis. Hypertrophy of the tonsils. Tonsillotomy. Instruments and methods of operating. Haemor- rhage following removal of the tonsils. CHAPTER XXXIV. Diseases of the Pharynx, Continued 414 Mycosis, or parasitic disease of the pharynx. Concretions in the tonsil. Non-malignant tumors of the pharynx. Adhesions of the soft palate to the pharyngeal walls. Uvulitis. Bifid and double uvulas. Tuberculosis of the pharynx. Syphilis of the pharynx. Cancer of the pharynx. CHAPTER XXXV. Diseases of the Pharynx, Concluded 433 Retropharyngeal abscess. Xeuroses of the pharynx. Xeuroses of sensation. Hyperesthesia. Anaesthesia. Paresthesia. Neu- ralgia. Neuroses of motion. Spasms of the pharynx. Globus hystericus. Pharyngeal chorea. Paralysis of the pharynx. Burns and scalds of the pharynx. Foreign bodies in the pharynx. PAET IV. DISEASES OF THE LARYNX. CHAPTER XXXYI. Diseases of the Larynx 443 Indirect laryngoscopy. Instruments. Apparatus. Difficulties of laryngoscopy. Direct laryngoscopy, or autoscopy. XIV CONTEXTS. CHAPTER XXXVII. PAGE Diseases of the Larynx, Continued 452 Acute laryngitis. CHAPTER XXXVIII. Diseases of the Larynx, Continued 159 Croup. Comparison of true croup with laryngeal diphtheria. CHAPTER XXXIX. Diseases of the Larynx, Continued 464 Intubation of the larynx. Instruments, method, and results. Care and feeding of patients. Tracheotomy. CHAPTER XL. Diseases of the Larynx. Continued 474 Chronic laryngitis. Atrophic laryngitis. Suppurative laryngitis. Abscess of the larynx. Trachoma of the vocal cords. (Edema of the larynx. CHAPTER XLI. Diseases of the Larynx. Continued 486 Xeuroses. Spasmodic croup. Anomalies of sensation. Nervous aphonia. Reflex affections of the voice. Paralyses. CHAPTER XLII. Diseases of the Larynx, Continued 494 Tuberculosis of the larynx. Syphilis of the larynx. CHAPTER XLIII. Diseases of the Larynx, Concluded 502 Tumors. Innocent tumors. Papillomata. Fibromata. Pachyder- mia laryngis. Miscellaneous growths. Malignant tumors. Car- cinomata. Sarcomata. Foreign bodies in the larynx. CHAPTER XLIV. Life-insurance Affected by Diseases of the Ear. Nose, and Throat -515 APPEXDIX. Remedies -5-1 Case-record Book 529 Index 541 LIST OF ILLUSTRATIONS. FIG. p AGE 1. Arrangement of instruments and apparatus ! . . . . 13 2. Pynchon's cabinet for instruments, etc 14 3. The author's light-condenser 15 4. Spring-band mirror-holder 16 5. The author's adjustable bracket 17 0. Toynbee's ear-specula 18 7. Gruber's ear-specula 18 8. The author's massage otoscope 18 9. The author's cotton-carrier 19 10. Normal drum-head of right ear 20 11. Normal drum-head of left ear 20 12. Outer surface of the left tympanic membrane of an adult. . 21 13. The author's automatic tuning-fork 23 14. Hartmann's tuning-forks 24 15. Galton's whistle 26 16. Politzer's acoumeter 27 17. The author's original compressed-air meter 30 18. Davidson cut-off 31 19. Dilators and combined air-reservoir and hand-pump 36 20. Compound hydraulic pump beneath the water-basin 38 21. Single-acting hydraulic pump 39 22. Eotary air-pump 40 23. Air-meter of improved pattern . 41 24. Politzer's air-bag 42 25. Buttle's inflator 42 26. The author's improved inflator 43 27. Eustachian catheter 43 28. Vertical section of the naso-pharynx with the catheter introduced into the Eustachian tube 44 29. Fixation of the catheter with the left hand 45 30. Toynbee's auscultation-tube 45 31. Gangrene of the ear; mastoid operation 49 32. Hypertrophied auricle 53 33. Alpha syringe 58 34. Author's small powder-blower for the ear 60 35. Ear-forceps 65 36. Rupture of the anterior-inferior segment of the drum-head caused by a box on the ear 67 37. Section through the tympanic membrane, malleus, and upper and outer tympanic wall of a decalcified preparation 6S 38. Eustachian tube and tympanic cavity 70 39. Eadiate vascular injection of the drum-head 74 40. Eadiate vascular appearance in acute inflammation of the middle ear. 7-i 41. Convexity of the drum-head due to pressure from within 78 42. Xipple-shaped bulging of the posterior portion of the drum-head, on the summit of which is the perforation 81 43. Fluid effusion in the tympanic cavity, marked by a bright line 83 44. Circumscribed bulging of the drum-head, due to pressure of fluid in the middle ear S3 45. Great concavity of the drum-head and foreshortening of the hammer- handle 84 (XT) XVI LIST OF ILLUSTRATIONS. FIG. PAGE 46. Semilunar chalky deposit in front of the handle of the mallet 91 47. Niche of the fenestra ovalis, with the crura of the stapes, in the nor- mal ear of an adult 91 48. Marked retraction of the drum-head 96 49. Circumscribed depressions in the anterior-inferior quadrant of the left drum-head 96 50. Circumscribed adhesion of the membrana tympani to the promontory underneath the handle of the mallet 97 51. Lucse's pressure-probe 99 52. The author's ossicle-vibrator 104 53. Section of the posterior fold of the membrana tympani 105 54. Internal surface of the left membrana tympani 106 55. Triangular resection, of the drum-head 107 56. Middle-ear instruments and handle Ill 57. The author's ossicle-hook Ill 58. Politzer's pincette 112 59. Vertical section of the external meatus, membrana tympani, and tym- panic cavity 113 60. Extensive destruction of the drum-head 116 61. Pear-shaped perforation of the drum-head 117 62. Perforation of the posterior half of the right drum-head 117 63. Destruction of the inferior half of the membrana tympani laying bare the promontory and niche of the round window 118 64. Large perforation of the right drum-head 118 65. Destruction of inferior half of the drum-head. Globular granulations on the inner wall of the middle ear 120 66. Slender middle-ear probe 120 67. The author's large powder-blower for use with a hand-bulb or com- pressed air 122 68. The author's ear-aspirator 125 69. Politzer's polypus-forceps 128 70. The author's middle-ear case 128 71. The author's caustic applicator on flexible shank 129 72. Vertical section of middle ear; drum-head in contact with the inner wall 130 73. Band-like cords between the lower end of the hammer-handle and the stapedo-incudal articulation 131 74. Central perforation of the drum-head and calcareous deposits 131 75. Facial paresis. Appearance the same as in permanent facial paralysis. The patient is photographed while laughing. 134 76. Same as Fig. 75, three months after Stacke operation and treatment with electricity 135 77. The author's ear-electrodes, attached to a head-band 137 78. Sequestra of dead bone, and the ossicles. Actual size _ 139 79. Post-mortem section of the temporal bone, showing a perforation of the lateral (sigmoid) sinus 14° 80. The author's middle-ear curette 141 81. Horizontal section of the ear 141 82. Interior of base of skull 150 The author's ice-bag : 15? T>,,^1,'^ -.-.t^ o + ^iz-1 Vt-ii-Fq lOO 83. 84. Buck's mastoid knife. The Nevius electric head-lamp 15 ° 80. _ 86. A strong scalpel j^i 87. The author's mastoid chisel. Actual width J5< 88. The author's long mastoid gouges. Actual width 15/ 89. Lead-filled mallet 15 ^ 90. The author's set of curettes |5b 91. The author's mastoid guide j^j 92. Mathieu's tongue-holding forceps loJ LIST OF ILLUSTRATIONS. XY11 FIG. PAGE 93. The author's periosteum elevator 159 94. The author's self-retaining retractors 160 95. A mastoid operation . , 163 96. Operating-room and accessories 164 97. Horizontal section through right temporal bone, cut two millimetres above the centre of the external canal 165 98. Side-view of a skull, showing opening in mastoid process for Schwartze operation 166 99. Schwartze operation 167 100. Opening of the antrum 168 101. Horizontal section through right temporal bone, showing distance between lateral sinus and external canal 169 102. 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 169 103. Perpendicular section through the right temporal bone 170 104. Adhesive-plaster dressing for mastoid wound 171 105. Line of incision healed two months after Schwartze operation 171 106. The Stacke operation completed 172 107. Side of skull, showing Stacke operation 173 108. Vertical section through the ear 174 109. Section of the temporal bone. Actual size Facing 174 110. Section of the temporal bone. Natural size Facing 174 111. Horizontal section of temporal bone, cut near floor of external meatus 175 112. Six weeks after Stacke operation 176 113. Appearance two weeks after the modified operation. Healed five weeks after the operation 177 114. Post-mortem section of mastoid process 178 115. Appearance three weeks after a modified Stacke and an operation for a neck-abscess 179 116. Abscess of the mastoid process extending over ten weeks, resulting in an enormous abscess of the neck, reaching nearly to the thoracic cavity 180 117. The same as Fig. 116, showing the outline of the swelling 181 118. The conical conversation-tube 199 119. The London horn 199 120. Electric illuminator, as used in posterior rhinoscopy 205 121. Xasal speculum of correct pattern, and the proper way to handle it. . 206 122. Bosworth's tongue-depressor 207 123. Throat-mirrors 207 124. White's palate-retractor 208 125. Hard-rubber palate-elevator 208 126. The posterior rhinoscopic image 209 127. The Davidson spray-producers 210 128. The De Vilbiss atomizer 210 129. The lavolin atomizer 211 130. Truax, Greene & Company's atomizer 211 131. Andrews's combined atomizer and vaporizer 212 132. The Universal vaporizer 213 133. The Globe nebulizer 214 134 to 139. Methods of receiving sprays and inhalents 214 140. Hot-water inhaler 217 141. The author's camphor-menthol inhaler 217 142. The author's soft-rubber nasal bougie 228 143. Xasal synechia 255 144. Posterior view of osseous bridge shown in Fig. 143 256 145. Transverse vertical section through the vault of the pharynx and Eustachian tube 256 XV111 LIST OF ILLUSTRATIONS. FIG. PAGE 146. Transverse vertical section through the posterior nares 257 147. Transverse vertical section through the orbits, nasal fossae, and maxillary antra 258 148. Transverse vertical section through the nasal fossse 258 149. The Wabash cautery battery, with electrodes, lamp, and handles. . . 260 150. The American storage battery. 261 151. Electric current-transformer and dynamomotor 262 152. Alternating electric current transformer for cautery purposes 263 153. Cautery-knife 264 154. Mcintosh electrocautery handle, with snare and windlass 264 155. Hobby's steel snare 267 156. The author's septum-knife 268 157. The author's nasal saws 268 158. Bellocq's cannula introduced. 273 159. Curette-forceps 275 160. Very strong cutting forceps 275 161. Casselberry's saw-tooth scissors 276 162. Destruction of the hard palate, the soft palate remaining unharmed. . 278 163. Destruction of the bones forming and supporting the bridge of the nose 281 164. Partial destruction of the bones of the nose, resulting in two per- forations 282 165. The author's nasal supporter 283 166. Moderate deflection of the septum nasi . 288 167. Deflection of septum nasi sufficient to cause stenosis of the left naris. 288 168. Deflection of septum nasi toward the right side, at nearly a right angle 289 169. Deflection of septum nasi toward the left side with apparent, but not real, adhesion to the left inferior turbinated body 289 170. Perpendicular portion of the ethmoid bone, consisting of two plates; the inferior turbinated bone of the left side is plainly visible . . . 290 171. Transverse vertical section through the nasal fossse , 290 172. Transverse vertical section through the nasal cavities 291 173. Hartmann's forceps * • • ■ ■ 295 174. Transverse vertical section through the nasal fossae and maxillary antra 297 175. Transverse vertical section of the nasal fossae 298 176. Transverse vertical section through the maxillary antra 299 177. Transverse vertical section through the maxillary antra 300 178. Cannula and trochar 300 179. Longitudinal vertical section (actual size) through the nasal and ac- cessory cavities 30l 180. Longitudinal vertical section (natural size) through the nasal and accessory cavities 304 181. Dissection showing nasal duct and its relations 308 182. Ducts connecting the nose with the accessory sinuses and the eye. . . 309 183. Lacrymal knife 316 184. Contracted upper jaw; narrow roof of mouth with very high arch, encroaching upon the nasal fossae 324 185. A mouth-breather • 325 186. Denhart's mouth-gag 3 -' 187. Position of child for adenoid operation or intubation; mouth-gag introduced 3-o 188. Gottstein's ring-curette 6 '- } 189. Diphtheria bacilli 3ob 190. Diphtheria bacilli. 191. Streptococcus pyogenes 35 358 192. The author's tonsillotome, with excised tonsil 408 193. Adhesion of soft palate to the posterior Avail of the pharynx 41/ LIST OF ILLUSTRATIONS. XIX FIG. PAGE 194. Bifid uvula in a man sixty years old 418 195. Complete double uvula in a boy of fourteen years 419 196. Large perforation of the velum palati 425 197. Destruction of the velum palati 426 198. Small powder-blower with long tube 429 199. Mackenzie's lateral throat-forceps 439 200. De Vilbiss illuminator 444 201. Position for autoscopy 448 202. Tongue-depressor for pharyngoscopy and direct laryngo-tracheoscopy. 448 203. Tangential plane * * 449 204. Standard spatulas 450 205. Types of instruments for autoscopie operations 451 206. O'Dwyer's intubation-tubes 464 207. Scale * 464 208. O'Dwyer's introducer, with tube attached 465 209. O'Dwyer's extractor 465 210. Eoswell Park's aluminium tracheal tube 470 211. Hard-rubber tracheal tube 471 212. Trachea dilator 472 213. Laryngeal cotton-forceps 479 214. Tobold's set of six forceps, knives, etc 506 215. Mackenzie's antero-posterior laryngeal forceps 507 PART I. Diseases of the Ear. (i) CHAPTEE 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 seventeen years at one of the author's clinics 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 relatively 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 instituted 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 con- dition 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 heading. For example, under the classification of clerks were embraced salesmen, book-keepers, office employees, etc.; with teamsters were grouped car-drivers, ped- dlers, 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 under the head of day-laborers, — a term borrowed from the laborers them- selves. (3) 4 CLASSIFICATION OF PATIENTS AND DISEASES. The abbreviations employed are: W. No., for whole number. Ac, for acute inflammation of the middle ear. Ac. S., for acute suppurative inflammation of the middle ear. C. N., for chronic non-suppurative inflammation of the middle ear. C. S., for chronic suppurative inflammation of the middle ear. Ext., for diseases of the external ear. Int., for diseases of the internal ear. D. M., for deaf-mutes. F. B., for foreign body. In. C, for inspissated cerumen. Fur., for furuncle. Ac. S. N. for acute suppurative inflammation of one middle ear with chronic non-suppurative inflammation of the other. Au. P., for aural polypus. M. D., for mastoid disease. N. Ph., for naso-pharyngeal catarrh. Ad., for adenoid growths in the vault of the pharynx. Hy. T.j for hypertrophied tonsils. Occupation. Miners . Firemen . . ... Coopers Butchers Packing-house laborers Engineers . ... Cigar-makers .... Plumbers Boiler-makers .... Tinners . Shoe-makers . . . Bakers ..... Printers . . Tailors .... Blacksmiths . ... Painters Sailors ... Railroad-laborers . . . Farmers Carpenters Iron-workers .... Teamsters Factory-hands .... Clerks Day -laborers Total 1 £ < 10 10 10 1 11 1 12 1 13 15 2 16 2 19 20 1 22 22 1 30 31 38 1 47 3 47 1 58 2 74 80 3 84 4 85 12 108 6 232 17 496 27 1590 85 1 1 3 4 2 2 2 2 2 1 2 5 1 4 4 11 13 19 26 109 9 5 6 8 10 6 7 10 9 14 14 10 18 26 26 28 35 55 57 54 33 59 117 300 922 4 1 1 3 2 2 3 1 3 5 1 4 12 8 3 10 9 12 18 8 11 23 19 39 77 279 10 6 9 36 171 24 CLASSIFICATION OF PATIENTS AND DISEASES. Summary. 1 6 < X < "J 6 +3 . ft Adult males without occupation . . Female adults Boys, 6 to 15 years Girls, 6 to 15 years Boys under 6 years Girls under 6 years 810 1662 557 562 243 276 1590 43 75 35 32 11 11 85 31 63 28 22 21 26 109 485 1070 230 225 41 45 922 197 317 205 232 125 139 279 46 106 34 35 26 38 171 7 27 19 11 8 9 24 1 4 6 5 11 8 With occupations Total 5700 292 300 3018 1494 456 105 35 Percentage of W. Xo 5.1 5.3 53. 26. 8. 2. 0.6 The combined tables show that, of the 21,000 cases, there are 11,167 patients with occupations, classified under 28 headings. Of this number, 3813 had ont-door and 7354 in-door work. In the first table a larger proportion would undoubtedly 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. Xext in order were about half that number of the out-door class, or 1493 day-laborers. Then follow groups of the next highest numbers: 858 clerks, 460 iron-workers, 452 car- penters, 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 list. While the great stores and factories furnish a large number 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 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 CLASSIFICATION OF PATIENTS AND DISEASES. \L ^H TfH CO ^ "* GO 04 CO 04 tH i> tF i-H CO © t- © X tF lO CO CO TT 04 PV . . 04 04 . © Tf 04 LO ' Oi Oi rH rH ^ •'Id *N ©TtiXTfiX©04" 04 rH CO . CO . OS . CO rH i> tF i> LO X CO 04 J ny 04 CO -f i-t tH 04 1— 1 1-1 . . . 04 TH Oi . . . 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OOrf04 04 000000COTf-<^OOCOGOf^0404i^iOLO^t l t^004CCCOO}OOOiOOr^OOOrH WlOCOU5tOlC040STH004i>C00404COi>'^ H T--(Osr*J>0 004i>LOiH05004040Jl> rH Tfl 00 TTOH^Nrf ^ ,_| ,h i-H ^j. ,_, ,_ rf H CO lO OS O M H rH CO l-H rH i-H © © CO to % o < Cm O o O Miners . . . Musicians Painters . . . Plumbers . . . Printers Professions . . , ,. Railroad-laborers . . Sailors . . . Sewing-women . . . Shoe-makers . . Tailors . . . . Teachers . Teamsters .... 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 Bakers ... Blacksmiths Butchers . . . Carpenters . . Cigar-makers . . Clerks . . Coopers . . Day-laborers Domestics Engineers Factory-workers Farmers Iron-workers Janitors lis o H CLASSIFICATION OF PATIENTS AND DISEASES. 7 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 prevention 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 domestics, 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 frequency of involvement between the two ears, not referring to the question of sex, and both ears were affected in 43 per cent, of all the cases. In acute sup- puration 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 2790 cases of unilateral ear diseases which the author has investigated to determine which ear was the more frequently affected, especially with reference to the question of sex and its influence, first in children under 15 years of age, and, second, in adults, the results are as follow: There were 456 boys with affections of one ear only, of whom 245 had diseases of the right ear, and 211 diseases of the left ear, an excess of about 7.6 per cent, of right ear affections. Of 569 girls, 334 had diseases of the right and 235 diseases of the left ear, or an excess of 17.4 per cent, of affections of the right ear. This shows that out of the total number of 1025 children under 15 years there was an excess of 25 per cent, of diseases of the right ear. Of 1046 men, 472 had diseases of the right ear, and 574 of the left, or an excess of about 10 per cent, of affections of the left ear. There were 719 women, of whom 363 presented troubles of the right ear, and 356 of the left, or an excess of diseases of the right ear amounting to a trifle less than 1 per cent. 8 CLASSIFICATION OF PATIENTS AND DISEASES. In the 5809 cases of chronic non-suppurative inflammation of the middle ear the two sides were abont 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 attached to these undeniable figures in formulating our prognosis when 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 oftener 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 affec- tions as would be desirable, this part of the diagnosis sometimes being entered on the patients' cards instead of upon the record-books. About 8 / 10 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 1 / 2 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 inflammation, 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 ihe 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 ETIOLOGY OF DISEASES OE THE EAR, NOSE, AND THROAT. 9 renders the soldier, Spartan-like, indifferent 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 nose demonstrates the existence of nasal trouble in a large proportion 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 diseases 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. A'ery many of them dated back to attacks of scarlet fever, measles, and the earaches and "running-ears" of infancy; so that a much larger percentage than appears should prob- ably be credited to the period of childhood. Only a small proportion of children were brought for treatment during the acute stage of inflammation. 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. Indeed, only 13 per cent, of the adults were seen in the acute stage. The tables show a large percentage of diseases of the external ear. Since impacted cerumen may be regarded as a symptom and a consequence of chronic non-suppurative inflammation of the middle ear, due consideration should be given this fact in estimating the 10 ETIOLOGY OF DISEASES OF THE EAK, NOSE, AND THKOAT. 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 embraced by these statistics, a large majority were residents of Chicago, — a very cosmo- politan 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 con- sidering 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 conditions that are character- istic 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 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 thermometric changes are sudden and great, It is not unusual for the ther- mometer 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 thoroughly 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 COMPARISON OF STATISTICS. 11 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. Loewenberg, of Paris, in the Deutsclien medicifiischen Wochen- schrift, arrives at the conclusion that ear diseases have a particular predilection for the left ear. He believes that if one ear only is diseased it is more frequently the left. If the affection attack both ears it generally begins in the left, and leads here often to a more profound malady and to a higher degree of deafness than with the right ear. In this respect the sexes differ, in that the predominant deafness of the left side is peculiar to the male, while the reverse is true of female patients. Loewenberg examined 3000 cases of im- paired hearing, excluding causes lying in the external ear. Of the whole number there were 1790 males and 1210 females. He found among those affected with one-sided deafness 478 men and 311 women. Of these, the right ear alone was afflicted in 212 men and 167 women, and the left ear alone in 266 men and 144 women. This leaves about 12 per cent, more men afflicted with deafness of the left than of the right side, and about 7 per cent, more females with right-sided than with left-sided deafness. Of those suffering from bilateral deafness 1074 men and 737 women were found, the right ear being the worse in 427 men and in 340 women; the left having the hearing more impaired in 647 men and in 397 women. There were 238 men and 162 women who were afflicted with a high degree of deafness affecting both ears equally B. Alexander Eandall has reported 4785 patients with 5412 diseases, tabulated as follows: — Men. Women. E. Ear L. Ear Both Ears R. Ear L. Ear Both Ears Middle-ear diseases .... 289 271 598 198 181 586 External-ear diseases. . 86 96 196 57 58 120 Internal -ear diseases... 4 3 5 3 1 379 370 799 258 240 706 12 COMPARISON OF STATISTICS. It will be readily seen that this table shows slight variations in the relative frequency of diseases of the right ear as compared with the left, in the sexes. Among both men and women diseases of the right side predominated in middle ear affections, of the left side in external ear diseases, and of the right side again in troubles of the internal ear. There is quite a wide difference between the conclusions arrived at from the Paris statistics and the deductions justified by the Philadelphia and Chicago tables aggregating 25,785 patients. During the past twelve years the author has taken pains to inquire of patients not only concerning the common causes of their varying diseases of the two ears, but also as to which ear they were in the habit of lying on mostly, in order to ascertain if that question could have any bearing on the one-sided character of their diseases, or on the fact of one ear's being worse affected than the other in bilateral affections, but no satisfactory solution of this problem has yet been evolved. CHAPTEE II. EXAMINATION OF PATIENTS. The examination of patients should be conducted so system- atically that no discoverable pathological process can escape detection. Fig. 1. — Arrangement of instruments and apparatus. 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 remark that there is no trouble with the other, when examination reveals that both are affected in different (13) 14 EXAMINATION OF PATIENTS. degrees. The examiner should not be misled, but should investigate for himself; otherwise he is not in a position to do credit to himself or his art or do justice to his patron. A very convenient arrangement of a treatment-room is illustrated in Fig. 1. It shows, in a compact space, an adjustable gas-lamp, fitted Fig. 2. — Pynchon's cabinet for instruments, etc. with a light-condenser, and electric forehead-lamp; a compressed-air reservoir and regulator, with two treatment-tubes and cut-offs attached; a dynamomotor for transforming the electric current for cautery purposes and for operating the dental engine with drills, etc. The relative positions of the illuminator and the chairs for the patient EXAMINATION OF PATIENTS. 15 and surgeon are correctly given. Fig. 2 shows Pynchon's cabinet for instruments, medicines, sprays, etc. 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. 2) 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 support the patient's back beneath his shoulders. After examining the right ear neither the Fig. 3. — The author's light-condenser. 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. The best illumination is had from an Argand gas-burner. It has not been possible to obtain an incandescent electric lamp that will afford such an evenly-diffused light as the gas gives, and the mantles of the incandescent gas-burners are too easily broken to permit of their being used on adjustable brackets. The flame should be inclosed in a light-condenser (Fig. 3), not only to increase the effectiveness of the illumination, but also to protect the operator's eyes. If. the light is allowed to shine in one's eyes it contracts the 16 EXAMINATION OF PATIENTS. pupils, interferes with perfect vision, and eventually impairs the sight. The condenser is constructed with a reflector instead of a lens. For this reason it is not top-heavy and requires no spring to hold it in place. By a slight stroke of the finger-nail or a probe, its position can be instantly varied without burning the finger. It fits over the Argand gas-burner or the large railroad-burners on oil-lamps. A special large size is made to fit the incandescent gas-burner. The three-inch forehead-mirror is worn over the eye that is next to the light, and the aperture in the mirror should fall opposite the pupil of the eye engaged in inspecting the ear, so that both eyes are Fig. 4. — Spring-band mirror-holder. shielded from the direct rays of light. The light should be thrown in such a manner as to bring the auditory meatus within the focus of the reflected rays. Except at a distance of 14 inches or more, the drum-head is seen with one eye at a time; so that the other eye may be kept closed. The mirror is best held in position by a self-retaining holder, like the spring head-band shown in Fig. 4. This has the advantage of never deteriorating or becoming soiled, and, with prop- erly-adjusted spring, it does not occasion the wearer a headache. It leaves the hair unruffled and is in every way more satisfactory than the cloth or rubber bands. The forehead-plate is lined with soft rubber, which renders it agreeable to wear and easy to cleanse. EXAMINATION OF PATIENTS. 17 The light should be adjustable to the varying positions and heights of patients. To accomplish this the author devised the lamp- bracket illustrated in Fig. 5. The lamp is easily adjustable to any point lying within a perpendicular line two feet in length;, and it will swing through the arc of a circle having a radius of three feet. The light may be placed either within a few inches of the surface to which it is attached or at a distance of three feet from the wall. To raise or lower the light it is necessary only to press the brake toward the arm above it, set the lamp at any desired level, release the brake- handle, and it then sets automatically. The gas is carried to the Fig. 5. — The author's adjustable bracket. burner through a rubber tube, and where there is no gas an oil-lamp is substituted for the Argand burner. The metallic ear-specula are preferable to the hard rubber, but they should be warmed, especially in cold weather, before inserting. The small end of the funnel should be oval, to correspond with the contour of the meatus. Toynbee's set of three sizes of short length are satisfactory (Fig. 6). The flanged border should be milled. Gruber's (Fig. 7) are also excellent, but they should be milled like Toynbee's to render them less slippery. The auricle needs to be drawn upward, outward, and backward in most cases to straighten 18 EXAMINATION OF PATIENTS. the canal while the speculum is introduced, but in children it is sometimes necessary to draw the auricle downward and backward. A massage otoscope should be employed for diagnostic purposes as well as for treatment. In no other way can it be determined how much mobility of the ossicles has been lost, and how much is regained o o o Fig. 6. — Toynbee's ear-specula. Oo o Fig. 7.- — Gruber's ear-specula. as the result of treatment. In 1887 the author devised the instrument shown in Fig. 8. It consists of a pneumatic chamber, a concave perforated mirror, and a lens, contained in a cylinder to which is attached forty-six centimetres (eighteen inches) of soft-rubber tubing and a diminutive air-syringe. The apex of the funnel is covered with Fig. 8. — The author's massage otoscope. a section of soft-rubber tubing to allow of its being fitted hermet- ically 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 clear view EXAMINATION OF PATIENTS. 19 of the drum-head and mallet under brilliant illumination 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 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 outward sufficiently to produce an outward excursion of the drum-head. Then it is pushed inward to condense the rarefied air and move the mem- brane inward. While these movements are being effected it is ob- served whether the mallet moves with the drum-head or not, and, if it does, how much freedom of movement is present as compared with Fig. 9. — The author's cotton-carrier. the normal mobility. In some old cases of sclerosis the mallet remains entirely motionless, 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. Xo more force should be applied than is necessary to obtain the natural excursions 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 ShrapnelFs mem- brane and the mallet, the procedure should cease for the time, so as not to occasion too great hyperemia. The forehead-mirror is not used with this instrument, since it contains its own mirror. Care must be taken to not allow the fingers to shade the reflector. The cotton-carrier is 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 instances cerumen or discharges have to be removed before the drum-head can be in- spected. The cotton-carrier usually suffices, but the beginner must 20 EXAMINATION OF PATIENTS. 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 drum-head (Figs. 10 Fig. 10. — Normal drum-head of right ear. (After Politzer.) and 11 and Plate I) has a pearly-blue tint, is translucent, lustrous, and always presents a triangular reflection of light, the apex of which is at the lower extremity of the mallet-handle. This luminous tri- angle extends downward and forward 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 Fig. 11. — Normal drum-head of left ear. (After Politzer.) with the stirrup, the posterior leg of which is sometimes visible running 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 TESTS TOR HEARING. 21 horizontal folds stretching forward and backward to the peripheral attachment of the membrane and separating the tense lower section from the membrana flaccida, or Shrapnell's membrane, above (Fig. 12 and Plate I). For convenience of description the drum-head is divided into four sections by a projection of the axis of the handle of the mallet to intersect the circumference of the membrane above and below and an horizontal line intersecting the drum-head at its centre. The four segments into which the drum-head is divided by these inter- secting lines are called the anterior-superior, anterior-inferior, pos- s ms s Fig. 12. — Outer surface of the left tympanic membrane of an adult, enlarged three and one-half times, v, segment of the tympanic membrane lying in front of the handle of the malleus; h, posterior segment of the tympanic membrane; s, s, Prussak's striae, passing from the short process of the malleus to the spina tymp. post, et minor; ms, membrana Shrap- nelli. (After Politzer.) terior-superior, and posterior-inferior quadrants, for convenience of description. Diseased appearances are described in their proper chapters. Tests for Hearing. It is difficult ordinarily 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 employment of very delicate sounds, like the ticking of a watch. Even this ticking may be heard by the opposite 22 TESTS FOR HEARING. ear when it is normal. The watch-sounds are the most constant in intensity, the most convenient at hand, and therefore the most uni- versally 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 considerable 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 usually varies from 30 to 60 inches (76 to 152 centi- metres), and determines the denominator of the fraction that ex- presses 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. E., 10 / 30 ( 25 / 76 ); H. D. L., 6 / 30 ( 15 / 76 ); which reads: Hearing- distance for right ear is 10 / 30 , or 1 / 3 of the normal; for the left ear, 6 / 30 or 1 /- of the normal distance. During the test the patient must keep his eyes closed, to elimi- nate 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 demonstrated 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: ~ (f6") ? mean i n g contact for the watch. If not heard until pressed against the mouth of the meatus, it is recorded thus: P.I. (-T-jr), — pressure for the watch. In case the watch cannot be heard at all it is written: °/ 30 (V-e)- ^ n y° im g 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 children's hearing, for they quickly answer in the affirma- tive 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 diagnosis between diseases of the transmitting and of 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 vibrations per second, — the TESTS FOR HEARING. 23 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, and if the vibrations are caused by an auto- matic hammer attachment (Fig. 13), producing a moderate and un- varying blow. Some are made with sliding clamps to prevent over- tones and to raise and lower the pitch. The fork-test is made by air-conduction 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 forehead, 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 dura- tion for a given fork, the amount of loss or gain in the hearing-power can be quite accurately recorded. Hartmanifs set of five forks (Fig. 11) are tuned to 128, 256, 512, 1024, and 2048 vibrations per second. Fig. 13. — The author's automatic tuning-fork. 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 distinguishes between the musical note and the mere concussion or tactile perception of the unmusical 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 it 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. In making a differential diagnosis between diseases of the con- ducting mechanism and affections of the perceptive apparatus, the labyrinth, or nervous centres, the following tests are employed: — Schwabach's Test. — The most important use to which the tuning-forks are put is in making a differential diagnosis between 24 TESTS FOE HEARING. diseases of the conducting, and of the perceptive, apparatus. In case there is an obstruction to the conduction of sound-vibrations through the external auditory canal, or through the middle ear, to the healthy internal ear, it was discovered by Schwabach that a fork vibrating in contact with the cranial bones was heard longer in the affected ear than in a normal ear. The opposite is true when the Fig. 14. — Hartmann's tuning-forks. auditory nerve is diseased; the fork then is heard longer by a normal ear. If the examiner have normal ears, he compares the patient's perception of sound with his own; or he may compare the percep- tions of the patient with the average tests of his standard fork as ascertained with normal ears. By this means the increased or di- minished length of time that the patient perceives the musical sounds can be accurately obtained and recorded. For example: The fork TESTS FOE HEARING. 25 is struck and placed quickly upon the patient's mastoid process; the patient indicates the instant that he ceases to perceive the sound; immediately the examiner brings the fork in contact with his own mastoid and notes whether he hears the vibrations after the patient fails to hear them. If so, labyrinthal disease is indicated. If he does not, he sounds the fork again and places it upon his own mastoid process; the instant the examiner ceases to perceive the sound he places the fork in contact with the patient's mastoid. If the latter hears the fork then, after the examiner's normal ear ceases to hear it, an obstruction to the conduction of sound, but not a disease of the auditory nerve, is indicated. The examiner notes, also, the number of seconds the patient's joerception lasts. There are elements of uncertainty and error in this test, for in elderly persons bone-conduction is poor, and when one ear is normal, or when both are unequally affected, the better ear will perceive the sounds and cause confusion. Rhine's Test. — Air-conduction is superior to bone-conduction normally. The fork is heard before the meatus twice as long as on the mastoid. AVhen 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 (positive Einne). If the fork is heard longer by bone-conduction (negative Einne), 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 becom- ing relatively better than air-conduction. Labyrinthal disease is characterized by (1) no alteration in the relative acuteness of per- ception of sound by air and bone, both being diminished; (2) by deafness for some tones, generally the higher. Weber's Test. — In normal ears the fork is heard better when in contact with the skull if the auditory canals are closed. If one ear is closed by the finger the sound is intensified. This phenomenon is probably due to increased resonance of an inclosed space and ob- struction to the exit of sound-waves. This has been observed in adhesions, when the middle ear contained fluids, and when the drum- head was relaxed. Sing'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 26 TESTS FOR HEARING. 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. Gelle's Test. — The mobility of the stirrup may be determined 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 per- ception for the highest notes in cases of bilateral ear diseases. If one ear is affected but little or not at all, the whistle-sounds can Fig. 15. — Galton's whistle. scarcely be excluded from it. This instrument (Fig. 15) has a com- pass of about three of the highest octaves, and it is blown by means of a small rubber bulb. The tones can be varied by shortening or lengthening the cylinder by a screw mechanism. 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. 16). It is used very much like the watch directly opposite the opening of the canal, and the hearing-distances are re- corded similarly to those of the watch. It is held by the thumb and index finger resting in the semicircular 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 mastoid process or the temple, while the meatuses are closed. I have observed that in sclerosis a patient may not be able TESTS FOE HEARING. 27 to hear the acoumeter by air-conduction, although he may hear 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 demon- strated by the speech-test. It is customary to choose words varying greatly in the relative preponderance 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 elim- inate the possibility of lip-reading the patient is required to keep his eyes closed during the examination. Since there is a tendency to use the same names repeatedly, in which case patients may introduce Fig. 16. — Politzer's acoumeter. 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 sclero- sis 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 deaf- ness a test should be made with both ears sealed with the moist fingers: if then the sound is heard as well as before, it is demon- strated 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. 28 RECORDING CASES. A record of every case ought to be kept in a convenient book for that purpose. A very complete form, compiled by E. Pynchon, may be found at the end of this book. The following headings indicate the method pursued by the author,, the details being worked out as suggested by the characteristics of each case: — Date. Occupation. Particular Lesions. Name. Eesidence. Eesults 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 the author has found that the maximum amount of pressure that can be obtained with a Politzer air-balloon of the capacity of eight fluid- ounces 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. Ten- and twelve- ounce bags are manipulated in Vienna by pressing them against the operator's side, but they are not much used in America. The Gruber balloons, with the opening or air-valve at the larger end, might possibly accumulate more force than we have mentioned, by repeatedly compressing them, but, on account of the valves being imperfect or soon becoming useless, we have discon- tinued their use. Professor Gruber himself prefers the bulb having a perforation in the end to be covered and compressed with the thumb. Experiments have not been made with this kind, for one could not be found. The rubber bulb usually supplied by the Davidson Company 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 3 / 16 -inch rubber tubing ordi- narily 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 Vilbiss atomizers will stand more, for (29) 30 C03IPRESSED-AIB, APPLIANCES AND THEIR USES. I have tested them with 45 pounds' pressure without even distending them. The force necessary for spraying 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 from 30 to 40 pounds to throw a spray of unheated glycerole of tannin. Fig. 17. — The author's original compressed-air meter. In adapting the improved compressed-air apparatus to the treat- ment 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. 17) will show, this has been accomplished by placing a pressure-gauge between two valves on the escape-tube of the air-receiver. This arrangement utilizes the gauge for registering not only the air-pressure in the reservoir, but also the force of the current of air while it is escaping at the cut-off of the COMPBESSED-AIE APPLIANCES AXD THEIB USES. 31 treatment-tube. The cut-off that has proven most satisfactory is known as the Davidson (Fig. 18). 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 up to the full amount of pressure in the reservoir. 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. Xow. 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. 26) for treating the ear- Fig. IS. — Davidson cut-off. the first impulse is expended in tilling the nasal and superior pharyn- geal cavities in addition to inflating the middle 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 Xo. 2 should be slowly opened until the needle indicates the number of pounds required. Xo 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 adapted to this purpose. 2 atmospheres, or about 30 pounds. Talve 1 bein°- 32 COMPRESSED-AIR APPLIANCES AND THEIR USES. opened, apply the cut-off to the nasal bulb containing the medicine on sponges; open the cut-off; turn on 10 pounds with wheel 2 and then close the cut-off. The needle rises. Now, if the inflator is in- serted 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 10. Close the cut-off and the needle mounts to 30 pounds. Open the cut-off at that moment and the needle descends again to 10; close the cut-off and the needle rises; the instant it touches the 30 pounds' mark open the cut-off again and so on; re- peatedly opening and closing the cut-off will give repeated impulses at any given pressure below that in the reservoir. 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 skill- fully 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 30 pounds' maximum pressure about 20 pounds should be allowed for the uninterrupted current. Experience with this method indicates that not more than 60 interruptions per minute should be made in order to produce per- ceptible vibratory movements of the drum-head and ossicles. The dose of air for ear treatment varies greatly in different in- dividuals. 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, we have often applied 60 or more pounds to old, thickened, and hardened drum-heads without rupturing them. It is evident that if it require 40 pounds in some cases to propel sprays into the middle ear, it follows that in such instances 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 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. 17) a little withdrawn from the mouth COMPRESSED- AIB APPLIANCES AXD TIIEIE USES. 33 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 Yolurne should he 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 membrana tympani by politzerization have been freely sounded. The author lias 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 caissons 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 owed to the fact that they are instructed to inflate 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. Xotwithstanding this, an eminent otologist has asserted that drum-heads have been lacerated by Po- litzers method. Professor Politzer says: "During thirteen years only fourteen 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 prob- ably be prevented by firmly pressing the tragus into the external meatus. As compared with the Yalsalvan method of autoinflation, the application of medicated nasal-tipped inflators as I have adapted them to the compressed-air apparatus makes an effective topical applica- tion of various medicaments possible without any active exertion on the part of the patient. In the Yalsalvan experiment there is no medication of the middle ears, but simply a mechanical effect of moderate pressure and a probable congestion resulting from the straining effort. A. Hartman has shown that 4 to 8 pounds' pressure by the Yalsalvan method is required to bulge forward a healthy drum-head. In numerous experiments the pressure averaged from 34 COMPRESSED-AIR APPLIANCES AND THEIR USES. 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 experi- ment often fails. The unwisdom of advising patients to practice the Valsalvan 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 instructions to excess. Politzers method is far preferable. He says: "The pressure 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 adap- tation 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, 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 irritation of the Eustachian orifices by the catheter. Gentle pressure will often accomplish this. Indeed, patients 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 increasing it, the permeability of the tube may be re-established by a weak air-pressure more easily than by a sudden, forcible current. In practicing this method we 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 closed nasal cavities become filled from the inflator the velum palati and base of the tongue press automatically upward and backward, completely closing the post-nasal space. When the effort to inflate the middle ears with air or lavolin jets alone fails, it can be made to succeed by placing 6 or 10 drops of sulphuric ether on 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 many instances in which the ears are more readily inflated during the act of swallowing. COMPRESSED-AIR APPLIANCES AND THEIR USES. 35 It has been suggested that these forcible air-currents might convey discharges into the mastoid cells, but 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 innator 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 inflation 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 practice is in Vienna. Proper precaution should be taken to prevent dust from enter- ing the air-reservoir, although by the author's methods all air enter- ing the ears is filtered and medicated. Finally, these methods make the middle ears nearly as access- ible as the nose and throat for treatment with the various volatile remedies and sprays. CHAPTEE IV. METHODS OF PRODUCING AND USING COMPRESSED AIR. For a considerable time the author has been using a new kind of instrument called a dilator in connection with the compressed-air receiver, and the results have been so satisfactory that he has intxo- Fig. 19. — Dilators and combined air-reservoir and hand-pump. duced it into all of his clinics. This instrument and process of admin- istering aeriform fluids, although used by a few physicians since 1888, appear to be little known. The dilator (Fig. 19) is not only different in construction, but (36) METHODS OF PRODUCING AND USING COMPRESSED AIR. 37 also in operation, from the various kinds of spray-producers or nebu- lizing 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 finely comminuted, 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 comparable to the most delicate un- dulating 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 discovered that medicines three or four times stronger than patients would tolerate from the ordinary atomizers could be thrown into the re- spiratory passages, and even into the middle ear, without evoking any disagreeable symptoms. Xo less pressure than 20 pounds or even 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, innate the middle ears, or to open op stenosed bronchioles and occluded air-cells. While a pressure of 20 pounds may be sufficient, no injury has followed the em- ployment of a much higher pressure, as the excess escapes from the lips. One of my assistants, A. H. Andrews, has devised a combined coarse-spray producer and nebulizer which requires less pressure than other atomizers (Fig. 131). It is similar to the dilator. The combined pump and receiver is a very practical, durable, and economical form of apparatus where the pumping must be done 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 the author before the section on Otology and Laryngology of the American Medical Asso- ciation at Detroit in 1892. Any spray-producer or inflator can be attached to the cut-off and employed in the usual manner. Ear Treatment. The dilator can sometimes be substituted for my improved middle-ear inflator for projecting medicaments into the ear. With the latter we never use a stronger solution of the camphor-menthol than 3 per cent., while with the dilator we have medicated the tvm- 38 EAE TREATMENT WITH COMPRESSED AIR. panic 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 politzerization. The cheeks are fully distended with air, and the current is turned on from the compressed-air reser- voir. The instant 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 produces not only inflation of the tube Fig. 20.— Compound hydraulic pump beneath the water-basin. and tympanum and motion in the ossicles and drum-head, but it medicates their mucous 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 necessary it is to employ a thorough medicinal as COMPRESSED-AIR APPARATUS. <59 well as mechanical treatment addressed to this section of the re- spiratory system; otherwise we cannot hope to effect a permanent improvement. In connection with the use of compressed air the question of air-pumps is an important one. In a city with water-works the com- pound hydraulic pump (Fig. .20) is effective, since it gives about double Fig. 21. — Single-acting' hydraulic pump. the amount of pressure obtained by the single-acting pump (Fig. 21). It requires to be cleaned and repaired occasionally, or it fails to afford the required pressure. The maximum of pressure to be had on a ground floor in Chicago, with a compound hydraulic pump, averages from 45 to 55 pounds, — an amount sufficient ordinarily for the aurist, for the air is constantly replenished. In the great modern 40 COMPRESSED-AIR APPARATUS. office buildings, compressed air is supplied to the tenants by means of Westinghoiise electric pumps, which are capable of affording any desirable pressure and quantity. In the country the surgeon must be satisfied with the hand-pumps (Fig. 22), 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 very convenient (Fig. 19). The Fig. 22. — Rotary air-pump. 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 efficient apparatus is manufactured by the Cleveland 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. 23). Below 30 pounds it operates to a nicety. Pressure above this point can be used nearly to the amount contained in the POLITZERIZATION. 41 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. Regarding all of these apparatus the author speaks from experience in their use. Politzerization. — The aurist who is not provided with a com- pressed-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. 24) is fitted with a nasal tip joined to the bag by eight inches of soft-rubber tube. One should also have Fig. 23. — Air-meter of improved pattern. a Buttle inrlator (Fig. 25) fitted with both 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. 26). The axis of the nasal bulb should be parallel to the plane of the floor of the nose. The object is to throw the column of air in the direction of the Eustachian orifice — not toward the nasal duct, through which the air is sometimes forced, nor toward the frontal sinus. The Politzer bag should be grasped with the larger end between the thumb and stronger fingers, so as to be able to exert the greatest 42 POLITZERIZATION. 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 im- Fig. 24. — Politzer's air-bag. portant 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. Fig. 25 — Buttle's inflator. Catheterization. — The soft-silver catheters are the best (Fig. 27). They can be easily bent to accommodate any irregularities in the nasal passages or in the vicinity of the Eustachian tubes. There are German silver catheters in our markets, but Albert H. Buck is CATHETERIZATION OF THE EUSTACHIAN TUBE. 43 very correctly opposed to their use. since they are far inferior to the pure silver or hard-rubber catheters. 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 skin- Fig. 26. — The author's improved inflator. It is provided with a tip to fit into the Eustachian catheter. 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 instru- ment enters the nose it must not be forgotten that the patient in- voluntarily moves his head backward. As soon as the beak touches the posterior 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 now be opposite the orifice of the tube. Then the hand is carried a little toward the median line, so as to bring the beak into the tubal opening (Figs. 28 and 145). "With practice one can determine when the catheter rests in r* Fig. 27. — Eustachian catheter. the tube by the sense of fixation imparted to the instrument. Dur- ing this manipulation the ring on the proximal end of the catheter will indicate the position of the concavity or the convexity of the distal extremity. Xo force need be used. In cases of certain deform- ities of the inferior turbinated bodies and of the septum the catheter 44 CATHETERIZATION OF THE EUSTACHIAN TUBE. must be rotated through forty-five or ninety degrees, or more, before it 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 Fig. 28. — Vertical section of the naso-pharynx with the catheter intro- duced into the Eustachian tube, a, inferior turbinated bone; b, middle turbinated bone; c, superior turbinated bone; d, hard palate; e, velum palati; f, posterior pharyngeal wall; g, Rosenmiiller's cavity; h, poste- rior lip of the orifice of the Eustachian tube. The frontal sinuses are shown above the line c. (After Politzer.) it is rarely necessary to resort to the catheter except for sclerosis. It is destined to pass out of vogue to a certain extent, for the reason that air, volatile medicaments, and even nuid-vaselin sprays can be successfully projected into the middle ears by means of the improved inflator (Fig. 26) adapted to the compressed-air apparatus. To the average patient this is a happy culmination of the inventor's efforts, for it averts positive suffering, the possibility of infection and Of irri- CATHETERIZATION OF THE EUSTACHIAN TUBE. 45 tative effects, and incidentally reduces the amount of skill required for treatment. It may be desirable to employ the catheter to inject liquids into the middle ear, or when the inflation must be limited to Fig. 29. — Fixation of the catheter with the left hand. Catheterization as it is practiced in Vienna. (After Politzer.) one ear, but even in the latter case we may generally accomplish this end with the improved inflator by closing the opposite ear with the patient's finger during inflation. However, we do not desire to be understood as having discarded entirely the use of the catheter after many years of experience with it. When occasion necessitates the use of the catheter (Fig. 29), the air-pressure must be greatly reduced, for, as Huntington Eichards ob- serves: "By it greater power is exerted, and it is more strictly limited Fig. 30. — Toynhee's auscnltation-tube. to a single ear." If more than 1 or 2 atmospheres (15 to 30 pounds) be used with the catheter-beak not properly adjusted, there is a pos- sibility of forcing the air into the submucous tissues and producing 46 AUSCULTATION OP THE EUSTACHIAN TUBE. a dangerous emphysema. We have never seen any such results from this cause, but three deaths are recorded. Thomas Faith has re- cently reported to me a case of emphysema of such character, with recovery. An aid in both diagnosis and treatment lies in Toynbee's aus- cultation-tube (Fig. 30). One end of the tube should terminate in a white tip and the other in a black one. 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 tym- pani, the resulting sound is conveyed along the continuous column of air in the patient's external canal, the rubber tube, and the sur- geons auditory meatus to his drum. It is not difficult, then, to dis- tinguish between the free, breezy puff of air through a patulous Eu- stachian tube and the high-pitched, squeaking sound occasioned by a stenosis. CHAPTER V. DISEASES OF THE EXTERNAL EAK. The Auricle. There are certain injuries and diseases of the auricle that are not properly classed as ear affections, the treatment of which is con- ducted on general principles sufficiently amplified in works on sur- gery. 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. — The symptoms of this condition are so familiar that a description would be superfluous. The chief object to be accom- plished is to prevent a sudden disturbance of the circulation in the skin, by insuring a very gradual return to the normal temperature. This is best secured by the application of continuous cold by means of snow inclosed in a handkerchief or by an ice-bag (Fig. 83) 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 described in general works that we may best confine ourselves to the subject of treatment. Eczema is usually associated with a chronic suppura- tive 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 dermatitis wherever they spread, even to the neck, side of the face, and head. So long as these dis- charges continue to bathe the skin, just so long will the treatment of the eczema prove unavailing. The ear must be so cleansed and (47) 48 LUPUS OF THE EAR. kept free from pus, by constant vigilance and the treatment out- lined 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 propor- tion of one-fourth or one-half carbolic ointment. This acts not only as an antiseptic, but as a grateful local anaesthetic also. Among the most prompt and effective remedies to relieve the pruritus are resinol and epidermol. 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 with absorbent cotton without any friction, and then covered with aristol or nosophen. Prompt drying and cicatrization follow. General treat- ment may be needed for an impoverished condition of the system, and, if so, Fowlers solution of arsenic is a valuable addition to in- ternal medication. Lupus. — Lupus vulgaris generally attacks the auricle second- arily to its existence in the face. Yet Ave have seen it confined to the auricle and external canal following, like eczema, a chronic suppura- tion 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 cic- atrices, which, in turn, may break out later. Lupus exulcerans ap- pears 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 in the early stages, 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, of a lawyer and prominent politician of 60 years, was secondary to a chronic suppura- tion of the middle ear. After stopping the suppuration the ulcers in the meatus and on the auricle healed under aristol. After three years, GANGRENE OF THE EAR. 49 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 gal- vanocautery, nitrate-of-silver stick, acetic acid, etc., under cocaine anaesthesia, and the wound is dressed with aristol or iodoform cov- ered with dry iodoform gauze. The prognosis must be guarded, on account of the strong tendency to recurrence. Fig. 31. — Gangrene of the ear; mastoid operation. Gangrene. — Gangrene of the auricle is a very rare disease. It may arise without any assignable cause; but any condition that viti- ates the blood and lowers the vitality and powers of resistance in the presence of a local exciting cause, such as intense cold, pressure, acrid discharges, burns, destructive chemicals, etc., predisposes to this necrotic process. The author has seen one case only. This applied at his clinic at the Illinois Medical College with the following his- tory: A boy, 2 years old, had been an inmate of an orphan-asylum 50 CARCINOMA OF THE EAR. five months. Two months before we saw him a suppuration of the right ear began. Five clays before he was admitted to the hospital 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. 31). 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 applied to stimulate the circulation until the necrotic tissue separates from the healthy; otherwise operative measures as indicated above are called for. Carcinoma. — This more frequently arises on the auricle or in the external meatus than in the middle ear or mastoid process. It begins with a sensation of irritation or itching, which the patient increases by persistent efforts to 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 the lupus exulcerans the ulcer is deep, excoriating, and penetrating, in carcinoma the ulcerating surface is raised above the surrounding tissues, exuberant granulations often projecting to a con- siderable degree. If the lateral cervical glands become infiltrated the diagnosis is more certain, but they are slow to participate. The ulceration may extend to the tympanic cavity, labyrinth, and cranial cavity, producing facial paralysis, haemorrhages, menin- gitis, brain-abscess, or thrombosis, and, after great suffering, death. The treatment consists in complete extirpation of the diseased tissue when possible, the knife penetrating beyond the disease into the sur- rounding healthy tissue. If the auricle is extensively involved it should be amputated, and if 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 possibly preserve its patency, which is important on account of the hearing. After-treat- ment is the same as for lupus. For treatment with alcoholic injec- tions see treatment of carcinoma of the pharynx. Perichondritis. — This is not a frequent disease, but early treat- ment 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- BLOOD-TUMOR OF THE AURICLE. 51 red surface, accompanied by heat and pain. We 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 an ice-bag (Fig. 83). If there is great swelling with fluctuation it must be incised, the fluid pressed out, and the cavity irrigated with antiseptic solutions. AYe have obtained the best results from inject- ing equal parts of tincture of iodine and water or alcohol, and apply- ing pressure with cotton and a bandage. Hsematoma. — 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 resti- form body in animals is followed by this disease. The appearance of the tumor is accompanied by heat and pain. It nearly always oc- cupies the anterior aspect of the auricle, and may cover a large por- tion 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. Dur- ing the first, or inflammatory, stage, when there are heat and pain, the constant application of cold is indicated (Fig. 83). If an ice-bag is not obtainable, a bladder can be filled with ice or snow as a sub- stitute. If the swelling does not diminish, it must be incised, in one of the natural folds to prevent disfiguration, and emptied of its con- tents. Most satisfactory results have followed washing out the cavity with a 5-per-cent. aqueous solution of carbolic acid, insufflating with aristol, and binding it with an absorbent-cotton compress. Eandall opens the sac, curettes it, rubs with iodine glycerite, packs with iodo- form gauze, and covers it with a 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. The author has seen many cases of deformities, ruptured drum-heads, abscesses, and deaf- ness resulting from this inhuman habit. Cystoma. — Cystoma is a tumefaction usually found on the ante- rior 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 52 DEFORMITIES OF THE AURICLE. suddenly from an unknown cause, without a previous injury or in- flammation. The treatment is the same as for hematoma, — incision,, etc. Intertrigo. — xAn excoriated condition of the skin on the adjoin- ing surfaces of the auricle and mastoid process is of frequent occur- rence among children of the poor. It may be due to an impoverished condition of the blood, but is more likely to be caused by uncleanli- ness 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 ingrafted 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 suffi- cient. The binding caps must be interdicted and the irritated sur- faces kept apart. Miscellaneous. — Herpes, pemphigus, and syphilis of the auricle are very infrequent lesions that differ in no way from the same affec- tions 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. DEFORMITIES OF THE AURICLE. Arrested and excessive development of the auricle in relation to^ degeneration have been 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. Talbot's illustrated article, from which Fig. 32 is taken, may be found in the Journal of the American Medical Association for January 11,. 1896. Auricular deformities may be divided for convenience into con- genital and acquired. Congenital deformities may be classified as correctable and irremediable. Acquired deformities fall under two headings: those resulting from disease and those from injuries. Hypertrophied Auricle. — The most common defect is the large, flattened, wing-like ear that stands out conspicuously from the side of the head (Fig. 32). This ear-mark serves as a butt of jest for the child's companions, and makes life a burden to the bearer. Its ex- aggerated prominence suggests its prototype among the lower animals,. HYPEKTEOPHIED AURICLE. 53 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 bar- barous mode of petty punishment — pulling the ears — may account for a certain amount of this deformity. We have been led to this conclusion by information elicited in many instances. The pressure produced by the tight caps so much in vogue with some people may be a factor. The treatment is operative. The author has proceeded in two ways: by reducing the actual size of the auricle, and by effecting a Fig. 32. — Hypertrophied auricle. 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 the corresponding 'integument on the posterior surface and bringing the edges of the wound 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 anterior 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, antiseptic gauze, and the net bandage. This bandage is made of white mosquito-netting, moistened through just before applying, and it dries in place somewhat like the plaster band- age. 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 54: SCEOLL-EAK AND ASSOCIATED DEFORMITIES. 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 approxi- mated and sutured with the stitches close together and penetrating the subcutaneous 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 we have been able to learn, this method of operating had not been practiced previously to its intro- duction by the author. Scroll-ear and Associated Deformities. — There is a deformity of the auricle in which the border of the helix turns forward and down- ward 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 illus- trate, we will cite one of the cases reported by the writer to 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 rudi- mentary 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 corresponds to the key-stone of an arch. It is interesting to note, in this connection, that the mother at- tributed 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 cul-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 us to believe that the child ANOMALIES OF THE EXTERNAL EAR. OD 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, we found nothing but a depression in the bone. Xo bony canal could be found, and it did not appear that further operative in- terference would be justifiable. However, a sufficient opening was maintained to give quite a respectable appearance of an external meatus. Virchow^s Archives says: "Congenital anomalies of the 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 fistulas of the other branchial clefts, cleft palate, and other forms of arrest of development in the facial bones, — as, for instance, with uni- lateral atrophy of the face." Certain acquired deformities have already been noticed in con- nection with the diseases that produce them, — perichondritis, etc. Treatment can hardly avail to remedy them. Those resulting from injuries must be treated on general surgical principles, with care to prevent any closure of the auditory canal. The latter subject will be presented in the following chapter. CHAPTEK VI. DISEASES OF THE EXTERNAL AUDITORY CAXAL. 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 provo- cative of other pathological manifestations. Eecurring 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 impacted. 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 outward; but, when the mouth of the canal is very narrow and when exostosis or other mechanical obstructions occur, they prevent the out- ward movement of the secretion, and it stops up the canal effectually. Patients often contribute to this impacting process by their efforts to cleanse the canal with towels, etc., at the bath. The middle ear may not be involved in the diseased process, or both parts may participate in trophoneurotic changes due to central causes. There may be, moreover, a simple desquamative inflammation with an abundant ex- foliation of the epidermis. In these cases the ceruminous plugs con- sist of the fatty secretion, epithelial scales, hairs, etc., which are often horn-like in their hardness. Symptomatology. — The hearing may not be perceptibly dimin- ished, 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 by the patient until his friends call his atten- tion to it. Tinnitus aurium often occurs, and, with complete blocking of the canal, intense subjective noises; autophony, or a hollow sound of 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 (56) INSPISSATED AXD IMPACTED CERUMEN. J. 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 for- eign body, works inward until it impinges upon the drum-head, caus- ing perforation or intralabyrinthal pressure, vertigo, and epilepti- form 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 suppurative 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 presence 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 the plug and (2) in remedies addressed to any pathological condi- tion revealed by its extraction. If one is adept in the manipulation of ear instruments he can dextrously pull out the plug with the little lever found in the middle-ear set of instruments (Fig. 70). 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 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 touch the drum-head or produce any abrasion of the canal-wall with the lever. Those avIio 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 un- der the name of ear-syringes are of no account whatever for this pur- pose. The hard-rubber piston syringe is made for the ear with a 58 DIFFUSE INFLAMMATION OF THE EXTERNAL MEATUS. 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, exert- ing undue pressure on the drum-membrane or even rupturing it. The Davidson alpha or omega syringe (Fig. 33) has proved even more effective than the fountain-irrigator. The stream should be thrown so as to enter any space that may be seen between the canal-wall and the cerumen, rather than against the centre of the plug. As 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 facilitated by preceding the use of the syringe with an instilla- tion of a 4-per-cent. solution of bicarbonate of sodium in glycerin Fig. 33. — Alpha syringe. and water, equal parts. The ear should be filled with this fluid warmed, several times during the clay, 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 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 con- fined either to the osseous or to the cartilaginous portion. 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. DIFFUSE INFLAMMATION OF THE EXTERNAL MEATUS. 59 Pathology. — If seen early the canal-wall presents a bright-red and smooth aspect. When the inflammation becomes intense and in- filtration of the integument causes it to swell, the lumen of the canal is so encroached upon as to make an examination of the drum-mem- brane 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, matches, 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 ex- citing causes. Symptomatology. — In the first stage, or hyperemia, there may be no pain or impairment of function, and the patient remains un- conscious of any unusual condition except for the itching. His at- tempts to relieve this only serve to increase the irritation, and, as the disease progresses, pain of a severe character is developed. The move- ments of the jaw and pressure about the ear aggravate the pain. With the occurrence of profuse transudation the hearing is dulled, and tinnitus and even vertigo may ensue. The more copious the exudation, the 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 stenosis 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 micro- cocci and vegetable fungi may clear up the diagnosis. Prognosis. — This depends upon the extent of the inflammatory process. It may invade the tympanic cavity and produce 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 inflammation is very active and painful and the stenosis complete, an ice-bag (Fig. 83) should be applied. Ab- 60 FURTJJs"CULOSIS. 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 a small powder-blower (Fig. 34). If this does not stop the secretion in a few days, nosophen or the fine boric powder should be substituted. FURUNCULOSIS. Synonyms. — Furuncle; boil; follicular or circumscribed inflam- mation of the external meatus. Pathology. — Furuncles are mostly limited to the cartilaginous portion, and most frequently to the posterior or anterior wall of the Fig. 34. — Author's small powder-blower for the ear. It can be operated by a small rubber bulb also. auditory canal. Although they may be secondary to a middle-ear inflammation, they are frequently idiopathic in character. Furuncles appear singly, in groups, or in successive crops, and probably are due to the staphylococcus pyogenes, aureus, and albus 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, matches, discharges from the tympanic cavity, too frequent syringing, and vegetable para- sites. The same may be said of a general impairment of health, dia- betes, 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 FURU2n t CUL0SIS. 61 a throbbing character, and, as the swelling increases, impaired hear- ing and subjective noises. The pain becomes intense for a day or two and subsides on the rupturing 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 may become 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. Occasion- ally 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 gen- eral systemic disturbance. Diagnosis. — This is not difficult on careful inspection with brill- iant illumination. This disease is not likely to be confounded with any other, when we consider the prominent symptoms. The boils 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 im- paired, 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, if there be any, for which bromidia internally and cocaine locally are effective, the former in teaspoonful doses in water every half-hour or hour for an adult until pain ceases, and the latter in a very warm, 10-per-cent. solution. As soon as the pain is relieved we should cleanse the meatus with hydrozone (dioxide of hydrogen, or peroxide) comfortably warm. It can be warmed to a little above blood-heat (105° F.) without im- pairing its effectiveness. Its effervescent action washes out the canaL and its bactericidal property strikes at the root of the trouble. After cleansing, a 20-per-cent. solution of camphor-menthol on cotton ex- erts a comforting and curative influence. It is to some degree a local anaesthetic, antiseptic, 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 a cotton tampon. As soon as a point of 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. After once thoroughly cleansing the canal, it is important to keep the skin as dry as pos- sible in and around the meatus, on the same principle that guides us 62 PARASITIC INFLAMMATION OF THE EXTERNAL MEATUS. in the treatment of suppuration of the middle ear. Thomas Barr has obtained marked benefit from the ointment containing 4 grains of iodoform or boracic acid, and 2 grains of menthol in a drachm of vaselin. This is smeared on cotton pledgets and placed so as to pro- duce a little pressure on the boil, but the plugs should be changed as often as the accumulation of the discharge requires. 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 ointment. Proper treatment is addressed to the general health. Sulphide of calcium is credited with the power of aborting or modifying the disease. Parasitic Inflammation of the External Meatus. Synonyms. — Mycosis; otomycosis; mycomyringitis; aspergillus; 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- Bur- nett's exhaustive work. The most frequent varieties are the dark- brown aspergillus, or nigricans; the yellow, or navescens; the green, or glaucus; and the grayish black, or fumigatis. When these para- sites once find lodgment in the ear they multiply rapidly. This usu- ally 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 condition is generally one of complete covering of the drum-mem- brane and meatus with the mold. On removing the growth, which I have peeled 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 para- sites. 