w - A;s : . THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES PI a te 1. VERTICAL ANTERO -POSTERIOR SECTION OF THE NASAL CAVITIES, MOUTH, PHARYNX AND LARYNX. C. E Sajous, Pmxit Mirk t M c Fetndge. L the blood in the stage of dilatation. Relieves the irritability of the nervous filaments and favors the action of the above. Maintains the . Opli. TT^XXiv. < continuity of the blood-current, thus preventing its transudation through the vessel-walls, and hindering the migration of white corpuscles. Sacch. Alb. Aq. Camphorae M. Sig. One teaspoonful in a half glassful of water every hour three times, then every two hours. The nose should be greased externally with lard or cold cream to limit the evaporation over its surface, while pulv. talc., snuffed or insufflated into the nostrils, protects them against the irritation caused by the respiratory current. When the headache is severe, fifteen grains of bromide of potassium added to each dose, are very effective, by inducing contraction of the arterioles of the membrane lining the accessory cavities and lessening its distention. When the fever is great, the chloride of ammonium might be replaced by tincture of aconite root, one minim to the dose, but not combined with it, on account of the antago- ACUTE RHINITIS. 69 nistic action of the two drugs on the circulation. The local effect is produced by the opium, assisted by the diaphoretic and diuretic properties of the aconite, which at the same time reduces the fever. The patient should not leave the house until at least six hours after taking the last dose of medicine, the action of the drugs having then ceased. He should be warmly clad. The derivative action of a purgative sometimes aborts a severe attack of rhinitis, the salines being the most effective by causing liquid stools. A large dose of quinine, gr. x-xv, repeated in six hours, has also given good results. If the patient is first seen when the affection has run into the stage of dilatation with free discharge, the hydrochlorate of pilocar- pine in doses of gr. , in water, repeated every two ho urs until free diaphoresis has been obtained, is sometimes very effec- tive. It first increases the fullness in the nostrils and the flow of secretion, these being soon relieved by profuse perspi- ration. When the latter has decreased somewhat the patient is briskly rubbed with a rough towel, under the blankets, until the skin becomes quite red. He is then allowed to sleep and will generally awaken much relieved, and at times cured. Ordinary cases of acute rhinitis can generally be aborted if seen in the first stage, and often in the second, by the fol- lowing powder : {Counteracts the local paretic influence upon vaso- motors, and stimulates the local and general circula- tion ; relieves the frontal headache by reducing the nervous irritability. A Inrmnis Antagonizes the vascular dilatation of the first stage ( and prevents or arrests serous transudation. Bismuthi Garb. f r> i m i -- > 1 Protectives. Pulv. Talc aa 9j. ( M. et ft. chart. No. xx. S. Insufflate one powder in each nostril every two hours, after clear, ing the nose. 70 DISEASES OF THE ANTEBIOR NASAL CAVITIES. Stimulating inhalations are sometimes very effective, by inducing a copious flow of serum, which relieves the tension of the membrane, causing contraction of the blood-vessels. The fumes generated by mixing pure iodine and carbolic acid are especially beneficial. A couple of drops are placed on a small piece of absorbent cotton, previously introduced into the bulb of the insufflator shown in Fig. 25, and the opening is closed with a stopper. The patient uses the instrument himself, his breath mixing with and warming the fumes, which are thus better prepared to meet the irritated mem- brane. This method is especially useful when the Eustachian tubes and accessory cavities are involved in the inflammatory process. By closing the other nostril with the finger, the nasal cavities are tightly closed when the act of blowing is performed through the mouth, and the velum palati adapts itself closely against the pharynx. Finding no other issue, the medicated atmosphere must of necessity penetrate into the accessory cavities and Eustachian tubes, especially the latter. The essential oils of tar, eucalyptus, and cubebs can be used with advantage in the same manner. I have of late been using, with much success, a four per cent, solution of the hydrochlorate of cocaine. This agent, by stimulating powerfully the vaso-motors of the membrane, antagonizes the vaso-motor paresis, thus counteracting the vascular engorgement and the transudation. It is serviceable in all the stages of the affection. It is best applied with the cotton-carrier, a thin film of absorbent cotton being employed. The membrane, previously dried as effectively as possible with another cotton-carrier, is freely covered with the solu- tion. At the end of a couple of minutes, the distended membrane having suddenly depleted itself and collapsed, the "stuffiness" completely disappears, and does not return until about three-quarters of an hour later. A renewal of the SIMPLE CHRONIC RHINITIS. 71 application is followed by the same result, while, after a third application, the distention and consequent stenosis do not generally recur. Five or six consecutive applications are sometimes necessary. Galvano-caustic applications, by suddenly stimulating the vaso-motors, are also very effective, the flat side of the knife at cherry heat, being applied two or three times to the most prominent portions of the distended membrane. SIMPLE CHRONIC RHINITIS. (Synonyms: Chronic Coryza; Chronic Blennorrhoea ; Chronic Rhinor- rhrea; Chronic Nasal Catarrh ; Purulent Catarrh ; Fluxus Nasalis.) Etiology. Chronic inflammation of the nasal mucous mem- brane is generally the result of repeated acute attacks. At times, however, it seems to occur without any apparent primary condition, assuming from the first the symptoms of chronicity. It is a frequent sequel to the rhinitis of the newborn, while in persons of debilitated constitution and in the aged, it often presents itself in the form of a watery flux, non-irritating in character, but sometimes very profuse. Certain occupations favor its 'development by exposing the mucous membrane to the irritating action of an atmosphere loaded with dust, smoke, etc. Weavers, for instance, are seldom free from it, while the majority of carpenters and cigar-makers are affected more or less. It is frequently seen in smokers, not as a result of the habit proper, but on account of the irritating character the surrounding atmosphere ac- quires when contaminated with smoke. Certain substances, among which may be mentioned arsenic, bichromate of potash, the fumes generated by the action of muriatic acid on lead solder, and the emanations of caustic acids, when inhaled for a certain length of time, as is the case with 72 DISEASES OF THE ANTERIOR NASAL CAVITIES. workmen manufacturing or using them, frequently produce chronic rhinitis, followed at times by perforation of the nasal septum. Pathology. Frequent inflammatory manifestations in the nasal mucous membrane, whether due to the action of cold or to that of a local irritant, gradually reduce to permanency the abnormal condition of the vascular supply accompanying an acute attack. The repeated distentions to which the vessels have been subjected, cause them to lose their con- tractile power, and they remain distended. Their walls be- come softened and more permeable, and blood-elements escape continually by a process of nitration. These blood- elements, however, now contain more white corpuscles, many of which crowd into the connective tissue under the epithelial layer, thus inducing induration and thickening, while others, having become metamorphosed into pus cells and unripe epithelial cells, penetrate through the epithelium, and with the glandular secretion, form the muco-purulent discharge frequently accompanying the affection. The tur- binate corpora cavernosa take part in the inflammatory process but slightly, although their power of erection is more susceptible to manifest itself upon the least exposure. Symptoms. When the affection is the result of frequent colds, the membrane becomes turgescent upon the least exposure, and all the local symptoms of the acute condition appear. Each exacerbation distending the membrane more and more, resolution becomes slower with each attack, until a state of permanent "cold in the head" is engendered, accompanied by more or less discharge of thick, tenacious, translucent mucus, which sometimes assumes a purulent character, and is generally drawn through the posterior nares into the mouth, and expectorated or swallowed Sneezing is a frequent symptom, most evident during the SIMPLE CHRONIC RHINITIS. 73 exacerbations, and in a large proportion of cases, the tip and alse of the nose are pinkish and sometimes quite red. These symptoms are in abeyance during warm weather, to resume all their vigor with the first damp days of Fall. In the variety sometimes termed "traumatic rhinitis," in which the trouble is due to constant local irritation, the most marked symptom is increased secretion,, in the form of a thick, creamy substance, also generally voided through the posterior nares. When the condition has lasted for some time, the discharges become purulent, and occasionally form small greenish masses, which can be seen adhering here and there, connecting like bridges the two sides of the cavity, and occasionally imparting to the breath a peculiar heavy odor. A hot, dry, spicy sensation is frequently complained of, located not only in the nose, but also in the pharyngeal vault and pharynx, these appearing, upon examination, con- gested and parched. Itching caused by the accumulation of irritating particles in the anterior portions of the nostrils, prompts the frequent introduction of the fingers, and the septum sometimes becomes perforated through repeated scratching, and as a result of the long-continued contact with the bulk of the irritating fumes or particles as they enter the cavity. Pain over the brow is often present, coupled with a feeling of weight, due to inflammatory narrowing of the infundibulum, the canal connecting the frontal sinus with, the nasal cavities. The Eustachian tubes are occasionally involved, through extension of the inflam- mation into them. The symptoms continue, regardless of seasons (provided, of course, that the causes of irritation are continued), differing in this from the chronic rhinitis due to repeated colds. In a small proportion of cases, and especially in persons of advanced age, the complaint consists of a profuse watery 74 DISEASES OF THE ANTERIOR NASAL CAVITIES. secretion, so abundant at times as to cause great annoyance. A sensation of itching is felt as the fluid trickles along the intra-nasal walls, which adds much to the patient's distress. The other symptoms of chronic rhinitis are usually absent. The appearances of the parts, anteriorly and posteriorly, differ with the causes of the affection. In the variety re- sulting from repeated colds, the membrane covering the middle and inferior turbinated bones and the septum, may not appear redder than in the normal state. This is espec- ially the case with children, notwithstanding the great amount of discharge which accompanies the affection in them. In adults the membrane is usually congested, some- times almost livid, and if seen during an exacerbation, bulges out, often sufficiently to touch the septum. The bulging portion pits under pressure and resumes its previous state sluggishly when the pressure is removed. In the traumatic variety, the membrane is always found highly congested, and bleeds when touched with a probe. It is not so prone to turgescence, the inflammatory process being confined principally to the superficial layers and involving but slightly the corpora cavernosa. When the condition is due to exposure to cold, on the contrary, the external in- fluence is transmitted through the sympathetic to the vaso- motors of all the layers, and the corpora cavernosa take part in the inflammatory process as much as the other layers. In the chronic rhinitis characterized by a watery flux, the membrane is usually pale, sometimes blanched. The pharyngeal vault takes part more or less in the three varieties of the affection, and its color corresponds with that of the anterior nasal cavities. Prognosis. If left to itself, chronic rhinitis either remains stationary, or gives rise to hypertrophic changes in the layers of the membrane. It is generally the starting point SIMPLE CHRONIC RHINITIS. 75 of polypi, and is frequently the origin of catarrhal occlu- sion of the Eustachian tubes. When properly treated, the chances of recovery are very favorable, provided the irri- tating cause be removed. Eecurrence, however, is very frequent when the affection occurs as the result of repeated attacks of acute rhinitis brought on by cold. This is es- pecially the case with the aged, and in debilitated constitu- tions. Treatment. The success of the treatment depends greatly upon a proper recognition of the cause of the trouble in each individual case. Cleanliness is of prime importance, especially when the affection is due to local irritation by extraneous matters, but great circumspection should be used in selecting the proper instrument. A too powerful stream would act as a local irritant, and while performing its office as a cleansing agent, would increase the inflam- matory process and encourage hypertrophic changes. The atomizer is undoubtedly the best instrument for the pur- pose, providing its spray be coarse enough to bathe the membrane thoroughly, and wash away accumulated dis- charges. As to the solution to be employed, preference should be given to one combining with its cleansing prop- erties, that of reducing local congestion. The following combination has proven itself very effective in the fulfill- ment of these conditions : &. oOdll UlCarb. ( Alkalinize the solution and give it proper specific Sodii Bibor. aa gr. Vlij. ( gravity. Antiseptic and solvent. J}xt fl(] Pinug Canad C Astringent and antiseptic. Contracts the capillaries J and the glands, diminishing secretion and encouraging "l xv ' C the absorption of inflammatory products. Glycerinae 5lJ- Aquam ad iv. In the variety originating from repeated colds, the above should be applied with the atomizer sufficiently often to keep the membrane free of accumulated discharges. This 76 DISEASES OP THE ANTEKIOR NASAL CAVITIES. requires generally two or three applications daily, each of three or four minutes' duration. A few days of thorough cleansing generally limit the active congestion markedly, and the membrane is prepared to undergo active treat- ment. In mild cases, the mere continuation of the spray is sometimes sufficient, through the astringency of the ex- tract of pine, to cause the membrane to regain its normal state, but such is not the case when the condition has pro- gressed for a certain length of time; more active measures must be adopted to counteract the inflammatory process; the new products must be absorbed and the tone of the vessels returned to its normal standard. Of many prepa- rations and combinations tried for the purpose, the glycerite of carbolized iodo-tannin, prepared as follows, has produced for me the most satisfactory results : R. lodinii jidi Tannici Aquse Oss. Mix, filter, and evaporate to Glycerinae 3 Stimulates the absorbents, inducing absorption of in- flammatory products. Causes contraction of blood-vessels, superficial and deep, giving them tone and hardening their walls, thus limiting infiltration and nutrition. Stimulates absorp- tion of new elements by mechanical constriction. and add Add! Carbol lia HI il "" f ' In weak solution reduces superficial hyperaesthesia, renderin g membrane less sensitive to atmospheric per- ^ turbations and irritating particles. Antiseptic and V. slightly astringent. This preparation forms a clear solution, which remains in contact with the membrane for a considerable period on account of its oily consistence. In order to obtain the best effects, it should be applied several times daily, each time after thorough cleansing. The patient must conse- quently be taught to conduct the applications himself, and to use a feather, the most efficient and the safest instrument for the purpose. This being dipped in the solution, is in- troduced into the nasal cavity and so manipulated as to SIMPLE CHKONIC RHINITIS. 77 bathe the mucous lining thoroughly. In most cases the end of the feather can be pushed back into the posterior nasal cavity, and these parts can thus take part in the treatment. The applications should be made on rising, twice during the day, and on retiring, thus maintaining a steady action, an essential factor in the treatment. Busi- ness men, who cannot return home during the day, can keep a small vial of the solution at their place of business, the feather being so connected with the stopper as to dip in the preparation when the latter is not in use. They are thus able to continue the applications at regular intervals during the day, after clearing the nose as well as possible with the handkerchief. The patient should be seen twice or three times a week, and thorough applications made to the an- terior and posterior nares, using for the former the small cotton-carrier (Fig. 20), and for the latter a cotton pledget, held in the grasp of the post-nasal forceps (Fig. 22). At times, the good effect may be enhanced by alternating with other remedies, such as the iodide of zinc (gr. v-5j), and the sulpho-carbolate of zinc (gr. ij-fj), both of which pro- duce their therapeutic action by inducing absorption of the inflammatory products and stimulating the blood-vessels. A two per cent, solution of hydrochlorate of cocaine, applied night and morning, produced excellent results in the two cases in which it was used. Powders are sometimes preferable in the treatment of these cases, especially when the discharge is very profuse. The following will be found effective : R Hvdrirff Clllor Mit Action the same as the iodine in the preceding for- ( mula, f Substituted for the tannin on account of its greater Pulv. AluminiS aa 388. power over serous glands. Its effect on blood-vessels S P< <- the Morphise Hydrochlor. ( same. Reduces hyperaesthesia. <- 78 DISEASES OF THE ANTEEIOB NASAL CAVITIES. Bismuthi Subnit. 3j- ] Protective. Sodii Bibor. 3 s8 - 1 Disinfectant. M. et fiat pulv. j. After cleansing the nose thoroughly, if possible, with the atomizer, if not, with the handkerchief, a pinch of the powder can either be snuffed or introduced into the nostrils with the auto-insufflator (Fig. 27). The latter method is of course much more effective, the powder being more evenly distributed. Blowing the nose should be avoided for at least ten minutes after the application. Repeated four or five times daily, this procedure soon limits the excessive discharge, and after some time frequently restores the mem- brane to its normal state. When during an exacerbation the degree of stenosis is great, indicating extensive distention of the membrane, the application of an escharotic over a limited area is indicated. One application of nitric acid generally suffices for each nostril. The small cotton-carrier shown in Fig. 20 is the most desirable instrument for the purpose, the diminutive thickness of the blade enabling the operator to wrap a thin film of cotton-wool around its tip, and still form a very small volume. The nostril being well dilated and illumi- nated, the end of the cotton-carrier is dipped into the acid and pressed against a piece of blotting-paper, so as to part with any excess of acid and prevent dripping. It is then introduced into the nose and drawn rapidly along the whole length of the most prominent portion of the inferior or middle turbinated bone, or both, as the case may be, taking care not to touch the septum. A sharp pain follows if the acid is applied pure, which will be avoided if hydrochlorate of cocaine has previously been dissolved in it to saturation. A long narrow eschar is the result, which upon healing forms SIMPLE CHRONIC BHINITIS. 79 a cicatrix which prevents future distention, this being as- sisted by the consolidation induced in the deeper layers of the membrane by the acute inflammatory process following the cauterization. Gralvano-cautery, which will be described under the next heading, can be used with advantage instead of the acid, the edge of the knife, at cherry heat, being introduced into the mos prominent portions of the membrane. In all applications of this character, there is danger of inflammatory adhesion with the septum, when the parts are in close apposition. To guard against this, the patient should be seen in a couple of days, and if any tendency to adhesion should show itself, i.e., bands of soft tissue con- necting the burnt area with the opposite surface, they should be torn by passing a probe through them, and a cotton wad, anointed with cosmoline, interposed. In the treatment of this form of nasal affection, more than in any other, easily digested food, cleanliness and avoidance of exposure to sudden changes of temperature are fully as important as the local treatment, and should receive care- ful attention. In the majority of the cases of so-called " nasal catarrh" we are called upon to treat, the nasal obstruction is due to a permanent turgescence of the membrane, in which all the phenomena accompanying one of the exacerbations above described are present. This condition is frequently mistaken for hypertrophic rhinitis, and treated as such. It can be recognized, however, by noting the sluggish recoil of the tur- gescent membrane when pressure upon it with a probe is suddenly discontinued, and the completeness of its collapse under the influence of a four per cent, solution of hydro- chlorate of cocaine. Systematic pressure by means of bougies is sometimes very effective in this form of the affection. Those generally 80 DISEASES OF THE ANTERIOR NASAL CAVITIES. used are either metallic, or made of medicated gelatine. The former give rise to much pain, and for that reason are not recommendable. As to the latter, their soft consistence and their small diameter enable them to be introduced into the nasal passages without difficulty. Gentle pressure is exerted, and the medicament is kept in contact with the membrane until the bougie has become completely liquefied. They are introduced with a rotatory motion, and left in position until complete liquefaction has taken place, which generally requires about twenty minutes. The head should be tilted backward while the bougie is in place, so as to enable the liquefied gelatine to escape through the posterior nares. This procedure should be repeated twice daily. I have ob- tained more satisfactory results, however, by using flat bougies instead of round ones, and by having them so made that a much longer* contact with the membrane is necessary to cause their liquefaction. The first modifica- tion increases their mechanical efficiency, by enabling them to be passed between the septum and the edges of the middle and inferior turbinated bones, the usual sites of greatest turgescence, thus locating the pressure where it is most re- quired. Bound bougies are held with difficulty in this posi- tion, and in the majority of cases slip into the meati. Their rapid liquefaction causes them to as rapidly reduce their diameter, and the pressure is reduced in proportion. By means of the second modification, the decrease in size is very slow and gradual; the pressure is therefore more continuous and even, and the contact of the medicament with the infil- trated membrane more prolonged. The applications are best begun with the smallest caliber, one of these being introduced twice daily. The first day, it should remain in situ but a couple of minutes each time, to accustom the membrane to its pressure. Pain is seldom complained SIMPLE CHKONIC BHINITIS. 81 of, the discomfort consisting principally of an intense itching sensation and lachrymation, which disappear after a few sit- tings. Two minutes being added each day, at the end of the first week, each application lasts about a quarter of an hour. No. 2 should then be introduced, beginning and gradually increasing as with No. 1, two minutes the first day, four the second, etc. With the third week, No. 3 is brought into requisition and used in the same manner, while No. 4 can be employed the fourth week, if necessary. When the cavity has become sufficiently dilated, the use of the Fig. ag. 1234 Flat and crescentic nasal bougie*. last bougie employed should be continued for some time, gradually diminishing the number of applications until one is made during the day, then every other day, etc. When the mucous membrane is very sensitive, the first few applications can be preceded with advantage by a local application of a two per cent, solution of hydrochlorate of cocaine. In a large proportion of the cases, the turgescence pro- jects downward from the free border of either the middle or the inferior turbinated bodies, or both, occluding more or 82 DISEASES OF THE ANTEKIOE NASAL CAVITIES. less the meati. When this condition is present, I use the erescentic bougies shown in Fig. 29, introducing them my- self once every day, so that the pendant portion rests in the concavity, and direct the patient to use the flat bougies every morning. The latter he can apply with the greatest ease, the shape of the instrument forcing it to enter where it is needed. As to the former, however, they are less easily applied in their proper position, and should only be intro- duced by the physician. The bougies, whether round, flat, or erescentic, containing either of the following ingredients, have been found most serviceable in this affection: Hydrastis Canadensis, gr. v; Erythroxylon Coca, gr. x; Ext. Belladonnse, gr. ; Boro- Glyceride, gr. v; Ergotin, gr. v. A complete list, with indi- cations, will be found in the Appendix. The drawback attending this method of treatment, how- ever, is that the relief is but temporary. If no measure be taken to maintain the membrane in the position to which the bougies have returned it, in a year, at most, the mem- brane will have relapsed into its former condition. This can be avoided, however, and the cure rendered complete, by applying an escharotic to the membrane, in two or three places, limiting each application to an area not larger than a millet seed, and located as far apart as possible on the sur- face of each turbinated bone affected. This will be followed by cicatricial bands, which will bind the membrane down, as it were, and cause it to maintain its proper thickness. Galvano-cautery is the most satisfactory agent for the pur- pose, but when this is not at hand, nitric acid can be used in the manner indicated. When the affection is due to local irritation, it stands to reason that a permanent cure can only be expected on the condition that the exposure to the irritating substances be SIMPLE CHRONIC RHINITIS. 