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 in- flammation supervenes decisive symptoms develop. At first there is only an itching or irritation or feeling of fullness, followed by pain, subjective noises, and diminished hearing. In my experience there PARASITIC INFLAMMATION OF THE EXTERNAL MEATUS. Go is rarely a discharge except when the disease is secondary to a suppu- ration of the tympanic cavity; but if the inflammatory action is severe a serous exudation occurs. Inspection shows in the black variety what is easily mistaken for a long-standing plug of inspissated ceru- men 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 con- siderable time and care in removing. After their removal there was revealed not only the characteristic inflammatory condition, but an enormous distension of the meatus, due to pressure and the absorption of the canal-Y\ T alls. Diagnosis. — Having the appearances described in mind, this is not difficult under good illumination, but a microscopical examina- tion will set all doubts at rest. Prognosis. — This disease is rapidly amenable to the following method of treatment, a few days or weeks, at most, effecting a cure. Treatment. — The ear should be syringed with a quite warm solu- tion 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 hydrozone (dioxide of hydro- gen, peroxide, H 2 2 ). This is left as long as it effervesces, then re- moved, and the canal is gently dried with absorbent cotton. Xow the meatus is filled with a 12-per-cent. solution of carbolic acid in glycerin for ten minutes; then this is removed and a saturated solu- tion of iodoform in alcohol is substituted. The carbolic acid does not corrode the tissues in this combination, but acts as an antiseptic, be- sides 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 treat- 64 DEFORMITIES OF THE EXTERNAL AUDITORY CANAL. ment on the following or second day. Should there be a considerable exudation 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 ex- ternal meatus are so rare that we will not enter into their considera- tion 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 auditory meatus, — two traumatic and two congenital. In the two congenital cases no external canal could be demonstrated. One of the traumatic cases Mas 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 the author made a new canal, maintained its patency by means of a hard-rubber tube, and succeeded in restoring the useful- ness of the organ. The other traumatic case was a man 32 years of age. It was caused by a wagon-wheel severing the auricle irom the head when the patient was 3 years old. The same error was com- mitted 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 ad- vised. 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 my rec- ords, embracing more than 21,000 cases of diseases of the ear, we found but 1 case of closure from exostosis, 3 cases of congenital ab- sence of the meatus, and 3 of traumatic closure. There were numer- ous cases of narrowing, and various irregularities of the canal, from causes that are not uncommon. foreign bodies in the external auditory canal. 65 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 com- panions' 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 symptoms that made their presence known. Sir William Bartlett Dalby found a piece of slate-pencil that had been in the ear for 30 years, and a stone that had been there for over 50 years. Xotwithstanding this, a foreign body is a menace to the integrity of the hearing organ so long as it remains in the canal. It may at any time set up an inflammation either by mechanical irritation or, if it be an organic substance, by swelling and by decomposition. Fig. 35. — Ear-forceps. 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. Insects, if alive, should either be immediately picked out with the delicate forceps (Fig. 35) 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, contained 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 66 FOREIGN BODIES IN THE EXTERNAL AUDITORY CANAL. expulsion. Tliey 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. The author has 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. D. B. St. John Eoosa and Albert H. Buck report similar cases. Eoosa removed a shot from the middle ear, and Buck extracted a hard locust bean by means of the same operation. Extreme care should be exercised, in efforts to remove foreign bodies, not to injure either the canal or drum-head and ossicles. We have seen numerous instances in which unskillful practitioners had mutilated the canal-walls and drum-membranes, 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 fre- quently necessary to assure anxious parents that they and their chil- dren 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. PLATE 1. PLATE I. Fig. 1.— Normal membrana tympani of the right side, showing the incudo-stapedial joint. Fig. 2.— Hypersemia of the right tympanic membrane. Slight injection of the vessels run- ning alongside of the hammer. Injection of the radiating vessels of the posterior segment, in a case of otitis media acuta. Duration. 9 days ; female patient ; age, 87 years. Fig. 8.— Injection of the radiating blood-vessels of the left tympanic membrane in a state of retrogression. A case of acute otitis media of ten days' standing ; female patient ; age, 45. Fig. 4.— Myringitis bullosa, showing formation of a blister the size of a hemp-seed, situ- ated behind the umbo ; second day of the disease ; male patient ; age, 19. Fig. 5. — Myringitis granulosa with extensive formation of sharply-defined wart-like eleva- tions or excrescences on the lower segment of the tympanic membrane. Numerous punctiform light-reflections appear on the granular surface. Duration, 6 months; age, 25. Completely cured after several applications of liquor ferri sesquichlorati. Fig. 6.— Myringitis granulosa chronica, the granulations covering nearly the entire tym- panic membrane. Duration unknown ; female ; age, 2(5. Fig. 7.— Catarrh of the middle ear, with secretion of an intensely-yellow color in the lower portion of the tympanum, and bulging of the lower segment of the drum-head. Duration, 2 weeks ; for four days there had been a marked injection of the vessels surrounding the handle of the hammer and those supplying the upper segment of the membrane. Acoumeter heard only on contact; conversational voice close to the ear. Age, 15. Fig. 8.— Secretive middle-ear catarrh, with great retraction of the tympanic membrane, which is of a yellowish-gray color. The posterior fold of the membrane is extremely prominent, and the lateral and middle folds of Shrapnell's membrane are well defined. Duration, 14 days ; age, 28. Fig. 9. — Chronic middle-ear catarrh. Retraction of the tympanic membrane, the hammer being invisible owing to the great prominence of the posterior fold, which describes a curve extend- ing from the short process above and in front and terminating below and posteriorly in the lower segment of the membrane. Fig. 10.— Chronic catarrh of the middle ear with cretaceous deposit in the drum-head, anterior to the hammer-handle. Fig. 11.— Two crescentic deposits of chalk embracing the handle of the malleus. Great im- pairment of hearing associated with continuous subjective noises in the ear. Duration more than 6 months ; female ; age, 18. Fig. 12.— Crescentic chalk deposit enveloping the umbo, or the deep concavity correspond- ing to the inferior extremity of the malleus. Fig. 13.— Acute suppurative inflammation of the middle ear. Tympanic membrane of a red color and covered with a thin layer of exudation. A round perforation in the lower segment. Otorrhoea is said to have developed one hour after the painful symptoms began. Duration, 14 days ; age, 39. FrG. 14. — Acute suppurative inflammation of the middle ear, tubercular. Anterior half of the drum-head is deeply injected, the posterior segment has a pale-gray color. Behind the malleus are two small tubercular "excrescences, a capillary blood-vessel crossing them from above. Two minute punctiform perforations above the tubercles. Duration, 5 days ; age, 25. Fig. 15. — Acute suppurative inflammation of the middle ear. Drum-head is yellowish gray, the external layer of the membrane appearing quite loose. Processus brevis scarcely visible. Beneath the umbo is a minute perforation. Duration, 12 days ; age, 33. Fig. 16.— Chronic suppurative inflammation of the middle ear. Oval perforation in the an- terior, inferior quadrant of the drum-head ; round perforation in Shrapnell's membrane. The ex- ternal layer of the remaining portion of the membrane is quite loose and of a gray color. Duration of the discharge from the ear was 2 years ; age, 28. Fig. 17— Chronic suppurative inflammation of the middle ear ; round perforation in the superior segment of the drum-head. The mucous membrane of the tympanic cavity is of a dark- red color, and the drum-head of a light-gray color. The short process is visible. Age,*ll. Fig. 18. — Chronic suppurative inflammation of the middle ear. Large defect of the pos- terior half of the drum-head. The mucous membrane covering the promontory is dark red and shining; the remaining portion of the membrane is grayish red. The handle of the hammer is hardly visible. In the upper portion of the perforation the round head of the stapes can be seen. Duration, 1U years; age, 41. Fig. 19. — Chronic suppurative inflammation of the middle ear, with extensive destruction of the membrana tympani. Toward the periphery is the narrow, grayish-Avhite remnant of the membrane. The mucous membrane of the inner wall of the tympanum is deeply red and swollen. The handle of the mallet occupies its normal position, hanging free in the perforation. Disease continued from childhood ; age, 22. Fig. 20.— Chronic suppurative inflammation of the middle ear ; very large perforation of the drum-head ; 'remaining portion grayish yellow and thickened ; somewhat bulging on account of a dark-red polypoid growth in the region of the promontory. Short process is barely visible. Duration, 10 years' ; female ; age, 29. Fig. 21. — Dry perforation below the umbo, the size of a pin-head ; blood-vessels around the handle of the hammer are much injected. The drum-head is grayish red. In front and behind the malleus are crescentic, serrated deposits of chalk. Duration, since childhood ; age, 41. Fig. 22.— Cicatricial adhesion of the.drum-bead to the inner wall of the tympanum. The membrane is retracted behind the malleus and attached to the incudo-stapedial joint. The an- terior portion of the drum-head, also, is retracted and attached to the inner wall of the middle ear. The unusually prominent handle of the mallet becomes less prominent as it extends downward toward the promontory, which is covered by scar-tissue. Duration unknown ; age, 28. Fig. 23.— Defect of the drum-head, only a small portion remaining, which is connected with the retracted handle of the mallet. The inner tympanic wall is of a grayish color. In front of the opening leading to the Eustachian tube a membranous septum is stretched, with a minute per- foration. Duration. 15 years ; female ; ajre. 56. Fig. 24 —Destruction of Shrapnell's membrane ; large bonv defect of the outer wall of the attic, through which the disarticulated head of the hammer is visible. The incus is missing. The tympanic membrane is opaque and marked by a sharp, white border toward the defect. Duration, 20 years ; female ; age, 30. Reproduced, by permission, from the "Atlas der Beleuchtun^sbilder des Trommel fells in gesunden iind in Kranken Znstande." Fourteen plates, 390 drawings, von Prof. A. Politzer. Wien bei Braumuller & Sohn. PLATE > *l € £ 1 2 3 1 " » # • ^ i^ 5 6 7 8 & 1 •"] 9 10 • • 1 1 9 12 # # 13 14 15 16 W 1 ^ # 17 18 19 20 21 22 23 24 CHAPTEE VII. DISEASES OF THE MIDDLE EAR. Injuries of the Dbeai-head. The drum-head is occasionally ruptured by blows (Fig. 36), ex- plosions, concussions from fire-arms, the pushing of pencils or straws into the ear. or by pulling the ears of children. Gorham Bacon says that during the laying of the foundations of the Brooklyn bridge many of the men working in the caisson suffered from rupture of the drum-head: but A. H. Smith, the medical officer in charge of the Fig. 36. — Rupture of the anterior-inferior segment of the drum-head caused by a box on the ear. (After Politzer.) men, belieyed that, in all those who suffered from an aural affection after working in the caisson, there already existed some obstruction to the entrance of air through the Eustachian tubes. The mere rupt- ure of the membrane is not usually of very serious import, for it will probably close in a few days without treatment: but concussions or wounds may penetrate sufficiently to affect seriously the middle or internal ear. If no inflammation follow such accidents, the perfora- tion itself requires no treatment further than to protect it from the air-currents by a light pledget of sterilized cotton. The consequent affections are treated in their proper classifications. (67) 68 inflammation of the membrana tympani. Inflammation of the Drum-head. Synonym. — Myringitis. Pathology. — Myringitis is of frequent occurrence and generally begins with an injection of the malleal plexus of vessels. At first they can be distinctly seen like minute red threads extending down- ward along the hammer-handle, but as the hyperemia increases they appear to coalesce until there is an even diffusion of redness envelop- ing the handle and overspreading the membrana Shrapnelli (Fig. 12) like an intense blush. This condition may co-exist with a dermatitis of the superior integumentary wall of the external meatus. In these eases one cannot discern any line of demarkation between the lining Fig. 37. — Section through the tympanic membrane, malleus, and upper and outer tympanic wall of a decalcified preparation. Is, ligament, mall, sup.; le, ligament, mall, ext.; s, membrana Shrapnelli; o, Prussak's space; r, system of cavities between the body of the malleus and incus and the external tympanic wall; t, tendon of the muse. tens. tymp. (After Politzer. ) of the wall and the drum-membrane. I remember to have seen an abscess in the drum-head of a violinist, located in the region of Prus- sak's space (Fig. 37). The hook-knife (Fig. 70) was introduced from above and brought downward and outward, dividing the external wall, thus laying the little abscess-walls open to view. Occasionally haemor- rhagic effusions are seen, but the blisters described by Politzer we have rarely observed. When the inflammation extends over the whole area of the membrane it assumes a cherry-red color, shining at first, swollen and dusky after serous infiltration takes place (Plate I). EUSTACHIAN TUBAL CATARRH. 69 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. t 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, ac- companied 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 in the absence of pain this is not difficult, for the symptoms are not indicative of middle-ear inflam- mation 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 tube is usually in- volved, a rapid serous exudation takes place, and swelling of the mem- brane, with marked impairment of hearing. All the symptoms are characteristic of a more profound disturbance. After the inflamma- tion 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-mem- brane. Then the ear is closed with cotton to retain it for twenty- four hours. In severe pain an 8-per-cent. solution of cocaine or eucaine, quite warm, gives relief used in the same manner. Xo other treatment is necessary except for complications or after-effects of the disease. Eustachian Tubal Catarrh, or Salpingitis. Pathology. — In Eustachian salpingitis the mucous membrane lining the tube may be simply hyperasmic or highly inflamed. Since it is lined with a continuation of the same mucous lining as that of the naso-pharynx, on the one hand, and of the tympanic cavity, on the other (Fig. 38), any inflammatory action in one is likely to spread along the membrane to another part, just as an erysipelatous inflam- mation 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 mucous membrane alone may be affected, with only 70 EUSTACHIAN TUBAL CATARRH. slight swelling and diminishing of its calibre; but in a severer grade the submucous layer becomes involved, transudation, of the fluid ele- ments of the blood takes place, and great swelling and stenosis or com- plete closure of the tube occur. As a result of the latter condition, new connective-tissue formation may make the narrowing or im- perviousness of the tube permanent, Both the inflammation and the constriction are mostly confined to the cartilaginous part of the tube, g h i ct Fig. 38.— Eustachian tube and tympanic cavity, a, membrana tym- pani; b, head of the malleus; c, lower end of the handle of the malleus; d, body of the incus; e, short process of the incus; f, tensor tympani; g, orifice of the Eustachian tube; h, isthmus of the tube; i, tympanic mouth of the tube. (After Politzer.) and the connective-tissue strictures to the middle of this portion. Granulations sometimes result from the inflammation. Etiology. — Tubal catarrh is rarely an idiopathic disease, but re- sults 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 TREATMENT OF EUSTACHIAN TUBAL CATARRH. 71 blow, or irritating fluids in the naso-pharynx may act as causes. The presence of hypertrophied oral or pharyngeal tonsils, or of adenoid vegetations in the vault of the pharynx, which are the seat of fre- quently-recurring attacks of inflammation, predisposes to the disease. Moreover, they form a nidus for pathogenic bacteria. Symptomatology. — In light attacks there are only slight deafness and subjective noises, which increase with the severity of the inflam- mation. 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 high-pitched, squeaking noise during politzeriza- tion, 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 connective-tissue growth. In the latter the noise may be wanting. 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 ven- tilation by the tube. The lower extremity of the mallet may lie close to the inner wall of the cavity, giving the hammer-handle a fore- shortened appearance, and causing the short process to project out- ward prominently toward the examiner's 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 is con- firmed. 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 predisposing causes. The most immediate relief is afforded the patient if we can at once inflate the middle ear. This restores the normal hearing, re- lieves the tension of 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. Politzeriza- 72 TREATMENT OF EUSTACHIAN TUBAL CATARRH. tion is, by far, preferable, at first with air alone, to gently and gradu- ally fill the tympanic cavity and restore the drum-head to its normal position. Too sudden inflation in this state may cause distress, ver- tigo, and nausea by the disturbance of the intralabyrinthal fluid. The tube being opened, it is my practice to inject with the improved inflator (Fig. 26) either pure lavolin — a purified non-irritating fluid vaselin — or a weak solution of camphor-menthol in lavolin, 3 per cent. The former is bland and emollient, as well as protective to the in- flamed membrane. The latter relieves the pain, constricts the capil- lary 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 com- pressed-air reservoir and while the patient swallows, this will, in most cases, reach the middle ear. There is not sutficient 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 observers con- cerning tubal affections. We have rarely met cases of constriction that we were 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 com- pound pumps, Westinghouse air-pumps, or some other device sup- plying at least three or four times the amount of force obtainable from the rubber air-bags. But the amount of pressure is regulated 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 two cases in which it required as long as three weeks of treatment without the bougie to effect this result. One was in a chronic catarrhal condition with connective-tissue strict- ure, but the result was satisfactory. The other required the bougie. ACUTE INFLAMMATION OF THE MIDDLE EAR. 73 A. B. Duel reports excellent results from electrolysis for stenosis (The Laryngoscope, February. 1898). The second indication for treatment is the reduction 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 sections, we will not repeat here. Acute Inflammation of the Middle Eae. Synonyms. — Otitis media acuta: acute tympanitis. Pathology. — Otitis media acuta presents at first a glow of red- ness 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 gen- erally 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 effusion 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 in- fluenza 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 blow- ing in the ear. getting wet. bathing, influenza, cauterizing the nose and throat, pouring or sniffing cold fluids into the nose, and the en- trance of soap and water into the auditory meatus are prolific causes. It is more common to childhood than adult life. F. C. Hotz believes that malarial poison is sometimes a cause. Symptomatology. — Sensations of itching in the ear sometimes 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. Espe- cially is this the case in children, who are thrown into a fever, de- lirium, 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 74 ACUTE INFLAMMATION OF THE MIDDLE EAR. in the corresponding 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 partici- pates in the disturbance to the extent of becoming hyperamiic, in which case subjective sounds become intense and even rhythmic, vary- ing synchronously with the heart's pulsations. It is not unusual to meet with a mild type of this disease in which all the symptoms are diminished in intensity and some are absent. Before the exudation occurs the hearing may show no impairment, but afterward it de- creases 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* 7 Fig. 39. — Radiate vascular injection of the drum- head. (After Politzer.) (Fig. 39), Plate I. The malleal plexus of vessels is injected with blood; their tracery along the upper region of the hammer-handle is distinctly made out; a red areola shows about the processus brevis, and later a glow of redness covers the membrana naccida. As the inflammation progresses the red appearance 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 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 out- ward, and the radiate traceries of the injected vessels show like the spokes of a wheel (Fig. 40). As the inflammation subsides the redness of the drum-head fades TREATMENT OF ACUTE IXFLAMWATIOX OF THE MIDDLE EAR. , 5 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 lustreless, 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 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 hear- ing after effusion, the general symptoms, and their duration are de- cisive. Children work at the affected ear, press it against warm ob- jects, or incline the head to the diseased side. Prognosis. — The tendency is to resolution in healthy patients Fig. 40. — Eadiate. vascular appearance in acute inrlanmiation of the middle ear. (After Politzer.) under favoring circumstances. In the opposite condition the tend- ency is either to suppuration and perforation of the drum-head or to a chronic dry catarrhal state. Treatment. — In the first stage, or before the serous effusion has taken place or the pain has become severe, gentle inflation and filling the ear-canal with warmed pure, or carbolated, vaselin will suffice to give relief. TThen 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 8-per-cent. solution of cocaine or eucaine may be instilled into the ear, and, if deemed necessary, 1 / 8 grain of morphia can be given in combination with V 400 grain of 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 76 TREATMENT OF ACUTE INFLAMMATION OF THE MIDDLE EAR. until relief is obtained. Then it must be discontinued. The bowels and general health should receive proper attention. We 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 can- not 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 bot- tle is removed and the leech allowed to fill and drop off. This man- ner of applying leeches is given because few seem to be conversant 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 inflammation 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 drawn 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 common practice indulged in by the laity of pouring oils, onion-juice, etc., into the ear is a vicious one, since these become rancid and irritating and predispose to a subsequent inflammation. Poultices are also mischievous and favor suppuration and perfora- tion of the drum-membrane. The author has seen the following sim- ple device, always convenient, give grateful relief: A piece of clean cotton is placed lightly in the mouth of the canal. A pipe is partly filled with tobacco and lighted. Then a piece of thin 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 grate- ful sedative effect is soon obtained. I do not remember to have seen this remedy mentioned, but its efficacy in the absence of other reme- dies has been demonstrated. Fever calls for antipyrin or its equivalent in some febrifuge that is less of a cardiac depressant. Phenacetin and acetanilid act well. Quinine, the enemy of the ear, must not be used. It aggravates the existing hyperemia and conduces to permanent deafness. Alcoholic TREATMENT OF ACUTE INFLAMMATION OF THE MIDDLE EAR. , i drinks and smoking are prohibited, and any inflammatory condition of the respiratory tract must he vigorously combated. If the pain and bulging of the drum-head continue, notwith- standing all efforts to counteract the disease, and rupture of the mem- brane is threatened, it should be incised with the paracentesis-knife (Fig. 57, Xo. 2), in the postero-inl'erior quadrant, so as to afford the most perfect drainage. A warm, 8-per-cent. solution of cocaine or eucaine should be left in the ear for twenty minutes before the para- centesis, 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 relief. The incision should be a long one, cutting through the entire area of the postero-inferior quadrant ver- tically. The longer it is, the more it relieves the tension of the nerves of the membrane and the freer the drainage. 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 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 accom- plish it. The air-pressure in the tympanic cavity promotes absorption of any fluid contents and will likely improve the hearing. This treat- ment is administered daily for a few days. As improvement progresses the treatments can be given at greater intervals until the normal con- dition is established. Diet, exercise, and clothing should be regulated on general hy- gienic principles. CHAPTER VIII. DISEASES OF THE MIDDLE EAE, CONTINUED. Acute Suppurative Inflammation of the Middle Ear. Synonyms. — Otitis media acuta suppurativa; acute suppurative tympanitis. Pathology. — The tissue changes already set forth in the descrip- tion of acute inflammation of the middle ear take place in the affec- tion now under consideration previously to pus formation. In the suppurative form the inflammatory action is more intense; the tis- sues break down; the drum-head bulges with the pressure of the Fig. 41. — Convexity of the drum-head due to pressure from within. (After Politzer.) accumulated fluids (Fig. 41), becomes softened, and, yielding to the consequent pressure, ruptures. The whole tympanic cavity becomes involved, and the purulent discharge may find its way into the mas- toid 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 (78) ACUTE SUPPURATIVE INFLAMMATION OF THE MIDDLE EAR. 7b) in pneumonia. Streptococci or pnemnoeocci are usually found in acute suppuration, followed by the staphylococci pyogenes. 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 in- flammation 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 chil- dren are so violently affected as to suggest meningeal or brain com- plication. In diseases that simulate intracranial affections the phy- sician should never fail to examine the ears. Diagnosis. — Before perforation takes place it may be impossible to differentiate between a simple acute inflammation with serous ex- udation into the tympanic cavity and a suppurative 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 (Plate I), 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 body are bad, — tubercular, syph- ilitic, etc., — or if the suppuration result from diphtheria or scarlet fever, the prognosis is unfavorable; otherwise, when all the symp- toms 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 a free exit for the secretions has been provided for, either by nature or the surgeon. The author has often observed that when the inflamed parts showed pulsation and were very sensitive to the gentlest touch of the cotton-fluff, the sup- puration 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, burrowing of pus, periostitis, or osteitis are indicative of serious complications. Treatment. — In the preceding chapter, in treating of acute in- flammation of the middle ear, are given in detail the methods that 80 TREATMENT OF ACUTE SUPPURATION OF THE MIDDLE EAR. should be adopted in acute inflammation up to the time of suppura- tion and rupture or paracentesis of the membrana tympani, 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 ma- terial and relieve pressure, the first observation to be made is relative to the capacity of the perforation to meet the necessity for free drain- age. 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 continuous, 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 medicating 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 repeatedly 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. 42). 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 carefully inflated with as low pressure as will propel a column of air outward through the perforation. The discharges are by 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 dried, and insufflated with aristol from the small powder-blower (Fig. 34). This remedy is preferable to boric acid in that it possesses a feeble anaesthetic property. It is an excellent cicatrizant, and, being an impalpable powder, it can be dusted through a narrow perforation. Or we may employ nosophen which, having no odor or irritating quali- TREATMENT OF ACUTE SUPPURATION OF THE MIDDLE EAR. 81 ties, with decided antiseptic and healing properties, possesses decided merits. It is a very light, impalpable powder, that is easily thrown in the form of a dust over the surface treated. Its color is yellowish- gray, and it contains nearly 62 per cent, of iodine in combination. It is not decomposed by heat up to 220° C, and it is not soluble in water. Xosophen does not act as iodoform does by liberating free iodine as it decomposes in contact with the living tissues; but con- tact with the alkaline fluids of the body converts the insoluble noso- phen into the soluble antinosine, and no free iodine is liberated by either to produce toxic effects. But, through this gradual transforma- tion of nosophen into antinosine, we get a continuous effect of the remedy. A small pledget of absorbent cotton is then introduced lightly into the mouth of the meatus and allowed to remain until a Fig. 42. — Nipple-shaped bulging of the posterior portion of the drum-head, on the summit of which is the perforation. (After Politzer.) 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 syringe the ear (Fig. 33), as previously described, and instill a warm, saturated solu- tion of boric acid in water or rose-water, allow it to remain ten min- utes, 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 treat- ment, the better the results. The ear already presents the most favor- able condition for the development and propagation of bacteria, — warmth and moisture. This condition we must combat; so that, whatever our treatment may consist in, the aim should be to leave bZ TREATMENT OE ACUTE SUPPURATION OF THE MIDDLE EAR. the parts as dry as possible. For this reason "boric acid is an excellent dressing, especially when all acute symptoms have subsided. How- ever, during the acute stage boric acid may cause pain for several hours after its application. We have met with quite a number of such instances in which it became necessary to discontinue the use of this powder. We have suspected that certain individuals 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 percolate through the perforation into the middle ear and there exercise its feebly germicidal power. No powder, how- ever, should be firmly packed into the ear, for it would prevent the ■escape of discharges and cause them to seek an outlet elsewhere: 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 con- necting blood-vessels, lymphatics, 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 unobstructed. 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 in this proportion with glycerin, and the latter unloads the blood-vessels of their superabundant serum. The turgescence of the vessels is dimin- ished and the pain relieved. General 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 this 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, and our efforts must be directed toward removing any permanent 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 CATARRH OF THE MIDDLE EAR. S3 Chroxic Xox-slppurative Inflammation of the Middle Ear. Under this name are classed hypertrophic middle-ear catarrh and adhesive middle-ear catarrh, — sclerosis (see Chapter IX). HYPERTROPHIC, OR SECRETIVE, CATARRH OF THE MIDDLE EAR. Synonym. — Hypertrophic tympanitis. Pathology. — Hypertrophic, or secretive, catarrh of the middle Fig. 43. — Fluid effusion in the tympanic cavity, marked by a bright line. (After Politzer.) ear generally occurs in association with a similar condition of the nose and naso-pharynx. There is an liyperaemic condition of the mucous membrane lining the tympanic cavity, with hypersecretion of a serous or mucous character. The exudation may be visible (Figs. 43 and Fig. 44. — Circumscribed bulging of the drum-head, due to pressure of fluid in the middle ear. (After Politzer.) 44 and Plate I) if the drum-head has not lost its translucency, more especially when air has been forced through the Eustachian tube into the fluid, thereby causing bubbles or a frothy appearance. In this disease the tube generally participates to the extent of losing its 84 HYPERTROPHIC CATARRH OF THE MIDDLE EAR. patency; so that the normal supply of air in the tympanic cavity is cut off. The result is that the air in the middle ear is absorbed; so that the resistance of the drum-head to the outer atmospheric pressure of nearly fifteen 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 in- creased concavity of the membrane, the foreshortening of the hammer- handle, the emphasizing of the posterior fold, and the changed loca- tion 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, pos- sibly, 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 poste- rior cms of the stirrup as to show their projecting outlines and those Fig. 45. — Great concavity of the drum-head and foreshortening of the hammer-handle. (After Politzer.) 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. 45 and Plate I), running directly inward until its lower extremity lies in contact with the inner wall of the cavity (Fig. 48). 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 cir- cular 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 retraction are due to an atrophied condition of one or more parts of the membrane, and, un- HYPERTROPHIC CATARRH OF THE MIDDLE EAR. bo less a careful inspection is made, these atrophies may be easily mis- taken for cicatrices. The latter, however, are more clearly defined by the distinct line forming a border to a previous perforation and now separating the cicatricial tissue from the opaque, thickened sur- rounding membrane. The atrophic area blends gradually in more indefinite outlines with the adjoining hypertrophic tissue. The manipulation of 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 quies- cent. But, when the drum-head is depressed against the inner tym- panic wall and has become adherent to it by organic adhesions, these adhesions prevent the depressed area from responding to the pneu- matic otoscope. In the advanced stage of this disease the drum-head may become 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 exuda- tion 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, result- ing in the more serious conditions described. George A. Leland makes the point that ear disease results from frequent and forceful efforts to cle,ar the nose. The air is blown into the middle ears with suffi- cient pressure to stretch the drum-heads and cause ultimate relaxa- tion. Symptomatology. — This is not a painful affection, although in the early stages slight twinges or darting and shooting transitory pains may occur. Sensations of fullness in the ear, pressure, and as if some- thing were moving in the ear are complained of. The last symptom is produced by movements of the fluid contents of the tympanic cav- ity, owing to the varying positions of the head, and to the entrance of air into the fluid through 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 86 TREATMENT OF HYPERTROPHIC CATARRH OF THE MIDDLE EAR. involved, as air passes through. The viscous mucous secretion ag- glutinates the walls together, and as they separate the clinging mu- cus first sticks, then stretches into filaments, and finally the breaking of these occasions the crackling noises. The movements of the jaw aggravate these symptoms. Sensations of numbness in the corre- sponding 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 conditions. Low barometer and ther- mometer, with great humidity of the atmosphere, increase the impair- ment of hearing, the sensations 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 predict approaching weather changes by the phenomena men- tioned. 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 transparent the line in the membrane indicating the surface of the liquid (Fig. -±3) can be made out unless it extends above into the attic, or the pro- pelling 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 dis- ease 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 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 important light on this subject. If there are no hypertrophies and exostoses, but a simple catarrh of recent origin, a cure is rapidly effected. Treatment. — Attention must first be directed to the passages that lead to the middle ear. If there is a catarrhal condition of the nose TREATMENT OF HYPERTROPHIC CATARRH OF THE MIDDLE EAR. 87 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. Permanent cure of the ear affection cannot be effected so long as the exciting cause of such attacks remains in the naso-pharyngeal 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 reduction of hyperemia and swell- ing of the mucous membrane. By this means the natural ventilation of the tube and tympanic cavity 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 visit 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, accord- ing to this rule, until the cure is complete. As soon as the organ is apparently restored to its normal condition treatment should be dis- continued, as a retrogression may otherwise occur. Overtreatment is certainly to be avoided. At each sitting the inflations are repeated from two to four or six times, with not enough pressure to cause pain or bright redness of the membrana flaecida. The vessels along the upper portion of the handle of the mallet often become injected even after gentle inflation. For the removal of the fluid contents of the tympanic cavity that do not disappear after inflation, a number of years ago the author devised a method that he has never seen mentioned except once, which was in a journal article that appeared about three years subsequent to his publication. The patient inclines his head forward and a little toward the opposite side, and practices an experiment that just reverses the Yalsalvan method. He closes the nose with his thumb and fore- finger and draws the air from the naso-pharyngeal space down into his throat. This method exhausts the air of the cavities above the phar- ynx and sucks the secretions from the Eustachian tube and middle ear into the throat: thev 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 for this disease does not mention the 88 TREATMENT OF HYPERTROPHIC CATARRH OF THE MIDDLE EAR. 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 not often a necessary instrument, The improved inflator (Fig. 26) 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. (See remarks on catheterization in Chapter IV.) If my method of autoaspiration of the tympanic cavity through the Eustachian tube should not suffice on account of the thick, tena- cious character of the secretion, paracentesis of the drum-head should be made under antiseptic precautions, as already 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 done by the para- centesis, for it will undoubtedly close in a few days. The expelled secretions should be removed 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 reopened, even repeatedly in exceptional cases. A few days or weeks of this treatment generally' suffice for a cure, but the more obstinate con- ditions 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 hypersemia of the lining tympanic membrane. A number of years ago the author introduced the use of purified liquid vaselin, and later camphor-men- thol in lavolin, for treating tubal and tympanic catarrh. The physio- logical 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 saturated with the liquid and, by applying the cut-off of the compressed-air tube to the inflator, a jet of the remedy is projected into the tube and tym- panum. I have since learned that Charles Delstanche, of Brussels, preceded me in the use of liquid vaselin in the middle ear. This treatment is usually best followed by the massage otoscope in obsti- nate cases. After the treatment has effected all that is possible we TREATMENT OF HYPERTROPHIC CATARRH OF THE MIDDLE EAR. 89 have observed that patients maintain their improvement and even con- tinue to progress, after changing their residence from low and damp surroundings to a high, dr} r , 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. Synonym. — Sclerotic tympanitis. The line of demarkation cannot always be distinctly and un- mistakably drawn between the early adhesive and the late hyper- trophic 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 — involv- ing ankylosis of the ossicles, especially immobility of the stapes, and labyrinthal involvement — characterize the adhesive, or sclerotic, ca- tarrh. Pathology. — While this form of catarrh may affect the whole lining membrane of the middle ear, it may be circumscribed 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 tym- pani and ossicles together alter the normal tension of the conducting apparatus, resulting in varying degrees of deafness and perversion of hearing. These bands become the seat of calcareous degeneration,, with the result of binding the ossicles to each other, to the mem- brana tympani, and to the tympanic walls with rigid or bone-like bridges. The drum-head is often the seat of these chalky deposits,, which generally appear like miniature drifts of snow in crescentic forms below and about the mallet (Fig. 46 and Plate I). Ankylosis of the ossicles takes place either by increased fibrous- tissue formation or by bony growth. Ankylosis is infrequent between (90) SCLEROTIC CATARRH OF THE MIDDLE EAR. 91 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 these ankyloses combined with bands of adhe- sions binding- the membrana tympani and ossicles together, and hy- Fig. 46. — Semilunar chalky deposit in front of the handle of the mallet. (After Politzer.) pertrophy 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 border of the oval foramen (Fig. 47) favor the fixation of this bone when fibrous or calcareous changes occur. Calcification or ossification may take place in the Fig*. -47. — Xiche of the fenestra oralis,, with the crura of the stapes. in the normal ear of an adult. Net-work of bands extending from the neck of the stapes to the walls of the niche, c, head of the stapes; 6?, s, crura of the stapes. (After Politzer.) ligamentous ring of the stirrup, and bony union with the oval window may result. Calcareous deposits have been found in the malleo-in- cudal joint, and I have suspected that in patients of a uric-acid diath- esis deposits of urate of soda might take place in these joints as well 92 SCLEROTIC CATARRH OF THE MIDDLE EAR. as in other articulations. Bichey believes sclerosis to be closely re- lated to progressive arthritis deformans. In a conversation with Pro- fessor Politzer upon this subject, the author 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. Christopher J. Colles believes that a rheumatic, gouty diathesis has undoubtedly much to do with the obstinate char- acter of many cases of middle-ear trouble, especially the chronic mid- dle-ear catarrh. 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 diseases that are destructive of tissues and exhausting to the general strength promote this form of middle-ear catarrh. Chronic catarrh of the nose and throat and excessive indulgence in alcohol and tobacco-smoking bear a close causative relation to sclerosis. Yet the author cannot place the em- phasis on smoking that some authors do, since he has 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 child- hood, 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 in the early stage 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 dis- tressing symptom. Patients often declare that if the noises only can be conquered they will be satisfied, whether their hearing can be im- proved or not. These are variously described as high-pitched ring- ing, like that produced by quinine or by boxing the ears; like roar- ing or rushing of waters; chirping of crickets; hissing; the singing of a tea-kettle; escaping steam; sighing of the winds, etc. The in- tensity of the tinnitus is usually in proportion to the loss of hearing, SCLEEOTIC CATAEEH OF THE MIDDLE EAE. 93 until the miserable subject can hear little or nothing but the inter- minable 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; tak- ing 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, the author has 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 some- times believe it is possible for others to hear these noises if the ob- servers ear were to be placed close to their own. I have known some patients to insist that crickets or other creatures were in their ears,, and that they must be removed, when the sounds were entirely sub- jective. On the other hand, persons with discipline of mind and strong- will suppress mentally these besieging enemies of consecutive thought and intelligent action until they are scarcely conscious of their pres- ence while engaged in active occupations. But when the mind be- comes 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 symp- tom 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 are not uncom- mon. Great sensitiveness to certain sounds and to concussions of the air exists. The slamming of a door may be painful, owing to the noise or to the concussion, or both. With abnormal tension of the sound- conducting apparatus and impaction of the foot-plate of the stirrup in the oval window, there is an increase of labyrinthal pressure and more or less headache, 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 hyper- 94 SCLEROTIC CATARRH OF THE MIDDLE EAR. trophic catarrh, and shows less variation either with or without treat- ment. The hearing may vary during the day. One individual hears better in the morning and worse in the evening. Another hears better until, perhaps, 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 he hears better, even better in some instances than those with normal hearing. A locomo- tive engineer under my care said he could hear better than his com- panions when his engine was in motion, and that his employers, for whom he had worked several years, did not suspect his impairment of hearing. 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 usefulness 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. Words could be heard, but not in- terpreted, on account of long disuse of the organ. It became neces- sary to practice with the various words in common use until they could be distinguished from each other and correctly interpreted. The process was comparable to learning a new language, but it was accomplished. In this case the sounds of the C and C forks, 128 and 256 vibra- tions, were perceived by air and bone conduction at the correct pitch by both ears. The C" and C", 512 and 1024 vibrations, were always heard at the proper pitch with the right ear, and by bone with the left ear; but by air with the left they were perceived as a half-tone above the real pitch. Fork C"", 2048 vibrations, was heard with each ear faintly, when almost touching the mouth of the meatus, but not by bone conduction with either ear. The patient distinguished with difficulty between this fork and the subjective ringing, which was of the same pitch. SCLEROTIC CATARRH OF THE MIDDLE EAE. 95 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 bet- ter in a noise, paracusis Willisii, is characteristic 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 an electric bell with the gong removed, or a spring and ratchet in an electric motor or fan, one with this form of deafness will be able to conduct a business conversation when otherwise he could not without a con- versation-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 altogether ab- sent for the highest and lowest notes. But it should not be forgotten that bone-conduction begins to show reduction after the thirtieth year. The hearing for the highest tones and the very low notes is diminished or lost in the order named. Certain notes in the medium register may also be unperceived, which indicates labyrinthal im- plication. Diagnosis. — The appearances of the drum-head vary greatly. There are thickening and retraction of the membrane (Figs. 48 and 49 and Plate 1) with foreshortening of the mallet-handle in some cases (Fig. 45), while in others there is atrophy with chalky deposits, or, in other instances, a membrane of quite normal appearance. The ad- hesive process may be confined to circumscribed areas on the surface of the inner tympanic wall which inspection does not reveal. The Eustachian tubes may have been involved during the early stages, while later in the history of the disease they may be freely permeable. The massage otoscope will show any adhesion of the membrane to the inner wall (Fig. 50) and the amount of mobility that the mallet may have lost. It will also reveal bands of adhesion that may exist superficially behind the drum-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 an- kylosed 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. 96 TEEATMENT OF SCLEKOTIC CATARRH OF THE MIDDLE EAR. Prognosis. — From what has been said it will be naturally in- ferred that brilliant results may not be expected from treatment in a large proportion of cases of sclerosis of the middle ear. The out- look will be more favorable if the disease is not of long standing, if tinnitus is either absent or only an occasional symptom, if the hear- Fig. 48. — Marked retraction of the drum-head. (After Politzer.) ing is not seriously impaired, if bone-conduction is normal, and if treatment produce a decided amelioration of the symptoms. The reverse of these circumstances renders the prognosis unfavorable. Age, general health, sanitary surroundings, personal habits, heredity, and occupation must also enter into the account. Fig. 49. — Circumscribed depressions in the anterior-inferior quadrant of the left drum-head. (After Politzer.) Treatment. — We can hardly speak of treatment in this form of middle-ear catarrh as being generally curative. We must candidly admit that in otology, as well as in other branches of medicine, there are maladies that sometimes 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 TREATMENT OE SCLEROTIC CATARRH OF THE MIDDLE EAR. 97 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 off?" 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 sensitive being almost deprived of normal, intelligible, sweet-toned sounds, 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 membrane and ossicles, to stretch or break bands of adhesions and to overcome anky- Fig. 50. — Circumscribed adhesion of the membrana tympani to the promontory underneath the handle of the mallet, a, point of adhesion. (After Politzer.) losis, 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 atmosphere, or 15 pounds, or less, we have em- ployed 60 pounds and even more pressure without producing much impression on these old, hardened, thickened, leathery drum-heads. This is not mentioned as an intimation to the unpracticed that they should use so much pressure, but 30 pounds' pressure is often required in this affection 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 probably indicates that bony union has not yet taken place between the base of the stirrup and the border of the oval 98 TREATMENT OF SCLEEOTIC CATARRH OF THE MIDDLE EAR. foramen. If inflation and massage are followed by an amelioration of the symptoms, improved hearing, abatement of the tinnitus, relief of a sense of pressure, and a feeling of clearness in the head, then the prospect is encouraging. If a few weeks of daily treatment should make no perceptible impression of any kind, the opposite is true. But the massage treatment on alternate days is a most important auxiliary 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 au- thor'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-head; (2) it affords a magnified view of the field; (3) it can be operated in a smaller 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 auditory meatus the amount of mobility in the drum-head and the chain of bones may be determined under brilliant illumination and a magni- fied view. If ankylosis of the joints of the ossicles, or if bands of ad- hesions 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. 41). When the membrane is greatly thick- ened in patches or contains calcareous deposits, these portions will be seen to resist the action of the vibrating column of air, while nor- mal parts and areas of thin, cicatricial tissue that indicate the loca- tions of former perforations may respond readily to the experiment. 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 per- ceptible 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 press- ure directly upon the processus brevis by means of a probe covered with a soft-rubber tip or Lucas's pressure-probe. Stiffness 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 TREATMENT OF SCLEROTIC CATAEEH OF THE MIDDLE EAE. 99 moves, then retract the probe until the malleus resumes its former position, press again, and so repeat the movement three or four times. Then the pneumatic principle of the otoscope should be applied until one is satisfied that the advantage 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 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 re- sults. Charles Delstanche, of Brussels, has also devised an excellent massage instrument. The pressure-probe which I devised in 1886, and which was men- tioned at the meeting of the American Medical Association in 1888, has been superseded by a much better one (Fig. 51) devised by my good friend Professor Lucse, of Berlin. It consists of a delicate shank set parallel to its hollow handle by a right-angle deviation, so as to Fig. 51. — Lncae's pressure-probe. bring the operator's fingers out of the field of vision. The distal ex- tremity terminates in a cup lined with soft fibre that fits over the short process of the mallet. The handle contains 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 fiaccida, but is often 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 membrana fiaccida, it should not be used further for that treatment. We have found the best results from a systematic plan somewhat as follows: For the first week or two lavolin is injected into the mid- dle ear by means of the improved inflator (Fig. 26) on Monday. Wednesday, and Friday, always preceding the ear treatment with the necessary cleansing and medication of the nose and throat. On the 100 TREATMENT OF SCLEROTIC CATARRH OF THE MIDDLE EAR. intervening days the massage otoscope is used sufficiently to obtain as nearly as possible the normal mobility of the ossicles, or until the hyperemia, 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 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 sulphuric ether added to the lavolin in the sponges contained in the inflator 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. Eichey advocates the iodine-vapor inflations and iodized cot- ton in the external canal. Dunclas Grant uses a self-inrlator charged, with chloroform. If it should be desirable to produce the effect of camphor-men- thol 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. 19) for the inflator,. 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 beneficial 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 predecessors in the employment of fumes from resublimed iodine crystals with which to douche the middle ear, but so little perceptible good and so much irritation attended its use that it has had little place for this purpose in his practice for a number of years. Pilocarpine hydro- chlorate, in 1- and 2-per-cent. solutions, is much used for injections into the middle ear through the catheter. Generally 6 to 10 drops of the weaker solutions are injected three times a week for four or six weeks. The medicine and catheter must be sterilized, and used while warm. These injections are best alternated with the massage treatment, The author has 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 pa- tients, and if the ankylosis 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 effect was nil. TREATMENT OF SCLEROTIC CATARRH OF THE MIDDLE EAR. 101 A considerable variety of 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 and others are positively harmful. The injection of fluids through the Eustachian catheter and tube is attended with irri- tation of the tube and tympanum unless accomplished by exception- ally skillful and gentle hands — and no others should attempt it. Pos- sibly a little tympanic irritation may prove beneficial, but the prob- abilities are in favor of its proving harmful. If hyperemia is desired it can more easily and safely be produced by the prolonged use of the massage otoscope and Lucas's pressure-probe. The Yalsalvan 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 prac- tice it not once or twice a day, but repeatedly, many times a day, until the membrana tympani loses its tension, becomes relaxed and re- tracted, and no more relief is had. Such a case is now under ob- servation. He began practicing autoinflation ten years before coming under my care. He was advised by a prominent anrist to practice the Valsalvan experiment, and he has grown progressively worse during all that time. It is an interesting incident, which should serve as a warning, that he had been under the care of three aural surgeons, two of whom are eminent, without the fact of his being addicted to this habit being disclosed. This is only one example of numerous instances which could be cited as illustrating the unwisdom of placing in the hands of patients methods for self treatment that are likely to result in more harm than good. The sole fact that the patient was worse after ten years of autoinflation is not mentioned as proof that the retrogression was due to the practice. The opinion is based on the results of studies of these cases, the details of which cannot be in- corporated with this observation. The use of the phonograph, vibrometer, and other expensive in- struments that produce sound-waves of speech, or musical vibrations that are conveyed to the ears by rubber tubes inserted into the ex- ternal canals, have been much vaunted by ill-advised laymen; but experimental investigation only confirms what a familiarity with the principles involved presages: their utter inutility. During a discus- sion 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. 102 TREATMENT OF SCLEROTIC CATARRH OF THE MIDDLE EAR. It is worthy of attention that the treatment with the improved inflator 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 treatment, and all the instruments must be kept scrupulously clean and disinfected in order not to commit the unpardonable sin of infecting a patient. A 5-per- cent, solution of carbolic acid is best for this purpose. Massage of the external meatus has been a part of the author's treatment for a considerable time, although he has refrained from mentioning the method until convinced of its undoubted value. After observing the beneficial effects of massage on other organs it oc- curred to me to try the effect of the application of the same prin- ciples to the external auditory canal in the atrophic condition accom- panying sclerosis. The result was not only that patients experienced a sensation of relief and freedom from itching, but the middle ear appeared to make better progress than when the massage was omitted. The method pursued is as follows: Cotton is twisted quite firmly on the slender silver holder (Fig. 9) so that it will not easily slip off; this is smeared with vaselin or a o-grain yellow-oxide-of-mercury oint- ment made with vaselin; then the anointed cotton is rubbed or stroked upon the canal-walls in a circular direction while the holder is rotated on its axis in the direction that will prevent the cotton from becoming disengaged. This friction is continued only long enough to thoroughly cleanse the skin and stimulate the circulation. The ceruminous glands, which are generally in an atrophied state in this disease, are aroused into greater activity. The skin, which is dry, scaly, and often eczematous, assumes a healthier appearance, and the effect upon the process of nutrition does not appear to be confined to the external canal, but seems to extend to the tympanic cavity. Care must be taken to avoid touching or irritating the drum-head, and the cotton must not be allowed to slide off the end of the holder so -as to allow the latter to abrade the skin. The author has not seen this method pursued or suggested by others, yet experience deprives him of the temerity to advance the claim to originality or priority. How long shall treatment be given? Only so long as improve- ment continues. If treatment is protracted much beyond the time in- dicated, it may be followed by an actual retrogression. Too much treatment is pernicious. When improvement takes place and a state is reached in which the benefit remains stationary, despite all efforts TREATMENT OF SCLEROTIC CATARRH OF THE MIDDLE EAR. 103 for a reasonable time, then treatment had best cease. The patient should he discharged with proper instructions for the care of himself, and for his return should he begin to lose the gain already made. In- deed, these 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 journeys 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 are favorable indications. If but one ear is affected, its early treatment may prevent the other from 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 dis- ease 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. 77) adapted to the con- centration of the current in the ears, because 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 connecting the electrodes with the battery are attached. In this manner the patient is relieved of the tiresome holding of the electrodes in place. However, we do not attach great importance to electricity in this disease. CHAPTEE X. DISEASES OF THE MIDDLE EAR, CONTINUED. Opeeatiye Teeatment of Tympanic Scleeosis. The author has devised an ossicle-vibrator (Fig. 52) for the pur- pose of breaking up adhesions in the middle ear and ankylosis 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 instruments. It is used in the fol- lowing manner: An incision is made through the drum-head close to the anterior border of the hammer-handle and parallel with it from the short process to its tip under cocaine anaesthesia. Then the end lever, which is curved for the purpose, is carried through this slit and behind the mallet, when the handle falls between the two little levers. Fig. 52. — The author's ossicle-vibrator. They are then slipped along upward, embracing the handle, until the stronger part of the bone is reached and the levers fit the handle some- what closely. Now the retracted hammer-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 nor- mal position. The gentlest care must be taken 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 instru- ment were allowed to slide downward upon the weaker portion of the handle. We 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 adhe- sions yielded to the traction, and nearly fainted. This was probably due to the disturbance of the intralabyrinthal fluid as exaggerated (104) OPERATIVE TREATMENT OF TYMPANIC SCLEROSIS. 105 motion was effected in the stirrup. Some most remarkably beneficial results have followed the use of this simple method of mobilization of the ossicles. No harm has been known from it. After making the incision and before introducing the vibrator, it conduces to the com- fort of the patient to instill a few warm drops of an 8-per-cent. cocaine or eucaine solution. Incision of the posterior fold of the drum-head is indicated when there is a great sinking inward of the membrane, with foreshortening of the mallet-handle, and exaggerated prominence of the short process, with a stretched appearance of the membrane about it. This condi- tion, associated with serious impairment of hearing, and head noises that are unimproved by the treatment already detailed, calls for this simple operation. The section is best made about midway in the folds (Fig. 53) and the knife (Fig. 57, No. 2) is made to cut from above Fig. 53. — Section of the posterior fold of the membrana tympani. (After Politzer.) downward, with care that it is not carried deeper than is required to sever the fold. Otherwise the chorda tympani (Fig. 54) may be severed, producing paralysis of taste. Although the author has made such sections frequently, lie has never known this to follow, but such results are reported. Patients generally observe a sense of relief from pressure, clearness in the head, diminution of subjective noises, and sometimes improvement in the hearing. In the class of cases in which we have mostly practiced this operation we have not been able to fol- low 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. Multiple incisions of the drum-head have proven beneficial in some instances. In 1886 the author reported the results of a series of cases to the meeting of the American Medical Association, from which 106 OPEEATIYE TREATMENT OF TYMPANIC SCLEROSIS. we quote: "For the purpose of making a crucial test of the efficacy of this procedure, the writer has made it the last resort in those that afforded no real hope for relief from any other treatment. Per- haps the propriety of operating on those patients that seemed to promise no results might be questioned, were it not for the fact that in nearly all of them there was an unexpected improvement and that no unfortunate consequences followed the operation. The cases 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 Fig. 54. — Internal surface of the left membrana tympani. a, head of the malleus; 1), neck of the malleus; c, tendon of the musculus tensor tympani and anterior fold of the membrana tympani; d, inferior extremity of the handle of the malleus; e, anterior portion of the membrana tym- pani; f, chorda tympani and posterior fold of the membrana tympani; g, incus; h, short process of the incus; i, long process of the incus. (After Politzer.) 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 seriously reflect upon the advisability of establishing the suppurative process in sclerotic inflam- mation of the middle ear. In 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 OPERATIVE TREATMENT OF TYMPANIC SCLEROSIS. 107 considered that they were the most unpromising and had proven the most intractable to the usual methods of treatment. But, as re- marked above, this experimental work, which was carried out mostly in dispensary practice, did not afford opportunities to follow up the results for a number of consecutive years. The simple incision, of course, closed in a few days, but the tension of the drum-head appar- ently was restored to more nearly the normal." At a recent time (April, 1898) one of these cases came under my observation again, showing that the really brilliant results obtained by this method twelve years ago have persisted to the present. Another method that the writer has since pursued with consider- able success was the excision of areas of the drum-head, usually tri- angular in shape (Fig. 55). Under cocaine triangular flaps were made with the apex above, then the attached base was severed, removing Fig. 55. — Triangular resection of the drum-head. (After Politzer.) this piece of the membrane entirely. It was sometimes easiest, after incising the two sides of the triangle, to grasp the apex with delicate forceps in one hand while the base incision w T as made with the other. The improvement in some patients in whom there was no labyrinthal disease was very gratifying, and in private patients the possibility of maintaining the aperture for a considerable time was demonstrated. In one instance 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 improvement that he requested that the same operation be performed on his right ear. It was done, and a slight, muco-purulent discharge followed, but soon ceased. While the discharge lasted, the hearing was consider- ably improved and the tinnitus relieved. After the discharge ceased the hearing began to diminish, when he expressed regret that the ear 108 EXCISION OF THE MEMBRANA TYMPANI AND OSSICLES. had not continued moist. This led me to anoint it with warm, pure vaselin, but when it was removed a few days afterward the very large perforation was entirely closed with cicatricial tissue. The removal of sections of the drum-membrane may prove other- wise advantageous. It affords accessibility to the tympanic cavity for the instillation of various remedies and the destruction of the adhe- sions, 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 responding 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 remedial. 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. The writer has 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 very clearly defined, and the appearances that suggest the shortening of this muscle — re- traction of the membrana tympani and foreshortening of the mallet- handle — are also just as characteristic of the presence 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 operate preferably with 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 upon any other. While a few American aurists, especially Burnett, Sexton, Blake, and Jack, have been enthusiastic advocates of the operation, and some others have followed their lead for a time, the majority ap- pear to have receded to a more conservative position. At the meet- ing 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. Sev- eral years ago the writer, through the columns of the Journal of the American Medical Association, invited all who had performed this EXCISION OF THE MEMBRANA TYMPANI AND OSSICLES. 109 operation to communicate the results to him for the purpose of pub- lishing a collection of experiences that would afford a just estimate 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 the ill as well as the good results. A number of cases have been under my observation upon whom the operation has been performed by surgeons both East and West, with the effects of pro- ducing a suppuration of the middle ear, destroying the hearing, ap- parently intensifying the noises, and producing more or less vertigo. The writer has had under treatment a physician from a far-western State whose ossicles were removed from one ear by a noted 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 has been totally deaf ever since, and the opposite ear has seriously deteriorated. This is a fair type of numerous similar instances that have come to my personal knowl- edge, and under the observation of other physicians who have been kind enough to report them to me. Out of six cases operated upon by a young aurist, and reported by him at a recent meeting of Western specialists, the results were unfortunate in four. In one under observation at the present time (August, 1898) the operation was followed by total deafness, sanguino- purulent discharge, and facial paralysis that treatment has failed to benefit. B. M. Behrens {International Medical Magazine, May, 1897) re- ports his experience as follows: "Up to the present time the radical operation of removing the drum-head and malleus has been performed on 34 cases, of which 30 have given very little improvement or none whatever." 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 a want of familiarity with the subject. 110 OPERATION FOR EXCISION OF THE OSSICLES. It is not our purpose to inveigh against this procedure as an opera- tion, but to emphasize the necessity not only of the utmost precision and gentleness in operating, but also the most painstaking prelimi- nary examination and experiments to determine the possibility or otherwise of beneficial results. For example, if the hearing-tests demonstrate 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 fenestras 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 ad- vantage certainly is to be conceded to this measure, although mo- bilization 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 good view of it is difficult to obtain, and it is easy to dislocate when it is not ankylosed. OPERATION FOR EXCISION OF THE OSSICLES. The ear should be prepared by syringing with a warm solution 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 exclusion of chloroform, in- structing the anaesthetizer to administer only so much as is absolutely necessary to secure quiet and freedom from suffering. Cocaine anaes- thesia is not as effective as ether. After removing debris of any nature from the canal, it is dried and closed with absorbent cotton until the operation commences. If ether is used, the patient must occupy a recumbent position. We have found it convenient to use tables of sufficient height to bring the patient's ear opposite the eyes of the operator while the latter is sitting (Fig. 95). A brilliant illumination is needed. We have used mostly the Argand gas-lamp and light- condenser (Fig. 5) or the sixty-candle-power incandescent 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. 56) are a paracentesis-knife (No. 2): a blunt-pointed bistoury (No. 1); two angular knives, right and left (^s T os. 4 and 5); two ossicle-hooks, right and left (Fig. 57); a OPERATION FOR EXCISION OF THE OSSICLES. Ill pincette (Fig. 58); a dozen slender cotton-carriers armed with cotton; a quart of hot, sterilized water, and a syringe. The operation proceeds as follows: The drum-head is incised with knife rTo. 2 near the periphery, behind the short process of the mallet. Into this opening the brunt-pointed knife (Xo. 1) is inserted Vjl i5 i3 32 CT~~fe Fig. 56. — ^Middle-ear instruments and handle. and carried first below, then sweeping the lower and the anterior attachments until the roof is reached; then this attachment 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 flaccida were first cut. There is less haemorrhage also if the knife is kept a little way from the periphery Fig. 57. — The author's ossicle-hook. of the membrane. Xow the angular knife is used to separate the articulation of the anvil and stirrup (Fig. 59). 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 de- taches the auricle and removes the integumentary canal first. The operation is a very short one, requiring but a few minute? 112 OPERATION FOR EXCISION OF THE OSSICLES. ordinarily if there is not much haemorrhage or if the adhesions are not embarrassing. Eapid use of the cotton-carriers, 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, sterilized water can be brought into requisition. It is difficult to avoid severing the chorda tympani in this operation, 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. 34), 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 Fig. 58.^— Politzer's pincette. takes place. By properly restricting the diet, both before and after the operation, 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 we have not removed,, for the reason that no possible good could come of it. In another case of a very robust man from Kansas the writer removed 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 sur- geon said that another had closed the tympanum. A third operation was had, and in fourteen days another drum-head had formed. Two OPERATION FOR EXCISION OF THE OSSICLES. 113 years afterward the patient came to me with the request that this remaining fourth drum-head with which nature had supplied him be removed. He suffered from great tinnitus and uncomfortable sensations of pressure, etc. Examination revealed labyrinthal involve- ment and the procedure was advised against. 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 the periphery of the Fig. 59. — Vertical section of the external meatus, membrana tympani, and tympanic cavity, a, cellular spaces in the superior wall of the meatus connected with the middle ear; 6, roof of the tympanic cavity; c, inferior wall; a, tympanic cavity; e, membrana tympani; f, head of the malleus; g, handle of the malleus; li, incus; i, stapes; A', Fallopian canal; I, fossa jugularis; m, apertures of glands in the external meatus. (After Politzer.) drum-head so as to completely destroy the whole circular attachment. A few days afterward I found the stirrup dislocated, and removed it. Xo unfavorable symptoms followed; the membrane has not been re- produced, 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 consid- erably improved. The patient thought he could hear, but accurate 114 OPERATION FOR EXCISION OF THE OSSICLES. tests proved the contrary. This case is instructive in showing that thorough electrocauterizing the peripheral attachment of the mem- brane will prevent its regeneration. We do not often employ this cautery in the ear on account of the great heat generated in such a minute inclosed space, but the chromic acid has too superficial an effect to accomplish the purpose. The reference to these unfavorable cases, — and I might cite others who have come under my care, one of whom is the most distinguished of American editors, — is not for the purpose of condemning the operation itself, for I believe that these unfortunate results are at- tributable either to an unwise selection of cases or to unforeseen acci- dents attending the operation. For example: Why should two inches of hearing for the watch be exchanged for total deafness, vertigo, etc.? What could have happened to cause destruction of the facial nerve? The results point toward an injury to at least one of the fenestrae 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 adhe- sive process has not destroyed the usefulness of the stirrup and the 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 favorable results, especially by Jack; but the crura of the stirrup are so exceed- ingly delicate and fragile that they are quite likely to break on apply- ing side-pressure to them or on traction with the hook. This ma- neuvre is not in favor with otologists generally. After the membrana tympani has been removed for sclerosis the conditions are most favor- able for mobilization. The probe can then be introduced alongside the stirrup and pressure exerted in all directions to break up adhesions 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, especially in the case of caries and necrosis of these bones OPERATION FOR EXCISION OF THE OSSICLES. 115 or of the walls of the tympanic cavity. Great cleanliness must pre- cede these operations, which can more easily be accomplished under eucaine or a 20-per-cent. solution of cocaine than in dry catarrh. The writer has often operated under these anaesthetics without any difficulty, especially when the patients were possessed of considerable self-control. The same instruments and methods are employed as in the operation for sclerosis. If much curetting of the bone is neces- sary, 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. CHAPTEE XL DISEASES OF THE MIDDLE EAR, CONTINUED. Chbostic Suppubatiye Inflammation of the Middle Eak. Synonym. — Chronic suppurative tympanitis. This is a common sequel of acute suppuration and full of im- port to the afflicted patient. While the laity, and unfortunately 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 relations of the tympanic and cranial cavities ought Fig. 60. — Extensive destruction of the drum-head. (After Politzer.) to suggest to the mind of every thoughtful physician the importance of prompt and skillful interference with the progressive destructive ravages of a suppurative process. It is not self-limited; it does not tend toward resolution, but toward dissolution, and no trifling make- shift is pardonable. Pathology. — The whole tympanic cavity is usually affected, the mucous membrane being hypertrophied and reddened, or yellowish and leathery in appearance. It seems unnecessary to remark that a perforation in the drum-head always exists, and in cases of long stand- ing the opening is likely to be quite large and to afford some view of the interior of the cavity (Figs. 60 and 61 and Plate I). The membrana tympani is rarely completely destroyed, and in (116) CHKONIC SUPPURATIVE INFLAMMATION OF MIDDLE EAE. 117 those instances in which the destruction is quite extensive (Fig. 62) the memhrana naccida usually remains. The rupture of the mem- brane takes place most frequently in the lower posterior or anterior quadrant, but may he found in Shrapnell's membrane, — a very un- Fig. 61. — Pear-shaped perforation of the drum-head. (After Politzer.) favorable location with reference to drainage. If the perforation appear above the short process of the mallet, we suspect necrosis of this bone. The instances are not infrequent in which the whole lower, or tense, membrane is destroyed, while the loose membrane from the short process upward is intact. The hammer-handle projects down- ward, free from any membrane except perhaps a border on each side Fig. 62. — Perforation of the posterior half of the right drum-head. Behind the mallet is the projecting, yellowish-gray promontory; above it the long crus of the incus lying free and the posterior eras of the stirrup. (After Politzer.) of the upper half of the handle (Figs. 63 and 61). This gives an excellent view of the inner wall of the cavity and of the long leg of the anvil and possibly the leg of the stirrup if they are present. When the ossicles participate in the necrotic process, the anvil is the first to succumb in three-fourths of the cases. This is to be 118 CHRONIC SITPPUBATIYE INFLAMMATION OF MIDDLE EAR. accounted for by its poorer blood-supply. Its nutrition is easily cut off by pressure in the upper part of the tympanum. In long-standing suppuration, and more especially when the de- struction of the drum-head is extensive, there occurs a shedding of Fig. 63. — Destruction of the inferior half of the membrana tympani, laying bare the promontory and niche of the round window. (After Politzer.) superficial epithelium of the middle-ear membrane, which takes on an epidermic character; so that it presents the appearance of skin rather than mucous membrane. This probably is brought about by an extension or growth inward of the epidermis of the canal through the perforated membrane, or cholesteatoma. While the perforations of acute suppurations generally close spon- Fig. 64. — Large perforation of the right drum-head. The handle of the mallet is free and the long crus of the incus and the niche of the round window are visible. (After Politzer.) taneously after the discharge ceases, they more often remain more or less permanently open after the chronic suppuration is cured. In a long course of suppuration the destruction of the membrane is far more extensive than in the acute or transitory variety. Yet we often CHRONIC SUPPURATIVE INFLAMMATION OF MIDDLE EAR. 119 come upon elderly people who show unmistakable evidences of ex- tensive loss of tissue of the membrane that has been repaired by nature — large sections in the lower posterior or anterior quadrant, or in both, that consist of translucent, thin, cicatricial tissue, surrounded by the ashy-gray, leathery tissue of the old membrane. Many of these people are unconscious of ever having had a discharge from the ear, but upon investigation the fact may be established that it occurred beyond their remembrance, probably during childhood. The disease may extend to the labyrinth, although it is not of frequent occurrence. It far more often invades the mastoid antrum and cells. If we recall the position of the antrum behind the middle ear, and the connection of these cavities by the aditus ad antrum, and then their relative positions when the patient lies upon his back, we shall appreciate how the fluids in the tympanum may drip through the aditus and enter the antrum. It is like the changing of the battery-fluid from one part of a Kidder tip-battery cell to the other by turning the cell upon its axis. It is apparent from these con- siderations that mastoid disease is a logical consequence of middle- ear suppuration. Etiology. — From what has already been said it is evident that this affection is only an extension of the acute suppurative process in most instances, the causes of which are enumerated in Chapter VIII. Neglect of an acute disease generally results in a chronic one. A tubercular or syphilitic habit of body predisposes to this condition. Symptomatology. — The presence of a purulent discharge issuing from a perforation in the drum-membrane is a simple matter to dis- cern. The pus may be abundant or very scant. The author has under treatment a case of more than twenty years' standing in which not more than a drop or two will exude in a day. For a few days or a week there may be no discharge, and then a foul-smelling exuda- tion is found. In other instances there is not enough purulent dis- charge to run out of the canal, but instead it dries in scales or yellow crusts on the walls of the canal. As these crusts of inspissated pus work toward the mouth of the canal they cause itching and conse- quent annoyance. The hearing may not be seriously impaired. It does not de- teriorate so generally nor to such a degree as in sclerosis. Still, the hearing is greatly affected in occasional cases. Crusts may form over a small perforation, obstructing the discharge and impairing hearing; but patients do not often complain of subjective noises. 120 CHRONIC SUPPURATIVE INFLAMMATION OF MIDDLE EAR. Granulations (page 127) often form on the border of the perfora- tion and over the surface of the intratympanic membrane (Fig. Go and Plate I). Large, cherry-red, spongy granulations sometimes may cover the inner wall like a cushion. They are sensitive and bleed readily. Polypi (page 127) occasionally spring from the membrane and occupy the canal. A single polypus often fills the canal and extends Fig. 65. — Destruction of inferior half of the drum-head. Globular granula- tions on the inner wall of the middle ear. (After Politzer.) to its mouth. We have seen them grow to such proportions that the pressure upon the canal-walls interfered with the circulation of the end projecting from the mouth of the canal to the extent that its color was livid or black and suggestive of gangrene. We also have multiple aural polypi of luxuriant growth and of the form of a minia- ture cauliflower. These are usually of a bright-red color. If the pus in which the polypus is macerating is carefully removed without irri- tating the polypus, the latter presents sometimes a very pale, ex- •™m*sr Fig. 66. — Slender middle-ear probe. sanguinated surface, but upon friction it assumes a bright-red color and bleeds upon being touched. Mucous polypi are more commonly met with than the fibrous variety. Carious bone (page 129) is to be suspected whenever granula- tions or polypi exist. The bent probe (Fig. 66) may detect denuded bone in the tympanic cavity. The anvil (Fig. 78) is occasionally lost, and, if the external wall of the aquasductus Fallopii, containing the TEEATMENT OF CHKOXIC SUPPUKATIOX OF MIDDLE EAR. 121 facial nerve, is imperfect or necrosed, facial paral) r sis of the same side will occur if the pressure is sufficient, or the nerve itself may par- ticipate in the inflammation. William Sotier Bryant calls attention to the fact that there is sometimes a perforation in the outer bony wall of the aqueduct, establishing a direct communication with the middle ear. If necrosis of bone is present, the odor of the discharge is generally offensive, even when care is taken of cleanliness. With neglect of the discharge it may become very foul, even when there is no osseous necrosis. Invasion of the labyrinth is ushered in by sudden dizziness, deafness, and nausea. Fortunately this is a very rare complication. Diagnosis. — If the description given be borne in mind, there is no difficulty in deciding upon a case of chronic suppuration of the middle ear. The long-standing discharge from a perforation in the drum-head makes the case clear. Prognosis. — This is a progressively destructive disease. Its tend- ency is not to spontaneous resolution. "While many attacks may ap- pear to get well of themselves, as long as the diseased condition re- mains, just so long recurring attacks will succeed each other. With every fresh cold, back comes the flux. The disease continues, though no discharge may make its appearance for a time, and the patient is lulled into a false sense of security. A slight exciting cause sets up another exacerbation of the existing inflammation. Moreover, the natural tendency of this trouble is toward the bone. The mucous membrane of the 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 suppura- tion 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 mercuric bichlo- ride solution, 1 to 5000, as warm as is comfortable to the patient. Unless a considerable quantity is used, all of the inspissated, greasy accumulation often found in a neglected suppurating ear is not re- moved. As much force as can be easily borne is generally required at 122 TREATMENT OF CHRONIC SUPPURATION OF MIDDLE EAR. the first cleansing, to remove all the discharges from the 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. 33), 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 j)ressed 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. We have found people (physicians!) committing that act. Crusts, inspissated pus, and cer- umen not expelled by the water can be removed with cotton on the Fig. 67. — The author's large powder-blower for use with a hand-bulb or compressed air. carrier or a blunt probe. Delstanche has devised a tympanic syringe to inject the attic. After cleansing thoroughly with the syringe, the ear is inflated (Fig. 26) so as to eject any possible secretion remaining in the Eu- stachian tube or middle ear. The parts are then dried with absorbent cotton, and a coating of aristol or nosophen (page 81) is dusted over the surface of the middle ear with the small powder-blower (Fig. 34), or boric acid with the large powder-blower (Fig. 67). Aristol is ex- cellent on account of its antiseptic, anaesthetic, and cicatrizant prop- erties. It never causes pain and does not interfere 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 TREATMENT OF CHEOXIC SUPPUEATIOX OF MIDDLE EAE. 123 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 tenaciously to the surface of the tissues. This adds the drying effect of boric acid to all of the excellent qualities of aristol, and consti- tutes an ideal treatment for such individuals as we haye mentioned who haye an idiosyncrasy against boric acid. AVe haye met a few- such instances with this disease, although they are oftener encoun- tered among the acute cases. After the first few treatments of this kind it is adyisable 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 a few treatments, and occasionally after the first one. The results of painstaking methods are more surprising to the surgeon than to the patient, who may haye been harassed for long years with annoying discharges. One of the most effective methods consists in packing iodoform, or nosophen, gauze quite firmly against the suppurating surface if it can be reached, more especially upon a granulating surface. If the iodoform disagree, other medicated or sterilized gauze must be sub- stituted. The dressings must be frequently repeated when the dis- charge is copious. Many other remedies are commonly used, but it is the author's purpose to giye only what years of experience haye proyen to be the most efficacious and to inform the practitioner upon the relative merits of those that have been given extensive trials. Some will be mentioned merely for the purpose of saving the reader's time in ex- perimenting with the useless. Iodoform in fine powder is useful when the odor of the discharge and other signs indicate the presence of dead bone; otherwise it is not preferable to aristol or nosophen, and its disgusting odor is usu- ally very objectionable to fastidious people. The old-time remedy, silver-nitrate solution, was formerly extensively used in my clinics, but for many years we have not employed it. Having tried it in solu- tions varying in strength from 1 per cent, to a saturated solution, it became apparent that its remedial qualities in this disease were in- ferior to remedies that were less objectionable. The blackening of everything it touches renders it especially disadvantageous in private practice. Zinc sulphate exerts too little influence to merit our con- fidence. Salicylic-acid powder, highly recommeuded a few years ago, has proven, in my hands, a total failure in this disease. Moreover, 124 TREATMENT OF CHRONIC SUPPURATION OF MIDDLE EAR. the violent irritation of the nares and the attacks of sneezing which its unavoidable inhalation produces during the insufflation would pre- clude the possibility of its employment were it not otherwise im- potent. Europhen proved unsatisfactory in this disease. We have persisted in experimentation with it alone and combined with aristol, and are 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 sup- puration. 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 partakes of the same char- acteristics, is very sensitive to the touch, and shows rhythmic pulsa- tions. These characteristics obtain in a small proportion of old cases. It is difficult to adapt the dry method of treatment to such condi- tions, for the touching of the drum-membrane with the cotton to absorb the discharges is productive of great pain. It is best then to irrigate and allow all the water to run out; then hydrozone, which is a stable 30-volume dioxide, or peroxide, of hydrogen (H 2 2 ), is warmed slightly, only sufficiently to make it comfortable 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 temperature of the body, or even ten de- grees above, does not impair its efficacy, as we have often demon- strated. It is allowed to remain in the ear until effervescence ceases. This requires about five or ten minutes, according 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 hydrozone decomposes pus- corpuscles, during which action free oxygen is liberated to exert its germicidal property upon bacteria. Besides this the active efferves- cence that takes place dislodges the accumulations, and its mechanical action brings to the surface materials that even syringing fails to dislodge, — for example, aristol that may have remained from a pre- vious treatment. This boiling out of the middle ear appears to cleanse the attic even better than the intratympanic syringe, and no un- pleasant results have ever attended my use of it. In suspected retained discharges in the attic or mastoid antrum, TREATMENT OF CHROXIC SUPPURATION OF MIDDLE EAR. 125 especially when the perforation is too small to admit of free drainage, it should be enlarged, as already described on page 77. But there are frequent instances in which the discharge does not diminish after thorough efforts at cleansing, disinfecting, and medicating. This may be owed to the fact that the means employed do not remove all of the retained secretions, and there is a consequent failure of the medicaments to reach all of the diseased surfaces. The author has devised an instrument to meet this condition. It consists of an im- proved miniature air-pump (Fig. 6S), containing a metallic valve that does not get out of order, fitted to a glass reservoir. The metallic tip of the reservoir should be covered with a section of soft-rubber tube so as to permit of its being fitted with firmness and nicety into the external meatus. 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 re- moved with the cotton absorbent. After the piston is moved the Fig. 68. — The author's ear-aspirator. 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 process is repeated two or three times. AVhen 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 of one hand at the same time, so as to prevent their being separated while the pump is in action. In order to prove the value of this simple device in numerous cases, I have given the most thorough treatment by the old methods with- out diminishing the discharges, and then have resorted to this treat- ment 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 have 126 TREATMENT OF CHRONIC SUPPURATION OF MIDDLE EAR. clraAvn an astonishing quantity of discharges that must, judging from their amount and character, have been stored in the mastoid antrum and cells, and these cases have recovered without mastoid operations. McBride {Edinburgh Medical Journal, June, 1895) opens the mastoid process and middle ear to cure chronic suppurative inflam- mation, and Jones (Liverpool Medico-Chirurgical Journal, July, 1894) advocates excision of the ossicles. CHAPTER XII. DISEASES OF THE MIDDLE EAR, CONCLUDED. Sequels of Middle-Ear Suppuration. graxulatioxs. The presence of granulations (Plate I) in the middle ear or on the drum-head protracts the cure of a suppurating process. If they are small and not very extensive, they can be made to shrink up and disappear by the use of alcohol and nosophen. 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 for using 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 contact of the alcohol for a sufficient length of time. Then the treatment should be completed with the powders, as described in Chapter XL Tincture of iodine is effective when applied to the granulation by the cotton-carrier, only enough being used to touch each granulation, but not to run over the surrounding surface. "When the granulations are very large and abundant, suggestive of beginning polypi, these are best removed by the curette (Fig. 80) under a warm, 20-per-eent. solution of cocaine or an S-per-cent. solution of eucaine. 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 de- scribed in the next paragraph. POLYPI. Two forms of aural polypi occur: the mucous and the fibrous. Suppuration cannot be cured so long as a polypoid growth is pres- ent. This is best removed under cocaine or eucaine by a polypus- forceps (Fig. 69) or the snare found in the middle-ear case (Fig. 70). (127) 128 AUEAL POLYPI. It requires less skill to use the forceps. The polypus should be de- tached as close to the attachment of its pedicle as possible, and, the method being so simple and identical with the same procedure in Fig. 69. — Politzer's polypus-forceps. other fields of surgery, it would be superfluous to enter into the details here. The bleeding ceases soon and can be stanched as described in Then cocaine is applied and the attachment treating of granulations Fig. 70. — The author's middle-ear case. cauterized with chromic acid. The loop of the flexible caustic ap- plicator (Fig. 71) 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 CAEIES AXD NECROSIS OF THE MIDDLE EAR. 129 drop on the most convenient site of the loop for application the in- strument is withdrawn from the heat and the drop of fused acid is blown upon to cool it suddenly into a bead. Unless the attachment of the polypus is well cauterized 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 pedicle in the aperture. Then, by pressing firmly against it and drawing outward, it is detached and extracted. CARIES AXD XECROSIS OF THE MIDDLE EAR. "When the tympanic walls are denuded of their lining membrane, which is, in effect, its periosteum, the treatment requires much patience and persistence. After cleansing by water, hydrozone, and the aspirator, as outlined, a 12-per-cent. solution 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 Fig. 71. — The author's caustic applicator on flexible shank. 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 iodoform powder is left covering the diseased tissues. This solution penetrates the diseased cavities deeply. Then the treat- ment 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 healthy 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 re- moved 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 130 NECROSIS OF THE OSSICLES. 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 reme- dies. 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 OE THE OSSICULA. The anvil, the first to yield to the necrotic process, is sometimes lost before patients apply for treatment, but when it is 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 ex- Fig. 72. — Vertical section of middle ear; drum-head in contact with the inner wall, a, ledge-shaped remnant of the membrane; b, 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. (After Politzer.) cite a continuation of the inflammatory process and to hinder the free evacuation of the retained secretions. Their excision, if skill- fully 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. Adhesions of the remnant or of cicatrices of the membrana tym- pani to the inner wall of the tympanic cavity may occur after the suppuration is cured (Fig. 72). This results in a cup-shaped de- pression in the drum-head. Adhesions and false membranes also form within the tympanum, subdividing it into several cavities (Fig. 73). Connective tissue and chalky deposits (Fig. 74 and Plate I) PEEFOEATIOXS OF THE DEOI-HEAD. 131 sometimes fill completely the middle ear. imbedding the chain of bones so firmly that their functions are entirely destroyed. In case the adhesions cause serious impairment of hearing by embarrassing the vibrations of the ossicles or by preventing sound-waves from reach- inn the labyrinth, thev can be divided or excised. Connective-tissue Fig. 73. — Band-like cords between the lower end of the hammer-handle and the stapedo-inendal articulation. (After Politzer.) formations and cretaceous deposits can be treated like cholesteato- matous masses, which are considered later. PEEFOEATIOXS OF THE DEOI-HEAD. Perforations (Plate I), 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 Fig. , 4. — Central perforation of the drum-head and calcareous deposits. (After Politzer.) 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 re- mains better with than without the perforation, but there are ex- ceptional instances in which the hearing is improved by closing the 132 DEAFNESS FOLLOWING SUPPURATION. 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 presence of this foreign body will excite sufficient irritation to iucrease 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, hypertrophied, or calcified (Fig. 74) 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 connection. We have seen a few persons who believed they were able to hear bet- ter 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 apparent increase in hearing-power. When there is suppuration they impede the outward flow and pro- mote decomposition of the discharge. In any event, they act as for- eign bodies, giving rise to irritation and resulting increase in con- nective-tissue formation. This increased thickening of the tympanic tissues insures a still greater decrease in hearing. DEAFNESS FOLLOWING SUPPURATION. Deafness following suppurative inflammation calls for treatment 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 per- foration has closed, is the method of throwing a spray of lavolin into the middle ear with the improved inflator (Fig. 26). 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 suppleness, and promotes greater freedom of mobility. This injection is followed by the use of the massage otoscope (Fig. 8). The drum-head is caused to make a dozen or more to-and-fro ex- cursions, with an endeavor to approximate as nearly as possible the CHOLESTEATOMA. 133 natural limits of movement. This is after the fashion of the ma- chinist, who first oils his machine and then works it. This method is best pursued on alternate days for three or four weeks, or as long as perceptible progress is made in improvement, and then discon- tinued. 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 aurium is not a very common symptom in purulent in- flammation, but it is an occasional sequel of that trouble. The treat- ment just detailed for the deafness is the best adapted for the sub- jective noises 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 epidermic formation from the ex- ternal canal to the middle ear. Luca? reports a case without any suppurative process. Yirchow 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, but the latter is the result of excessive proliferation of epidermis accompanied with exfoliation. The concretions are of a caseous appearance, containing, besides epithelial cells, fat-globules, bacteria, and crystals of cho- lesterin. 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 de- stroyed 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 des- quamation of epidermis are noticeable in the external meatus, and if the epidermic masses are visible in the middle ear through a per- foration. Chunks of foul-smelling, gritty, cheesy particles may be found in the washings from the ear. The perforations are most likely to be found in Shrapnell's membrane, for the growth of epidermis in- ward is marked on the upper wall 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 decom- 134 FACIAL-NERVE PARESIS AND PARALYSIS. position of pus and the growth of polypi are encouraged. This con- dition 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 posi- Fig. 75.— Facial paresis. Appearance the same as in permanent facial paralysis. The patient is photographed while laughing. tively made out, the question of operative measures is settled. The methods of treatment are found under the headings of "Chronic Sup- puration" and "Mastoid Operations." Bezold advises epidermic trans- plantations 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 participate in a middle-ear inflammation; ulceration and necrosis of the bone FACIAL-NERVE PARESIS AND PARALYSIS. 135 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 that are dis- tributed to the orbicularis palpebrarum. But in some cases the fore- Fig. 76. — Same as Fig. 75, three months after Stacke operation and treatment with electricity. head 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 paraly- sis. If the muscles of the side of the face and angle of the mouth are paralyzed, the patient cannot drink liquids without their driveling from the lips; he cannot innate 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. 75). The facial expression is entirely lost on the 136 TREATMENT OF FACIAL-NERVE PARESIS AND PARALYSIS. side that is paralyzed. 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 inflam- mation of the Fallopian canal and the sheath of the facial nerve secondary to the middle-ear inflammation, and from slight injuries to the nerve during mastoid operations (Fig. 76). Paralysis, or com- plete loss of conduction of the nerve, resulting from caries or necrosis of the facial canal, or from division of the nerve during an opera- tion, jDresents an unfavorable prognosis. In this condition the eye cannot be closed. Dench says: "Injury to the facial nerve is not a serious acci- dent, 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 to six months; but the author has 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. He has seen varying degrees of inter- rupted transmission in the different branches of the nerve, with corre- sponding variations in the recovery. The eye being the least and the side of the face and mouth next least affected would recover com- pletely, while the occipito-frontalis remained powerless, giving a noticeable drooping effect to the eyebrow. On the other hand, we have had cases of paresis, affecting all the branches, occurring after operations for excision of the ossicles through the meatus, etc., recover completely after the use of the galvano-faradic current for three or four months. But we must make the distinction between paresis, or partial paralysis, and actual paral- ysis, which is a complete loss of nerve integrity. In the course of the nerve which is most exposed to traumatism during the mastoid operation the bundles distributed to the obicularis oris, the muscles of the side of the face, the occipito-frontalis, and the corrugator supercilii seem to lie external 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 exu- TREATMENT OF FACIAL-NERVE PAKESIS AXD PAEALYSIS. 13? date recovery takes place. If there be pressure of the pus on an ex- posed nerve in middle-ear suppuration, or if a sequestrum of bone produce the pressure, either must be removed. If syphilis is the cause, iodides and mercurials must be employed on general principles. Sexton mentions facial paralysis due to dental irritation. These cases recover after a course of the iodides, pilocarpine, and 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. 77), and the positive to the op- posite 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 Fig. 77. — The author's ear-electrodes,, attached to a head-band. 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 saturating a pledget of absorbent cotton with sterilized water or hydrogen dioxide, placing it in the bottom of the wound, and connecting the ear-elec- trode directly with this. The other pole is then applied to the trunks of the several branches of the nerve distributed to the groups of mus- cles 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. 112 Xo. 1 shows the point where the elec- trode will afreet 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 138 CAKIOUS PEOCESSES IK THE TEMPOBAL BONE. 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. CABIOUS PEOCESSES IK THE TEMPOEAL BONE. These do not characterize a large percentage of the cases of mid- dle-ear suppuration. They are sometimes due to tuberculous and other constitutional taints. AVhile very small areas are likely to be affected, they may extend to involve the wdiole 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 tym- panic w^alls and adjacent 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 free discharge of pus. Other dis- tressing symptoms in addition to pain characterize this condition: dizziness, noises, nausea or vomiting, insomnia, and fever. The dis- charge 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. 78). The meatus may be involved, — swollen or ulcerated. If the disease attack the inner tympanic wall, the external wall of the Fallopian canal may be destroyed, exposing the facial nerve to pressure or to the inflammatory process, resulting in facial paresis or paralysis of the same side. Exfoliation of the cochlea takes place in rare instances. Kichey reports two such cases. Goldstein (Annals of Ophthalmology and Otology, April, 1895) reports a case of exfoliation of the cochlea,, vestibule, and semicircular canals. A fair degree of hearing for con- versation with the affected ear remained. Later Euedo, of Madrid, reported a similar case with retention of hearing. Toeplitz (Archives of Otology, No. 2, 1892) reports a case of pri- mary labyrinthal necrosis with facial paralysis and deafness from scar- let fever. During the suppurative process two sections of the cochlea were exfoliated and removed through the external auditory canal. The diagnosis of necrosis or caries is not an easy affair unless it can be seen or felt. The probe may detect it if within reach, but the diseased bone may be defended by a growth of granulations form- CARIOUS PROCESSES IN THE TEMPORAL BOXE. 139 ing a more or less complete carpet. Great caution is required in probing so as not to displace the little bones or open up the labyrinth to the introduction of pus. If the treatment detailed under the cap- tion "Chronic Suppuration of the Middle Ear" does not succeed, after a considerable time of persistent effort, in diminishing and finally stopping the foul discharge, it is safe to infer that there is a carious condition of the bone. Caries is especially dangerous when the roof of the middle ear is its seat, for it may terminate in a rupture which will admit the pus into the cranial cavity. When the pyramid is in- §># fp%]£" t\ 1 1 3 ' 1 * 6 * m §m * 7 f f 10 // /I f 4 « 13 /* is- Fig. 78. — Sequestra of dead bone, and the ossicles. Actual size. The smooth surfaces of the walls of the tympanic cavity and of the meatus are shown in Xos. 1, 2, 3, 4, 5, 6, and 11; 13, mallet; 14, anvil; 15, stirrup. (Author's specimens.) vaded the hearing is destroyed and an unfavorable prognosis must be given. Erosion of the carotid canal may occur, or of the lateral sinus, with fatal haemorrhage. ' Such a case of destruction of the carotid canal came under my observation by the kindness of J. E. Davey, recently, which required ligation of the common carotid artery. Eepeated 140 CARIOUS PROCESSES IJS T THE TEMPORAL BONE. copious haemorrhages occurred from time to time, that could only be stopped by packing the meatus. Complete recovery followed ligation of the common carotid artery. Another method of termination is an extension of the caries to the cranial cavity and lateral sinus, or it may excite suppurative men- ingitis or phlebitis, or end in brain-abscess. A perforation of the inner table of the mastoid process may allow the pus to filter into Fig. 79. — Post-mortem section of the temporal bone, showing a perforation of the lateral (sigmoid) sinus at 1. Borders of sinus bounded by black lines. (Author's specimen.) the current of blood in the lateral sinus, producing pyaemia. The writer has such a typical specimen in his collection (Fig. 79). This was the case of a man with mastoiditis for whom I advised an immediate operation. The physician in attendance deferred the operation until, when it was performed, the patient was suffering profoundly from pyaemia. A hopeless prognosis was given. Autopsy TREATMENT? OF CARIOUS PROCESSES IN TEMPORAL BOXE. 141 revealed the perforation of the lateral sinus shown in the foregoing figure, through which the purulent contents of the mastoid cells were flowing. Fig. 114 is the same mastoid process as Fig. 79, showing where the fistula (No. 2) opened beneath the tip of the process and the attachment of the sterno-cleido-mastoid muscle, resulting m an 2^S£ Fig. 80. — The author's middle-ear curette. abscess of the neck, located underneath this muscle. No. 3 shows the opening made by a small trephine directly into the antrum, in which the probe rests. No. 4 is a tuft of cotton in the external au- ditory canal. There is no doubt that this patient's life could have- been saved had the operation been submitted to when it was first advised. Treatment includes thorough cleansing and disinfecting of the suppurating cavities and removal of granulations or polypi, as de- h d i f Fig. 81. — Horizontal section of the ear. a, anterior wall of the osseous meatus; /), its posterior wall; c, section of the membrana tympani, of the handle of the malleus, and of the posterior pouch; d, promontory; e, ostium tymp. tubse; f, stapes in connection with the inferior extremity of the long process of the incus and of the tendon of the stapedius; (j mastoid process; li, cochlea; i, vestibule; k, carotid canal. (After Politzer.) tailed in the foregoing pages. Anodynes must be given for severe pain. The denuded, roughened bone, if within reach, should be scraped free of all carious tissue with the middle-ear curette (Fig. 80), but 142 TEEATMENT OE CAEIOUS PEOCESSES IN TEMPOEAL BONE. only the most delicate resort to such procedure should be had in case the caries is located on the inner tympanic wall, for it is thin and easily perforated when carious (Figs. 81 and 101). After curetting, the treatment as detailed for chronic suppuration is called for. Sequestra are removed with ease or difficulty according to their size, shape, and location. Patients sometimes present pieces of dead bone that have become exfoliated and appear in the syringing process. The author has removed quite a large sequestrum from a boy 4 years old by means of cotton on a holder. During the examination the cotton used for drying out the ear was observed to become engaged in the angular spiculae of a sequestrum. So it was twisted firmly into them and drawn upon, with the result of extracting the quite large sequestrum completely (Fig. 78, No. 2, actual size). Other sequestra (actual size) from various cases are shown in the same figure. When the sequestra are too large and irregular to be extracted through the meatus without inflicting unwarrantable injury, they may be crushed by sequestrum forceps and removed in fragments. When an extensive sequestrum cannot be removed through the natural channel and sup- puration cannot be cured, and especially if urgent or dangerous symp- toms supervene, it is advisable to open the mastoid process and re- move as much of the posterior wall of the meatus as is required to extract all the dead bone. The diseased surface should then be cu- retted, dressed, and treated as detailed under "Mastoid Operations." The general condition of the patient may call for tonics and alteratives, which will readily occur to. the practitioner. CHAPTEE XIII. EXTEXSIOX OF EAR DISEASES TO THE CRANIAL CAVITY. Intracranial complications of suppuration of the middle ear take place in the following ways: By an extension of the carious process in the temporal bone to the cranial cavity, with evacuation of pus into the latter; by extension through the vessels and fenestras that penetrate the hone, resulting in purulent meningitis; by the formation of a subdural or brain-abscess, and by septic involvement of the venous sinuses, resulting in phlebitis, thrombosis, embolism, and septicaemia. Meningitis Complicating Otitis. Symptomatology. — Severe and continuous headache, localized or general, increasing in intensity and accompanied with photophobia, generally characterizes the onset of this disease. There are nausea or vomiting, sleeplessness, loss of memory, general hyperesthesia, dullness of intellect, and in children delirium and convulsions of the face (same side) and extremities. In the advanced stage opisthotonos may occur. The pupils are firmly contracted at first, afterward dilated and not responsive to bright light, but they are sometimes unequal. The temperature, like many of the other symptoms, is not constant, but it varies from 101° to 105° F. The pulse is accelerated at first, becoming slower by cerebral compression, and later again increasing. The respiration is irregular and jerky in inspiration, followed by a pause, and of a lengthened, sighing character in expiration. Hemi- plegia or paralysis of one or more extremities may occur, and when the third, fourth, or sixth nerve is involved strabismus follows. At last the power over the bladder and bowels is lost, the respiration is accelerated, the pulse rapid and compressible, and finally general pa- ralysis is followed by coma and death. Diagnosis. — This is, many times, difficult to determine, especially in children. The elimination of any other affection in the course of a purulent inflammation of the middle ear, the occurrence of con- stant fever, headache, and vomiting constitute the most important (143) 144 EXTRADURAL ABSCESS. diagnostic points. Add to these the signs of injection of the retinal vessels and often neuritis, and the diagnosis is rendered quite certain. Prognosis. — Without operation, death. Treatment. — If cold is agreeable the ice-cap should be continu- ously applied, bromidia given for pain, and the bowels relaxed. If a specific infection is suspected, iodide of potassium is indicated. The great fatality warrants an early surgical operation, which is described below and in Chapter XV. Extradural Abscess. This is a localized accumulation of pus hemmed in by adhesions of the meninges to the internal table of the skull. It generally re- sults from a slow extension of the disease of the tympanic cavity through the thin partition of the bone separating the latter from the cranial cavity. Symptomatology. — There are generally some fever, intense pain over the temporal bone, and the symptoms of meningitis; exacerba- tions are followed by improvement after a sudden discharge occurs from the ear. The abscess may not be located in any part of the motor tract; so that no localizing symptoms appear. Frank S. Mil- bury details an instance of suppuration of the middle ear and mas- toid process eventuating in a subdural abscess with consequent press- ure on the left temporo-sphenoid lobe of the brain. There were facial paralysis of the left side, slight paralysis of the right arm and leg, impaired mentality, and amnesic aphasia. (The Laryngoscope, December, 1897.) The temperature rarely rises above 102° F. Ten- derness over the painful area is usually present. When the cerebellar fossa is invaded, giddiness and vomiting may be expected. Diagnosis. — This is obscured, as appears from what has been said, by the indefiniteness of the symptoms. The points in diagnosis are detailed above. Prognosis. — This is unfavorable if the abscess rupture internally, but if it breaks externally or is evacuated by operation recovery may take place. Treatment. — Operative treatment only is effective. It consists of laying bare the tympanic cavity by the Stacke method (see "Mas- toid Operations"), evacuating the pus-cavity, removing all granula- tions and dead bone, cleansing, disinfecting, and dressing with aristol or iodoform and sterilized gauze. If no pus is found and the cerebral CEREBRAL AND CEREBELLAR ABSCESS. 145 pulsation is absent, as often happens in brain-abscess, the aspirator- needle may be used to explore the site of a suspected pus collection. Cerebral and Cerebellar Abscesses. These are the result of a chronic, rather than acute, suppuration of the middle ear. Over one-fourth of all cerebral abscesses follow this disease. Twice as many men as women are subject to brain- abscesses. They are generally located either in the temporal lobe or in the same side of the cerebellum as the aural disease (Bergmann). They may be deep-seated or superficial, single or multiple, in one or both sides of the cerebrum. Caries in the roof of the tympanum usually causes cerebral abscess, which covers the posterior surface of the pyramid, but caries in the mastoid process causes cerebellar ab- scess. The size of the pus-cavity varies from an eighth of an inch (three millimetres) to several inches (centimetres) in diameter. Symptomatology. — Bergmann classifies the symptoms of such abscesses as follow: 1. Those of suppuration: paroxysmal fever, chills, dullness, depression, loss of appetite, indigestion, rise of tem- perature in region of abscess, and tenderness on percussion. 2. Pressure symptoms: headache, dizziness, unconsciousness, delirium, twitching and paresis in extremities and facial muscles, strabismus, disturbance of vision and speech, slow pulse, sleepiness, Cheyne- Stokes respiration, eclamptic attacks, and intermissions. 3. Pus in the temporal lobe, with inability to speak certain words, is rare. In the cerebellum it produces dizziness and a staggering gait. The time-limits of brain-abscess are very variable. It may exist indefinitely without urgent symptoms. An old abscess contained within a connective-tissue capsule may remain innocuous until it ruptures outwardly, producing meningitis, or until encephalitis su- pervenes in its vicinity, or it may discharge into the ventricle. A fatal issue may result from metastatic abscesses. For example, the waiter has seen the whole anterior aspect of the thigh converted into an immense pus-reservoir. There is a marked predilection for the lungs. The end may be preceded by cerebral compression, great prostration, or paralysis of the respiratory or circulatory centres. Diagnosis. — This is sometimes impossible, for the symptoms are absent until the end approaches. When the health steadily declines without other assignable cause, coupled with otorrhcea, insomnia, con- stant temperature of about 99° F., localized pain in the same side of 146 OPERATIONS FOR BRAIN-ABSCESSES. the head or in the occiput, we are safe, by the process of exclusion, in arriving at a diagnosis of this disease. Prognosis. — Without operative interference the termination is fatal, but the prognosis has been illuminated with the brilliant rec- ords of Macewen and Ivorner, 95 per cent, recovering from operations by the former and 60 per cent, of the cases compiled by the latter. Treatment. — Until a diagnosis can be made, there remains little to do except to direct our efforts toward improving the general health and relieving temporary symptoms. A surgical operation is the only curative measure. Operations for Brain-abscesses. Eeferring to the skull (Figs. 98 and 99) that the author has prepared to illustrate the various operations for trephining and for mastoid diseases, the surgical relations of the parts involved will ap- pear. The field of operation is prepared on the previous day by shav- ing, scrubbing with soap and water, and afterward with alcohol or ether, leaving a generous margin hairless (Fig. 113). Then the head is bandaged with sublimated gauze. The bowels are relaxed by a saline draught on the previous evening and evacuated by an enema on the morning of the operation. Nothing but beef-tea is allowed on the operating day. While ether is generally to be preferred in other operations, chloroform is allowable in this instance, since it causes a depression of the cerebral centres, while ether acts as an excitant. The point selected for the centre of the half-inch trephine is seven-eighths of an inch above the centre of the meatus (Fig. 98). Incisions at right angles to each other are usually made, intersecting each other at this point, although Horsley prefers a semicircular flap. The cut should penetrate to the bone, and all the soft tissues are raised (Fig. 93), preserving the periosteum, and retracted by the double hooks (Fig. 94). The trephine now having been used, if the opening is not capacious enough it can be enlarged without injuring the dura by an ingenious device of DeVilbiss, of Toledo, or with the chisel. The dura is opened in a valve-shaped flap by a circular in- cision one-eighth of an inch inside the bone-perforation, so as to permit of this remaining margin being sewed to the flap of the dura afterward if necessary. If there is no cerebral pulsation the abscess may be expected to be superficial, but even if pulsation is present there may be a deeply-seated pus-cavity. SINUS-PHLEBITIS AND SINUS-THKOMBOSIS. 117 The aspirating-needle should now be inserted in the supposed direction of the abscess if no pus appear. Or a sharp bistoury may be cautiously introduced once or twice or even a third time in dif- ferent places. If pus escape the opening is enlarged, as complete evacuation as possible is effected, and the cavity is cleansed, disin- fected, and packed with iodoform gauze, or a rubber drainage-tube may be inserted. If no pus is found the dura is sutured; the bone button, having been preserved in sterilized warm water, is replaced; the periosteum stitched in situ, the soft parts brought together, and the skin-wound is closed with the finest catgut suture. Sterilized gauze, absorbent cotton, and a bandage complete the dressing. "When the abscess is located over the roof of the mastoid antrum, the latter is opened, and in most of these cases it is filled with either pus or a cholesteatoma. Enough of the roof of the antrum is chiseled away to allow of examination of the dura. If the latter is covered with granulations or if no pulsation is present, it should be entered. If no pus is found, a way is made leading to the roof of the middle ear (Krister), avoiding the facial nerve and semicircular canals by going above the former and external to the latter. An incision is then made in the middle portion of the temporal lobe. The after- treatment is described above. Knapp (Archives of Otology, April, 1895) performs the tympano-mastoid cranial operation for otitic brain-abscess. Cerebellar abscesses may be reached by chiseling the mastoid process so as to penetrate the posterior fossa without opening the lateral sinus, or the trephine may be used so as to perforate the occi- put between the occipital and the lateral sinuses (Fig. 98, v). It should not be forgotten to always give a very guarded prognosis. Besides the causes of fatal termination already mentioned the end may be hastened by haemorrhage from the middle meningeal artery, gangrene of the brain, pyaemia, and prolapsus of the brain. Zaufal {Archives of Otology, April, 1895) first opens the posterior fossa, and if results are negative then the middle fossa, if the cranial cavity is to be opened after a mastoid operation. Sinus-phlebitis and Sinus-thkombosis. These complications result from caries or necrosis of the poste- rior tympanic wall in a considerable proportion of cases, but the lateral (sigmoid) sinus is the vessel most often affected. The supe- rior petrosal and cavernous sinuses and the internal jugular vein are 148 TREATMENT OF SINUS-PHLEBITIS AND SINUS-THROMBOSIS. rarely involved, the latter in caries of the inferior tympanic wall. While the cause is generally an extension of the necrotic process of the bone to the walls of the sinus, phlebitis may also result from septic infection transmitted by the veins communicating with the sinus. We may have accompanying this condition cerebral abscess or meningitis. The preceding suppuration has generally, but not always, been of long duration. The attack is sudden and character- ized by pain in the occipital region and neck, chills, loss of appetite, and a temperature above 104° F., with remissions. The pulse is rapid, the skin dry, the tongue dry and coated, but consciousness may or may not be affected. Occasional symptoms are dizziness, stiffness of the muscles of the neck, optic neuritis, vomiting, delirium, con- vulsions, coma, and others suggestive of septicaemia. When the in- ternal jugular vein is affected, a dense cord, tender on pressure, may be distinguished along the anterior border of the sterno-mastoid mus- cle if the neck has not become too oedematous. If the cavernous sinus is involved the oedema may extend to the face, nose, and eyelids. The fatal termination, which often occurs in about three weeks, is most likely to result from pyaemic pneumonia. However, the dura- tion varies greatly from a few days to months. Eecovery cannot be expected without surgical interference. Treatment. — Stimulants, nourishing diet, and antipyretics are indicated until the operation is decided upon. The mastoid process should be opened (see "Mastoid Operations") and the sigmoid sinus laid bare. If it has not the natural dark-blue color or pulsation, but is hard, thickened, and inflamed, a thrombus is probably present. If a broken-down thrombus or pus is present, there will be fluctuation and absence of pulsation. The aspirating-needle should be inserted to ascertain the nature of the contents. If either condition mentioned is found, the sinus should be laid open longitudinally with a sharp bistoury, cleaned out with forceps and curette, washed with bichloride solution, 1 to 2000, and dressed with iodoform gauze. If the internal jugular vein is thrombosed, it should be ligated low enough in the neck to get below the thrombus. The upper seg- ment is brought out of the wound, the thrombus removed and the vein is treated as already indicated. This will prevent infection of the lungs if resorted to early enough. CHAPTER XIV. DISEASES OF THE MASTOID PROCESS. Pathology. — Primary acute inflammation of the mastoid process is a rare disease. Any affection of this part is nearly always conse- quent upon a middle-ear inflammation. The disease may he limited either to the lining membrane of the pneumatic spaces or to the peri- osteum of the cortex, or both membranes and the bone itself may be involved. In the acute form the latter condition is most likely to prevail, especially when it is consecutive to an acute middle-ear sup- puration. Unless the inflammatory process is speedily interritpted, necrosis of the hone may occur, with a growth of unhealthy granula- tions; the formation of a fistula, either externally through the cortex, presenting a post-aural abscess, or through the posterior wall of the bony meatus (Fig. 99), or internally, communicating with the cranial cavity through the lateral-sinus wall (Fig. 79) or through the roof of the tympanic cavity. In this manner the posterior or the middle fossa (Fig. 82) may be invaded by the purulent discharge, thus giving rise to meningitis, subdural abscess, sinus-thrombosis, pyaemia, or brain-abscess. M. D. Lederman reported a case of extension of mid- dle-ear and mastoid suppuration to the cranial cavity, in which "soft- ening of the lower portion of the right temporo-sphenoid lohe of the brain was found, accounting for paralysis of the arm and leg of the opposite side** {The Laryngoscope, July, 1896). Moos (Archives of Otology, July, 189-1) reported a case of "mastoid disease extending outward by way of the mastoid fissure, the continuation of the petro- squamous suture.'* In the more favorable cases the discharge contained within the antrum and cells may find exit through the middle ear and external canal, or, if pus form beneath the mastoid periosteum, the resulting post-aural abscess may rupture spontaneously. This often occurs when the pus has found its way from the antrum through a fistulous opening in the cortex: so that the mastoid antrum comes into direct communication with the external world. In 1881- the author treated such a case in a lady nearly 80 years old. The discharge had ceased and there was a fistulous opening, surrounded by the blackened, ex- (119) 150 DISEASES OF THE MASTOID PEOCESS. posed bone three-eighths of an inch (one centimetre) in diameter, leading into the tympanic cavity. The hearing for conversation was not lost, no inconvenience was suffered, and she did not wish the opening to be closed. The patient remained in excellent health when last seen, twelve years afterward. An occasional result of inflammation of the mastoid cells is a Fig. 82. — Interior of base of skull. LS lateral (sigmoid) sinus; U, parallel lines over the superior semicircular canal; 0, internal auditory meatus; X, opening by trephine for abscess over the middle ear. The cranial fossae and sinuses are shown. (Author's preparation.) proliferation of osseous tissue, which fills and obliterates the pneu- matic spaces, leaving the whole area a dense, ivory-like mass. I have encountered a few such processes in which no pneumatic cells could DISEASES OF THE MASTOID PEOCESS. 151 be found, and the chisels were bent and chipped as though driven against stone (osteosclerosis). Etiology.; — Primary mastoiditis may occur as the result of trau- matism or exposure to cold. Generally mastoid disease is a complica- tion and is most prevalent during influenza epidemics. In the latter case, at least, it is probable that a bacterial infection occurs through the Eustachian tube from the respiratory passages, since it has been demonstrated that the diplococcus of pneumonia is present in the mastoid discharge (Scheibe). Frank Eumbold reported a. case of mastoiditis in April, 1898, in which he attributed the attack, in a patient suffering from diabetes, to carious teeth of the lower jaw. After a mastoid operation had been performed without marked relief the diseased teeth were extracted, after which the patient experienced freedom from pain and made a good recovery. It should be borne in mind that the relations of the antrum and middle ear, being connected by the aditus ad antrum, or passage from the tympanic attic to the antrum, are such that any fluid in the tym- panic cavity naturally gravitates into the mastoid antrum when the patient reclines upon his back. Indeed, the antrum is the drip-cup of the tympanum, and whenever there is considerable fluid in the middle ear it finds its way into the antrum. This does not of ne- cessity imply an inflammation of the pneumatic cells, but when micro- organisms — streptococci, etc. — are present the danger to the integrity of the lining membrane and delicate cellular structures is apparent. Symptomatology. — Acute mastoiditis is accompanied with pain, which, though slight and annoying at first, becomes violent and ex- hausting as the disease progresses. After a few days the tongue be- comes coated and the temperature elevated two or three degrees. If there is periostitis there are also tenderness, redness, and swelling over the mastoid region. Pain is sometimes referred to the temporal, the supra-orbital, or the occipital region. Fluctuation denotes either a subperiosteal abscess or a fistula. Great variations in temperature during the day should excite suspicion of sinus-thrombosis; but as descriptions of intracranial complications have already been given (Chapter XIII) they will not be repeated here. A most noticeable sign of mastoid periostitis and oedema of the overlying structures is a pronounced prominence of the auricle, which projects out promi- nently at a right angle to the side of the head. Pain is not always present in mastoid disease, especially after the acute stage has passed, and one must not expect to find the whole 152 DISEASES OF THE MASTOID PEOCESS. group of symptoms present in every case. They are not constant. Great destruction may take place in the process without proportionate discernible manifestations. This demonstrates the insidious and dan- gerous character of the disease. If there is no ear discharge in acute mastoiditis of the cells, one may expect to find a bulging drum-head, and the postero-superior wall of the meatus may be found depressed. The inflammatory process may continue for several weeks with recurrences and remissions of the symptoms, but the closest watch must be kept in order that any impending invasion of the cranial cavity may be averted by prompt surgical interference. Pus may in- vade the middle fossa through the tympanic roof or antrum. If it break posteriorly from the middle ear or mastoid cells, it reaches either the lateral sinus or the posterior fossa.. If it advance ante- riorly from the middle ear, it may form a superficial abscess in the neck or a retropharyngeal abscess. It may break through the inferior surface of the mastoid process and form an abscess beneath the sterno- mastoid muscle (Fig. 11^1). If it find an outlet through the inferior surface of the petrous portion of the temporal bone, it may burrow beneath the deeper layer of muscles even to the thoracic cavity. When the cervical tissues become infiltrated in the region of the sterno- mastoid muscle, or an abscess of the neck forms, the head becomes more or less fixed, the face everted, and movements involving this muscle are restricted and painful. When a retropharyngeal abscess is present the jaw is fixed and cannot be moved or depressed suffi- ciently to examine the tongue or throat except with great pain (Plates IV and Y). Diagnosis. — In acute mastoiditis the symptoms enumerated are so prominent and characteristic that no difficulty presents itself in recog- nizing the condition, but in chronic suppuration of the mastoid cells, in the absence of a fistula, it is not so simple a task. Persistent dis- charge, notwithstanding the treatment, foul odor, bulging of the postero-superior wall of the canal, tenderness over this region, and impaired nutrition indicate a mastoid disease. Prognosis. — Uncomplicated acute mastoiditis, subject to early treatment, presents a favorable outlook. A large proportion of such cases will recover without an operation; but the treatment must be instituted promptly in order to prevent extensive destruction of the bone and intracranial complication. When the latter occurs the jorognosis is unfavorable without an operation; but surgical interfer- ence presents good chances of recovery if not delayed until the occur- TREATMENT OF DISEASES OF THE MASTOID PEOCESS. 153 rence of septicaemia, brain-abscess, sinus-thrombosis and phlebitis, or meningitis. Yulpius (Archives of Otology, April, 1895) reports three cases of influenzal otitis, mastoiditis, and epidural suppuration cured by operations. Treatment. — If the patient is seen before perforation of the drum-head occurs, and signs of fluid in the middle ear are discovered, paracentesis should be performed at once, as described in treating of acute inflammation of the middle ear (page 77). The incision should be a long one, for its tendency is to close soon. A case to the point occurred while writing this. It became necessary to make an ex- tensive opening in the drum-head and to incise the bulging posterior wall of the meatus, under ether, although a few days earlier a minute perforation was enlarged under cocaine. The first incision had healed, Fig. 83. — The author's ice- the discharge ceased, and great pain and a sense of pressure ensued from the accumulated pus that was unable to escape. In acute inflammation the ice-bag '(Fig. 83) should be applied without delay, and kept continuously in place until either the in- flammation subsides or it becomes evident that an operation is im- perative. The crushed ice must be replenished as fast as it melts. One or two days may be long enough, but I have found it necessary at times to maintain constant cold for three or four consecutive days and nights. Sometimes an exacerbation occurs and the ice must be resorted to again. This plan succeeds in some very serious cases, but if pus has formed the ice may fail. For example: two children about 6 years old presented acute mastoiditis on the same day. and ice was applied alike to both. In five days one was discharged cured and the 154 TREATMENT OF DISEASES OF THE MASTOID PROCESS. other' developed a post-aural abscess, on opening which a fistula was found leading to the antrum. The ice-bag was powerless in the one ease to avert a mastoid operation, because destruction of osseous tis- sue had already taken place. Counter-irritation by mustard over the whole mastoid region, and along the course of the Eustachian tube when it is involved, often assists materially. It should be used nearly, but not quite, to the point of vesication, and then replaced by spirit of camphor on a flannel compress until the blush fades and the cutaneous irritation is again indicated. Leeches afford speedy relief during the acute, intense stage . of the inflammation. They should be applied over the mastoid process near the auricle. Detailed directions for applying leeches will be found in the treatment of acute inflammation of the middle ear (page 76). General antiphlogistic treatment and anodynes are fre- quently called for, with laxatives for the bowels, as mentioned under the same heading. If the application of the ice-bag is followed in a few days by subsidence of pain, fever, and the other symptoms, or if the cold is badly borne, it should be discontinued. If, in spite of all these antiphlogistic measures, the steady march of the destructive process is not stayed, an operation must not be too long delayed. A week or ten clays may give sufficient time for extensive infiltration and invasion of the more vital organs. Nevertheless, the writer has seen numerous instances in which very grave and alarming symptoms have yielded to this palliative method of treatment, — cases in which ex- cellent surgeons believed an operation to be unavoidable. But it is a matter of duty to emphasize the possibility of a sud- den fatal termination if the necessary operation is too long post- poned. Fatal results have followed such delays and refusals to allow operations, but I have never seen a fatal termination due to the operation itself. The disease is dangerous; the operation itself is not, in the hands of a competent operator. If the mastoid process con- tain necrotic tissue, the operation affords immediate relief. It gives free exit to the pent-up discharges and removes a threatening cause of disaster. Any well-informed surgeon, after sufficient practice on the ca- daver, can perform the operation with safety and success if he follow closely the rules laid down; but in order to have well at command all the surgical relations of the parts concerned, the operation ought INDICATIONS FOE OPERATING ON MASTOID PROCESS. 15-3 to be previously studied and performed numerous times on the ca- daver. To illustrate: out of seventeen mastoid operations the author has made in one month, twelve were on cadavers and five only on patients. M. D. Lederman advises, as an abortive measure, incision through the posterior fold of the drum-head, extending through Shrapnelhs membrane and into the superior wall of the meatus, so as to produce free blood-letting. (The Laryngoscope, January, 1898.) Wilde's incision, at least, should be made as soon as it becomes evident, by the presence of a fluctuating swelling back of the ear, that pus is present. Any one can do this with a sharp, strong bis- toury (Fig. 84:). The cut is made as nearly as possible in the line of the incision that may be required later for the mastoid operation, — about three-eighths of an inch (one centimetre) posterior to the insertion of the auricle and parallel with it (Fig. 105). The incision is carried down to the bone, the pus evacuated, and a fistula searched for with a strong probe. If none is present, and it is apparent Fig. 84. — Buck's mastoid knife. that the abscess is subperiosteal, and no superficial caries of the bone needs curetting, the cavity is treated antiseptically, as will appear later, until pus formation ceases. Then it is allowed to close. Indications and Peepaeations foe Mastoid Opeeations. Indications for Operating.— The following six rules, by which the perplexing question of when to operate is decided, were presented by the writer in a paper before the first Pan-American Medical Con- gress, and received the approval of the aural surgeons present, in- cluding Professor Politzer, with unanimity of opinion: — The mastoid process should be opened 1. When there is acute inflammation of the bone that resists palliative treatment. 2. When repeated swellings and abscesses occur. 3. When there is a bulging of the posterior and superior wall of the meatus, with suppuration of the middle ear. 4. When there is a fistula. 156 PREPARATION OF THE PATIENT POP AN OPERATION". 5. When there are severe pains in the same side of the head as the diseased ear and they resist all other treatment. 6. When a foul otorrhcea cannot be cured by any other means. These rules may be termed conservative, and whatever deviation we may indulge in ought to be at once favorable to the operation and the welfare of the patient. Too great temporizing favors sinus- thrombosis, septicaemia, brain-abscess, and meningitis. There are a few points in this connection worth mentioning, for they are closely related to a successful issue. Excellent illumination is had by the use of light reflected from a mirror on the operator's forehead, after the cortex is opened (Fig. 4). This affords a decided advantage over window-light. It is more intense, especially from the sixty-candle-power incandescent gas-burner (Fig. 5); it can be thrown Fig. 85. — The Nevius electric head-lamp. into the opening of the bone in every direction, and there are no shadows to obscure the field. The Nevius electric head-light (Fig. 85) affords an ideal illumination for mastoid operations. It is at- tached to the head-band by a ball-and-socket joint, and it gives a very brilliant light, exceeding a 16-candle-power lamp. It is op- erated by connecting it by a plug to an incandescent-electric-lamp fixture. I have used this illuminator in mastoid operations with the utmost satisfaction. Preparation of the Patient. — The day preceding the operation the patient's mastoid region, together with an area of three inches in extent above and behind the auricle, is shaved and washed with soap and warm water, then with ether, and finally with very warm bichloride solution (hydrargyrum bichloride), 1 to 1000. The meatus PREPARATIONS FOR OPERATIONS. 15' is syringed with the latter solution. The parts are then dressed with sublimated gauze and a bandage. The bowels are relaxed the same evening, and beef-tea only is allowed on the day of the operation. Fig. 86.- — A strong scalpel. Ether is preferable to chloroform on account of its greater safety. Only so much as is absolutely necessary to procure freedom from pain, movement, and shock is employed, in order to avoid a subsequent bronchitis or pneumonia. Fig. 87. — The author's mastoid chisel. Actual width. The patient's clothing is removed from his shoulders and a blanket, covered with a rubber sheet, is substituted, so as to have the clothes clean when he is returned to bed. The hair, especially in the case of females, need not be entirely sacrificed (Fig. 113), as is siiiigggigiiiMii ^^^^^^22SK3«2ES ww;TOK ''«i amillli Fig. 88. — The author's long mastoid gouges. Actual width. often done, but it is preserved in a cleanly condition by enveloping it in a sublimated cap or towel. The operator and assistants prepare by rolling the sleeves above the elbows and vigorously scrubbing their forearms, hands, and nails 158 INSTRUMENTS KEQUIEED FOR MASTOID OPERATIONS. with brush, warm water, and soap, and lastly with alcohol. Kubber aprons and operating-gowns complete the surgeon's toilet. A table forty-two inches high is preferred by the writer in order to escape Fig. 89.— Lead-filled mallet. the necessity of a wearying, stooping position during the operation. The patient's head rests on a small rubber drainage-cushion (Fig. 95). The instruments, a quarter of an hour before they are needed, are boiled for five minutes in a 1-per-cent. solution of bicarbonate Fig. 90. — The author's set of curettes. of sodium, which does not corrode, and then they are placed in warm, sterilized water. The scalpels are simply immersed in boiling water a moment. For many years the writer used a 5-per-cent. carbolic- acid solution for the instruments, instead of boiling, but a serious Fig. 91. — The author's mastoid guide. objection to this was that the operator's fingers were benumbed by the acid, for the instruments were kept immersed in the solution during the operation. The instruments required are a couple of strong, sharp scalpels INSTRUMENTS REQUIRED EOR MASTOID OPERATIOXS. 159 (Fig. SG), four artery-forceps, a periosteum elevator, self-retaining retractors, a strong chisel (Fig. 87), three sizes of long gouges (Fig. 88), a metal mallet (Fig. 89), several sizes of curettes (Fig. 90), strong probes and forceps, a mastoid guide (Fig. 91), tongue-forceps (Fig. 92), and a syringe (Fig. 33), with hot water. Fig. 92. — Mathieu's tongue-holding - forceps. The Periosteum Elevator, Retractor, and Curette. This hoe-shaped device (Fig. 93) overcomes a serious objection to the misnamed periosteotomes we have formerly used. Indeed, these instruments should not be "tomes" at all. They should not cut the membrane, but should lift it from the bone in continuity, so as to carefully preserve its integrity. The old periosteotomes put the operator at a disadvantage by necessitating an unnatural play of his muscles. With a pushing motion one has not perfect control of the movements of the instru- ment and it is likely to slip and cut where it is not desirable to wound. In the use of this kind of a lifter the motion is one of drawing or Fig. 93. — The author's periosteum elevator. pulling toward one's self; so that the muscles brought into play are, together with the instrument, under easy control, — on the same prin- ciple as the farmer's use of his hoe, after which it is patterned. As the separator serves the purpose not only of detaching the periosteum, but of retracting the loosened tissues, or of curetting necrosed bone, it may be said to constitute three instruments in one. 160 INSTRUMENTS REQUIRED FOR MASTOID OPERATIONS. The self-retaining retractors (Fig. 94) take the place of an as- sistant in keeping the soft tissues out of the way of the operator and in controlling the hemorrhage during mastoid and other operations of like magnitude. The retractors consist of two shafts, each armed with a series of hooks that can be brought together and interlocked for insertion into the incision, when they can be separated and fixed at any desirable point up to two inches apart. After they have been drawn apart as far as may be required, the thumb-screw on the fixa- tion-bar next to the hooks should be screwed down firmly into the bar, the handles should be pressed a little together until the tissues are well stretched as the distal ends of the retractors separate, then the thumb-nut on the thread-bar should be turned down against the movable handle. If the instrument is properly adjusted the tissues cannot slip out Fig. 94. — The author's self-retaining retractors. of its jaws, and their pressure on the stretched lips of the wound reduces the haemorrhage to a minimum. In some operations these hooks have proved more effective than five artery-forceps. The following arrangement renders these retractors equally useful in the smallest and the largest mastoid operations: The terminal half of the shaft of hooks can be slipped out of the main half, leaving the retractors only an inch long. Eeplacing the adjustable series of hooks makes them two inches long, and by drawing these adjustable hooks outward one-half inch one can lengthen the hooks to two and one-half inches. This has the effect, when the instrument is in position in a large wound, of making an opening two inches to three and one-half inches wide by three or more inches long, through which to work. However, the opening can be made as small as one wishes, and the capacity of the instrument is far beyond what we usually re- quire in operations on the skull; but the writer has had it made so INSTRUMENTS REQUIRED EOR MASTOID OPERATIONS. 161 as to be of service in other and more extensive operations, since its size in no way impairs its efficiency in mastoid cases. The handles are constructed to take up as little room as possible. When the adjustable parts of the hooks are removed for small operations the openings in the permanent hook-shafts, into which the adjustable hooks fit, may be securely sealed by a bit of beeswax to prevent the entrance of blood, etc. After being used, this wax will run out on the application of a little heat. A drop of oil should then be put in the same openings to prevent corrosion or sticking of the adjustable shanks. The straight-edged chisel is employed to open the firm cortex, but after the antrum or cells are reached the writers long gouges are better adapted to the work (Fig. 88). The length of the shafts allows the operators hand to be sufficiently removed from the cavity to give an unobstructed field of vision. As we cannot know the extent of the pathological process before entering the bone, it does not appear to be advisable to decide in ad- vance upon any special method of procedure save one: remove all dead and diseased tissue. "Whatever method does this is best. Stackers and Bergmanms operations have the advantage of affording the great- est accessibility to the tympanum; so that if it is necessary to remove necrosed ossicles or diseased tympanic tissue it can be done with greater facility and thoroughness. CHAPTER XV. THE MASTOID OPERATIONS. For our purpose it is most convenient and practical to treat of mastoid operations under three headings: (1) the Schwartze mastoid operation; (2) the radical tympano-mastoid operation; (3) the modi- fied operation. The Schwartze operation is the one most commonly performed, and is adapted for primary mastoid abscess, or that condition in which it is necessary to penetrate the bone without entering the tympanic cavity. The radical operation, devised by Stacke, is much more exten- sive and complicated, and is intended to open not only the antrum, but to expose the whole tympanic cavity and to remove one or more of the ossicles and any diseased tissue that may be found in the mid- dle ear. The modified operation is a convenient combination of the best principles governing the other two, more thorough than the first, and less menacing to important structures than the second. The Schwartze Mastoid Operation. All preparations having been made as already detailed (Figs. 95 and 96), the ear cleansed, etc., the auricle is bent forward and the incision is made, beginning at the apex of the mastoid and extending upward and forward until within three-eighths of an inch (one centi- metre) of the auricular attachment; then it is carried parallel to the auricle to a level with its superior attachment. The incision should be made from below upward, for if made in a downward direction it is possible for the knife to slip off from the rounding surface of the mas- toid tip and plunge into the soft tissues of the neck, for one naturally bears hard upon the knife to cut to the bone. The posterior auricular artery or its anterior branch will have been severed and is caught up with the small artery-forceps and twisted. The forceps, can be left holding it, instead of stopping to ligate. The bleeding may be considerable for a few minutes, and if a (162) THE SCHAVABTZE MASTOID OPEEATIOX. 163 .pus-cavity is opened the contents usually gusli out with considerable force. The haemorrhage is dried rapidly with small pieces of moist sterilized gauze, the assistant consuming as little time as possible. If necessary, several small artery-forceps can be used to arrest the venous now, and they can be left in situ when the retractors are Fig. do. — A mastoid operat applied. The periosteal elevator (Fig. 93) is now used to separate the periosteum backward far enough to expose all the surface cov- ering the cellular part of the bone, and forward to the posterior mar- gin of the external meatus. The periosteum should be kept intact and carefully preserved. The self-retaining retractors (Fig. 94) are then inserted into the wound, the teeth being interlocked and resting 16 J: THE SCHWARTZE MASTOID OPERATION. on the denuded bone. They are then separated as far as possible and fastened as previously described. In short incisions, as in chil- dren, the additional hooks are not needed. The haemorrhage now l^ractically ceases from the soft tissues because of the pressure and stretching by the hooks. If a fistula in the bone is found, it is en- larged; if there is none, and the antrum is sought, the bone is opened on a level with the superior border of the external meatus and three-eighths of an inch (one centimetre) back of its posterior wall (Figs. 97, 98, and 99). The mallet and straight-edged chisels are used to remove the Fig. 96. — Operating-room and accessories. 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 be removed is inward, forward, and a little upward (Fig. 97); but one must always bear in mind that these are relative terms, 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 the horizontal plane of its axis if the antrum is to be opened (Fig. 100) and the facial nerve avoided. THE SCHWARTZE MASTOID OPERATION" 165 As soon as the cortex is removed the forehead-mirror or electric lamp (Figs. 4 and 85) and brilliant illumination should be used (Fig. 5). If dead bone is reached there is little or no difficulty in distin- guishing 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 re- moved until nothing but healthy tissue is to be seen. The opening in the cortex should be made spacious enough to 5 4 Fig. 97. — Horizontal section through right temporal bone, cut two millimetres above the centre of the external canal. 0, opening in mastoid leading to antrum; the heavily-dotted lines indicate the depth to which the opening penetrated in the upper section of this bone; small arrow in- dicates the relative position of the spina ; 22, wedge between opening in mastoid and external meatus; M, mastoid; 23, dotted lines indicating how osteosclerosis may increase the depth to which it is necessary to pene- trate; C, external canal; *, large cell in direct communication with the floor of the antrum above; LS, lateral sinus; z, posterior semicircular canal; A, facial nerve; x, horizontal semicircular canal; 2, vestibule; 1, internal canal; 3, cochlea; 4, fenestra ovalis; 10, Eustachian canal; MT, membrana tympani. (After C. E. Holmes.) 