83 discontinued. In most cases, however, a change of occu- pation is an impossibility, and the only course to be pursued is to mitigate the deleterious effects by keeping the nasal cavities as clean as possible, and by protecting the mem- brane against the offending substances during exposure. The method of cleansing and the formulae described above, are especially valuable in this class of cases. The patient should be carefully taught the manipulation of the instrument and directed to use it after his day's work, on retiring and rising. At work he should wear, in each nostril, a piece of loose cotton-wool, which will act as a sieve, and retain the greater paii of the foreign matter floating in the atmos- phere. The same medicinal treatment as that described for the preceding variety of chronic rhinitis is indicated, the pathological processes of both being identical. When the local inflammation is caused by the fumes of acids, etc., the officinal belladonna ointment, used several times daily, seems to be the most effective application, the protection afforded by the excipient against their irritating action doubtless coming in for a large share of the good effect. In this way, cosmoline is also useful. The cotton wad should also be worn by these cases, and by dipping it occasionally in a saturated solution of bicarbonate of sodium, the acid fumes will be partially neutralized when inhaled, thus losing much of their irritating property. In the variety of chronic rhinitis characterized by profuse watery secretion, cleansing is obviously unnecessary. The watery flux being due to complete relaxation of the mem- brane, astringents are indicated to induce contraction of the elements entering into its composition. Their action is but temporary however, unless coupled with a systemic treatment calculated to counteract the paretic state of the local blood- vessels. The condition is at best exceedingly difficult to 84 DISEASES OF THE ANTEKIOR NASAL CAVITIES. treat successfully. Powdered alum gr. j in talc gr. ij, applied with the auto-insufflator four times daily, has served the best for the local .treatment, with sulphate of strychnia g 1 *- A) gradually increased to gr. 2 V, internally administered three times daily, after meals. A weak faradic current passed through the nose by placing one of the poles on each side of its external surface below the bridge, care- fully wetting the sponges to insure penetration, is sometimes followed with gratifying results, especially if combined with the medicinal treatment described. In some cases, the local irritation is so great that seda- tive applications can alone be borne. Much relief can be afforded by using as cleansing agent, the bromide of potash solution (gr. xv-3j) with the atomizer, three or four times daily. Slight anaesthesia is induced, and the membrane is not influenced by the passage of the air-current and what foreign particles it might contain. An exceedingly effective application in these cases x is a two per cent, solution of hydrochlorate of cocaine, applied every three hours with a camel's hair pencil. It not only modifies the superficial irritability, but limits markedly the general congestion by causing contraction of the blood-vessels and sinuses. One drachm of the solution will last three or four days if used carefully. When it cannot be procured, the fluid extract or the concentrated infusion of coca can be used instead, applying it pure. The powder recommended for acute rhinitis (p. 69) will also be found very satisfactory, its modus operandi being the same as in that affection. When the membrane is dry, however, the sedative steam inhalations, described on page 61, are preferable. PLATE n. PLATE II. FIGURE 1. Posterior view of left nasal cavity in the normal state. 2. Lateral " " 3. Anterior " " " " " 4. Rhinoscopic " " " " * " 5. Rhinoscopic " mirror slightly turned. " 6. Microscopical section of the nasal mucous membrane over the turbinated bones. a, Superior turbinated bone. b. Middle " C, Inferior " " d, Eustachian orificx e, Soft palate. /, Uvula. g. Posterior nasal cavity. i, Vestibule. j, Sphenoidal sinus. Jt, Frontal " /, Epithelium. n isubmucous layer. *. i. orpora cavernosa. o, Fossa of Rosenmuller. FIGURES 7 to 12. Acute rhinitis, or appearances during an exacerbation of simple chronic rhinitis.* FIGURE 11. Rhinoscopic view of hypertrophied adenoid tissue in the posterior wall of the naso-pharynx during an acute exacerbation. FIGURES 13 to 18. Hypertrophic rhinitis; anterior, middle and posterior hyper- trophies ; fimbriated adenoid vegetations in the naso-pharynx. * Represented as seen under gas-light. Under natural light, the red color is much lighter. Plate I! Sajous, hnxit Burk &M c Fetrtdge,Litri. Phi la. HYPEBTROPHIC EHINITIS. 85 HYPERTKOPHIC KHINITIS. (Synonyms : Hypertrophy of the Turbinated Bones ; Hypertrophic Nasal Catarrh; Hypertrophic Ozoena.) Etiology. Hypertrophy of the nasal mucous membrane occurs, in the majority of cases, as a result of frequent attacks of acute rhinitis, or as a complication of chronic rhinitis. The causes of these affections are consequently the initial factors in the production of the hypertrophic changes, to which may be added improper treatment, such as the frequent use of irritating snuffs, solutions of nitrate of silver, or the too forcible application of the douche. In some cases, it seems to occur idiopathically. Pathology. While in uncomplicated chronic rhinitis there is already a certain amount of thickening and induration in the epithelial layer, it only becomes hypertrophic rhinitis when this thickening involves, besides the epithelial layer, the other elements of the membrane. When the chronic condition has existed for some time, the infiltration, stimu- lated now and then by an inflammatory exacerbation,, finally becomes organized, and connective tissue is formed, not only in the mucous membrane proper, but in the sub-mucous layer, the " corpora cavernosa." The walls of the venous sinuses become abnormally thickened and rigid through this increase of new connective tissue, and cannot collapse as they do when their walls are normal, but remain distended, thus contributing largely to the general increase in thick- ness. As the formation of connective tissue progresses, new blood-vessels are formed, and all the normal elements of the membrane are increased in proportion. Its thickness can thus be multiplied several times, but as the new formations are not evenly distributed, the surface is irregular in out- 86 DISEASES OF THE ANTEKIOB, NASAL CAVITIES. line, i.e., less hypertrophied in 'some localities than in others. The free borders of the middle and inferior tur- binated bones are the most frequent sites of these hyper- trophies, but the septum is also occasionally involved. The venous sinuses of the posterior portions of the turbinated bones being much larger than in other localities, hyper- trophies are frequently found there, sometimes sufficiently large to cause complete stenosis of the posterior nare.s. These are termed posterior hypertrophies, in contradis- tinction to those situated in the anterior portion of the nasal cavity, which are called anterior hypertrophies. Hypertrophic changes usually progress slowly, many years sometimes elapsing before a simple chronic rhinitis will have merged int the hypertrophic variety. Symptoms. The most prominent symptom of hyper- trophic rhinitis is the interference with nasal respiration. As the mucous membrane increases in thickness, it becomes much more sensitive to the action of cold and other irri- tants, and the least exposure to their effects causes it to become suddenly engorged, the swelling induced thereby being added to that already existing as a result of the hypertrophic changes. When in that state the membrane is sometimes sufficiently distended to occlude the nasal cavity completely, while at times, the hypertrophy proper is so great that the cavities are permanently occluded. Any position favoring the gravitation of the blood to the hyper- trophied parts is sufficient in the majority of cases to cause their distention; lying on the right side, for instance, will cause occlusion of the right nostril, tilting the head forward will cause occlusion of both, etc., while suddenly assuming the erect position, or any startling noise or stroke, will cause immediate collapse of the membrane by suddenly stimu- lating the sympathetic system and inducing sudden con- HYPEKTROPHIC RHINITIS. 87 traction of the vessels. When the occlusion is great and constant, the patient soon acquires the habit of breathing through the mouth. The physiological functions of the nose not being performed, the air reaches the other portions of the respiratory tract without having been purified of its irritating elements, dust, etc., and without having been supplied with moisture and heat. Follicular pharyngitis and catarrhal laryngitis are, for that reason, frequent ac- companiments of the affection, while in persons predisposed to pulmonary affections, it may become the starting-point of phthisis. The voice acquires a peculiar muffled character, complicated with the so-called "nasal twang," due to the partial or complete absence of nasal resonance, as the case may be. The face sometimes assumes an air of stupidity, owing to the constantly opened mouth. The eyes are some- times reddened and watery, on account of the occlusion of the lachrymal canal. Hearing may be gravely compromised, through mechanical impediment of posterior growths, the accumulation of discharges in the mouth of the Eustachian tubes, or inflammatory infiltration of their mucous lining. The distended membrane preventing the access of odor- iferous bodies to the olfactory region, the sense of smell may be completely absent, while that of taste may be sensibly diminished on account of its intimate relation with the former. Periodical headaches in the frontal and supra- orbital regions are often complained of. There is usually considerable increase in the amount of nasal secretion. Quantities of thick viscid mucus accumulate in the posterior nasal cavity, and adhering there, force the patient to hawk and scrape until the discharges are drawn into the mouth and expectorated. These do not originate only in the anterior cavities, but also in the pharyngeal vault, the glands of which are over-stimulated. When the 88 DISEASES OF THE ANTERIOR NASAL CAVITIES. hypertrophy is great, the impediment to their free egress causes them to accumulate in the sinuosities of the pas- sages, to form there, through the evaporation of their watery constituents, fetid masses or scabs, generally of a greenish- brown color. The breath is consequently very offensive at times, this being especially the case in persons of a strumous diathesis. The frequent contact of these irritating discharges with the pharynx on their passage downward, adds another cause for pharyngeal inflammation to the pre- ceding, while the constant hawking keeps up an active congestion of the soft palate, which soon induces elongation of both it and the uvula, adding to the original affection new causes for active symptoms. The larynx is also ex- posed to the action of what discharges are not expectorated, by acting as a receptacle for them, owing to its proximity to the pharyngeal wall. The secretions run down along the latter and meeting the posterior laryngeal border, either pass into the cavity of the larynx between the arytenoids or are swallowed. In order to clear the throat of the em- barrassing agent, hemming is resorted to, which, added to the hawking and scraping already described, make the sufferer an unpleasant companion. The catarrhal laryngitis excited by oral breathing is thus aggravated, cough super- venes, and this, in conjunction with what muco-purulent discharges are expectorated, frequently leads the patient to believe that he is phthisical. The diminished lumen of the larynx, when highly congested, may give rise to asthmatic symptoms, and these, combined with the difficulty ex- perienced in breathing through the nose, cause the patient great annoyance, especially at night and upon exertion. Reflex asthma is also occasionally present as a result of the intra-nasal pressure. Upon examining the parts anteriorly, the membrane will HYPERTROPHIC RHINITIS. 89 appear normal in color in some cases, and red in others, according to the intensity of the inflammatory process. The lumen of the cavity examined being decreased in propor- tion to the degree of hypertrophy, it may be but slightly encroached upon by the thickened membrane, or to a degree sufficient to cause complete stenosis. The surface of the inferior turbinated bone is usually the most prominent por- tion, and bulges out sufficiently, sometimes, to compress the septum, frequently giving rise to ulcerations and slight epistaxis ; ordinarily it only approximates the latter, and its edge rests against the floor of the cavity. It yields upon pressure with a probe, to suddenly recover its former shape, differing in this from simple chronic rhinitis, where the resumption of shape is sluggish. In the former case, the newly-organized tissue forms an elastic bed which im- mediately recoils, while in the latter, the pressure merety displaces a certain amount of infiltration which is slower in returning to its former position. The middle turbinated, when much hypertrophied, stands out more horizontally, and as its longitudinal axis slants from before backwards more than the inferior, the under surface of its free edge is usually seen resting against the septum, and appearing to form part of it. The septum often takes part in the hypertrophic process, its mucous membrane presenting the same appearances in color as that over the turbinated bones. Whether located on the septum or over the latter, the thickening is not evenly distributed, occurring in some cases in irregular prominences, and in others as thick, cushion-like protuber- ances, involving the whole length of the affected portion. The turgescence differs from that of simple chronic rhinitis by its permanency, occurring in the latter affection only during exacerbations. The turbinated bones proper are 90 DISEASES OF THE ANTERIOR NASAL CAVITIES. sometimes hypertrophied, their conformation being easily determined by means of a probe. Hypertrophies involving the posterior ends of the tur- binated bones and the posterior portion of the septum, can only be seen with the aid of the rhinoscopic mirror. They present appearances altogether different from those just described, not only in shape but in color. There are two varieties, the white and the j>nrj>(( j . The white hy- pertrophies, by far the more common of the two, are usually rounded, and present an irregular surface much like tha^ of a raspberry. They protrude more or less into the posterior cavity, frequently compromising mechanically the openings of the Eustachian tubes, which are immediately behind, on each side. The inferior turbinated bone is most frequently their seat, but they are also often present at the posterior portion of the middle turbinated, and on each side >f the septum near its posterior border, bulging out in the direction of the turbinate hypertrophies, and assisting in the production of stenosis. The second variety, purple in color and much softer to the touch, are rarely met with, and occur principaUy on the inferior turbinated body. They bleed easily, sometimes upon the least contact of an in- strument. The vault of the pharynx is often implicated in the affec- tion, being merely congested in some cases, while in other cases it is the seat of pathological changes so important as to merit special consideration in another portion of this volume. Prognosis. Occurring in a subject in whom no faulty diathesis exists, hypertrophic rhinitis, so far as the local condition is concerned, does not tend to assume a danger- ous character. When it has reached a certain limit, amount- ing to complete nasal occlusion in some, and to hardly perceptible interference with nasal respiration in others, it HYPERTROPHIC RHINITIS. 91 either remains in that state until the patient has passed middle life, when the hypertrophied membrane, influenced to a greater degree than the system at large by the general atrophic process, gradually recedes to its normal state, or merges into atrophic rhinitis, which will be described under the next heading. "When the degree of hypertrophy has been great, a certain amount of nasal obstruction sometimes remains, the bones proper having taken part in the hyper- trophic process and remained hypertrophied. Hearing is frequently compromised, and sometimes lost. The sense of smell is generally impaired, resulting occasionally in com- plete anosmia, and involving, in the majority of cases, the sense of taste. Pharyngitis sicca, occurring as a result of the oral breathing, and the contact of the pharynx with the discharges, is a frequent sequel. The affection is the origin of a vast majority of the many cases of catarrhal laryngitis we are called upon to treat during the winter months, and it is but reasonable to conclude that in an individual predisposed to pulmonary consumption, it may act as an exciting cause. Emphysema is frequently ob- served when the nasal obstruction is of long standing. Since the introduction of surgical measures in the treat- ment of hypertrophic rhinitis, its. prognosis as to recovery has become very favorable. When medicinal treatment was solely relied upon, the benefit it procured was but temporary, the organized state of the .new cellular tissue elements rendering their absorption hardly to be expected. Treatment. Clinical experience has demonstrated that when the new connective tissue elements characterizing the affection are yet undergoing formation, their absorption can be induced by medicinal treatment or by pressure, but that When these tissues have become firmly organized, surgical interference can alone produce permanent results. A clear 92 DISEASES OP THE ANTERIOR NASAL CAVITIES. differential diagnosis between these two conditions is con- sequently of the greatest importance before instituting treat- ment. Whether hypertrophic rhinitis occur as a result of simple chronic rhinitis, or from any other cause, its early pathology and initial symptoms are so allied with those of the latter affection as to render any differentiation between them ex % ceedingly difficult, if not impossible. As the hypertrophic process advances, however, the two affections gradually as- sume distinct positions, not only in pathology, but in their subjective and objective symptoms. The differential diag- nosis consequently resolves itself into determining whether the pathological condition is as yet in that state in which it cannot be distinguished from the simple chronic condition, in which case the treatment described for that affection would be indicated, or whether the pathological changes have so far progressed as to make the diagnosis hyper- trophic rhinitis, rendering surgical procedures necessary. As already explained, the resiliency of the redundant portions, when pressed upon, furnishes means by which the presence of hypertrophic tissue can be estimated, while the degree of hypertrophy can be ascertained by inducing contraction of the turgescent areas, by a local application of a four per cent, solution of hydrochlorate of cocaine. The membrane, completely emptied of its fluids, cannot contract more than the organized elements in its layers will allow, and its actual thickness can then easily be determined. In uncomplicated chronic rhinitis the contraction is almost complete, the thick- ening in the sub-epithelial layer not being sufficient to cause any appreciable difference in the appearance of the mem- brane. Its surface is smooth and uniform, the conformation of the bone beneath being often descernible. As soon as sufficient hypertrophic tissue has formed to become notice- HYPERTKOPHIC EHINITIS. 93 able ? however, the smoothness and uniformity are lost, and irregular prominences appear, indicating the localities in which the hypertrophic process is most advanced, and where surgical measures will be most effective. The presence of hypertrophic rhinitis having been recog- nized, a successful result can only be obtained by resorting to a treatment calculated to destroy a sufficient quantity of the redundant tissue, to insure, with the assistance of the resulting inflammation and the subsequent cicatricial con- traction, its complete reduction. Cleanliness, however, as in the other forms of rhinitis, is an essential part of the treat- ment, but great care should be practiced in conducting the cleansing measures, lest too much mechanical irritation or stimulation encourage the morbid process. When the degree of hypertrophy is moderate, and the discharges are soft, sat- isfactory ablution of the parts can be conducted through the anterior nares. The atomizer serves the best for the purpose, all other methods, even inhaling liquids from the palm of the hand, involving undesirable mechanical irrita- tion. When the hypertrophic process has so far progressed as to cause marked narrowing of the cavity, the spray will not reach the mucous surface behind the bulging portions, and the solution must be applied posteriorly. In these cases, however, the discharges are generally considerable, and they agglomerate into thick masses, which adhere with so much tenacity that the cavities cannot be thoroughly cleansed unless more mechanical power accompany the stream than is the case when the atomizer is used. A very satisfactory instrument for the purpose is Hall's bulb syringe (Fig. 16). Its stream can be so nicely regulated that any degree of force can be employed, while any quantity of fluid can be injected at a given time. This becomes of great importance when the limited space remaining free in the anterior nasal 94: DISEASES OF THE ANTERIOR NASAL CAVITIES. cavity for the egress of the liquid is remembered. The glass nozzle, shown in Fig. 16, cannot be used, however, the volume of liquid it allows to pass being too considerable. That represented in the cut below, a hard rubber tube with end turned upward and perforated with minute holes, allows the solution to flow in numerous little 'streamlets, which Fig. 30. The nozzle for posterior irrigation in position. bathe the parts thoroughly without causing a too rapid ac- cumulation of fluid. The directions given for post-nasal douching should be carefully followed by the patient. The cleansing solution recommended in simple chronic rhinitis can also be used in this affection. It is very pleasant to the patient, effective in removing accumulated discharges, and does not irritate the parts, when used lukewarm (100 F.). It is best prescribed prepared in tablets, one of these con- HYPEKTROPHIC RHINITIS. 95 taining twenty grains of each of the three ingredients, and forming the exact proportion for one pint of water. The solution formed possesses, besides cleansing and medicinal properties, the proper specific gravity. When the breath is very offensive, three grains of permanganate of potassium may be added. A complete list of these tablets will be found in the Appendix. The means at our disposal for the reduction of the hyper- trophied mucous membrane differ according to the degree of hypertrophy, and consist in the use of caustic acids, galvano-cautery, the galvano-caustic snare, and the cold-wire snare. The three acids usually employed are the nitric, chromic and glacial acetic. The first is by far the most powerful, and its action can only be limited by using it in very small quantities at a time. If too much is applied to the mem- brane, deep-seated ulceration may ensue, and give rise to much annoyance. As already explained, a very thin probe should be used, with a film of cotton wrapped around the tip. Being dipped in the acid, and applied against a blotter to prevent dripping, the cotton pledget is applied to the most prominent portion of the membrane, limiting the application to an area about the size of a small pea. A sharp pain is felt, unless the membrane be previously anaesthetized with cocaine, or the acid contain a sufficient quantity of the latter in solution. When the cocaine is not used, however, the pain can be quickly arrested by applying with the atomizer a saturated solution of bicarbonate of sodium, which will also limit the penetration of the acid. During the day, the patient ex- periences a sensation of fullness in the nostril cauterized. This, however, only lasts a few hours, and in some cases does not occur at all. The next day, shreds of the destroyed 96 DISEASES OF THE ANTERIOR NASAL CAVITIES. mucous membrane are discharged, and a feeling of relief is at once experienced. This continues until all the cauter- ized tissue has been thrown off, leaving a groove to mark the seat of the exfoliation. This groove gradually fills up, not by reproduction of tissue, but by a displacement, as it were, of the surrounding superficial stratum, which con- tracts, thereby constricting the parts beneath. This process requires for its completion about a week. A great advan- tage possessed by nitric acid is that it requires but one or two applications to contract markedly the hypertrophied membrane. At least two weeks should elapse between each application. An earlier renewal of the cauterization on the same spot might give rise to serious inflammation, and perhaps erysipelas. In inexperienced hands, glacial acetic acid is a much safer agent, but requires a greater number of applications to produce the same effect. The instrument shown below, devised by Dr. Bosworth, of New York, is very convenient for its application. Its end is flattened, and when wrapped Fig. 31- Bosworth's probe. with cotton, presents a comparatively wide surface, while at the same time it can be introduced into the narrowest cavity. It is dipped into the acid if both sides of the cavity are to be treated, that is, if there is septal hyper- trophy besides the turbinate, and dropped on one side if the hypertropy be limited to the latter. The vestibule being dilated and illuminated, the charged end is passed into the nasal cavity along the free edge of the hypertrophied tur- binated body, or applied to the septal growth, as the HYPEKTEOPHIC RHINITIS. 97 case may be. The pain induced is much less severe than when nitric acid is used, but again the amount of tissue destroyed is much more limited. Seven or eight applica- tions at a week's interval are necessary to produce the effect of one application of nitric acid, but the improvement is gradual and steady, and if care be taken to touch the same spot each time, in order to as much as possible avoid the destruction of the ciliated epithelium, not only will the stenosis be remedied, but the physiological functions of the membrane proper will be preserved. Chromic acid is highly recommended by several eminent specialists. The most convenient method for its employ- ment is to heat the tip of an ordinary probe and to apply it against one of the acicular crystals of the acid. Care should be taken not to overheat the instrument, lest decom- position of the acid occur. Enough adheres for two appli- cations. Chromic acid gives rise to little or no pain, and is very effective, but systemic intoxication is liable to occur if too great a quantity is used at one sitting. Its applica- tion should consequently be limited to a small area, and renewed from two to five times as the case may be. As with nitric and glacial acetic acid, any excess can be neutralized by applying over the cauterized surface, a sat- urated solution of bicarbonate of sodium. Gralvano-cautery possesses many advantages over any method employed for the reduction of hypertrophies. Its application gives rise to but little pain, and the local inflam- mation following its use is so limited, that it is hardly per- ceived by the patient in the great majority of cases. A number of excellent batteries are at our disposal, among which may be mentioned Seller's, of Philadelphia, and Pif- fard's, of New York. The former is the more convenient of the two instruments, and was used by me until lately, 7 98 DISEASES OF THE ANTERIOR NASAL CAVITIES. when, having replaced cold wire snaring by galvano-caustic snaring in my practice, I found it necessary to devise an apparatus capable of furnishing a greater quantity of elec- tricity when this was required, without increasing the bulk of the instrument. Fig. 32 represents the battery as the plates are being immersed, the foot of the operator having depressed the pedal and caused the plates to descend into the glass jar containing the fluid. The degree of heat can thus be easily regulated at will by raising or lowering Fig. 32. Author's galvano-cautery battery. the foot, an advantage introduced by Seller's battery. The foot-motion, however, is much more limited than in the latter, and does not necessitate raising the heel from the ground. The body being thus well supported, the steadiness of the hand is not compromised. An important feature in its construction is that the mechanism for lowering and raising the plates is wooden, and is, therefore, not influenced by the acid fumes. The plates being corrugated, as suggested by my friend, Mr. Arthur Kitson, electrical engineer, more HYPERTROPHIC RHINITIS. 