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 bv twelve or fifteen millimetres, with the 166 THE SCHWARTZE MASTOID OPERATION long axis in the vertical. The surgeon should be satisfied with noth- ing but thoroughness of detail. If the carious bone extend to the dura or lateral (sigmoid) sinus it is removed thus far, exercising great caution not to injure either, and, although it has often been neces- sary to expose both, we have never seen any ill results follow. If the sinus should be accidentally opened, the hemorrhage will be profuse and will probably necessitate tamponing the cavity with iodo- Fig. 98. — Side-view of a skull, showing (Hi) opening in mastoid process for Schwartze operation. The wavering black line just above 1 is the course of the facial nerve exposed; above and at the left of this is seen the tym- panic cavity; ii, opening by trephine to explore the roof of the middle ear; Hi lie over the course of the lateral sinus; iv, Heed's base-line; f, trephined opening for cerebellar abscess. (Author's preparation.) form gauze and postponing further operative procedure for a fort- night, unless sufficient pressure can be exerted to suppress the bleed- The variation in the distances between the external canal and the lateral (sigmoid) sinus is shown in the same individual on the opposite sides of a skull in my possession (Figs. 82, 101, and 102). The surgical relations and close proximity of the sigmoid sinus, the THE SCHWARTZE MASTOID OPERATION. 167 tacial nerve, and the semicircular canals are plainly visible in Figs. 97, 101, and 103 (LS, X, etc.). In many cases this operation suffices to effect a cure and it is not necessary to proceed farther. All projecting spicule of bone are removed, rough corners rounded off, the wound is syringed with quite warm bichloride solution, 1 to 1000, then dried and sprinkled with aristol (Fig. 34) or iodoform powder (Fig. 67). The upper sec- tion of the wound is stitched to a level with the upper border of lig. 99. — Schwartze operation. View of skull from below, showing tympanic cavity, looking from below upward and inward. The antero- inferior wall of the osseous meatus is removed, i, postero-superior wall of the meatus; at the right of i is an opening into the mastoid cells; ii, opening above meatus for cerebral abscess; Hi, Schwartze opening into antrum; v, opening for cerebellar abscess; 6, exit of facial nerve (black line running downward) ; 7, stirrup in foramen ovale. The dark space just above the stirrup shows the opened Fallopian canal. (Author's prep- aration.) the bone-opening only. The cavity is packed very lightly with iodo- form gauze, covered thickly with absorbent cotton, and the dressing is completed with a net or crinoline bandage. These bandages are 168 THE SCHWARTZE MASTOID OPERATION. not to be applied very firmly, since the sizing they contain, being moistened before they are applied, dries and contracts, setting some- what like a plaster-of-Paris bandage. Later, a rubber adhesive plaster Fig. 100. — Opening of the antrum. W W and T Y, horizontal and perpendicular planes of the skull; 0, opening in mastoid leading to antrum; OA, antrum; LS, lateral sinus; M, mastoid process; 22, posterior wall of external meatus; 15, styloid process; MT, membrana tympani; 14, 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. (After C. R. Holmes.) THE SCHWARTZE MASTOID OPERATION. 169 O^lfiZ 2\« 3\0 "i Fig. 101. — 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. LS, lateral sinus; M, mastoid; N, 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. (After C. R. Holmes.) Fig. 102. — 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, a, internal carotid artery; T 7 , internal jugular vein. For explanation of other letters see Fig. 97. (After C. R. Holmes.) 170 THE SCHWARTZE MASTOID OPERATION, can be substituted for the bandage (Fig. 104). 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. In case the temperature was 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 tissue formation, while too infrequent dressings favor decomposition, septic infection, and exuberant granulations. Even -ZS Fig. 103.- — Perpendicular section through the right temporal bone, be- ginning at line B B, behind opening O in mastoid (Fig. 100), and directed inward and forward, cutting Eustachian tube in its long axis. N, dotted lines show the course of the facial and chorda- tympani nerves; M, mas- toid; Ck, 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. 100); LS, lateral sinus;*, antrum; O, dotted lines indicating funnel-shaped opening (Fig. 100). (After C. R. Holmes.) in this operation the author often connects the middle ear with the mastoid opening so as to permit a current of water to pass into one and out of the other for the sake of absolute cleanliness. THE SCHWAETZE MASTOID OPEEATIOX 171 Fig. 104. — Adhesive-plaster dressing for mastoid wound. (Author's case.) Fig. 105. — Line of incision healed two months after a Schwartze operation. (Author's case.) 173 THE KADICAL TYMPANO-MASTOID OPERATION 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 as- sistants one can acquire dexterity in operating without incurring any risks, and the patients make a better recovery than when narcosis is protracted. The length of time required for complete recovery varies greatly. We 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 would be a fair average time to give Fig. 10G.— The Stacke operation completed. (After C. R. Holmes.) as necessary for a cure, and patients should be informed that it may require longer (Fig. 105). The Radical Tympanomastoid 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. 106). After the periosteum is raised to the margin of the meatus the periosteal end of the mastoid guide (Fig. 91) is inserted between the posterior wall of the osseous canal and its periosteal THE RADICAL TYMPANOMASTOID OPERATION. 173 Fig-. 107. — ^ide of skull, showing' Stacke operation. 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. (Author's preparation.) 174 THE RADICAL TYMPANOMASTOID OPERATION. lining, and the latter is raised as far as the membrana tympani. One can tell when the middle ear is reached, for at that instant resistance ceases. The instrument is carried no farther inward, but is moved carefully 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 detached. The poste- rior canal-wall is chiseled away, backward into the antrum and in- ward as far as the tympanic attic (Fig. 107), removing the wedge- Fig. 108. — Vertical section through the ear. I, wedge-shaped portion of hone forming outer boundary of the 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 4 and 5 is the end of the probe, seen through the aditus ad antrum, resting in the antrum; 6, remnant of the drum-head. (Author's preparation.) shaped portion of bone constituting the outer boundary of the attic (Fig. 108, 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 surgical relations Fig. 109. — Section of the temporal bone (actual size) through the mas- toid cells, Fallopian canal, and middle ear, severing the incudo-stapedial articu- lation. 1, membrana tympani. 2, tip of the mallet-handle. 3. chorda-tympani nerve, at the left of which is seen the canal for the tensor-tympani muscle. 4, head of the mallet. 5, articulating surface of anvil for the mallet. 6, aditus ad antrum, connecting the tympanic attic with the mastoid antrum. 7, usual location of the mastoid antrum; but in this anomalous specimen there are only capacious pneumatic spaces, instead of a large cavity. 8, Fallopian canal for the facial nerve. 9, long crus of the anvil for articula- tion with the stirrup. 10, large cavity, or antrum, in the tip of the mastoid process, another anomalous condition, with a thin shell of bone forming the cortex: between this antrum and 7, where the antrum should be normally. is a series of large cells connecting the two portions. 11, articulating surface of the stirrup for the anvil. wi^S^^^S'^S^*- i^^^i ^^^^^^^v^ ^^ |^H Iv |H IfiHIHflfiSnT A * %mw 1 \ -^LI i 2 1» ^ . ^ ^-^wJ a ■^^^ BHi^,, «-xi 1 ~ ■• /xSHf' ^sfl ^p*— ^ ' k 6 -H^SF^*. Jl ,-- — >J[ Vv ^** * b . ■ ^P-P^ Jl4 ^il t-« l^-l'^J • . ^ ; 1 ^v 1 ^r**|i| L " > ^. - . v ^^. .'-' .' -^H ^& \ ' .-* V-- J^M ■K.^l fa 93£{iB«B m. • ^ ■■ ^^^ k ^H 1 i&Em ' ' ■ -* \"-.<. BhSBSBB ^^_^b Fig. 110. — Section of the temporal bone (natural size) through the mid- dle ear, Fallopian canal, mastoid antrum, and cells, showing dense bone be- tween the antrum and cells, with no communication between them. 1, drum- head. 2, tip of the mallet-handle. 3, anvil, showing the long crus at the right for articulation with the stirrup, and the short process at the left which serves the purpose of an anchor to the bone. 4, head of the mallet. 5, tensor- tympani muscle and tendon. 6, dense bone where pneumatic spaces are usu- ally found. 7, pneumatic cells in the tip of the mastoid process. 8, Fallopian canal, for the facial nerve. 9, the stirrup. At the right of 9 and at the left of the anvil is the aditus ad antrum, connecting the tympanum with the antrum. THE RADICAL TYMPANOMASTOID OPERATION. 175 of these parts are clearly shown in Figs. 109 and 110. The anvil is detached from its articulation with the stirrup (Fig. 59) and removed with the pincette (Fig. 58), care being taken not to dislocate the stirrup and thus open the vestibule. The drum-head is removed in its entirety, together with the mallet. This is a simple maneuver, under the present conditions. All carious or necrotic tissue, granu- lations, or cholesteatomata are curetted away (Fig. 80). When the membranous canal is returned to its place it is incised along the median line of the posterior wall, longitudinally, up to the ***■*-.■■•. . • Fig. 111. — Horizontal section of temporal bone, cut near floor of ex- ternal meatus, a, canal for internal carotid; TC, tympanic cavity; MT, membrana tympani; T, bulbus of internal jugular vein; N, facial nerve; LS, lateral sinus; J/, mastoid. (After C. E. Holmes.) concha, where an incision at right angles to the first is made through the posterior half of its circumference. The two resulting flaps are packed, — the one upward and backward 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 (sigmoid) sinus and dura to avoid, but the facial nerve and semicircular canals. To 176 THE RADICAL TYMPANOMASTOID OPERATION. escape wounding the facial nerve, as soon as we arrive in its vicinity the mastoid guide (Fig. 91) is inserted into the attic, and the nar- row toe of the foot-plate is passed through the aditus ad antrum and toward the antrum. The long handle is brought forward and down- ward 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- Fig. 112.— Six weeks after Stacke operation. 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. (Author's case.) plate falls over the Fallopian canal containing the nerve, and the chisel will strike the guide before it can reach the nerve. An as- sistant is instructed to hold the guide scrupulously in place and to give warning instantly when it is touched. The facial canal is some- times deficient or destroyed, leaving the nerve exposed. THE EADICAL TYMPANOMASTOID OPERATION 177 It is of the greatest importance to avoid injury of the facial nerve, as it produces a shocking deformity of the face (Fig. 75). 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 Fig. 113. — Appearance two weeks after the modified operation. Healed five weeks after the operation. (Author's case.) the middle-ear curette one should not forget that the tympanic walls are sometimes as thin as an egg-shell (Figs. 103 and 111). The in- ternal carotid artery and the internal jugular vein are sometimes very imperfectly protected and liable to be penetrated. As one proceeds upward and backward the external 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 op- 178 THE MODIFIED MASTOID OPERATION. erators from one to two hours. Longer time is required for healing also on account of the greater extent of wound-surface. Fig. 112 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. 106). The writer does not dissect out the whole integumentary canal, but separates only its postero-superior half from the bony wall Fig. 114. — Post-mortem section of mastoid process. T, tip of process; 2, fistula below T leading into mastoid cells; 3, opening made by trephine, probe resting in antrum; 4, cotton in. external meatus. (Author's speci- men.) and then depresses it sufficiently to give easy access to the 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 pre- THE MODIFIED MASTOID OPERATION 179 vented by lightly packing the mastoid wound and by packing the canal or inserting a firm-rubber tube. In other respects this method, which the author has preferred for several years, corresponds to the Stacke operation. It is safer not to close the wound entirely until it has healed from tlie bottom. When the interior has filled with firm cicatricial tissue up to the surface of the bone-opening it is safe to allow it to close. We have had good results after closing the wound completely at the end of the operation, but it is certainly not so safe a plan. Fig. 115. — Appearance three Aveeks 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 best dressing is one of dithymol diiodide (aristol) sprinkled over the wound-surfaces, covering them entirely. Then iodoform gauze should be placed lightly in that part of the wound chosen to remain open. It should not be packed down to the bottom of the wound so firmly as to crowd any discharge inward, but it should fill 180 THE MODIFIED MASTOID OPERATION. the cavity and keep the cutaneous tissues from closing over the su- perficial opening in the bone. Dithymol diiodide has two excellent qualities: it is the best cicatrizant we possess, and it has the addi- tional advantage of being to some extent an anaesthetic. While iodo- form is irritant and toxic and boric acid sometimes produces pain, dithymol diiodide soothes without any ill effects. Fig. 116. — Abscess of the mastoid process extending over ten weeks, re- sulting in an enormous abscess of the neck, reaching nearly to the thoracic cavity. Cured by an operation. (Author's case.) After stitching that part of the wound to be closed, and dress- ing the open mouth for drainage, the whole is covered with sterilized 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 preparation of glue. The roll of bandage is dipped in sterilized water just before applying, until it is wet through. Then the water is squeezed out and the bandage is applied as usual. ABSCESS OF THE XECK. 1S1 When it dries, the layers adhere tog-ether firmly, so as to retain their position for many days in succession without any attention. This operation requires more time than Sehwartze's and less than Stackers, both to perform and for healing. Fig. 113 shows progress two weeks after the modified Staeke operation. Three weeks after the operation taste was suddenly lost, hut returned again. The ex- Fig. Hi. — The same as Fig. 116, showing the outline of the swelling. uberant granulations seen on the right border of the wound were re- pressed with silver-nitrate stick. Abscess of Xeck ebcoi Middle-Ear axd Mastoid Sutpcbatiox. This is an occasional complication that requires operative in- terference. It arises from the purulent process penetrating the bone and burrowing beneath the superficial or deep layer of muscles. If 182 ABSCESS OF THE NECK. it break through the inferior wall of the tympanic cavity, the pus-channel may extend along underneath the deep layer of mus- cles even to the thoracic cavity. If it rupture through the anterior wall of the middle ear, a retropharyngeal abscess or a superficial cer- vical abscess may develop. When the pus breaks through the inferior surface of the mastoid process (Fig. 114), 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 sur- rounding tissues become infiltrated; the tumefaction extends over a larger surface; the overlying skin becomes tense and shiny to such a degree as to suggest erysipelas; the movements of the head become restricted and painful; the temperature rises; the tongue becomes coated; headache, loss of appetite, and other febrile disturbances su- pervene. Although fluctuation does not occur early, especially if the abscess is deep-seated, the diagnosis is promptly suggested by the pres- ence of the suppuration above it. 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 it in a dependent position. Further treatment should be on general surgical principles. Fig. 115 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, carried upward, and brought out through the mastoid wound. Figs. 116 and 117 show an extraordinarily large abscess of the neck complicating mastoid and middle-ear suppuration. The swelling over the mastoid process is best shown in the front view. The great swelling of the neck is indicated by the curved line below the ear in the posterior view. CHAPTEE 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 axd Anemia of the Labyrinth. Hyperaemia may occur as a result of middle-ear inflammation or some intracranial disease, or secondarily to a disturbance of the cir- culation in the blood-vessels of the neck, such as pressure on the large veins, or it may be due to certain medicines, — quinine, sodium salicy- late, amyl-nitrite, etc. It sometimes complicates the fevers. Anaemia of the labyrinth may follow great haemorrhages, exhaust- ing affections, and various anomalies of the circulation. The symptoms need not necessarily include impairment of hear- ing, but tinnitus aurium and giddiness are the principal manifesta- tions. These conditions will be recognized as accompaniments to the main diseases which give rise to them, and the diagnosis, prognosis,, and treatment will be determined accordingly. 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: co- caine, local bleeding, counter-irritation, catharsis, bromides, rest, the mastoid ice-bag (Fig. 83), etc. In anaemia of the labyrinth the primary condition that causes the anaemia will suggest the treatment. IXFLAMUATIOX OF THE LaBYRIXTH (OTITIS IxTERXA). Primary inflammation of the internal ear is of very rare occur- rence; but a disease of the surrounding structures, the middle ear, or mastoid process may extend to the labyrinth. An intracranial 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 bac- teria and discharges is effected into the labyrinth. (183) 184 INFLAMMATION OF 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 dis- cernible 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 deaf- ness. In case this deafness is due to a serous exudation into the laby- rinth, producing 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 jeopards 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 mis- taken 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 irre- parable deafness and for some time a staggering gait. A separate description of this disease is not necessary, since it is a combination of two conditions already presented. The prognosis of inflammation of the labyrinth is unfavorable. Some cases recover; more do not. One such case, complicated with mastoiditis, recovered entirely after four months, without mastoi- dectomy, although I was in doubt for a time if further postponement of the operation were justifiable. Another became entirely deaf dur- ing meningitis at the age of 2 years. During the sixth year she began to distinguish sounds. She has improved under treatment, and has learned to talk without special instruction or lip-reading. At the present time, 1898, improvement continues. She hears conversation well, and attends the public schools. The author has met with a number of such instances; yet it is safest to give a very guarded and conservative prognosis. Treatment.— Potassium iodide, pilocarpine, iodine ointments, etc., have been used by Politzer, Moos, Gruber, and others. Of a 2-per-cent. solution of pilocarpine hydro chlorate, 2 to 6 drops are injected into the forearm daily, in increasing doses. General anti- Meniere's disease. 185 phlogistic treatment must be resorted to in the acute stage, such as is detailed in the division on acute inflammation of the middle ear. In syphilitic "infection the iodides and pilocarpine are indicated. In suppuration the methods given for middle-ear suppuration are ap- plicable. Hjemobehage ixto 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. Eesolution may take place by absorp- tion, or an inflammatory process may be set up. with its train of con- sequences, or the clot may undergo organization. Meniere's Disease. Meniere first described a group of symptoms that characterized a case of effusion of blood into the labyrinth: deafness, vertigo, and vomiting. The attack comes on suddenly, the patient falling as in an epileptic seizure and presenting an appearance, on regaining con- sciousness, similar to one coming out of an epileptic fit. In addi- tion to the symptoms mentioned, there may be subjective noises and total deafness. After consciousness returns and vomiting ceases, the great deafness, dizziness, and tinnitus auriurn remain. AValking with the eyes closed is difficult and the body may incline toward the dis- eased side. The mental faculties evince impairment. Diagnosis. — This is based on the suddenness of the attack: the extreme loss of hearing without previous serious disturbance of func- tion; the presence of a group of symptoms pointing, in unison. toward aural disease: absence of disease of the conducting apparatus or of any other structure than the auditory nerve. Prognosis. — This, for the most part, is unhappy. The hearing may improve, but this is not likely. The dizziness soon diminishes sufficiently to allow the patient to walk, though unsteadily, and he staggers toward the side of the affected ear. The tinnitus may dis- appear, but is likely to continue indefinitely. Treatment. — Eest in bed and perfect quiet are important. The bowels should be relaxed, an ice-bag (Fig. 83) applied to the mastoid. and a counter-irritant to the side and back of the neck. Potassium bromide and iodide in large doses and pilocarpine may be employed as directed for labyrinthitis. Charcot recommended quinine, but, 186 SYPHILIS OF THE INTERNAL EAE. since it produces labyrinthal congestion, it appears to the writer to be contra-indicated. Letjcocyth^mic 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 ex- udative processes, although it is not as frequently implicated as the eye. Inflammation may follow, resulting in proliferation of connec- tive tissue or bony growths. The treatment consists in measures for the general condition and the remedies recommended in Meniere's disease. Syphilis of the Labyrinth. Syphilitic lesions of the labyrinth are most likely to occur dur- ing the tertiary stage, but sometimes manifest themselves in the sec- ondary 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 diminished 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. 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. Treatment. — This is the same as for constitutional syphilis, with the addition of pilocarpine injections, in 2-per-cent. solution, of 4 to 12 drops in increasing daily doses. Any improvement to be had from the pilocarpine should show within two weeks. Edmund D. Spear speaks highly of the results from subcutaneous injections of pilocarpine. The writer generally employs the mixed treatment, — mercury and potassium iodide combined. Albert H. Buck cites a case of congenital syphilitic disease of the ears in a boy, giving rise rapidly to a high degree of bilateral deafness. The hearing was much benefited by treatment, which fact DISEASES OF THE AUDITORY NERYE. 187 led the reporter to conclude that it was an instance of localized peri- ostitis affecting either the internal surface of the cochlea or the articular borders of the stapes and oval foramen. Max Toeplitz reports, in the New York Medical Journal, Octo- ber 7, 1893, a case of aural syphilis in which "the labyrinth 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 affec- tion 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 trouble. u 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 increase of cellular elements and hemor- rhages. All these changes disappeared after energetic antiluetic treat- ment. " Diseases of the Auditory Nerve. The acoustic nerve may become the seat of various changes — hyperemia, hypertrophy, atrophy, secondary inflammation, and sup- puration — through invasion from the contiguous intracranial or tym- panic structures. It must be admitted that the present state of our knowledge of these pathological processes affords no basis for a prom- ising system of treatment. NEUROSES of the perceptive apparatus. Hyperaudition. — A transitory increase in the intensity of the hearing-power affects some persons. For this condition the author proposes the term "hyperaudition" as conforming to our system of nomenclature and as being correctly and briefly expressive. This con- dition is a symptom of cerebral excitement or irritation, and may con- stitute a precursor of intracranial disease. Hypersesthesia. — Auditory hyperesthesia is an insufferable sen- sitiveness to sounds or noises. Highly-nervous subjects often present 188 PARACUSIS. 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 the pitch of sounds. 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 abnormal tension of the transmitting mechanism. The writer has observed in such cases that certain tones only, and mostly the higher, were thus incorrectly per- ceived by one ear, both being similarly diseased, while all tones were correctly heard by bone-conduction. The apparent alteration in pitch varies in different subjects 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 inflam- mation. The tone was perceived as a primary, accompanied or fol- lowed 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. Paracusis Willisii. — This is hearing better in a noise, and is pathognomonic of sclerosis. It is undoubtedly due to the fact that, when powerful sound-waves set the ossicles in vibration, the lesser vibrations 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 hear- ing-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 hearing and total deafness patients have declared to me that they would not care whether the treatment bene- fited the hearing, if only the interminable head-noises could be stopped. It is sometimes imagined that insects have gained entrance into SUBJECTIVE SOUNDS. 189 the ears, and the surgeon is importuned repeatedly to look for them, being assured that they must he 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 state- . ments to the contrary, she rilled her ears with spirit of turpentine to kill the crickets. Very susceptible individuals may have their minds unbalanced by this harassing, unceasing din. vVe have seen instances in which subjective voices were heard, but they were hallucinations of hearing in persons of unsound mind. Whether the psychoses were attribu- table to the ear 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 in 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 or tinkling 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 G of the piano, while the pitch of the tinnitus of the other ear may be much lower and the sound of a different quality. Probably in most cases it is like the ringing produced by overdoses of quinine. There may be two different qualities of sounds in the same ear. The noises are increased during a combination of low barometer 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 salicylate, alcoholic beverages. excessive tobacco-smoking, loss of sleep, sneezing, coughing, much use of the voice, very cold drinks or food, and a damp, cold, moldy atmosphere, such as is found in basements. On the other hand, warm, 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 can- not 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 190 SUBJECTIVE SOUNDS. 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 auriuni is an affection in which the ear is not of necessity involved. 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 contractions of the muscles of the ear, are rare. In one case I could plainly see, synchronously with the clicking noises, a rhythmical movement of the drum-head, — excursions inward and outward, — undoubtedly oc- casioned by spasmodic contractions of the tensor tympani muscle. Spasmodic contractions of the Eustachian tubal muscles may cause snapping sounds. Mucous rales occur in the Eustachian tube and middle ear in the same manner as they do in the bronchial tubes. Circulatory disturbances of the heart, the internal carotid artery, or the arteries of the ear give rise to pulsating sounds in unison with the pulse. Prognosis. — This depends principally upon the cause of the sub- jective sensations, but, excepting in sclerosis and diseases of the laby- rinth 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 auriuni is a. symptom of various pathological processes, we can speak of its treatment here in a gen- eral 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 intract- able. We may diminish the noises or change their character, while we cannot by any known means eradicate them, in many cases. It is unwise to promise to cure or even to diminish them. In the ma- jority of instances the tinnitus is a 'symptom of sclerosis. In addi- tion to the treatment outlined for sclerosis the author has used coun- ter-irritation with mustard or its oil, and has vesicated with can- tharidal collodion. These applications sometimes produce a bene- ficial effect. When the tinnitus has continued after an acute inflam- mation of the middle ear has subsided, we have found medium doses PARESIS AXD PAEALYSIS OF THE AUDITORY XERVE. 191 of sodium bromide afford complete relief. This was attributed to its sedative effect on the labyrinthal irritation. Charcot and Guye have recommended quinine. It may prove serviceable in periodical tin- nitus, but as it produces congestion of the middle ear and labyrinth, and, in large or continued doses, deafness, its utility in ear affections is very limited. Paresis a^d Paralysis of the Auditory Xerve. There are certain forms of paresis and paralysis of the auditory nerve that are so rarely met with as to merit only a passing 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 ac- cessible to inspection. Treatment of these aberrations is largely based on the associated causative conditions; but, in addition to the general treatment, special measures may be employed by means of the ear-electrodes (Fig. 77). The writer has generally preferred the primary current of a faradic battery to the galvanic, for the former unites the properties of both currents, as he has shown in his batteries by means of the galvanom- eter. The negative pole is connected with the electrode that rests in the ear which requires stimulation or irritation. The current is turned on very mildly at first and gradually strengthened until it is as strong as can be comfortably borne, and continued for six to ten minutes. By means of my 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 detriment 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 mas- toid operation the wound can be filled with wet cotton and the elec- trode placed in contact with it. This conducts the current to the injured nerve. The other electrode is held in contact with the op- posite mastoid process. During a part of the treatment the electrode is removed from the opposite ear and applied to the groups of mus- cles affected (Fig. 112). 192 cerebral causes of deafness. Cerebral Causes of Deafness. Cerebral deafness may arise in two ways: by a disease of the hear- ing-centres or by an extension of a disease of the brain or of the meninges to the origin or course of the acoustic nerve or to the laby- rinth. The most frequent cause of intracranial deafness is menin- gitis. The loss of hearing may not become apparent at the time that it occurs, but it will be discovered when the patient regains conscious- ness. The destruction of hearing takes place within the first few weeks of the disease. This form of deafness is not amenable to treat- ment, the reason for which is apparent when we consider the patho- logical processes that destroy the function of the nerve: "Softening or thickening of the ependyma of the fourth ventricle, purulent in- filtration 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 inflamma- tion 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 observa- tion 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. We have not been able to verify the statement that tinnitus aurium is a frequent symptom, but most of my cases of deaf-mutes 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. 83) 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 should be tried, such as potassium iodide, and pilocarpine in a 2-per-cent. solution, 6 to 10 drops at an injection. Many pathological processes in the brain are capable of disturb- ing the Rearing. It has been observed repeatedly that a disease of the left temporal lobe, involving the first convolution, produces word- deafness. In this peculiar state there is a hearing for sounds, but in- capacity for interpreting the compound' sounds entering into the formation of words. This circumstance 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: NEW GROWTHS OF THE INTERNAL EAR. 193 dizziness, tinnitus, varying degrees of deafness, and gastric disturb- ances. The diagnosis is often impossible. In the case of tumor, how- ever, 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 besides the acoustic or facial. Anaesthesia of the skin of the corresponding side of the head is some- times 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 consideration 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. Injueies of the Labyeinth. Penetbating wounds of the labyrinth are of infrequent occur- rence, 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. The author has seen quite a number of in- stances in which the symptoms of irritation or paralysis of the audi- tory 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 exam- ined many soldiers of the war between the States, who suffered more or less loss of hearing from concussions produced by cannons, ex- ploding shells, etc., in battle. Instances have also come under my observation in which blows on the head from the "sand-bags" of rob- bers, and from other weapons, and concussions from falls, have pro- duced 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. Blacksmiths, tinsmiths, coopers, and iron-workers suffer similarly. This is due to the constant concussions of the drum-head, ossicles, and intralabyrinthal fluid and the auditory nerve from their incessant hammerings. The effect is to produce, in addition to the labyrinthal affection, the sclerotic form of middle-ear catarrh, which has already been considered. Treatment of these forms of disturbances of hearing, of co-or- dination, etc., is generally of little or no avail if several months or (194) DEAF-AUTISM. 195 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 indicated. 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 1 / 2 of 1 per cent, of all the cases of ear-defects that the writer has studied in hospital, dispensary, and private practice are of the deaf-mute class. Pathology. — In congenital deaf-mutism the precise condition to which it is due cannot be determined. This subject presents an opportunity for the application of the theory of reversion as affect- ing types of degeneracy. It may be owed to lack of development in some part of the organ of hearing, deformities of the fenestras 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, men- ingitis, or cerebritis. 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 ac- quired later in life may be more or less perfectly retained after hear- ing 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 known dumbness to follow the loss of hearing even after speech was acquired. The ability to articulate words gradually de- clined until nothing more than mumbling and mouthing of unin- telligible sounds remained. In about 50 per cent, of 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. Among the 158 deaf-mutes of the institution for this class at Prague, Frankenberg (American Medico- Surgical Bulletin, December 10, 1897) found 94, or 59 per cent., with adenoid vegetations in the vault of the pharynx large enough to fill this space. Of these, 56 were boys and 38 girls. In 69 of these cases there were anomalies of the ears as follow: Impacted cerumen, 21; chronic suppuration with granulations, 11; sunken drum-head, 12; stenosis of the external meatus, 1; atresia of the meatus, 1; foreign body in the meatus, 1; 196 DEAF-MUTISM. adhesion of the drum-head to the internal wall. of the middle ear, 1; hyperemia of the drum-head, 4; dry perforation of the drum-head, 3; absence of the membrana tympani due to suppuration, 4; polypi, 3; mastoid cicatrix from periostitis, 1. Of these cases, 37, or 53.6 per cent., had adenoids. These facts indicate the importance of examining for these growths in children having ear affections. Arslan found 6 deaf- mutes among 426 cases of adenoids, and cured one and relieved another, with respect to both the hearing and speech, by the adenoid operation. In 118 autopsies on deaf-mutes performed by Mygind there were evidences of middle-ear diseases in 79. There were only 19 that were free from pathological conditions of the labyrinth or nervous centres. "In most of the cases the changes were due to severe and extensive inflammations, especially in acquired deaf-mutism. Other anomalies were almost identical in the two classes of cases, congenital and ac- quired. The opinion hitherto accepted that deaf-mutism results from congenital deafness, due to some anomaly of development of the organ of hearing, is invalidated by the fact that anomalies are of very great variety. Changes usually affect both ears, though unequally. The middle ear has been found most often affected. The internal ear was affected most in the semicircular canals, rarely in the vestibule; and in a great number of deaf-mutes these anomalies could be con- sidered the chief cause of the deaf-mutism. In some cases the audi- tory nerve presented phenomena of atrophy and degeneration, but more often the nerve was intact. In some cases there were anomalies of the brain." (Medicine, January, 1898.) Etiology. — Congenital deaf-mutism may be due to heredity, but it is not a frequent occurrence. A constitutional predisposition 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 the writer has examined he does not know of one whose parents were deaf-mutes, although some have had various middle-ear affections. Consanguineous marriages, as well as specific disease and intra-uterine influences, are believed to account for deaf-mutism in quite a large proportion of instances. 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, but I have TREATMENT OF DEAF-MUTISM. 197 had recently under treatment the ease of a girl, 6 years of age, who had lost her hearing entirely for four years in consequence of an at- tack of the grip. Under treatment the hearing has returned suffi- ciently at the present time to enable her to hear ordinary conversa- tion and to learn to speak intelligibly. Inspection revealed no change in the drum. Symptomatology. — In infants the defect is not likely to be dis- covered until about the time that children begin to talk, and even then it may be overlooked by the parents, who attribute the back- wardness to slow development. We 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 at- tention by movements within the range of vision. Calling its name from behind, clapping the hands in such a position as not to pro- duce waves of air that will strike the child, and out of its sight, the tuning-forks (Fig. 14), the Delstanche whistle, etc., are conclusive. If the child hear vowel or other sounds, a change of expression, a light- ing 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 pres- ent in hopeless cases. Such sounds are primordial and are uttered by the lower animals. Prognosis. — AYhile the writer has 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 ac- quired form is generally regarded as less promising still. Treatment. — In many cases examined by me there were evi- dences of middle-ear dry catarrh, but whether this bore any signifi- cant relation to the absence of hearing-power was a debatable ques- tion. 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 and may 198 EDUCATION OE DEAF-MUTES. have anchored the stirrup in the oval window so firmly as to pre- clude the possibility 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. 77), may demonstrate the pos- sibility 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 improvement. 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 be- fore leaving the city. Special 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 ex- perience with the deaf-mute class. Indeed, the author has often been led to a correct diagnosis in deaf-mute children before an examina- tion was made, and before any information 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 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-supporting. M. A. Goldstein has published {The Laryngoscope, June, 1897) the excellent results obtained by the method of Urbantschitsch in persistent teaching of deaf-mutes by speaking vowel sounds, con- sonants, and their varying combinations into their ears until they are able to understand and repeat words and sentences. The author can recommend this method from practical experience with it. 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 HEARIXG-IXSTROIEXTS. 199 no fault of their own. The means already enumerated are efficient. They are provided by private and public schools in the cities, and by the States in their deaf-and-dumb asylums. The formation of classes in the public schools of cities for the instruction of partially-deaf children is advocated by H. A. Alderton (The Laryngoscope, August, Fig. 118. — The conical conversation-tube. 1896). 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. Hearixg-ixstroiexts. 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. 118) and the London horn (Fig. 119). Fig-. 119. — The London horn. The conversation-tube consists of a trumpet-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 200 ARTIFICIAL AIDS TO HEARING. of the speaker, when a low, conversational tone can be employed, enabling the listener to hear words that are inaudible to others. The speaker should never talk loudly or cough or clear his throat with the month-piece near his lips, for often the hypersensitiveness of the affected ear renders these harsh, explosive sounds painful and irri- tating. These tubes are generally worn about the neck, nncler the coat, or rolled up in the coat-pocket. For near conversation they are, by far, superior to any other device. The London horn (Fig. 119) is an excellent instrument for use at long distances, as in the church 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, 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 principal sound. 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 news- paper editors is entirely dependent upon it, and cannot be prevailed upon to try the tube. After an extensive destruction of the drum-head the hearing 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 (TurnbiuTs), is inserted into the meatus and nicely adjusted to the exposed mallet. The audiphone, consisting of a fan-shaped disc of vulcanized 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. The writer has tested it with numer- ous patients, but with few exceptions it was of little value. The rubber disc, 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 provocative of irritation, in- flammation, and even ulceration of the canal and tympanic membrane and cavity. Occasionally we have been told by the wearers that their hearing was better while these devices were in their ears. We have frequently found them in contact with the drum-head, bathed in de- composing pus. ARTIFICIAL AIDS TO HEARING. 201 Xo efficient and harmless liearing-instrnment for wearing in the ear has yet been devised. Fame and fortune await the inventor of the aural equivalent of spectacles. Alexander Graham Bell related to me that he discovered the useful principles of his telephone while, endeavoring to invent a microphone to aid the deaf to hear. In response to my question. "Do you not consider it possible to con- struct an instrument for defective hearing that will be comparable to the lens for defective vision ?" Mr. Bell replied, "I will not say that it is impossible; but, in the present state of our knowledge, it is improbable/' PART II Diseases of the Nose. (.203) PLATE II PLATE II. Vertical anteroposterior section of the nasal cavities, mouth, pharynx, and larynx. 1. Frontal sinuses. 2. Superior turbinated body. 3. Sphenoid sinuses. 4. Middle turbinated body with posterior hypertrophy. 5. Adenoid growths. 6. Inferior turbinated body. 7. Orifice of the Eustachian tube. 8. Fossa of Eosenmiiller. 9. Oral tonsil. 10. Epiglottis. 11. Vocal cord. 12. Trachea. The mirror and line of reflected light illustrate laryngoscopy. PLATE II CHAPTER XVIII. DISEASES OF THE XOSE. Examination and Instruments. Bhixological practice requires an illuminating apparatus like the one shown in Fig. 5, or the electric forehead-lamp, or a student- lamp. Fig. 120 shows an electric light attachable to a portable bat- tery. 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 Fig. 120. — Electric illuminator, as used in posterior rhinoscopy. inch (sixteen millimetres) in diameter, 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 illuminator is particularly 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 sidewise by the patient, immediately in front and facing him. using" (205) 206 EXAMINATION AND INSTRUMENTS. the three-inch forehead-mirror, which is shown in Fig. 4. Eeflected light only can be used to advantage in this practice. The surgeon should wear the mirror in front of his eye so as to look through the perforation in the glass, and in such a manner as to shade both eyes from the light. The room is best darkened in order to avoid the con- tracting effect of the light on the pupils of the surgeon's eyes. During the examination of the nose, one hand of the operator 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 Fig. 121. — Nasal speculum of correct pattern, and the proper way to handle it. speculum (Fig. 121), a long cotton-carrier (Fig. 9) to remove secre- tions that obstruct a view of the parts, and a bent long probe for searching out hyperaesthetic areas and determining the contour and extent of anomalies. The nasal speculum is best held in the palm of the hand with the back of the fingers directed toward the patient's chin. The handle of the speculum should project straight outward and downward from the bivalves, so as to leave sufficient room between the patient's chin and the surgeon's fingers. The valves should be small enough at their tip to use with children. In manipulating the speculum the pressure ought to be exerted mainly on the soft, yielding ala of the nose, and not on the septum. De Vilbiss has devised an excellent ANTERIOR RHINOSCOPY 20 r self-retaining nostril-dilator to be held in place by a rubber band about the head. Anterior rhinoscopy, or the examination of the anterior nares, reveals the anterior extremities of the turbinated bodies and the side of the septum. The patient's head is tilted backward or forward, as Fig. 122. — Boswortlrs tongue-depressor. the upper or lower parts of the nasal cavities are to be inspected. In many instances we can obtain a clear view entirely through the naris to the vault and posterior wall of the pharynx. In others, hy- pertrophies 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 Fig. 123. — Throat-mirrors. 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. 122), rhinoscopic mirrors (Fig. 123), and occasionally a palate-re- 208 POSTERIOK KHIXOSCOPY. tractor (Fig. 124). 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 aids materially in the examination, and only a little practice is necessary to success. When the rhinoscopic mirror is introduced, the tongue-depressor is held by the left hand and the mirror by the right. Just before in- troducing the mirror it is warmed by passing it with the glass side Fig. 124.- — White's palate-retractor. downward over the lamp for an instant only, to avoid the condensa- tion of the patient's breath on it, which would prevent a reflection of the post-nasal image. If the mirror is too greatly heated its back- ing is destroyed. A better method, which the author has employed satisfactorily for a considerable time, is to cover the glass surface of the mirror with liquid soap, and then polish it with a dry cloth. This soft soap prevents the breath from condensing on the glass, and renders the use of heat unnecessary. I have used Lee's liquid soap for this purpose. With the light reflected into the throat by the forehead-mirror,, the nasal mirror is carried over the depressed tongue until it nearly,. Fig. 125. — Hard-rubber palate-elevator. but not quite, touches the posterior pharyngeal wall with the mirror- surface directed upward and forward (Fig. 126). The natural in- clination 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 from contact with the post-pharyn- geal wall. Then, with the light properly directed upon the mirror, an image of the posterior nares should be seen. If the palate still embarrasses the view, it can be lifted and drawn slightly forward by POSTERIOR RHINOSCOPY. 209 the palate-elevator (Figs. 124 and 125). Painting the uvula and velum with a 4-per-cent. solution of cocaine or eucaine will facilitate this procedure. The rubber elevator is convenient. It is placed so as to lift the uvula with the soft palate, and the handle is held a little to one side, so as not to obstruct the field of vision. As large a mirror should be used as the space will permit (one- Fig. 12G. — The posterior rhinoseopic image. (After Bosworth.) half to three-fourths of an inch — thirteen to nineteen millimetres), but it must be small enough not to necessarily come in contact with the surrounding parts and produce gagging. The mirror is so manip- ulated as to bring the plane of its surface at an angle of about sixty degrees to the perpendicular plane of the posterior nares, in order to obtain a perfect image. 210 SPRAY-PRODUCERS. 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 Eustachian tube on the other come prominently into view/ with the posterior ends of the tur- Fig. 127.- — The Davidson spray-producers. binate bodies in the centre of the field. The two lower ones, of a light-pink hue, are easily distinguished; but the superior body, yel- lowish and dimly outlined in its remote recess, is not so easily seen. The vault of the pharynx is rendered visible by tilting upward the mirror-handle in varying degrees until one obtains an image of the pharyngeal tonsil. It is often necessary to cleanse the nasal pas- sages with the detergent solutions before a complete inspection can be made. The Davidson atomizers (Fig. 127) are very convenient for Fig. 128. — The De Vilbiss atomizer cleansing and medicating the nares. They throw a very coarse spray, bathing the parts profusely. They hold a large amount of fluid, do not leak, and are supplied with both straight and curved tips for the naso-pharynx and larynx. The De Vilbiss atomizer (Fig. 128) has ATOMIZERS. 211 an excellent adjustable tip. It can be turned so as to throw the spray in any direction desired, from the posterior nares to the larynx. His latest device to be used with compressed air has a flange upon Fig. 129. — The lavolin atomizer. which the fingers rest to prevent the column of air from throwing the instrument out of the grasp. It is made with a broad base so as to prevent it from tipping over, and it can be used with the hand- bulb also. The lavolin atomizers (Figs. 129 and 130) are very con- Fig. 130. — Truax, Greene & Company's atomizer venient for home treatment. We often prescribe these with a 3-per- cent, solution of camphor-menthol in lavolin or benzoinol for patients to use at bed-time, to aid in the treatment. By this means they keep 212 ATOMIZERS AND VAPORIZERS. the upper respiratory passages cleansed and protected and they are more faithful to the treatment. The results are more satisfactory with this method. My assistant, A. H. Andrews, has recently devised an atomizer which will produce both coarse sprays and fine vapors, and it can be operated by a rubber bulb or by the compressed-air apparatus (Fig. 131). Many devices are employed for treating the nasal cavities, but few are necessary. Some are capable of doing actual harm. The Weber nasal douche has thrown watery solutions through the Eusta- chian tubes into the middle ears, setting up an inflammation. This Fig. 131. — Andrews's combined atomizer and vaporizer. With the nasal tip lightly adjusted a fine vapor is produced; with it firmly pressed upon the spray-tube, a coarse spray results. is especially liable to happen when any stream of fluid is passed into the nostril, for there is a strong inclination to swallow, provoked by the presence of the liquid. In the act of deglutition the orifices of the tubes open and allow the entrance of the fluid into the tympanic cavities. One of the most useful instruments for medicating the re- spiratory passages, after they are properly cleansed, is shown in Fig. 132. It consists of a nebulizer which projects the most finely dif- fused spray obtainable, and admits of the use of much stronger medicaments than are ordinarily used. It is so constructed that the medicament from one of the nebulizing globes (JE) can be propelled into the nose, throat, or middle ear in a steady current, or with in- terrupted currents by tapping on the valve (I). Or the inhalents in VAPORIZERS. 213 two or all of the nebulizing globes can be combined and used at the same instant. An important addition to this vaporizer is the air-regulating collar below the push-button (I). By this device the amount of press- ure 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 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. Fig. 132. — The Universal vaporizer. For those practitioners who are not supplied with a compressed- air apparatus the Globe nebulizer (Fig. 133) is an excellent 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. 134 repre- sents an inhalation taken through the aseptible face-mask. Fig. 135 shows the inhalation through a small vulcanite mouth-tube, and in Fig. 136 the returning medicated vapor is seen to issue from both nostrils. Figs. 137 and 138 illustrate the medication of the nasal passages and vault of the pharynx by permitting the vapor to enter 214 NEBULIZERS AND INHALATIONS. one nostril and return through the other or through the mouth. In Fig. 139 the opposite naris is closed while the vapor is made to in- flate the middle ears, as we have already described. With such perfect instruments as are here shown, and with suffi- Fisr. 133.— The Globe nebulizer. cient air-pressure, the most effective treatment is rendered possible with accuracy and ease. Homer M. Thomas has demonstrated by experiments in Cook County Hospital that a vaporized medicament penetrates into the pulmonary alveoli of the human lung. He writes: Fig. 134. Fig. 135. Fig. 136. Fie:. 138 Fig. 139 "I have repeatedly seen good results in the treatment of localized in- flammations of the bronchial tract, by inhalation, as far as the second division of the bronchi. I have obtained results in that way that I have repeatedly failed to secure with internal medication. It is sur- SPRAYS AXD IXHALEXTS. 215 prising how the respiratory ability can be increased by a little in- struction and effort.'* (The Laryngoscope, Xovember, 1897.) Sprays axd Ixhalexts. 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 mu- cous membranes, but accurate studies have not been sufficiently de- voted 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 internal medicine should be administered without fulfilling a special indica-- tion 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 contracts the capil- lary blood-vessels of the mucous membrane, reduces the swelling; relieves pain and fullness of the head, or stenosis; arrests sneezing, checks excessive discharges, and corrects perverted secretions. We know, also, that it possesses antiseptic qualities. Since my introduction of this remedy at the meeting of the Mis- sissippi Valley Medical Association, in 1891, it has come into quite general use for catarrhal conditions of the upper respiratory tract. Although the author did not recommend it until long after he had discovered that the union of these two camphors resulted in a fluid of the chemical formula C 10 H ls O, and after becoming satisfied that we possessed a valuable remedy in this new drug, he is now able to express greater confidence, and to verify former statements 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. Specialists 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 Pure camphor-menthol is the product resulting from bringing together equal parts of gum-camphor and menthol crystals without heat. They soon form a colorless liquid by uniting in nearly equal parts. This pure camphor-menthol is used in combination with lavolin or benzoinol in various strengths for producing sprays and vapors. Lavolin is a purified, colorless, petroleum-oil. Benzoinol is 216 SPRAYS AND INHALENTS. a similar oil, with the addition of benzoin. The former is manufact- ured by Truax, Greene & Company, of Chicago; the latter by the Benzoinol Company, of New York. 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), hy- pertrophic rhinitis, simple sore throat, acute laryngitis, tracheitis, bronchitis, and after nasal cauterization to prevent hemorrhages and inflammation. For home use and ordinary office treatment we do not employ a stronger solution than the 3 per cent, in lavolin or benzoinol, and for very sensitive cases, like hay-fever sufferers, the 1- or 2-per-cent. solution at first. The lavolin is a bland and soothing protective to the membrane, and in the combinations indicated we have a most effective and harmless remedy. This means a great deal to both pa- tient and physician, for many of the sprays in use give indifferent results: — or worse. Patients should be instructed to treat themselves thoroughly every night on retiring, by throwing a spray of the 3-per-cent. solu- tion from an atomizer (Fig. 129) into both nostrils while slowly in- haling. The rubber bulb should be forcibly and rapidly compressed at least eight times for each nostril. For the throat, larynx, or bron- chial tubes the spray should be thrown through the mouth during inhalation. In diphtheria, croup, etc., in infants, when it is very difficult to throw a spray into the throat, the medicine may be made to reach the parts in a volatile form by placing a few drops of the pure, undiluted camphor-menthol in a hot-water inhaler (Fig. liO) or 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. Inflamma- tion of the throat, larynx, trachea, and bronchi can be effectually treated by inhaling the camphor-menthol steam in this manner. The writer has found that we can prevent haemorrhage and in- flammation, following galvano-cauterization of the turbinated bodies, by gently packing a pledget of cotton wet with a 10-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 re- placed by a fresh dressing, and, at the end of four or five days, instead IXHALEBS. 21? of finding sloughs filling the passages, swelling, and stenosis, the tis- sues appear shrunk and mummified and the strait is clear. Unless the electrode has been allowed to eool before removing, no haemor- rhage or only slight oozing occurs. There is also less discomfort fol- lowing this method than after others. The cotton should not he saturated to the dripping point with the solution, so as to allow it Fig. 140. — Hot-water inhaler. 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- solution to cause stimulation of the glands and osmosis can be taken in treating ozsena 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. 141, which can he carried in the pocket, and contains a liquified mixture of equal Fig. 141. — The author's camphor-menthol inhaler, 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. It can be used unnoticed in public places the instant any irritation appears, and thus prevent or cut short attacks. Three or four slow, deep inhalations should be taken from it in one nostril while the other is closed, or until the irritation is relieved. The -18 SPEAYS AND INHALENTS. 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 purpose, 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 combined with the 10-per-cent. strength of camphor-menthol and benzoinol. There is a, prevalent mistaken opinion that the cubeb-spray 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. Eucalyptol 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 combined with benzoinol 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. Car- bolic acid combined with benzoinol, 2 grains to the ounce, is valuable when the antiseptic and anaesthetic effects are required. It is very useful in ozama, especially when followed with aristol or nosophen. Antiseptic aqueous solutions are necessary for properly washing out and cleansing the nasal cavities preparatory to the application of other medicaments. DobeH's solution is the most universally used. It consists of biborate and bicarbonate of sodium, of each, 1 drachm; carbolic-acid crystals, 12 grains; glycerin, 2 drachms; water, enough to make 8 ounces. Seiler s antiseptic solution is also satisfactory, and is easily and quickly made by dissolving one of his tablets in 2 ounces of pure water. These solutions dissolve, loosen, and wash out the secretions and crusts, so that the diseased membrane itself can be reached. Many other formulae will be found in the appendix. CHAPTER XIX. DISEASES OF THE NASAL CAVITIES. Influenza. There are two types of this disease. One is an uncomplicated catarrhal condition of the respiratory tract prevailing generally dur- ing 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 fol- low: 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 epi- demic 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 Isl- ands, from which nearly all the inhabitants suffer; but this is very suggestive of hay fever. In the year 1510 the British Islands were visited by a very extensive 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, generally 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 climates 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 triflers in medicine, it is more to be feared than small- pox or cholera. It cannot be quarantined and controlled by protective 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 vic- tims future maladies. When it first appeared in Paris the effects were (■no) 220 INFLUENZA. 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 congestion 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 in- vades the gastro-intestinal canal. F. B. Turck illustrates the im- portance of clearing the nose and throat of diseased conditions. He demonstrated that the micro-organisms found in diseased stomachs were the same as those found in the post-nasal cavities and mouths of the same patients. (The Laryngoscope, July, 1896.) 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 consti- tutes the specific infection that gives rise to the attack. Some ob- servers believe that the true influenza bacillus has been found, while others are of the opposite opinion and suggest that the micro-organ- isms 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 appearing 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 evolved from subterranean sources may be ex- truded into the great ocean of atmosphere about us and prove detri- mental 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 INFLUENZA. 221 winds have varied greatly in different countries during the same epi- demic, extremely dry air has been a constant factor. This unusual dryness of the air and earth has led some to believe that the conse- quent liberating and floating of the resulting dust in the air and its inhalation and irritating effects upon the respiratory passages ac- counted 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, ob- struct 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, fac- tories, 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 appears 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 respira- tory 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 intestinal disturbances that add to the exhausted condition already present. We often see the nervous and respiratory forms combined, but not the simultaneous invasion of the air-passages and alimentary canal. Two of the three forms are some- times consecutive to each other. To illustrate: One of our younger professors in the Post-graduate Medical 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 sneez- ing, running at the nose, sore throat, hoarseness, and mild bronchitis. Chilliness and heat may often be marked when the temperature 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 ex- 222 TREATMENT OF INFLUENZA. tremities or abdomen, aching of the back and loins, and in the respira- tory 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 week after we become conscious 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 epidemics. 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 respiratory 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 com- plaint. Prognosis. — Robust individuals are able to resist the attacks suffi- ciently to recover in a few days or weeks, but persons already debili- tated 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 percent- age of cases die during the attacks, this does not convey any ade- quate 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 reduced with anti- pyrin or one of its efficient substitutes, and the pain and other dis- tressing symptoms are relieved by the coryza tablets containing a com- bination of morphia, atropia, and caffeine in the proportion of 1 / 1S grain of morphia with 1 / (500 grain of atropia and 1 / 6 grain of caffeine. The morphia relieves the pain and nervous irritability, suppresses the excessive secretions, and stimulates the circulation; the atropia ele- ACUTE EHIXITIS. 223 vates the tone of the blood-vessels, quickens the pulse, decreases all the secretions except the urine, stimulates the respiratory centre, and counteracts the constipating effect of the morphia; and the caffeine stimulates 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 cam- phor-menthol in lavolin or henzoinol with the atomizer three or four times a day. This treatment, with repetition of the doses as the symptoms demand, minimizes the suffering, diminishes the intensity of the dis- ease, and shortens its course. For rheumatic symptoms salicin or salicylate of sodium should be given. Complicating diseases call for their appropriate treatment on general principles. Acute Ehixitis. Synonyms. — Cold in the head; coryza; acute nasal catarrh. Pathology. — Simple acute rhinitis is an acute inflammation of the mucous membrane of the nasal cavities. The first stage is char- acterized by an engorgement of the blood-vessels, not only of the mucous membrane, but of the turbinated bodies also. The membrane is abnormally red, dry, and swelled. The turgescence of the vessels remains during the second stage of the inflammation; but the mem- brane becomes bathed in mucus and a copious exudation of serum, the strong saline character of which irritates the nostrils and the cutaneous surfaces bordering them. Xumerous white blood-corpus- cles escape from the vessels into the surrounding tissues; and in- creased cell-proliferation in the mucosa announces the third stage. Xow the character of the secretions changes from a mixture of serum and mucus to a muco-purulent and finally a purulent discharge. 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 impression of cold on certain surfaces of the body appears to paralyze the inhibi- tory power of the vasomotor nerves controlling the capillary circula- tion of the nasal mucous membrane. The most vulnerable surfaces are the back of the neck and head and the feet. In speaking f the causes of two of the principal symptoms of rhinitis and the manner 224 ACUTE KHINITIS. of their production, Joseph A. White says: "Such phenomena differ somewhat in different persons, as I have found by experiments made upon myself and others. If I irritate my intranasal tissues it takes some time to produce any reflex whatever, but the first to be mani- fested is lacrymation on the side irritated, followed by evident swell- ing of the corpora cavernosa and by a serous exudation; cough I can- not produce at all. On the contrary, if I sit in a warm room with my back to an open door or window, I will begin to sneeze almost before I am aware of the draught of cooler air. I have observed the same effect in others, while, in some, artificial irritation of the nose will cause sneezing immediately, and in nearly all such persons con- tinuance of the irritation will cause cough." The climatic and me- teorological causes are discussed in Chapter I. The nervous tempera- ment predisposes to this affection. Wagner (New York Medical Jour- nal, 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. The uric-acid diathesis predisposes one to this disease. Symptomatology. — The earliest manifestation of cold in the head is a sensation of dryness or irritation in the nostril, prompting one to snuff the air as if to dislodge some foreign substance. This gives place to itching, tickling, or stinging sensations, followed by parox- ysms 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, if continued long, 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 breathing. Eespiration 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 indicates the seat of the trouble. It has a characteristic nasal quality, and the sounds of m and n cannot be produced. The disease mav extend to the antrum of Highmore, the frontal sinuses, TREATMENT OF ACUTE RHINITIS. 225 the ethmoid or sphenoid cells, or the Eustachian tubes and middle ears. Diagnosis. — The group of symptoms described presents so char- acteristic a picture that there is no likelihood of confounding this dis- ease 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 post- poned longer in severe attacks. Treatment. — The course pursued in the treatment of influenza, varying according to the severity of the attack, can be relied upon here. Indeed, this disease can be averted by the use of the coryza tablets mentioned for influenza, containing caffeine, morphia, and atropia. By giving one of these at the onset of the attack the symp- toms subside with as much certainty as can be affirmed of any me- dicinal specific. The effect of this remedy lasts several hours, although the close is small, and it should be repeated in two, four, or six hours if the symptoms begin to reappear. (See page 222.) In the uric-acid diathesis (see Chapter XX) lithia should be given, and the diet should be carefully regulated (page 250). The writer has often aborted attacks by the effervescent lithia prepara- tions given in 6- to 10-grain closes two or three times in the twenty- four hours for one or more days. Prescriptions for the coryza tablets should never be given to patients. I have never allowed them to know the composition of the tablet, 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 whatever of becoming re- sponsible for a baneful habit. Spraying the nose with a 3-per-cent. solution of camphor-men- thol in lavolin or benzoinol (Figs. 129 and 130) affords great relief. The physiological effects and uses of this remedy are dwelt upon in Chapter XVIII. The camphor-menthol pocket-inhaler (Fig. 141) affords much relief in mild attacks. Its uses are given in the preceding 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, 226 SIMPLE CHRONIC RHINITIS. 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 com- fort and sufficient protection. Simple Chronic Ehinitis. Synonyms. — Chronic coryza; blennorrhcea; rhinorrhcea; puru- lent catarrh. Pathology. — This is a chronic inflammation of the nasal mucous membrane, generally consequent upon recurring seizures of acute coryza. The membrane is swollen and puffy and the venous sinuses are dilated and relaxed (vasoparesis). Extensive infiltration of the- interstitial tissue with serum and leucocytes occurs, with a consequent; hydrorrhea 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 mem- brane 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. Uricacidemia is sometimes an important predisposing cause. - 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 discharge. Its presence provokes fre- quent hawking and expectoration. Sneezing is not a constant or fre- quent symptom as compared with acute coryza or hay fever. An annoying sensation of fullness in the head — especially if the infundib- ulum, 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 Eustachian tubes, the middle ears, or the nasal ducts, causing impairment of hearing and obstruction of the natural tear-passages. The thickening of the membrane and the turgescence of the turbinate bodies so con- strict the meatuses as to impart a nasal intonation to the speech. The walls of the passages are frequently seen to be agglutinated to- gether by a viscid, tenacious secretion, or bathed in pus. The mem- PLATE III. PLATE III. Figure 1. — Male, set. 38; hypertrophy of the entire mucous membrane of the nasal cavities; relieved by means of bougies and galvanocautery. Figure 3. — Rhinoscopic view of above (normal size). Figure 2. — Male, set. 30; syphilitic perforation and exostosis of septum; mer- curial 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 syphilitic necrosis. Mercurials and iodides; extraction of necrosed bones with forceps. Potas- sium-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; mer- curials and iodides; mitigated stick locally. Figure 8. — View of palate through the mouth (in state of active inflammation). 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 pharyngeal vault; re- moved with electric 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 III TEEATMEXT OF SIMPLE CHEOXIC RHINITIS. 227 brane is generally redder than the normal, but in the variety in which the hydrorrhea 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 constant 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 simple chronic rhinitis 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 hyper- trophic 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 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 confi- dently be predicted. But one is not warranted in promising no re- turn of the trouble under provocative 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, Seller's, and other solutions, — mentioned in Chapter XVIII. These can be injected successfully with the hand-atomizer (Figs. 129 and 130) 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 absorbents, con- tract the blood-vessels, disinfect, and render the mucosa less sensi- tive. 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 vaporizer (Fig. 131), 228 TREATMENT OF SIMPLE CHRONIC RHINITIS. followed by a spray of the following infusion made with lavolin: Calendula, 1 per cent.; hamamelis, 2; pinus strobus, 2; lavolin 95. Camphor-menthol in the nebula does not bathe the membrane with the liquid, but relieves the irritability and stenosis and prepares the parts for the coarser spray which will remain in contact with the dis- eased surface for many hours. Another excellent spray consists of: Camphor-menthol, 3 parts; pine-needle oil, 2; eucalpytol, 1; and benzoinol, 94 parts. (See appendix.) 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 con- verting one's patron into a pernicious-drug slave. Cocaine has no place in my practice except as an anaesthetic in surgical procedures. Fig. 142. — The author's soft-rubber nasal bougie. Bougies and dilators of medicated gelatin, hard and soft rubber (Fig. 142), 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. When the engorgement of the vessels of the turbinate bodies pro- duces great intumescence of those structures and consequent con- striction of the nasal passages that proves unyielding to the methods' already mentioned, the cautery is indicated. The electric cautery is the most effective, but in its absence chemical cauteries can be sub- stituted. A detailed description of the apparatus and methods will be found in the treatment of hypertrophic rhinitis. The question of proper clothing is considered in the treatment of acute rhinitis. CHAPTEE 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 catarrhus sestivus; coryza vasomotoria periodica. French equivalents: catarrhe d'ete; catarrhe de foin. German equivalents: Fruhsommer-catarrh; Heu-asthma. Italian equivalent: asma dei mietitori. Pathology. — In a paper read before the Section on Psychological Medicine and Nervous Diseases of the Ninth International Medical Congress in Washington in 1887, the author argued the neurotic char- acter of this disease. The assembly, which was very large and repre- sentative, agreed almost unanimously to the theory that hay fever is a neurosis. Only three members who participated in the discussion dissented from this view. The name "hay fever' 7 is a misnomer. It is employed to desig- nate 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, the author had the temerity to add another. In a published lecture, delivered in the Chicago Medical College in 1885, he 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, sig- nifying only a running at the nose, while the word catarrh, from xarappEG), admits of a much broader application and, with properly modifying adjectives, 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 is so comprehensive a term, and is so tersely suggestive of the pathology and symptomatology of certain neurotic derangements, as to be sus- ceptible of a much larger usefulness than has been accorded it. To illustrate: There is a truly nervous intestinal catarrh which attacks (229) 230 HAY FEVEK. and leaves a certain class of individuals' of the nervous temperament as suddenly as an attack of hay fever does. The writer has known a musician to suffer from severe attacks of diarrhoea just previously to his appearance before an audience which he was announced to en- tertain. Immediately after his performance all symptoms of intestinal disturbance would vanish, only to return again at his next appearance in public. We 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 turbi- nated 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 intestinal mucous coats are the scene of this breaking of a nerve-storm, resulting in coj)ious watery discharges, — intestinal nervous catarrh. All these are undoubtedly co-ordinate morbid conditions of the nervous sys- tem, finding expression in exaggerated and perverted functional ac- tivity. The pathology of this disease has been evolved from a chaotic state, in which it remained from the time of its first description by John Bostock, of London, in 1819, until the last decade. Instead of looking upon hay fever as a simple congestion or inflammation of the Schneiderian membrane, as eminent English authorities have in the past, prominent American authors favor the neurotic theory. In this connection it is interesting to note that a writer for the London 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 suscepti- bility of nervous tissue, there exists no organic lesion of the nervous centres to which the disease is attributable. Being a functional dis- turbance, it never destroys life, and no opportunity is afforded the neuropathologist to make post-mortem observations. But, if the affec- tion be a reflex neurosis, can we hope for microscopy to determine HAY FEVER. 231 with precision the condition of nervous structure which primarily con- stitutes the disease? The arrangement of the nervous snppl} 7 of the respiratory pas- sages is favorable to the existence of reflex nervous phenomena. One sympathetic nervous centre, the sphenopalatine ganglion, supplies branches to the lining membrane of the nose, pharynx, and Eusta- chian tubes. It has a motor, a sensory, and a sympathetic root. It communicates with the facial and pneumogastric nerves, thus uniting in the closest conection the nose, pharynx, middle ear, larynx, and bronchi. Furthermore, the Schneiderian membrane is continuous with the lining membrane 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 ca- tarrhal 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 erysipelatous in- flammation from one area of the skin to another. But the continuous- ness of the membranes throughout these various organs does not sat- isfactorily account for all the s}unptoms produced in one part by im- pressions upon another. Certainly 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 with the external auditory meatus or with the inferior turbinated body or the septum nasi, or for the paroxysm of sneezing produced by irritating the scalp. All these symptoms are examples of reflex nervous impulses, and these intimate sympathetic relations between various portions of the animal economy exhibit 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, symptomatology, 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 232 HAY FEVEK. 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 in- tense 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, swelling, and flux; and, on the other hand, along the pneumogastric and sympathetic nerves to the muscles concerned in the act of sneezing, and, through ex- tensive 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 conditions upon which the existence of the disease depends: (1) abnormally susceptible nerve-centres, (2) hyperesthesia of the peripheral termini of the sen- sory nerves, and (3) the presence of one of a large variety of irritating agents. Exclude one of these conditions and the paroxysms are pre- vented. 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. Eemove the patient beyond the reach of exciting causes and he is as comfortable as any mortal. Another fact in support of the theory that this is a functional disease of the nervous system is its hereditary character. We might quote many illustrative cases, but three representative ones will suf- fice: In Dr. Morrill Wyman's family there were six sufferers from hay fever besides himself. In the family of the Eev. 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 dis- tressing 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 constitutional disorder of a neurotic type. Again, the nervous temperament is the predominating one in this class of patients, — an argument which needs no elucidation, — and the same may be remarked concerning asthmatic sufferers. The periodicity of the disease points to nothing if not to its nervous HAY FEVER. 233 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 reasonable to assume that the pollen of various plants that give rise to attacks in different individuals will he 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 situa- tions and vocations simultaneously year after year? The variations that occur in the yearly advance of the seasons preclude this hy- pothesis. And, again, the identity of the different forms of the mal- ady strengthens the nerve theory, while it weakens the pollen argu- ment, for it shows that the disease exists under conditions that are the least favorable to the operation of pollen; in fact, where the joollen theory is inadmissible, — in the winter and spring. The author does not undervalue the importance of pollen as an exciting cause, but he wishes 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 sudden- ness 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 parox- ysms. 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 population who have no experience with hay fever. That we should find nasal hypertrophies, etc., concurrent with hay fever is not surprising in this catarrh-pro- ducing climate. Indeed, the diseased turbinated tissue may be a coin- cidence or sequence rather than the cause, for it is natural to sup- pose that years of constantly recurring attacks of even functional dis- turbance of the vasomotor supply of these parts would result in a passive hyperemia which would eventuate in proliferation of cells in mucous and submucous tissues, and the growth of hypertrophies which might serve as a nest for the reception and retention of irri- tating 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. 234 HAY FEVER. It lias been hoped 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 considerable disappointment at the results. Some cases that were supposed to have been cured still suffer, while others are benefited. So far as we have been able to obtain definite data, they demonstrate that not much more than one-half the number cau- terized are claimed to be cured. This points to the fact that it is not a simple local inflammatory disease. 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 ad- mission, 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 sys- tem, and you remove an essential element in the disease, — destroy its entity. But what shall we say of that other large proportion of pa- tients in whom paroxysms are produced by irritation of the retina, the scalp, etc., or by chilling 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? Yet, if you follow the reasoning of this school of theorists to its logical conclusion, it will lead to this reductio ad absurdum. The neurotic theory is supported by the nature of the following causes: Electric light and gaslight; overexertion; anxiety; indiges- tion; dampness; chills; gases; feathers; perfumes; odors from ani- mals; 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 state- ments 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 cult- ure. This is far from being an idle assertion, for it voices the experi- HAY FEVER. 235 ence of the best authorities and is borne out by reference to the list of membership of the United States Hay Fever Association. TTe cannot consider the treatment of this subject as approaching 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 diseases 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 pas- sages, and acts as a local irritant in the same manner that any foreign body would. Analysis may demonstrate that this gravel consists of deposits of urate of sodium. 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. Xeumann says: "There is no doubt that a large proportion of cutaneous diseases de- pend upon disorders of the vasomotor nerves which cause certain derangements of circulation 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." Xow, since it is admitted that there are both immediate and re- flex 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? The latter membrane is more vascular, more delicate, more sensitive, and more highly organized than the skin. It possesses susceptibility to all agents which affect the skin, and to many others besides. For ex- ample, 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 vasomotor nerves of the skin also regulate the vaso- motor supply of the mucous membranes. If itching and burning of the skin are produced by morbid alterations in the ovaries, so is pru- ritus urethra? 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 membrane; so may asthma arise in the same manner or from an irritant applied to the nasal mucous surface; ear-couoh. is occasioned bv contact of instru- 236 URIC ACID AS A CAUSE OF HAY FEVER. ments with the skin of the external 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 disturbed by a relative increase of the uric acid, certain disturbances of a vascular and neurotic character arise. The effects of uric acid in producing these disturbances have been the subject of an extensive and interest- ing series of experiments by Alexander Haig. For years he was a sufferer from migraine, and studied in his own person the relation of uric acid to the production of attacks of this disease, and the effects of anti-uric-acid treatment in subduing attacks, and of diet in pre- venting them. I desire at the outset to acknowledge my great in- debtedness to this painstaking observer for many of the facts ad- duced 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 lithsemia are: aching pains in the limbs, lassitude, pain in the shoulder, hepatic neuralgia, severe cramps in the legs, headache, vertigo and temporary dimness of vision, convulsions, paraly- sis, noises in the ears, sleeplessness, depression of spirits, irritability of temper, cerebral symptoms, and a typhoid state. Haig maintains that the presence of uric acid in excess accounts for the exacerbation of pains in rheumatism and gout, and Lever con- tends 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 ad- ministered 3 to 6 grains a day to the human subject. The most com- mon results were boils and patches resembling eczema, — the dermal analogue of coryza. URIC ACID AS A CAUSE OF HAY FEVER. 237 Thomas J. Mays attributes attacks of angina pectoris to "the increased formation of uric acid, which is incidental to the gouty and rheumatic diathesis." He agrees with Haig in attributing mi- graine to the irritating effects of uric acid. Conklin details a number of well-marked cases of nervous, men- tal, nephritic, and other diseases that support the proposition that they are the result of the action of uric acid. X. S. Davis and others add the following to the list of manifesta- tions of uricacidgemia: Loss of appetite, nausea and vomiting, flatu- lent indigestion, diarrhoea, intense itching, asthma, blindness, deaf- ness, numbness of the skin and creeping 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, over- sensitiveness 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 per- sons, like the late Henry Ward Beecher, 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 Haig 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 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 excretion of the acid was greatly diminished before the attacks, — i.e., during mental exaltation. The author has 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 ad- vocated the same theory. So far as the writer knew, he was the first 238 URIC ACID AS A CAUSE OF HAY FEVER. to propose this doctrine. In 189-1 it was brought to my attention that Shawe Tyrrel, of Toronto, had published a paper in 1892, en- titled "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, proper reference would have been made to his work. Haig says: "Uric acid in the blood contracts the arterioles and capillaries all over the body, producing the cold surface and extremi- ties, raising tension of pulse, and, according to Marcy's law, that pulse- rate varies inversely as the arterial tension, slowing the heart. Head- ache is a local vascular effect of the uric acid. Excretion of this acid may even explain the mental depression and irritability and their re- sults in the excess of suicides and murders in July. There is an ex- cessive secretion of this acid in the warm months, and a minus excre- tion 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 Eoy and Sherrington have shown, an in- crease 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 in- fluenza 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, dimin- ishing 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 accumula- tion 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 UKIG ACID AS A CAUSE OF HAY FETER. 239 excretion, contracted the arterioles, slowed the circulation of the blood, and caused languor, depression, headache, and, in epileptics, a fit. Epilepsy, migraine, spasmodic asthma, etc., are, like neurotic catarrh, functional nervous diseases. \That 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. 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 anryl. 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 followed 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 at- tack 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 diseases. The particular form of manifestation may be determined by the growth, or seat of irritation, located in the nasal cavities. Where this is the only 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 disturb- ances 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 condi- tions in winter, as well as during the warm months. It also unifies 24:0 TTKIC ACID AS A CAUSE OF HAY FEYEB. 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 func- tional 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 Haig very markedly, at times of excess of uric acid in the blood, with mental depression, lethargy, and headache. The histories of such cases are paralleled by the histories of nervous catarrh in many fami- lies. 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. Beeves Jackson he expressed his conviction that various neurasthenic symptoms — sleep- lessness, headache, vertigo, neuralgia, vague pelvic symptoms, mus- cular 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 man- ner 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 uricacidaemia will produce in any given case, but also explain why one person 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 disturbance of function than at other times. If uricacidaemia is prevented, the nervous sys- tem will not itself originate disturbances. 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, hypertrophies, etc. — have already been considered. UKIG ACID AS A CAUSE OF HAY FEVER. 241 Heredity is probably the chief factor in determining the direction in which the uric-acid diathesis will afflict an individual, whether it results in migraine, angina pectoris, asthma, nervous catarrh, or some other neurosis; but undoubtedly accidental or acquired conditions may act as directing or localizing agents. For example of the latter class: a student who is predisposed to such neurosis accidentally in- hales the fumes of burning phosphorus in the laboratory, and this excites the first attack of his nervous disorder, which naturally, un- der these conditions, takes the form of asthma. On the other hand, many attacks of severe cold, some injury to the nose, or the develop- ment of a polypus may determine the nasal form of neurosis, or nerv- ous 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 nervous 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 pre- vious afternoon and evening may have been free from suffering, and the night one of restful repose, with no direct access to dust-laden at- mosphere from without and no change in the contents of the sleeping- apartments. 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 alkalinity. 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 cir- culating 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, car- tilages, joints, and fibrous tissues, — and with the increasing alkalinity and solvent properties of the blood it becomes rich in uric acid until it produces the drowsiness, heaviness, or other nervous phenomena peculiar to any given case. Joal found, among 127 cases of hay-fever patients, a family his- 242 PREDISPOSING and aggravating causes of hay fevee. tory 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 nor- mal (Revue de Larijngologie, Nos. 7 and 8, 1895). PREDISPOSING AND AGGRAVATING CAUSES. Heredity and the temperaments classed as nervous are, strictly speaking, the predisposing causes. Broadly speaking, whatever di- minishes 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 paroxysms, inasmuch as the mere con- tact 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 varying cur- rents 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 na- tive soil. Dust may be deposited in curtains, carpets, etc., and be retained for indefinite periods before finding lodgment in the respi- ratory 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. The greatest suffering occurs from May to October, especially 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 occa- sional rains; the dry surface-soil affords the winds a never-failing supply of dust, and one is not protected from the dazzling brilliancy of the sun by tall buildings in the country as he may be while pur- suing the vocations of city-life. The streets of cities are deluged with EXCITANTS OF HAY FEVER. 243 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 capil- lary 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 immediately there follow a correspond- ing 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 sneez- ing, 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 comparable 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 temperature rises, the sudorifer- ous glands resume their activity, and the skin is again bathed in per- spiration. 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 saturate many handker- chiefs, — a dozen or a score in a day in severe cases. One peculiar symptom I have observed, but have never 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 (244) HAY FEVER, SYMPTOMATOLOGY. 245 same length of time at each recurring season. A sudden mental ex- citement 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. The author has 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 painful. In sleep it is necessary to breathe through the mouth, which occasions distress- ing 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 be- tween 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 res- piration. In some cases we 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-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 feel- ing perfectly well, with the nasal passages comfortable 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 subside. The attacks may reappear at intervals during the day, with 246 ABOKTIVE TREATMENT OF HAY FEVER. 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 consciousness 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 refu- gees 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 provoke sneezing at any season. Diagnosis. — Considering the characteristics and the description 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 morn- ings was followed by freedom of respiration and a sense of well-being that seemed like a physical millennium. After this result of pre- venting the morning increase in the alkalinity of the blood, in order to prove the correctness of his deductions, the writer used an alka- line treatment, and was both delighted and disgusted with the re- sults. The old enemy raged again, but here was clinical proof of his ABORTIVE TREATMENT OF HAY EEVER. 247 first proposition. These experiments have been successfully repeated until I am satisfied of the correctness of these conclusions. The first acid used for these experiments was the dilute sul- phuric 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, we ay ere obliged to substitute another. It occurred to me to try Hors- ford's acid phosphate that I had used for other purposes for some years, on the recommendation of the late Professor Jewell. We used teaspoonful doses of this acid without any ill-effects, and with the result of giving complete immunity from suffering. One or two teaspoonfuls in a glass of water at bed-time and on first awakening in the morning were sufficient to break up the habit en- tirely. 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 reappeared, 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. While the author has 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. We have made it a point to have the morning dose well diluted with Yvater, for the purpose of starting perspiration, for we have observed that as soon as a patient has sneezed violently enough to produce free sweating the symptoms either decreased or disappeared. The sweat- ing carries off uric acid and helps to free the blood. I am aYY^are of the differences of opinion that exist concerning the influence of an excess of dilute phosphoric acid on the elimi- nation 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. We are 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 eliminating, 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 excitant-: and, if the morbidly-susceptible condition of the nervous centres is due to the action of the uric acid, its oversensitiveness to all excitants may be relieved by correcting' the uricacidamiia. After relieving- the 248 ABORTIVE TREATMENT OF HAY FEVER. suffering with the acid phosphate I have produced it again by neu- tralizing the acid with an excess of bicarbonate of sodium and em- ploying 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 ca- tarrhal 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 treat- ment. Nitroglycerin, nitrite of sodium, nitrite of amyl, antipyrin, etc., have a similar effect. Opium raises the acidity of urine, dimin- ishes the alkalinity of the blood, and reduces the 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 ex- cretion of uric acid, reduces tension of pulse, and produces diuresis. If opium is employed, its ill effects should be prevented by follow- ing 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 temporary use only, like the acid treatment. . The author has employed it for the last sixteen years or more, but in this case it is, like old wine, the better for age. This is a combination of atropia and morphia, in the proportion of 1 part of atropia to 50 of morphia. The ordi- nary adult dose is from 1 / 16 to 1 / 8 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 it is more often given away than charged for, but in order to obviate the possibility of being responsible for a drug habit. The morphia clears the blood of uric acid, dimin- ishes the nervous irritability, suppresses oversecretion from the mu- ciparous glands, and stimulates the circulation and activity of the nervous centres, while the atropia elevates the tone of the blood- TREATMENT OF HAY FEVER. 249 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 antispasmodic. Caffeine, 1 / 6 grain, may be added to this dose to stimulate the nervous centres and kidneys. Local Self-treatment. — The most useful self-treatment probably is (1) the use of a convenient pocket-inhaler (Fig. 141) that I have devised for patients who take cold easily. It is called the "camenthol inhaler." It can be used in an inconspicuous and expeditious man- ner in public places, where it would be impracticable to combat a sudden seizure with other and slower measures. Several gentle, pro- longed 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 men- thol crystals, iodine, or carbolic acid. When the throat is involved, it can be inhaled through the mouth for self-treatment. .2. For home treatment, morning and night, we usually prescribe a solution of cam- phor-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 with the weaker, and increase gradually to the 3-per-cent. solution. Joseph A. White applies a much stronger solution than the last named in the asthmatic type. He first applies a 1-per-cent. solution of cocaine, and follows this with camphor-menthol, of which he gives the following formula (Burnett, vol. ii, p. 126): Menthol, gum cam- phor, of each, gr. xxx; liquid cosmolin, §j. (The quantity of liquid cosmolin was printed as a drachm, but an ounce was probably in- tended. However, this is about four times as strong as this very sensi- tive class of patients will generally tolerate with equanimity unless preceded by cocaine, and liquid cosmolin is not as bland a vehicle as lavolin, benzoinol, or albolene, all of which have been deprived of the irritating properties characteristic of cosmolin when applied to the nasal mucous membrane. Preventive Treatment. — The treatment to eliminate uric acid cannot be undertaken to advantage during the season of attacks, ex- cept 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 250 PREVENTIVE TREATMENT OF HAY FEVER. considerable study of this subject, one is forced to the conclusion that an excess of uric acid in the system is not due alone to continued re- tention 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 fol- lows, then, that it is necessary 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, etc. Exercise also aids in the excretion of uric acid, although there may be an actual increase in the amount of acid. Lange treats peri- odical mental depression successfully by reducing the amount of food and by systematic exercise. A diet of milk with occasional very small quantities of egg and fish, with no other animal food, will prevent suffering from sick head- ache entirely, without medicinal treatment. With this diet the nat- ural 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 headache. 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 produce uricacidaemia and precipitate an attack of the trouble we are endeavoring to pre- vent. For an attack, then, a dose of acid should be given to free the blood of uric acid; then the salicylate 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 regular 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 advanta- geous, also. Warner's 3-grain tablets of effervescing citrate of lithia are excellent, and the same may be said of alkalithia and the effervescent citrate of lithia, soda, and potash. The writer now depends mostly upon lithia as a preventive remedy. This treatment, combined with proper diet, should be successful, provided that there is no organic disease of the structures, central HAY FEVER, MEDICAL OPINIONS. '251 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 uricacidaemia only, as a cause of suffering; hut it should not he 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. In this connection it is worth while to note the apparent effect of an operation on the ear in relation to hay fever. In June, 1897, I removed an aural polypus and the ossicles, and curetted granula- tions of the middle ear under a 20-per-cent. cocaine anaesthesia in a case of long-standing chronic suppuration. The patient, who was an educator, was a hay-fever sufferer. Heretofore the attacks had come on in June and lasted until the frosts of fall. In November,. 1897, the patient, who lives a considerable distance from the city, called and informed me that the operation had relieved her from hay fever, for she had escaped it entirely the past summer. The sup- puration ceased; but whether the freedom from hay fever was a con- sequence or a coincidence is a debatable question. The author is of the opinion that, with this new theory, im- proved therapeutics, and proper diet of this disease, the medical pro- fession need no longer say to ha} T -fever patients, in a patronizing way, "Suffer little children, for of such is the kingdom of heaven/ 7 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 OPIXIOXS. YTe 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 unnecesary to write, and others who were inaccessible; so we have in such cases searched the literature and endeavored to present a fair and impartial account of the present status of medical opinion on the nature and treatment of hay fever. From some articles it is impossible to gather any definite knowledge of the opinions of the writers on the nature of the disease; we have stricken out much for that reason, but 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 neu- 252 HAY FEYEE, MEDICAL OPINIONS. rotic or local affection, is indicated by a single word following his name, — neurosis or local. E. L. Shurly. Neurosis. "I am very glad that you 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 body, as well as in the nasal passages. I also believe that its purely nasal origin is overestimated. I have found snuff of daturine with starch sometimes more effective than the galvano-cautery." 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 hay fever to be amenable to thorough surgical treatment, establishing a complete cure in a minority of cases only, — those particularly which present gross deformities of the septum and the turbinates, and polypi. 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 thorough- ness of the treatment. A small minority are not amenable to surgical treat- ment. They include the highly-neurotic individuals in whose noses, between the paroxysms, little or no structural change is apparent. Much can be ac- complished toward palliation by 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 by supportive and tonic treatment, as the individual's gen- eral health improves and the neurotic element lessens. Of local palliative remedies, cocaine is probably the most powerful and at the same time the most dangerous remedy. Its use and sale should be regulated by law." C. H. Knight. Neurosis. Destroys all enlargements. "When it is im- possible to define a distinct abnormality, the nasal membrane throughout 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 always essential. I must confess that my proportion of cures is small. I feel quite pleased if I succeed in mitigating the severity of the symptoms 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, antipyrin, etc., lessens the dis- turbance and sometimes controls it." Jonathan Wright. Neurosis. "I have seen several cases with no ap- preciable intranasal lesion except the acute condition during the attack. I have operated a few times for intranasal lesions of various kinds. All were improved somewhat, — some markedly, some slightly. My impression 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 resorted to HAY FEVER, MEDICAL OPINIONS. 253 cautiously, and only when absolutely necessary.'' He recommends 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, 1 / 2 part; menthol, 1 part; creasote, 1; oil of eucalyptus, 2; oil of pine-needles, 2; albolene, 93 1 / 2 parts. J. 0. Eoe. 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: "Irrita- tion reflected from other situations to the nasal chambers is not hay fever." F. H. Boswoeth. Neurosis. He believes that intranasal surgery affords permanent relief. This method is clear in its indications, easy of accomplish- ment, and promises not only more immediate, but more permanent, relief than any other method. He believes that hay fever and spasmodic asthma are patho- logically identical. J. N. Mackenzie. Neurosis. Better results were obtained from constitu- tional 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 by surgical operations. J. Solis-Cohen. Neurosis. Any local nasal trouble may be simply inci- dental. He prescribes tonic treatment and restricts the use of meat. H. Geadle. Neurosis. He removes any nasal growths. Kitchen, of Xew York. Local. He believes it is due to the membrane being deficient in the epithelial covering, etc., that calls for local remedies. B. O. Kinneae. 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 treatment addressed to this condition was successful. He used the well-known ice-bags of J. Chap- man, 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 con- gested centres. The applications lasted from sixty to ninety minutes, one to three times a day. E. F. Ingals. Neurosis. About 40 to 50 per cent, of cases may be cured by cauterization. He gives tonics and uses cocaine locally. M. R. Beown. Neurosis. The supersensitive areas should be destroyed with the cautery. Atropine, 1 / 100 grain, once or twice daily or a 4-per-cent, solution of cocaine locally may give temporary relief. H. H. Curtis. Neurosis. He sears the enlarged tissues with chromic acid in preference to all other escharotics. C E. de M. 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, and he gives strychnine and coca-wine after meals. William Cheatham, of Louisville. Neurosis. He praises antipyrin in 10 to 30 grains; also acetanilid, 4 to 6 grains a day. T. M. Haedie. Neurosis. He believes that operations will benefit a large proportion, but constitutional treatment is necessary in most instances. 254 HAY FEVER, MEDICAL OPINIONS. Beverly Robinson. Neurosis. Soothing applications and constitutional 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-per-cent. solution of atropine after anaesthetizing with cocaine-phenol. He gives aconitine 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 hypodermic- ally is advised. All enlargements should be removed; he gives dilute phos- phoric acid, 30 drops a day. De Lamalleree. Neurosis. He believes it is a neurosis of nasal origin, and claims to subdue morbid sensitiveness of the membrane by douches of car- bonic-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 mixture: 1 ounce each of glycerin and carbolic acid, 1 drachm of quinine, and V2000 part of the 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 galvanocautery. He deprecates indiscriminate cauter- ization, however. D. B. Lees. Neurosis. He claims to abort it with bromide and bella- donna. John North. Neurosis. Employs anti-uric-acid treatment, and removes hypertrophies, with satisfactory results. Gouguenheim. Neurosis. He uses nervines, and cocaine locally. The author operates with the electrocautery or by other methods when there are indications for such measures. PLATE IV. PLATE IV. Figure 1. — Male, get. 21; anterior view of extensive osteo-enchondroma of sep- tum, occluding completely left nasal cavity; mass reduced with dental engine. Figure 2. — Lateral view of above. Figure 3. — Posterior view of asymmetrical nasal cavities of above case; com- plete stenosis of the left naris. Figure 4. — Male, get. 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, get. 48; relaxation of soft palate, causing symptoms of elon- gated uvula; astringents found useless; amputation of uvula. Figure 8. — Female, get. 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 char- acter of pain, color of tongue, odor of breath, and dysphagia. Figure 10. — Male, get. 28; hypertrophy of the tonsils; amputation with ton- sillotome. Figure 11. — Appearance of tonsils in above case during an attack of tonsillitis. [Note. — Eepresented as seen by gaslight. By daylight the red color appears much paler.] PLATE IV. CHAPTEE XXII. DISEASES OF THE XASAL CAVITIES, CONTINUED. Hypebtbophic Rhinitis. Pathology. — In this form of nasal catarrh there is not only a thickening of the mncoiis membrane, but also an increase of connec- tive-tissue formation in the submucous layer, or corpora cavernosa. Fig. 143. — Xasal synechia. Point of probe is inserted between the inferior turbinated body and the projection of the septum at the point of their union. (Author's specimen.) 'The venous sinuses, having passed through the stage of vasoparesis, have now become permanently dilated. The newly-formed fibrous tissue prevents their contraction and maintains them rigidly dilated (255) 256 HYPERTROPHIC EHIXITIS. Fig. 144. -Posterior view of osseous bridge shown in Fig. 143. (Author's specimen.) Fig. 145. — Transverse vertical section through the vault of the pharym and Eustachian tubes. 1, posterior border of the vomer; 2, Eustachian tube; 3, inferior turbinated body. HYEEETEOElilC RHINITIS. 2b: until pressure upon their walls by contraction of this tissue, the pres- ence of leucocytes, or the formation of connective-tissue septa and thrombi within the sinuses finally obliterates them. During the hypertrophic stage there is increased vascularity of the turbinate and of the septum. The most frequent situations of thickening of the membrane and tissues beneath are the posterior ends of the turbinate bodies (Plate V and Figs. 145 to 148). Depressions and spurs of the septum nasi, ecchondroses and exostoses, and sig- moid deflections resembling corrugations are frequent accompani- Fig. 146. — Transverse vertical section through the posterior nares. 1, sphe- noid antra; 2, posterior end. of the inferior turbinated body. rnents (Plate IV). Occasionally adhesion occurs between the septum and turbinate, forming a bridge, or synechia (Figs. 143 and 144). Etiology. — This is a sequel of simple chronic rhinitis. Symptomatology. — The obstruction to the free passage of air through the nose, by great thickening and deformities of the turbinate and the septum, causes partial or complete mouth-breathing. Patients complain that they take cold easily and that when lying on one side the lower nostril closes. The latter symptom occurs in consequence of the blood gravitating to the lower turbinate and causing them to swell. A slight exposure results in stenosis of both nostrils, and as 17 258 HYPEKTKOPHIC RHINITIS. Fig. 147. — Transverse vertical section through the orbits, nasal fossse, and maxillary antra. 1, ethmoid cells; 2, superior turbinated body; 3, middle turbinated body; 4, antrum of Highmore; 5, inferior turbinated body; G } embryonic tooth. Tig. 148. — Transverse vertical section through the nasal fossse. 1, ethmoid cells; 2, deflection and spur of septum with adhesion to the left inferior turbinated body. TREATMENT OF HYPERTROPHIC RHINITIS. 259 a result the constant passing of air through the throat instead of the nose dries the throat and larynx and gives rise to more or less irrita- tion or inflammation of these parts. "When the stenosis is marked the nasal voice is a characteristic sign. Invasions of the nasal ducts and Eustachian tubes lead to in- volvement of the conjunctivae and the middle ears. Watery eyes, impairment of hearing, and tinnitus annum are common sequels of this disease. AVhen the very young are affected the pharyngeal and oral tonsils are often found hypertrophied (Plates II and IT) and require excision. Anosmia (absence of the sense of smell) and im- pairment of taste are occasional symptoms. "When headaches are pres- ent, they are referred to the supra-orbital or frontal region. Asthmatic attacks are sometimes due to pressure of the enlarged turbinals against the septum (Fig. 17.1). The secretions, which are much more abundant than in health and more copious in the morn- ing on account of their accumulation during the sleeping-hours, cause a disagreeable habit of hawking and hemming to clear the throat, especially on rising in the morning. Diagnosis. — The septum, like the turbinals, is red and thick- ened, particularly near its base. The turbinals, instead of presenting a smooth, glassy surface, as in the simple form, are hypertrophied unevenly and sometimes present a somewhat nodular appearance. The inferior turbinate body usually shows the Greatest enlargement, but the middle one is often found in contact with the septum. Their posterior extremities may blossom out into berry-like buds of a gray or purple color (Plate V). The former are the commoner. Probe- pressure meets with a firm, instead of a yielding, resistance. Prognosis. — After middle age the hypertrophies generally become absorbed and disappear, when this form often merges in atrophic catarrh. The hearing is likely to suffer, and there is a strong pre- disposition to catarrhal affections of the pharynx and larynx. Mod- ern methods of surgical treatment afford an excellent prognosis. Treatment. — Cleanliness is of prime importance in this as in other forms of nasal catarrh. The solutions and methods given in treating of the simple form are indicated here, but medicinal treat- ment alone will not suffice to remove hypertrophies. Operative meas- ures must be brought into requisition. Of these the electric cautery is now the most frequently resorted to except for cartilaginous and osseous outgrowths, which require the knife, the saw, or the drill. Por the fibrous growths the hot or cold snare, scissors, chemical 260 TREATMENT OF HYPERTROPHIC RHINITIS. caustics, etc., are employed. We will first consider the electrical ap- paratus. For physicians who practice in the country, where the incan- descent electric lights are not a part of their office equipment, the Wabash cautery-battery (Fig. 149) is satisfactory. It has the ad- vantage of a mechanism which prevents the immersion of the zinc and carbon elements in the cautery fluid except when in use. This extends the life of the battery very materially. By keeping a fresh supply of the fluid on hand for immediate use one need never be Fig. 149.— The Wabash cautery battery, with electrodes, lamp, and handles. disappointed by the battery's not working. The Flemming battery, also, is effective. 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. 150 is to be recommended. It is more easily port- able than the fluid battery, and will give a white heat. Unlike the plunge battery, it deteriorates in consequence of disuse, and is better for being worked at least three times a week. When lying idle it sulphates; that is, sulphate of lead forms on the plates and renders it inoperative. ELECTROCAUTERY APPARATUS. 261 The most thoroughly useful combined electrocautery and motor instrument with which the author has had any experience is the rotary-current transformer and dynamomotor shown in Fig. 151. Above the transformer is seen the switch, and at the left are the cautery-rheostat and cautery-handle, with the cautery-snare, ready for use with the 110- volt direct current, such as is used in Chicago. The cautery-current furnished by this transformer has an electro- Fio-. 150. — The American storage battery motive force of T 1 / 2 volts and a volume sufficient to heat the largest cautery-electrode, and it is perfectly controlled by the rheostat: so that the operator has at command and under entire control the full range of any desired strength of current. This transformer is quiet in its operation, and it may be placed in the treatment-room or in any convenient location at a distance from the operating chair by extending the wires leading from the generator to the rheostat. It has o-iven entirely satisfactory service in mv work both for cautery 262 ELECTBOCAUTEBY EYXAMOMOTOB. purposes and for operating drills, burs, etc., in connection with the dental arm. For the perfecting of this superior apparatus I am under obligations to C. S. Neiswanger, and the Mcintosh Battery and Opti- cal Company, of Chicago. Fig. 151. — Electric current-transformer and dynamomotor. In many of the smaller towns the electric current employed for the purposes of illumination is of the alternating kind, and is trans- formed for house and office purposes to a pressure of 52 or 104 volts. ELECTRIC CURRENT-TRANSFORMERS FOR CAUTERIZING. 263 When this current is obtainable it is much cheaper, and more easily adapted to cautery uses, than the 110-volt direct current. A transformer for this current is illustrated in Fig. 152. The current from the mains enters the binding-posts on the side of the instrument, and by flowing through a magnetizing coil consisting of a large number of turns of fine wire, induces a rapidly-reversed flow of magnetism through a centre bundle of soft-iron wires. This flow of magnetism encircles the secondary coil, which, consisting of a few turns of very coarse wire, delivers a current of low voltage and high amperage to the binding-posts on the top of the instrument. Fis. 152.— Alternating electric current transformer tor cautery purposes. By means of the hand-wheel on the transformer the secondary coil may be raised out of the magnetic field of the primary, thus diminishing the current supplying the cautery electrode. In this manner the current is placed under absolute control: and so perfeci is the adjustment that a fraction of a turn of the wheel raises c lowers the temperature of the cautery knife a perceptible degree. The voltage of the current obtained may be varied at will from 2 to 1; volts, and it may be utilized for lighting small lamps. The transformer, when heating the largest cautery-knife, takes 264 ELECTRIC-CAUTERY INSTRUMENTS. from the mains about 2 amperes, and delivers to the cautery-knife 40 amperes. The large increase of current in passing through the transformer is offset by a corresponding diminution of voltage. A large volume of current at a low voltage is what is required for cau- tery purposes. Figs. 149 and 153 show several of the most useful cautery elec- trodes, and Fig. 154 a convenient handle. One must select the elec- trode according to the individual requirements of each case. Fig. 153. — Cautery-knife. The electrodes should fit into the handle in such a way 'as to permit the operator's arm to rest naturally by his side while cauter- izing, the same as while using the nasal speculum (Fig. 121). They are not now so constructed, but they should be. If the physician does not happen to have the conveniences of the electrocautery, he may resort to chromic, or nitric, or monochloracetic acid. Of these the chromic acid possesses decided advantages over the others. It is fusible into an easily manageable bead on the chromic- acid applicator (Fig. 71). To accomplish this, the platinum loop is dipped into the dry acid crystals and held over a small flame to heat. As soon as the acid begins to melt it is quickly withdrawn from the Fig. 154. — Mcintosh electrocautery handle, with snare and windlass. It answers for snaring as well as for holding electrodes. 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 moist surface too long, or moisture will be absorbed sufficiently 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 sur- plus fluid must be pressed out of the cotton pledget by which it is applied before introducing it into the nose, otherwise it will spread over the surrounding surface. ELECTBOCAUTERIZATIOX. 265 Ten or fifteen minutes before cauterizing the mucous membrane an 8-per-cent. solution of cocaine hydrochlorate or eucaine is to be 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 anaes- thetic solution, and then adjust it nicely to the particular area we desire to cauterize and slip it off the carrier, leaving it pressed lightly between the septum and turbinate. Like the liquid acids, the surplus of the anaesthetic 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 and dried 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. It is 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 the anaesthetic 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 should be used at a white heat, with care that it does not melt, or burn out, and it 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 beins: taken to avoid touching any but the anaesthetized area. If the electrode is permitted to touch the border of the naris in its withdrawal, the re- sulting 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 reaction occa- sions considerable swelling, a copious serous discharge, pain, headache, irritation of the corresponding eye, and even tumefaction and dis- coloration of the cheek and loose areolar tissue of the lower eyelid. It is generally best to allow about a week to intervene between cauter- 266 ' ELECTKOCAUTERIZATION. izations of the same side, but when patients from a distance can re- main 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 ex- tensive. After each cauterization the most satisfactory results are obtained by introducing a light packing between the burned surface and the septum, consisting of a thin pledget of cotton moistened with a 10- per-cent. solution of camphor-menthol in lavolin or benzoinol. The packing is only large enough to cover the cauterized area with slight pressure, 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 i; ttle or no haemorrhage, pain, or reaction, but the parts pursue a placid course to recovery. 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. We have seen acute suppurative inflammation of the middle ear result from such procedures. Seiss (Therapeutic Gazette, Novem- ber 15, 1891) cites cases of ear disease made worse by nasal treat- ment. The membrane being anaesthetized, a speculum is introduced and the light from the forehead-mirror is thrown into the nostril. The chosen electrode is introduced cold and placed on the benumbed area, when the current is turned on sufficiently to give a white 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 in- stant 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 intervals 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 and sloughs occlude the passage until about the fourth or sixth day, when the sloughs separate. 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 away from it, and the burning is not carried deeply enough to include the peri- SUEGICAL TBEATMENT FOR HYPEETEOPHIC RHINITIS. 267 osteum. If suppuration is feared, glycozone may be substituted for the camphor-menthol. Acute pharyngitis and ulcerative tonsillitis occasionally follow closely upon nasal cauterization, especially if the cauterization be quite extensive as to surface area or depth. The patient will be less likely to have pain, sneezing, and discharge from his nose after the operation if one or more coryza tablets are given. On the days following cauterizations the nose is sprayed with the antiseptic solutions already mentioned, and then by a 4-per-cent. solution of eucalyptol in lavolin, or the same strength of pine-needle oil, or benzoinol. For posterior hypertrophies Seiss prefers curettement. The snare (Fig. 155) is preferred by many specialists. It is introduced with the loop open, as shown in Fig. 154, and passed over the enlargement so as to engage it as near its base as possible, when, by drawing- Fig. 155. — Hobby's steel snare. upon the wire 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 haemorrhage. In removing posterior growths the rhinoscopie mirror is required, in order to view the field of operation (Plate V, Xo. 2). When deformities of the cartilaginous septum necessitate their removal, this is best accomplished by means of a specially fashioned knife having a tapering, blunt point (Fig. 156). After anaesthetizing, the hypertrophy is severed by entering the blunt probe-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 expeditiously. 268 ATKOPHIC BHIXITIS. Exostoses are sawed off in a like manner (Fig. 157). 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. With practice one can work rapidly with this instrument. The electric drill is a very efficient instrument and is~ manipulated like a dentist's drill (Fig. 1). Fig. 156. — The author's septum-knife. When the turbinate bone becomes enormously hypertrophied, turbinotomy is resorted to in order to remove the entire bone. This is accomplished with the saw; but this operation is seldom necessary. William Scheppegrell and G. Melville Black (The Laryngoscope, No- vember, 1897) have devised electromotor saws for operating in the nasal cavities. Hygienic measures and internal treatment must be employed according to the indications and on general principles, and the mat- ter of clothing is considered in the treatment of acute rhinitis. Fie-. 157. — The author's nasal saws. Ateophic Ehinitis. Synonyms. — Ozsena; fetid catarrh; cirrhotic rhinitis, etc. Pathology. — This form of nasal catarrh is a sequel of a pre- existing inflammation; indeed, it may be said to be the third stage of rhinitis in the logical order in which we have treated of the sub- TKEATMENT OF EPISTAXIS. 273 ice-bag (Fig. 83) 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 accomplished if pos- sible. Antipyrin in 3-per-cent. watery solution or in powder and the liquor ferri perchloridi are useful. Some writers speak highly of the electrocautery, but the author cannot indorse it for this purpose. If the simpler measures fail, resort must be had to tampons. The following method is 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. Fig. 158. — Bellocq's cannula introduced. 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 sur- plus 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. 158) 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 after its introduction, as shown in the cut. Then the sound is introduced like the Eusta- chian catheter until the distal 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 firmlv to it. This 274 NASAL POLYPI. is drawn backward and upward through the mouth and throat into the posterior nares. It should be made to plug effectually both poste- terior 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 per- spiration will loosen it and allow the tampon to become displaced or swallowed. After a day or two the packing must be removed to pre- vent septicaemia. In the absence of Bellocq's cannula the Eustachian catheter can be substituted, and the writer has 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 nu- merous (Plate III). They are a pale-pink or ashy-gray color, and are most troublesome in damp weather, when they absorb moisture, caus- ing them to swell and occupy increased space. They are usually found in middle life, from 20 to 40 years, and occasion stenosis of the nares and mouth-breathing (Fig. 185). The mucoid variety is the most common. Patients often observe movements in these polypi, which are occasioned by forcible currents of air in sniffing or blowing the nose. They are generally attached either to the middle turbinal or to the outer wall of the middle meatus. (See "Treatment," below.) FIBEOUS 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 V) 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 absorption of the turbinals. Ne- crosis of the bones and invasion of the adjacent sinuses may occur. TREATMENT OF XASAL POLYPI. 275 The nose in some cases is bulged outward at the sides, which gives the arch a flattened appearance. (See "Treatment," below.) CYSTIC POLYPI. These are very rare, and consist of a cyst or sac filled with a yellowish or bloody, serous fluid. Fig. 159. — Curette-forceps. TREATMENT. Polypi should be removed preferably with the cold-Avire snare (Fig. 155). The loop of the snare is introduced expanded, as seen in the electric snare (Fig. 15-1), 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 electrocautery or Fig. 160. — Very strong cutting forceps. 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 forceps (Figs. 159 and 160) are especially serviceable for searching out and removing the mere buds of polypi in the upper nasal passages. 2*76 XASAL TUMORS. 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 the lower part of the septum or inferior turbinal. (See "Treatment" under "Erectile Tumors.") Erectile Tumors. These are very rare. They have the appearance of an hyper- trophy of the turbinate body, except that pulsation can be detected in them. This is in consequence of their close relationship to an artery, and their removal is likely to be attended with considerable haemorrhage. Treatment consists in removal of the growths either by chemical Fig. 161. — Casselberry's saw-tooth scissors. or mechanical means. Chromic acid or the galvanocautery may suf- fice, or the nasal scissors (Fig. 161) may prove preferable. Choxdromata. 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 fibro- mata. The color is a light pink, and they have not the smooth sur- face 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 electrocautery, etc. The cartilaginous growth is easily removed, under cocaine or XASAL GROWTHS. 277 eucaine, by the authors septum-knife (Fig. 156). The cutting should be done as already described, and care should be taken not to per- forate the septum. It is claimed by some rhinologists that healing does not take place so readily after the electrocautery as after cutting, but the author has not been able to confirm this opinion. OSTEOMATA. The bony tumors also are very rare. They are offshoots from the mucous membrane and the product of an osseous degeneration of connective tissue. Their pressure produces headache, asthenopia, occasional haemorrhages, and ulceration with a purulent 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 usu- ally take the form of ridges or spurs upon the bony septum, encroach- ing upon the lumen of the passage sometimes to a considerable ex- tent. Occasionally the growth attains to very large proportions until pressure is produced on the opposite turbinal or adhesion to it occurs, forming a synechia or bridge across the canal. Figures 143, 144, and 172 show such conditions. In Fig. 143 the probe is inserted to the point of adhesion between the exostosis and the inferior turbi- nate bone. The contour of the latter will be seen in Fig. 144 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 inferior turbinal, reflex asthma may result. They are hard, immovable, light pink, and bleed easily on pressure with the probe (Plate TV). They may cause headache, amblyopia, and other ocular disturbances. 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. 157). 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. 278 RHINOLITHS. 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 irreg- ular shapes and sizes and of gray or dark color. The discharges en- velop them and obscure their identity until washing reveals their nature. Ehinoliths may develop to such a size as to obstruct the nasal passages and give rise to a foul discharge and epistaxis. The Fig. 162. — Destruction of the hard palate, the soft palate remaining unharmed. Through the very spacious perforation in the hard palate is seen a dark object with round and roughened surface: 1, a myaloid sar- coma. treatment consists in their removal as detailed under the heading "Foreign Bodies in the Nose." Sarcomata of the Nose. These are, fortunately, rare occurrences. Sarcoma and carcinoma are sometimes developed in this region. Sarcoma does not differ in MALIGNANT GROWTHS IN THE XOSE. 279 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, obstruction of respiration, fetid dis- charge, 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, roughened surface in some instances; in others they are pale. Fig. 162 shows a myaloid sarcoma springing from the inferior turbinated body of a syphilitic. I am indebted to the courtesy of E. Pynchon for a photo- graph of this case. 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 constitutional disturbance. The probe causes bleeding and discovers a soft, fleshy mass. This is a rapidly-fatal disease of less than a year's duration. Treatment. — Complete extirpation is the only remedy. Ano- dyne and astringent applications after the disinfecting and cleansing washes are only palliatives. CARCTX03IA. Cancer of the nasal passages differs in no way from the same dis- ease 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 certain curative treatment. The growth may be somewhat retarded and the suffering ameliorated by anodyne and astringent applications. Cocaine and aristol are the best. Hasse and others report good results from interstitial injections of alcohol. Those are treated of under the heading of "Treatment" in "Carcinoma of the Pharynx." CHAPTEK XXIV. DISEASES OF THE NASAL CAVITIES, CONCLUDED. Tuberculosis of the Nose. Fortunately tins is a rare affection. It appears in two dif- ferent forms: an ulceration and a neoplasm, or tumor. The nicer appears on trie 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 affec- tions of other organs than a primary manifestation. The ulcer ap- pears 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 clue to the bacillus tubercu- losis, invades the larynx and lungs and terminates in death. See "Pathology" of "Tuberculosis of the Larynx," page 494. Treatment. — Cleansing, antiseptic solutions, such as are noted in Chapter XYIII, must be freely used. Curettement, the electrocau- tery, 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-surface should be cau- terized. Astringents and iodoform are useful in retarding disintegra- tion and the invasion of adjacent structures. If pain is present, mor- phine, cocaine, or eucaine 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. For other remedies consult the sections on "Tuberculosis of the Pharynx" and "Tuberculosis of the Larynx." Syphilis of the Xose. The manifestations of syphilis in the nose correspond to the three stages of syphilis occurring in other organs. It may be heredi- (280) SYPHILIS OF THE XOSE. 281 tary or acquired. In the former it appears either before the third month of ehildlife 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 irri- tating than that of simple rhinitis, and produces a red and raw ap- pearance of the upper lip. The borders of the nostrils are cracked and chapped. Xasal respiration is embarrassed, and, in consequence of the interference with sucking, the babe is ill nourished and puny. If the disease attack the cartilage or bone, an offensive odor is im- parted to the discharge. Fig. 163. — Destruction of the bones forming and supporting the bridge of the nose. The later form of hereditary syphilis presents manifestations 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 pro- duce the exaggerated pug-nose deformity (Figs. 163 and 164). Diagnosis.- — "With care one will be able to distinguish the obsti- nate, persistent, pus-producing rhinitis of a syphilitic infant from an 282 TKEAT3IEXT OF SYPHILIS OF THE NOSE. ordinary cold in the head which in an uninfected child tends toward speedy resolution. Mucous patches may be discernible in the nares and a papular eruption on the skin. These children are often badly nourished, old looking, and unpromising. After taking into account all the characteristics mentioned, if in the later form there exist any doubt as to the nature of the disease, a course of antisyphilitic treat- ment will dispel the uncertainty. Prognosis. — If the pathological process has not involved the cartilaginous or bony walls, and if the patient is not greatly debili- tated, the chances of recovery are good. K : '''W: Fig. 164. — Partial destruction of the bones of the nose, resulting in two perforations: one in the centre of the bridge and another at the inner angle of the right eye. (From the author's clinic.) Treatment. — Cleanliness and specific medication are often re- warded by brilliant results. The antiseptic sprays given in Chapter XVIII are indicated, after which tincture of iodine applied to the ulcerating surfaces will be followed by healthy granulations and cica- trization. If the ulcers do not cicatrize promptly, it is advantageous- to dust the parts with aristol or nosophen (Fig. 34) after the cleans- ing process. We generally use the mixed treatment, — small doses of mercury with potassium iodide. The latter may have to be given in LUPUS OF THE NOSE. 283 increasing closes until the system is saturated. This treatment, vigor- ously pursued and carefully watched, gives gratifying results. In great debility and malnutrition codliver-oil, malt, 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. When the cartilaginous support of the end of the nose has been destroyed so as to let the tip fall upon the upper lip, the author has restored the natural lines by a device shown in Fig. 165, which he has 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. They were first constructed of aluminium, but the bright, reflecting surface was observable. Later I experimented with vulcan- ized rubber, and found that, after making the surface a dull black, Fig. 165. — The author's nasal supporter. it answered all requirements. The improvement in the facial appear- ance after restoring the pendulous nose to its normal position is some- thing to be appreciated. Destruction of the major portion of the septum nasi does not necessarily result in external deformity. The writer has under ob- servation such cases in which there is no external discoverable evi- dence of the internal architectural desolation. Lupus of the Nose. Lupus affecting the nasal cavities is a rare affection except as an extension of primary lupus of the face or pharynx. The nodules — which are found more abundantly on the septum than on the turbi- nals — 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, tumefactions, or nodules. As the dis- 284 GLANDERS. charges 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 sensi- tive to touch. This is easily differentiated from ozsena. 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 encountered 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 quantities. Constitutional symp- toms characteristic of a serious systemic invasion or toxaemia indicate the gravity of the disease. When the infection extends to the lym- phatic glands and skin in various parts of the body it is termed "farcy." This disease is either acute or chronic. The acute form is ush- ered 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 disclosed that shows no in- clination to heal, but rather to extend over the surrounding parts. The pustular eruption invades the nose and throat, causing embar- rassment of respiration. The copious, tenacious discharges from the nose and throat, and sometimes from the eyes, keep the patient oc- cupied to free the passages. In the chronic variety the secretion is not so copious, 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: colliquative diarrhoea and sweats, huskiness of the voice, and difficulty of degluti- tion 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 FURUXCULOSIS OF THE XOSE. 2So characteristic of oilier affections, such as typhoid fever, rheumatism, syphilis, pyaemia, etc., but the history of the patient, exposure to in- fection 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 dis- charges and ulcerations; from articular rheumatism, pains in the muscles and tenderness surrounding the joints; from syphilis, the constitutional disturbance and absence of proving by specific reme- dies; from pyaemia, even when abscesses are found there is little or no chilliness. Treatment. — Xo antitoxin has yet been evolved that acts as a specific for this disease. From the nature of the case it is to be ex- pected that such a remedy will yet be found. Xo treatment so far tried has a 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. FURUXCULOSIS OF THE X"OSE. 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, lasting about a week. Small furun- cles 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 the nose very painful. Treatment consists in local and constitutional remedies. To the boil situated within the border of the naris a pledget of cotton may be applied after moistening it with a 10-per-cent. solution of cam- phor-menthol in lavolin or benzoinol, 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 car- bolic-acid ointment. Sulphide of calcium has a reputation of repress- ing or preventing pus formation, and can be given in those cases in which recurring crops of furuncles torment the patient. The author has used with satisfactory results arsenious acid in doses of 1 / 30 grain three times a day, increasing gradually to two or three times that quantity for a short time, until the patient was free from 286 LOSS AND PERVERSION OF THE SENSE OE SMELL. these symptoms, and, if they reappeared after a few months, repeat- ing 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 opening. 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 obstructions as to render them inaccessible to odors. Acute inflammation 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, ozasna, 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 in 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 olfactory nerve. The sense of taste generally surfers 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 restoration is not encouraging. Yet the writer has seen a partial return after the whole mucous lining of the nasal cavities had gone through a protracted siege of ulcera- tion in consequence of an irregular physician's 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. Absolute 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 sub- DEFORMITIES AND DISEASES OF THE NASAL SEPTUM. 287 jective 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.' 7 This symptom may be due to disease of the nasal mucous membrane, the decomposition of retained nasal secretions, 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 hypertro- phies, polypi, etc., are present to account for increased, retained, and perverted secretions, suitable treatment, such as has already been dis- cussed for these conditions, 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 faradi- zation, as mentioned for anosmia, may prove beneficial. Deformities and Diseases of the Nasal Septum. Exostoses ecchondromata and synechias have already been con- sidered and are illustrated by Figs. 143 and 144 and Plate IV. It is unusual to find a nose with an interior that is architecturally syin- metrical. The septum in many instances is either curved (Figs. 166 to 172), thickened, 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 irritation, epistaxis, and obstruction to nasal respiration (Plate IY), no symp- toms referable to the anomaly are present. According to Zuckerkandl, the septum is not found deviated before the seventh year, but the author has under observation a boy 5 years and 9 months of age with deflection, spurs on both sides, hypertrophied turbinals, and adenoids. The causes of malformed septa are not known, but the theories are many. 0. B. Douglas believes that "traumatism is a more fre- quent cause than all the others combined. Pressure at birth is doubt- less a cause in certain cases" (The Laryngoscope, March, 1898). J. W. G-leitsmann attributes deflections of the septum nasi to the press- ure upon the septum from below by the abnormally-high arch of the roof of the mouth, occasioned by mouth-breathing in consequence of 288 DEFORMITIES OF THE NASAL SEPTUM. Fig. 166. — Moderate deflection of the septum nasi. The deflection generally involves more or less of the cartilaginous portion of the septum and may extend to its anterior, free border. In the latter case the lumen of the anterior naris is diminished, and the breathing space is seriously encroached upon. Fig. 167. — Deflection of the septum nasi sufficient to cause stenosis of the left nostril ; capacious right naris at the expense of the left nostril. In this condition pressure of the septum on the turbinals may cause sufficient reflex irritation to provoke asthma, hay fever, ocular disturbances, and other reflex neurasthenic symptoms. DEFORMITIES OF THE XASAL SEPTU.M 289 Fig. 1G8. — Deflection of the septum nasi toward the right side, at nearly a right angle. Such deformities are characteristic results of fractures of the osseous septum by falls or blows upon the nose, particularly in child- hood. The pressure on the opposing turbinals results in their atrophy, while the opposite turbinated bodies are often found hypertrophied. Fig. 169. — Deflection of the septum nasi toward the left side with ap- parent, but not real, adhesion to the left inferior turbinated bone. Such deformities extending throughout the cartilaginous portion of the septum are accountable for the tilting of the tip of the nose to one side of the median line, producing the crooked-nose deformity. 10 290 DEFORMITIES OF THE NASAL SEPTUM. Fig. 170. — Perpendicular portion of the ethmoid bone, consisting of two plates; the inferior turbinated bone of the left side is plainly visible. Fig. 171. — Transverse vertical section through the nasal fossae. 1, deflected septum nasi in contact with the left inferior turbinated body; its deflection toward the left side has caused atrophy of the left middle turbinal, and has permitted an hypertrophy of the right middle turbinal. 2, two maxillary antra of the left side, while there is only a single one on the right side. TREATMENT OE DEFORMITIES OF THE XASAL SEPTUM. 291 adenoid vegetations in the vault of the pharynx. The deflection may be so exaggerated as to give a twisted or bent appearance to the whole nose. The irregularity is limited mostly to the anterior and middle sections of the septum. Symptoms of nasal irritation — epistaxis, discharges, reflex neu- rosis (such as asthma), nasal voice, naso-pharyngeal catarrh, etc. — result from considerable septal deformities. The diagnosis is readily made on inspection with brilliant, reflected illumination. Treatment. — If the deformity is limited to the cartilaginous sep- tum the most satisfactory procedure in my experience has been the amputation of the offending projection by means of the septum-knife Fig-. 172. — Transverse vertical section through the nasal cavaties. 1, ethmoid cells; 2 3 right maxillary antrum; 3, deflected septum, and spur with adhesions (synechia?) to the inferior tiirbinal and to the floor of the meatus; 4, the maxillary antrum should be above this line, but it is absent. (Fig. 156). The method is described in connection with the figure. We have always taken pains to avoid perforating the septum, but we have seen many cases in which surgeons had made large apertures without any unpleasant consequences. AVhen the bony partition is involved the saw or the drills are called for. Various punches have been constructed to fracture and restore the deviated septum, after which bougies (Fig. 142), splints, and tampons are employed to main- tain the reduced deformity in proper position. 292 DISEASES OF THE NASAL SEPTUM. 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 hamiatomata, These tumors are easily recognized and should be opened before their contents degenerate into a purulent mass, result- ing in abscess. (See "Treatment" under "'Abscess,'' below.) ABSCESS OF THE NASAL SEPTUM. Like blood-tumors, abscesses are generally in the cartilaginous portion of the septum. They may assume such proportions as to com- pletely blockade the nostrils and compel mouth-breathing. In a case recently under my care the swellings were symmetrical and had at- tained such a size as to protrude sufficiently from the nostrils to be plainly visible. They are usually the result of blows, and their his- tory 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 hydrozone. Then equal parts of alcohol 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 coaptation of the separated mucous membrane to the cartilage again. This method may prevent perforation of the cartil- age, 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 (Plate III), but occasionally a small perforation causes a whistling sound as the current of air moves rapidly over it, annoying the patient and at- tracting the attention of others. A prominent educator of my ac- quaintance was troubled in this manner. He was apparently in excel- lent health and there was no assignable cause for the anomaly. Per- forations are usually considered as indicative of syphilis, but they are not necessarily so. We 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 the nose with the fingers. Abrasions are pro- duced, and the crusts that form over them are not allowed to remain until healing occurs beneath. In the course of exhausting diseases, FRACTURES OF THE NOSE. 293 such as tuberculosis and typhoid pneumonia, the septum may become perforated. Treatment. — Unless the perforation causes a whistling sound per- ceptible to others or annoying to the patient, no treatment is required except the application of benzoinol 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 correspond to the air- current. In operations on the nose Delavan {Journal of Laryngology, 1895) deprecates perforating the vomer on account of the dispropor- tionate shock resulting. French {New York Medical Journal, De- cember 1, 1894) perforates the septum when necessary 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 Xose. 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 pro- duced by such accidents is shocking. The sense of smell is likely to be destroyed on account of the damage done to the olfactory nerves. Examination 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 emphysema of the tissues demand immediate attention to check the haemorrhage, relieve the pain, and reduce the swelling. Anodynes and the ice-bag (Fig. 83) meet these requirements. Then the fractures must be re- duced to as perfect coaptation of the parts as possible, since nasal deformity, above all others, influences the business and social in- terests of the patient. The pure-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 294: FOEEIGN BODIES IN THE NOSE. muscular contraction to again displace them. Union usually takes place rapidly. Congenital Defoemities of the Nose. These are exceedingly infrequent occurrences. If a deformity consist of an impervious membrane of the posterior nares it must be perforated to establish nasal respiration. Foeeign 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 vom- iting occasionally forces the ejected matter into the post-nasal space. Bodies inserted into the nostrils are generally located near the vesti- bule in the inferior meatus and are readily seen on inspection. Sneez- ing, lacrymation, nasal obstruction 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 mem- brane occlude the offended nostril. Unless the body is removed it provokes inflammation and ulceration, with frontal and facial neu- ralgia 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 backward into the middle portion of the meatus, it may be shielded from view by the swelled turbinal or by a covering of the discharges. The secre- tions should be soaked up by the careful 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 pos- sible to prevent serious consequences. This can generally be accom- plished by angular forceps (Fig. 173). They should be applied with LARY^E IN THE NOSE. 295 care not to crowd the body farther inward. It is best not to close the jaws of the instrument until 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 en- larged bj the absorption of moisture, a sharp hook like the one found in the authors middle-ear case (Fig. 70) 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, and mouse-tooth forceps offer de- cided 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, Fig - . 173. — Hartmann's forceps. and destruction of the soft tissues and even of the nasal bones ensue. M. A. Goldstein reported having removed over 300 larvse from the nose of a patient who had been infected by a blow-fly (The Laryngo- scope, December, 1897). Itching, crawling, gnawing sensations and intense pain are experienced. A bloody, purulent discharge of fetid character appears. The intense inflammation may invade the sur- rounding structures, causing redness and oedema of the face and men- ingitis, with convulsions, coma, and death. Diagnosis. — Inspection readily reveals the cause of the trouble. Treatment. — Chloroform is the most efficient remedy. Inhala- tion may be sufficient to destroy the larva?; if not, it should be in- 296 LAEV^ IN THE NOSE. jected into the nose after enough has been inhaled to prevent pain. This is made to syringe out all the maggots and effectually empty the cavities. William Scheppegrell found that oil freely sprayed into the nostrils killed the larvae (The Laryngoscope, February, 1898). After- treatment should be attended to according to the condition present until the health of the membrane is restored. CHAPTER XXY. DISEASES OF THE ACCESSORY CAVITIES OF THE XOSE. 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 symp- toms are more common when there is obstruction to the outward flow Fig. 174. — Transverse vertical section through the nasal fossae and maxillary antra. 1. superior turbinated body united to the middle turbi- nal; 2, polypoid growth from the shelving outer wall of the fossa; 3, in- ferior turbinated bodv: 4. tumor in the maxillary antrum. of the secretions. If the disease does not subside coincidently with the subsidence of the rhinitis, a chronic suppuration results, or em- pyema. 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 (Fig. 179). (297) 298 INFLAMMATION OF THE M AXILLAE Y SINUS. This affection is generally unilateral. Examination reveals a purulent discharge in the middle nasal meatus and its foul odor is noticed by the patient, showing the difference between this and ozama, in which the sense of smell is destroyed. Empyema of long standing affects the general health to such a degree that a constitutional dis- turbance is readily apparent, and tumors sometimes develop (Figs. 174 and 175). 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 pulsa- tion is seen in the pus lying in the middle meatus, antral suppura- Fig. 175. — Transverse vertical section of the nasal fossae. 1, ethmoid cells. 2, deflection and spur of the nasal septum, probably the result of a fracture separating the two plates of which this bone consisted; the con- sequent pressure on the left turbinals has caused their atrophic condition. 3, tumor in the antrum of Highmore. tion is suggested. The pus should be removed and observation made to determine if it reappear 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 injected into the antrum through the opening beneath the mid- dle turbinal, the usual effervescence will disclose the presence of pus, and is likely to cause pain. In exploring the antrum some operators TREATMENT OF INFLAMMATION OF THE MAN1LLAEY SINUS. 299 prefer to enter the cavity through the 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, under cocaine, going outward and downward to avoid the orbit. Then, the author's aspirator (Fig. 6S) 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 h, 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 Fig. 176. — Transverse vertical section through the maxillary antra, a. antra, of Highmore; 6, very thin alveolar process, allowing the teeth to nearly penetrate the floor of the antra. 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 treatment for the latter is indicated. If the mouth of the sinus is closed it should be cleansed with the antiseptic sprays, mentioned in Chap- ter XVIII, with diluted hydrozone, 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 inspissated, 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 Moses Gunn. make a crucial incision 300 OPERATIONS ON THE MAXILLARY SINUS. in the cheek, and perforate through the canine fossa, but it is better to penetrate through the alveolus of a tooth, especially if it prove to be the exciting cause of the trouble (Figs. 176 and 177). The weight of argument and experience is in favor of entering Fig. 177. — Transverse vertical section through the maxillary antra, showing on either side that an operation to open the antrum through the socket of a tooth would result in penetrating the nasal cavity instead of the antrum of Highmore. the sinus through the nose, just below the natural opening. The cannula and trochar (Fig. 178) 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 Fig. 178. — Cannula and trochar. similarly to the medicinal treatment detailed for middle-ear suppura- tion. Miscellaneous. — Phlegmonous inflammation of the antrum is a very rapidly fatal form of inflammation. Tumors of the antrum are exceedingly rare, but require extirpa- tion through the anterior wall. Daly (New York Medical Journal, Xovember 10, 1894) urges early operation in antral disease to prevent ETHMOID DISEASE. 