99 surface is exposed to the fluid, and a slight to-and-fro motion, which can be communicated to the plates from the outside of the case, causes them to agitate the fluid to such a degree as to liberate the hydrogen bubbles deposited on their surface. Polarization can thus be prevented to a marked degree. Notwithstanding its small size (being only fifteen inches wide, fourteen high, and nine deep), this battery can heat from the smallest platinum point to a thick loop of the same metal. fO 70 Author's universal handle. a, handle; a', central section of handle; b, side view of clasp; 6', full view of clasp; c, finger-lever; d, electrode for flat applications; e, electrode for linear incisions; f, cautery snare for horizontal growths; f, the latter, seen from behind; g, cautery snare for perpendicular growths; A, cold- wire snare; h', the latter. seen from above. Some years ago Dr. Shurly, of Detroit, devised an in- genious handle with a set of electrodes, for galvano-caustic applications to the nose and pharynx. For my own use, I had constructed the handle shown in Fig. 33, preserving the convenient shape of Dr. Shurly's instrument and the relative angle of the electrodes. The mechanism, however, 100 DISEASES OF THE ANTERIOK NASAL CAVITIES. is different, and enables it to be used not only for holding electrodes, but for either cold or galvano-caustic snaring, and for a number of purposes which will be described under the headings of the diseases in which it is applicable. The handle a, ', is made of hard rubber and hollow throughout. A metallic rod or conductor is fastened to each side of its interior, extending from the middle of the handle to within one-quarter inch of its extremity, each end serving to secure one of the posts of the canula used, when the latter is inserted as shown in the cut. These posts being notched, are maintained in position by a cor- responding tooth at the end of each conductor, the latter possessing enough spring to insure perfect hold. By press- ing on a button situated on each side of the handle, near its extremity, the ends of the conductors are approximated, thus disengaging the teeth from the notches, and allowing the canula to be withdrawn. When the instrument is to be used for snaring purposes, the posts of the canula em- ployed are adjusted and held in the same manner. The wire having been passed through the cylinders of the electrode, or through the tube of the cold- wire snare, its two ends are attached to the end of a movable vulcanized strip, which protrudes somewhat, and can slide up and down in the interior of the handle. Traction can then be induced by turning the milled nut at the posterior extremity of the instrument, which revolves around a threaded screw fastened to the rear end of the hard-rubber strip, or by pressing upon the finger-lever c, the arm of which pushes the strip backward by working in a ratchet screwed to its upper surface. For cold snaring, what is known as No. 5 piano wire is the most satisfactory, possessing the required tensile strength and elasticity. For galvano-caustic snaring, platinum wire must be employed, of a thickness proportionate with the degree of resistance to be met with. HYPERTROPHIC RHINITIS. 101 The handle is connected with the battery cord by means of a clasp, b and &', the two arms of which are furnished at their extremity with right-angle posts. These rest against the conductors by passing through holes penetrating the sides of the handle on each side. Although grasping the latter firmly, through the action of a strong spring-hinge which unites the arms of the clasp, one of the posts is not in perfect con- tact with the conductor on the same side (this being pre- vented by a short spring between the arm and the handle), but the contact becomes perfect by slight pressure of the thumb when the instrument is held, and the circuit can thus be closed or opened at will, leaving the index finger Fig. 34- Allen's nasal specula. free, to work the finger-lever c if required. When the circuit- is closed the current passes through the clasp to the con- ductors, which in turn transmit it to the canula. To disengage the clasp from the handle, the lower ends of the arms of the former are approximated, thus causing the upper sec- tions to open out. When the hypertrophy is situated anteriorly and is not very large, a linear incision, made with knife S Facilitates the removal of the crusts by increasing . Sodll BoraCIS J the solvent property of , he liquid. Ammonii Chlor. aa 3j $ Stimulates the blood-vessels and the glandular ele- *^ J | ments to action, and tends to relieve their engorgement. / Powerful disinfectant. Stimulates the superficial PotaSSU Permang. gr. X. vessels, and encourages resolution of suppurative (. areas. M. Sig. To be dissolved in one pint of water at 100 F. This should be used by the patient at regular intervals, ATROPHIC RHINITIS. 119 three times daily, if the formation of crusts is rapid. If the latter are few in number, however, twice a day will suffice. Used faithfully, this solution is sometimes sufficient to restore the membrane to a comparatively healthy state, that is to say, as far as the patient's comfort is concerned; but its use has to be continued for a long time, in some cases one, and in others two or three years. Occasionally the ablutions must become a permanent part of the daily toilet, to avoid impure breath, once daily being sufficient, however, to keep the cavities free from scabs. Carbolic acid might sometimes be used with good effect, but its odor renders it objectionable to most patients. Phenol-sodique, one tablespoonful to the pint of water, takes its place advan- tageously, without leaving a disagreeable smell. Before instituting active treatment, the patient should 'be allowed to use the cleansing solution a few days, after which the crusts will be detached with more facility. Directing him not to use the wash at least three hours before his next visit, sufficient discharge will mark each suppurative area to indicate where the applications are to be made. The nostrils being well dilated and illuminated, each scab should be carefully raised (or wiped off with a cotton pledget if too soft to be raised) with a probe, such as Bosworth's (Fig. 31). Another probe of the same kind, previously covered with cotton and dipped into the solution used, or the galvano-caustic knife, is then introduced, and each spot is touched separately and carefully. In my practice, I have used the galvano-cautery knife d (Fig. 33) at white heat, as recommended by Fraenkel, applying its flat surface to each suppurative area. In order to do this, however, the battery must be sufficiently powerful to heat the platinum knife suddenly, notwithstanding the local moisture. The knife is introduced cold, and as soon as it is properly located 120 DISEASES OF THE ANTERIOR NASAL CAVITIES. the circuit is closed. The result is immediate cessation of the discharge and complete alteration of the morbid process, while no cicatricial formation occurs. Not more than two spots should be cauterized on each side at one sitting. The next best agent to galvano-cautery is a fifty per cent, solution of glacial acetic acid. This remedy seems to modify the suppurative process, changing the character of the dis- charges from the thick consistence described to that of a glairy mucus. In some cases, where the suppuration is great, the pure acid may be used, taking care not to touch the surrounding surfaces. It does not act here as an escha- rotic as in hypertrophic rhinitis. This is probably due to the fact that in the latter affection, the epithelial covering. for which glacial acetic acid has great affinity, is generally intact, while in the former, especially in the suppurative areas, it has disappeared. Cotton-wool tampons, as suggested by Gottstein, are often very effective. They can be introduced by means of a probe, a pellet as large as the first phalanx of the little finger being massed in the cavity, leaving a breathing space between it and the floor of the nose. Its presence induces a certain amount of irritation, which causes copious flow of mucus; this not only keeps the membrane moist, but prevents desiccation of the discharges. Some cases become so accustomed to their presence that they can bear them the greater part of the day, changing them now and then. In the majority of cases, however, one hour in the morning and one in the evening will suffice. The essential oils of tar, cubebs and eucalyptus, used for five minutes three times a day with the auto-insufflator (Fig. 27), are frequently productive of good effect. They stimulate the glandular elements and thus encourage the flow of lubricating fluids. The stimulating action of a weak PLATE in. . PLATE III. FIGURE 1. Female, set. 23 ; posterior view of large poste'rior hypertrophy of left inferior turbinated body ; removed with snare. Patient referred by Dr. B. F. McElroy. r IGUBE 2. Female, set. 26 ; hypertrophy of middle and inferior turbinated bodies, both sides, causing bilateral stenosis; removed with snare. Case referred by Dr. M. O'Hara. FIGURE 3. Dr. Lefferte' (of New York) ease of complete occlusion of both nasal cavities by hypertrophies, complicated with adenoid vegetations of the vault. FIGURE 4. Lateral section of pharynx and larynx ; g, Section of mass of hyper - trophied adenoid tissue of the naso-pharynx seen in Fig. 6 (uvula cut off). FIGURE 5. Anterior section of above, showing relation between nasal cavities and the larynx. (The vocal bands in the latter are in the cadaveric position) a, Superior turbinated bon,. #, Junction of hard and soft palate (the latter b, Middle " being cut otf). c, Inferior *. ' ' * y, Anterior portion of the pharyngeal vault d, Orifice of Eustachian tube. or posterior nasal cavity. p, Posterior aspect of septum. FIGURE 6. Posterior section of pharynx, showing mass of hypertrophied tissue in the posterior portion of the pharyngeal vault, as seen in a patient in whom con- genital absence of the uvula existed. FIGURE 7. Posterior view of left cavity in atrophic rhinitis. 8. Lateral " 9. Anterior " " " " " " 10. Ehinoscopic view of left cavity. " " 11. " " " " mirror slightly turned. " 12. Microscopical section of the mucous membrane in atrophic rhinitis. [NOTE. The Nos. 4, 5 and 6 had to be shortened one inch from below the Eustachian prominences so as to enable them to be represented. The other proportions arc accurate.] Plate 111 C L Sajous, P/nxiL. urk & M c Fetridge, Lith. Pfi/la ATROPHIC RHINITIS. 121 solution of nitrate of silver applied three times daily with a cotton pledget, is sometimes of great benefit. It induces the formation of new elements in the membrane and causes prompt resolution of the suppurative areas. A preparation called "Listerine", a combination of the essential oils of eucalyptus, gaultheria, thyme, etc., and benzo-boracic acid, is principally efficient when the membrane is not too sensi- tive. Mixed with equal parts of water, it serves as an excel- lent disinfectant and gentle stimulant. Irritating medicines in the form of powder are warmly advocated by some specialists. Not having found them satisfactory in my practice in this class of cases, I cannot recommend them. A momentary relief is experienced, but this is of short duration and is usually followed by increased dryness. CHAPTER VII. DISEASES OF THE ANTEEIOK NASAL CAVITIES. (Continued.) SYPHILITIC RHINITIS. (Synonyms : Specific Rhinitis ; Specific Catarrh ; Syphilitic Ozoena.) Etiology. As indicated by its name, this affection occurs as an inflammatory process induced by syphilitic intoxication. It may be primary through contamination by direct contact of the mucous membrane of the nostrils with syphilitic matter. It frequently presents itself as a symptom of the secondary period, occurring usually between two and nine months after the primary infection, although occasionally it follows it sufficiently early to be considered by some authors as forming part of it. As a manifestation of ter- tiary syphilis, the affection rarely presents itself until sev- eral years after the initial stage, twenty and thirty years frequently elapsing. Syphilitic rhinitis also occurs as a result of heredity. Pathology. Lesions occurring on the surface and in the layers of mucous membrane in general, are all of an in- flammatory character. In the nose, as in the other por- tions of the mucous tract, the eruptions are analogous to, and often coincide with, those appearing on the skin, their appearance being modified by the structure of the mem- brane, its functions, and the presence of more or less irri- tating secretions. The superficial lesions may present themselves as a mere local hyperaemia of short duration, or in the shape of papular protuberances which rapidly lose their epithelium and present the appearance of erosions, or as (122) SYPHILITIC EHINITIS. 123 round or oval erythematous patches, the epithelium of which comes off, after having degenerated into muco-pus, leaving the membrane proper bare and reduced to a secreting sur- face of an ashy color and of a granular aspect. Left to themselves, these patches, which are manifestations of the so-called secondary period, and the most frequently met with in the nose, gradually spread, bulge out, or become cup- shaped, and secrete quantities of yellow, offensive muco- pus, which adheres closely to them. They are almost always surrounded by a red areola, indicating circuitous congestion. When the lesions are deeper-seated as a result of tertiary syphilis, all the layers of the membrane become infiltrated and an hypertrophic process involving the blood-vessels and glandules begins, followed by the deposition, in the meshes of the new elements, of quantities of small prolifer- ating round cells, which are thought to be characteristic of syphilis. This hypertrophic process being unevenly dis- tributed, nodules are formed, which soon ulcerate through the pressure exerted upon the blood-vessels by the adventitious elements themselves. This ulceration may end in resolution, and be followed by cicatricial contraction, or the underlying perichondrium or periosteum may become involved in the ulcerative process, and necrosis of the cartilage or bone follow. The septum, the turbinated bones, and the ethmoid are more predisposed to necrosis than other portions of the skeleton. While the process may start in the mucous mem- brane, as stated, the diathetic influence may be exerted on the bones or cartilages primarily. Symptoms. When the affection is primary, i.e., a result of direct contamination, the local process follows the same course as in other parts, the initial sore and the inflamma- tion causing swelling of the nose, pain, difficult nasal respi- ration, and fever. 124 DISEASES OF THE ANTERIOR NASAL CAVITIES. As a symptom of the secondary form of the systemic disease, syphilitic rhinitis usually begins with an attack of mild coryza, which gradually increases in intensity and soon assumes the stage of purulent exudation. Examined anteriorly, the membrane appears puffy and congested, with here and there a mass of greenish-yellow discharge, which emits a peculiar fetid odor, quite characteristic of syphilis. Later on, this discharge becomes sanguinolent, and close examination anteriorly and posteriorly reveals patches, which at first are of a darker hue than the surrounding membrane, but soon assume an ashy-gray color. These patches are covered with masses of the yellow secretion alluded to, and are generally surrounded by abnormal redness. The dis- charges being frequently drawn down along the wall of the pharynx, the latter may become involved in the inflam- matory process and undergo ulceration. The larynx is also exposed to the same danger. In the tertiary form of the affection, the deep-seated origin of the pathogenic process causes the ulceration immediately to assume a formidable character. After a local swelling of varying magnitude, generally accompanied by local pain and swelling, a deep ulcer makes its appearance, with ragged edges, and surrounded by a red, angry-looking areola. The discharge covering the ulcerations is greenish-yellow, often streaked with blood and studded with shreds of necrosed tissue. Its tendency to become rapidly desiccated causes it to be soon turned into crusts, which adhere tenaciously to the ulcer, and impart to the breath an odor, the fetidity of which is beyond description. The ulceration may eventually un- dergo resolution, or the underlying bone or cartilage become affected by the inflammatory process. The cartilage of the septum is usually the first to disappear, causing depression of the tip of the nose; the vomer soon follows, and the SYPHILITIC KHINITIS. 125 patient becomes permanently disfigured by a flattened nose. The turbinated bones gradually slough away, or become detached whole or in the shape of spiculae. In two cases in the author's practice, the antra of Highmore were pene- trated, and could be examined with the assistance of a small rhinoscope introduced through the anterior nares. In aggravated cases the bony and cartilaginous structures of the entire cavity may disappear, the soft parts being sometimes included, so that the anterior nasal cavities are represented by an irregular hole in the centre of the face. The floor of the nose is often perforated, giving rise to great interference with speech, and rendering deglutition difficult, especially that of liquids, which are frequently forced into the nasal cavity. The disease may extend to any of the osseous structures, slowly destroying them, until the cranial cavity is penetrated. As soon as necrosis of the cartilages or the bones begins, the odor of the breath changes in char- acter, and becomes so penetrating that prolonged ventilation of the apartments in which the patient may have remained only a few moments becomes peremptory. Hereditary syphilis of the nose generally presents itself at the time of birth or soon after, or in the second decade of life. In girls it often manifests itself at the approach of puberty. In the infant, its symptoms are those of the coryza of nurslings at first, soon 'aggravated by the character of the discharges, which, becoming muco-purulent, cause ex- coriation of the upper lip. The trouble shows little tendency to subside, and if left to itself, generally assumes a dangerous character. The bones of the nose are in danger of being necrosed, causing permanent disfigurement, while extension of the necrosis to the bony surfaces in close proximity to the brain may follow, rendering a fatal issue most likely if penetration occurs. In youths, the disease progresses as if it were the tertiary manifestation of direct contamination. ('26 DISEASES OF THE ANTEKIOR NASAL CAVITIES. Prognosis. The affection being the result of a systemic dyscrasia, a cure, in the true sense of the word, could only be expected if the latter were curable. This being out of the question, we can but subdue the local manifestation. With this object in view, the prognosis may be said to be very favorable, provided the patient be not too exhausted to withstand the necessarily active treatment. As a result of the ulcerative process, bands of cicatricial tissue may compromise seriously the functions of the parts, including the Eustachian tubes, the pharyngeal apertures of which may be completely closed. Treatment. The patients rarely, if ever, present them- selves at the onset of the local trouble, ascribing the early symptoms to a slight cold, etc., and generally do so when the impediment to the nasal respiration, the fetid breath, or the pain have persisted for some time. The history of the case, coupled with the objective symptoms, generally renders a proper diagnosis easy ; at times, however, the presence of syphilis cannot be ascertained from the patient, especially when it is the result of heredity. Dependence must then be placed on the character of the ulceration. In secondary manifestations, the color of the mucous patches is quite characteristic ; in the tertiary, the nature of the ulcer, its excavated surface with everted edges, the color of the discharge and its odor, furnish sufficient evidence to render the differential diagnosis positive. When necrosed bone is present, the penetrating odor of the breath furnishes unmistakable evidence, which can be verified by the use of the probe. Unlike in the affections previously described, systemic medication is of primary importance, while local measures are valuable to limit the ulceration, and frequent cleansing contributes to the patient's comfort and prevents inflamma- SYPHILITIC RHINITIS. 127 tory contamination of the surrounding parts. In secondary syphilis of the nose, resolution frequently takes place with- out the assistance of remedies, the site of a patch being marked by a cicatrix which eventually disappears. At times, however, ulcerations assume the form of vegetations,, which retard greatly the recovery. The red iodide of mer- cury, administered in doses of one-sixteenth of a grain three times daily, has in my hands produced the most satisfactory results. It should be continued until the first evidences of ptyalism occur, when a course of iodide of potassium will be of service to eliminate it from the system. Locally, the nitrate of silver, fused on the end of a heated aluminium wire, causes rapid obliteration of the ulcerations by destroying the ulcerative surface and stimulating the absorbents. As a cleansing solution, that described page 118, used with the douche or with Hall's syringe, is very efficient in keeping ihe cavities clear, and as a disinfectant. In the tertiary form of the affection, mercurial prepara- tions are not nearly so effective as the iodide of potassium, but the latter must be given in full doses. Beginning with ten grains three times a day, one grain is added to each dose until two scruples are administered each time. lodism generally supervenes when the half of that quantity is taken, but I have not found it disadvantageous to continue the administration of the iodide, notwithstanding the eruption and the coryza. On the contrary, the latter, by increasing the natural flow of mucus, prevents desiccation of the dis- charges, and renders their elimination much easier. The continuation of the treatment is guided by the effect pro- duced, and as soon as evidence appears that the remedy is mastering the disease, the dose should be decreased as it was increased, one grain each time. The constitutional treatment should be assisted by such 128 DISEASES OF THE ANTERIOE NASAL CAVITIES. local measures as the state of the nasal cavities may warrant. Cleanliness, obtained by means of the solution recommended for the secondary form is essential. It not only corrects the fetor of the breath, but assists the local curative process. Considerable difficulty is occasionally experienced in re- moving the crusts, and the physician is sometimes obliged to extricate them himself by means of slender forceps, after having softened the masses with a saturated solution of bicarbonate of sodium, applied with the atomizer. This is, of course, only necessary when the patient is first seen, as after that, sufficiently frequent cleansing will prevent the accumulation of discharges and their desiccation. The application of the solid nitrate of silver is as service- able in this form of syphilis as it is in the secondary. Its stimulating properties are here of the greatest value, and, in conjunction with the internal treatment, soon cause reso- lution of the ulcer. lodoform, insufflated three times a day by the patient himself, is also very valuable, but its dis- agreeable odor renders it objectionable to the majority of patients. When necrosis of the cartilages or bones is present, the pungent character of the breath is prevented with difficulty, and sometimes can hardly be modified. Carbolic acid (gr. v-j), phenol-sodique (3j-ij), and permanganate of potassium (gr. v-lj), used with Hall's syringe, have been the most serviceable in my hands for the purpose. More effective than all, however, and the essential condition for a suc- cessful local treatment, is the immediate removal of the dead portions of the cartilage or bone. The cartilage of the septum is generally the first to become affected, and that at its line of union with the vomer. A fistulous opening usually covers the seat of necrosis, and serves for the intro- duction of the probe. When the characteristic sensation of SYPHILITIC RHINITIS. 129 roughness is felt, the opening is enlarged sufficiently to allow the introduction of the instrument shown in Fig. 42. The sharp edge of the spoon being applied to the rough surface, this is gently scraped, taking care not to exert too much pressure, lest penetration occur. When the surface is .smooth, the edges of the fistulous surface are trimmed with a sharp bistoury, and the wound being left to itself, heals without further trouble. The same procedure can be em- ployed for superficial necroses situated in the portions of the cavities accessible anteriorly. When a loose piece of bone can be detected, the fistulous opening should be suffi- ciently enlarged to allow its withdrawal. Fig. 42. Volkmann's curette. In many cases the septum is perforated, and the circum- ference of the opening presents a rough edge of carious cartilage or bone, which breaks down very slowly and main- tains a profuse discharge. The septal punch, shown in the chapter on the diseases of the septum, can be utilized, the semi-lunar blade serving to cut the irregular edges away, or the sharp spoon can be used to scrape them down until normal cartilage or bone is felt. When the turbinated bones, the vomer, and the perpendicular plate of the ethmoid are involved, ordinary dressing forceps can be employed to extract the diseased bone or break the necrosed portion, which usually projects into the cavity. They sometimes 9 130 DISEASES OF THE ANTERIOR NASAL CAVITIESt become detached of their own accord, and instances have been reported in which large portions of dead bone had fallen into the larynx and caused dangerous symptoms. In hereditary syphilis of the nose, the symptoms follow the same course as in the tertiary form, and are treated in the same manner. When syphilitic rhinitis occurs in the infant, calomel seems to exert the most satisfactory influ- ence, administered in doses of from one-half to two grains three times daily, according to the age, with one to three grains of bismuth to prevent diarrhoea. The nose should be kept as clean as possible, a difficult matter in young children. Sneezing, induced by tickling the nostril with a feather or any other harmless object, is sometimes very effective, the sudden blast causing the contents of the nose to emerge on the upper lip ; or, a small syringe may be used to absorb the discharge, while absorbent cotton or a piece of blotting paper can also serve for the same purpose. A spray of the carbolic acid solution (gr. i-!j) or of that of the permanganate of potassium (gr. iii-lj), often succeed, in conjunction with the internal treatment, in arresting the affection in a very short time. When the ulceration are per- sistent, iodoform, applied with the auto-insufflator (Fig. 27), by the mother or attendant, can be added with advantage. SCROFULOUS RHINITIS. (Synonyms : Fetid Coryza : Scrofulous Ozoena ; Ozoena ; Fetid Catarrh ; Strumous Catarrh.) Etiology. As its name implies, scrofulous rhinitis finds its origin in a constitutional weakness, a depressed state of vitality through which resistance to external influence is diminished. This state of debility may be due to inherited scrofula, or occur as a sequel to eruptive affections such as measles, scarlatina, smallpox, diphtheria, etc. SCROFULOUS RHINITIS. 131 Pathology. The abnormal susceptibility of scrofulous sub- jects to inflammation and the tendency to relapse peculiar to all scrofulous affections, readily explain the onset of rhinitis and its continuation. This susceptibility, although more or less general, being frequently most marked in the mucous membranes, the exposed position of the nasal cavi- ties to atmospheric perturbations and to external irritants, furnishes an explanation for the almost universal prevalence of rhinitis in persons of a scrofulous diathesis. In scrofu- lous inflammation, there is a remarkable tendency to per- manent infiltration of the affected tissues, which infiltration is much less readily absorbed than in the healthy subject. There being little or no tendency to the development of new blood-vessels, nutrition of the adventitious elements is not carried on, and the organization of new connective tissue does not take place, as in hypertrophic rhinitis, for instance. The infiltration is sometimes so great that the corpuscles, which are much larger than in normal exudation, fill the sub-epithelial layer, penetrating sometimes to the sub-mucous layer, and many are thrown out on the surface, after having undergone a granulo-fatty degeneration. These, with what mucus may be secreted, form a thick, adhesive secretion, possessing to a high degree fermentative prop- erties, and tending to form scabs. Its irritating nature compromises the ciliated epithelium, which, as in the pre- ceding affection, is abundantly shed, and the physiological properties of the latter not being performed, the discharges accumulate in the sinuosities of the fossae, to form there, fetid masses which contaminate the exhaled breath. The mucous membrane of the accessory cavities takes part in the pathological process when the affection is of an aggra- vated form. Symptoms. The most prominent symptom of scrofulous 132 DISEASES OF THE ANTERIOR NASAL CAVITIES. rhinitis is the fetid discharge. This may be slight or great in quantity, but the latter is most frequently the case. It is voided anteriorly and posteriorly in the shape of scabs or lumps, which are of a greenish-brown color, sometimes tinged with blood, and frequently preserving the conforma- tion of the surface which they covered. The fetidity of the odor they emit depends upon the length of time the mass has lain in the sinuosities of the cavity, undergoing decomposition. When the evaporation of its watery con- stituents has reduced its density so that it will preserve its shape, the emanations from it are almost intolerable. When they are in situ, each breath becomes saturated with the foul odor; the inhalations infect the patient, the ex- halations the surroundings, and make the presence of the sufferer almost unendurable. The mental suffering of a sen- sitive person afflicted with this disease is generally very great. The cognizance of his infirmity causes him to shun the society of his friends, and the constant dread of ren- dering himself obnoxious leads him to seek a life of soli- tude. This, coupled with the toxic effect of the impure breath he is forced to inhale, generally impairs his health; his complexion is sallow, his bowels irregular, and occa- sional febrile manifestations occur, principally towards even- ing. In some cases, the exhalations seem to be perma- nently foul, this being probably due to a constitutional idiosyncrasy which may be compared to that manifested in certain individuals who suffer from offensive perspiration of the feet and -axillae, which is constantly present, notwith- standing the most scrupulous cleanliness. The nasal dis- charge may not be profuse, but it is prone to desiccate rapidly, and to adhere tenaciously to the surface of the membrane, in which case the breath is particularly offen- sive, sufficiently so, sometimes, to impregnate the air of a SCROFULOUS KHINITIS. 