301 the transformation of a benign growth into a malignant one (Figs. 174 and 175). Ethmoid Disease. An inflammation of the nasal membrane sometimes extends into the ethmoid cells (Fig. 179), the membrane of which, like that of the mastoid cells, lines the osseous cavities and serves as a periosteum. 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 be- tween the eye and the root of the nose, and the eyeball may protrude abnormally. In a girl of 17 years, now under treatment (Fig. 185), 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 suppura- tion of both middle ears. The polypi, adenoids, and tonsils were re- moved, but the polypi were reproduced with mushroom-like rapidity. The ethmoid cells were opened up and curetted, and she is improv- ing satisfactorily, the discharges from the ethmoid cells and ears having ceased. Diagnosis. — The antrum of Highmore is often involved coin- cidently. 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 symptoms help to clear up the uncertainty. The discharge is generally 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— hydrozone, etc. — must be employed for cleansing purposes. All polypi should be removed and then the curettes shown in Fig. 90 can be used to scrape out carious and necrotic tissue. If the middle turbinate body is too large to admit of proper observation and manipulation, it must be removed, as already 302 ETHMOID DISEASE. Fig. 179. — Longitudinal vertical section (actual size) through the nasal and accessory cavities. 1, right termination of the left frontal sinus; 2, right frontal sinus; 3, probe extending from the right frontal sinus through the infundibulum into the right nasal fossa; 4, ethmoid cells; 5, large opening into the maxillary sinus; 6, anterior antrum of the sphenoid bone: 7, posterior sphenoid antrum; 8, middle nasal meatus; 9, inferior meatus; 10, inferior turbinated bone; 11, probe extending through the nasal duct. (Author's specimen.) SPHENOID DISEASE. 303 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, pro- ducing pressure on the surrounding structures. The result is apparent, especially in the increased breadth of the nose and the prominence of the eyes (Fig. 185). Osteomata produce like appearances. The treatment for growths in this locality consists in extirpation. Sphenoid Disease. It may be observed that I have departed from the custom of add- ing "al" to the adjectives ethmoid and sphenoid. This is because it is ctymolpgically correct to do so; it is in keeping with the American tendency to brevity and terseness, and in conformity with the com- mon use of the corresponding term "mastoid"' instead of "mastoidal/' These terms are Greek adjectives merely transferred into English, and are not rendered more perfect by additional terminations. Sphenoiditis occurs as a complication or sequel of inflammation of the nasal accessory cavities (Fig. 179) 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 character- istic of this disease. The prognosis is unfavorable on account of the tendency to in- vade the cranial cavity (Fig. 180). 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 (Figs. 179 and 180), the in- strument should be passed over the middle turbinal, backward and upward, until it enters the lower part of the cavity. The sinus can be opened through its under wall, also by perforating through the pharyngeal vault immediately back of the posterior nares. Subse- quent treatment has been indicated in treating of the other sinuses. Tumors are rare in the sphenoid sinuses, but if they produce blindness or other serious symptoms they must be removed. Diseases of the Feoxtal Sixtjses. Inflammation of these cavities (Figs. 179 and 180) occurs mostly from extension of rhinitis. It is not to be expected under the 301- DISEASES OF THE FROXTAL SINUSES. twentieth year, since these sinuses, being developed from the ante- rior ethmoid cells, are not formed earlier. Acute inflammation is characterized by a severe, continuous, frontal headache and pain Fig. 180. — Longitudinal vertical section (natural size) through the nasal and accessory cavities. 1, left frontal sinus; 2, termination of the right frontal sinus; 3, crista galli; 4, cribriform plate of the ethmoid bone; 5, perpendicular plate of the ethmoid; 6, part of the anterior sphenoid antrum; 7, posterior sphenoid antrum; 8, vomer; 9, palate bone. (Au- thor's specimen.) TREATMENT OF DISEASES OF THE FRONTAL SINUSES. 305 about the eyes. There is tenderness over the sinuses on percussion, and on pressure beneath the supra-orbital ridge. Nausea and vomit- ing are occasionally present. The pain may not be due entirely to the swelling of the mucous membrane lining the cavities, but to the loss of the natural air-pressure, for I have observed that the pro- pelling 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. 179), becomes clogged, the retained secretions, mucus or pus, will cause great pain. The pressure 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 illumination, flow- ing 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, drowsiness, 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 lamp and con- denser of Heryng are useful in making diagnoses in this class of dis- eases. Transillumination of the frontal sinus is accomplished by ap- plying the lamp to the lower border of the supra-orbital ridge and inner angle of the orbit in a dark room. In health the sinus is illu- minated 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 application 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 secre- tions, and relieve the pain. The detergent, 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 of a 10-per-cent. solution of camphor-menthol in lavolin or benzoinol 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-press- 20 306 TEEATMENT OF DISEASES OF THE FBONTAL SINUSES. lire in trie sinuses, besides medicating the remote membrane as ordi- nary treatment fails to accomplish. In the acute stage an ice-bag (Fig. 83) is indicated to subdue and avert the inflammation. It should be applied over the frontal j)rotuberances 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 pre- viously described. If the discharge contained in the sinuses cannot be liberated by opening the naso-frontal duct with air-pressure, co- caine, 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 diseased contents. Tumors of the frontal sinuses are treated on the principles already laid down for tumors of the other accessory cavities. CHAPTER XXYI. RELATED DISEASES OF THE EYE AND NOSE. Foe many years it has been recognized that diseases of the eye and of the nose were often associated and interdependent. In cer- tain cases pathological conditions originate in the nose and extend, by continuity of tissue or by migration of morbific germs, to the eye. Occasionally the reverse process occurs. More recently reflex ocular disturbances arising from nasal affections have received attention. "When one considers the close relationship existing between the eye and the nose and its adjoining cavities, it is not surprising that morbid conditions of these parts are closely related. The mucous membrane of the eyeball and lids is continuous with that lining the lacrymal sac, the nasal duct, and the nasal and connecting cavities (Fig. 181). The eye is in close proximity to these cavities, and the blood- and nerve- supplies of the nose and eyes are intimately con- nected with each other. The nasal duct is the drainage-canal of the eye, through which the surplus moisture of the latter is emptied into the nose. Hence, organisms inhabiting the nose or its accessory sinuses and antra may migrate through the nasal duct to the eye (Fig. 182), and, conversely, disease-germs that lodge in' the eye may pass through the lacrymal sac and the nasal duct to the nasal fossa, there to set up their pathological processes. In health there is a free communication between the nose and the eye; so much so that inflation of the nasal cavities may cause the air to pass through the nasal duct, the lacrymal sac, and canaliculi to the eye. Indeed, the author remembers to have seen the loose areolar tissue about the eye, the side of the nose, and the upper part of the cheek made greatly emphysematous after a nasal inflation, due to rupture of the lacrymal sac. The swelling occasioned no inconveni- ence, and it subsided in a few hours. This case illustrates the ease with which morbific material may be propelled from the nasal cavity through the patulous nasal duct to the eye by the acts of sneezing and inflation of the nasal fossa? by the Yalsalvan experiment and by blowing the nose. From this cause may originate inflammatory affec- tions of the lids, cornea, or sclera. (307) 308 BELATED DISEASES OE THE EYE AXD XOSE. In order to set forth fairly the present status of opinions on this subject among ophthalmologists we will refer to the experiences of several authors. W. F. Mittendorf says: "Inflammatory 'conditions of the lining membrane of the nose are, perhaps, the most frequent of all the causes of inflammatory actions in the tear-passages. How often do we not see diseases of the conjunctiva or cornea, especially those that are accompanied by lacrymation, followed by inflammation of the Fig. 181. — Dissection showing nasal duct and its relations. 1, inferior turbi- nate bone; 2, nasal duct and valves; 3, middle turbinate body; 4, lacrymal sac; 5, laerymal canaliculi and their orifices. Schneiderian membrane; and, on the other hand, mild forms of conjunctivitis generally accompany catarrhal inflammation of the nose or the tear-sac." Gr. E. de Schweinitz, in his work on the eye, 1893, says: "Dis- eases of the lacrymal sac are rarely primary. In nearly every case of disease of the lacrymal sac and of the lacrymo-nasal duct morbid conditions of the nasal chambers and of the naso-pharynx are pres- RELATED DISEASES OE THE EYE AXD XOSE. 309 ent. Although it might seem natural that conjunctivitis, and espe- cially purulent conjunctivitis, should cause lacrymal disease, this is by no means frequently the case. Conjunctivitis and blepharitis, so often accompanying diseases, follow rather than cause the lacrymal affection. Obstruction of the duct and diseases of the sac are sequels of measles, scarlet fever, and especially small-pox, because these exan- themata are accompanied by inflammation of the nasal mucous mem- brane.^ George M. Gould says that in the vast majority of cases of related Fig. 182. — 1, middle turbinated body turned aside and held by a hook; 2, nasal duct and valves; 3, canal leading to the maxillary and frontal sinuses; 4, inferior turbinated body showing location of the mouth of the nasal duct in the cul-de-sac. affections of the nose and eye the nose is the point of departure of the morbific process, the eye more seldom setting up disease in the nose. Bresgen observes that the nose is infrequently invaded in con- junctivitis, while the eye is implicated in coryza. 310 BELATED DISEASES OF THE EYE AND NOSE. Thomas F. Rumbold, in 1886, emphasized the importance of nasal catarrh as a cause of eye affections. Griihn reports thirty-eight cases of dacryocysto-blennorrhoea as- sociated with hypertrophy of the turbinals, spurs and deflections of the nasal septum, and atrophic rhinitis and pharyngitis. He attributes the lacrymal troubles to the nasal diseases. W. Franklin Coleman, of the Chicago Post-graduate Medical School, expressed his views in a private letter to me on February 4, 1898, to the effect that in nasal inflammation, whether independent of or accompanied by hay fever, it is common to find the ocular con- junctiva hypersemic or inflamed. Many cases of epiphora are not due to stenosis of the lacrymal passages, but to a nasal disease. Purulent inflammation of the lacrymal sac has its origin, as a rule, in a nasal disease, and rarely in an ocular affection. The extension of rhinitis to the nasal duct is followed by stenosis, decomposition of the. con- tents of the sac, and suppuration. Asthenopia, occasionally, is not relieved by correction of refractive or muscular errors, neurasthenia, or other constitutional faults. In these cases relief comes through attention to the etiological factors: nasal diseases. Phlyctenular conjunctivitis and keratitis, though often essentially due to malnu- trition, are so frequently accompanied by rhinitis and eczema of the lower lid and face that we may assume the nasal disease to be a causative factor of the ocular. Yet, in some cases the rhinitis seems to follow the excessive lacrymation, just as the eczema of the lid and face follows the ocular disease and its attendant epiphora. E. W. Seiss has reported several cases of closure of the nasal mouth of the lacrymo-nasal duct caused by unskillful use of the cau- tery. The effect on the drainage of tears is evident. A number of illustrative cases are reported in the "American Year-book of Medicine and Surgery" for 1897. Among them is a case cited by Panas, in which there was double purulent dacryoadeni- tis, coincident with a severe tonsillitis and muco-purulent nasal ca- tarrh. Ramsey, in treating of lacrymal obstructions, advocates the necessity of examining the nasal fossae, of treating inflammatory or hypertrophic conditions found, and of investigating for a syphilitic history. T. K. Hamilton found eye diseases in 51 out of 106 cases of post- nasal vegetations. In 6 of these there was blepharitis, in 7 follicular, in 16 granular, and in 22 catarrhal conjunctivitis. John Dunn believes that in the vast majority of cases of chil- BELATED DISEASES OF THE EYE AND NOSE. 311 dren suffering from phlyctenular troubles there will be found a coin- cident rhinitis, and behind this unhealthy adenoid vegetations. Samuel G. Dabney has seen obstinate cases of ciliary injection and lacrymation disappear immediately on removing a septal spur which was pressing against a turbinated body. Photophobia and asthenopia are occasionally caused by hypertrophic rhinitis. More grave diseases, such as glaucoma and organic affections of the optic nerve, have also been attributed to nasal influence. D. B. St. John Koosa, in his book on the eye, in treating of lacrymal catarrh, says that in a large proportion of cases it is a purely catarrhal affection, produced by the same causes that bring on catarrh in other parts of the naso-pharyngeal tract, colds in the head, and catarrhal conjunctivitis. Influenza has given rise to orbital cellulitis, and out of three such cases recently two have died of the influenza. Nieden maintains that phlyctenular keratitis almost invariably takes its origin from a disease in the nose. Puech observed instances of lacrymation occasioned indirectly by decayed stumps of teeth which set up chronic inflammation of the antrum of Highmore and the nasal fossa, thence extending upward into the nasal duct (Fig. 179). Herman Knapp records an instance of lupus extending from the nasal fossa toward the lacrymal canal, followed by dacryocystitis. Bresgen lays stress on the causal relation of nasal disease to strict- ure of the lacrymal canal, and insists that every lacrymating patient, even when he first visits an ophthalmic surgeon, ought immediately to be referred to a rhinologist for a scientific examination, and for eventual nasal treatment. Fischer attributes cases of chronic conjunctivitis, trachoma, iritis, keratitis, and glaucoma to ozama; and gonorrhceal ophthalmia has been traced to infection by way of the nose and the lacrymal canal. Guenod states that the pneumococcus, which is a normal resident of the upper, anterior air-passages, has been found in conjunctivitis, dacryocystitis, deep ulcers of the cornea, and in panophthalmitis. Guttman has reported a case of diphtheric conjunctivitis in which true diphtheric bacilli were found occurring during an attack of measles, and which was complicated by corneal abscess, purulent cellu- litis of the lids and cheek, and extension of the false membrane to the nose and throat. Antitoxin was injected early, but had no in- 312 KELATED DISEASES OF THE EYE AND NOSE. fluence whatever in staying the progress of the disease or in averting a fatal termination. On the other hand, Coppez and Funk speak, from a large experience, in the highest terms of the efficacy of serum- therapy in the treatment of diphtheric conjunctivitis. An appearance of excessive lacrymation may be caused by an obstruction to the passage of tears into the nose, due to ethmoid dis- ease or pressure of a nasal polypus or other growth on the nasal duct. On account of this the tears flow over the lid and cheek (epiphora). Ethmoid disease may produce sufficient pressure to increase the dis- tance between the eyes, causing the globes to protrude, and giving the appearance known as frog-face (Fig. 185). These variations in the anatomical relations of the bones of the orbit and the recti mus- cles may produce disturbances of the functions of the eye, such as strabismus and astigmatism; or overdevelopment of the sphenoid bone may produce pressure on the optic nerve and impair or destroy its functions. Thus it will be seen that a growth in the nasal fossa, exceeding the natural limit of the cavity, may be the cause of serious ocular disturbances. Hansell referred acute, double optic atrophy in a young man to a purulent disease of the ethmoid and sphenoid cavities. Reflexes. — In 1882, and later, Hack called attention to the prob- ability of reflex ocular symptoms origin ating in pathological condi- tions of the nasal cavities. He also observed the causative relation of inflammatory conditions of the Schneiderian membrane to sick headache, neuralgia, cough, asthma, pain and swelling of the eyelids, and that, while the ordinary treatment for these latter affections was ineffective, they yielded to measures which restored the pituitary mem- brane to its normal condition. Eecently M. Georges Laurens has pointed out that more extended experience has added a large number of morbid phenomena to those that Hack regarded as taking their departure from nasal affections. Among these are epilepsy, vertigo, nightmare, sensations akin to those produced by a foreign body in the eye, heat, pricking, injection of the conjunctival blood-vessels, amblyopia, amaurosis, and photo- phobia. Numerous illustrative examples could be cited in which reflex irritation of branches of the fifth nerve occasions ocular disturbances, such as conjunctival irritation and lacrymation. When these symp- toms are owed to diseased conditions of the inferior turbinated body they have disappeared on cauterization of the turbinal. On the other BELATED DISEASES OF THE EYE AND NOSE. 313 hand, Alt reports a case of optic neuritis consequent upon cauteriza- tion of the turbinals in a syphilitic patient. "The reflex troubles of motility consist of blepharospasm, strabismus, mydriasis, and asthe- nopia; the trophic disturbances consist in congestion of the con- junctiva, iritis, and glaucoma, while exophthalmic goitre may, in some instances, be regarded as a condition associated with disease of the nasal mucous membrane. Contraction of the visual field has been observed by several practitioners. The affection of the eye is always, in accordance with the law of unilaterality, on the same side as the disease of the nose, though, in accordance with the law of symmetry, in some instances both eyes are affected, and in accordance with the law of intensity the eye ]3rimarily affected is always the most severely attacked." ("Year-book of Treatment," 1897.) The nasal diseases that are the most prolific of ocular manifesta- tions are chronic hypertrophic rhinitis, especially when there are con- tact, pressure, and even adhesions of the nasal septum and turbinals; acute rhinitis, inflammation of the membrane lining the sinuses con- necting with the nose, ulceration of the nasal membrane, ozama, and polypoid growths. "The reflex conditions that may be excited have reference to the sensibility of the eye, to the character of the secre- tions, to motilit} r , and to trophic and vasomotor disturbances.'*' (Laurens.) The effects of nasal hypertrophy, pressure, irritation, and con- sequent ocular and other disturbances were well exhibited in a some- what exaggerated case in the author's practice. A musician, 22 years old, presented symptoms of amblyopia and chronic non-suppurative inflammation of her middle ear, with subjective noises. The morbid manifestations were confined to her left eye and ear. The results of examination of these organs were negative, but there was an osseous adhesion between the left middle turbinated body and the septum nasi, and hypertrophy of the inferior turbinal of the same side. The patient suffered from frontal headache; and a most peculiar and in- teresting incident was a loss of power and uncomfortable sensations of her left arm, together with pain in her left side. The asthenic condition of her arm, combined with the impairment of vision, com- pelled the young lady to discontinue her piano-playing. After thor- ough electrocauterization of the inferior turbinal and the removal of the osseous synechia, not only did the eye and ear disturbances sub- side, but the neurasthenic symptoms referable to the left arm and side also vanished. Normal sight and hearing were restored, the 314: RELATED DISEASES OE THE EYE AXD XOSE. tinnitus anrium ceased, the headaches disappeared, and the power and natural sensibility of the arm returned. Henry D. Noyes, in his work on the eye, relates the case of a medical friend who suffered from asthenopia, headaches due to ex- cessive strain of accommodation, heat at the vertex of the head, in- somnia, facial neuralgia following use of the eyes, and intense photo- phobia — a case of refractive and muscular and general nerve-exhaus- tion. There were extreme palpebral congestion and a tendency to lacrymation on exposure to light and attempting eye-work. The nasal passages were found to be narrow, with a slight protuberance of the septum from undue thickening, decided congestion, and tenderness on being touched. Anaesthesia by cocaine afforded relief in some measure to the eye-symptoms. Examination of the eye, after the fitting of glasses failed to afford relief, showed that there was much spasm of the extrinsic and ciliary muscles. Sprays, the ingredients of which were not mentioned, afforded relief. The patient was an asthmatic. After removal of the thickened portion of the septum with a saw, marked improvement took place, and within four months the patient laid aside his glasses and was restored to a condition of comfort. Galezowski has seen persistent lacrymation caused by slowly- growing exostoses of the nasal cavities. S. S. Bishop, of Pennsylvania, observes that discomfort of the eyes and lids and vasomotor disturbances are sometimes the reflex effects of diseases of the nasal mucous membrane. He lays especial stress on spurs of the septum nasi and hypertrophy of the turbinate bodies as causes of these troubles. Cheatham is authority for three cases of asthenopia accompanied by other ocular symptoms. In each instance the ciliary weakness was found to be dependent upon local nasal trouble, such as catarrh,, polypi, obstructions from deflected nasal septum, or engorged tissue. Ocular relief and strength immediately followed upon a cure of the nasal abnormality. Many sufferers from hay fever are attacked with itching of the lids, lacrymation, injection of the conjunctival vessels, and photo- phobia during the season of suffering. The first attacks of this dis- ease are likely to be announced by the appearance of itching and suffusion of the eyes. Gradle speaks of a periodic discomfort allied to hay fever, or co-existing with conjunctival lesions, at first of follicular enlargement,. TEEAT3IEXT OF EYE DISEASES DUE TO NASAL AFFECTIONS. 315 and finally of a formation of large, flat, yellowish, follicular grannies which disappear in winter, arising from nasal affections, and he adds to these acute congestion of the lids with irritable nose, erysipelatoid in character, subject to recurrence and lasting from two to six days. Diseases of the eye are sometimes responsible for pathological states of the nose. Of 315 cases of functional nervous affections ex- amined by Miles with reference to eye-strain, 107 presented nasal symptoms, such as frequent sneezing, epistaxis, and annoying sensa- tions referable to the nasal fossa?. Nearly all of these cases had errors of refraction. After relieving the ocular irritation by correcting the ametropia with proper lenses the nasal symptoms diminished or dis- appeared. This was particularly true of those cases characterized by asthenopia and headache. Ocular disturbances that cause a profuse flow of tears give rise to nasal hydrorrhcea and chronic rhinitis. Treatment.- — When ocular disturbances are suspected of being- caused or perpetuated by diseases of the nasal cavities, — for example venous stasis, stenosis, or reflex irritation, — we may often be able to demonstrate the correctness of our conclusions by the application of a 10-per-cent. solution of cocaine to the diseased area. If it re- lieve the ocular symptoms, the line of successful treatment is indi- cated; but one had best bear in mind the case recorded by Marckwort, in which glaucoma followed a prolonged application of cocaine in the nose. Moreover, the author has met with cases in which the secondary effect of cocaine on the nasal mucous membrane was that of paresis of the blood-vessels, engorgement and complete nasal steno- sis, with intensified symptoms of hay fever. YThen obstruction to the free drainage of the tears through the nasal duct into the nose depends upon a disease of the nasal fossa, the latter must receive prompt treatment, as laid down in the fore- going chapters. In all such cases the nasal cavities should be thor- oughly examined without delay, and in many the nasal treatment alone will suffice to establish a normal condition. But the disease may have progressed so far as to call for treatment addressed to the lacrymal drainage-canal itself. Stenosis, fibroid adhesions, etc., may have produced permanent changes in the nasal duct or the lacrymal sac that will require special attention from the ophthalmic surgeon. However, tentative treatment should be instituted first, and it may succeed in obviating the necessity for surgical interference. The lacrymal sac can be emptied of pent-up secretions by gentle pressure, and the eye should be washed clear of them by a 2-per-cent. 316 TREATMENT OE EYE DISEASES DUE TO NASAL AFFECTIONS. solution of boric acid in distilled water. If an astringent lotion is desired, sulphate of zinc can be added in the proportion of 2 grains to the ounce of the solution. The manipulation and medication are effected in the following manner: The surgeon's finger is made to exert pressure on the sac from below and toward the eye, while the patient's head is tilted backward and toward the opposite side. After the sac is emptied of secretions the boric solution is made to rest in a little pool over the canaliculi while the sac is emptied as before, with the- result that the solution enters the evacuated sac and medicates the nasal duct. This simple treatment, combined with proper meas- ures addressed to the nasal disease, will cure a large proportion of these cases. When this method proves ineffectual, the orifice of the canaliculus Fig. 183. — Lacrymal knife. (Fig. 181) must be enlarged. This can be done with the iris-scissors or the lacrymal knife (Fig. 183), which is introduced with the sharp edge directed toward the eye, cutting the punctum open perpendicu- larly toward the palpebral fold for a distance of about one-sixteenth of an inch (two millimetres) or more. The lower canaliculus is the one that is generally opened. Then the solutions just mentioned, or silver nitrate, 2 to 5 grains to the ounce of water, should be used until either a cure is effected or it is demonstrated that there is a stricture of the duct. In the latter case the smaller probes of Bowman may be gently employed to dilate the stricture. For further surgical treat- ment the reader is referred to works on the eye. CHAPTEE XXVII. DISEASES OF THE NASOPHARYNX. Nasopharyngeal Catarrh. Synonyms. — Post-nasal catarrh; rhino-pharyngitis; retronasal catarrh; follicular naso-pharyngeal catarrh. Pathology. — Xaso-pharyngeal inflammation may be acute or chronic, but the acute stage merges into the chronic form, leaving a thickening of the mucous membrane, — a proliferation of tissue that gives rise to a roughened and granular appearance of the membrane and increased secretion from the mucous glands. This is the condi- tion most often encountered, but the dry form is not uncommon. Etiology. — Sudden and extreme changes in meteorological condi- tions, especially in a low, damp climate, are undoubtedly the chief exciting causes of this disease. Inhaled dust is another 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. In the Mississippi Valley and the Great Lakes Eegion 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, chill- ing the skin, and causing internal congestions that naturally attack the respiratory passages. The 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- (317) 318 NASOPHARYNGEAL CATARRH. ditions. The fogs of the early morning and the cold, penetrating- winds of the afternoon, with only a few hours of congenial warmth to lure one to don warm-weather attire, present the conditions favor- able to the production of naso-pharyngeal 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 ca- tarrhal 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 conformation, posi- tion, 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 membrane find lodgment here, and, if sufficient moisture has not been absorbed by contact with the nasal chambers proper, the secretions of the pharyngeal membrane are taxed to perform this function. The resulting storage of dust and the drying of the mem- brane, which is devoid of the acute sensibility characteristic- of the nose and larynx, and therefore lacks prompt reflex efforts at dislodg- ment, tend to excite irritation and consequent inflammation. Other predisposing causes of naso-pharyngeal catarrh are discussed in the first chapter on "General Consideration of Ear, Nose, and Throat Diseases/' This disease, like hay fever, is undoubtedly more prevalent in America than in European countries. The reasons assigned for its prevalence 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 pres- ence 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, and especially in the uric-acid diathesis. Symptomatology. — In the early history of naso-pharyngeal ca- tarrh the patient notices a sense of irritation in the upper and back part of the throat. This provokes attempts at clearing the throat, XASO-PHAEYXGEAL CATAEEH. 319 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 dur- ing a lecture or sermon are wearisome 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 con- dition of the upper throat. Posterior rhinoscopy often 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 rough- ened by the formation of granulations. These are round and punc- tated or irregular and flat, with broad bases suggestive of particles of a filled sponge. Frequently they coalesce, especially 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 sur- rounding tissues. The Eustachian prominences are swelled and red- dened and the orifices constricted or closed. Extension of the in- flammation a little farther through the Eustachian openings results in tubal catarrh, or salpingitis, and impaired hearing, as already de- scribed in the ear division. The pharyngeal, or Luschka's, tonsil is sometimes hypertrophied. and in children adenoid vegetations may so occlude the vault of the pharynx as to preclude nasal respiration (Plate II). Mouth-breathing and its train of evil consequences result. The faucial pillars are more or less involved, presenting a swelled, infiltrated condition. Diagnosis. — There is little likelihood of confounding this affec- tion with any other. Adenoid vegetations are confined to the young and are easily seen with the rhinoscopic mirror or 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 repre- sent 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 treatment, but after it has existed for a number of years it becomes persistently chronic and 320 TREATMENT OF NASO-PHARYNGEAL CATARRH. intractable to nearly all methods of treatment. However, much relief can be afforded by hygienic measures, combined with proper cleansing and stimulating topical applications and surgical treatment. Treatment. — The first object of treatment is perfect cleanliness; detergents — such as Dobelfs 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 nasopharyn- geal 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 a curved post-nasal cotton-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 ben- zoinol, 5-per-cent. course spray, or a 10-per-cent. solution in the form of a nebula, in the hand-dilator (Fig. 19) 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 prep- aration consists of oil of cubebs, 50 parts; pure camphor-menthol, 10 parts; and lavolin, 40 parts. However, the latter solution must not be used in the form of a coarse spray. This and a 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 prepara- tion into both^ nostrils and throat to satisfy him that the parts are entirely covered with the medicine. The application of this remedy proves very grateful and refreshing, especially to public speakers. Upon being used at bed-time it remains in contact with the mucous membrane 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. All hypertrophied tissues should be destroyed with the electrocautery. 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 ex- isting 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 ATROPHIC CATARRH OF THE XASO-PHARYNX. 321 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 per- spiration, 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, wines, and beer. Atrophic Catarrh op the Naso-pharynx. This disease usually accompanies the same condition of the nose which has already been described, but it may exist independently of atrophic nasal catarrh. In the early stage of this affection the mu- cous membrane of the naso-pharyngeal space usually appears dry and shining. Later, crusts are formed similar to those described in ozama. Sometimes quite large patches of these crusts, which adhere closely to the membrane and are removed with difficulty, are expelled. They are generally 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 neighbor- hood of factories, hotels, and buildings in which soft coal is largely in use. These crusts sometimes are detached with so great difficulty that the patient is under the necessity of inserting his finger into the vault of the pharynx and detaching them with his finger-nail. The pathology and etiology of this disease are the same as for nasal ozama, 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 hyper- secretion. 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 sometimes vomiting, and for this reason they produce gastric disturbances. The points of diagnosis are identical with those given for ozsena under the heading of "Atrophic Nasal Catarrh." The prognosis is unfavorable. This is a persistent, chronic dis- ease, which is not easily amenable to treatment. However, much re- lief may be afforded until such time as the processes of nutrition can be so improved as to give permanent relief. Treatment. — Hydrozone and antiseptic detergent solutions — such as Dobell's and Seiler^s — must be used abundantly to dissolve and dis- lodge the crusts. "When no crusts are present, but there is merely a pale, dry, shining, mucous membrane, remedies that stimulate the 322 TUMORS OF THE XASO-PHARYXX. 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 ozaena. Fibrous Polypi of the Xaso-pharyxx. Fibrous polypi in this locality are of infrequent occurrence (Plates III and V). They are not found above the twenty-fifth year and occur more frequently in males than in females. They cause 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-reel 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 dis- charge. 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, aud difficulty in articula- tion of speech. Pressure upon the orifices of the Eustachian tubes may cause obstruction to the ventilation of the middle ears, Eusta- chian 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" (Fig. 185), Pressure may be sufficient to cause separation of the nasal bones and absorption of the facial and cranial bones, pro- ducing intracranial 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 occurrence only under the twenty-fifth year. They are distinguished from adenoid vegeta- tions in the vault of the pharynx by the soft, spongy, lobulated ap- pearance of ihe latter and their occurrence only in the very young. The appearance of the two in the rhinoscopic mirror and the sensa- tions 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 TUMORS OF THE XASO-PHABYXX. 32 3 from three to five years, they prove fatal. If their development can be repressed by local treatment until the patient arrives at the age of 25 years, the prospects of recovery are improved. 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 commenced the body of the polypus should be secured by a strong thread so as to prevent its dropping into the throat and producing suffocation. After removal, the attachment of the pedicle should be thoroughly cauterized. Fibbomucous Polypi of the Xaso-phabyxx. These tumors are of somewhat rare occurrence. They vary in size from one to ihree 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 occa- sioned 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 par- take of their character. They are dissimilar to the fibrous polypi: are adenoid in appearance, texture, and history; and they do not tend to recur after extirpation. Treatment. — Evulsion should be made with strong forceps through the mouth, or the cold-wire or galvanocautery snare can be used through the nose. After their removal the site of attachment should be cauterized. aLaligxaxt Toiobs of the Xaso-phaeyxx. These tumors are of very rare occurrence. They are attended with pain in the throat and back part of the nose, extending to the ear; catarrhal symptoms, with increased discharges from the nose and throat; difficulty in swallowing; and, 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 recurrence after their removal. Only a micro- scopic examination will 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. 324 ADENOID VEGETATIONS IX THE VAULT OE THE PHAEYNX. 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. (See "Can- cer of the Pharynx.") 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 con- sists of spongy, stalactite projections from the vault of the pharynx; the second of smooth, fibrous tumors of irregular shape. They are Fig. 184. — Contracted upper jaw; narrow roof of mouth with very high arch; encroaching upon the nasal fossse; found in habitual mouth- breathers who have adenoid vegetations in the vault of the pharynx; hypertrophied turbinals and oral tonsils are often associated with these conditions. very vascular and contain lymph-cells and a follicular structure re- sembling that of the oral tonsils. The relation of adenoid growths to deaf-mutism has been made the subject of investigation by Frankenberg (American Medico-Sur- gical Bulletin, December 10, 1897). He examined 158 inmates of the deaf-mute institute in Prague. Including adenoids only that were large enough to fill the naso-pharyngeal cavity, there were 59 per cent, with these growths. Out of the 94 cases, there were 56 boys and 38 girls. The particular pathological conditions of the ears in these ADENOID VEGETATIONS IN THE VAULT OE THE PHARYNX. 325 subjects can be found under the heading "Deaf-mutism/' page 195. Among 426 cases of adenoids Arslan found 6 deaf-mutes. He cured one and relieved another of these, both as to speech and hearing, by removing the adenoid growths. The superior maxillary bone often presents a contracted appear- ance; the roof of the mouth is narrow and is highly arched, convey- Fig. 185. — A 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 eth- moiditis requiring curettement ; and chronic suppuration of both middle ears. (Author's case.) ing the impression that the conformation of the roof of the mouth has resulted from the necessities of constant mouth-breathing, en- larging the cavity of the mouth at the expense of the nasal fossae (Fig. 184). 326 TREATMENT OF PHARYNGEAL ADENOIDS. Etiology. — This is mostly a disease of childhood and is oftenest seen under the tenth year. Heredity is an important factor. Oft- times several children in the same family are subject 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 pronounced type of this affection are the parted lips, prominent eyeballs, oblitera- tion of the normal lines of expression of the face, and a consequent appearance of listlessness and inferiority (Fig. 185). Mouth-breath- ing, a noisy respiration, snoring, and a lack of resonance of the voice are the typical symptoms. There is a characteristic thickness of speech, and nasal intonation. As Chaucer said, "He intunes in his- nose." Such children are absent-minded and have the appearance of being inattentive, which may be due to mental dullness or impaired hearing, or both. There is inability to fix the attention, or aprosexia (Eumbold), and defective memory. There is a plentiful, tenacious discharge of a grayish or bloody color. Examination with the finger causes bleeding. The history is one of recurring colds in the head, earache, diminished hearing, noises in the ears, or otorrhoea. There may be pressure on the Eustachian tube or an extension of the adenoid inflammation through the Eustachian 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 we rely mostly on the digital examination, with the finger well protected. Prognosis.— The tendency is to absorption during early adoles- cence and to disappearance when adult age is reached. Treatment. — Notwithstanding the fact that, with the advent of adult life, adenoid growths in the vault of the pharynx tend to ab- sorption, there are most excellent reasons why it is for the patient's interest to be rid of them. Semon has formulated these reasons as follow: (1) the ever-threatening danger of ear complications; .(2) the greater liability to, and seriousness of, infectious diseases, espe- cially scarlet fever and diphtheria; (3) the influence of the obstruction on the general health, mental development, and the formation of the face, results which may remain even if the glands themselves undergo atrophy. TEEAT^IEXT OF PHARYNGEAL ADENOIDS. 327 While it is the practice of some rhinologists to treat adenoids with washes, sprays, caustics, the galvanocautery, etc., for periods varying from four to fourteen months, I much prefer the one painless opera- tion, lasting but five minutes and insuring a radical cure. The instruments are sterilized by boiling for five minutes in a 1-per-cent. solution of bicarbonate of sodium, and placed within easy reach. The mouth-gag (Fig. 186) is inserted between the molar teeth before the anaesthetic is administered, and is held carefully in place by an assistant until the operation is completed; otherwise it slips out of place and allows the jaws to close, after which they are sep- arated with much difficulty. The preferable anaesthetic for this operation is ethyl-bromide (hydrobromic ether; monobromethane). It is dispensed in 1- (fluid) ounce tubes. Before administering it the patient should be calmed Fig. 186. into a tranquil state of mind, for if there is great excitement the drug is not so efficacious. The patient is held in a sitting posture on an assistant's lap (Fig. 187), with his feet and arms gently, but firmly, pinioned. An ounce of the bromide of ethyl is poured into the in- haling-cone or mask and given in the same manner as in etherization, allowing a minimum of air to enter. Anaesthesia is induced in about one minute and lasts about five minutes. Probably not more than half an ounce of the anaesthetic is taken, but the remainder will not keep for subsequent use on another day and must be thrown away. Fessler gives excellent, practical suggestions regarding the use of ethyl-bromide: The preparation must be pure and fresh. The con- tents of a bottle must be used up the same day that the bottle is opened, or thrown away. Preparations that have been exposed to bright light or to air should not be used. For this reason, also, the cloths or flannel masks which have once been employed in producing 328 BROMIDE-OF-ETHYL ANAESTHESIA. the narcosis should not he used again hefore having heen thoroughly cleansed and aired. A good device for administering the anaesthetic can he improvised by wrapping a thick towel into the form of a cone and tying a strong- cord about its apex to render it the more air-tight, or it can be folded into a box shape and pinned with safety pins. Into this inhaler should be placed sufficient clean cotton to absorb the fluid. When Fig. 187. — Position of child for adenoid operation, or intubation; mouth-gag introduced. an Esmarch^s mask is used for narcosis with bromide of ethyl the flannel should be double the usual thickness, and folded in two layers. As soon as the patient is quieted by the means usually employed by anaesthetizers and hypnotizers he is directed to draw a long, deep breath, to breathe quietly; then the inhaler, into which the anaesthetic has just been poured, is held closely over his nose and mouth. A slight extension of the extremities will be noticed to follow after a OPERATION FOR PHARYNGEAL ADENOIDS. 329 few inspirations, and the breathing usually continues deep and quiet. Complete anaesthesia is attained as soon as this extension begins to disappear, and at this instant is the time to operate rapidly, for sensi- bility returns again in a few minutes. We may prolong the narcosis for a few minutes, only, by adding another ounce (30 grammes) of the bromide of ethyl to the inhaler. The patient quickly recovers consciousness, and after lying down for a few minutes he is ready to be taken home. The instant anaesthesia is complete Gottstein's large or small ring- curette (Fig. 188) is inserted behind the velum palati 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 poste- rior pharyngeal wall as far as the growths extend. The same move- ment 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 Fig. 188. — Gottstein's ring-curette. with the finger-nail or the curette. J. E. Schadle operates by means of the finger nail trimmed to a point and hardened by immersion for a few minutes in alcohol. (The Laryngoscope, July, 1896.) As soon as all the adenoid tissue is extirpated, the gag is re- moved and the patient's body is inclined quickly 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 under the anaesthesia. Haemorrhage lasts but a few minutes and generally ceases by the time full consciousness is restored. This method deprives the opera- 330 HEMORRHAGE FOLLOWING- ADENOID OPERATIONS. tion of the horrors experienced by children whose adenoids are ex- tirpated without anaesthesia; and neither children nor parents, who are excluded from the room until the bleeding ceases, retain any re- volting memories of the affair or their doctor. Many cases receive no after-treatment; but it is better to give a spray of camphor-men- thol and benzoinol — 3 per cent. — with an atomizer (Fig. 129) for home use four times a day for a week or more. While instances of severe haemorrhage from this operation are reported, I have never witnessed any. C. H. Knight reported a case of death from haemorrhage following an operation for adenoids in a boy 4 years old. Death occurred two days after the operation. (The Laryngoscope, April, 1898.) James E. Xewcomb had three cases of haemorrhage. One was a woman about 18 years old. Another was a girl of 13 years whose adenoids were removed under cocaine anaesthesia. Bleeding occurred forty-eight hours after the operation. In the third case, which was a fatal one, the patient was a boy of 4 years. Four hours after the operation haemorrhage set in, and terminated fatally on the morning following the operation. The two other cases recovered. On look- ing up the subject 16 cases of haemorrhage were found following adenectomy, with two deaths. Hooper reported a case of death following a digital examination. Among 11 cases of these haemorrhages 4 occurred in patients under 10 years of age, 5 were between 10 and 20 years oi age, and 1 was 28 years old. Chloroform was used in 3 cases, and cocaine in the same number. Various instruments, as well as the finger-nails, were employed. Generally the haemorrhage takes place immediately after operating, but it has occurred as late as 24 and 48 hours after- ward. Delavan has reported a fatal case in a child of 4 years, and 3 other cases whose ages are not given. In Delavan ? s case there was a bleeding diathesis. Newcomb mentions "a case of a boy 2 1 / 2 years old who had adenoids removed with the finger and forceps, under ether. Haemor- rhage occurred 8 hours afterward, and death in 24 hours." Van der Poel reports 2 cases of profuse bleeding in his practice. The first, a girl of 8 years, was a case of haemophilia. She had suf- fered one year before from an alarming haemorrhage following the extraction of a tooth. The second was a boy of 14 years who was operated on without anaesthesia, and who had a mitral regurgitant ADEXOID OPERATION UNDER BROMIDE-OF-ETHTL NARCOSIS. 331 murmur resulting from rheumatic endocarditis. Both cases recov- ered. In my experience with the operation none but satisfactory re- sults 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 mem- brane intact. I have observed this condition after what must have been a hasty and incomplete operation. 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 ascer- tain if the adventitious tissue has been completely removed. We have never observed any bad effects from ethyl-bromide. It is as safe as ether and far preferable for such short operations. The operation is not formidable if skillfully performed. It should be a thorough curettement, and the cavity is not difficult of access, providing that the mouth is kept properly gagged. In more than 700 operations by my assistants and myself with bromide-of- ethyl anaesthesia no accident or haemorrhage of importance has oc- curred. Referring to the operation under this anaesthetic, T. Melville Hardie says: — "The advantages of the drug are: — "1. The laryngeal reflex very probably persists, and any blood or tissue entering the larynx is promptly expelled. "2. The sitting posture of the patient, possible in the exhibition of this anaesthetic, is the most convenient one for operating upon tonsils and adenoid growths, and makes easy the passage of blood from the nose and mouth; little of it is, as a rule, swallowed. "3. Xausea and vomiting are rare, and the patient generally ex- periences but little discomfort after the operation. "The disadvantages of the anaesthetic are: — "1. It is not perfectly safe, four or five deaths having been re- ported. "2. The time of anaesthesia is not always long enough to permit of thorough operation. In my experience this is not usual, but it cannot, on the other hand, be called very infrequent. "3. The anaesthetic is not always well taken." TTitzel, who reports 465 anaesthesias, and who believes it to be the least dangerous anaesthetic, tabulates the following unpleasant effects occurring: in 28 cases: — 332 ADENOID OPERATION UNDER BROMIDE-OF-ETHYL NARCOSIS. "(a) Great excitation in 9 cases, in 4 with much sweating. "(d) Cyanosis in 2 students somewhat the worse for liquor. "(c) Asphyxia, but rarely with his method: first a few drops, then the whole quantity of the anaesthetic. "(d) Malaise, lassitude, vomiting. "(e) Urination in 3 cases. "(f) Great sexual excitement. "(g) In 2 cases he could not produce anaesthesia with 1 and 2 ounces." Conclusions. 1. Adenoid vegetations should be removed under general anaes- thesia in the great majority of young children. 2. The cold-wire snare and cocaine anaesthesia are satisfactory in older children and in adults, but cocaine should not be used in young children. 3. Nitrous-oxide anaesthesia is frequently of too-brief duration for the proper performance of this operation. 4. Ethyl-bromide, apart from the question of its safeness, which is still undecided, is a desirable anaesthetic in many cases. 5. Ethyl-bromide is not well taken, as a rule, by very nervous or frightened children. 6. Ether should be substituted for bromide of ethyl when the op- eration is likely to be a lengthy one. 7. The Gottstein curette is, all things considered, the most satis- factory single instrument, and particularly in bromide-of-ethyl opera- tions. PART III Diseases of the Pharynx. (333) PLATE V. PLATE V. Figure 1. — The anterior nares are dilated by the nasal speculum, exposing the inferior turbinated bodies greatly hypertrophied; the head is inclined backward. Figure 2. — Hypertrophy of the left inferior turbinated body; removal by means of the snare and transfixion-pin under cocaine or eucaine anaesthesia. Figure 3. — Posterior rhinoscopic image, normal appearance. 1. Nasal septum, or vomer. 2. Superior turbinated body. 3. Superior meatus. 4. Middle turbinated body. 5. Orifice of the Eustachian tube. 6. Fossa of Rosenmuller. 7. Inferior turbinated body. 8. Velum palati and uvuia. 9. Nasal passages between the septum and turbinated bodies. Figure 4.— Posterior rhinoscopic image showing left inferior turbinated body. a posterior hypertrophy of the Figure 5. — Posterior rhinoscopic appearance of a case of hypertrophic rhinitis showing: — 1. Superior turbinated body. 2. Middle turbinated body. 3. Hypertrophy and great thickening of the septum. 4. Orifice of the Eustachian tube. Hypertrophies of the posterior ex- tremities of the right middle tur- binated body and of the left in- ferior turbinal. Figure 6. — Pharyngoscopy. 1. Soft palate. 2. Uvula. 3. Anterior pillar of the fauces. 4. Posterior pillar of the fauces. 5. Oral tonsil. 6. Posterior wall of the pharynx. 7. Retropharyngeal abscess. Figure 7. — Pharyngoscopy, pharynx. revealing a fibromucous polypus of the naso- Figure 8. — Laryngoscopy, showing the image of the larynx in the laryngo- scopy mirror. The vocal cords are widely separated as seen during a deep inspiration. Below the white vocal cords four rings of the trachea are visible. The handle of the mirror and the towel on the tongue are cut off. Figure 9. — The larynx during forcible inspiration. 1. Inferior surface of the epiglottis. 2. Anterior commissure of the vocal cords. 3. Cushion of the epiglottis. 4. Superior glosso-epiglottic fold. 5. Lateral glosso-epiglottic fold. 6. Cricoid cartilage. 7. Ventricular band. 8. Ventricle of Morgagni. 9. Trachea. 10. Left bronchus. 11. Literary tenoid fold. 12. Right bronchus. 13. Cartilage of Santorini. 14. Cartilage of Wrisberg. 15. Ary epiglottic fold. 16. Hyoid fossa. 17. Right vocal cord. 18. Pharyngo-epiglottic fold. 19. Superior surface of the epiglottis. PLATE V. 8 IftFETODGE CO UTH FHTL' CHAPTER XXVIII. DISEASES OF THE PHARYNX. Acute Pharyxgitls, or Simple Soke 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 sub- mucous tissues. The secretions contain epithelial cells, pus-corpus- cles, and micrococci. Etiology. — There is quite a wide divergence of opinion respect- ing the causes of acute catarrhal inflammation of the throat. There are excellent students who deny the classic theories of taking, or catch- ing, cold. Thorner and Fick combat the idea. But what shall we say of the common experiences of life among laymen and doctors alike? "When individuals possessed of unusual intelligence and pow- ers 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 inflammation 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 testi- mony 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 subjects 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 inflammation of the nasal or pharyn- geal mucous membrane as the inhalation of the fumes of a lighted match by a person subject to attacks of hay fever will precipitate a paroxysm of that disease. Chilling the skin of the chest by ex- posure to cold winds causes a reflex paresis of the blood-vessels of the bronchi or lungs, resulting in hyperemia and congestion, or in- flammation, of the lining mucous membrane. The same condition of (335) 336 ACUTE PHAKYNGITIS. the corresponding membrane of the nose or throat is caused in cer- tain 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 uni- versal observation and experience, that one cannot ignore or resist their force. The theory that these diseases are the result of bacterial infec- tion may be, in some part, true, for such 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 pre- cise relations to the disease, cause or product, have not been deter- mined. Acute pharyngitis occasionally follows an extensive or deep cauterization in the nasal cavity. This affection is an accompaniment or a sequel of the exanthe- mata, 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, and living in overheated and ill-ventilated rooms. 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 proportionately extended. There are likely to be headache and symptoms referable to the ear, such as a feeling of stuffiness, dullness of hearing, and ringing in the ears. Of course, these symptoms are attributable to an extension of the inflammation to the 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 swallowing causes pain, to avoid which the head and neck are made to perform certain movements characteristic of painful deglutition. The voice sounds muffled and obstructed and its use is avoided on account of the dis- comfort produced. During the act of swallowing the food is prone to enter the post-nasal space and occasion much discomfort. TREAT^IEXT OF ACUTE PHARYXGITIS. 337 After the dry stage of inflammation has passed, the throat he- comes bathed in a sticky mucus. This happens about the second day, and soon after this pns-eorpuscles begin to make their appearance. The efforts to clear the throat of these rapidly-accumulating dis- charges cause so much acute suffering that they are often swallowed. when nausea and vomiting are likely to follow. The breath becomes foul and the tongue thickly coated, indented, and flabby in severe attacks. Early inspection shows a bright-red color of the membrane cov- ering the fauces and pharynx. At first this is simply hyperamiic, but as exudation of serum takes place there appears a swollen, cedematons condition, especially marked in the loose tissue of the soft palate and uvula. The velum is thickened and its movements restricted and painful. The uvula is swelled to much more than its normal size: it is elongated and feels like a foreign body in the throat, exciting frequent attempts to swallow (Plate IY, Fig. 8). 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, which points to the probability that there has been a predisopsing chronic inflammation that requires treatment to avert future attacks. Diagnosis. — Simple sore throat cannot always be distinguished 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 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 dan- gerous unless it extends to the larynx. Treatment. — If seen during the first stage of the attack it can be averted or greatly ameliorated by the administration of atropia combined with morphia in the proportion of 1 / 400 grain of atropia to V 8 grain of morphia. Even in the second stage of inflammation, when serum and mucus are pouring forth in abundance, the siccative effect of these remedies lessens the secretion and the consequent painful efforts to swallow it, while their anodyne properties reduce the suffering to a minimum. The atropia antagonizes the nauseating, depressing, and constipating effects of the morphia. I have often 338 TREATMENT OF ACUTE PHARYNGITIS. averted these attacks in patients who had been subject to sieges of this disease with such distressing regularity that their experience was not to be ignored. Instead of suffering for a week or more, the symp- toms would either disappear quietly in a few hours or coyer a period of only a clay 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. Some families buy quinine by the ounce and keep it in the medicine 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 contain- ing the atropia and morphia, or the coryza tablets, containing, each, caffeine, 1 / 6 grain; morphia, 1 / 12 grain; and atropia, 1 / 600 grain. There is seldom any necessity for repeating these more than two 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 to revive. He is never allowed to know the nature or the name of this remedy for fear of establishing a drug habit. The bowels should be opened with a saline draught or a laxative pill. A half drachm or more of sodium phosphate is effective. 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 weak- ening. 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 (Fig. 140), 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, cam- phor, 10 drops of pure camphor-menthol, or a few crystals of menthol, are added to the steaming water, a thick 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 irri- tating effect. When both the nose and throat are suffering from an attack of TREATMENT OF ACUTE PHARYNGITIS. 339 acute inflammation, we have found that menthol afforded relief, espe- cially during the dry stage, by employing it as follows: a few of the crystals are placed in a teaspoon or saucer and heated over a lamp or stove until the crystals melt and produce fumes that penetrate every part of the rooim 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 chloride on the blood-vessels, and the soothing effect of Tolu and licorice, I have prescribed with satisfaction a tablet consisting of the following ingredients, or their equivalents: — R. Ammonii chloridi, gr. j. Tincturse opii camphoratae, Syrupi seillse compositi, Syrupi Tolutani, . . . . .of each, min. v. Extracti glycyrrhizge, . . . . . gr. iij. — M. This tablet is dissolved slowly in the mouth, and the resulting medicated saliva is kept in contact as much as possible with the in- flamed membrane. During the dry stage pilocarpine can be used, if it is desired to produce diaphoresis, 1 / 10 or 1 / 6 grain two or three times during the day, or enough to produce considerable perspiration. Gargles are not very efficient, since they reach only the anterior sur- face of the fauces and generally produce 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 pro- duces 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 ap- plying it to the throat with a camel's hair pencil or cotton-applicator. It cannot be sprayed with an atomizer without heating it to an un- comfortable temperature. After using it in my private and dispensary 340 TREATMENT OF ACUTE PHARYNGITIS. practice for many years I must say that it is an effective remedy if thoroughly and gently applied, notwithstanding the recently expressed disapproval of this remedy by so eminent an authority as Lennox Browne. By applying it several times a day the inflammation is sub- dued and the attack materially shortened. The author has used guaiacol in these cases, but has found different purchases to vary considerably in strength. Some specimens 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 we used the pure guaiacol the membrane looked immediately after the application as if an escharotic had been used. It was covered with a light-gray pellicle, and on the following morning the mucous membrane of this area was 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 condemned. 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 writer has experienced similar results with this remedy and with salophen. The application of ice to the throat externally, which can be accomplished with an ice-bag (Fig. 83) and by sucking pieces of ice, if they can be relied upon as being free from disease germs, may modify and abbreviate the in- flammation. Antipyrin, acetanilid, phenacetin, salophen, and aconite are useful during the fever and painful stage. After a muco-puru- lent discharge has formed, the antiseptic sprays, followed by the sooth- ing, 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 com- fort. The strong tendency of this disease to extend to the Eustachian tubes and middle ears makes prompt and efficient treatment impera- tive. 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. 341 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. Frequently-re- curring attacks of congestion and inflammation cause a loss of tonus of the blood-vessels, which remain permanently dilated. Varicose veins stand out prominently in their tortuous courses, and the mem- brane remains thickened. The infiltrated tissues (Plate IV) are de- prived, of the power 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 sometimes 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 contact of the uvula with the tongue aggravates the condition already present by provoking a cough and frequent swallow- ing occasioned by a feeling as if a foreign body were in the throat. Diagnosis. — The conditions already described render the diag- nosis a simple matter. It is not likely to be confounded with any other disease. Prognosis. — This affection is annoying, but not dangerous 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 antiseptic solutions given in Chapter XVIII, Sajous prefers silver- nitrate solution, 40 grains to the ounce. It reduces the 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 342 ACUTE KHEUMATIC PHARYNGITIS. on a holder, with care not to let it drip or press out into the larynx. The author has found that patients experience great relief by using at home — every morning and night at first, and later, when improve- ment is marked, only at bed-time — a 3-per-cent. solution of camphor- menthol in benzoinol or lavolin. I have prescribed this for hundreds of patients, and they often say, many months afterward, that their im- provement 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. 129). For office-treatment, after the cleansing throat-douche in coarse spray with sufficient air-pressure to dislodge and expel all the secre- tions that may stick to the membrane, we use, for a protective and emollient, benzoinol; for antiseptic and stimulant purposes eucalyptus in lavolin, 4 per cent., and pine-needle oil in the same proportions; and, if the membrane become too dry from insufficient secretion of mucus, 90 parts of oil of cubebs with 10 parts of pure camphor-men- thol. 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 Eheumatic Pharyngitis. Synonyms. — Eheumatic 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 gen- eral medical works. The uric-acid diathesis is discussed under the heading of "Hay Fever" (page 236). Etiology.— In persons who are subject to attacks of sore throat the acquirement of the rheumatic habit of body is likely to be fol- lowed by this type of throat affection. Attacks usually follow ex- posure to cold and damp. Symptomatology. — Attacks come on suddenly after the im- pression 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- TREATMENT OP ACUTE RHEUMATIC PHARYXGITIS. 343 ments characteristic of attempts to avert the inevitable painfullness 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 visitations 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 ap- pears of an intense-red color and has a puffy, swelled 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 sore- ness 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 manifesta- tions in the throat are concerned, for it passes off in about four days, but to return again on exposure. Prompt treatment will avert at- tacks. Treatment. — Salicylic acid in some form is the most effective remedy. The author prefers a freshly-prepared salicylate of sodium, and generally prescribes it in the following formula: — R Acidi salicylici, 3iij. Sodii biearbonatis, 3ij. Elixiris gaultherise, §ss. Glycerini. . 3iij. Aqiue, . . . . . . . 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 im- provement is shown or until the physiological effects are manifested: ringing in the ears and slight impairment of hearing. Then the doses are stopped or diminished or placed sufficiently far apart to avoid 344 CHRONIC RHEUMATIC SORE THROAT. these effects. The latter are similar to those of quinine, and must be avoided as far as possible, so as not to produce hyperemia or con- gestion of the middle ears or irritation of the auditory nerves. If the salicylate is not well borne, if gastric disturbance and head symp- toms indicate unusual susceptibility to this drug, salicin can be ad- vantageously 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, although the latter and salophen, as well, produce excellent effects. For the fever and pain antipyrin affords the most decided relief. Indeed, this remedy appears to exercise a special influence in quelling this disease, and is superior to phenacetin, acetanilid, etc., not only in reducing temperature, but in transcending 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. Effervescent citrate of lithia, soda, and potash and alka- lithia are indicated to rid the blood of uric acid and to prevent sub- sequent attacks. As an external application, I have found the following liniment efficacious: — B Olei tiglii, 3ij. Chloroformi, 3ij. Aquae ammonii fortioris, . . . . • Bj- Olei sesami, Siij- 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 and then covered with a thick layer of cotton. The underclothing should always consist of wool. Chronic Bheumatic 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 mor- bid phenomena, are discussed at length in the chapter on hay fever (page 236). TKEATMENT OF CHROXIC BHEUMATIC SOEE THEOAT. 345 Symptomatology. — This disease differs from acute rheumatic sore throat principally in degree. There is not acute suffering ex- cept in exacerbations of the disease, when it lapses into the acute form. It usually comes on at the same changeable 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, sometimes 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, suggestive of perichondritis or periostitis. The patient is conscious of an indefinite sensation described as a constric- tion 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 can- cer. 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 distinguished by visible lesions. In the latter diseases we find the cachexia or constitutional condition indi- cated by the particular 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 already 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 news- papers. 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. E. Warner & Company. Two or three of these are dissolved in a large glass of water — the more water, the better — and taken once or twice a dav 3±6 TREATMENT OF CHRONIC RHEUMATIC SORE THROAT. for months in succession until the rheumatic or gouty habit is over- come. I have known of no serious disturbances following the pro- longed use of lithia in this form, although I have given it over very protracted periods. A few persons are susceptible and have symptoms of strangury if too much is taken. Others do not use a sufficient quantity of water and have a slight gastric disturbance. Alkalithia and the effervescent citrate of lithia, soda, and potash, of Keasbey and Mattison, are also very effective. 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 it is 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 blood when it becomes sufficiently alkaline in re- action 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, bv the use of this combination. CHAPTER XXIX. DISEASES OF THE PHARYNX. CONTINUED. Sore Throat of Measles, Scarlet Fever, axd Small-pox. sore throat of 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 diph- theric throat. In this class of cases the mortality amounts to 80 per cent. If the throat is examined ahout the time the fever appears it is found to he hyperaernie, 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 commonly affects the trachea and bronchial tubes; but, if the diphtheric 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 treatment principally to prevent middle-ear involvement. The measures rec- ommended for acute pharyngitis are sufficient, but the membranous form should be treated with as unremitting thoroughness as diph- (347) 348 SORE THROAT OF SCARLET FEVER. theria, the treatment for which is indicated here. (See chapter on diphtheria.) SORE THROAT OF 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 present a swollen appearance. The glandular bodies with which this region is so richly supplied — the tonsils and the parotid, submaxillary, and lateral cervical glands — may all be in- vaded by an intense phlegmonous inflammation with resulting ab- scesses. 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 ab- scesses may occur if the necrotic process extend deeply into the sub- mucous tissues. Middle-ear diseases more often result from scarlatina than from measles, and the results are far more disastrous than from measles. Suppuration of the tympanic cavities with resulting granu- lations, 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 disap- peared. Then the throat is attacked, the submaxillary 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 some- times 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 of 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-Loffler bacilli should be made to determine whether or not we have to deal with true diphtheria, and in the absence of bacteriological 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 prominent feature of the disease, must be guarded, for the throat affection often FOLLICULAR PHARYNGITIS. 349 causes death. In the simple form it is not dangerous; 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 properly 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. 83), may modify the intensity of the inflammation and avert or retard the tendency to suppuration. The throat-tablets and other remedies recommended in the treatment of acute pharyngitis are more effective than gargles. In the pseudomembranous form, which may prove to be a diphtheric complication, the treatment for diphtheria must be followed. Eufus P. Lincoln recommends the application of pyoktanin. SORE THROAT OF 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 corresponds to the viru- lency of the attack. The swelling and inflammation may become suffi- cient to cause pain and difficulty in swallowing. The inflammation extends in many instances to the larynx and trachea, and the result- ing oedema has caused suffocation and death (Plate VII). 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, scarifi- cation must be resorted to in order to prevent suffocation, and indeed it may become necessary to intubate or 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; clergyman'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 membrane, while in the second, or exudative, form there is a secretion of a light color, 350 FOLLICULAR PHARYNGITIS. which may become dried and cheesy in consistence 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 some- times 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 secretions. This pro- tracted exercise results in increased blood-supply and deposit of nu- triment, or an excess of growth of the glandular tissues, and this, together with occlusion of the apertures of the follicles, accounts for their hypertrophic condition. 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 sensation that occa- sions 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 shoot- ing 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 cov- ered with them. They are in some instances punctated, appearing like little nipples; in others they have broad bases, are flat, and become coalesced in patches. Behind and external to the posterior faucial pillars their union forms a ridge extending upward and out- ward toward the Eustachian orifices. The blood-vessels are engorged and the veins are abnormally prominent. TREATMENT OF FOLLICULAR PHARYNGITIS. 351 The tonsils are enlarged in a considerable proportion of these cases and the uvula is relaxed and tickles the tongue (Plate IV). 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 mistake 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 expected 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 hypertrophic 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 opportunity of treating this disease in its early stages, for the 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 treat- ment, the follicles, two or three at a sitting, should be reduced by the application of chromic acid, London paste, or — better still — the galvanocautery. If the acid or paste is used, great caution is neces- sary 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 ap- plicator (Fig. 71). The London paste is applied in small particles so that they will adhere like minute spots of plaster on the surface of the follicles. The galvanocautery (Fig. 149) is the most satisfactory means of eradicating the tumefied follicles. The long electrode is chosen ac- cording to its fitness for the particular 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 destroy it to a point a little below the surface of the 352 MEMBRANOUS SORE THROAT, NON-DIPHTHERIC. adjacent membrane. 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 clay, preferably at bed-time and on rising in the morning. General treatment is demanded by a uric-acid diathesis to pre- vent 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. Membranous Sore Throat, Non-diphtheric. Synonyms. — Simple membranous sore throat; herpetic pharyn- gitis. 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 time. 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 and is dotted with follicles that are inflamed or pustular in character. As these pustules rupture and their contents escape over the surrounding surface the appearance of a false mem- brane 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 confounded with diphtheria, but it is not so grave a disease. Although it may TREATMENT OF MEMBRANOUS SORE THROAT. 353 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 mu- cous 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 detach- ment of diphtheric membrane reveals raw, uneven, ulcerating tissues exposed to view. Bacteriological examination in diphtheria shows the presence of the Klebs-Lorfler bacillus, which is the germ of that 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, bitt it should not be forgotten that true diphtheria sometimes is ingrafted 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 we have found on the day following its application an ulcerated surface corresponding to the area touched with the pure guaiacol. Hydrozone 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 produced by the H 2 2 , it probably contains too lar^ge a proportion of acid and requires dilution. Ingals prefers the following pigment: Morphia? sulphatis, gr. iv; acidi carbolici, gr. xxx; glycerini, fgj; to which he adds 30 grains of tannin when an astringent is required. John Xorth has stated to me that potassium permanganate will dissolve the false mem- brane. He uses 30 grains to the ounce of water. Inhalations and sprays are more easily applied and cause less dis- comfort than swabs and probangs. I have seen much relief afforded by adding 10 drops of pure camphor-menthol to a pint of hot water 354 TREATMENT OF MEMBRANOUS SORE THROAT. for the patient to inhale through the month. A benzoinol inhaler (Fig. 140), an ordinary tea-kettle, small tea-pot, or coffee-pot can be pressed into service for. this purpose. The nozzle is wrapped with sev- eral thicknesses of cloth, not occluding the opening itself, so as to prevent burning the lips, and the end of the 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. Carbolic acid in glycerin, of 5- or 10-per-cent. strength, will deplete the blood-vessels and anaesthetize the mucons membrane sufficiently to relieve pain. Sprays of encalyptol, 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 meas- ures appropriate to this disease are the same as those recommended in the treatment of coryza and acute pharyngitis. CHAPTER XXX. DISEASES OF THE PHARYNX,. CONTINUED. DlPHTHEEIA. Unlike the sore throats of scarlatina, measles, and sniall-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 con- stitutional malady, in diphtheria we recognize a veritable throat affection with systemic infection. The importance of the disease and the advancements recently made in its pathology and treatment war- rant 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 Loffler, 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 propagated 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 sci- entific 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 comparable 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 morphological 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 News for Xovember 17, 1891: "It was (355) 356 DIPHTHEKIA. observed that the genuine, virulent diphtheria bacillus was liable to fluctuate in the degree of its pathogenic properties, at times possess- ing 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, 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. 