133 large room. The patient seldom perceives the fetidity of his own breath. The other symptoms correspond somewhat with those occurring in atrophic rhinitis. The sense of smell is frequently blunted, this condition being probably due to infiltration of the sub-epithelial layer of the olfactory area. That of taste is necessarily often compromised. Fron- tal headache is sometimes very distressing, indicating in- volvement of the frontal sinus. When the antrum takes part in the inflammatory process, pains over the malar bones may be present, complicated with supra-orbital neu- ralgia. Implication of the sphenoidal sinus occasionally gives rise to a dull headache, located on the top of the head. When the affection involves the accessory cavities, especially the last-named, defective memory is frequently complained of. The Eustachian tubes are sometimes involved, catarrhal deafness occurring in a small proportion of the cases. Anterior inspection of the nasal cavities will generally reveal a condition resembling somewhat that of atrophic rhinitis. They are usually capacious, the ill-nourished mem- brane having shrunken under the pressure of the desiccated discharges. Their color varies from the normal to that induced by marked congestion. At times, however, the cavities are almost normal, the lumps of muco-purulent dis- charge alone testifying to the presence of the affection. Posteriorly, the appearance, as to color, corresponds with that of the anterior cavities. The fossae of Eosenmiiller are sometimes obliterated through the excessive infiltration, and the vault is studded here and there with purulent masses more or less advanced in the process of decomposition. Prognosis. The affection being more systemic than local, the complete eradication of the nasal trouble could only be expected were we able to rid the system of the scrofulous diathesis. As this is now considered beyond our means, we 134 DISEASES OF THE ANTERIOR NASAL CAVITIES. can but mitigate the intensity of the local trouble, and place our patient in a condition of comparative comfort. As he becomes older, the disease moderates in severity, disap- pearing entirely in the majority of cases when adult life has been attained. Treatment. Much benefit can be produced by efficient local cleansing, strict attention to hygienic measures, and by the internal use of alteratives and tonics. The nasal douche is, in my opinion, the most efficient instrument, while Hall's syringe (Fig. 16) becomes necessary when the tendency to desiccation is great and the crusts are difficult to detach. The cleansing solution described on page 118 has been more satisfactory in my hands than any other, its stimulating properties contributing greatly to the limitation of the discharges. The frequency of its use depends upon the amount of secretion, three times daily usually sufficing to keep the cavities free. The hygienic measures consist in the maintenance of bodily cleanliness, thus encouraging the secretory functions of the skin. Frequent bathing, alternating the ordinary tepid bath with one of salt water, made by dissolving one pound of rock salt in the quantity of water generally em- ployed, stimulates the capillary circulation of the skin, especially when vigorous friction is practiced over the whole body, after drying it thoroughly. A well regulated diet is also of importance, coupled with due attention to proper intestinal action. The internal treatment should be guided by the condition of the patient as to general health. If he is not too weak to bear them, alteratives are sometimes productive of excel- lent results. The syrup of iodide of iron, gradually in- creased from five drops to thirty drops, three times daily after meals, has in my hands caused recovery of the senses ol SCROFULOUS RHINITIS. 135 smell and taste in a patient in whom they had been lost ten months, this action being probably due to absorption of the infiltration in the layers of the olfactory region. Its admin- istration can be continued for weeks, until marked iodism occurs, when the dose can be gradually decreased, to be again steadily increased when the minimum dose has been reached. Tonic doses of bichloride of mercury (gr. A) admin- istered three times a day, act more rapidly in some cases. Both of these agents should as much as possible be em- ployed in connection with a generous diet. When marked anaemia is present, the tone of the system should be im- proved by the administration of tonics and chalybeates. Quinine, iron, and strychnia, or the syrup of hypophosphites (preferably Fellows'), Fowler's solution of arsenic (m. v.), used alternately three weeks each, have produced excellent effects. Oleo-resin of cubebs, ten drops on a lump of sugar every four hours, seemed to moderate the discharge. Local treatment is not as effective in this affection as in those described in the preceding chapter. This may be accounted for by the degenerated state of the membrane, the absorbing powers of which are decreased, owing to the paucity of blood-vessels. Calomel, fifteen grains to four drachms of sugar, as recommended by Trousseau, is effective in some cases. The glycerite of carbolized iodo-tannin, described on page 76, has been of benefit in some cases, limiting the discharges permanently in several of them. The galvano-cautery knife, applied flatwise here and there to the membrane, reduced the secretion markedly in the cases in' which it was tried. CHAPTEK VIII. DISEASES OF THE ANTERIOR NASAL CAVITIES. (Continued.) TUMORS. THE anterior nasal cavities are occasionally the seat of tumors, which, in the majority of cases, arise primarily within them, or may involve them secondarily through ex- tension from the accessory cavities or other neighboring regions. They may be benign or malignant, the former being by far the most frequently met with. Among the benign growths, the most common form is the nasal polypus, of which there are two varieties, the myxoma, or soft mucous polypus, and the fibroma, or hard fibrous polypus. The fw/ptiloma, or warty tumor, and cysts, are also benign growths, while the ecchondroma, or cartilaginous tumor, and the osteoma and exostosis, or osseous growths, can also be classified among the non-malignant neoplasms. The malignant tumors, which fortunately invade the nasal cavities but rarely, are the sar- coma and the carcinoma. Mucous polypi are most frequently found growing on the upper or lower surface of the middle and inferior turbinated bodies, and sometimes the superior. They occasionally spring from the accessory cavities, especially the frontal sinus, penetrating into the nose through the communicating canal or aperture which connects them; but they very rarely grow from the septum. They are at first sessile, but as they grow, their increase in size, which is usually very slow, manifests itself principally at the extremity, so that a neck is formed 136 MYXOMATA, OB MUCOUS POLYPI. 137 close to their point of attachment, which gives the growth the shape of a pear. This is not always the case, however, a small proportion of polypi having a broad base. As they grow, they assume the shape of the surrounding spaces, and penetrate into them. Etiology. Mucous polypi are generally considered to be due to chronic inflammation of the Schneiderian membrane. Intra-nasal pressure, owing to narrowness of the cavities or to a deviation of the septum, seems to favor their forma- tion They are seldom seen in children, and are somewhat more frequent in males than females. No underlying dys- crasia, syphilitic or scrofulous, seems to influence their growth. Pathology. Gelatinous polypi grow by a localized increase of the submucous layer with its epithelial covering, the glands of which may either be absorbed, undergo cystic dila- tation or hypertrophy, or remain in their natural state. This epithelial layer forms the outside covering of the growth, which is otherwise mainly composed of a gelatinous sub- stance, very rich in mucine, containing bundles of connec- tive tissue, cells, glandular and epithelial elements, and sparsely supplied with blood-vessels, excepting at the point of attachment, which is very vascular. Symptoms. The symptoms occasioned by the presence of nasal polypi depend upon their position in the cavities and upon the size the tumors have attained. At first, no discomfort is experienced; but as the growth increases in size, the lumen of the cavity is more and more compromised, and respiration through the nose is rendered proportionately difficult. When the weather is damp, the hygroscopic nature of polypi causes them to increase in bulk, and the obstruction is proportionately marked until fair weather returns. At .times, the position of a large polypus causes 138 DISEASES OF THE ANTERIOR NASAL CAVITIES. it to act like a valve in the cavity, so that expiration may be freer than inspiration, or vice versa. This, however, is only a passing symptom, which disappears as soon as the polypus becomes sufficiently large to occlude the cavity per- manently. When such is the case, however, damp weather, by increasing the intra-nasal pressure through its dilating influence on the growth, frequently occasions frontal head- ache, violent attacks of sneezing, and such reflex symptoms as cough, asthma, facial neuralgia, fugitive pains in the neck and chest, and other portions of the thorax. A pro- fuse whitish discharge is usually present, which gives the breath a peculiar mousy odor, and which, through its irri- tating character, frequently excoriates the margins of the nostrils. The sense of smell is greatly impaired in most cases, and abolished when complete occlusion takes place, while that of taste is implicated in proportion. The voice becomes nasal, according to the degree of obstruction. The conjunctiva is generally congested, and lachrymation is present when the tear duct is occluded by the presence of the polypi, or by the local inflammatory process. Hemor- rhage is an occasional symptom. When polypi attain a very large size, they may induce lateral expansion of the nose and partial absorption by pressure, of the mucous membrane, and even of the turbinated bones, a fact con- firmed by a case under my care. Reflex asthma is occasion- ally due to the presence of nasal polypi, as first shown by Voltolini in 1872, through the pressure upon, or irritation of, the posterior ends of the turbiuated bones.^ Cough may also have the same origin, as demonstrated by J. N. Mac- kenzie. Mucous polypi are of grayish-white, pearly color, some- times tinged with pink, semi-translucent, and somewhat resembling an oyster. Occasionally they appear decidedly MYXOMATA, OR MUCOUS POLYPI. 139 red, owing to great vascularity. When pressed upon with a probe, they are easily indented, but they soon resume their normal shape. Prognosis. Soft polypi present no danger to life, but their presence causes great annoyance to the patient and compromises more or less the senses of smell, taste, and hearing. Deformity of the features through the mechanical expansion which they occasion is of very rare occurrence. They occasionally degenerate into sarcoma. The danger of recurrence after their evulsion by me- chanical means is very great, unless the point of origin be within reach to receive thorough prophylactic treatment. The fact, however, that polypi most frequently grow in the deep recesses of the meati, increases the liability to recurrence, through the difficulties presented to the intro- duction of instruments. Treatment. Gelatinous polypi may be treated by medi- cinal or surgical means. When there is much discharge and momentary obstruction by hygroscopic swelling of the growths, a powder composed of equal parts of alum, tannin, and pulverized extract of coca, has several times proven beneficial in restoring whatever degree of nasal respiration was usually present, and when continued for a length has seemed to reduce the polypi. It should be used as a snuff, four times daily, the auto-insufflator (Fig. 27) being con- venient for the purpose. Daily applications of the tincture of the chloride of iron, applied by means of Bosworth's probe (Fig. 31), are highly recommended by Beverly Rob- inson, of New York. The growths gradually shrivel up, and are blown from the nose after a couple of weeks of treatment. The method recommended by Donaldson, of Baltimore, is especially satisfactory when used for small polypi. It con- 140 DISEASES OF THE ANTERIOR NASAL CAVITIES. sists in the application of chromic acid to each growth by means of a pointed glass rod, the extremity of which is previously dipped into a solution or paste of chromic acid (100 grs.-!j), and then forced into the polypus. The growths shrink through coagulation of the albumen forming the principal component of their mucin, and sometimes fall of their own accord. I have found a fifty per cent, solution of carbolic acid, a few drops of which are forced into each tumor by means of an hypodermic syringe, Very effective in cases in which the growths were very soft. Coagulation is induced and contraction follows, which sometimes culminates in spon- taneous detachment from the base. When the polypi are numerous, not more than two should be treated at one sitting, lest inflammation be induced. When the growths do not become detached of their own accord, they are easily picked off with forceps. Of the surgical means at our disposal, evulsion by means of forceps is probably the method most employed. The instrument shown in Fig. 43, can be employed for the pur- pose, its bend enabling the operator to guide its tip in the cavity without having his view obstructed by the handle. The great difficulty frequently met with, is the proper deter- mination of the point o f attachment of each polypus, so as to be able to grasp it between the blades of the instrument. The four per cent, solution of cocaine, however, is of great assistance here, and when applied freely to the surrounding membrane, causes contraction of its layers, generally ex- posing the base of the tumor, and increasing the working space. Besides, it limits markedly the hemorrhage, which is almost invariably present when the forceps are used. The growth being seized at its base, is then twisted on its axis and torn out. If cocaine is not used, a severe hemor MYXOMATA, OE MUCOUS POLYPI. 141 I'hage usually follows, which obscures the view of whatever other growth may be present. The usual practice is to renew the operation, notwithstanding the bleeding, until all the polypi have been extirpated, seizing what soft, non- resisting surface may present itself in the grasp of the for- ceps, and to tear it out. In this manner, the mucous mem- brane proper, and sometimes pieces of bone, are pulled out, while great pain is inflicted upon the patient. Although this, method presents the advantage of rapidity, it is cer- tainly a brutal and bloody one, and more calculated to Fig. 43. Polypus forceps. inspire the patient with a desire to keep all future polypi which may recur, than to apply for relief. A much more satisfactory method, in my opinion, is evulsion by means of the snare, followed by the application of galvano-cautery or of some caustic acid to the site of the tumor. Straight snares, such as that shown in Fig. 38, are inconvenient for this purpose; the hand of the operator obstructs the view, and the milled nut does not cause sufficiently rapid traction on the wire. The instrument shown in Fig. 44 does not possess these disadvantages, and enables the operation to be per- formed rapidly and without pain. It consists of a pair of ring handles, shaped and united 142 DISEASES OF THE ANTERIOR NASAL CAVITIES. like those in Tiemann's tonsillotome, the straight blade being furnished with a narrow cylinder and needle-rod such as that in my snare. The needle-rod being connected with the curved blade, it follows all the motions of the latter, when the rings are approximated or separated. The end of the cylindrical tube is furnished with a flattened, bulb-like enlargement, the edge of which is grooved. When the wire loop is connected with the needle in the manner described page 105, traction on the latter, by approximating the rings, will cause the wire to follow, and the end of the loop, Author's polypus snare. instead of entering the tube and form a sharp bend, will rest in the grooved edge of the bulb, preserving its rounded form at the portion of the loop which would otherwise be the bending point. This arrangement not only prevents "kinking" of the wire, but renders it able to assume the loop shape by merely separating the rings. The loop can thus be contracted or enlarged at will. An important feature of this arrangement is that the instrument can be introduced into the nasal cavity with no loop to interfere with its proper location. Once in situ, the rings of the handle are separated, and the loop is enlarged as required, and being slipped over the growth until its point of attach- MYXOMATA, OK MUCOUS POLYPI. 143 ment is reached, the tumor can either be torn off or cut off, this being easily done by reason of the powerful lever- age the mechanism presents. For my part, I prefer the cutting operation. Hemorrhage almost always follows when a polypus is torn away, whereas such is not the case when the growth is severed close to the membrane. That thorough extirpation can only take place when the " roots" are pulled away is doubtful in the extreme, since polypi frequently break off some distance from the seat of implantation at the narrowest portion of the pedicle. By cutting the tumor off close to the membrane, no hemorrhage follows to obscure the view for the evulsion of the other polypi, and what por- tion of the tumor is left behind can be thoroughly destroyed by the application of galvano-cautery, chromic, or glacial acetic acid. For the two latter, a probe such as Harrison Allen's (Fig. 20) may be used. When a pedicle is easy of access, chromic acid fused at the end of the probe is the most effective agent, while parts difficult to reach are best treated with glacial acetic acid, which can be applied over much greater surface. In this case a probe is bent so that its tip will penetrate into the sinuosity in which the polypus grew ; the instrument being then withdrawn and armed with a thin pledget of cotton, the latter is dipped in the acid, then applied thoroughly to the site of the tumor. With this treatment, I have seldom if ever, had recurrence on the same spot, while the result was far less favorable in extir- pation by forceps. The galvano-caustic snare may also be used, and is pre- ferred to any method by some specialists. The procedure is the same as for the ablation of posterior hypertrophies (see Fig. 40), the wire loop being pushed up as near the attach- ment as possible. The soft consistence of the growth renders a much more rapid section possible. When the wire has 144 DISEASES OF THE ANTERIOR NASAL CAVITIES. been tightened around it by depressing the finger-lever, the mere act of closing the circuit is often sufficient to detach the polypus from its base. If this does not occur, another movement of the finger-lever will cause the glowing wire to penetrate the pedicle. An advantage of this pro- cedure is, that if the tumor can be cut off flush of the membrane, the cauterization produces sufficient effect upon the latter to destroy all vestiges of the severed tumor ^ but the limited resiliency of platinum renders this procedure F'g- 45- Morell Mackenzie's nasal bone-forceps. very difficult, the least resistance causing it to bend down- ward and remain bent. Steel wire, on the contrary, responds to the motions of the canula, and adapts itself closely to the surface on which the tumor is attached. In repeated recurrence of polypi, some authors advise the removal of a portion of the underlying turbinated bone. Having never performed this operation, I can only state that, according to these authors, the operation is not fol- lowed by evil results. Dr. Morell Mackenzie's punch forceps (Fig. 45), seems to me to be the most convenient instrument MYXOMATA, OE MUCOUS POLYPI. 145 for the purpose. " It consists of deeply-grooved blades some- what flattened from side to side, opening vertically and con- stituting a tube when closed. Each blade, in fact, is a half tube, and has, therefore, an inner and an outer edge. The inner edges of each blade (those which, when the instrument has been introduced, are nearest the septum), are slightly serrated to enable the operator to seize the turbinated bone securely. Within the tube formed by the closed blades, a third blade, beveled at its anterior extremity to a sharp edge, like a chisel, can be projected forward when the in- strument is in position. The forceps is introduced with the chisel drawn back, and the tissue to be removed having been firmly grasped by the forceps, the cutting point is driven home with the author's free hand." Dr. Woakes' nasal plough (Fig. 41), it seems to me, would also be very useful for the same purpose. When the polypus is situated very far back, or protrudes into the posterior nasal space, the instrument shown in Fig. 44, can be utilized, either through the anterior cavities, or posteriorly by means of the curved tube, which can be con- nected with the handles, instead of the straight one. In either operation, the tube is introduced with the wire loop drawn in, and when the extremity of the canula is in the desired position (which can be ascertained with the rhino- scope, or if the tumor is too large, with the finger passed behind the soft palate), the loop is allowed to expand, and passed over the tumor, using digital assistance if required. In moderately large polypi, the blades can be approximated rapidly and the growth severed in an instant; but when it is very large, the threaded screw and milled-nut arrange- ment, attached between the two levers, had better be used, to gradually snare the growth off. This is to avoid hemor- rhage, should large vessels be present in the pedicle of the growth. 10 146 DISEASES OF THE ANTERIOR NASAL CAVITIES. Electrolysis is another method occasionally employed to destroy mucous polypi. A zinc or silver needle, connected with the positive pole of a moderately powerful galvanic battery, is introduced into the tumor, while the other sponge electrode, thoroughly wetted, is applied over the nose. A tingling sensation is experienced during the operation, which is not followed by the least annoying symptom. When the polypi are small, a few sittings are generally sufficient to cause their destruction, but when large, several are required. Each sitting should occupy about fifteen minutes, and be renewed every three or four days. FIBROMATA, OE FIBROUS POLYPI. This variety of nasal polypus is much more formidable than that just described, and may present itself at any period of life. It rarely occurs primarily in the anterior nasal cavity, generally invading it from the posterior nasal or the accessory cavities. The roof seems to be its favorite site in the nose, although cases have been reported in which fibrous polypi sprang from the septum, the inferior tur- binated bones, and even the floor. They grow much more rapidly than mucous polypi, regardless of surrounding parts. Pathology. Fibrous polypi arise from the periosteum, and occasionally from the bone proper. Their external envelope is the same as in the gelatinous variety, but their bulk is mainly composed of fibrous tissue with numerous cells and nuclei, freely supplied with blood-vessels. Both varieties of polypi may be represented in the one growth, i.e.. fibro-myxoma. Symptoms, Fibromata at first present the same symptoms as small gelatinous polypi, but as they grow, this similarity gradually decreases. When obstruction to nasal respiration begins, it is constant and gradually increases, while no influ- FIBROMATA, OK FIBROUS POLYPI. 147 ence is exerted by dampness, as in gelatinous polypi. When the entire lumen of the cavity has become occluded by the tumor, its growth still continues, to the detriment of bones, 'cartilages, etc., that may be in the way, causing absorption of the osseous walls, and penetrating into what fissures may be formed, and sometimes into the accessory cavities. When this stage is reached, the walls of the nose proper are fre- quently forced apart, and the face assumes the appearance termed "frog-face." Ulcerations over the surface of the growth give rise to a purulent discharge, and to frequent attacks of epistaxis. Fibrous polypi sometimes attain an enormous size, and give rise to frightful deformity of the face. The appearance of a fibrous polypus differs greatly from that of the soft variety. The color is much like that of the surrounding membrane perhaps somewhat darker-red, with a large vessel here and there. There is, of course, no translucency, and when pressed upon with the probe, it is firm and resistant. It is most frequently sessile. Its base, which can rarely be seen, is generally very broad. Prognosis. Left to itself, a fibroma is liable to degenerate into sarcoma. The growth gradually progresses until the patient's vital forces are exhausted by repeated hemorrhages, while his death may be caused by gradual septicaemia, through the constant swallowing of purulent discharges. Treatment. Radical extirpation by surgical means can alone be of benefit. When the growth is small, the cold wire snare, or better still, the galvano-caustic snare, may be employed to sever the tumor as close to its seat of implan- tation as possible. When the growth is pedunculated, this is easily accomplished, but great difficulty is encountered when it is sessile. Its location in the majority of cases ren- ders the application of transfixing needles impossible, while less gentle means, such as tearing the growth off by pieces 148 DISEASES OF THE ANTEKIOB, NASAL CAVITIES. with forceps, is likely to be followed by dangerous hemor- rhage. Again, when the tumor is situated in the upper part of the cavity, extirpation may be followed by fatal con- sequences, owing to the close proximity of the brain and its* membranes. Electrolysis, described under the preceding heading, has produced very satisfactory results in the hands of Dr. Lincoln, of New York, who reduced some large tumors prior to their extirpation. This method, if used per- sistently in small sessile growths, may suffice to induce their obliteration. When the tumor cannot be reached through the nares, an operation to render free access to the roof of the nose pos- sible, becomes necessary. Among the methods employed, the following are the least formidable: Eouge's operation consists in dissecting the upper lip and the nose proper from their points of attachment on the superior maxillary bones, then doubling the detached por- tions upward on the forehead. The anterior nasal cavities are thus fully exposed, and the tumor is within easy reach* This operation possesses the advantage of producing no dis- figurement. Cassaignac's operation is to partially detach the nose from the face by severing its bony and soft connections above the bridge, on the one side, and below. The uncut side serves as a hinge, and the nose can be turned over on the cheek like the lid of a box. Ollier's operation consists in detaching the nose from the face by incising the soft tissues and the bones on both sides from the root down to the * edge of each ala, after which the nose can be turned down, its tip resting against the upper lip. (Full descriptions of these operations and a number of others will be found in works on general surgery.) The anterior nasal cavities being fully exposed and the PAPILLOMATA. 