189 and 190), after the scientists who have brought Fig. 189. — Diphtheria bacilli. Culture on agar-agar, twenty-four hours old; stained in alkaline methylene-blue ; magnified 1000 times. (After Krieger.) 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 the development and propagation of bacilli, — warmth and moisture, — and, while the microbes them- selves do not enter into the lymph or blood circulation, their poison- ous 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. DIPHTHEE1A. 357 According to Yersin and others, the bacillus itself is not virulent, but the poisonous product of the microbe is the material 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 diph- theria and who have not been exposed to it. To all appearances this is the true Klebs-Loffler 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 practical]}- two diseases have formerly passed under It* both with hoods omitted. (Thorner.) While it is not claimed by Thorner or Kirstein that this method should supplant the use of the laryngoscopic mirror, they assert for it certain advantages, which may be summarized as follow: Direct laryngoscopy gives a more realistic view of the organs inspected, in regard to both the normal color and the absence of reversal of the picture, both of which are important considerations in operative procedures; the posterior wall of the larynx and the deep portion, of the trachea are subject to inspection; operations on the larynx and trachea are performed with greater exactness and facility under direct linear inspection. DIRECT LARYXGOSCOPY 451 Thorner regards this method of direct laryngoscopy "the most important addition to our technical resources since the discovery of the laryngoscope by Garcia. " It is evident that the obliteration of the obtuse angle formed by the intersecting axes of the buccal cavity and the laryngotracheal tube, by rendering these axes coincident, calls for instruments without the curve that characterizes those com- monly employed. Operations by the new method require that in- struments be constructed after the types shown in Fig. 205. Fig. 205. — Types of instruments for autoscopic operations. (Thorner.) Inspection with the autoscope — an unfortunate choice of name, since it is likely to be confounded with the word otoscope in speak- ing — necessitates monocular vision. About 50 per cent, of patients cannot be examined by this method. It requires considerable self- possession on the part of the patient as well as much practice on the part of the surgeon. Both Ivirstein and Thorner concede that it should supplement, but not supplant, the use of the laryngoscopic mirror. CHAPTER XXXVII. DISEASES OF THE LARYNX, CONTINUED. Acute Laryngitis. Synonyms. — Acute catarrh of the larynx; spurious cronp. Pathology. — Acute inflammation of the mucous membrane lining the laryngeal cavity (Plate VII) is characterized by an engorgement of the blood-vessels, — an hyperemia, — accompanied, at first, by dry- ness of the membrane and afterward by an exudation of serum upon the mucosa, mixed with undeveloped epithelial cells and white cor- puscles. The thin, translucent secretion soon gives place to a more copious secretion of a thick, opalescent, 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 per- spiration 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. Persons riding over the alkali deserts or plains of the western part of the United States are sufferers from rhinitis, laryngitis, and con- junctivitis, 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 induce attacks of acute laryngitis. In- stances of this affection are very common during political campaigns, when stump-speakers are driven from the field by the inordinate use of their vocal organs. Firemen — who shout in the heat and smoke of burning buildings, and who often inhale much of the hot air, steam, and smoke — are subject to this disease. The uric-acid diathe- sis, rheumatic and gouty conditions, and the eruptive diseases stand in a causative relation to acute laryngitis. Symptomatology. — The premonitory symptoms of acute laryn- (452) ACUTE LARYNGITIS. 453 gitis 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 were 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 irri- tation, only adds to the feeling of roughness. A sense of constriction or of soreness soon follows, but palpation of the larynx seldom de- velops tenderness, except in rheumatic attacks. As the disease pro- gresses and the vocal cords become involved, the voice changes in quality, or timbre. It takes on a rough, 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 degluti- tion may come a complete loss of voice, so that the only speech pos- sible to the patient is a forced whisper. Cough is not necessarily a symptom of acute laryngitis, but is frequently present. Its hoarse character is indicative of the location of the causative lesion in the larynx. Auscultation of the larynx will demonstrate 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 passing of air through these fluids gives rise to easily- detected rales. The expectoration is characterized by the presence of the secretions just mentioned, and later in the disease by the pres- ence 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. Acute laryngitis does not usually give rise to very serious gen- eral disturbances of the system in adults, but it often presents alarm- ing 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 embar- rassed and the respiratory effort is marked by an audible, stridulous 454 ACUTE LAKYXGITIS. 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 con- gested 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. Conse- quently 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 in- spired 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 con- traction may play a role as a complication, but the mechanical ex- planation 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. Inspection of the larynx during an attack of acute inflammation reveals a mucous lining of a bright-red color (Plate VII). The con- gested 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 VII, 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 (Plate VII). 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 TREATMENT OF ACUTE LARYNGITIS. 455 true croup. In ease of doubt, an examination of the fauces will likely reveal false membrane if diphtheria is present. A laryngoscopic ex- amination should be had if obtainable. The secretions should be subjected to bacteriological examinations if there is reason to suspect diphtheria. However, this disease does not run such a course as does diphtheria 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 Dobell's, will dissolve and wash away the discharges, and. besides leaving the mucous mem- brane clear and free for the application of other medicaments, the effect is a very agreeable and soothing one. In the dry stage the author has found menthol very efficient when inhaled in several dif- ferent 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 with the volatile fumes. The patient is directed to keep his eyes closed to prevent any smarting, and. unless his nostrils participate in the inflammation, he is instructed to breathe through the mouth. The inhalation starts a refreshing flow of mu- cus to bathe the parched membrane of the dry stage. Another ex- cellent treatment consists in putting 10 drops of pure camphor-men- thol into a half-pint of hot water contained in a hot-water inhaler (Fig. 140) or 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 nozzle. 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. The writer has found his throat tablets useful, and they can be given freely, without producing any unpleasant consequence-, except, perhaps, nausea. Each tablet contains 1 grain of ammonium chlo- ride and the equivalents of 5 minims each of paregoric, compound syrup of squills, and syrup of Tolu, with 3 grains of extract of licorice. These are held in the mouth and allowed to dissolve slowlv and trickle 456 TREATMENT OF ACUTE LARYNGITIS. down the throat. Besides the desirable action of the ingredients of this tablet on the mucous membrane of the throat, the licorice gen- erally produces a laxative effect on the bowels. J. D. Arnold recom- mends, 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 pain- ful, 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. 83) is indicated. Leeches to the neck are sometimes employed, but cold is preferable. Counter-irritation by mustard, tincture of iodine, aqua- ammonia, chloroform, etc., is useful. General treatment consists, first, in putting the patient in such a condition as is favorable to successful treatment. He need not necessarily be put to bed, but he had best remain in-doors for a few days, where the temperature is uniform and where he will not be ex- posed to those conditions that brought on the attack. In the dry, or first, stage, 1 / 6 or even 1 / 3 grain of pilocarpine is useful to stimu- late the sudoriferous and salivary glands to activity. This is a sub- stitute 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 experience goes. One or two doses of morphia, 1 / 12 grain, combined with atropia, 1 / 600 grain, and caffeine, 1 / 6 grain, have often appeared to greatly ameliorate, and even shorten, the attacks ma- terially. Irritants — tobacco-smoke, alcoholic liquors, etc.— must be forbidden. If oedema, 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 suffocation, trache- otomy must be performed. The rheumatic type of acute laryngitis is attended with con- siderable 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 discontinued until these transitory symptoms TBEATAIEXT OF ACUTE LAEYXGITIS. 457 abate, and renewed again in smaller doses until after complete re- covery. A fresh preparation should always be made, like the formula given in the article on the treatment of rheumatic pharyngitis (page 343). If the sodium salicylate disagree with the stomach or produce serious aural symptoms, and more especially if the patient already has an affection of the ear, salicin should be substituted for the salicy- late. I hare 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 of lithia are taken three or four times a day. Antipyrin is often very beneficial in this disease, and the same may be said of salophen and salol. 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 Eegion, 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 masic in their effects are climatic conditions. CHAPTER XXXVIII. DISEASES OF THE LARYNX, CONTINUED. Ceoup. Synonyms. — Pseudomembranous croup; idiopathic membranous croup. Pathology. — The question of the identity or duality of croup and laryngeal diphtheria is still a mooted one. Excellent authorities differ on this subject. So scholarly an author as Sir Morell Mac- kenzie believed the two to be identical. Both diseases affect the mu- cous membrane, with the result of producing a false membrane. Both diseases attack the same organ, — i.e., the larynx. Both obstruct res- piration. In these three particulars there is a close similarity in the two diseases, but the author is not prepared to admit their identity. Croup is primarily 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 hun- dred and fifty-one diphtheric cases the membrane was limited to the larynx only once. In eighty-eight the membrane appeared first in the larynx or simultaneously with that of the pharynx" (Xorthrup). Croup is more frequent in the country, while diphtheria is more prevalent in cities. In the opinion of the author, the wide differences 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 inocula- tion or infection, directly or indirectly, from a previously 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 (458) croup. 459 the Klebs-Loffler bacillus does. The clinical pictures of the two dis- eases are similar in their mechanical effects upon the respiration and consequent deoxygenation 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. Porter agrees with this view, that there is a plastic exudation in the larynx which is not diphtheric. 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 con- fined 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 deposited 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 epithelial layer to the submucosa as the diph- theric 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 dis- coverable exciting cause, or it may occasionally be secondary to in- juries, various irritants, scarlet fever, measles, small-pox, etc. Ex- posure to cold and moisture, especially combined with strong winds, may give rise to attacks. I have not observed that the previous con- dition 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 con- siderable opportunity to study these subjects in his practice in con- nection with the children's departments of the South-Side and of the TTest-Side Free Dispensaries, 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 ex- posed to cold, as is the almost universal custom; the carrying or wheeling of infants bare-headed in the cold; allowing children im- properly clad to sit about in the open air in chilly weather, and to 460 ceoup. rim 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 subjective symp- toms 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 appears 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 an unnatural 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 increases with the increasing false membrane. The true inflammatory 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 obstructing mem- brane 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 membrane 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 laryngeal diphtheria, acute laryngitis, or laryngismus stridulus. TBEATMENT OF CBOTJP. 461 It may be difficult sometimes to distinguish croup from diph- theria. In croup the constitutional disturbance is less profound than in diphtheria. Obstruction to breathing is really the principal symp- tom 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 contagious; 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. Xo 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 at- tended 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 laryngitis. The cough of the two diseases differs, that of croup 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 respiration 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 to TO per cent. Since the introduction of intubation of the larynx by O'Dwyer the death-rate has materially improved. In a collective in- vestigation by Eanke concerning intubation in Germany he reports 1445 cases intubated for croup, with 553 recoveries, or 38 per cent. O'Dwyer (New Tori- Medical Journal. March 10. 1894) claimed that the ''mortality of laryngeal diphtheria without treatment is 90 per cent., which can be reduced to from 27 per cent, to 4T per cent." Attacks of great severity may progress rapidly to a fatal termina- tion, 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 at- 462 TREATMENT OF CEOUP. mosphere. I have made it a rule to put the child in a room contain- ing 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. Wet sheets are hung about the stove, 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 Jwo quarts of hot water. As chemical combination takes place an abund- ance of steam is generated which is conducted to the patient's head by a tent-shaped arrangement of a sheet. In the first, or catarrhal, stage counter-irritation is useful over the larynx by means of mustard. An ice-bag (Fig. 83) may modify the intensity of the inflammation. Gottstein advises not only these, but the use of leeches on the upper part of the sternum. Glasgow uses a spray of hydrozone thrown directly into the larynx. He believes the mechanical effect of the effervescence pro- duced is to detach the false membrane and facilitate 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 tea- spoon 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 valuable remedy. It is believed to be potent in preventing the formation of an exudate. It increases the secretions, which action in itself con- tributes to the casting off of the false membrane. 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, 1 / 2 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 percentage 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 origin- TREATMENT OF CROUP. 463 ally suggested some years ago by Corbin, of Brooklyn, and later rec- ommended by Dillon Brown. It should be used when there are symp- toms 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, for a period varying from ten minutes to one-half hour. In one hun- dred cases thus treated no case has been subject to deleterious results. In one case only did slight ptyalism occur. Salivation, diarrhoea, depression, prostration, and anaemia must be prevented by watchful- ness 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 suffocation 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 ex- haustion 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 garments, and kept in-doors until a normal condition of the larynx is re-established. Sprays of cubebs, camphor-menthol, lavolin, pine-needle oil, oil of tar, etc., will assist materially in a complete restoration of the mucous membrane to a state of health. CHAPTER XXXIX. DISEASES OF THE LARYNX, CONTINUED. Intubation of the Laeynx. To Joseph O'Dwyer, of New York, is due the credit of intro- ducing the operation of intubation, which is now so commonly per- formed. Bouchut, of Paris, demonstrated in 1858 that the operation was practicable, but no practical results followed his discovery until O'Dwyer, without knowledge of Bouchufs work, showed actual re- coveries due to it. The instruments for this procedure are a set of tubes of varying Fig. 206. — O'Dwyer's intubation- tubes. I Fig. 207.— Scale. calibre, with a scale for measuring the tube, to assist in selecting the proper size; a mouth-gag (Fig. 186); an introducer; an extractor, and a protector for the surgeon's finger. The tube (Fig. 206) 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 accidentally pass into the oesophagus, instead of the larynx, it can be withdrawn. The ob- struction of the tube with particles of membrane may also render it necessary to draw the tube out by the thread. It is safest to employ (464) INTUBATION OF THE LARYNX. -±05 a strand of braided silk or linen thread, being certain that it con- tains no inequalities to catch in the fenestra. The scale (Fig. 20?) is used to determine the size of the tube to be employed, according to the age of the patient. The introducer (Fig. 208) is screwed into the obturator of the Fig. 208. — O'Dwyer's introducer, with tube attached. tube, as shown in the illustration, and, when the tube is inserted into the larynx, pressure on the button of the introducer separates the obturator from the tube, leaving the latter in the larynx while the obturator is withdrawn. The extractor (Fig. 209) is so constructed that, when the blades Fig. 209. — O'Dwyer's extractor. at the curved extremity are introduced into the mouth of 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 against being bitten during the operation. J. E. Rhodes (Journal of Hie 466 INTUBATION OF THE LAKYXX. American Medical Association, January 15, 1895) lias "devised a pro- tector. It consists of a rubber glove that covers the hand from the wrist to a little beyond the metacarpophalangeal joints. On the in- dex 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 in front of 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 unneces- sary 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 children younger than 2 years, the next for those be- tween 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 in- troducer by screwing the latter into the obturator contained within the tube, with the short side of the tube toward the handle, as shown. The tube is threaded as already described, and the instrument is 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. 187, illustrating the operation for removing adenoid vegetations from the vault of the pharynx. The position assumed in the direct examina- tion of the larynx, or autoscopy, would be a good one for intubation if it could be secured (Fig. 201). 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. 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 at- tend assiduously to the holding of the gag in place and keeping the child's head, thrown a little backward on the nurse's shoulder, im- INTUBATION OF THE LARYNX. 467 movably fixed. If these directions are efficiently followed there can he no kicking, sliding down, snatching of the instrument, or disloca- tion 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 recognizes the epiglottis and the opening be- tween 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 latter 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 button and the tube is released, the introducer 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 eyes, mouth, and nose during the introduc- tion of the tube. A bite of the child or the ejection of a diphtheric discharge may cost the operator his life or communicate 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 introduced. 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 respiration 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 secre- tions in it. In either condition the tube must be removed forthwith. So the thread loop is secured by attaching another thread to it and passing it around the child's neck, and his hands must be kept away from it. As soon as it becomes apparent that the operation has fulfilled its purpose by affording freedom of breathing, the gag is reintroduced, the thread is cut, the finger-tip placed on the end of 468 INTUBATION OF THE LARYNX. the tube to prevent its dislodgment, and the thread loop is with- drawn, leaving the tube in position. If the operation has been suc- cessful, 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 quench- ing 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, trache- otomy is the last resort. The physician should always be prepared for this emergency by having the tracheotomy 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 resus- citate the little patient. For the removal of the tube the patient is prepared the same as for its introduction. The extractor is carried down, under the guid- ance 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-blacles expanded to engage the tube, and the in- strument 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 the throat. Removal of the tube may be necessary to clear it of obstructions or to ascertain when the patient no longer requires it. Should it be necessary to reintroduce it, a second tube had best be at hand already attached to the in- troducer, 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 has been in the larynx for a quarter of an hour, and there are no indications that it will have to be removed, the loop of thread is cut, and, with the finger in the pharynx and rest- INTUBATION OF THE LAKYNX. 469 ing 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 retching. The tube is allowed to remain in the larynx for several days, sometimes five or six, but, as soon as it becomes apparent that the disease has progressed so favorably as to render its presence there un- necessary, 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 certain to enter the larynx and excite violent coughing, which may expel the tube, or they may enter the lungs and cause pneumonia. 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 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 pro- duces less shock than tracheotomy, and the air is better prepared for contact with the mucous membrane below the trachea after intuba- tion than when it enters directly through a tracheotomy-tube. Xo 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 emergencies trache- otomy will have to be brought to our aid. Intubation is not diffi- cnlt for the laryngologist, but one needs considerable practice in order to be reasonably sure of success. The best means of acquiring 470 TRACHEOTOMY. 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 completely out of sight in the hand while its aperture 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 intuba- tion it is important that skilled assistance be at hand for these ex- igencies. Tracheotomy is easier to perform, and can be done in extremi- ties without skilled assistants. If the tube become clogged the nurse can prevent suffocation by removing it and maintaining the opening Fig. 210. — Eos well Park's aluminium tracheal tube. free until the surgeon arrives. In these respects tracheotomy pre- sents advantages over intubation. In cities where skilled laryngolo- gists are within quickly-calling distances intubation possesses superior merits. In the country, with all its unavoidable disadvantages, trache- otomy is hardly likely to be superseded. Tracheotomy. The instruments necessary for this operation are a small knife, double retractors (Fig. 9-1), haemostatic forceps, tracheal forceps, a tenaculum, a grooved director, a flexible catheter, and tracheotomy- tubes of various sizes (Figs. 210 and 211). The average size, up to 3 years, is one-fourth inch (six millimetres). Other convenient arti- cles should be at hand, if circumstances permit of their being sup- plied: sharp-pointed forceps, an aneurism-needle, thread, absorbent gauze, and tapes. TKACHEOTO:\IY. 471 Aii 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 sen- sibilities are sufficiently obtunded by carbonic-acid poisoning. In this operation chloroform is to be given the preference over ether, on account of the effect of ether in exciting glottic spasm and in- creasing 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 VI). Another advantage gained in the high operation lies in the more superficial position of the trachea. 000 Fig. 211. — Hard-rubber tracheal tube. 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 prominently the ante- rior 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 car- tilage, 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 ligatecl 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 472 TRACHEOTOMY. the incision is completed, after which the deep fascia is similarly incised. The knife-handle is used to separate the sternohyoid and the sternothyroid muscles; the self -retaining retractors (Fig. 94) 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 sufficiently to necessitate its being drawn out of the way. A transverse incision is now made, about one-half inch (one centimetre) long, over the superior border of the cricoid cartilage, penetrating the superficial layer of the deep cervical fascia. The grooved director is then intro- duced, 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 down- ward, 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 Fig. 212. — Trachea dilator. 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 tracheal tube shall not be inserted between the membrane and the wall of the trachea, thus blocking up its opening. 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 membrane 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 (Fig. 212) is employed by many surgeons until the haemorrhage ceases and free respiration is established. Sponging must be rapid; the opening must be main- tained 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 TRACHEOTOMY. 473 used. The patient must be closely watched and, if necessary, arti- ficial respiration must be performed; clogging of the tube and in- terference 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. The low operation is performed similarly to the one already de- scribed, except that the incision begins at the cricoid cartilage and ends about one-half inch above the sternum. The trachea lies deeper here; the blood-vessels are larger and more numerous and the thy- roid isthmus is in the way. It is a more difficult procedure. After tracheotomy the tube is best protected by a layer of bichlo- ride 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 tem- perature of 76° to 80° F., and impregnated with moisture to prevent irritation of the mucous membrane of the deeper air-passages. Dur- ing the first day the inner tube must be removed frequently for cleaning with a 5-per-cent. solution 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 can- nula has to be removed. The nurse should always be instructed as to the possibility of such an accident, and that, should it occur, she must at once cut the tapes, remove the tube, cleanse and free the opening, and maintain its patency until the surgeon can be sum- moned. In two or three days the tube should be closed momentarily to determine if respiration is normal without it; if so, it can be dis- pensed with and the wound closed. CHAPTEE XL. DISEASES OF THE LARYNX, CONTINUED. Cheoxic 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 mem- brane. 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, there are variations of the same malady. Formerly the mild grade of acute inflammation of the middle ear was described separately as a subacute inflammation, although it is not a different disease;, but the leading books on otology now discard this adventi- tious distinction, and laryngologists should lend encouragement to a sensible simplification of a terminology which is encumbered with unwarranted parasites of nomenclature. So we will not attempt to multiply the varying grades of intensity of an acute inflammation into separate diseases. Pathology. — When acute laryngitis is neglected it naturally terminates in a chronic inflammation (Plate VII) 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 portion of the cav- ity 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 inter- fered with as to render its changes very difficult. If the mucous mem- brane 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 repeated (474) PLATE VII. PLATE VII. Figure 10. — Imperfect view of the larynx resulting from an improper inclina- tion of the patient's head, or an incorrect position of the mirror. The head and mirror are not carried far enough backward. Figure 11. — The conditions are similar to those mentioned in the description of Figure 10, but with some improvement, giving a partial view of the laryngeal cavity. Figure 12. — Omega-shaped larynx of a child. Figure 13.- — Hyperemia of the mucous membrane of the larynx, not involving the vocal cords or the epiglottis. The vocal cords are in the position of phonation. Figure 14. — Congestion of the larynx involving the epiglottis, and the vocal cords to a slight degree. Figure 15. — Acute laryngitis involving both vocal cords. Figure 16. — Acute laryngitis involving the vocal cords and the epiglottis. The blood-vessels of the epiglottis are injected; there is an cedematous condition of the right half of the larynx. Figure 17. — Chronic laryngitis involving the vocal cords, which are ulcerated near the posterior commissure. Figure 18. — (Edema of the larynx; phlegmonous inflammation. Figure 19. — Tubercular infiltration of the arytenoid cartilages, with superficial ulceration of the interarytenoid fold and the vocal cords. Figure 20. — Tubercular infiltration of the larynx. The epiglottis is pale and greatly thickened, together with the arytenoid cartilages, which are pear-shaped. The depressions between the cartilages of Wrisberg and Santorini are obliterated. Figure 21. — Tuberculosis of the larynx: tumefaction of the arytenoid cartil- ages; ulceration of the vocal cords, the left ventricular band, and the interarytenoid membrane. PLATE VI 10 t^ : m 12 15 18 19 20 21 BUFK B McFETTWGE CO. 1/77/. PHIL' CHBOXIC LARYNGITIS. 475 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 spontaneously. Many patients who are afflicted with chronic hypertrophic rhinitis present a chronic laryngitis as a com- plication or result of the nasal hypertrophy. This is easily under- stood when we take into consideration the continuity of mucous mem- brane 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 irritation 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 dis- ease lies in the forced mouth-breathing in consequence of nasal steno- sis. The air then reaches the larynx without the processes of puri- fying, 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 political campaigns, huck- sters, intensely-emotional revivalists, etc., are frequent sufferers. In- activity of the liver, and dyspepsia, alcoholic excesses, and atmos- pheric irritants are prolific producers of this disease. According to the observations of Ziemssen and Mulhall, boys are rendered sus- ceptible to attacks of catarrhal laryngitis by the changes incident to the age of puberty. Symptomatology. — The most marked symptoms are developed when attempts are made to use the voice. While it is at 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 sensation 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 irre- sistible desire to cough. Burning and prickling pains are felt in the larynx, which one endeavors to relieve by clearing the throat. In -±76 CHRONIC LARYNGITIS. the midst of a sentence a cutting pain shoots- through the organ, that may be described as a feeling as though the vocal cords 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 speakers of providing themselves with a glass or a pitcher of water before be- ginning a discourse. The voice shows the most marked effect of this disease, but there are great variations in different patients, and peculiarities dis- tinguishing certain cases. When a speaker, for example, 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 peculiarity. This is probably due to the increased secretion stimulated by a quickened circulation, as well as to improved innervation resulting from the intensity of will-impulse. Another characteristic is the natural quality observed in the cus- tomary 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 in uncomplicated chronic laryn- gitis. They are generally tenacious and of a gray color, but if ulcera- tions are present they assume a yellow hue. As in the acute inflam- mation, there is rarely any blood in the expectorations, unless an unusually violent effort at coughing has ruptured the vessels. Inspection with the laryngeal mirror shows an hypergeniic con- dition of the mucous membrane (Plate VII). As the figures illustrate, the small blood-vessels of the epiglottis are engorged and conspicu- ous. The vocal cords are sometimes red, one or both of them; at other times they do not participate in the inflammatory 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 condition 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 condi- tions of the mucous membrane in other localities, a gradual thicken- ing of the mucosa and submucous tissues results from inflammation of long duration, and the vocal cords may be affected by this hyper- plasia to the extent of granulation formation, or trachoma. The presence of these excrescences materially embarrasses the vibration of the cords and changes the character of the notes produced. CHROXIC LARYXGITIS. -IT? 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 ventricular hands obliterates the ventricles and deranges the actions of the vocal cords. One cord becomes paretic (Plate YIII) 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 de- gree, and voice-production is made possible. Ulcerations of a shallow kind are occasionally to be seen, gen- erally in the interval between the arytenoid cartilages. Diagnosis. — Chronic laryngitis is likely to be confounded with laryngeal oedema (Plate VII), 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, 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 character of the voice in paralysis is constant, but less noticeable immediately after a night's rest. Paresis in the catarrhal condition more often affects one vocal band than both, ac- cording 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 ami the presence of a tubercular condition of the lungs assist ma- terially in making a differential diagnosis. The impaired nutrition and strength, the temperature and pulse, the night-sweats, and painful and difficult swallowing are characteristic of tuberculosis, but not of chronic laryngitis. The intralaryngeal pictures show certain dif- ferences in the two diseases. While redness is a symptom of catarrhal iT8 TREATMENT OF CHRONIC LAEYNGITIS. inflammation, the membrane in tuberculosis of the larynx may pre- sent a bloodless appearance, especially in the initiatory stage of the disease. Erosions, rare in simple catarrh, are characteristic of the tubercular 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 VII), affecting the epiglottis, the posterior commissure, the ventricular bands, and the vocal cords. The polypoid conformation of the arytenoid car- tilages produced by the great thickening in advanced cases is well illustrated in the plate to which reference is made. This swelling extends to the aryepiglottic folds and appears dense instead of cedema- tous, although the paleness of the membrane may be suggestive of a case of oedema. Syphilis of the larynx (Plate YIII) may closely simulate 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 spe- cific remedies in experimental diagnosis are determinative in syphilis. In both tuberculosis and syphilis of the larynx characteristic lesions in the pharynx may help greatly in arriving at a correct con- clusion. Chronic laryngitis may be with difficulty distinguished from a malignant disease, at first, but the histories of the two conditions vary. In the early stage of malignant disease the red, tumefied ap- pearance is limited to a certain area instead of being diffused over a large surface. As the neoplasm increases in size it changes the con- tour 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 outlook is favor- able. 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 accomplished all it will, the voice may still retain a coarse, unpleasant quality. Treatment. — The topical application of remedies is easily accom- TREATMENT OF CHRONIC LARYNGITIS. 479 plislied with the improved apparatus of our day. Compressed 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 treatment. Improved appliances for com- pressing air, both by hand and hydraulic power, are described in Chap- ter IV. Various medicated sprays — as recommended by Lennox Browne, E. L. Shurly, Charles E. de M. Sajous, and others — will cleanse and disinfect the larynx, as well as produce astringent, sedative, stimu- lant, or tonic effects. It is claimed by Eoe 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 properly-curved extremity (Figs. 127 and 128) for directing the current downward and a little forward from a Fio-. 213. — Laryngeal cotton foiveus. position similar to that occupied by the laryngeal mirror in situ, the spray enters directly into the larynx. When the nebulizer is used with the lips closed over the mouth-tube and the patient inhaling through the instrument, the medicinal vapor not only reaches the laryngeal cavity, but the bronchi and lungs also. In former years I used the complete steam-atomizer of Codman & Shurtleff, but. as I could not discover compensating advantages of the steam method over the improved apparatus referred to, and as the latter requires far less time and trouble in giving treatments, I have for a consider- able time preferred the instruments described. Eor the application of pigments to the laryngeal membrane spe- cial camel's hair brushes, sponges, and cotton are used. I prefer the cotton, either twisted firmly on a holder or used with Cohen's laryn- geal cotton-forceps (Fig. 213). The bristles of the brush sometimes become detached and stick in the larynx, like the voice of JEneas. This is not amusing to the patient. Applicators for caustics are spe- 480 ATROPHIC LARYNGITIS. cially 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 some- times serviceable. They should be applied to the skin directly over the larynx and at its sides. It is exceedingly important that 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 com- pound spirit of chloroform or Hoffmann's anodyne will relieve the irritation. The inhalation of camphor-menthol from the pocket-in- haler (Fig. 141) allays the tickling sensation. When the thickening of the membrane 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 copious 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, hyclrozone, diluted one-half with warm water, at first, should be sprayed upon the ulcers; then aristol should be sprinkled over them. Iodoform is preferred by some, tannin and alum by others. Chromic acid, 5 or 10 grains to the ounce, and silver nitrate have able advocates. Atrophic Laryngitis. For the pathology of atrophic conditions of the mucous mem- brane, see "Atrophic Khinitis." This requires stimulating applications. The lavolin-sprays con- taining the 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 ammonium-chloride tablets, the formula of which will be found on page 339. 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 wth the mucous membrane about the entrance to the larynx as long as possible. suppukative laryngitis. 481 Suppueative Laryngitis. Synonyms. — Phlegmonous laryngitis; purulent laryngitis; dif- fuse abscess of the larynx. Pathology. — This is an inflammation of the submucous tissues of the larynx (Plate VII), 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 a perichondritis which is secondary to syphilitic infection or other wasting disease. Symptomatology. — Difficult respiration and impairment or sup- pression 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 ex- aggerated; the breathing is strident, the voice feeble and cracked, the face puffed and purple, and suffocation seems imminent. Fre- quent attempts are made to free the throat by hemming rather than by coughing. Laryngoscopy reveals the inflamed, tumefied mucous membrane obstructing the air-current. Circumscribed swelling may be seen in the region of the aryteno-epiglottic folds, and other parts of the larynx may become (Edematous. Diagnosis. — Inspection discloses the differences between this dis- ease and the presence of foreign bodies, diphtheria, croup, tumors, pharyngeal abscess, and spasmodic croup. The dyspnoea of this dis- ease appears more gradually than that occasioned by the presence of foreign bodies or laryngismus stridulus, in which the obstruction to breathing occurs suddenly. The history of a tumor does not pre- sent 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 attack, cold, in the form of ice-bags (Fig. 83), 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 482 (EDEMA OF THE LARYNX. 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 inevitable fail- ure of strength. Suffocation must be prevented by tracheotomy or intubation. Abscess oe 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 tanta- mount to tautology. The treatment is the same as for abscesses oc- curring in suppurative laryngitis. Trachoma oe the Vocal Cords. As a result of chronic laryngitis of long duration, a roughened condition of the vocal bands is found, to which the name "chorclitis tuberosa," or granulations, is sometimes applied. There is a prolifera- tion 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. F. I. Knight claims that the granulations may disappear without treatment. Treatment. — The remedies recommended for chronic laryngitis are applicable here. Charles E. de M. Sajous advises applying chromic acid to the cocainized hypertrophies. This is best accomplished by fusing the acid on a protected applicator, bent to the proper curve. Only a few of the prominent points should be touched at each treat- ment. Silver nitrate is preferred by Eice and Cohen, and the curette by Heryng. The biting curette (Fig. 214) or the electrocautery may be adapted to certain cases. The writer prefers the electrocautery, but has employed the chromic-acid and silver-nitrate beads with satis- factory results. (Edema of the Larynx. Synonyms. — (Edematous laryngitis; purulent laryngitis; oedema glottidis. (EDEMA OF THE LAEYXX. 483 Pathology. — The loose attachment of the mucous membrane to the walls of the larynx favors infiltration and separation of the mu- cosa from the cartilages (Plate VII). The changes that take place in acute (Edematous inflammation occur so rapidly 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 exudate than any other portion of the larynx, and the ventricular bands suffer nearly as much. The true vocal bands may escape alto- gether or participate to the degree of slight swelling. The laryngeal muscles may present a water-soaked appearance if a post-mortem ex- amination is made, after death due to this disease. Associated with oedema of the larynx may be a similar infiltration of the pharynx and even of the neck. Etiology. — Most cases of laryngeal cedema 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 symptomatic. Xearly 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 "contiguous oedema"; and when laryngeal oedema is secondary to some other disease of the larynx it is designated as con- secutive. Any cause that operates to produce inflammation of the lar- yngeal mucosa or submucosa may be a cause of cedema. Exposure to cold or impure air containing irritating particles or gases, injuries, scalds, corroding chemicals, and certain diseases cause or predispose to this disease. Such affections as Bright's disease, syphilis, tuber- culosis, and typhoid and the eruptive fevers. Symptomatology. — The prominent and most distressing symp- tom 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. 4:84: (EDEMA OF THE LAKYNX. Frequent efforts are made to clear the throat of the obstruction, but they are not of the character of a cough. There is but little expectoration, and this consists of mucus. The suffering occasioned by this disease is intense, not only of the patient, 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 par- oxysm 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 agonizing 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, palpation with the finger, not interrupting respiration to a dangerous degree, may enlighten the examiner as to the condition present. The roll- like character of the epiglottis and the spongy feeling of the aryepi- glottic folds are characteristic. Diagnosis. — (Edema of the larynx may be mistaken for the pres- ence of foreign bodies, polypus, retropharyngeal abscess (Plate V), acute laryngitis (Plate VII), or pulmonary emphysema. The symp- toms 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 gen- erally found in the pharynx also. Prognosis. — About one-half of all cases of this disease terminate fatally. Acute laryngeal oedema has an average duration of about a week. Cases arising in the course of pharyngeal oedema generally pursue a favorable course, but those resulting 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 TREATMENT OF (EDEMA OF THE LARYNX. 485 the syphilitic type is amenable 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. Pilocar- pine depletes the blood-vessels of their serum and is indicated here to drain the water-soaked tissues. It can be given in closes of 1 / 8 or Vie g' r ain until free salivation and diaphoresis are produced. Enough to cause heart-depression should not be administered. In violent acute cases the blanching, shrinking, and anaesthetic 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 suffoca- tion 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. Dilata- tion 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 XLI. DISEASES OF THE LARYNX, CONTINUED. Leukoses. spasmodic ckoup. Synonyms. — Spasm of the larynx; spasm of the glottis; laryn- gismus 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 food 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 complete 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 incom- pletely closed, the air passes through it with a harsh, croupy sound, which resembles closely the crowing of croup or the whoop of whoop- ing-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 be- tween the attacks. They occur usually at night, waking the child out of a sound sleep. They are not accompanied 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 (486) NEUROSES OF THE LARYNX. 487 than girls. Those whose systems are impoverished are the most likely to suffer. In this respect spasmodic croup differs from true croup. Diagnosis. — Spasmodic croup does not closely resemble any other disease except true croup, from which it can be differentiated by the absence of fever and false membrane and by the presence of good health as soon as the transitory paroxysm yields and normal respira- tion succeeds. Prognosis. — When the attacks do not show a high degree of in- tensity 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 complete 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 owed to cerebral 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. Hypodermic 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 teaspoonful doses is a harmless and efficient emetic. The cause of the attacks must be ascertained and prophylactic measures adopted. Laryngitis, indigestion, troublesome teeth, or irritation of the genital organs, especially of the prepuce, 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 paresthesia of the larynx are most commonly met with in singers and public speakers who strain their vocal organs. Pathology. — Congestion of the laryngeal mucous membrane is often present, but inspection may not reveal any apparent structural 488 TKEATMENT OF ANOMALIES OF SENSATION. change; this is true when the affection is purely of a neurotic char- acter. Etiology. — Excessive use of the voice after faulty methods, over- indulgence in alcoholic beverages, excessive smoking, varicose veins and hypertrophied glands at the base of the tongue, and inflamma- tory affections of the larynx occasion hyperesthesia. 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 inflammatory 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 often ex- quisitely 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 tickling in the larynx that excites hemming or slight coughing to give relief. Neuralgia here, as elsewhere, is not constant. Fugitive 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. Pa- tients 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 generally fails to discover any physical signs. The symptoms are quite character- istic. Prognosis. — These troubles are rather annoying than serious. They are persistent, but amenable to treatment. Treatment. — If any irritation is found, the throat-tablets — con- taining ammonium chloride, 1 grain; camphorated tincture of opium, compound syrup of squills, and syrup of Tolu, each 5 minims; and extract of licorice, 3 grains — may allay the irritation and cough. In- halations of oil of cubebs, carbolic acid, salol, and eucalyptus in lavo- lin, as described under the heading of "Sprays and Inhalents," are beneficial. When hypertrophied glands and varicose veins are found in the pharynx, and especially about the base of the tongue, they are to be eradicated by means of the cautery. The bromides and other nervous sedatives and nervous stimulants, like valerianate of ammonia, are demanded in certain cases. General tonic treatment is often necessary, combined with a fattening regimen. W. Peyre Porcher emphasizes the fact that the lithic-acicl di- NERVOUS APHOXIA. 489 athesis may stand in a causative relation to these neuroses, and that such cases must receive antirheumatic treatment, including colchi- cum, salol, guaiac, the salicylates, etc. NERVOUS APHOXIA. 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 relations 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 debili- tating 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 pa- tient may not be able to utter the common conversational tone, but may cough or laugh audibly, which does not occur in complete pa- ralysis. 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 whispering is sometimes out of the question. The attacks are irregular, appearing one day and disap- pearing the next, without any 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 re- lationship. Efforts to approximate them may cause a spasmodic ap- proaching of the cords, followed immediately by their wide separation. Unless a catarrhal condition exists, the larynx is pale and presents no inflammatory appearances. Diagnosis. — The history, symptoms, and appearances described 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 vari- ous sorts of "mind-cures" are effective. The mental impression made by simply introducing any indifferent instrument, such as a laryngeal 490 REFLEX AFFECTIONS OF THE VOICE. mirror, into the throat may restore the voice. In other cases actual treatment must he pursued for a considerable time to effect a cure. Treatment. — Strychnine, beginning with 1 / 30 grain and increased gradually until its physiological effects are produced, and electricity are efficient remedies. Sir Morell Mackenzie devised a laryngeal elec- trode for this purpose, by means of which one electrode is applied within and the other without the larynx. The galvano-faradic cur- rent 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 diffusive nervous- stimulant, meets the indication admirably. Zinc valerianate in 1- grain closes every four hours is recommended by Sajous, as well as coca-wine. EEFLEX AFFECTIONS OF THE VOICE. The condition of the vocal cords is affected by certain states of the generative organs. Singularly enough, the same causes seem to produce opposite effects in different subjects. The author has ob- served that in some soprano singers the occurrence of the menses is accompanied by a huskiness, or roughness of timbre, of the voice;, but in others the same periods are characterized by a clearer, fuller, and more flute-like quality of tone. However, the latter effect is probably exceptional. Uterine and ovarian diseases have a deleterious- effect on the voice, especially noticeable in the singing voice, and any treatment to restore the voice-deterioration must include gynaeco- logical measures. C. H. Leonard has reported cases in which voices- impaired by uterine disease have been restored, and in one case two full notes were said to have been added to the upper register of a high mezzosoprano as a result of uterine treatment. In the latter case there were anteflexion, narrowing of the uterine canal, and endome- tritis. These facts are not surprising when we consider the close sympa- thetic relations existing between the uterus and the central nervous system. Bischoff has shown that division of the spinal accessory nerve,, or of the inferior laryngeal, causes aphonia. The close relationship of the nervous supply of the sexual organs in the male to the in- nervation of the larynx is aptly illustrated in the unnatural voices of the castrated male sopranos. LARYNGEAL PARALYSIS. 491 LARYNGEAL PARALYSIS. The laryngeal muscles may he paralyzed singly or in pairs, or several muscles may he affected simultaneously. The paralysis may be unilateral (Plate VIII) or bilateral^ affecting only one side or both. Anaesthesia of the laryngeal mucous membrane may exist 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 char- acter, the muscles being affected, either primarily or secondarily, to some debilitating systemic malady. Pathology. — Cerebral causes of paralysis of the laryngeal mus- cles are : the gummata of syphilis, apoplexy, multiple sclerosis, tumors, etc. Diphtheria is one of the most frequent causes, aneurisms in the neck, tumors, progressive bulbar paralysis, hypertrophied 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 result 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 paraly- sis results. The laryngeal muscles may become the seat of disease which, independently of any affection of the nerves, may impair or destroy their function. An extension of the inflammatory action from the mucous surfaces to the muscular tissue, with exudation and swelling, may produce a paretic condition of a transitory nature. Degenera- tive 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, ar- senic, mercury, lead, and alcohol. Such diseases as diphtheria, rheu- matism, 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 to respira- tion. The breathing is noisy and labored, and suffocation is immi- 492 LARYNGEAL PARALYSIS. nent. The voice is not affected because of the action of the aryte- noideus muscle in approximating the vocal bands. When unilateral paralysis of the posterior cricoarytenoid muscle takes place there is no dyspnoea except on great exertion (Plate VIII). When both sides are affected it may be clue 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 cricoarytenoid — results in the vocal cords remaining in a condition of abduction, or separation from each other as far as possible. This occurs most fre- quently in hysteria and leaves no vestige of the voice. If this pa- ralysis is unilateral, whispering may be possible. When paralysis of the arytenoideus muscle happens the voice is very feeble or altogether lost. A triangular space between the vocal cords, behind the vocal processes, remains during phonation in conse- quence 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 thyro- cricoid muscles leaves the vocal cords relaxed and uneven. They may be seen in contact with each other at irregular intervals 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 embarrassed. Paralysis of the thyro-arytenoid muscles prevents approximation of the vocal bands, especially at their centres, so that an elliptical aperture remains be- tween them. 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 jDassively half-way between abduction and adduction, or in the ca- daveric 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 perforin vicarious function, so that the voice is but little TREATMENT OF LARYNGEAL PARALYSIS. 493 roughened in quality; but, unless the power exists to draw the healthy cord beyond the median line to approximate its paralyzed 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. Le- sions 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 laryn- geal mucous membrane, tumors, and rheumatic and syphilitic con- ditions call for treatment adapted to each disease. Drug and chemi- cal poisoning must be met with antidotes, restorative measures, and removal of the cause. Strychnia, internally and hypodermically, to the degree of pro- ducing its physiological effects, is valuable. The faradic current, ap- plied to the interior and exterior of the larynx by the special laryn- geal electrode, is efficacious. If the mucous membrane of the larynx is sensitive it may have to be cocainized 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. Com- pound 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 clays. General tonic treat- ment and appropriate hygienic measures must be employed, accord- ins: to the necessities of each case. CHAPTEK XML DISEASES OF THE LARYNX, CONTINUED. TUBEECULOSIS OF THE LaEYNX. This is one of the most common of laryngeal affections and gen- erally 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 consists in a micro-organism, — the tubercle bacillus, — which gains entrance into the laryngeal tissues by becoming ingrafted upon an area of mucous membrane denuded of its epithelium. Within a few weeks after the development of primary laryngeal 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. Generally the first changes observable in the larynx are: an un- natural paleness and tumefaction of the epiglottis (Plate VII), suc- ceeded by a superficial, ragged-edged ulceration on the posterior sur- face of the epiglottis, as seen in the mirror. Multiple ulcers soon form in other parts of the respiratory tract, extending below to in- volve 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 tuberculosis. These areas of miliary tubercle are easily made to bleed by pressing upon them. The mucosa and submucosa become Infiltrated, sometimes in- volving the mucous glands, and, as the disease advances, caseous de- generation occurs in the tubercles and adjacent tissues. In the acute form 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 (494) TUBERCULOSIS OF THE LABYXX. 495 larynx, and leave the cords unaffected, although the ventricular bands are involved even to the extent of so great tumefaction as to com- pletely hide the vocal cords. Sometimes, however, the latter become thickened to such a degree as to threaten suffocation. The processes of infiltration, caseation of the tubercles, 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 con- tinues until the cartilage itself becomes ulcerated, necrosed, and dis- integrated. As seen in Plate VII, 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 affections, 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 secondary 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 experi- ence. Symptomatology. — The visible pathological conditions already 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. 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. Sometimes 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 sen- 496 TREATMENT OF TUBERCULOSIS OF THE LARYNX. sations 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 pulmonary 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 localized 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 pulmonary consump- tion 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 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 tuber- culosis have this laryngeal complication, which shortens the duration of life. Treatment. — The treatment given in detail for tuberculosis of the pharynx is just as applicable here, and to avoid unnecessary rep- etition 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 preulcerative stage. For pain he uses the ethereal solution of aristol in a spray. Morphia in- sufflations are used in hopeless cases only, but codeia largely, and cocaine before manipulations and in advanced dysphagia. Sprays are better than insufflations of powders. Excepting for relief of TBEATMEXT OF TUBERCULOSIS OF THE LAEYXX. 497 acute dysphagia, lie prefers applications of the tincture-of -benzoin compound, tincture-of-eamphor compound, and tincture of bella- donna 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 curette- ment 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 nour- ishment through a tube from the dish placed below his head. The antitubercular serum of Paul Paquin has been used in a considerable number of cases of tuberculosis with benefit. I have at this date, Xovember, 1897, reports from 369 cases that are of value, besides a large number that have been reported with such a degree of inexactness and indefiniteness that in giving the results it is neces- sary to eliminate them from the records. These ambiguous state- ments appear even more reassuring than the carefully-prepared ones. Paquin has reported 293 cases, with the following results: Recoveries that seem permanent, 57; considerably improved, 38; improved, 121; disappeared from observation, 41; deaths, 36. I have reports of 76 cases to add to the above, giving the total results as follow: Re- coveries, 71; improved, 205; unimproved, 14; disappeared, 41; deaths, 38. Similar results from an oxygenated serum are being reported from San Francisco at the present time, but it is too early to speak judiciously regarding them. Since the beginning of the year 1898 unfavorable reports from the use of Koch's new tuberculin in tuberculosis and lupus of the throat and nose have emanated from Munich, Hamburg, and Prague, although some improvement, rather than any cure, was recorded in the Berlin clinics. When abscesses, growths, etc., produce so great obstruction to respiration as to threaten suffocation, tracheotomy must be done as a last resort. 498 syphilis of the larynx. 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 mucous 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 occurring 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 absorption or ulceration. A sudden infiltration of the mucous and submucous tissues is an occa- sional occurrence, and in this situation is of serious import, since the resulting oedema may impede respiration to the point of strangula- tion. The tertiary stage is characterized by the presence of gummata, which become the seat of ulceration. When the erosions penetrate deeply into the submucosa the invasion of the blood-vessels gives rise to haemorrhages. Following these deep ulcerations are found white, corrugated, contracting cicatrices that lessen the lumen of the cavity by their contractions. Adhesions of adjoining denuded tissues pro- duce the same effect sometimes in a very short space of time. In this manner gross and obstructive deformities of the epiglottis, ven- tricular bands, and vocal cords give rise to a dangerous stenosis of the larynx. In the later stages of tertiary syphilis the laryngeal muscles and cartilages are invaded, with the result of producing paralysis, as well as ankylosis and destruction of the cartilages. 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 SYPHILIS OF THE LARYNX. 499 the larynx are very rarely primary, and they are more frequent in men than in women. Symptomatology. — As will he 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 he impossible to distinguish early between the two unless a spe- cific history can be obtained. But in the syphilitic form of congestion or inflammation the rosy hue of the mucous membrane assumes a comparatively mottled arrangement, which is quite characteristic of this affection. These patches of redness are likely to be elevated above the surrounding surface and to show early evidences of be- ginning 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, occasioning little inconvenience, and accompanied by a muco-purulent expectora- tion. Inspection reveals 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 bilateral when one side of the larynx is involved to a greater extent than the other. Mucous patches are most frequently found on the epiglottis, in the interarytenoid space, and on the ventricular bands. They do not differ in appearances from those described as occurring in the pharynx. Papillomata are occasionally 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 condylo- mata may become absorbed or may ulcerate away. In the tertiary stage the epiglottis is most likely to be first in- vaded by the destructive process, ulcerations generally breaking 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 mu- cous membrane, in the roughened surfaces due to granulation forma- tion, or to papillomata. The ulcers of the secondary stage are super- ficial patches; the ulcers of the tertiary period are deep-seated and destructive. Symmetrical bilateral lesions are characteristic of syphilis. When 500 TREATMENT OF SYPHILIS OF THE LARYNX. an ulcer forms on one side of the larynx one may confidently 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 discharge, which is expec- torated 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, serious haemorrhages may take place. Deformities due to swellings, cicatricial contractions, expulsion of parts of the cartilages, and muscular paralysis occur in the ter- tiary stage. Stenosis and consequent embarrassment of the respira- tion may then endanger life. Diagnosis. — This disease may be mistaken for tuberculosis, and in the early stage may be confounded with a simple catarrhal inflam- mation of the mucous membrane; but the latter yields readily to treatment, while the syphilitic disease progresses uninfluenced 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 syph- ilis have more regular, clearly defined borders, and are deeper than in tuberculosis. The pain of the latter disease, especially in swallow- ing, 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. — 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 dissipate laryngeal syphilitic lesions without the introduction of local treat- ment. 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. TREATMENT OF SYPHILIS OF THE LARYNX. 501 The use of the voice, alcoholic stimulants, and tobacco must be interdicted, and in the secondary manifestation 1 / 16 grain, or even more, of the bichloride of mercury may be given thrice daily. If the green iodide is employed, 1 / c grain may be used. Inunctions of mer- curial 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 sur- faces. 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 re- sults. I have generally prescribed the mercuric bichloride, 1 / 16 grain, and the potassium iodide, 5 or 10 grains, to be taken three or four times a day in 1 drachm of syrup of sarsaparilla, well diluted. 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 J s favorite topical application consists of cupric sulphate in crystals or in solu- tion, or chromic acid, 1 part in 1 or 10 parts of water. Nosophen and aristol may be dusted over the ulcers with the throat powder-blower (Fig. 198). 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 res- piration is considerable, the aponeurotic membrane and other ad- ventitious tissue must be incised or removed (Fig. 214), or they can be divided and destroyed by means of the galvanocautery. When ex- treme stenosis threatens suffocation, intubation 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. CHAP-TEE XLIIL DISEASES OF THE LARYNX, CONCLUDED. TUMORS. For convenience of description, tumors of the larynx are con- ed tumors. sidered under two main headings, — "Innocent" and "Malignant 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, inhalation of air con- taining much dust, especially of a metallic nature, etc. PAPILLOMATA. Papillomata are more common than any other form of tumors of the larynx (Plate VIII) . They present widely-differing variations in size and physical appearances. They may be white or a light-red color, and the size of a bean or less, sessile and rough, single or multiple. Others resemble gray warts, springing from the vocal cord like little cones. These are most common in adult life. Children or young people are often subject to laryngeal papillomata, which assume a multiple form comparable to the raspberry or miniature cauliflower. They are rapidly regenerated after being removed. Indeed, all of these varieties may recur; but they may be very slow in returning, or they may not be reproduced at all. Papillomata develop, not only on the vocal cords, but on the ventricular bands, and on the aryepiglottic folds, and they may attain to such numbers or size as to occlude a view of the cords, interfere with respiration, and stifle the voice. A guarded prognosis must be given when a papillomatous growth is found on one side and above the cord, or upon its margin in elderly people, since it is suggestive of laryngeal cancer. FIBROMATA. Fibromata usually develop near the anterior extremity of the vocal cord (Plate VIII). These tumors vary from a gray to a deep- (502) PLATE VIII PLATE VIII. Figure 22. — Syphilitic infiltration of the arytenoid cartilages and the right vocal cord; gummata of the right half of the epiglottis. Figure 23.— Tertiary syphilitic ulceration of the epiglottis and the right aryt- enoid cartilage; great thickening and congestion of the epiglottis and of the aryt- enoid cartilages. Figure 24. — Pachydermia laryngis; the growth springing from the posterior portion of the left vocal cord, causing a corresponding depression in the right cord. Figure 25. — Pachydermia of the larynx; twin tumors springing from the poste- rior portions of the vocal cords; the convex surface of the left growth fits into a corresponding depression in the right. Figure 26. — Pachydermia laryngis located in the interarytenoid space. Figure 27. — Papilloma growing from the anterior portion of the right vocal cord, preventing close approximation of the cords in voice-production. Figure 28. — Papilloma of the left vocal cord, presenting an appearance sug- gestive of a raspberry. Figure 29. — Multiple papilloma of the larynx completely covering the vocal cords. Figure 30. — Fibroma of the right vocal cord producing hoarseness and, finally, aphonia. Figure 31. — Carcinoma of the larynx, ulceration and necrosis of the left aryt- enoid cartilage, and paralysis of the left vocal cord. Figure 32. — Unilateral paralysis of the adductors of the left vocal cord, as seen during an effort at voice-production. Figure 33.— Unilateral paralysis of the left abductor, as seen in forced inspira- tion. The left cord is in the cadaveric position. PLATE VIII 27 29 PACHYDERMIA LARYXGIS. 503 red color, and they may be attached by a broad base or by pedicles. They are generally solitary, and present a smooth surface, but when a large size is attained they may become lobnlated. Their size varies from that of a small pin-head to a pea, or, indeed, they may fill the larynx; but such an enormous development is seldom seen. When touched with an instrument they impart the feeling of a firm, dense tissue. Their removal is followed by more satisfactory results than obtain after operations on other tumors of the larynx, for they do not often reappear. PACHYDERMIA LARYXGIS. Virchow and Frankel were among the first to describe a thick- ening of the mucous membrane covering the free edges of the vocal cords and lining the interarytenoid space, and especially in the region of the vocal processes (Plate VIII). Pathology. — There is a great increase in the thickness of the epithelium, and in the number of papillae, and horny changes in the outer cells. The tendency is to the formation of oval tumors, and when they occur on the vocal cords there are frequently two seated opposite each other. In this case the apex of one fits into a depres- sion in its fellow. The interarytenoid pachydermia is not so often seen as the growths upon the cords. The color is whitish gray, or possibly pink. Etiology. — Pachydermia is found more often in middle-aged men than in women, and they are probably caused by excessive use of the voice, tobacco, and alcohol. Symptomatology. — There are huskiness of the voice, sensations akin to a foreign body, possibly dull aching, and even labored breath- ing and painful swallowing. The neoplasms may attain to so large a size as to suppress the voice. In such cases the tumors assume a pink color. Diagnosis. — The symptoms are generally much less pronounced than in malignant disease. The interarytenoid growth is suggestive of tubercular infiltration, but the latter is more clearly defined, is of a deeper-red color, and produces more disturbance than the former. Moreover, pachydermia more often occurs in the form of symmetrical, or twin, tumors on some part of the free margins of the vocal cords. The unilateral form of this tumor, known as singers nodule, might be mistaken for a fibroma. Pachydermia is found most frequently on 501 LARYNGEAL TUMORS. the posterior portions of the vocal cords, while cancer occurs on the anterior parts generally. Prognosis. — The outlook is favorable to life, but unfavorable in respect to the voice, when the growths occur on the vocal cords. When they are situated in the interarytenoid space the vocal func- tions may not show impairment. Treatment. — Measures should be first addressed to the correction of any catarrhal conditions that may be present, along the lines already laid down in the previous pages. In addition to local treatment, potas- sium iodide should be administered in moderate doses. When the voice is affected, strong astringents, such as a 10-per-cent. solution of silver nitrate, may be applied, or the electric cautery may be resorted to. If the tumor is of sufficient size to permit grasping it with in- struments, it should be crushed by the biting-forceps (Fig. 214). In a discussion on this subject before the Twelfth International Medical Congress in Moscow, August, 1897, Heryng spoke of the operative treatment of the vocal cords affected by a pachydermatous condition resulting from repeated attacks of catarrh. He remarked that "it was not the beautiful pearly-white cords that produced the finest voices, this pearly whiteness often being produced by numerous layers of thickened epithelium. Some of the best singers had dis- tinctly red, catarrhal-looking vocal cords; for example, Jean de Keszke's vocal cords were slightly red before, and very red after, sing- ing. One should be in no hurry to treat a singer's larynx in any radical way." He especially warned young laryngologists to be ex- tremely careful in their dealings with singers. It is easy to under- stand why pachydermia is frequent among them. They are exposed by the nature of their calling to frequent catarrhal attacks; they are prevented from obtaining proper treatment for each attack; they are compelled to sing whether it prove detrimental to their voices or not; and, although overindulgence in eating, drinking, and smoking are destructive to singing voices, "nearly every singer smokes too much, eats too much, and drinks (alcoholic beverages) too much. By these means a slight catarrh or cold easily becomes chronic, and proceeds to produce pachydermia." (Medicine, March, 1898.) MISCELLANEOUS. Other very rare specimens of growths may be found in the larynx. Polypoid excrescences, such as mucous polypi, or myxomata, some- times make their appearance in the vicinity of the anterior com- LARYNGEAL TUMORS. 505 missure. 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. Vascular, fatty, and cartilaginous tumors are so very seldom met with as to require a description in exhaustive works only. The symp- tomatology and treatment are the same for these as for laryngeal tumors generally. Symptomatology. — The symptoms are those characteristic of ob- struction to respiration, phonation, and deglutition. Respiration 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. Wjth the increase in the bulk of the tumor, difficulty in respiration increases until it may end in asphyxia, unless relief is afforded. The voice may not be impaired if the tumor is situated 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 clamper, impeding the movements 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 growths. 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 posterior 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 accumula- tions 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 be- nign tumors seldom complain of suffering pain. Prognosis. — So far as the question of life is concerned, one is able to give a favorable prognosis in the case of an innocent laryngeal neoplasm. Should the growth reach such proportions as to render death imminent by asphyxia, tracheotomy will avert a fatal termina- tion. If the tumor be not removed by an endolaryngeal operation, thyrotomy in ay lie resorted to, although the effect on the voice is 506 TREATMENT OF LARYNGEAL TUMORS. better in endolaryngeal operations, more especially when the tumors are readily accessible and pedunculated. As has been already re- marked, there is a strong tendency to regeneration of the growths after operations for the removal of papillomata. Treatment. — There are numerous methods for the removal of tumors of the larynx. Forceps, knives, and curettes (Fig. 214) have been devised for this purpose. Snares, the galvanocautery, and caus- tics 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 Fig. 214. — Tobold's set of six forceps, knives, etc. the flexible applicator (Fig. 71) and accurately applied to the surface of the growth. Silver 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 in- struments in the larynx, the operation is done by the aid of the laryn- geal mirror, so that every movement and the relations 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 move- ments 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 firm MALIGNANT TUMORS OF THE LARYXX. 