149 location of the growth ascertained, the galvanic snare, with the assistance of Jarvis' transfixing needles, is probably the most satisfactory method at our disposal. Hemorrhage is much less likely to occur than when the cold wire, the knife, or the forceps are used. The manipulation is the same as that described for anterior hypertrophies. The same may be said of tumors which can be treated through, the anterior nares without preliminary operation. Strangulation of the tumor by means of a ligature is an- other method, which can, of course, only be applied to pedunculated growths. The plan is objectionable through the repulsive odor to which the sloughing mass gives rise, and the danger of septica3mia. PAPILLOMATA. Papillomata are wart-like growths occasionally found in the nasal cavities of young subjects. They are most fre- quently attached to the septum, and to the inferior turbi- nated body. They vary in size from that of a lentil to that of a small chestnut, and present a light brownish color, with an irregularly corrugated surface. Pathology. Papillomata are mainly composed of connec- tive tissue arranged in papillary processes on the surface, into which capillary vessels are freely distributed. Symptoms. In children, papillomata cause considerable irritation in the nose, a catarrhal condition being main- tained, and the discharge causing excoriation of the upper lip and the edge of the nostril. Cough may be induced by the reflex irritation occasioned by their presence. Sneezing is also a marked symptom when the growth is sufficiently large to touch the septum, its size also causing obstruction to nasal respiration. Treatment. When the growths are small, a couple of 150 DISEASES OF THE ANTERIOR NASAL CAVITIES. applications of nitric acid are usually sufficient to destroy them. This may be applied with Allen's probe (Fig. 20) armed with a small pledget of cotton. When they are larger, the polypus snare, or the ordinary wire ecraseur (Fig 38), can be used, after which the point of implanta- tion can be touched with chromic or glacial acetic acid to prevent recurrence. CYSTS. Cystic growths are occasionally met with in the nasal cavities. They are grayish, more or less rounded and smooth, and are generally found in the posterior nares. Their resemblance to mucous polypi is very great, their differentiation being difficult. Cysts originate in the mucous membrane, and contain a clear, colorless, viscid fluid, which escapes when the invest- ing sac is accidently ruptured. Treatment. Evulsion by means of the snare is doubtless the best and the simplest procedure. Removal of these growths is not followed by recurrence. ECCHONDROMATA. Ecchondromata or cartilaginous tumors are not infre- quently met with in the anterior nasal cavities. They almost always spring from the septum, the exceptions springing from the frontal and ethmoidal cells and from the floor of the nose. The septal tumors, which are frequently associated with deviations of the septum, grow very slowly until they have attained a certain size, when their growth ceases. The tumor, which is really but a local overgrowth, then causes more or less trouble, according to its dimension. Situated in other portions of the nasal cavities, ecchondromata assume great importance, behaving much like fibrous polypi, although their progress is less rapid. Their attachment is by a broad ECCHONDROMA. 151 base. On the septum, they are usually cone-shaped, while in the other portions of the nose, their form is spherical. Pathology. Ecchondromata, when originating from car- tilage, grow from the deeper layers of the perichondrium. Those which arise from bone start from the medulla and tend to cause absorption of the underlying osseous tissue. The latter occasionally assume a sarcomatous character, and grow much more rapidly than the former. Symptoms. In septal ecchondromata, nasal obstruction, proportionate with the size of the growth, may be the first cause of complaint. If the tumor is large enough to touch the other side of the cavity, erosion of its surface takes place, and a sanious, irritating discharge may be present. Pain, occasioned by pressure against the opposite surfaces, may also be induced, while headache, sneezing, impaired intona- tion of the voice, anosmia, etc., are of occasional occurrence. These symptoms usually continue without aggravation in septal ecchondromata, but when the tumor is located in other parts of the cavity, and is of a semi-malignant or sarcomatous type, its rapid growth causes the same symp- toms as fibrous polypi, displacement of neighboring portions of the nasal walls, deformity of the nose, etc. Such tumors tend to recur after removal. To the eye, septal tumors do not differ greatly in color from the surrounding membrane. Their broad base serves to distinguish them from polypi, which are extremely rare on the septum, while they can be differentiated from osseous tumors by the introduction of a fine needle, which the former would not admit of. In the other portions of the nasal cavity, their hardness, their spherical form, and their regularity of surface are characteristic. Treatment. Septal ecchondromata being in the great majority of cases located just within the nostril, they can 152 DISEASES OF THE ANTERIOR NASAL CAVITIES. be readily removed. They may be shaved off with a sharp, probe-pointed bistoury, or transfixed with a needle and detached by means of the cold wire or the galvano-caustic snare. The same methods are applicable to ecchondromata occurring in the other portions of the cavity, below the olfactory region. The tendency of ecchondromata originating from bone to cause absorption of the osseous tissue underlying them, be- comes an important consideration when surgical measures are to be adopted, especially when the neoplasm is located in the upper part of the cavity near the brain. Operative procedures are, therefore, hazardous when the tumor is situ- ated in those regions, especially if it is of large size. Should an operation be deemed advisable, however, the means recommended for fibrous polypi may be employed. OSTEOMA. This name is applied to a rather rare form of osseous tumor, which, growing from the mucous membrane, inde- pendently of the bony framework of the nose, is generally met with in young subjects. In some cases, its starting point is in the accessory cavities. Pathology. Osteomata are the result of the ossification of newly-formed connective tissue. They may be of great hard- ness, in which case they consist of densely crowded osseous lamellae, or comparatively soft, cancellous bone preponder- ating in their internal construction. Symptoms. Pain usually accompanies the presence of these tumors, through the pressure they exert. Headache is frequently present, and epistaxis is an occasional symptom. They are pedunculated in most cases, hard to the touch, and are either the color of the surrounding mucous membrane or somewhat darker, their surface being irregular in outline. EXOSTOSIS. 153 Where they are sufficiently large to touch the opposite sur- face, they become eroded and give rise to a muco-purulent discharge. Their hardness is characteristic. A needle, which will penetrate any other kind of growth, will not penetrate an osteoma. Treatment. When the growth is not very large, it can generally be broken off with the polypus forceps. If its pedicle is too thick to allow this, the little saw shown in Fig. 46 will soon separate it from its point of attachment. Occasionally, the portion connecting it with the mucous mem- brane is so soft that it can be easily cut with scissors. When deep-seated in the nasal cavity, the snare can be used as for posterior hypertrophies. EXOSTOSES. Exostoses are bony growths frequently met with, which usually spring from the septum. When located anteriorly they are situated at the junction of the latter with the floor of the nasal cavity, presenting the appearance of a spur or pointed crest. When in the middle or posterior portions of the septum, they generally assume the shape of a longi- tudinal shelf with a broad base. Their growth is very slow, and is arrested, in the majority of cases, when a certain size has been attained Occasionally, their crest seems to bury itself in the opposite surface, generally the upper portion of the inferior turbinated body, thus forming a bridge across the cavity. .Pathology. Exostoses spring from the periosteum, and are almost always composed of lamellae of ivory hardness, arranged concentrically. Cancellous tissue is generally ab- sent in anterior exostoses, but is frequently present at the base of middle and posterior growths. Symptoms. In the majority of cases, exostoses give rise to .154 DISEASES OF THE ANTERIOR NASAL CAVITIES. no inconvenience. Occasionally, their growth is not arrested before the other side of the cavity is reached, and a series of symptoms occur much like those due to the presence of a foreign body. The membrane, first irritated, then com- pressed by the apex of the growth, undergoes an inflam- matory process with profuse secretion, which nothing short of surgical procedures can arrest. Pain, due to pressure, is sometimes quite severe, and manifests itself in the course of the fifth pair, while reflex asthma, due to pressure upon the posterior portion of the inferior turbinated body, may be induced, as was the case in one of my patients. The ob- struction to nasal respiration is hardly ever sufficient to be noticed. Deflection of the nose is sometimes caused by the lateral pressure occasioned when the exostosis is suffi- ciently large to rest against the opposite side of the nostril. Fig. 46. Author's exostosis saw. Upon inspecting the nasal cavity, a growth situated in its anterior portion can be readily seen. Hardness, a broad base, and a light pink color are characteristics, while its im- movability upon its seat of implantation serves to differen- tiate it from an osteoma. It bleeds readily when touched. Situated deeper in the nasal channel, its physical properties cannot be as readily ascertained, but the probe will be found of advantage to discern its conformation. Treatment. When exostoses give rise to active symptoms, the only effective procedure is to remove them. This can be accomplished by a number of methods, among which the simplest, perhaps, is by means of the fine saw represented in Fig. 46, the teeth of which are so disposed as to cut rapidly and evenly through the bony tissue. EXOSTOSIS. 155 When the growth is large, the periosteum and the mucous membrane should be detached from the base of the tumor by means of the knife shown in Fig. 47, the upper curved portion of which is blunt on top and very sharp below. An elliptical incision being quickly made around the growth, the blunt edge is passed between the periosteum and the bone, and the former is raised. The saw being then passed into the cut, its elasticity will allow it to bend when used, and a cup-shaped surface will remain, over which the periosteum and the mem- brane will readily adjust themselves. Performed in this manner, the operation will be followed by no annoying after- effects. When the exostosis is deep-seated in the cavity, the saw alone can be used, and the growth detached as close as Author's periosteal knife. possible to the septum. The surgical engine is occasionally more satisfactory for the removal of these growths. A small drill or burr, revolved sufficiently fast, cuts effectively into the osseous tissue without affecting the soft membrane. A small incision being made in the latter, the burr is introduced through it and the redundant portion of bone drilled off, under the membrane. The case alluded to above was treated in this manner, the entire thickness of the posterior portion of the vomer being reduced from an abnormal local thickness of one-third inch to that of one-eighth inch. The most satis- factory instrument, in my opinion, is that of Dr. Bonwill (Fig. 48), which combines speed and great delicacy of motion. In bridge-like exostoses extending from the septum to either wall of the cavity, the surgical engine is by far the most 156 DISEASES OF THE ANTERIOR NASAL CAVITIES. efficient instrument for their removal. A burr with a dia- Fig. 48. Bonwill's surgical engine. meter corresponding with that of the cavity, is rested upon the surface of the growth, and pressure is exerted upon it as SARCOMA. 157 it revolves. The sharp instrument soon cuts its way through the growth, shaving it off the septum. These operations are usually accompanied with much hemorrhage, and must therefore be done rapidly. The pain induced is remarkably slight, no general anaesthetic being required. This is especially true if a four per cent, solu- tion of cocaine is used. It not only prevents what little pain would otherwise be caused, but also limits bleeding. The parts heal kindly, without giving rise to systemic disturbances. Fig. 49. Burrs for surgical engine. SAKCOMA. Sarcoma may occur primarily in the nasal cavities. In a large proportion of the cases, its starting point is the septum or the outer wall of the cavity, soon extending to the neighboring parts. Mucous and fibrous polypi and ecchon- dromata, as already stated, occasionally degenerate into sarcomata. Pathology. The pathological characters of sarcoma in the nasal cavity are the same as those presented when the neo- plasm is situated in other parts of the economy. It originates 158 DISEASES OF THE ANTERIOR NASAL CAVITIES. from connective tissue, which preserves its embryonic type. The cells which form the bulk of the growth are principally the round, fusiform, or myeloid, all of which may be present together, although one form usually predominates to a marked degree. Symptoms. The first manifestation of the affection is obstruction to nasal breathing. A fetid, greenish and some- times bloody discharge, due to superficial ulceration, soon sets in, and pain, due to the expansion of the surrounding parts, follows. The conformation of the latter being altered, the features may become deformed if the tumor grows anteriorly, or great headache, deafness, dysphagia, etc., may occur if the growth is in the posterior portion of the nasal tract. If located near the roof, destruction of the bones forming it may take place, causing death by extension to the brain. Sarcomata usually present a red, fleshy appearance, assum- ing at times a violet hue. They bleed easily when touched, and communicate a doughy sensation when a probe is applied to them. They are generally single and sessile. Prognosis. The rapidity with which sarcomata usually grow in children makes an early end in them quite proba- ble. In adults, their growth is much slower and the chances of an early and complete evulsion are thereby increased. Treatment. Thorough extirpation of the growth is the only recourse, when the patient is seen sufficiently early to render this possible. Imperfectly done, this procedure will be fol- lowed by recurrence, with marked increase of malignancy and rapidity of growth. Much comfort may be given the patient by means of detergent and anodyne sprays. Morphia, and belladonna, either of which may be added to a borax solution, or a five per cent, solution of cocaine, are the most effective agents. PLATE iv. PLATE IV. FIGURE 1. Male, set. 38; hyper- trophy of entire mucous membrane of nasal cavities ; relieved by means of bougies and galvano-cautery. Case re- ferred by Dr. T. G. Morton. FIGURE 3. Rhinoscopic view of above (normal size). FIGURE 5. Female, set. 26 ; appear- ance of nasal cavity after loss of septum and turbinated bones, and enlargement of the orifice of the antrum through syph- ilitic necrosis. Mercurials and iodides ; extraction of necrosed bones with forceps. Pot. permang. washes. FIGURE 7. Rhinoscopio vitw of above with mirror facing obliquely from left to right (normal size). FIGURE 9. Female, set. 19; mucous polypi ; removed with snare, subsequent galvanic cauterizations. \ FIGURE 11. Anterior view of above (normal size). FIGURE 13. Female, set. 30 ; large fibrous polypus of laryngeal vault; re- moved with galvanic snare. Dr. Louis Jurist's case. FIGURE 2. Male, set. 30 ; syphilitic perforation and exostosis of septum ; mer- curial treatment, and mitigated stick locally. Case referred by Dr. L. Web- ster Fox. FIGURE 4. Rhinoscopic view show- ing exostosis of septum in the above (normal size). FIGURE 6. Female, set. 17 ; syphilitic perforation of hard and soft palate ; mer- curials and iodides ; mitigated stick locally. FIGI as t View of palate through the mouth (in state of active inflamma- tion). FIGURE 10. Female, set. 45; large mucous polypi ; removed with snare ; subsequent galvanic cauterizations. FIGURE 12. Anterior view of above (normal size). FIGURE 14. Male, set. 28 ; central curvature and exostosis of septum ; longi- tudinal incision with knife ; oakum plugs ; exostosis removed with saw. Case re- ferred by Dr. William S. Little. [NOTE. Represented as seen by gas-light. By day-light, the red color appears much paler.] Plate IV C. E Sajous,Pinxii Burk & M c retrid(/e, Lith Phila CARCINOMA. 159 CARCINOMA. True cancer of the nasal cavities is of rare occurrence. In the majority of cases it presents itself in children, and is either of the encephaloid or epitheliomatous type. Scirrhus occasionally occurs in subjects beyond middle age. It frequently invades the nasal cavities from the surrounding parts. Pathology. As is the case with sarcoma, carcinoma presents the same pathological characters in the nose as in other parts of the system. They vary, of course, according to the variety of cancer present. Symptoms. A soft, inflamed pimple is generally the form first assumed by the growth. This rapidly increases in size and finally opens, a thin, brownish liquid escaping. Severe pain and epistaxis are almost always present. A deep, ragged ulcer forms at the opening, which spreads to all the neighbor- ing parts, the thickness of the growth increasing at the same time. The cervical glands become enlarged, and constitutional infection, followed by extreme exhaustion, soon causes death. Prognosis. Recovery is as hopeless as when carcinoma occurs in any other part of the body. Treatment. Operations merely advance the fatal issue, unless undertaken at the very start. Palliatives, nutrients, and cleanliness constitute the indications, to which may be added the application of mild astringents,- which are said to retard growth. CHAPTEK IX. DISEASES OF THE ANTERIOR NASAL CAVITIES. (Continued.) DISEASES OF THE SEPTUM. THE septum being implicated in almost all the affections so far described, the majority of the diseases to which it is liable have already been alluded to. This chapter will therefore be devoted to the consideration of abnormal conditions which may affect it independently of the surrounding parts. DEVIATION OF THE SEPTUM. The term "deviation of the septum," as here understood, means a lateral curvature of the septum, which may be per- pendicular or horizontal, localized or general, or a dislocation of its framework from the middle line, sufficiently marked to interfere with the functions of the anterior nasal cavities. Etiology. Few, if any, subjects may be found in whom the septum nasi presents a perfect perpendicular plane. It gen- erally bends or curves toward one side or the other, enlarging one nasal chamber at the expense of the other. This irregular conformation is ascribed to many causes : Inordinate growth of the septum as compared to that of the bony framework of the nasal cavity; traumatism, such as blows, falls, etc., by which it is either broken or forcibly bent to one side ; great height of the palatine vault, through which the floor of the nose and its roof are in closer proximity than normal, the septum (the growth of which continues notwithstanding) being bent to one side by the resistance of its unyielding points of attachment (Jarvis). The pressure exerted upon the nose in the act of blowing is also considered as a cause (160) DEVIATION OF THE SEPTUM. 161 by Beclard. Deviation of the septum is more frequently observed in males than in females, the greater degree of exposure to which the former are liable being probably accountable for the difference. Bryson Delavan advanced the opinion that hypertrophy of the middle turbinated bone can act as a cause of deviation, basing his opinion on the fact that in eighteen crania in which it existed, sixty per cent, presented hypertrophy of the turbinated bone facing the concave side of the septum. I am more disposed to consider such an hypertrophy as an effort of nature to restore as much as possible the normal distance between the sides of the cavity, to enable it to perform its physiological functions. Pathology. The deviation may involve the entire septum or be limited to its cartilaginous portion, the perpendicular plate of the ethmoid, or the vomer, but in the majority of cases, the cartilage alone is affected. The bend may be angular or rounded. In the former case, a wedge-shaped prominence, which may be oblique, perpendicular, or hori- zontal in its longitudinal axis, is formed, a more or less deep sulcus or sharply defined depression existing on the opposite side of the septum. In the latter, the prominence is smooth and globular, presenting a much greater degree of obstruction to the cavity and showing a corresponding depression on the other side. Angular curvatures generally exhibit hyper- trophic changes at the apex of the prominence. At the junction of the cartilage with the perpendicular plate of the ethmoid, a simulated deflection which, according to Harrison Allen, is due to hyperostosis of the sutural line, is frequently found. In these cases, but little, if any, depres- sion exists on the other side of the septum. The deviations are sometimes double, the convexity of one bend presenting in front on the one side, and the convexity of the other bend presenting further back on the other side, thus forming 11 162 DISEASES OF THE ANTERIOR NASAL CAVITIES. a double deviation resembling in shape the letter S. In cases of fracture, the cartilage is the portion of the septum most frequently broken. Next in order comes the perpendicular plate of the ethmoid, its articulation with the vomer being the usual seat of fracture. The vomer is very rarely in- fluenced by the concussion, its anterior edge being posterior to the bones of the face, and the cartilage yielding to the force of the blow. Symptoms. When the septum is considerably deviated, there is usually some deformity of the nose; the tip may be turned to one side or the other, or the organ may appear depressed just below the nasal bones, or assume a variety of other shapes. The degree of obstruction to respiration is of course in proportion to the degree of the deflection, complete occlusion sometimes taking place. At times the complete obstruction is due to the atmospheric pressure which causes the ala3 during inhalation to adapt themselves against the lower edge of the septum on each side. A naso- pharyngeal catarrh is almost always present, due principally to the interference with the flow of the secretions anteriorly, causing them to accumulate behind the prominence and flow backward over the sides of the soft palate, down along the pharynx, and then be swallowed or expectorated. The cavity opposite to that of the prominence is sometimes the seat of chronic inflammation also, its patency rendering its proper cleansing difficult. In most cases, however, there is com- pensatory hypertrophy of the portion of the turbinated body lying opposite the concavity of the septum, and the functions are carried on normally on that side. Anosmia is a frequent symptom. The voice occasionally acquires a nasal intona- tion, especially marked in antero-posterior sigmoid deflection, when both cavities are partially or completely closed. When the prominence presses against the opposite turbinated body, DEVIATION OF THE SEPTUM. 163 erosion of the latter may take place, which gives rise to frequent attacks of epistaxis. Atrophy may be induced through the pressure exerted. Catarrhal deafness is an occasional result. The convex portion of a deviated septum may be confounded with a polypus; but its hardness, and its color, coupled with the corresponding depression on the other side of the septum, will soon establish the correct diagnosis. The varieties of deviation are so numerous that the judgment of the physician is greatly taxed in each case when the choice of a procedure is to be made. Treatment. Among the remedial measures proposed, that of Michel is perhaps the simplest. The patient is directed to press with the finger upon the convex portion of the devia- tion several times daily. After a time, a slight deflection can be reduced and the septum returned to its normal shape. In the great majority of cases which apply for treatment, how- ever, the deviation is too marked to be influenced by anything but surgical means. The least difficult operation, and one which has always given me great satisfaction, in simple car- tilaginous deflection, is an incision through the protuberance, following its long axis. A smart hemorrhage occurs as soon as the incision is made, but it soon ceases. The end of the finger being introduced into the nostril, the septum is forcibly pushed beyond the centre and maintained there by packing the previously obstructed nostril with carbolized oakum. The cut edges of the cartilage override each other, and, after a couple of weeks, are firmly united. The oakum plugs should be changed daily and both cavities sprayed with a solution of permanganate of potash (gr. j-lj). A method recommended by Dr. Fletcher Ingals, of Chicago, in anterior cartilaginous deviations, is to make an oblique incision through the membrane of the convex portion of the prominence. He then detaches the membrane a certain dis- 164 DISEASES OF THE ANTERIOR NASAL CAVITIES. tance on each side of the cut, from the underlying cartilage, exposing the latter. A triangular piece is then cut out, the base of the triangle being at the floor of the nose. Care should be taken to detach the cut piece from the lining membrane of the other cavity, without tearing or cutting through it. The first incision is then closed by stitches and the cartilage is pressed into line and supported by means of tampons. Dr. John B. Roberts, of Philadelphia, makes a long incision, oblique or horizontal, according to requirements, through the septum from back to front along the line of deviation or projection. This is done with a knife introduced into the occluded nasal chamber. If the bony septum is deviated, it is divided by a chisel in the same way and direction. He then introduces a long steel pin into the normal nostril, and passes its point, with about two-thirds of its length, through the septal cartilage, a short distance above and in front of the incision. This brings the point of the pin into the occluded nostril. Pressing the end of the nose and septum, according to the character of the case, into proper position, he brings the "head-end" of the pin close to the anterior part of the septum or columella, thus causing the " point-end," or portion in the occluded chamber, to lie across the incision and adapt itself lengthwise along the surface of the septum beyond the incision. The pin is then pushed in up to the head, and its point is thus deeply imbedded in the soft tissues of the septum and upper and posterior part of the occluded chamber. It may be said that theoretically, the point is by this movement passed through the cartilage of the septum, so that it re- enters the nasal chamber by which it was originally intro- duced, namely, the normal one, and that the head and point are on the same side with the severed septum, held straight by the rigid pin. Practically, however, the point never comes DEVIATION OF THE SEPTUM. 