50? a grip upon the tumor as Mackenzie's instruments. Much care must be exercised that a tumor once severed from its attachment does not drop back into the larynx as it is being removed. Evulsion of laryn- geal tumors is preferred by some operators. For this purpose the strong forceps of Mackenzie afford a firm grip upon the growths (Figs. 199 and 215). These instruments are used without great difficulty if the larynx is properly anaesthetized. This is accomplished if the co- caine solution is applied two or three times at intervals of five min- utes. The benumbing effect of cocaine in the larynx is very transi- tory, not extending over ten minutes, so that operative measures must not be prolonged without renewed anaesthesia. When operating in the larynx, one ought always to have his Mackenzie's anteroposterior laryngeal forceps. tracheotomy instruments at hand, for instances have occurred in which spasm of the glottis has immediately followed the procedure, 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. Malic xaxt Tumors. Malignant growths of the larynx are not uncommon. They may be classed as carcinomata and sarcomata. 508 LARYNGEAL CANCER. CARCINOMATA. These are commonly known as cancers (Plate VIII), 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 malig- nant growths, two hundred and four were cancers and one hundred and thirty were sarcomata. There is considerable variation in the nomenclature of this sub- ject. Browne treats of cancer under two headings: "Epithelioma" and "Alveolar Epithelioma" (adenoid, scirrhous, or encephaloicl can- cer). These growths may occur as primary diseases of the larynx or they may result from an extension to this organ from adjacent tissues. Pathology. — The existence of epithelioma cannot be determined positively by the mere evidence of a microscopic examination that there is a proliferation of epithelium and cell-nests. It is settled that the process is of a malignant character only when the epithelial pro- liferating process invades the underlying connective tissue, and its infiltrating nature is established. The disease more often originates on the ventricular bands than on the vocal cords. In the early stage of cancer the tissues present an hypergemic and indurated appearance, which gradually extends to the surrounding structures. The thick- ening increases irregularly until a more or less well-defined tumor results; the enveloping membrane softens, breaks down, and the stage of ulceration is established, with its wide-spread destruction of the parts involved. Excision of a deep portion of the growth may be made for a microscopic examination. Etiology. — Heredity is an important etiological factor, and any occupation or habit that excites a constant irritation of the tissues, according to Virchow, may result in converting an innocent neoplasm into a malignant growth. Cancers usually do not occur before 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 aryepiglottic 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, interfering with their functions, the voice is altered accord- LARYNGEAL CANCER. 509 ing to the muscles affected. Hoarseness may exist from near the be- ginning of the growth, and later the voice may be entirely lost. In the intrinsic form not only the voice, but respiration, is em- barrassed. 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 deg- lutition is present, especially in the extrinsic variety of tumor. 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 ears. So con- stant and conspicuous a symptom is the involvement of the ears 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 "cancerous 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 granular proliferation of the 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. As the disease advances the destructive process becomes so great as to cause abscesses; the cartilages are at- tacked, and portions of necrosed cartilage are loosened and expecto- rated; haemorrhages occur; the breath is foul; the larynx becomes constricted, and, unless surgical interference be resorted to, death ensues. Diagnosis. — Laryngeal cancer is not always easily distinguished from other affections in which there is tumefaction or ulceration. In chronic hypertrophic laryngitis and in pachydermia laryngis the hyperaemia and thickening of the mucous membrane simulate the early stage of cancer, but in the former diseases we will note the ab- sence of pain, ulceration, infiltration of the cervical glands, and the microscopical appearances. However, it should not be overlooked that a microscopical examination of a section of a tumor may show that the portion removed is non-malignant, while it does not prove that the whole growth is benign. The author could cite repeated instances in which many careful microscopic examinations have been made by different bacteriolo- 510 LARYNGEAL CANCER. gists, when their conclusions were not borne out by the ultimate clinical results. So frequently are the histological evidences, inter- preted by the microscope, negative in character, it is all the more incumbent on the clinician to exercise the utmost patience and skill in determining the differential diagnosis. In this connection it is interesting to recur to the discussion on this subject which took place at the meeting of the Twelfth Inter- national Congress, at Moscow, in August, 1897. Chiari reported 70 cases of carcinoma laryngis occurring under his own observation. Comparing the clinical with the microscopic diagnosis, he maintained that, when the clinical evidences favored a diagnosis of cancer, a negative microscopic examination was not to be considered; whereas, positive microscopic evidences obtained by a thoroughly competent microscopist must outweigh clinical evidences to the contrary. Hajek claims that intrinsic and extrinsic carcinomata of the lar- ynx are to be put into two totally separate categories, the former being- much milder in its course than the latter, on account of the very poor supply of lymphatics to the larynx. Carcinoma on the poste- rior wall of the larynx is rare; when occurring at that situation it is difficult to diagnose. Pachydermia, as a rule, occurs on the poste- rior parts of the vocal cords, whereas cancer occurs on the anterior portions. Pachydermia is almost always bilateral, but cancer is uni- lateral. "The lazy, limited movement of the vocal cord, so much spoken of in cancer, is hardly a trustworthy symptom, because it is often absent in cancer and present in pachydermia. Much more valuable is the fact that pachydermia appears, on laryngeal examina- tion, to be a growth on the vocal cord, while a commencing carcinoma does not appear as a growth at all, but rather as an indefinite thick- ening of the cord itself, of which one cannot say where it begins and a healthy cord ends." (Medicine, Januar}^ 1898.) From papilloma, cancer may be distinguished by the facts that these warty growths occur in early life, as a rule, while carcinoma is usually found in persons past middle life. Papilloma is a more clearly defined tumor, while cancer presents an irregular infiltration and thickening. The cancerous cachexia and pain, also, are to be remem- bered as characteristically distinguishing features. If the cancer be extrinsic, enlargement of the lymphatic glands in the vicinity may be found. In tuberculosis of the larynx there are the characteristic cough, pulmonary complication, history of consumption, lighter color, and TREATMENT OE LABYXGEAL CANCER. 511 less swelling of the tissues preceding ulceration. After ulceration sets in it is not likely to erode the tissues as deeply as cancer does. The absence of the bacillus of tuberculosis is only negative bacte- riological evidence, for the author has watched the destructive process do its deadly work through long, weary months to a fatal termination, while various microscopes and bacteriologists utterly failed to dis- cover a single bacillus. From syphilis it is sometimes difficult to distinguish epithelioma, especially from the gummatous stage of the former. Gummata, how- ever, ulcerate early in most cases. The question is simplified if the history be obtainable. Comparing the ulcerative stages of the two diseases, it is not an easy problem to solve. Xow comes the most reliable test. If it be syphilis, the exhibition of the iodides will cause a progressive clearing up of the symptoms, which, moreover, con- tinues; while, in the case of cancer, although there may be a per- ceptible improvement for a short time, this benefit is soon lost and the patient retrogresses in spite of the iodides. But the syphilitic increases in weight, and shows a general improvement as well as marked mitigation of the local symptoms. From innocent growths it may be exceedingly difficult to dif- ferentiate cancer in its early history, but the manifestations of the cancerous tumor are more pronounced than those of non-malignant neoplasms. The pain, age of the subject, and the appearances of the various tumors already described, taken with the history of the case, will form a group of facts that will tend to the formation of a cor- rect diagnosis. 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 epithelioma. The results of tracheotomy are more favorable than those of thyrectomy or thyrotomy. Xo operation cures; starvation, haemorrhage, or as- phyxia ends life. Treatment. — By certain methods of treatment life may be pro- longed 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 production of euthanasia, cancer of the larynx is that 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. Xo 512 SARCOMATA OF THE LARYNX. words can depict the agonies of these coughing, choking, strangling sufferers. Local anaesthetics and anodynes must be added to detergents 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. Chloroform and belladonna liniment may be employed for ex- ternal applications. Steam-inhalations containing conium and ben- zoin 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 im- pending suffocation, and may prolong life for several months. In October, 1895, Eoswell 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." Op- erations within the larynx are deprecated by some authorities: Browne and Newman. Oalvanocauterization produces only temporary benefit. Tracheotomy offers the greatest promise of relief from suffocation and may prolong life from two to four years. Chiarf's best results have been obtained from an operation, laryn- gofissure, when it is required to excise a vocal cord or false cord only. "This method, which is not attended by danger, insures a good voice and respiration, and it obviates the necessity of wearing a tube." It is only for intrinsic carcinoma that partial or total resection should be practiced. Ivrause maintains that the results from laryngofissure are not often permanent, recurrence taking place some time later. In fourteen of his cases treated by total extirpation of the larynx there was but a single death. In these cases the new method was employed in which the end of the trachea is stitched to the skin. This closes the communication of the trachea with the throat by stitching the mucous membrane, and by the use of tampons. SARCOMATA. These are very rare tumors of rapid growth, and attain to a large size. Their appearances differ widely, sometimes resembling fibromata or papillomata. Only a microscopical examination can give a positive diagnosis. They do not kill as quickly as epithelioma does, but are destructive of life sooner or later. They should be removed by some FOREIGN BODIES IX THE LARYNX. 513 of the methods already described for the extirpation of other tumors. Max Toeplitz reports a case of chondrosarcoma cured by intralaryn- geal operation. Foreign Bodies in the Larynx. During inspiration while eating or in the act of laughing for- eign bodies are drawn near or into the larynx, where they find lodg- ment. Lefferts reported a ease in which a brass watch-ring became imbedded so as to rest astride the aryteno-epiglottic fold and ventric- ular band, where it remained four years. Symptomatology. — The presence of any foreign body in the larynx excites most violent coughing and symptoms of strangulation. If the body is of such a size and contour as not to completely fill up the lumen of the canal, breathing may proceed until the reflex spas- modic efforts at dislodgment succeed in expelling the body. When the entrance to the larynx or the glottis is completely obstructed, suf- focation 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 oedema 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 some- times 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 a serious lesion of the mucosa. Treatment. — The finger can sometimes be made to reach and dis- lodge the body if it is 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 expiratory effort. Gravity may be brought into play in case of a foreign body with some material weight. The pa- tient 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 suffi- ciently 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 514 FOREIGN BODIES IN THE LARYNX. laryngeal forceps of Tobold (Fig. 214) or Mackenzie (Figs. 199 and 215) may be made to grasp and extract the offending invader. If failure attend the attempt to extract the foreign substance, 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. CHAPTER XLIV. LIFE-INSURANCE AFFECTED BY DISEASES OF THE EAR, NOSE, AXD THROAT. Theee are certain diseases of the ear, nose, and throat that would unquestionably deter any competent examiner for life-insurance from accepting risks in which they were involved. Such diseases, for exam- ple, are lupus, carcinoma, cholesteatoma, and tuberculosis. Tertiary syphilis, especially when the middle ear or the larynx is invaded, would be a valid cause for rejection of a candidate for life-insurance. This disease, on the one hand, may invade the labyrinth and even the more vital structures in the cranial cavity, or, on the other, its ex- istence in the larynx threatens the deeper tissues, endangering life by strangulation from an exfoliated necrosed cartilage or by a final stricture of the larynx. There are other diseases in respect to which there may be an honest difference of opinion as to their vitiating effect upon the ap- plication for insurance, and it is more particularly such as require a special knowledge and practical experience that we will consider. The external ear is occasionally the seat of pathological condi- iions that are apparently innocent in their incipiency, although they pursue a steady course to the development of a malignant disease with a fatal termination. A person may complain of nothing extraordinary relative to the ear beyond insignificant sensations of uneasiness and itching at some point which is slightly more prominent than the sur- rounding surface. Close examination may reveal a little thickening of the integument, possibly an abrasion produced by scratching. These points are easily overlooked by one who is not alert to the fact that lupus and carcinoma have their beginnings in such unsuspicious symptoms. Moreover, the patient's habit of scratching a given point and the resulting irritation may, according to Yirchow, convert a benign neoplasm into a malignant growth. AVe may pass over the subject of acute inflammatory conditions, since no examiner would be expected to accept such risks. The effect of a chronic dry catarrhal inflammation of the middle ear on life-insurance is a question of considerable interest. Experience has demonstrated that persons who are afflicted with such a disease (515) 516 LIFE-INSURANCE AND EAR, NOSE, AND THROAT DISEASES. generally enjoy immunity from acute inflammatory attacks, and from suppurating processes in the middle ear. We very rarely observe a case in which an acute inflammatory action or a suppurating process supervenes upon a chronic non-suppurative inflammation of long standing. But another important question relates to the possibility of life being shortened, not by the disease itself, but by accidents that are rendered more liable to occur by reason of the impaired hearing which the disease produces. Occasionally it happens that a person is run over by cars or other vehicles in consequence of an inability to hear their approach. There can be no sincere difference of opinion with respect to the greater liability to injury or death from such causes among those who suffer from a high degree of deafness; but many of this class are gifted with a compensating acuteness of vision and a quick, high order of intelligence which counterbalance their hearing-defect to a large extent. It is evident, then, that the ex- aminer should estimate, not only the amount of impaired hearing, but should also take into account the keenness of sight and the in- telligent alertness of the person. If he be dull mentally, slow to see, think, and act, he may be expected to become the easy victim of a careless driver or engineer; but if he possess an active muscular sys- tem well under the control of a vigorous mind, supplemented by nor- mal vision, he may be relied upon as being quite capable of taking care of himself. Furthermore, a distinction must be made between the hyper- trophic or secretive form of dry catarrh of the middle ear, and the adhesive or sclerotic form. Although the former may be but a pre- cursor of the latter, in itself it is a much milder disease and is sus- ceptible of far more brilliant results from treatment. One may have the first, or milder, form for many years without suffering the ex- tinction of a large proportion of his hearing; but sclerosis causes a great loss of the hearing power. Chronic suppurative inflammation of the middle ear in an ap- plicant for life-insurance, aside from the resulting deafness, is a subject that cannot be lightly passed over. Examiners appear to ex- ercise especial care in such cases. The author has observed repeatedly that life-insurance examiners have insisted that persons with dis- charging ears must have the suppuration cured before their applica- tions would be accepted. At the present time a patient has just complied with an insurance examiner's requirement that he present a statement from the writer certifying that the suppuration of his mid- LIFE-INSURANCE AND EAR, NOSE, AND THROAT DISEASES. 517 die ear had been cured, notwithstanding the fact that it had ceased a year ago, and the ear had remained well ever since. In another instance an examiner refused to accept an applicant for life-insurance because he had a chronic suppuration of the middle ear, but stated that the application would be favorably acted upon if the ear were cured. Examination revealed granulations, necrosed ossicles, and carious tympanic walls, causing a foul discharge. The writer removed the granulations and ossicles and curetted the carious bone; a cure resulted and the patient secured his insurance-policy. That the insurance examiner's judgment was sound is evidenced by the fact that such, cases tend strongly toward mastoid involvement, and that the patient still remains well after the lapse of six years. These instances are fair examples of the care and intelligence mani- fested by the medical examiners in protecting their companies against loss. On account of the vast possibilities of damage from suppuration of the middle ear it becomes a matter of the highest importance to the insurance companies. While the disease is easily curable if treated properly in its early stages, if neglected it not only jeopards the general health, but imperils life itself. The mucous membrane lining the tympanic cavity, which is the structure inflamed, serves the double purpose of a mucous lining of this cavity and also of a peri- osteum. Therefore, it is so closely related to the bone that the latter is prone to become involved in the inflammatory process. The pneu- matic spaces of the mastoid process are lined by mucous membrane, which is a continuation of the membrane lining the middle ear; hence by continuity the inflammation extends from the tympanic attic through the aditus ad antrum into the mastoid antrum and cells. It is probable, in view of the relations of these cavities to each other, that whenever there is pus in the middle ear there is pus in the mastoid antrum also. Having in mind the conditions just described, it is not difficult to comprehend the .far-reaching consequences of a suppurative inflam- mation of the middle ear and the mastoid process. The pus, break- ing through the confines of the softened bone upward through the roof of the tympanic cavity, reaches the middle cranial fossa, pro- ducing a subdural or cerebral abscess or meningitis; breaking forward it forms a retropharyngeal abscess, which may break suddenly into the pharynx and fill the larynx with pus, producing strangulation; breaking downward it may burrow beneath the deeper layer of the 518 LIFE-INSURANCE AND EAR, NOSE, AND THROAT DISEASES. muscles of the neck until it reaches the thoracic cavity; breaking backward from the mastoid cells, the pus empties into the posterior cranial fossa or into the lateral sinus. In the latter event pyaemia and phlebitis and thrombosis of the sinus may result. Without prompt and skillful surgical interference the fatal character of these condi- tions need not be dwelt upon. That it is well worth the while for medical examiners for life- insurance companies to attach sufficient importance to diseases of the ear is aptly illustrated by the experience of J. Morrison Eay (The Laryngoscope, August, 1897), who reported that out of 350 ear cases treated during the preceding year there were 6 fatal cases following suppuration of the middle ear. Diseases of the nose do not often prove fatal. Lupus, syphilis, and tuberculosis of this member are generally secondary to the oc- currence of these diseases in other locations. Carcinoma and sar- coma are rare in this part of the economy, and the examiner is not very likely to find causes here for the rejection of an applicant, un- less they are merely associated with the same causes in adjacent structures. However, one should be slow to accept an applicant who has a purulent discharge from his nose while such discharge con- tinues, since it might be the result of a purulent inflammation of the ethmoid cells or the frontal sinuses, which are in close relation to the meninges of the brain; or it might indicate empyaema of the maxillary antrum. If an applicant be subject to frequently-recurring attacks of sore throat, especially every spring and fall, it should suggest rheumatic sore throat, and a possible rheumatic heart affection. The throat ought to be inspected for tubercular, syphilitic, or cancerous lesions; and one should not forget that the ravages of syphilis in the throat may reach an appalling extent without the patient complaining much of pain, and that the tonsils are sometimes the portal of entrance of tubercle bacilli into the system. The larynx is often the seat of tubercular manifestations, but these are so often secondary to pulmonary infection that they are quite likely to be suggested by an examination of the lungs. But one must not be thrown off his guard by this fact, for instances of primary laryngeal tuberculosis are not infrequent, and the larynx should be examined in every case in which hoarseness, difficulty of deglutition, and soreness in the region of the throat are found. The existence of tumefaction or ulceration in the larynx is sufficient cause for either LIFE-INSURANCE AXD EAR, NOSE, AXD THROAT DISEASES. 519 rejecting the applicant or for holding his application without action until the abnormal condition is corrected or shown to be innocent beyond a reasonable doubt. A course of the iodides may demonstrate that the lesion is syphilitic and in a curable stage, or it may reveal a tubercular or carcinomatous incurable disease. Even in this test one may be easily deceived unless he remembers that carcinoma may improve temporarily under the iodides; but the improvement is transi- tory only, and is lost as the case progresses, while in syphilis the benefit remains and increases with a marked betterment of the general health. There is a common belief among those who are not well read in medical matters that the existence of a catarrhal condition of the upper respiratory tract is necessarily a forerunner of grave lung le- sions. This fallacious notion is propagated with cunning zeal by the advertising medical charlatans for commercial reasons. The sug- gestiveness and plausibility of the idea render its exploitation an easy and profitable source of practice. They find the public mind ready to accept the belief that a catarrh of the nose and throat is almost certain to eventuate in consumption of the lungs. There is enough of the element of truth in such notions to be useful to the honorable practitioner, and to be susceptible of gross abuse at the hands of the mountebank. Certainly there is more likeli- hood of a bronchitis or pneumonia occurring in a person of a pro- nounced catarrhal type than in one who "never takes cold." So, too, there is more liability of finding a rheumatic lesion of the heart in one who is subject to attacks of rheumatic laryngitis or pharyngitis. Indeed, there are subjects in whom a severe attack of pharyngitis or laryngitis almost invariably either terminates in bronchitis or evinces a very strong tendency to do so. A uric-acicl diathesis should be looked for and corrected if found in applicants for life-insurance. Inquiries ought to be made with reference to their being subject to even slight onsets of rheumatism, neuralgia, migraine, sore throat, or symptoms of gout. The possibility of the development of angina pectoris should not be overlooked, since it is the result of uricacid- a?mia; and, besides the aids already suggested as afforded by the con- dition of the upper respiratory tract, the examiner should be in- fluenced by the evidence of hay fever and asthma, which are distinctly neuropathic diseases of a gouty origin. APPENDIX. REMEDIES. Speats. Lavolin: a liquefied vaselin with- out color, taste,, odor, or irritating properties. Benzoinol: a product similar to lavolin, with the addition of benzoin. Camphor-menthol, pure: the liquid product resulting from bringing to- gether equal parts of camphor-gum and menthol crystals without heat (C 10 H ls O). Micrazotol contains boroglvcerid, eucalyptol, thymol, resorcin, menthol, and benzoic acid. (Acid reaction.) Listerin contains the essential anti- septic constituents of thyme, eucalyp- tus, baptisia, gaultheria, and mentha arvensis in combination. Each flui- drachni also contains two grains of re- fined and purified benzoboric acid. Pasteurin contains the active prin- ciples of cassia zelanicum {Lauracece), eucalyptus (Myrtacece) , gaultheria (Ericacece), menthol combined with boroglvcerid, and 0.3 per cent, of formaldehyd. (Acid reaction.) Formolid contains formaldehyd, ace- tanilid, boroglvcerid, benzoborate of sodium, eucalyptol, thymol, menthol, oil of gaultheria, witch-hazel, and alcohol. (Acid reaction.) Borolyptol consists of 5 per cent, of acetoboroglycerid, 2 per cent, of formaldehyd, in combination with the active antiseptic constituent of pinus pumilio, eucalyptus, myrrh, storax, and benzoin. (Acid reaction.) Glycothymolin contains sodium, boric acid, benzoin, salicylic acid, eucalyptol. thymolin. menthol, and pine. (Alkaline reaction.) ' B Camphor-mentholis, 3 per cent. Lavolinis, 97 per cent. — M. I£ Camphor-mentholis, 5 per cent. Lavolinis, 95 per cent. — M. I£ Camphor-mentholis, 10 per cent. Lavolinis, 90 per cent. — M. B> Olei cubebae, 4 per cent. Benzoinolis, 96 per cent. — M. R. Camphor-mentholis, 10 per cent. Olei cubebse, 90 per cent. — M. R. Eucalyptolis, 3 per cent. Olei picis liquidse, 3 per cent. Lavolinis, 94 per cent. — M. — M. R. Brown. R^ Salolis, 4 per cent. Mentholis, 4 per cent. Lavolinis, 92 per cent.- -M. R. Olei eucalypti, 1 per cent. Thymolis, 1 per cent. Mentholis, 3 per cent. Olei gaultherise, 1 per cent. Lavolinis, 94 per cent. — M. R. Calendulse, 5 per cent. Hamamelidis, 5 par cent. Lavolinis. 90 per cent. — M. Prepared from the flowers of calen- dula and the leaves of hamamelis by percolation (Truax. Greene & Com- pany). R> Thymolis, gr. x. Eucalyptolis, gr. xx. Mentholis, gr. xxx. Olei cubebae, gr. xl. Benzoinolis, §iv. Olei rosse. q. s. — M. - — O. B. Douglas. R> Eucalyptolis, 4 per cent. Benzoinolis, 96 per cent.— M. (521) 522 APPEXDIX REMEDIES. P* Mentholis, 3 per cent. Lavolinis, 97 per cent. — M. P* Olei pini sylvestris, 4 per cent. Benzoinolis, 96 per cent. — M. P* Iodini, Acidi carbolici, of each, gr. ij. Benzoinolis, §j. — M. P* Iodoformi, gr. ij. Benzoinolis, %}.- — M. P* Olei pini sylvestris, min. xxx. Olei eucalypti, 3j. Olei gaultherise, min. xxx. Camphor-mentholis, 3j. Terebinthinse Canadensis, 3j. Tincturse benzoini, q. s. ad %iv. — M. P* Iodini, gr. xx. Acidi carbolici, gr. xij. Camphor-mentholis, 3j. Lavolinis, q. s. ad §iv. — M. P* Calendula?, 4 per cent. Hamamelidis, 8 per cent. Pini strobi, 8 per cent. Lavolinis, 80 per cent. — M. Infusion of the flowers of calendula and the leaves of hamamelis with lav- olin. IJ Salolis, 3 per cent. Olei gaultherise, 4 per cent. Thymolis, 3 per cent. Benzoinolis, 90 per cent. — M. IJ Aristolis. 10 x Mentholis. 3 per cent. Benzoinolis Aristolis, 10 per cent. Mentholis. 3 per cent. "7 per cent. — M. IJ Aristolis, 5 per cent, Mentholis, 8 per cent, Benzoinolis, 87 per cent. — M. IJ Creasoti, 4 per cent. Acidi carbolici, 3 per cent. Olei picis liquidse, 3 per cent. Olei gaultherise, 4 per cent. Benzoinolis, 86 per cent. — M. IJ Acidi borici, Sodii bicarbonatis, Sodii chloridi, of each, 3ij. Glycerini, 3iij. Aquse rosse, %\v. Aquse, q. s. ad Oj. M. Filter. IJ Camphor-mentholis, 3 per cent. Olei pini sylvestris, 2 per cent. Eucalyptolis, 1 per cent. Benzoinolis, 94 per cent, — M. IJ Sodii chloridi, 3j. Sodii phosphatis, gr. ij. Sodii sulphatis, gr. xij. Potassii sulphatis, gr. ij. Potassii chloridi, Potassii phosphatis, of each, gr. iij. Mentholis, gr. j. Glycerini, 3iij. Aquse, q. s. ad Oj. — M. IJ Acidi tannici, gr. xl. Acidi gallici, gr. xx. Sodii bicarbonatis, 3ss. Aquse, Oj. — M. — Sajous. Bi Sodii chloridi, Sodii bicarbonatis, Sodii biboratis, of each, 3j. Aquas, Oj. — M. P* Sodii biboratis, Sodii bicarbonatis, of each, 3ij. Acidi carbolici, gr. xlviij. Glycerini, 3iiiss. Aquse, q. s. ad Oj. — M. (Dobell's solution.) F* Sodii biboratis, Sodii bicarbonatis, of each, §j Sodii benzo al_ Sodii salicyj^ps, of each, gr. xx. Eucalypt( ThymolJdB^ each. gr. x. Menthd^Pgr. v. Olei gaultherise, gtt. vj. Glycerini, gviiiss. Afcoholis, §ij. Aquse, q. s. ad Oxvj. — M. ( Seller's solution. ) F* Acidi carbolici, gr, xx. Sodii boratis, 3j. Sodii bicarbonatis, 3j. Glycerini, Aquse rosse, of each, §j. Aquse, q. s. ad Oj. — M. — Leffert F* Zinci sulphatis, gr. xv. Thymolis, gr. V 3 . Alcoholis, Glycerini, of each, §iss. Aquse menthse piperitae, §x. — M- APPENDIX — REMEDIES. 523 IJ Pulveris aluminis, gr. v-xxx. Aquae, 3j- — M. — J. Solis-Cohen. IJ Antinosinae, gr. v. Aquae, gj. — M. IJ Antipyrinae, gr. xv. Aquae, 5j.— M. IJ Aristolis, 5-10 per cent. iEtheris, 95-90 per cent. M. Signa: Spray for tulerculous ulcers. IJ Morphiae sulphatis, gr. iv. Acidi tannici, Acidi carbolici, of each, gr. xxx. Aquae destillatae, of each, §ss. M. Signa: Spray for tubercular ulcers. IJ Sodii boratis, gr. v. Aquae rosse, §j. — M. Steam-inhalations. Infusion of opium, 3i-Oj. Infusion of belladonna, 3i-Oj. Infusion of hyos8yamus, 3i-Oj. Infwwen of coniuniv 5i-Oi. m. Compound tincture ^^benzoin, a teaspoonful to the pint of hot water. Pure camphor-menthol, gtt. x to the pint. Glycerinum acidum carbolicum, a | teaspoonful to the pint. IJ Glycerini, §j. Aquae calcis, Siij- M. Signa: Use in a steam-atom- izer. IJ Acidi carbolici, Zinci sulphocarbolatis, of each, 3j. Glycerini, Bj- Aquae, q. s. ad Biv. M. Signa: Use in a steam-atom- izer. Antiseptic and Astringent Solutions, etc. IJ Acidi borici, gr. xx. Aquae rosae, Sj. — M. (For the ear.) IJ Acidi borici, gr. x. Aquae destillatae, §j. — M. (For the eye.) 1$. Zinci sulphatis, gr. ij. Acidi borici, gr. x. Aquae destillatae, Sj- — M. (For the eye.) 1$. Zinci sulphatis, gr. viij. Acidi carbolici, gr. viij. Glycerini, 3j. Aquae, §ij. — M. (Ear-lotion.) IJ Acidi borici, gr. xx. Alcoholis, gj. — M. (For the ear when granulations are present. ) IJ Sodii bicarbonatis, gr. xx. Glycerini, 3ij. Aquae, 3vj. M. Signa: Use (warm) in the ear to soften cerumen. IJ Acidi borici, gr. xv. Aquae rosae, Bj- — M. IJ Iodoformi, 20 per cent. Alcoholis, 80 per cent. — M. Hydrargyri bichloridi, q. s. ad 1- 5000 in aquam. IJ Hydrargyri bichloridi, gr. j. Aquae cinnamomi. Bx. M. Filter. IJ Hydrargyri chloridi corrosivi, 3j. Acidi tartarici, 3v. Aquae, q. s. ad Siv. M. Signa: Ounce ss ad Oj aquae (1 to 1000). IJ Hydrargyri chloridi corrosivi, Sodii chloridi, of each, 3j. Aquae, q. s. ad 3j. M. Signa: Drachm j ad Oj aquae (1 to 1000). 524 APPENDIX REMEDIES. B Hydrargyri chloridi corrosivi, 3j. Ammonii chloridi, gr. xxxij. Aquae, q. s. ad 3j- M. Signa: Drachm j ad Oj aquas (1 to 1000). I£ Acidi carbolici, 3vj. Aquas, q. s. ad Oj. — M. I£ Acidi carbolici, 3j. Olei olivae, 3x. M. Signa: Carbolized oil. Hydrozone: a 30-volume dioxide (peroxide) of hydrogen; H 2 2 . Glycozone, a chemically-pure, anhy- drous glycerin saturated with ozone- gas at 0° C. ; powerful non- toxic, non-irritating germicide. I£ Creolinis, §j. Signa: Drachm i-vj ad Oj aquae. — Esmarch. I£ Acidi borici, 3iv. Aquae destillatae, Oj. M. Signa: Saturated solution. P* Potassii permanganatis, 3ij. Aquae, Oj. — M. Py Acidi salicylici, 3ss. Boracis, gr. xx. Aquae, Oj. — M. (For ozaena.) P* Aluminis, 3j. Acidi carboiici, gr. viij. Glycerini, §j. Aquae destillatae, Svij. M. Filter. IJ. Potassii chloratis, 3j. Aquae cinnamomi, Bviij. M. Filter. P* Potassii chloratis, 3j. Extracti hamamelidis, Sj. Aquae destillatae, §v. M. Filter. F* Tincturae ferri chloridi, Sj. Glycerini, §j. Aquae destillatae, 5vj. M. Filter. Px Sodii bicarbonatis, 1 per cent. Aquae, 99 per cent. M. Signa: Use for boiling instru- ments (to prevent corrosion). P* Acidi carbolici, 5 per cent. Aquae, 95 per cent. M. Solution for disinfecting instru- ments. Gargles. -M. P* Boracis, 3ij. Acidi carbolici, gr. xvj. Glycerini, 3ij. Aquae rosae, q. s. ad 5 viij . Pp Aluminis exsicc, 3j. Aquae rosae, Sviij. — M. P* Aluminis, Potassii bromidi, of each, 4 per cent. Aquae, 92 per cent. M. Signa: Gargle. P* Potassii chloratis, 3iv. Or P* Potassii bromidi, 3iv. Dissolve in a pint of nure water and gargle. P* Boracis, Potassii chloratis, of each, 3iv. Potassii carbonatis, 3vj. Sodii chloridi, §ij. Aquae, q. s. ad Oj. — M. Solutions foe Injecting into the Middle Ear Through the Eu- stachian Tube. Pilocarpine hydrochlorate, 2-per- cent, solution. Six or 8 drops to be injected through the Eustachian catheter. F* Sodii bicarbonatis, gr. x. Aquae, Bj.— M. F* Potassii iodidi gr. v. Aquae, 3j— M. / APPEXDIX REMEDIES. 525 1$. Camphor-mentholis, 3 per cent. Lavolinis, 97 per cent. — M. Pigments. F* Aeidi tannici, gr. x-xxx. Acidi salicylici, gr. v. Glycerini, 3ij. Aquae destillatse, 5vj. — M. P* Aluminis. gr. x. Glycerini. 3ij. Aquae destillatae, 3vj. — M. P* Zinci sulphatis, gr. v. Glycerini, 3ij. Aquae destillatae, 3vj. — M. P* Zinci ehloridi, gr. x-1. Glycerini, Aquae destillatae, of each, 3iv. — M. F* Cupri sulphatis, gr. x. Glycerini, 3ij. Aquae destillatae, 3vj. — M. F* Iodoformi. 3j. Collodii, 5x.— M. ( Iodof orm-collodion. ) — Ktjster. P^ Iodoformi. 3j. ^theris, gj.— M. ( Iodof orm-ether.) P* Iodoformi, gr. xxx. JEtheris, §ss. Aquae destillatae, q. s. ad §j. — M. (Iodof orm-ether.) — Xussbatjm. F* Glycerini acidi carbolici, 3ij. Glycerini acidi tannici, §ij. — M. F* Acidi carbolici, 12 per cent. Glycerini, 88 per cent. — M. Glycerinum acidum tannicum. F* Olei eucalypti, Acidi carbolici, of each, %]. Terebinthinae, §viij . — M. F* Guaiacolis, §ss. Glycerini, Sss. — M. P* Morphiae sulphatis, gr. iv. Acidi carbolici, gr. xxx. Glycerini, Sj- — M. F* Morphiae sulphatis, gr. iv. Acidi carbolici, gr. xxx. Acidi tannici, gr. xxx. Glycerini, gj. — M. F* Argenti nitratis, gr. xl. Aquae, gj.— M. F* Argenti nitratis, gr. x. Aquae, Zj.—^SL P* Creasoti. 2 per cent. Mentholis, 10 per cent. Lavolinis, 88 per cent. M. Signa: Apply to tubercular ulcers. Acetic acid, applied to tubercular ulcers. At first it should be used in a solution of 20 to 40 per cent., gradu- ally increasing to 100 per cent. P*. Creasoti, gr. x. Mentholis, 3j. Lavolinis, §j. M. Signa: Apply to tuberculous ulcers. Tincture of iodine. P* Plumbi acetatis, gr. v. Aquae, Bj- M. Signa: For syphilitic throat. P* Zinci ehloridi, gr. xx. Aquae, I]. M. Signa: For syphilitic throat. P* Cupri sulphatis, gr. xv. Aquae, gj. M. Signa: For syphilitic throat. Pyoktanin. Sulphocalcin, either diluted or full strength, for dissolving false mem- branes. Px. Potassii permanganatis, gr. xxx. Aquae, Sj- — M. (Antiseptic, and solvent of false membranes.) 526 APPENDIX REMEDIES. Lactic acid, applied locally by in- halation or by a cotton swab. (A solvent of false membranes.) I£ Acidi carbolici, gtt. xx. Liquoris ferri subsulphatis, 3iij. Glycerini, gj. Aquae destillatse, §ij. — M. (Local application for diphtheria.) B Alcoholis, 60 per cent. Toluolis, 36 per cent. Liquoris ferri chloridi, 4 per cent. — M. (Loffler's formula for the local treat- ment of diphtheria. On account of the pain this solution produced, Loffler added to this 20 per cent, of menthol. ) COTJNTER-IRR T TANTS AND LINIMENTS. Cantharidal collodion. Essential oil of mustard. Tincture of iodine. 1$ Linimenti saponis, Linimenti camphoris compositi, of each, §j. — M. 1$. Linimenti belladonna?, Linimenti opii, of each, 3iv. — M. Bi Linimenti chloroformi, Linimenti aconiti, Linimenti belladonnas, Linimenti opii, of each, 3iv. Linimenti saponis, §j. — M. P* Tincturse Valeriana?, 3ij. iEtheris sulphurici, 3j. Glycerini, 3xij. — M. F, Olei tiglii, 3ij. Chloroformi, 3ij. Aquse ammonii fortioris, Sj- Olei sesami, giij. M. Signa: Apply on cotton. Ointments. Vaselin, petrolatum, or petroleum ointment: the purified residue after distilling off the lighter and more volatile portions from American petro- leum. P* Unguenti zinci oxidi benzoinati, P* Hydrargyri oxidi flavi, gr. v. Unguenti petrolei purificati, gj. — M. B) Unguenti acidi carbolici, gj. fy Unguenti acidi carbolici, gss. Unguenti zinci oxidi benzoinati, giss.— M. P* Acidi salicylici, gr. xv. Petrolati, gj.— M. Epidermol. Besinol. Caustics. B> Acidi chromici, Aqua?, of each, 3j. — M. Chromic acid fused into a bead (page 129). Silver nitrate fused on a probe. Glacial acetic acid. Mtric acid. Monochloracetic acid. London paste. Trichloracetic acid. Electrocautery. Powders. Aristol. Nosophen. Iodoform. Boric acid. Morphia?, gr. 1 / 2 - 1 / 6 (for insuffla- tion). F* Bismuthi carbonatis, gr. ij. APPEXDIX REMEDIES. 527 IJ Sodii bicarbonatis, Sodii boratis, Amyli, of each, gr. iss. Cocainse hydrochloratis, gr. x. Sacehari lactis, q. s. ad gr. c- -M. IJ Morphise hydrochloratis. gr, ij. Bismuthi ?ubnitratis, 3vj. Pulveris acacise, 3ij. M. Signa: '"Terrier's snuff."' for cold in the head. Tablets. IJ Ammonii chloridi, gr. j. Tincturse opii canrphoratse, Syrupi scillse compositi, Syrupi Tolutani, of each, min. v. Extracti glycyrrhizse, gr. iij. M. Signa: Throat-, or cough-, tab- let. IJ Morphia? sulphatis, gr. V 12 . Atropise sulphatis, gr. 1 / 600 . CafTeinse, gr. V 6 . M. Signa : Coryza-tablet. R Local Anesthetics. Cocaine. Eucaine. xxcidi carbolici, 12 per cent. Glycerini, 88 per cent. — M. Gexeral Anesthetics. Ether. Chloroform. Ethvl-bromide : hvdrobromic ether Gexeeal Remedies. Sodium bromide in doses of 30 or 60 grains in large amount of water, especially at bed-time. IJ Zinci valerianatis, gr. ij. Extracti nucis vomicae, gr, Extracti gentianae. gr. ij. M. Fiat pilula. Signa: One pill thrice daily l A. IJ Ammonii chloridi, 3j. Tincturse opii camphoratae, Syrupi scillae compositi, Syrupi Tolutani, Syrupi glyeyrrhizae, of each, §j. M. Signa: Teaspoonful every two or four hours. (Cough-syrup.) IJ Calcii sulphidi, gr. iij. Fiat in pilulas Xo. xij. Signa: One three times a day for suppuration. Acidi arseniosi, gr. 1 / 3 „ thrice daily for furunculosis oid herpes. IJ Tincturse ferri chloridi, 3ij. Glycerini, 5 j . Aquae, Siij- — M. IJ Ferri reducti, Quininae sulphatis, of each, gr. j. Strychnia? sulphatis, gr. 1 / 60 . M. Fiat in pilulam Xo. j. This pill may be taken two or three times a day, after meals. IJ Tincturse ferri chloridi. Glycerini, Aquae, of each, Sj- — M. (Billington's formula.) 5j. IJ Hydrargyri chloridi mitis, . Sodii bicarbonatis, of each. gr. j. — M. IJ Hydrargyri chloridi corrosivi, gr. /lOO" /50- Sacehari albi. gr. iii-v. M. Triturate: fiat in chartulam Xo. j. Signa: Apply dry on the tongue every hour. (For diphtheria or croup.) Eemedies for Tixxitus Atjeitjm. IJ Acidi hydrobromici diluti, 3j- Aquae. Biij- M. Signa: A teaspoonful well di- luted three times a day. 528 APPENDIX REMEDIES. Fluid extract of cimicifuga race- mosa, in 30-drop doses daily. Febrifuges. Antipyrin. Phenacetin. Acetanilid. Sedatives. Exalgin. Potassium bromide. I£ Bromidise, §ij. Signa: One-half teaspoonful in water every half-hour until pain is relieved. Aconite. 1$, Tincturse aconiti, 3ss. Potassii bromidi, 3iss. Aquse §ij. M. Signa: Teaspoonful every hour in tonsillitis. Emetics. Apomorphine. Hydrargyri subsulphas flavus (tur- peth mineral). Powdered alum. Ipecac. Sulphate of copper. Remedies for Rheumatic and Gouty Affections. Salicin. Salicylic acid. Salol. R^ Acidi salicylici, 3iij. Sodii bicarbonatis, 3ij. Elixiris gaultherise, §ss. Glycerini, 3iij. Aquse, q. s. ad Siv. — M. Lithium carbonate or citrate. Alkalithia. Citrate of lithia, soda, and potash (effervescent). Sodium phosphate (alkaline laxa- tive and cholagogue). Remedies for Tuberculosis. Codliver-oil and maltine. R< Vini ferri citratis, §iv. Signa: Dessertspoonful after each meal. R. Syrupi hypophosphitis compositi (Fellows's), Oj. Signa: A teaspoonful three times a day, after meals. IJ Olei morrhuae, Oj. Signa: A teaspoonful thrice daily, after meals, in lemon-juice or coffee; or inunctions twice daily, rubbing a tablespoonful into the skin of the ab- domen, and covering with oiled silk or flannel. Guaiacol in doses of 1 to 10 minims after each meal, given in glycerin, milk-broths, or wine. Creasote, 1 to 10 minims or more three times a day, given in milk, alco- holic or tonic preparations, or in cap- sules. Remedies for Syphilis. R Hydrargyri bichloridi, gr. j. Potassii iodidi, §ss. Syrupi sarsaparillae, 5iv. — M. APPENDIX EEMEDIES. 529 I£ Potassii iodidi, 3iv. Ammonii carbonatis, 3j. Elixiris simplicis, 3J- Infusionis calumbae, gv. M. Signa: Tablespoonful in water three times daily. (For syphilis and caries.) P* Syrupi ferri iodidi, 3iv. Glycerini, 3iss. Aquae, %iv. M. Signa: Teaspoonful three times a day. I£ Potassii iodidi, gr. viij. Ferri et ammonii citratis, gr. xxiv. Elixiris aurantli, Bij- Aquae, §ij. M. Signa: Drachm j or ij thrice daily. (For children.) Ifc Potassii iodidi, 3j. Ferri et ammonii citratis, 3ij. Infusionis calumbae, q. s. ad 5vj. M. Signa: Tablespoonful in water thrice dailv. Pilocarpine-hydrochlorate solution, 2 per cent. Ten or 15 drops to be in- jected under the skin. (For labyr in- thai disease, syphilitic.) F* Sodii iodidi, §ss. Essentiae pepsinae (Fairchild), Syrupi zingiberis, of each, Biij ■ M. Signa: Drachm j ter die. Miscellaneous. Nitrite of amyl; used for inhala- tion in hay fever, asthma, and col- lapse from anaesthetics. Dose, 10 or 20 drops. Pure camphor-menthol inhaled from a bottle or glass tube, for hay fever and cold in the head. 530 APPENDIX. CASE-RECORD BOOK. Date Name Nn. Residence Tel. No. Occupation Business address Tel. No. Fees Referred by Age Sex Height Weight J Losing j Gaining Where born Single Married Widower How long in this climate Previous residence Chief complaint Other symptoms Ledger Page Onset Pruggist Supposed cause Tel. No. Family history — Heredity APPENDIX CASE-RECORD BOOK. 531 Personal History Diphtheria Scarlet fever Tonsillitis Grippe Measles Croup Hay fever Asthma Epistaxis Scrofula Lymphatic swelling's Paracusis Fluctuations Meningitis Otitis media Mastoiditis Phthisis Hemoptysis Night sweats Neuralgia Lues Paralysis Typhoid Erysipelas Eczema Lithemia Antrum trouble Autophonia Vertigo Cerumen Traumatic history Idiosyncracies Passed Life Ins. Exam.': Alcoholics Tobacco Former treatment Snu£! Narcotics 532 APPENDIX CASE-RECORD BOOK. Present Condition General health Deglutition Taste Appetite Empty swallowing Digestion Bowels Respiration Oral do. Sleep Snoring Mouth dry in morning Smell Coryza (recurrent) Which nostril most free Alternating stenosis Nasal secretions, Ant. Post. do. Frontal Temporal After exercise— reading Headache Occipital General Worse in morning Pain Memory Cough Expectoration Ozena Odor of breath Vocalist Vision Voice, (Hoarseness, aphonia, etc.) APPEXDIX CASE-RECORD BOOK. 533 Examination of Ear RIGHT LEFT DURATION Hearing impaired DURATION Tinnitus (kind) Discharge Pain 1 1 Causation 2 2 Course Auricle Ext. canal M. T. and Tympanum Eustach. tube Mastoid 534 APPENDIX CASE-RECOKD BOOK. Ear continued RIGHT LEFT 1MPROV. PATENCY INFLATION PATENCY IMPROV. Valsalva Politzer Catheter OSSICLES M. T. Siegle M. T. OSSICLES AFTER INFL. BEFORE INFL FUNCTIONAL TEST BEFORE INFL AFTER INFL Speech Whisper Watch Aeoumeter Galton Subjective Sounds T.F. aerial Through Tube Weber Rinne BONE AIR Sehwabaeh AIR BONE 2D TONE 1 s t TONE Bing 1st TONE 2°TONE RELAXATION PRESSURE Gelle' PRESSURE RELAXATION Worse in bad weather Prognosis APPEXDIX CASE-RECORD BOOK. 535 Ear continued RIGHT o D Q Z o :r,i:£t untie _i LL Z o _i Lu I- 1 Lu Date C-l 64 c 128 Ci 256 C2 512 C3 1024 C4 2048 A B B A A B B A A B B A A B B A A B B A A B B A A B B A A B B A A B B A A B B A 536 APPENDIX CASE-EECOED BOOK. Ear continued LEFT o 3 ZRIZsTItTIE . iP=i o i— _i ul LtZ Date Q Z C-l c C1 C2 C3 C4 u. z H- 1— u o 64 128 256 512 1024 2048 < s C3 A B B A A B B A A B B A A B B A A B B A A B B A A B B A A B B A A B B A A B B A APPENDIX CASE-RECORD BOOK. 537 RIGHT Examination of Nose Ant. naris and vestibule Ala nasi Septum // ,- Floor and inf. meatus Inf. turb. V Mid. meatus 1/ Mid. turb. Sup. meatus and attic Ace. sinuses Polypi NASO-PHARYtU. Vomer Mid. turb. !nf. turb. Eustach. orifice Vault of pharynx 538 LEFT APPENDIX CASE-EECOED BOOK. Nose continued Ant. naris and vestibule Ala nasi Septum Floor and inf. meatus Inf. turb. Mid. meatus \ f Mid. turb. Sup. meatus and attic Ace. sinuses Polypi NASO-PHARYNX. Vomer Mid. turb. Inf. turb. Eustach. orifice Aprosexia Pharyngeal tonsil APPEXDIX CASE-RECORD BOOK. 539 Examination of Mouth and Fauces Teeth Gums Hard palate Velum Uvula Pharynx Lateral folds Tongue Lingual tonsil— Varices RIGHT LEFT Tonsil Ant. pillar Post, pillar Thyroid Cerv. glands 5^0 APPENDIX CASE-KECOED BOOK. RIGHT Examination of Larynx LEFT Epiglottis Ary-epiglottic foids Arytenoids Inter-aryt. space Ventricular bands Vocal cords Abduction Adduction Trachea Esophagus Lungs INDEX, Abbott, 355, 359 Abbreviations, 4 Abel, 269 Abscess, cerebral and cerebellar. 121, 145 extradural, 144 metastatic, 145 of brain, 121, 145 of larynx, 481, 482 of neck, 141, 181 of nose, 292 retropharyngeal, 152, 182, 433, Plate V subdural, 144 tonsillar, 399 Accessory cavities of the nose, dis- eases of, 297 Acoumeter, 27 Acute otitis externa, 58 Acute otitis media, 73 appearances of membrana tympani, 20, 21, Plate I grip as a cause, 73 leech, artificial, 76 leeches, 76 naso-pharynx, 73 paracentesis membranae tympani, 77 relief of pain, 75 treatment, 75 Acute purulent otitis media, 78 grip as a cause, 73 influenza as a cause, 73 membrana tympani, appearance of, 78, 81, Plate I micro-organisms, 78 treatment, 79 Adenoid hypertrophy of vault of pharynx, 324 ear complications, 195, 324 Adenomata of pharynx, 324 Adjustable light, 13-17 Age, influence of, in diseases, 5 Agnew, 184 Air, compressed, and apparatus, 29-41 Air-pressure, 29 Alderton, H. A., 199 Alkaline sprays, Appendix Alt, 313 Amaurosis, 312 Amblyopia from nasal disease, 312 Anaesthesia, local, in nasal surgery. 265 of pharynx, 436 Anaesthetics, general, 146, 157, 327 Andrews, A. H., 212 Angina, catarrhalis acuta, 335 Ludwig's, 405 rheumatic, 342, 344 Ankylosis of the ossicles, 90, 95, 98 Anomalies, of auricle, 52, 55 of external meatus auditorius, 54. 55 of sensation in larynx, 487 Anosmia, 286 Antiseptic sprays, Appendix Antrum, aditus'ad, Figs. 108, 109. 110 mastoid, Figs. 109, 110 of Highmore, 297 Aphonia, 476, 489, 490 applicator, caustic, 129 Aquaeductus Fallopii, 166, 167. Figs. 109, 110 Arnold, J. D., 456 Arrangement of instruments, 13, 14 Arslan, 196 Artificial drum-heads, 132 Aspergillus of the ear, 62 Aspirator for the ear, 125 Asthenopia from nasal disease, 310 Asthma, 229 from nasal disease, 231, 259, 277, 291 Astigmatism from nasal disease, 312 Asymmetry of nasal bones, 255 Atmospheric causes of disease, 8-11, 317 Atomizers, 210 Atresia, of external auditor v meatus. 54, 64 nasal, 294 Atrophic rhinitis, 268 Audiphone, 200 Auditory canal, 56 acute inflammation, 58 boils of, 60 bony growths, 64 cerumen. 56 chronic inflammation, 58 exostoses, 64 foreign bodies. 65 furuncles, 60 » (541) 5+2 INDEX. hyperostosis, 64 imperforate, 64 malignant disease, 48, 50 narrowing, 64 neoplastic closure, 64 parasitic inflammation, 62 sequestra, 139 Auditory nerve, 187-191 Aural, fungi, 62 vertigo, 57, 183, 185, 186, 193 Auricle, benign tumors of, 51 carcinoma, 50 cutaneous diseases, 47 cystoma, 51 deformities, 52-55 eczema. 47 frost-bite, 47 gangrene, 49 hematoma, 51 herpes, 52 hypertrophy, 52 inflammatory affections, 47-52 intertrigo, 52 lupus, 48 malignant disease, 50 othematoma, 51 pemphigus, 52 perichondritis, 50 scroll-deformity, 54 syphilis, 52 wounds and injuries, 55 Auscultation-tube and method of using, 45, 46 Autoaspiration, 88 Autoinnation of the middle ear, 101 Automatic tuning-fork, 23 Autophony, 74, 86 Autoscopy, 447 Babcock, R. H., 382 Bacon, G., 67 Bag, ice-, 153 Baginsky, 358 Baldness not a cause of disease, 10 Bandage, net, 180 Barclay, Robert. 114 Barr, Thomas, 62 Baum, W. L., 395 Baurowicz, 269 Bean. C. E., 403 Becker. B., 384 Behrens, B. M., 109 Behring, 375, 377 Bell, A. G., 201 Bergmann, 145 Bertillon, 238 Bezold. 78, 133, 134 Bifid uvula, 418 Billings, Frank, 397 Bing's hearing-test, 25 Bischoff, 490 Bishop, D. D., 395 Bishop, S. S., 314 Black, G. M., 268 Blake, Clarence J., 114, 115 Bleeding, local, in acute otitis media, 76 Blepharitis, 309 Blindness from sphenoid disease, 303, 312 Boils in the external ear, 60 Bone, turbinated, inferior, Plates II, V middle, Plates II, V superior, Plates II, V. Bone-conduction, 22, 24 in chronic aural catarrh, 94 Bostoek. John, 230 Bosworth, Francke H., 253 Bouchut, 464 Bougies, Eustachian, 72 nasal, 228 Boxing the ears, 51, 67 Bracket, adjustable lamp-, 17 Brain-abscess, 121, 145 Brannon, John Winters, 383 Braun, 270 Brennecke, H. A., 395 Bresgen. 309, 311 Broadbent, 239 Brown, Dillon, 463 Brown, Moreau R., 253 Browne, J. Lennox, 369, 370, 385, 421, 511 Brown-Sequard, on hematoma, 51 Bryant, W. S., 121 Buck, A. H., 66 Burnett, Charles H., 62, 114 Burns and scalds of the pharynx, 437 Caisson, effect on ear, 33 Calcareous degeneration of the middle ear, 90, 91, 131, Plate I Camphor-menthol, 215 inhaler, 217 Canal, external auditory, 56, 113 Fallopian, 166, 167, Figs. 109, 110 glands, 113 imperforate, 64 section of, 113 Canalis tensoris tympani, 70 Cancer of pharynx, 430 Carcinoma, of ear, 50 nose, 279 larynx, 508 pharynx, 430 Caries and necrosis from middle-ear diseases, 117, 120, 129, 130, 134, 138 INDEX. 543 Carotid artery, rupture of, in suppura- tion of middle ear, 139 canal, 169, 170 Cary, Frank, 469 Case-records, 22, 28 Casselberry, William E., 252 Catarrh, chronic, of middle ear, 83, 90 exudative, 83 hypertrophic, of the nose, 255 of the middle ear, sero-mucous, 83 Catarrh, heredity of, 318 Catarrh, nervous, 229 Catarrhal otitis media, acute, 73 Catheter, Eustachian, 43 in chronic aural catarrh, 88 method of using, 42, 44, 45 Causes of disease, atmospheric, 8-11, 317 Caustic, applicator, 129 chemical, 128 for nose and throat, 260 Cautery, electric, 259-267 Cavities, accessory, of nose, 297 Cerebellar abscess, 145 Cerebral abscess, 145 Cerumen, impacted and inspissated, 56 Chapman, J., 253 Charcot, 191 Cheatham, William, 253, 314 Chiari, 270, 510, 512 Cholesteatoma, of mastoid, 133 of middle ear, 133 Stacke's operation, 172 Chondromata, nasal, 276 Chorda tympani nerve, 106 Chorditis tuberosa, 482 Chorea, of pharynx, 436 Chronic catarrh of the middle ear, 83 adhesive inflammation, 90 age, 92 alcohol, effects of. 86, 92 ankylosis of ossicles, 90, 95, 98 atrophic stage, 85, 90, 95 auditory hallucinations, 189 autoaspiration in, 88 autophony, 74, 86 calcareous degeneration, 90 climatic conditions, 86, 89, 93, 317 deafness, 90, 93-95 differential diagnosis, 86, 95 electricity, 103 Eustachian, catheter, 88, 100 tube, 69, 85 excision of membrana tympani and ossicula, 108, 110 exudation, 83 foreshortening of handle of mal- let. 84. 96, Plate I frequency of, 7, 8 Chronic catarrh of the middle ear, heredity, 92 hygienic surroundings, 8-10 hypersemia, 83 hypertrophic, 83 injection of liquids, 99, 100 injection of vapors, 100 loud noises, effects of, 93 ossicles in, 90 otalgia, 85 pain in ear, 85, 93 paracentesis, 88 paracusis, 95 partial excision of membrana tympani, 107 peculiar modifications of hearing, 94, 95 pneumatic tests, 85, 95 proliferation, 90 removal, of membrana tvmpani and ossicles, 108, 110 stapes, 115 retraction of membrana tympani, 84 sclerosis, 90 secretive, 83 sensations of discomfort, 85, 86, 92, 93 statistics, 4-12 tenotomy of tensor tympani, 108 tinnitus aurium, 92, 97, 188 tobacco, effects, 92, 189 uric acid, 91 vertigo, 93, 97 purulent otitis media, 116 antiseptic, powders, 122-124 solutions, 121, 124, Appendix appearances of membrana tym- pani, 116, Plate I caries and necrosis, of adjacent tissues, 120, 129, 138, 139, 140, 141, 142 of ossicles, 117, 130 caries of carotid canal, 139 cause of intracranial lesions, 121, 139, 152 cerebral abscess from, 121, 139, 152 cholesteatoma. 118, 133 excision of drum-head and os- sicles, 108, 130 exfoliation of cochlea, 138 facial paresis and paralysis, 121, 134 granulations, 120, 127 mastoid complications, 119, 152 meningitis, 121, 143 metastasis, 145 paralysis and paresis, facial, 121, 134 5U INDEX. Chronic purulent otitis media, per- foration of the membrana fiaccida, 117 phlebitis of lateral sinus and jug- ular vein, 140, 147 polypi, 120, 127 pyaemia, 121, 140 rupture of carotid artery, 139 seat of intracranial lesions, 121, 140, 152 sequelae, 121, 127, 152 symptoms, 119 of brain-abscess, 145 of sinus-thrombosis, 147 thrombosis of lateral sinus and jugular veins, 147, 148 treatment, 121 Chronic suppurative tympanitis, 116 Chronicity of diseases, 9 Circumscribed otitis externa, 60 Cirrhotic rhinitis, 268 Clark, Sir Andrew, 254 Classification, of diseases, 4-12 of occupation, sex, etc., 3-11 Climatic influences, 18, 317, 335, 423, 457 Clinical records, 3, 28, Appendix Clothing, 225, 321, 346, 463 Cocaine, 228 Cochlea, 141 exfoliation, 138 Cohen, J. Solis-, 253, 351, 422, 423 Cold, catching, 317, 335 Cold in the head, 223 Coleman, W. F., 310 Colles, C. G., 92 Comparison of statistics, 11 Compressed air, 29-41 apparatus, 36-41 meter, 30, 37 Congenital deafness, 195 Conjunctivitis from nasal disease, 308, 310 Conklin, 237 Coppez, 312 Corbin, 463 Corneal inflammation from nasal dis- ease, 310, 311 Coryza, 223, 226 tablets, 222, 225 Cotton, A. C, 395 Cotton-carrier, 19 Cough-tablets, 339 Cozzolino, 115 Croup, 458 intubation, 464 laryngismus stridulus, 461 membranous, idiopathic, 458 spasm of the glottis, 459 spasmodic, 486 Croup, spurious, 452 tracheotomy, 470 choice of operation, 471 treatment, 461 Curettes, 141, 158 Curtis, H. H., 253 Cut-off, compressed air, 31 Cutter, Ephraim, 507 Cystoma, of auricle, 51 larynx, 505 Dabney, Samuel G., 311 Dacryocystitis from nasal disease, 310 Dalby, W. B., 65 Daly, W. H., 253, 300 Darwin, 242 Davey, James R., 139 Davis, Nathan Smith, 237, 250 D'Espine, 358 De Lamalleree, 254 De Vilbiss, Allen, 146, 443 Deaf-mutism, 195, 324 Deafness, causes of, 71, 74, 86, 94, 119, 184, 185, 186, 191, 194, 319 congenital, 195 following suppuration of middle ear, 1L2 hereditary, 196 hysterical, 191 Deflections of septum nasi, 287 Eeformities, of auricle, 52 of nasal cavities, 287, 294 Delavan, D. B, 293, 330, 414 Delstanche, Charles, 88, 99, 122 Dench, Edward B., 136 Desire, 497 Dilators, for ear treatment, 36 for nose, 228 Dionisio, 270 Diphtheria, 355 age of patients, 358 bacillus, 356 diagnosis, 363 diphtheric exudate, 355 diphtheroid, 363 effect, on ear, 362 eye, 311, 312, 362 incubative period, 359 intubation. 464 microbe, 355 modes of propagation, 360 of the nose and naso-pharynx, 362 prophylaxis, 366, 376, 380 pseudodiphtheria, 331, 363 symptoms, 360 treatment, 365 antitoxin, 375 hygienic, 366 internal, 373 INDEX. 545 Diphtheria, treatment, local, 369 serum-therapy, 375 tracheotomy, 442 vitality of Klebs-Loffler bacillus, 358, 3ou Diphtheroid, 363 Direct laryngoscopy, 447 Disinfection, lOki DobelFs solution, Appendix Double hearing, 188 Double retractors, 160 Double uvula, 418 Douche, nasal, 212, 271 Douglas, O. B., 287 Drumhead. See Membrana tympani. Ducts emptying into nasal meatuses, 'Figs. 179, 181, 182 Duel, A. B., 73 Dunn, J., 310 Dynamomotor, 262 Dysphonia, 505 Ear, electrodes, 137 internal, 183 malformations, 52, 54 middle, 67, 69, 113, Figs. 109, 110 noises, subjective, 56, 74, 85, 92, 188 relation of nose to, 69 specula, 17 Ear-cough, 57 Ear disease, brain-abscess, 145 from disorders of nervous system, 187, 191, 192 from exanthemata, 73 from grippe, 73 from influenza, 73 from intracranial growths, 193 from leucocythsemia, 186 from meningitis, 192 from syphilis, 186 Ear- fungi, or mold, 62 Ebstein, "236 Ecchondrosis, nasal cavities, 276 Eczema of auricle, 47 evelid and face, 310 Ehrlich, 375 Electric current-transformer, 262, 263 Electric motor, 2.J2 Electricity in various diseases, 103, 137, 259-267 Electrodes, ear-, 137 Emphysema from Eustachian catheter, 46 Empyema, of antrum of Highmore, 297 of frontal sinuses, 303 of maxillary sinuses, 297 Fno-ehnann. Rosa, 382 Enslee, Charles L,, 3 Epiphora from nasal disease, 310, 312 Epistaxis, 272 plugging nares, 273 Epithelioma, of ear, 50 of larynx, 508 of nose, 279 of pharynx, 430 Erectile tumors of nasal cavities, 276 Ethmoid sinuses, diseases of, 301 osteoma, 303 polypi, 303 Etiology of diseases, 9-10 Eustachian, catheter, 43 emphysema from use of, 46 method of using, 42 salpingitis, 69 tube, 69, 256, Plate II canal is tensoris tympani, 70 cartilage of, 70 constriction of, 72 fossa of Rosenmiiller, 44 isthmus, 70 membranous part, 70 orifice, 44, 70 patency, 72 stenosis, 72 Euthanasia, 511 Ewing, 387 Examination of patients, 13, 205, 443 Exanthemata, effect on ear, 9 Excision, of membrana tympani and ossicula, 108, 110 partial, of membrana tympani, 107 Exostoses, of auditory canal, 64 of nasal cavities, 277 External ear, 47 auricle, 47 Extradural abscess, 144 Exudative catarrh of middle ear, 83 Eye diseases from diseases of the nose, 307 Eye-strain, 315 Facial expression in diseases of the nose and throat, 325 Facial paralysis, 121, 134. 177 Faith, Thomas, 46 Fallopian canal, 166, 167, Figs. 109, 110 False diphtheria, 357 False hearing, 188 Farcy, 284 Fatality of chronic suppuration of the middle ear, 116, 139, 143, 145, 152 Fenestra, ovalis, Fig. 107 rotunda. 118 Fessler, 327 Fibroids, of larynx, 502 of nasal cavities, 274, 322 5-46 INDEX. Fick, 335 Fischer, 311 Floor of the tympanum, 113 Folds of membrana tympani, 21 Foreign bodies in ear, 65 in larynx, 513 in nose, 294 in pharynx, 438 Fork, automatic tuning'-, 23 Fossa of Rosenmliller, 44, Plate II Foster, 381 Fournier, 427 Fracture, of base of skull, 194 of nose. 293 Frankel, 503 Frankenberg, 195, 324 French, J. M., 293, 395 Frequency of disease, relative, 3, 7, 8 Frontal sinuses, diseases of, 303 transillumination, 305 Frost-bite of auricle, 47 Fruitnight, 462 Fungi, aural, 62 Funk, 312 Furuncles, of ear, 60 of nose, 285 Galezowski, 314 Galton's whistle, 26 Galvanocautery, 260 Ganglion, sphenopalatine, 231 Gangrene of the ear, 49 Garcia, 451 Gelle, 115 Gelle's hearing-test, 26 General considerations, 3 Glanders, 284 Glasgow, W. C, 252, 423, 462 Glaucoma, 311 Gleason, on sclerosis, 114 Gleitsmann, J. W., 287 Glenoid fossa, 168 Globus hystericus, 436, 439, 488 Glottis, spasm of, 454 Gluck, I., 254 Goldstein, M. A., 138, 198, 295 Gonorrhoea, nasal, eye symptoms, 311 Gottstein, 462 Gouges, 157 Gouguenheim, 254, 403 Gould, G. M., 309 Gout, a cause of hay fever, 242, 248 effect on the ear, 91 Gouty sore throat, 342, 344 Gradle, Henry, 129, 253, 314, 380 Grant, J. Dundas, 100, 462, 506 Granulations, in suppuration of the middle ear, 120, 127 of vocal cords, 482 Gray, L. C, 240 Greene, J. O., 108 Grippe, 219 cause of otitis media, 73, 222 effect on ear, 94, 222 Gruber, Josef, 29, 184 Gruhn, 310 Guenod, 311 Gummata, of larynx, 498 of pharynx, 424 Gunn, Moses, 299 Guttmann, 311, 373 Guye, 191 Hack, 310 Hsematoma, of auricle, 51 of nose, 292 Haemorrhage, from adenoid operation, 330 of internal ear, 185, 194 nasal, 272 Hagenbach, 386 Haig, Alexander, 236, 237, 238, 239, 240 Hajek, 269, 510 Hall, Marshall, 486 Hallucinations, auditory, 189 Hamilton, T. K., 31u Hanau, 405 Hansell, 312 Hardie, T. Melville, 253, 331 Hare, 382 Hartmann's inflation experiments, 33 tuning-forks, 23, 24 Hasse, 431 Hay fever, 229 etiology, 242 gout, 248 medical opinions, 251 nasal disease in, 231 neurosis, 229 pathology, 229 symptomatology, 244 treatment, 246 uric acid, 236 Head-mirror, 16 Hearing, double and false, 188 instruments, 199 tests of, 21-27 Henoch, 358 Hereditary deafness, 92, 196 Herpes of auricle, 52 rieryng, 305, 422, 482, 504 Highmore, antrum of, 297 Hollister, J. H., 395 Holmes, C. R., 165-172 Hooks, double mastoid, 160 Hooper, 330 Horslev, 146 Hotz, F. C, 73 Hubbard, Thomas, 431 INDEX. 5L7 Hutchinson. 186 Hydrorrhea, 227.. 24^. 315 Hyperesthesia acoustica, 187 Hyperesthesia, of larynx. 487 of nose. 232. 244 of pharynx. 435 Hyperaudition. 187 Hyperostosis in auditory canal, 64 Hyperplasia, nasal cavities. 244 Hypertrophies, nasal cavities. 255, 324 posterior, surgery of. 324 Hypertrophy, of auricle, 52 of tonsils, 405 Hysterical, deafness. 191 aphonia. 489, 492 Ice-bag. 153 Illumination, 13-17, 156 Imperforate external meatus, 64 Incision of membrana tympani, 105, 155 over mastoid process. 155 Incus. 106. 113. 139. 141 articulation, 106, 113. 141 Inflation of tympana. 41-44 Politzers method, 41 Valsalva's method. 34 Inflators. 42. 43 Influence, of age on diseases, 3, 5, 7 of occupation. 3. 5. 7 of sex. 3. 5. 7, 11 Influenza. 219 cause of otitis media. 73. 222 effect on ear. 94. 222 Ingals. E. Fletcher, 253. 353. 422 Inhalents. 215 Inhalers, 217, 249 Instruments, ear, 111, 128 hearing-, 199 mastoid. 157-163 Insufflators, 60, 122. 429 Insurance, life-. 515 Internal ear. 183, 194 anaemia, 183 aural vertio-o. 93. 144. 145. 148. 183. 185. 186, 192, 312 concussion of labyrinth. 194 fracture at base of skull. 194 haemorrhage, 185 hyperemia, 183 hyperesthesia acoustica. 187 hysterical deafness. 191 leucocythemic deafness, 186 Meniere's disease, 185 new growths, 193 panotitis, 184 primary acute labyrinthitis. 183 suppurative exfoliation, 138 syphilis, 186 Intertrigo of auricle. 52 Intubation of larynx. 464 Iritis from nasal disease, 311 Jack, Frederick L., 114 Jackson, 186 Jackson. A. Reeves, 240 Jar vis, 506 Jewell. J. S.. 247 Joal. 241 Jones, 126 Jones. Bence, 247 Jugular, fossa, 113, 169 vein, phlebitis of, 147, 148 thrombosis of, 147, 148 Karlinski, 381 Kassowitz. 386 Keratitis from nasal disease, 310, 311 Kinnear. B. O.. 253 Kirstein. A.. 448 Kitasato. 375. 379 Kitchen, 253, 403 Klebs. Edwin Theodore, 355, 388, 389 Knapp. H.. 147, 192 Knife in septum deformities. 268 Knight. C. H.. 252, 330 Knight. F. I.. 482 Koch, 378 Koerte, 384 Korner, 146 Kossel. 378 Kramer. 196 Krause, 422. 512 Krieger, George E., 377 Kriickmann. 405 Kuh. Edwin J., 253 Krister. 147 Labyrinth, concussion, 194 injuries. 194 Labyrinthitis, nrimary acute. 183 Lacrymal canal, affection of, from nasal disease, 308. 310* Lacrvmation from nasal disease. 308 Laker. 270 Lange. 250 Langerhans, 38S. 390 Laryngeal, paralysis, 489. 491 spasm. 454. 486 Laryngismus stridulus. 4Hi> Laryngitis, acute. 452 symptoms, 452 treatment. 455 atrophic. 480 catarrhal. 452 chronic, 474 treatment. 47S cedematous. 4S2 phlegmonous. 481, 482 purulent. 481 548 IXDEX. Laryngitis, rheumatic, 456 simple, 452 spasmodic, 454 stridulous, 454, 461 suppurative, 481 syphilitic, 498, Laryngoscopic image, Plate V Laryngoscopy, difficulties of, 446 direct, 447 indirect. 443 Larynx, abscess of, 481, 482 acute catarrh of, 452 anomalies of sensation, 487 chronic catarrh of, 474 examination, 443, 447 foreign bodies in, 513 treatment, 513 laryngotomy, 507 tracheotomy, 470 growths in, 502, 507 carcinomata, 508 cystomata, 505 epitheliomata, 508 fibromata, 502 mucous polypi, 50i myxomata, 504 pachydermia, 503 papiilomata, 502 polypi, 504 sarcomata, 512 intubation of, 464 neuroses of, 486 aphonia, 476, 489, 490 hyperesthesia, 487 neuralgia, 487 paralysis, 489, 491 spasm of glottis, 454, 486 oedema of, 482 stenosis, 484, 498, 500, 501, 509 syphilis, 498 tuberculosis, 494 tumors, 502, 507 vocal bands, Plate V Lateral sinus, 140, 150, 166, 169 phlebitis of, 147 thrombosis of, 147 Laurens, 312. 313 Lavolin, 72, 215 Lederman, M. D., 149, 155 Leeches, 76, 154 Lees, D. B., 254 Lefferts, 513 Leflaive, 237 Letter, 403 Leland, G. A., 85 Leonard, C. H., 490 Leucaemia, effect on ear, 186 Lever, 236 Levy, Robert. 423 Life-insurance, 515 Light for examination, 13-17, 156 Light-condenser, 15 Lincoln, P. P., 349 Linea temporalis, 168 Loewenberg, 269 Loftier, 355, 371, 372 Love, I. N., 373 Lucse, 99, 133 Ludwig's angina, 405 Lupus, of the ear, 48 of the nasal cavities, 283 Luschka, tonsil of, 319, 324 Lyman, H. M., 395 MacCoy, Alexander W., 434 Mace wen, i46 Mackenzie, John Noland, 253 Mackenzie, Sir Morell, 406, 490, 511 Ivxaggots in the nose, 295 Malformations of the ear, 52, 54, 55 Malignant disease from suppuration of the middle ear, 48 Malignant neoplasms, in nasal cavi- ties, 279 Malleus, 68, 106, 113, 139, i41 fracture of, 104 ligaments, 68 Marckwort, 315 Marcy, 238 iviartin, 375 Massage, otoscope, 18, 98 of external meatus, 102 treatment, 18, 98 Mastoid, antrum, Figs. 109, 110 cells, Figs. 109, 110 curettes, 158 disease in otitis media, 78, 149 guide, 158 hooks, 160 inflammation, 149 cholesteatoma, 133 complications of, 143, 149, 181 instruments for operation, 155-163 operative treatment, 155, 162 primary, 149 sclerosis, 151 operations, 155, 162-181 haemorrhage in, 162, 166 portion, temporal bone, Figs. 109- 110 Maxillary sinus, 297 Mavs, Thomas J., 237 McBride, P., 126, 254 Meatus, external auditory, 56. 113 internal auditory, 150, 165, 174 Membrana flaccida, perforations of. 117, Plate I Membrana tympani, 20, 21, Plate I atrophy of, 84, 95 chorda tympani, 106 IXDEX. 549 Membrana tympani, excision of, 108, 110 folds, 21, 106 granulations, 120, 127 haemorrhage, 07 hyperaemia, 08 inflammation, 08 adhesions, 91, 97, 130, 132 injuries. 07 inspection, 20 massage of, 18 membrana, flaccida, 21 propria. 21 normal, 20, 21 paracentesis of, 77. 88. 105 perforation, 73, 77. 110. 118, 131 pockets, or pouches. 08 polypi, 120, 127 position of ruptures. 117 Prussalcs fibres. 21 space, 08 resection of. 107, 108. 110 retraction of. 71. 84. 95. 97. Plate I rupture of. 33, 07, 73. 194 shape, 20. 21 ShrapnelPs membrane. 21, 68 thickening of. 85, 95 topographical relations. 113 topography, of outer surface, 21 of inner surface, 106 umbo, Plate I Membranous sore throat. 352 Meningitis, 143 effect on ear, 192, 195 Metastasis in suppuration of the mid- dle ear. 145 Meter, air-, 30. 37-40 Michael's inflation experiments. 35 Middle ear. 73. 113. 141. Figs. 109, 110 chronic catarrh of, S3. 90 gouty and rheumatic diathesis, 91 instruments, 111, 128 Migraine, 230 Milbury, F. S.. 144 Miles. 315 Mirror, forehead-. 16 -holder. 16 throat. 207 Mittendorf, W. F.. 308 Mobilization of the ossicles. 104. 114 Moisard. 378 Monod. 378 Moos. 149. 184, 192 Mouth-breathing, 319. 325. 406 Mulhall, 475 Murchison, 236 Murdoch. E. P., 393 Mutes, deaf-. 195 Mycomyringitis, 62 Mycosis, of ear. 62 of pharynx, 414 Mvgind, 196 ' Myles, R. C„ 403 Myringitis, 68 parasitica, 62 Myxomata, of larynx, nasal, 274 504 Xarcosis, bromide-of-ethyl. 327 Nares, posterior, plugging in epistaxis. 273 Xasal adenomata, 324 atresia, 294 carcinomata, 279 cavities, abscess of septum nasi. 292 adenoma. 324 anosmia, 286 blood-tumors, 292 bony occlusion, 277 chondromata, 276 cold in head. 223 cystic polypi, 275 deformities. 287, 294 deviation of the septum. 28/ ecchondrosis. 270 erectile tumors, 276 exostosis, 277 eve diseases from nasal affections. 307 fibrous polypi, 274 foreign bodies. 294 furuncles, 285 glanders, 284 hyperplasias, 255 hypertrophies. 255 lupus. 283 maggots. 295 malignant neoplasms, 278 mucous polypi. 274 osteomata. 277 papillomata, 276 parosmia, 286 perforations of septum. 227. 292 polypi, 274 rhinoliths, 27S sarcomata. 278 sen^e of smell. 286 supporter for nose. 283 synechia?, 255 syphilis, 280 tuberculosis, 280 disease in hay fever, 231, 233 diseases from eye affections, 315 douche, 212, 271 cause of inflammation of the mid- dle ear. 73 duct. 308 haemorrhage, 272 myxoma, 274 550 INDEX. Nasal polypi, 274 reflex neuroses, 231, 312 septum, 255, 287, 297 speculum, 206 stenosis, 255 Naso-pharyngeal diphtheria, 362 Naso-pharynx, 317 climate, effect of, 317 Eustachian tube, 70,' 256, Plate II fossa of Rosenmuller, 44, Plate II tonsil of Luschka, 319, Plate II diseases of, in otitis media, 69 atrophic catarrh, 321 diphtheria, 362 examination, 205 facial expression, 325 follicular catarrh, 317 polypi, fibromucous, 323 fibrous, 322 tumors, 322 voice, 326 Neck-abscess, 181 Necrosis of adjacent structures in middle-ear disease, 138 Neisvr anger, C. S., 262 Neoplasms, of larynx, 502, 507 of nose, benign, 274 malignant, 278, 279, 507 Nerve, auditory, 187 facial, 134, 166, 167, 170, 177, 191 olfactory, 286, 293 Nervous catarrh, 229 Net bandage, 180 Neuralgia, of larynx, 487 of pharynx, 435 Neuroses, nasal reflex, 231, 312 of ear, 187 of larynx, 486 of nose, asthmatic, 244, 245, 259, 291 eye disease, 312 hyperesthesia, 232, 244 migraine, 236 reflexes in the eye, 312 respiratory, 231, 244 treatment', 246, 315 of olfaction, 286 anosmia, 286 parosmia, 286 of pharynx, 435 Neurotic character of hay fever, 229 Nevius, the, light, 156 Newcomb, J. E., 330 Newman, 512 Nieden, 311 Noises in the ear, 74, 86, 92, 133, 188 North, John, 254, 271, 353, 369 Northrup, 458, 468 Nose, 205 diseases of, abscess of septum, 292 accessory sinuses, 297 Xose, diseases of, affecting the eye, 307 animate foreign bodies in, 295 anosmia, 286 asthma, 244, 245, 259, 291 carcinoma, 279 deformities, 287, 294 diphtheria, 362 epistaxis, 272 examination, 205 foreign bodies, 294 furunculosis, 285 glanders, 284 hematoma, 292 lupus, 283 maggots, 295 nose-bleeding, 272 ocular symptoms, 307 ozena, 268 parosmia. 286 polypi, 274 rhinitis, acute, 223 chronic, hypertrophic, 255 simple, 226 rhinoliths, 278 sarcomata, 278 septal perforations, 292 sprays, 215 supporter for bridge and tip, 283 syphilis, 280 tuberculosis, 280 ducts, 308, 309 examination and instruments, 205 fractures, 293 hematoma, 292 pathological conditions affecting the eye, 307 relation to the ear, 69 Nose-bleeding, 272 Noyes, H. B. f 314 Nuttall, 382 Occlusion of nasal cavities, 255, 294 Occupations, influence of, 3, 5 , classified, 3 O'Dwyer, Joseph, 461, 464 (Edema, of eyelids from nasal disease, 312 glottidis, 482 of larynx, 482 Ohmann-Dumesnil, A. H., 420 Olfaction, neuroses of, 286 Olfactory nerve, 286 Ophthalmia, gonorrheal, from nose, 311 Optic nerve, compression of, from sphenoid disease, 303, 312 Orbital cellulitis, 311 Ossicles, auditory, 106, 113, 139, 141, Figs. 109, 110 IXDEX. 551 Ossicles, articulation. 106, 113 caries of, 117, 120. 130 chronic aural catarrh, 83, 90. 104 excision of, 108, 130 hook. Ill incudo-stapedial articulation. 106. 113 vibrator, 104 Osteomata, nasal cavities. 277 Othematoma of auricle. 51 Otitis, externa, acuta, 58 chronica. 58 circumscripta, 60 diffusa, 58 parasitica. 62 media, acuta. 73 from nasal douche. 73 paracentesis. 77 chronica, S3, 90 purulenta, acuta, 78 chronica, 116 Otomycosis, 62 Otorrhcea, chronic, 116 Otoscope, massage, 18, 98 Overtreatment, 87 Ozena, 268 cause of eye diseases. 311 Pachvdermia larvnais. 503 Palate, Plates II, IV. V Panas, 310 Panophthalmitis. 311 Panotitis, 184 Papillomata, of larynx. 502 of nasal cavities. 276 Paquin, Paul, 497 Paracentesis membranae tvmpani. 77. 88 Paracusis, duplicata. 188 Willisii, 188 Paresthesia, of larynx, 487 pharynx, 436 Paralvsis. of auditorv nerve. 191 facial nerve, 121. 134. 177 larynx, 489, 491 pharynx, 437 Parasitic otitis externa. 62 Paresis of auditory nerve. 191 facial nerve. 134. 191 Park, Roswell, 512 Parosmia. 286 Peiper. 238 Pemphigus of auricle, 52 Perforation of membrana tvmpani. 73. 78. 116. 118 of nasal septum, 227. 292 Perichondritis of auricle. 50 Periosteum separator. 159 Pharyngeal tonsil, 319. 324 Pharyngitis, acute. 335 effect on ear, 33 Li treatment, 337 chronic, 341 follicular, 349 herpetica, 352 in measles, 347 membranous, simple. 352 rheumatic, 342, 344 ' scarlatina, 348 small-pox, 349 syphilitic, 424 tubercular, 420 Pharyngomycosis. 414 Pharynx, 335, Plates II. V acute inflammation. 335 burns and scalds, 437 diphtheria. 355 effects of nasal disease on, 350 foreign bodies, 438 herpes, 352 malignant disease. 430 morbid growths, 416 innocent growths, 416 fibroma, 416 papilloma. 416 malignant growths, cancer, 430 carcinoma, 430 epithelioma. 430 sarcoma. 323 neuroses, 435 of motion, 436 of sensation. 435 parasitic disease. 414 uvula, bifid and double, 418 uvula, inflammation. 416 malformations, 418 Phlebitis of sinuses, 147 Phlegmonous inflammation of antrum of Highmore, 300 Phlyctenular disease from rhinitis. 310, 311 Phonograph, 101 Photophobia from nasal disease. 312 Politzer. Adam, 33, 34, 41. 92, 184, 192 Politzerization. 41 Pollen as a cause of hav fever. 233 Polypi, aural. 120. 127" cystic, nasal. 275 mucous, of larynx, 505 nasal. 274 naso-pharvnx. 322. 323 Pomeroy, 0*. D.. 108 Porcher. W. P., 488 Porter. 459 Post-nasal catarrh. 317 Powder-blowers, 60. 122. 429 Powders, antiseptic. SO, 81, 122-124. Appendix INDEX. Preparation of patients and instru- ments for operations, 156- 158 Prognosis in ear diseases, 8 Prophylaxis of acute rhinitis, 225 Prudden, 355 Prussak's space, 68 Pseudomembranous croup, 458 Psvchic influence in hay fever, 230 Puech, 311 Pulling the ears. 51, 67 Pumps, air-, 36-40 Purulent otitis media, acute, 78 chronic, 116 pyaemia in, 121, 140 Pynchon, Edwin, 413 Quain, 248 Quine, William E., 396 Quinquaud, 236 Quinsy, 399 Ramsev, 310 Randall, 51 Ranke, 461 Ray, J. M., 518 Records of cases, 3, 28 Reflex affections of the eye and nose, 312 nose, 229, 231, 259, 277, 291, 312 voice, 490 Reflexes, laryngeal, 490 ocular, 312 sexual, 490 Regulator, air-, 30 Reichat, 449 Related diseases of the eye and nose, 307 Relative frequency of diseases, 3, 7, 8 Resection of drum-head, 107, 108, 110 Reservoirs, air-, 36-41 Retractors for mastoid operations, 160 Retropharyngeal abscess, 152, 182. 433, Plate V Reynolds, A. R., 390 Rheumatic sore throat, 342, 344, 456 Rheumatism and gout, effects on ear, 91 Rhinitis, acuta, 223 clothing, 225 complications, 225 atrophica, 268 hypertrophica, 255 simple chronic, 226 Rhinoliths. 278 Rhinoscopic instruments, 20o Rhinoscopv, 207 Rhodes, J. E., 465 Rice, 482 Richards, H., 45 Richey, S. O., 100 Rhine's test for hearing, 25 Ritter, M. M., 393 Robinson, Beverly, 254 Robison, John A., 397 Roe, John O., 253, 479 Roof of tympanum, 113, 150, Figs. 109, 110 Roosa, D. B. St. J., 66, 311 Rosenmiiller's fossa, Plate II Rosenthal, Edwin, 381 Roux, 355, 375, 376 Roy. 238 Ruedo, 138 Rumbold. Thomas F., 310, 326 Frank, 151 Sajous, Charles E. de M., 253, 341, 422, 429, 479 Salpingitis, 69 Sarcoma, of larynx, 512 of nose, 278 Saw in nasal deformities, 268 Scarlatina, pharynx in, 348 Schadle, J. E., 329 Scheibe, 151 Scheppegrell. William, 268, 296 Schrotter, 485, 501 Schwabach's test for hearing, 23 Schwalbe, 431 Schwartze, 162, 184, 192 Schweinitz, G. E. de, 308 Sclerosis, of mastoid, 151 middle ear, 90, 104 Scroll-ear, 54 Sea-bathing, effect on ear, 73 Seiler. Carl, 254 Seiss, Ralph W., 252, 266. 267, 310 Semon, 326 Septum, nasi, diseases and deformities, 255, 287, 294, 297 knife, 268 perforation, 227, 292 Sequels of middle-ear suppuration, 127 Sequestra from ear, 139, 142 Serous otitis media, 83 Sex, influence, in disease, 3, 7, 490 Sexton, Samuel, 114, 137 Sexual anomalies, effects on voice, 490 Sherrington, 238 Shrapnell's membrane, 21, Plate I Shurley, E. L., 252, 479, 480 Sinus, inferior petrosal, 150 lateral, 140. 150, 165, 166, 169, 170, 173 Sinuses, accessory, of nose, 297 ethmoid. 301 frontal, 303 maxillary, 297 sphenoid, 303 IXDEX. 553 Sinus-phlebitis and sinus-thrombosis, 147 Small-pox, throat in, 349 Smell, sense of. 286 Smith. A. H.. 07 J. Lewis, 358, 3G8, 371 Snare, ear, 127 Sokolowski, 405 Solutions, antiseptic. Appendix Sore throat, acute, 335 chronic, 341 clergymen's, 349 common membranous, 352 folliculous. 340 gouty, 342. 344 granular. 349 measles, 347 rheumatic, 342, 344 scarlet fever, 348 small-pox, 349 Spasm of larynx, 454 of pharynx, 436 Spasmodic croup. 486 Spear, E. D., 186 Specula, aural, 17, 18 nasal, 206 Siegle's pneumatic, 98 Speech in testing the hearing, 27 Sphenoid sinuses, 303 diseases of. effect on eye, 303 tumors. 303 . Sphenopalatine ganglion, 231 Sprays, 215 for ear. 34. 35. 88 Spurious croup. 452 Stacke's operation, 172 Stapes, 91, 105, 139, 141. 167 mobilization of, 110, 114 removal of. 115 Statistics, 3, 391 Stenosis of Eustachian tube, 35. 72 of larvnx, 484, 498. 500. 501. 509 of nasal cavities, 224, 245, 259. 274. 319, 326 Sterilizing instruments, 158, 327 Strabismus from nasal disease, 312 Stridulous larvngitis, 454, 461 Strueh, 387 Subjective sounds, 74, 86, 92. 133. 188 Synechia of nasal cavities, 255, 313 Syphilis, of auricle. 52 internal ear, 186 larynx, 498 nasal cavities, 280 pharynx, 424 Syphilitic stenosis of larynx, 500 Syringes, 58 Tables, statistical. 4. 5. 6. 11. 391 Tablets, corvza, 338 Tablets, cough-, 339 throat-, 339 Talbot, E. S., 52 Tamponing nares. 273 Taylor, James L., 387 Tegmen. mastoideum, 150, 170, Figs. 109. 110 tvmpani. xl3, 150. Figs. 109, 110 Temporal bone, 140, 141, 165-170, Figs. 109, 110 caries of, 138 Tensor tvmpani, 70 tendon of, 68 tenotomy of, 108 Tests of hearing, 21-27 acoumeter, 26, 27 Bing*s test, 25 expressions for. 22 Galton's whistle, 26 Gelle's test. 20 Rhine's test, 25 speech, 27 tuning-forks, automatic, 23 Hartmann's, 24 watch, 22 Weber's method, 25 whispers. 27 Thomas. H. M.. 214, 415 Thorner. Max. 335. 340, *47. 451 Throat-tablets, 339 Thrombosis of sinuses, 147 and jugulars, 148 Tinnitus aurium, 74, 86. 92, 133, 188 Toeplitz. Max. 138, 187, 415, 513 Tongue-depressor, 207 Tonsil, calculi, 415 hypertrophy, of oral, 405 pharyngeal, 324 mvcosis. 414 of Luschka, 319, 324 pharyngeal. 319, 324 syphilis. 424 tuberculosis. 420 Tonsillitis, acute, 399 treatment, 402 Tonsillotome, 409 Tonsillotomy, 408 Tonsils, acute inflammation, 399 chronic inflammation, 405 adenoids in vault of pharynx. 324 aural symptoms from, 326 treatment. 407 anaesthetics, 408 haemorrhage from tonsillotomv, 411 hot snare, 413 tonsillotome, 409 tonsillotomy, 408 Wright's electric amvgdalotome 413 554 INDEX. Tonsils, hypertrophied, 405 lacunae of, 407 large, 405 parasites in, 414 varieties of inflammation, 399 Toynbee's auscultation-tube, 45, 46 Tracheotomy, 470 choice of operation, 471 high operation, 471 low operation, 473 Trachoma from nasal disease, 311 of vocal cords, 482 Transfixion needles in nasal hypertro- phies, 267, Plate V Trelat, 420 Tuberculin in tuberculosis, 423, 497 Tuberculocidin in tuberculosis, 423 Tuberculosis, effect, on ear, 119 larynx, 494 nasal cavities, 280 pharynx, 420 Tumors of antrum of Highmore, 300 auricle, 51 larynx, 502 nasal cavities, 274, 322, 323 pharynx, 416 Tuning-fork, automatic, 23 Turbinated bodies, 255-258, 290 ?91 297-302, Plate II Turk, F. B., 220 Turnbull, 200 Tympanic cavity, 113, Figs. 109 110 floor of, 113 inner wall, Figs. 109, 110 mucous membrane. 121 outer wall, 70, 106 Tympanum. See Tympanic cavity Tyrrell, Shawe, 238 Umbo of membrana tympani, Plate I Urbantschitsch, 198 Uterine reflex neuroses of larynx 489 490 Uvula, Plates II, IV, V Uvula, bifid and double, 418 Uvulitis, 416 Valsalva's inflation, 101 3>v C \ Van der Poel, 330 Vapors, use of, in ear, 37, 38 Variola, pharynx in, 349 Vegetable parasites in ear, 62 Veilon, A., 399 Velum palati, Plates II, IV V Vertigo, 93, 144, 145, 148,' 183 185 186, 192, 312 Vestibule, 165, 169 Vibrator, ossicle, 104 Virchow, Rudolph, 133, 358, 405, 503 Visual field, contraction from nasal disease, 313 Vocal cords, granulations of, 482 trachoma, 482 Voice in laryngeal diseases, 452 476 477, 502, 508 m nasal diseases, 259, 326 in sexual abnormalities, 490 Voice, reflex affections of, 490 "Vulpius, 153 Wagner, Clinton, 224 Walls, F. X., 393 Watch-test for hearing, 22 Wax in ear, 56 Weber's test for hearing, 25 Webster, 184 Welch, W. H., 355, 390 Whisper-test for hearing, 27 Whistle, Galton's, 26 Whi taker, H. W., 415 White, J. A., 249 Wilde's incision, 155 Wile, William C, 369 Winters, 386 Witzel, 331 Wolfenden, Norris, 405, 497 Wright, Jonathan, 252, 293, 413 Wurdemami, H. V., 97 Wyman, Morrill, 232 Yersin, 357 Zaufal, 147 Ziemssen, 475, 477, 509 Zuckerkandl, 287 U