165 through, the partition, but is deeply, buried somewhere in the neighborhood of the superior or middle meatus of the ob- structed side in the septal or perhaps in the turbinated wall of that side. It makes little difference where the point is fastened so that it is firmly fixed and holds the incised septum straight. Often, two pins will be needed to correct this deformity. In such cases, Dr. Roberts usually inserts the second one, not from the mucous surface within the nostril, but from the cutaneous surface of the dorsum of the nose just below the nasal bone, having previously, if necessary, forced the cartilage loose with a tenotome. The operation is necessarily a bloody one, because of the vascu- larity of the parts and because the operation will be useless unless the incision or incisions are very free, so as to take away all resiliency of the cartilage. If the deflection of the septum is a general rather than an abrupt one, he weakens the septum, after the primary incision, by multiple incisions with the stellate punch, which should make large cuts, com- pletely through the cartilage. The pins are then introduced as before. Any spur of cartilage or bone along the floor still prominent is cut away with the knife or saw. Dr. Eoberts says that it is sometimes wise to thread a small disk of rubber upon the pin before inserting the point, as carpet tacks are sometimes given a leather collar, below the socket when the pin has been thrust entirely in; the rubber will prevent its head from ulcerating through the tissues and thus losing its power of holding the parts in proper position until union occurs. The pins are left in position two weeks. This method possesses the advantage of simplicity and effective- ness. The patient is subject to but little inconvenience, and the cavities can resume their functions at once, and no dis- figuring apparatus is apparent. A small square of court plaster will cover the end of the external pin, which should 166 DISEASES OF THE ANTEBIOR NASAL CAVITIES. have a flat head. The other does not show, for its head lies within the nostril. Another method of dealing with deviation of the septum is to forcibly return it to its normal position by means of forceps, as suggested by Adams, of London, who used an instrument similar in shape to that shown in Fig. 50, and which served as a model for the latter's general conformation. The blades being introduced separately and united, like ob- stetric forceps, the septum is grasped firmly and moved back to the median line, breaking it if necessary. After being maintained in position by means of a clasp for a few days, ivory plugs are introduced and left in situ until the cartilage has become firm. Too great pressure must carefully be Fig. 50. Author's modification of Adams' punch. avoided, while frequent cleansing should be practised. After a time the ivory plugs may be replaced by wadding or oakum ones. Blandin, of Paris, overcame the unilateral obstruction to respiration by perforating the septum by means of a punch, a round or oval hole about one-quarter inch in diameter being made. A disagreeable feature of this operation is that the margin of the opening is continually covered with crusts, which excoriate the underlying membrane and keep it in an irritated and sometimes ulcerated condition. Steele, of St. Louis, uses a punch with diverging blades (see Fig. 51), which serves to render the septum flexible prior to straightening with forceps such as Adams'. The subsequent treatment is the same as in the latter surgeon's operation. DEVIATION OF THE SEPTUM. 167 The modification of Adams' forceps, shown in Fig. 50, enables the operator to perform the different operations in which such an instrument is required, without rendering necessary the possession of a special forceps for each variety. The punches being adjustable in a perforation near the ex- tremity of one of the blades, any shape of punch may be used with the one forceps. Fig. 51 represents a set contain- ing an oval Blandin and a Steele punch, an elliptical punch with diverging blades to cut off sharp bends of cartilage and reduce its elasticity prior to straightening, and two small blades one curved and one straight with which any shape of figure or cut can be made in the septum. The arrowhead- Fig, sr. -H- Set of punches and blades. shaped punch serves very effectively for redundant devia- tions. A piece of that shape being punched out with the arrow point turned towards the tip of the nose, the punch- knife is detached from the forceps, and the latter are then used to bring down the sharp end of cartilage into the retiring angle of the cut, where it is kept in position by means of carbolized oakum plugs. When the deviation is great, the straight blade can be used to lengthen the lower line. The after-treatment of these cases bears great influence upon the result. Hard plugs, such as those made of ivory, wood, etc., are, in my opinion, not recommendable. The pressure they exert interferes with the nutrition of the seat of operation, and occasionally gives rise to sloughing. Plugs 168 DISEASES OF THE ANTEEIOE NASAL CAVITIES. of oakum are much more cleanly and exert sufficient pressure to hold the parts in the required position. They should be changed at least once daily. In angular deviations complicated with hypertrophy of the tip of the prominence, a bone forceps, such as that shown in Fig. 52, is sometimes very convenient. The edges of the blades being placed behind the nodular extremity of the bony edge formed, a firm grasp of the handles will cause the growth to be quickly penetrated, with but little hemor- rhage. Jig. 58. Nasal bone forceps. Cocaine applied before any of these operations not only prevents pain but limits the bleeding and hastens resolution of the cut surfaces. H^MATOMA OF THE SEPTUM. As a result of direct injury, an extravasation of blood may take place between the framework of the septum and its mucous lining. A bulging tumor of a purplish-red color is formed, giving rise to more or less obstruction of one or both cavities. Sometimes the blood is absorbed and resolution takes place, but at other times, inflammation occurs and an abscess results. The history of the case, the fluctuation of the tumor, and its general appearance, make the diagnosis easy. ABSCESS OF THE SEPTUM. 169 A small extravasation generally disappears of its own accord. When it is large and gives rise to marked obstruc- tion, some of the blood may be withdrawn with a large hypodermic syringe, which will relieve the tension and advance resolution. When inflammation presents itself, the growth had best be depleted by free incisions. ABSCESS OF THE SEPTUM. An abscess may follow an extravasation of blood or present itself after a traumatism, as a result of the local inflamma- tion. It may be of short duration or last a considerable time, especially when it is due to necrosis of the underlying car- tilage. The tumor, which is generally bilateral, is usually soft and yielding, and painful when touched near the base. Perforation of the cartilaginous septum occurs in the majority of cases, especially if the abscess is not evac- uated early. Free incision into the growth, evacuating carefully the pus, will soon bring on resolution. Abscess of the septum occasionally occurs as a result of syphilis, preceding perforation and perhaps destruction of the cartilaginous portion. In these cases, deformity of the nose may occur, a subject already alluded to under the heading of syphilitic rhinitis. SUBMUCOUS INFILTEATION OF THE SEPTUM. This condition is a comparatively frequent accompaniment of chronic rhinitis, as shown by Cohen. It consists of an cedematous tumefaction situated on each side of the septum, generally near its posterior border, contrasting by its whitish color with the surrounding membrane. The masses may be torn off with forceps passed behind the soft palate, or cauterized by means of galvano-cautery or acids. The operation should be conducted with the aid of the rhinoscope. CHAPTER X. DISEASES OP THE ANTERIOR NASAL CAVITIES. (Continued.) NEUROSES. PERIODICAL HYPER^STHETIC RHINITIS. (Synonyms : Ha}' Fever; Hay Asthma; Rose Cold; Summer Catarrh; Autumnal Catarrh; June Cold; Peach Cold; Rag-weed Fever; Catarrhus ^Estivus; Idiosyncratic Coryza; Coryza Vasomotoria Periodica; Pruritic Rhinitis, etc.) HYPER^STHETIC RHINITIS may be defined to be an affection characterized by periodical attacks of acute rhinitis, compli- cated sometimes with asthma, occurring as a result of a special susceptibility on the part of certain individuals to become influenced by certain substances, owing to a deranged state of the nerve-centres. It manifests itself only provided the mucous membrane primarily affected in the course of an attack is in a state of hypersesthesia, and when the irritating substances are present in the atmosphere. Etiology. Since 1819, when Bostock first described the affection, of which he was himself a sufferer, numerous theories have been advanced to explain the peculiar period- icity of the affection and its cause. As early as 1839, Elliot- son pointed to pollen as the probable cause of the affection, while twenty years later, Abbott Smith, Pirrie, and Moore, ascribed its active cause to the emanations of plants. In 1869, Helrnholtz suggested that the disease was due to the presence of vibrios in the nasal cavities, which remained dormant in the winter months, and became active through the effect of the summer heat. Twelve years ago, Blackley (170) PERIODICAL HYPER^ESTHETIC RHINITIS. 171 of Manchester, reiterated Elliotson's opinion, that the affec- tion was caused by the pollen of flowers and grasses, and demonstrated by a series of experiments the power of these substances to bring on an attack. In 1876, Beard, of New York, published a monograph, in which he showed that a large number of the sufferers were of a nervous tempera- ment, and that the exciting agents were very numerous, and not limited to the pollen of flowers and plants, as was formerly thought. In 1882, Daly, of Pittsburgh, published a paper, in which he attributed the annually recurring attacks " to local chronic disease, upon which the exciting cause acts with effect," adding that " the parts should be put in order, and thereby enable them to withstand the exciting influence of the next recurring crop of bacteria." In 1883, Roe, of Rochester, N. Y., advocated the same theory, and stated "that hyperaesthesia is associated with, or occasioned by, a dis- eased condition, either latent or active, of the naso-pharyn- geal mucous membrane," and " that the removal of the dis- eased tissue in the nasal passages removes the susceptibility of the individual to future attacks of hay fever." Later in the same year, I published an essay, in which I advanced " that hay fever was due to an idiosyncrasy on the part of certain individuals to become affected by certain emanations," that " organic alteration of the surface of the nasal mucous membrane altered its sensibility, and destroyed what morbid irritability might have attended the nervous filaments dis- tributed over it," and, furthermore, "that hypertrophies of the nasal membrane increased its irritability, and the inten- sity of the symptoms." In January, 1884 r Harrison Allen, of Philadelphia, in an article on the treatment of hay fever, attributed the disease to permanent or temporary obstruction of one or both chambers, and advanced the opinion that by overcoming this obstruction by the usual methods, a cure 172 DISEASES OP THE ANTERIOR NASAL CAVITIES. could be effected. In June of the same year, J. N. Macken- zie, of Baltimore, suggested the term "Coryza vaso-motoria periodical on the ground that "the disease is essentially a coryza, showing in most cases a decided tendency to periodic recurrence, and dependent upon some functional derangement of the nerve-centres as its predisposing cause," and stated that "for the production of a paroxysm, a certain excita- bility of the nasal cavernous tissue is necessary (brought on by a multitude of external irritating causes), plus a hyper- aesthetic state of (probably) the vaso-motor centres." As advocated by myself in my paper of December, 1883, three conditions are essential factors in the production of an access of hay fever: Firstly, an external irritant ; secondly, a predisposition on the part of the system to become influenced by this irritant; and thirdly, a vulnerable or sensitive area through which the system becomes influenced by the irritant. As to the first condition, the elaborate and persevering researches of Blackley and the observations of Beard 011 the subject, demonstrate conclusively to my mind the power of certain substances to produce an access in individuals susceptible to their influence. Blackley caused, by applying to the mucous membrane of certain individuals, less than instil of a grain of the substance to which they were sensi- tive, all the symptoms which presented themselves during the course of an ordinary attack, while in his own person the simple inhalation of pollen produced all the characteristic symptoms. Cases are frequently met with, in which the mere approach of certain substances are sufficient to bring on a paroxysm even out of the usual time, while the removal of the subject from the irritating agent in the midst of the yearly period, and while an access is present, will cause the latter to cease. Again, as demonstrated by Dr. Blackley, the attacks can be greatly modified, if not prevented, by placing PERIODICAL HYPERjESTHETIC RHINITIS. 173 in the nostrils some contrivance which will purify the 'inhaled air of its irritating substances, showing plainly the power of the latter to induce a paroxysm. Another evidence that pollen is a factor in the etiology of the affection, is the regularity with which the majority of plants undergo the different phases of their growth, each recurring the same day every year, and in some the same hour. This not only explains the periodicity of the accesses, but the precision with which most sufferers can prophesy the onset of their attacks. The mere irritating property of a substance is evidently not the only factor in the production of the attack. This is exemplified by the fact that one subject may be affected by a certain substance which will in another be absolutely harmless. A gentleman under my care, for instance, although a great sufferer yearly almost since birth, can take rag- weed between his hands, crush it and inhale its emanations without experiencing the least ill-effect; and yet this plant is recog- nized as one of the greatest enemies of .hay fever sufferers. In another case, the pollen of roses alone produces the mani- festations and all others are absolutely ineffective. Subjects are seldom found, however, in whom a single agent will give rise to an access, the majority being influenced by several substances, with one in particular as the most active. Among the substances which are considered as causes of the affec- tion, are dust, the pollen of plants in general, grasses and cereals, the emanations of certain flowers and perfumes, fruit, animals, sulphur, smoke, cinders, etc., while a small propor- tion of the sufferers ascribe the origin of their paroxysms to summer heat, sunlight, exposure to draughts of air, etc. Dust, as observed by Beard, is the most common irritant, a fact which apparently weakens the pollen theory, but which in reality strengthens it. If we consider that pollen, like any 174 DISEASES OF THE ANTERIOR NASAL CAVITIES. other substance, is subject to the laws of gravitation, and that its very light weight is a provision of nature to insure its far as well as near dissemination, and its final fall to the ground; and that immense quantities of it are wafted through the atmosphere, subject to the mechanical displace- ment of its currents, we can understand that the dust of the earth is but a part of what is generally considered as dust, the principal of its other constituents being an agglomeration of the pollen of all the plants in the surrounding country, and sometimes of those of distant districts, as well as all ponderable agents capable of acting as irritants. It can thus be seen that dust is the most frequent cause of hay fever, because it is the common carrier of all the obnoxious agents. The universal distribution of dust in cities as well as in the country, furnishes a ready explanation for the prevalence of the disease in all regions excepting in those which contam- inated dust, on account of its weight, can only reach in very small quantities or not at all, such as high altitudes, the open sea, etc. The entire or partial freedom which the so-called "hay fever resorts " enjoy is due to this fact. Very few, if any, of these places, however, enjoy absolute immunity. A strong wind, which, having passed over fields and become impreg- nated with their pollen or with the dust of a country road, is liable to bring one, a few, or many of the noxious agents within reach of the susceptible individual and cause in him the manifestations of the disease, if one or any of the sub- stances to which he is sensitive are present. It thus fre- quently happens that only one or two persons among many are influenced. That some resorts insure immunity to some people and not to others, is explained by the fact that this immunity depends upon the presence within a certain radius, of the irritating substance. If a plant to which a subject is PERIODICAL HYPER^ESTHTCTIC RHINITIS. 175 sensitive happens to grow within that certain radius, the location will naturally be unfavorable to him. It has been frequently demonstrated that hay fever can be induced at any time of the year, and in regions where the disease never presents itself primarily, as in high altitudes or on the high seas, by the accidental presence of an irritant, brought there as a part of the dust covering clothes, parcels, etc. Wyman and his son were thus attacked, while spending the hay fever period at a resort where they enjoyed absolute immunity, when a package of rag-weed plant was opened there. The paroxysms brought on by handling dusty objects which have been so for some time, or those occurring at sea several days after leaving port, are thus accounted for. The extreme degree of irritation occasioned in most suffer- ers by riding in steam-cars or in a carriage only during the hay fever period, and due to the quantity of dust shaken up by the vehicle, adds further evidence in favor of the fact that uncontaminated dust is not a factor in the production of an access, since dust is present the year round and the membrane is not irritated at all times of the year; but that that dust becomes an active irritant in this affection only when con- taminated with the substances to which the subject is sus- ceptible. This contamination only taking place at a certain period each year, dust is only an irritant during this period ; in other words, it only acts as a cause of the affection at certain seasons, because it is only during those seasons that the pollen in its active state is present in it. As to the second condition essential to the production of an access, a predisposition on the part of the system to become inordinately influenced by certain substances, a close ex- amination into the family history of the patient, and into his own since birth, will elicit much evidence towards prov- ing that there is a systemic dyscrasia, through which the 176 DISEASES OF THE ANTERIOK NASAL CAVITIES. resisting power to certain diseases is diminished. In a list of forty cases now before me, I find that thirty-five per cent, have near relatives who present a clear history of hay fever or rose cold, and that forty-two per cent, have asthmatic relatives. It is thus shown that in a majority of cases (the percentage of family histories presenting either asthma or hay fever being fifty-five) there is an inherited predisposition to the affection. Groing further and taking a glimpse into the early life of these cases, I find that forty per cent, have had six of the diseases incident to childhood, that sixty per cent, have had at least five, eighty-two per cent, at least four, ninety per cent. at least three, and that none were exempt, while one only had but one of them. These diseases were whooping-cough, measles, mumps, chicken-pox, scarlet fever, and croup. This singular proclivity to so many of these affections is certainly not a mere coincidence, the number of cases being too large to render such a proposition tenable. It seems to indicate a predisposing state of the system to all affections in which a neurotic element plays an important part, evidenced in the exanthemata by the eruption, in whooping-cough by the abnormal irritability of the pharynx, larynx and trachea, in the mumps by the marked tendency to reflex metastasis, and in croup by the spasmodic element inducing the dysp- nceal paroxysms. That an inherent liability to these dis- eases must be present is further demonstrated by a com- parison with the histories of forty persons not subject to hay fever, in whom ninety-two of the so-called diseases of childhood had occurred, representing an average of two and two-tenths per cent,, while in hay fever sufferers, one hundred and eif/lity-nine children's diseases had presented themselves, an average of four and seven-tenths per cent. Still more curious in this connection, is the fact that of the PERIODICAL HYPEILESTHETIC KHINITIS. 177 forty cases upon which these remarks are based, all have had whooping-cough. Of all the affections cited, this is without doubt that in which the neurotic element is most marked. Both the respiratory and sympathetic nerve-centres are dis- turbed in its early stages, while the pneumogastric becomes implicated before the local causes of excitation are estab- lished, doubtless indicating a primary nervous element as a predisposing cause, while the universal presence of the affec- tion in forty cases of hay fever, certainly suggests a common systemic cause for both diseases an abnormally sensitive nerve-centre upon which the element of contagion or the irritant acts with effect. In further support of the theory of systemic predisposition, I will enumerate a few of the cases presenting the greatest evidences of heredity, in which this heredity seems to have exerted some influence in the production of the so-called children's diseases: Case No. 14, whose mother, uncle, and brother have hay fever, while his grandfather and first cousin have spasmodic asthma, has had the six diseases of childhood. No. 13's two brothers have hay fever ; his mother and sister asthma ; has had five (croup omitted). No. 15, great grandfather and first cousin, hay fever; grandaunt asthma; has had five (scarlatina omitted). No. 31, father, hay fever; great grandfather, two great uncles, asthma ; six diseases, while all those presenting a direct maternal or paternal heredity of hay fever and rose cold, with one exception, have had the six diseases. Accepting the theory as conclusive, as far as the question of heredity as a factor in the causation is concerned, a new problem suggests itself : In those cases in which no evidence of heredity appears, what is the origin of the inordinate irritability? In other words, the possibility of an inherited liability being demonstrated, can it be acquired independently of heredity! 12 178 DISEASES OF THE ANTERIOR NASAL CAVITIES. Of the nineteen cases in which no hereditary history, could be traced, fifty -five per cent, have had six of the children's diseases enumerated, while eighty -tico per cent, have had at least four, one case only having had but two. In the three cases which presented two or three diseases, I find that in one case, there is a subsequent history of typhoid fever, malarial fever, and bronchitis, all occurring before the first access of hay fever ; in the second, migraine was a frequent visitor before the hay fever presented itself; while in the third, a child, the whooping-cough and chicken-pox had been very severe. Taking the rationale of these sixteen cases, with a history of at least four diseases, all of them presenting marked neurotic element, is it not probable that a functional derange- ment of the nerve-centres resulted, and that they were thus rendered more sensitive to influences which, had they been in their normal state, would not have affected them ! Again, is it not reasonable to suppose that in the first exception, the subsequent diseases accomplished what the others had begun, debilitating still more the nerve-centres, which had already been weakened to a certain degree by the early diseases I In the second exception, a neurotic element is apparent in the character of the primary disease, while in the third the virulence of the diseases must certainly have borne its in- fluence on the secondary results. Evidence to show that a neurotic element is an essential part of the affection, can easily be adduced by merely in- vestigating the origin of the premonitory symptoms which are present in a number of cases. It would certainly be very difficult to explain their presence, were we to overlook the implication of the nervous system. Among the forty cases described, may be found one young man who complains of "a tickling in the roof of the mouth" one week before the PEEIODICAL HYPEK^STHETIC EHINITIS. 179 onset ; another patient speaks of dull pains in the head and back two weeks before ; still another experiences chills and shuddering ten days before the attack, etc., while a large proportion complain of palpebral pruritus from two to ten days before the nasal symptoms begin. If the local irritant is the only cause, why does the respiratory tract, the portion of the body first and most exposed to its effects, not become immediately influenced? At this juncture a question natu- rally suggests itself: What then induces these premonitory symptoms 1 Again referring to the cases, we will find that premonitory symptoms only present themselves in cases in which hay fever is of some years' standing. As the accesses become more frequent, the system habituates itself to these annual or bi-annual attacks, and periodicity becomes an ele- ment of the case, marked in proportion with the degree of impairment of the nerve-centres. As an illustrative case, I will cite that of a medical friend, who, in a letter to me, spoke as follows : " My attacks for some years past came with much regularity, about August 12th to 14th. On these dates this year, I arranged to be on the water, on Lake Ontario and the St. Lawrence River, and entirely escaped everything like sneezing and irritation of the nose and eyes. Still, I had the usual slightly hot and irritable skin, then an eruption of urticaria, accompanied by disordered stomach. This expe- rience is precisely the same as in 1880, except that then I was on the Atlantic, on shipboard." In this case, the neurotic element is distinctly shown by the eruption and the gastric disturbance, while periodicity alone can explain the presence of the symptoms at the precise time and the favorable locali- ties in which they manifested themselves. As to the nervous symptoms occurring during the course of an attack, I am more disposed to consider them as due to reflex irritation from the local trouble than as originating 180 DISEASES OF THE ANTEKIOR NASAL CAVITIES. primarily in the nerve-centres. During the access, the sus- ceptibility of the reflex centres is developed to its utmost extent, and sunlight, a draught of air, etc., will give rise to most violent symptoms, which would not be the case ,ai other times. Accepting the above as conclusive in demonstrating the presence of a neurotic element, another question presents itself, which, left unanswered, would expose the theory to potent criticism : It being a recognized fact that in many individuals, there is impairment of the nerve-centres, either due to heredity or to disease, fully as extensive as in the worst hay fever subject, how is it that hay fever does not manifest itself in all these individuals I To answer this, the third condition comes to our rescue : In persons who are not subject to hay fever, the nasal mucous membrane is either in its normal state, or, if diseased, the local trouble is not of a nature to induce an abnormal susceptibility to irritation, and the systemic dyscrasia is not awakened to action, while in the hay fever patient, an hypera3sthetic state of the mucous membrane, either latent or due to local disease, is always present, furnishing a vulnerable or sensitive area through which the impaired nervous system can become influenced by the external irritant. Both systemic and local elements must exist simultaneously to render a paroxysm possible. That the local condition of the nasal mucous membrane is an essential factor in the production of an attack, was de- monstrated by the results attained with a treatment in which this point was kept in view. As long as it was overlooked, all efforts to conquer the disease were fruitless. As soon, on the contrary, as its true importance was duly appreciated, the chances of cure became greater than in any chronic affection of the nose. PERIODICAL HYPER^ESTHETIC RHINITIS. 181 In July, 1883, Dr. J. N. Mackenzie, of Baltimore, demon- strated that " there exists in the nose a well-defined sensitive area whose stimulation through a local pathological process, or through ab extra irritation, is capable of producing an excitation which finds its expression in a reflex act, or in a series of reflected phenomena." It is located at the pos- terior end of the inferior turbinated bones and the corres- ponding portion of the septum (b Fig. 53). I have frequently been able to verify this assertion, not only in the production of cough, but also in the production of reflex asthma, in cases in which a predisposition to this affection existed. Professor Hack, of Freiburg, Germany, has also demon- strated that various reflex neuroses originate in a diseased condition of the nasal mucous membrane. Unlike Dr. John Mackenzie, however, he locates the area from which the reflex symptoms take their origin at the anterior extremity of the inferior turbinated bone (c Fig. 53), and advises the removal of the latter for the cure of hay fever. In cases in which there was anterior hypertrophy, without a history of hay fever, I have not succeeded as yet in producing by local pressure, any evidence of reflex action, while in some of the cases, the same procedure in the posterior portion of the nasal cavity (Mackenzie's area) would elicit marked reflex symptoms. The fact, however, that the terminal fibres of the nasal branches of the spheno-palatine ganglion and of the nasal branch of the ophthalmic meet there and form quite a network, certainly verifies the view held by Hack, as to its being a reflex area of importance. In cases of hay fever, however, I have almost invariably found marked hyperajsthesia in this portion of the nasal cavity, with reflex symptoms in the superior maxillary region. In addition to these two sensitive areas, practical expe- rience in a large number of cases has demonstrated to me 182 DISEASES OF THE ANTERIOK NASAL CAVITIES. that a third area, of no less importance than that of Dr. J. N. Mackenzie, exists in the anterior portion of the nasal cavity, near the angle forming the anterior boundary of the vestibule, and located upon the nasal wall, as well as on the septum. This area is indicated in Fig. 53 by the letter d. In the great majority of persons subject to hay fever, if not in all, the surface of the membrane in this locality is exquisitely sensitive, and the contact of a probe provokes intense itching and lachrymation. Fig- 53- a, Spheno-palatine ganglion ; b, posterior area ; c, middle area ; d, anterior area ; e, olfactory bulk It thus becomes evident that there are in the nose three areas capable of producing reflex symptoms in the course of a paroxysm of hay fever, and that the three combined form the key of the local nervous element. I do not wish to imply, however, that the three areas must necessarily take part in the production of an access ; in some, only one of the three will be the " sensitive spot ;" in another, the posterior and middle areas will be involved, etc., etc. Again, a difference of intensity may exist in the degree of hyperaesthesia ; while one area may be but slightly sensi- tive the next may be extremely so. In cases complicated PERIODICAL HYPEB^STHETIC KHltilTIS. 183 with asthma, for instance, I have noticed that both ante- rior and posterior areas are sensitive, the latter being prin- cipally so, both giving rise to more or less reflex manifes- tations, but that when the paroxysms are uncomplicated, the anterior area is much more sensitive than the pos- terior. An explanation of the origin of this local hyperaesthesia would not be difficult did it involve the middle and poste- rior areas of the nasal cavity only. Here it may be caused by most of the affections of the anterior nasal cavity, from simple chronic rhinitis down to nasal polypi. But how can we explain its origin in the anterior portion of the cavity, which seldom takes part in the diseases to which the other portions are liable ? This leads us to the dis- cussion of another question : Can hypenesthesia of the nasal mucous membrane occur idiopathically or is a patho- logical process necessary as a primary cause? In three of the cases which have so far come under my care, examination some weeks before the access appeared, not only presented the cavities in their normal state, but I could not obtain from the patient any indication of the presence during the period intervening between the ac- cesses of any, even temporary, local trouble. Artificial stim- ulation with the probe to ascertain the location of the hyperaesthetic spots, as first suggested by Roe, however, demonstrated clearly the presence of several of them, and in one case gave rise to a number of reflex symptoms. It thus appears evident that a healthy membrane, in the or- dinary sense of the word, can become hypersesthetic with- out having undergone a local pathological process, and this be due to implication of the nasal nerve-supply in the general neurasthenia. But the small number of hay fever sufferers among the large number of neurasthenic people, 184 DISEASES OF THE ANTERIOE NASAL CAVITIES. makes this theory hypothetical, and the more plausible and less criticisable one of local chronic disease as a cause of the hyperffisthesia must be accepted. In the three cases in which no disease could be discovered, then, a pathologi- cal process, not sufficiently marked to be appreciated by ocular inspection, must have been present. As far as the anterior sensitive area is concerned, it is not unlikely that the proximity of an active pathological process maintained, by continuity of tissue, a latent inflammatory state which caused the hypersesthesia. As to the differentiation of one irritant from another, I believe, with Dr. J. N. Mackenzie, that it resides in the nerve-centres themselves. Their abnormal state renders them much more susceptible to the effects of external in- fluences, and their discriminating power is increased in pro- portion. Let there be in a certain subject any unusual susceptibility to any particular substance or substances, this will be increased in proportion to the degree of disturbance in the nerve-centres, the result being an exalted reflex man- ifestation. This peculiar susceptibility to certain substances is well exemplified by the violent coryza brought on in some persons by ipecacuanha. So sensitive are some to its effects, that a few moments spent in a drug store are sufficient to cause an attack. A number of secondary circumstances seem to exert some influence in the production of the affection, the principal of which is nationality. It is a strange fact that the Ameri- cans and the English are the principal sufferers. It might not be amiss to suggest that these are the only two great tea-drinking nations, and that this beverage may exert a depressing influence on the nerve-centres, and aggravate an inherited or acquired neursesthenia. The affection seems to be most frequent among people PEKIODICAL HYPER^ESTHETIC KHINITIS. 185 of education and those in comfortable circumstances, or whose occupation is sedentary. This may be due to a lack of wholesome exercise in the open air, a fact which I have been able to appreciate in the great majority of cases. Heredity has been shown to exert great influence in the etiology of the affection, thirty-seven per cent, of the forty cases alluded to in the first part of this essay, having rela- tives who are sufferers of either rose cold or hay fever, while asthma, which is, as shown, a predisposing cause, is present in eighteen per cent. more. The affection seems to be somewhat more frequent in men than women, the use of tobacco and other pernicious habits in the former being possibly accountable for the difference. Pathology. An iiriportant point in connection with the curative measures to be adopted, is a proper recognition of the fact, that each nasal cavity is divided into two regions which have distinct physiological functions, the olfactory region, in which the sense of smell is located, and the res- piratory region, the function of which is to purify the air of foreign substances, besides furnishing it with the neces- sary moisture and warmth before it reaches the lungs. As can be seen in Fig. 53, the filaments of the olfactory nerve cover the superior turbinated and the upper third of the middle turbinated bone. They also cover the correspond- ing portion of the septum. The upper part of the nasai cavity is thus devoted entirely to the sense of smell and not involved in the pathological etiology of hay fever. The respiratory region which includes, as already stated in the chapter on anatomy, all the surfaces below the olfac- tory, .is under the control of vaso-motor nerves of the sym- pathetic system, and is exceedingly sensitive to local or peripheral irritating causes. This sensitiveness, however, does not reside in the vaso-motor supply, which is only a 186 DISEASES OF THE ANTERIOR NASAL CAVITIES. secondary factor in the production of turgescence, but in the terminal filaments of the sensory nerves distributed over the surface of the membrane. A brief allusion has already been made to these, when speaking of the different hypera3sthetic areas, but they were not sufficiently described to render a clear outline of the pathological process pos- sible. Commencing with the posterior area, we find that the membrane of that location is supplied by several branches of the spheno-palatine ganglion, which enter the back part of the nasal fossa by the spheno-palatine fora- men. Besides its motor and sensory roots, the spheno- palatine ganglion possesses a sympathetic root, which is derived from the carotid plexus through the vidian, thus forming a well-defined connecting link between the nasal membrane and the sympathetic system. In the production of the reflex symptoms peculiar to the posterior area, cough and asthma, the impression is conse- quently transmitted from the posterior end of the infe- rior turbinated bone or the corresponding portion of the septum, to the spheno-palatine ganglion ; from that to the carotid plexus, which is closely connected with the poste- rior pulmonary plexus, formed not only by the branches of the sympathetic but also by some from the pneu- mogastric, and finally to the ramifications of the air-tubes through the ultimate filaments of the former, which are lost in the bronchial mucous lining. In many cases, how- ever, the asthma is not due to reflex action, but to the gradual extension of the catarrhal inflammation from the nasal 'membrane, down along the pharynx, trachea and bronchi. In these cases, the asthmatic symptoms only manifest themselves some time after the onset of the par- oxysm. In both varieties the exciting cause and the ulti- mate results are the same, but in the one the link between PERIODICAL HYPER^ESTHETIO RHINITIS. 187 them is the nervous system, while in the other it is the mere continuity of tissue. The frequently complained of symptom, itching at the roof of the mouth, is readily ex- plained by the presence of a large number of branches which emanate directly from the spheno-palatine ganglion and are distributed throughout the membrane covering the inferior surface of the hard and soft palate. The middle area being formed by the terminal fibres of the branches constituting the posterior and anterior areas, irritation over it may give rise to any of the reflex symp- toms which the two former occasion. The anterior area includes the nasal nerve, one of the principal branches of the first division of the fifth pair, the ophthalmic, which supplies the eyeball, the lachrymal gland, the mucous lining of the eye and nose, and the in- tegument and muscles of the eyebrow and forehead. This distribution, and the fact that the ophthalmic is a sensory nerve, explains readily how a pathological condition in- volving the nasal nerve may produce so many varied symp- toms. In the production of lachrymation and palpebral pruritus, we have the lachrymal branch, which supplies not only the lachrymal sac, but also the conjunctiva. In addition to this cause, however, closure of the tear duct certainly contributes greatly to the profuse lachrymation. The photophobia also finds an easy explanation, if we con- sider the communication existing between the first division of the fifth pair and the ophthalmic or ciliary ganglion, the filaments of which are distributed to the ciliary muscle and the iris. If we couple this with the fact that the pupil is dilated when the eyes are implicated in the paroxysm, we can understand how exposure to sunlight can aggravate symptoms of the affection, and appreciate the pathological verification which it furnishes. The conjunctiva, however, is often irritable per se. 188 DISEASES OP THE ANTERIOR NASAL CAVITIES. In accordance with these views, the production of a par- oxysm may be briefly described as follows: A given irri- tant coming in contact with the hypersesthetic nasal mem- brane in a neursesthenic subject, the impression made on the former is transmitted through the afferent fibrillae of the nearest set of sympathetic ganglia to those ganglia, and returned by them to the vaso-motor nerves of the mem- brane. The result is the same as in acute rhinitis a pri- mary contraction of the vessels followed by dilatation, the venous sinuses or corpora cavernosa becoming filled with venous blood and remaining distended. Violent sneezing occurs as soon as the membrane of the septum and that over the turbinated bones touch, and reflex asthma presents itself if the distention is sufficiently great in the posterior area to cause pressure against the septum. In the anterior area, the manifestations are not local, but occur in the parts which are in direct nervous communication with it. We thus have lachrymation, photophobia, headache, facial and palpebral pruritus, and so forth. If the distention is great in the middle area and nowhere else, we may have the whole train of symptoms, both anterior and posterior areas being involved, while implication of the posterior area will give rise to asthma if there is sufficient turges- cence to cause pressure against the septum, and if the asthmatic tendency exists in the patient. As to the general systemic disturbances present in connection with the head symptoms, they are easily accounted for by the momentary increase of the abnormal excitability of the nerve-centres. In my opinion, a paroxysm brought on by peripheral irri- tation, exposure to draughts, wind, dampness, etc., or occur- ring as a reflex manifestation from other parts of the body in an abnormal state at other times than in the hay fever season, cannot be considered as hay fever. It is an attack PERIODICAL HYPER^STHETIC RHINITIS. 189 of acute coryza, due to the fact that the nasal mucous membrane receives its vaso-motor innervation from a gan- glion which is the part of least resistance in the patient's economy, and which does not require a special agent to become influenced. Symptoms. The symptoms of hay fever may be limited to those of a mild coryza and last only a few days, or they may assume such violent form as to cause the patient great suf- fering. The attack usually begins with a sensation of itching in the nostrils, which soon becomes very intense, and causes violent and prolonged sneezing. A pricking, burning sensa- tion in the inner canthi, followed by profuse lachrymation, may accompany this symptom, or constitute the first evi- dence of the access. Very soon the nose becomes occluded through turgescence of its lining membrane, and respiration through it is practically impossible. A watery discharge appears, which soon becomes very profuse, and its strongly alkaline character causes it to irritate the nostrils and the upper lip, sufficiently sometimes to give rise to painful ex- coriations. Violent sneezing may begin at once, or occur when the watery discharge begins to trickle down along the intra-nasal walls, and the patient makes futile efforts by im- moderate use of the handkerchief, to clear the nose of the cause of irritation and obstruction. Chilly sensations, frontal headache, tinnitus aurium, loss of smell and taste, violent itching at the roof of the mouth, pain over the bridge of the nose, facial pruritus, and general symptoms, such as slight pyrexia, urticaria, disordered stomach and flatulence, are among the possible accompaniments of this stage. As the affection progresses, the nasal secretion assumes more of a mucoid character, becoming at times muco-puru- lent. The conjunctiva may become greatly inflamed, and photophobia and marked chemosis follow, rendering, in some cases, a prolonged stay in a dark room necessary. 190 DISEASES OF THE ANTERIOR NASAL CAVITIES. Premonitory symptoms are present in a small proportion of the cases, especially in those of long standing. Frontal headache, general malaise, chilly sensations, and itching at the roof of the mouth and eyes, occurring from two days to two weeks before the attack, are among those most fre- quently complained of. Asthma may occur as a complica- tion of the affection, or as its only symptom. In the former case, it may present itself any time during the course of the disease ; in the latter, it manifests itself suddenly as soon as the irritating agent is inhaled. In the majority of cases, however, it begins a few days after the primary nasal symp- toms have shown themselves, and as soon as these become marked. A feeling of soreness in the region of the pharynx is experienced, followed shortly after by hoarseness, slight cough, scanty expectoration, arid a feeling of constriction about the chest, and the asthma comes on insidiously, gradu- ally increasing in intensity as the disease advances. It is generally much worse at night than in the day-time, relief coming on with the dawn of the day. In some cases it ceases with the nasal symptoms, or soon after ; in others, and this forms the majority, it lasts much longer, prolonging the suffering of the patient over weeks and even months. The affection presents itself twice in the year in some individuals, while in others it either occurs in May or June, or during the last two weeks of August or early in Septem- ber. The summer variety, generally called "rose cold," is not as a general thing as severe as the autumnal variety or " hay fever," and does not last as long. Subjects of the dis- ease can in almost every instance predict the exact day, and sometimes the hour, of the onset of the expected attack. Curative Treatment. The first indication in the curative treatment of hay fever is to ascertain by careful examina- tion of the nasal chambers, whether the condition which gave PERIODICAL HYPER^ESTHETIC RHINITIS. 191 rise to the hypersesthesia is sufficiently marked to receive special attention. In the great majority of cases, a simple chronic rhinitis exists with a tendency to frequent or perma- nent turgescence of the mucous membrane. In others we have true hypertrophy, involving either the anterior or pos- terior portions of the nasal cavities, or both. Occasionally we find polypi, which occlude more or less one or both cavi- ties, while a deviated or thickened septum may keep up a marked irritation and constitute a serious obstacle to a sub- sequent thorough treatment. When these, or any other ab- normal condition compromising mechanically the lumen of the cavities, are present, they should first receive attention, and the nasal cavities returned as nearly as possible to their normal state. If the treatment employed be one of a de- structive nature, the organic changes induced by it in the mucous membrane proper will often be sufficient to annul its hyperaesthesia. This was exemplified by the cases re- ported by Daly, Roe (first paper), in two of the first reported by me, and in several reported by Dr. Harrison Allen. In a large proportion of patients, however, it does not suffice, and immunity from the disease can only be expected after each sensitive spot has been thoroughly cauterized. Organic alteration of the surface of the membrane, first proposed by me in December, 1883, can be induced by the application of galvano-cautery or of caustic acids. Each sensitive spot must be ascertained -and treated with the agent used until the exaggerated sensitiveness is replaced by the normal sensation of contact. When the galvano- cautery is to be used, it is very essential to have a battery powerful enough to cause the platinum loop to suddenly attain white heat, so as to avoid the pain caused by the gradual increase of the temperature, and prevent prolonged radiation. This condition being fulfilled, we require a loop, 192 DISEASES OF THE ANTERIOR NASAL CAVITIES. which, upon being entered into the nasal cavity, will be sufficiently blunt at the point and edges not to scratch or cut the mucous membrane, when gently passed over it. I have found the tip shown in Fig. 54, which resembles an ordinary cautery knife, but is more rounded at the point and somewhat broader, most satisfactory. It can be easily introduced in all the sinuosities of the fossa3. Fig. 54- The cautery knife applied to the anterior area, c, middle area ; a, posterior area; d and , sensitive surface of middle turbinated body. The nasal cavity being properly dilated and illuminated, the cautery knife is introduced gently and applied flatwise to the anterior area as indicated in the cut. If the part is not sensitive, the patient will not wince, the sensation being liardly more than a slight itching. If it is hyperaesthetic, a PERIODICAL HYPEE^STHETIC RHINITIS. 193 feeling of intense itching or burning will be complained of, followed, in some cases, by profuse lachrymation. As soon as the evidences of abnormal sensitiveness appear, care should be taken not to move the platinum tip, and the circuit being closed, the metal singes the spot, destroying the super- ficial nervous filaments. If the platinum becomes white hot immediately, comparatively little if any pain -will be experi- enced, but the contrary will certainly be the case, if a weak current, or a knife so thin that the nasal mucus will prevent it from becoming heated rapidly, is used. One spot being cauterized, another sensitive spot is searched for by gently passing the loop over the surface until the patient complains of the sensations experienced before, when the current is again applied. In this manner the entire respiratory area should be gone over, until the instrument can be applied to any part of the membrane without exciting reflex symptoms or causing the violent itching or burning, which the patient soon learns to recognize. The pain accompanying these applications varies according to the degree of heat employed. White heat, which cauter- izes in an instant, destroys the nerve filaments before they have time to convey the sensation of pain to the nerve-cen- tres. Cherry heat causes some pain, while black heat is ex- ceedingly painful. White heat, therefore, should always be employed for superficial applications. The cauterizations should always be -"begun in the anterior portions of the nasal cavity (except when reflex asthma is present as a complication of the affection, for reasons which will be explained later on), so that the anterior hypersesthesia will not be present when the posterior parts are examined, and thus conceal the sensitiveness, or convey a wrong idea as to its location. The septum should be as carefully examined as the turbinated bones, and any spot of even doubtful hyper- ffisthesia cauterized. 13 194 DISEASES OF THE ANTEEIOK NASAL CAVITIES. Three or four spots in each cavity can be cauterized at one sitting, and it is best to locate them some distance apart. A sensitive spot being found in the upper part of the ante- rior area, for instance, and cauterized, the next spot should be looked for in the lower part of the septum, etc. In -short, the object should be to avoid large superficial abrasions, numerous small ones healing much faster and producing no disagreeable after-effects. In the great majority of cases, a few minutes after the applications are made, all annoying sensations are passed, and the patient can return to his business without fear of being in the least troubled. In some few, however, the membrane swells for a while, and the patient may experience difficulty in breathing through the nose. When such is the case, one nostril should be treated at each visit, so as to preserve for the patient the patency of the other, and thus insure him comparatively free respiration. In two cases, so far, the applications were followed by an attack of coryza, accompanied by reflex symptoms. In one case it lasted ten hours, in the other it continued about twenty-four. The membrane covering the middle turbinated bone does not seem to enter the process of resolution after galvano- cautery applications, as readily as the other portions of the respiratory region. In three cases in my practice, redematous inflammation took place, which caused me to mistake the overhanging grape-like protuberance for a polypus. In one case I snared it off, causing immediate recovery; the two others were left to themselves, and disappeared after a few weeks. Fortunately, the limited innervation of the surface of the middle turbinated membrane, renders but few applica- tions necessary, and they should be made sufficiently far apart to insure complete resolution after each sitting. PERIODICAL HYPERJESTHETIC RHINITIS. 195 Important in this connection is the proper topographical recognition of the olfactory membrane, which includes the upper third of the middle turbinated body. Care should of course be taken not to cauterize it, and to limit the applica- tions over the turbinated bone to its lower half. With this precaution, no danger to the sense of smell need be appre- hended. The number of applications required to render immunity positive, depends of course, upon the number of sensitive spots. With some, five sittings are sufficient, while in the majority of patients from fifteen to twenty are required, each from three days to one week apart, the length of the interval depending upon the rapidity with which resolution of each cauterized spot takes place. When the physician is not possessed of galvano-cautery in- struments, acids may be used instead. Chromic acid would be the best of any, were it not for the danger of general tox- semia following its application over comparatively large sur- faces. Glacial acetic acid, with which I treated my first cases in the spring of 1881, is the most satisfactory in every way except one the pain its application gives rise to, on account of the quantity which has to be used. This fact, however, can in a great measure be corrected by dissolving in it hydro- chlorate of cocaine to saturation. Another feature character- izing its use, is the turgescence which takes place after each application, as stated when speaking of the treatment of an- terior hypertrophies. The hydrochlorate of cocaine seems also to influence this result, by limiting the inflammation markedly and advancing resolution. Dr. Beverly Eobinson, of New York, has reported good results with applications of pure carbolic acid. Unlike when it is applied to other parts I found that this acid caused much pain, besides imparting its well-known odor, and I therefore discontinued its use. 196 DISEASES OF THE ANTERIOR NASAL CAVITIES. Nitric acid should never be used, except for the reduction of hypertrophies as described. For the application of glacial acetic acid, the instrument shown in Fig. 54 will be found very satisfactory. It consists of two probes, shaped like Bosworth's (Fig. 31), in close appo- sition, their surfaces being so flattened as to render their contact perfect. One of the probes is fastened to the handle and is furnished with a number of shallow holes, a distance of one-half inch along the inner surface of its extremity, so that a drop of acid will be retained when the other probe is placed Fig. 54- Author's glacial acetic acid applicator. over it. The latter having free longitudinal motion, can be moved freely along the other by means of a finger lever, thus uncovering at will the acid-covered surface. The two probes are so arranged that they can be rotated together on their axis, so that the acid-covered surface can be made to face any direction. Their broad ends being of silver, the acid does not affect them. The manipulation of this instrument is precisely -the same as that of the galvano-caustic knife. Being introduced into the cavity, a sensitive spot is searched for with both probes in apposition, and as soon as it is found, the finger lever is depressed and the acid probe being uncovered, the spot is PEEIODICAL HYPER^STHETIC RHINITIS. 197 cauterized. The finger lever is then allowed to raise, and the instrument can be withdrawn without cauterizing any other surface. Care should be taken to cleanse the instrument carefully before entering it into the nose, lest some acid remain over its surface. As to the period when the applications should be made, I am of the opinion that the treatment should be begun at least two months before the expected attack. There is suf- ficient time left then, to annul all the hyperaesthetic spots (in the great majority of cases) without having to crowd the applications together, an unsatisfactory procedure, since the inflammation is likely to impair the abnormal hyper- aesthesia and prevent proper recognition of the sensitive spots. In three cases so far, I have been able to arrest the paroxysm from one to three weeks after it had begun, and when it was at its height. This result, however, cannot be expected in every case, but the applications are beneficial in all, and reduce in a marked manner the intensity of the paroxysm and its duration. Of seven cases treated last season in the midst of the hay fever, three were entirely relieved, three were much benefited, and the seventh was enabled to return to his business, from an imprisonment in a dark room. Although his sufferings were much abated, they continued until the end of his usual six weeks. When the treatment is begun at the proper time, i.e., several weeks before the paroxysm, its success depends en- tirely upon the thoroughness with which both nasal cavities have been relieved of their sensitive spots. An insufficient number of applications, or a timid patient, are as likely to prevent a radical cure, as a thorough treatment in a plucky patient is certain to be rewarded with permanent immunity. 198 DISEASES OF THE ANTERIOR NASAL CAVITIES. An important point in connection with the results of im- perfect cauterization is that however limited the number of applications may be, the benefit produced, as far as the nasal symptoms are concerned, is proportionate with that number, and with the thoroughness with which they are performed. When but a limited number of applications are made before the period of attack, the onset of the parox- ysm is retarded, which naturally curtails the duration of the disease, while its intensity is reduced. Again, when reflex asthma is a complication of the affec- tion, and an insufficient number of applications have been made, this symptom is likely to appear as the sole expres- sion of the paroxysm, the head symptoms being absent, or if present, exceedingly mild. This is doubtless due to the fact that the first applications being made anteriorly, the sensitive spots in the anterior and middle areas are more or less deprived of their hypersesthesia (the presence and intensity of the head symptoms depending upon the thor- oughness with which this is done), and the posterior area being only cauterized towards the end of the treatment, the symptoms which are secondary to its irritation present themselves. A conclusion which I have come to lately, and which is borne out in the above cases and by close observation in all the others, is that when reflex asthma exists as a com- plication of the head symptoms, a greater number of appli- cations are required than when it does not, and that im- munity from all the symptoms can only be obtained when all three of the sensitive areas have been thoroughly treated, the treatment of the posterior area being such as to limit the inordinate power of turgescence, which is always present when true hypertrophy does not exist. In accordance with this view, I now direct my attention first to the posterior PERIODICAL HYPER^ESTHETIC RHINITIS. 199 area, when reflex asthma exists, employing chromic acid, galvano-cautery, or the snare ecraseur as needs be. This is greatly facilitated by annulling the hypersesthesia of the anterior and middle areas with a four per cent, solution of cocaine. In the cases in which asthma is the only symptom, this procedure, when thoroughly conducted, will often suffice to cure the affection, even, sometimes, when mild head symp- toms are present (these being due to implication of what terminal filaments of the nasal nerve may extend in the sensitive region), but, as these cases are rare, applications to the anterior and middle areas are nearly always neces- sary. Again, a mild case of hay fever, complicated with reflex asthma, may be due solely to hyperaesthesia of the middle area, and be cured by a treatment limited to it. Here, the asthma is due to the turgescence of the posterior area oc- curring as a result of the inflammatory process, while the head symptoms are induced, as just stated, through impli- cation of the nasal nerve in the hypersesthetic region. I am of the opinion, however, that it is always best to in- clude the posterior ends of the turbinated bodies in the treatment. As stated under the heading of Pathology, catarrhal asthma, which occurs late in the history of the affection, is much more frequently met with than the reflex variety, which comes on as soon as the Schneiderian membrane has become sufficiently turgid, through the local inflamma- tion, to induce pressure against that of the septum. Being due to extension of the inflammation by continuity of tissue, it can only present itself, provided the nasal symptoms take place, and prevention of the latter will obviously deprive the asthma of its primary cause and prevent it. 200 DISEASES OF THE ANTERIOR NASAL CAVITIES. When the membrane is free from hypertrophies, etc., cauter- ization of the sensitive spots, whether these be situated in the anterior, middle, or posterior areas, will therefore be sufficient to prevent both head symptoms and asthma, a fact so far demonstrated in six cases. When the head symptoms solely characterize the ac- cesses, the greatest hypersesthesia will be found in the anterior area, which will of course require the brunt of the treatment. Any other sensitive spot, however, should also be effectively cauterized. After-effects of the local treatment. Although the number of cases treated so far has been rather large, I have not had to regret any ill-effect occurring as a result of the treatment. The sense of smell instead of being obtunded, is frequently improved, especially when anterior hypertro- phies are reduced in the course of the treatment. This is easily explained by the fact that the olfactory membrane is not involved in the treatment, and that by facilitating the passage of air by the reduction of the tumefactions, the .odoriferous particles can reach the olfactory area in greater number and with more freedom. The permanent nasal hypereesthesia which exists in the majority of hay fever cases, through which irritating sub- stances cause much annoyance, itching, sneezing etc., is naturally obviated in every instance. As to the permanency of the immunity, it depends, of course, upon the thoroughness with which the treatment is conducted. A spot as large as a small pea, left in its hyperaesthetic state may not be active during the period of the first paroxysm, owing to the proximity of the curative treatment and the temporary local inflammation set up by it, while the following year, having reassumed its hyperaesthesia, it may occasion unmistakable, although PERIODICAL HYPER^ESTHETIC RHINITIS. 201 slight symptoms of the disease. The patient should there- fore be requested to call a couple of weeks before the usual date of the onset, in order that any hypera3sthetic spot that might exist, may be thoroughly cauterized. Palliative Treatment. The palliative treatment of hay fever may be conducted either during the attacks or, with a view to prophylaxis, during the interval between them. A well conducted tonic treatment, begun two or three months before the onset of the paroxysm, sometimes suc- ceeds in markedly diminishing its intensity, nerve tonics, such as nux vomica, arsenic and phosphorus, being espe- cially valuable. When anaemia exists, iron should be given. Rabuteau's pills of the carbonate of iron have in my hands given better satisfaction than any other make, not giving rise to constipation or producing other deleterious effects. Quinia, six grains taken daily in divided doses, is also very valuable in some cases. Morell Mackenzie recom- mends a pill of valerianate of zinc, one grain, and compound assafoetida pill, two grains, beginning some time before the expected attack, and doubling the dose at the end of ten days or two weeks. Out-door exercise is an important ad- junct to the treatment, while vigorous friction with a rough towel every morning, tends greatly to invigorate the system. When the patient cannot leave for some location in which the absence of the irritant or irritants which affect him insures immunity, high altitudes, the sea or the seashore, a number of prophylactic measures may be taken to reduce the violence of the attack. Of these, plugging the nostrils with cotton is probably the most effective, the irritant be- ing thus arrested at the entrance of the cavities, and not reaching the sensitive areas. Care should be taken not to push the plug too far in, lest the contaminated atmosphere 202 DISEASES OF THE ANTEEIOE NASAL CAVITIES. pass above it. It should be introduced just within the nos* tril, and so adjusted that the inhaled air be forced to pass through it. In some cases, even that does not prevent the entrance of the irritating agent. The nostril should then be hermetically closed with cotton, and the respiration be con- ducted through the mouth for the time being, taking care to keep the lips moist and as near together as possible, in order to imitate in a degree .the functions of the nasal cav- ities. The patient should as much as possible avoid the sun, the reflex irritation of the nerve-centres which it in- induces through the eyes, increasing not only the local symptoms, but also those of the respiratory tract. Large smoked blue spectacles are very effective for this purpose. Ladies can wear thick veils, which not only limit the access of pollen to the nose, but also avoid for them the effect of the glare of the sun and the irritating action of the wind upon the skin of the face. Medicinal treatment is sometimes of benefit. The most effective drug at our disposal is cocaine, which is capable in some cases, of subduing a paroxysm. Applied in solution, however, its effect is slight, its strength being much reduced by the unusual amount of secretion present. Tablets of cocaine, gr. each, as proposed by Dr. Watson, of London, are much more effective. Being introduced into the nostrils, they dissolve in the mucus, and the solution formed comes in direct contact with the membrane. Ointments are, in a large number of cases, the most satisfac- tory agents for local applications. The benzoated oxide of zinc ointment and vaseline, equal parts, not only soothes greatly the irritated surfaces, but if applied frequently, it seems to curtail the attack by limiting the access of the irritating bodies to the membrane. It should be applied as thoroughly as possible with a camel's hair pencil, after PERIODICAL HYPER^STHETIC RHINITIS.. 203 having liquefied it by holding the vessel containing it in hot water. Lennox Browne, of London, recommends highly an ointment containing a drachm of oil of hamamelis and one ounce of vaseline. Belladonna ointment, made with the aqueous extract, is also beneficial, the relief being further augmented by applying it over the nose likewise. The quinine spray, advocated by Helmholtz, is occasionally bene- ficial. In the majority of cases, however, it causes irrita- tion, especially when used cold. One grain is dissolved in an ounce and a half of water and heated to 100 Fahr. A spray of bicarbonate of soda or of borax, three grains to the ounce, used at the same temperature, is sometimes very effective. Inhalations of the emanations of conium juice, using the auto-insufflator (Fig. 27), in which a cotton pledget has been introduced, is also beneficial at times, while three drops each of liquid carbolic acid and the oil of tar, used in the same manner, sometimes gives much relief. For the eyes, a solution of two drachms of spirits of nitrous ether in six ounces of water, used with a coarse spray atomizer or applied with compresses, will be found useful. A two per cent, solution of cocaine, applied with a dropper, is very effective in most cases. Internal remedies are sometimes of value. The elixir of valerianate of ammonia, a teaspoonful being taken every two hours, is sometimes surprisingly effective. Quinine, two or three grains three times a day, seems also to exert a beneficial influence. Morell Mackenzie recommends highly the pill of valerianate of zinc or assafoetida, already alluded to. For the asthma, a preparation containing iodide of potassium, gr. v, tincture of belladonna, KIV, suspended in syrup of orange peel, administered every two hours until the symptom ceases, has proven exceedingly efficient in 204 DISEASES OF THE ANTEEIOR NASAL CAVITIES. almost every case in which it was ordered. The inhalation of the fumes of nitrated blotting paper, or the smoking of stramonium or belladonna cigarettes is also advantageous in some cases. The depression which invariably follows and sometimes precedes an attack requires the moderate use of stimulants. The best of them, in my opinion, is wine of coca, which, theoretically, is admirably adapted to counteract the depressed state of the nerve-centres. ANOSMIA. Anosmia, or loss of the sense of olfaction, occurs as a symptom of several affections of the nasal cavity, and as a result of lesions of the olfactory bulb or other portions of the brain, of idiopathic or traumatic origin. Nasal affections may give rise to anosmia by interfering mechanically with the access of the odoriferous bodies to the olfactory nerves, or by annulling their sensitiveness through extension of the inflammatory process to the olfac- tory area. Acute rhinitis, hypertrophic rhinitis, and nasal polypi can thus cause anosmia by the obstruction to which they give rise, while simple chronic and syphilitic rhinitis may act as exciting causes by involving the mucous mem- brane of the olfactory area in the local inflammation. Atrophic rhinitis may also give rise to it, the impaired or arrested action of the lubricating glands failing to furnish the fluids necessary to dissolve the odoriferous particles over the olfactory nerves. Lesions of the olfactory bulb are in most cases due to a blow received either over the supra-orbital region or upon any other portion of the head. Its soft consistence causes it to become easily disorganized, and once broken up, it does not recover. Central brain lesions, tumors, abscesses, etc., are occasionally accompanied by . loss of smell. The ANOSMIA. 205 other symptoms of the case serve to clear the diagnosis. The olfactory bulb or its branches may be imperfectly de- veloped or absent. The continued inhalation of strong odors, or tobacco smoke, by over-stimulating the olfac- tory nerves, also causes anosmia. This over-stimulation may also be brought about by the prolonged use of to- bacco or other irritating snuffs. Certain drugs, such as morphia, alum, tannin, etc., when used to excess have been known to impair and even destroy the sense of smell. The sense of taste, owing to its close relationship with the latter, is impaired in the majority of the cases of anosmia. Treatment. When anosmia is due to an acute affection, the sense of smell usually returns when the latter disap- pears. In chronic conditions, the treatment applied for their relief is obviously that indicated for the anosmia, and it will meet with success if the integrity of the twigs of the olfactory nerve is not too greatly compromised. When olfaction has been absent for a number of years, the chances of recovery are very meagre, while in cases caused by blows or falls, a cure is not to be expected. When the condition . acting as primary cause has been treated and the anosmia still persists, strychnine used locally is sometimes very efficient, combined with the application of the faradic current. The former may be administered as a snuff, one-fortieth of a grain being thoroughly triturated in two grains of sugar and used with the auto-insufflator (Fig. 27) night and morning. Care should be taken to in- troduce the tip of the instrument as far as possible, directing it towards the roof of the nose. The faradic current should be used every day, a moderate current being passed from the inter-orbital space to the occiput, the negative pole being placed over the former. Thoroughly wetting the sponges will insure penetration of the current, which would otherwise pass around the head. CHAPTER XI. DISEASES OF THE ANTERIOR NASAL CAVITIES. (Continued.) BPISTAXIS. (Synonyms: Nose-bleed; Hemorrhagia Narium ; Rhinorrhagia.) Etiology. Bleeding at the nose may be due to trauma- tism, such as blows, falls, picking with the finger-nails, the introduction of a foreign body, forcibly blowing the nose, sneezing, etc. It is a frequent symptom of the majority of nasal tumors, and of the forms of rhinitis accompanied by ulceration. It occasionally occurs as a vicarious substitute for menstruation. An obstruction to the general circulation or any condition increasing the tension of the blood-vessels, may give rise to it, while a weakened state of the vessel walls, which may be local through prolonged catarrhal in- flammation, or general, through degeneration of the vessels at large as a result of disease or old age, may act as a primary cause. It may also be the result of obstruction to the return of blood to the heart through pressure upon the jugular veins by tumors, closely-fitting neck-wear, etc. A constitu- tional susceptibility to hemorrhages exists in some individ- uals, the bleeding being at the nose in the majority of cases ; in these, the liability to epistaxis may be congenital. Epistaxis occurs as a premonitory or concomitant symp- tom in a number of affections, such as typhoid and remit- tent fevers, scurvy, diphtheria, and the exanthemata. In plethora and when the cerebral circulation is overloaded, a free nose-bleed is generally productive of great relief. Pathology. The profuseness with which the nasal mucous membrane is supplied with blood-vessels, furnishes a ready explanation for the copious hemorrhages which occur as a (206) EPISTAXIS. 207 result of traumatism. A blow, by suddenly increasing the blood-pressure readily causes rupture of one or several blood- vessels. The fact that arterial blood is generally lost indi- cates that the venous sinuses are but seldom involved. Picking the nose, by denuding the membrane of its epi- thelium, exposes the underlying membrane proper, tearing some of the numerous blood-vessels. The hemorrhage some- times originates in the posterior nasal cavity, especially in the mass of glandular tissue with which the vault is furnished. Symptoms. In epistaxis due to traumatism, the blood flows freely in most cases from one side. These hemor- rhages usually cease of their own accord, and are not of long duration. In most of the other forms of epistaxis, the blood trickles by drops, which follow each other in more or less rapid succession. In nose-bleed occurring as a result of cerebral congestion, premonitory symptoms, such as headache, tinnitus aurium, injection of the conjunctiva, etc., are usually experienced, which are much improved or disappear altogether as soon as a certain amount of blood has been lost. In individuals subject to hemaphilia, the attacks may occur at any time, the least exertion serving sometimes to bring on a severe epistaxis. When the con- dition is due to vicarious menstruation, it usually presents itself about the time the latter should begin, with inter- mittent recurrences during the usual duration of the men- strual flow. In general softening of the vessel walls, nose- bleed usually begins after an exertion, and is exceedingly difficult to arrest. When the bleeding originates in the vault of the pharynx, the blood flows posteriorly when the patient is sitting up or standing. Prognosis. In almost every case, epistaxis is not followed by serious results. The lost blood is soon reformed, and 208 DISEASES OF THE ANTERIOR NASAL CAVITIES. prompt recuperation of lost forces takes place. When oc- curring in persons of great debility it may cause death by exhaustion. Treatment. The position of the body bears great influence upon the violence and duration of an attack of nose-bleed. In a case seen in consultation, the epistaxis, although not profuse, had already lasted upwards of twelve hours, the patient having remained in the recumbent position, with his head hanging over a pail, throughout the entire time. The mere return to the upright position caused the flow to cease at once. When there is great tendency to coma, however, the sitting posture should be tried, and if this cannot be endured, lying flat on the back is the next best position. The hemorrhage can frequently be arrested by simply closing tightly the bleeding nostril for a few minutes, es- pecially when the flow arises from the anterior portion of the septum. Pressure upon the artery of the septum as it enters the nostril, or upon the branch of the facial, situated close to the alee, will sometimes suffice. Eaising the arms above the head to force the blood to mount against gravity, thus encouraging the formation of a clot, is also recom- mended. Derivative treatment, such as hot foot-baths, mus- tard plasters to the back of the neck, ankles, or chest, may also be employed, while stimulation of the vaso-motors can be induced by the application of cold in the form of ice, cold compresses, ice bags over the nose, forehead, nucha, etc. When these simple means fail, the local application of styptics may be employed. Sniffling' ice-water, into which a little salt has been dissolved, is sometimes very effective. Insufflations of tannic acid, gallic acid, or alum, either sepa- rate or combined, by means of the auto-insufflator (Fig. 27), or posteriorly with the scoop insufflator (Fig. 25), will arrest EPISTAXIS. 209 the bleeding in most of the severe cases. The styptic preparations of iron are preferred by some, but I have not found them more effective than the above, while their use is much more unpleasant to both patient and physician. Solutions of sulphate of zinc, acetate of lead, or sulphate of copper (gr. xxx-3J) may be applied with a syringe or with the atomizer. In connection with the treatment, blowing of the nose should be avoided for some time, so as not to remove the clots which arrest the bleeding mechanically. When evidences of weakness become apparent, such as pallor, vertigo, etc., mechanical means must be resorted to. The simplest of these is to pack the bleeding cavity with pledgets of cotton, lint, or bits of sponge, previously dipped Fig. 56. BeHocq's canula when not in use, in some styptic solution, and of sufficient size to exert pressure when in place. Any blunt instrument may be used to mass them in, one after the other. They can be withdrawn with dressing forceps after twenty-four hours, and new ones replaced if necessary. Dr. E. J. Levis, of this city, uses small pieces of sponge passed successively over a piece of twine. In some cases, the point of origin of the hemorrhage is so far back that anterior packing is not sufficient. Re- sort must be had to posterior tamponing, a rather difficult procedure in most cases. Bellocq's canula, an instrument especially adapted for the purpose, may be used. It cou- 14 210 DISEASES OF THE ANTERIOR NASAL CAVITIES. sists of a metallic tube through which a curved steel spring moves freely. When the instrument is passed through the bleeding nostril, the curved spring is forced out by a movable rod connected with it, and its shape causes it to curl into the mouth, presenting a perforated knob, to which a string furnished with a cotton tampon the size of the patient's thumb, is attached. The instrument being drawn out, the tampon is pulled up behind the soft palate, and into the narium, which it closes up tightly. This procedure is very effective when the nasal cavity is sufficiently well formed and wide enough to allow the introduction of the canula. In the Fig. 57- Bellocq's canula when in position. majority of cases, however, great trouble is experienced in introducing it, and in some cases, through marked devia- tion of the septum, the presence of hypertrophies, etc., the manipulation cannot be accomplished. A more univer- sally successful procedure is to use a small flexible rubber bougie; when pressed into the nostril, it accommodates itself to the irregularities of the respiratory tract and finally emerges into the naso-pharynx, the wall of which causes the tip to turn downward and protrude below the soft palate, when it can be seen through the mouth and drawn out with a pair of forceps. A string furnished with a tampon being attached to it, when the bougie is drawn EPISTAXIS. 211 out, the tampon is drawn into place. The string should always be double so that one end will protrude through the nose and the other through the mouth, the two being tied over the upper lip to retain the tampon in place. Much trouble is sometimes experienced in passing the latter behind the soft palate, which will adapt itself against the pharynx and prevent its introduction. This can be avoided by passing the index finger through the isthmus and leav- ing it there until the tampon has passed into the pharyn- geal vault. If left in place too long, tampons may cause systemic poisoning and tetanus; they should therefore be changed after twenty-four hours, or at most forty-eight. FOREIGN BODIES IN THE NASAL PASSAGES. Children frequently insert foreign bodies, such as but- tons, pebbles,, cherry stones, beans, hairpins, etc., in their nasal passages, where they may remain impacted for a num- ber of years. Insane people do likewise occasionally. In adults, foreign bodies are very rarely met with in the nasal passages, their introduction being generally due to acci- dental causes. Necrosed bones, when detached, become foreign bodies, and give rise to all the symptoms charac- terizing their presence. In a few rare cases the foreign bodies are ascarides or other human parasites, which are either forced up into the posterior nasal cavity by coughing or crawl up along the pharynx. Symptoms. At first the presence of a foreign body attracts but little attention. The timid child refrains from men- tioning his mischievous act, and soon forgets it. After some time, a discharge of- glairy mucus begins; this soon becomes purulent, and, if the foreign body presents asperi- ties, may be tinged with blood. In some cases the dis- charge becomes extremely fetid. Round bodies, if small, 212 DISEASES OF THE ANTERIOR NASAL CAVITIES. cause a hardly perceptible discharge, which, nevertheless, is sufficient to excoriate the nostril. Beans, peas, and other vegetable substances, absorb the watery constituents of the secretion, swell considerably, and occasionally germ- inate, increasing greatly the intensity of the symptoms. When the bodies are large or hard, such as bullets, large pebbles, etc., they may occasion considerable pain of a neu- ralgic character, headache, etc. Obstruction to nasal respi- ration is of course proportionate with the size of the for- eign body. Treatment. The extraction of a foreign body from the nasal passages is at times exceedingly difficult, especially when it has been in the cavity for a prolonged period, during which it sometimes becomes covered with a calca- Fig. 58- Gross' ear curette. reous coat. It is generally deeply imbedded in the mucous membrane, and occasionally surrounded by fungous growths. In ordinary cases, forcible sneezing, induced by tickling the inside of the nose, may be tried. If unsuccessful, the posterior douche may be more successful, used by raising the can above the head so as to obtain a powerful stream. Hall's syringe (Fig. 16) will be found very convenient, the force of the current being easily regulated. These failing, surgical means must be resorted to. In the majority of cases, such an instrument as Gross' ear curette (Fig. 58) may be used, the spoon-like tip giving the operator good purchase. Another convenient instrument is that shown in Fig. 59. A pair of delicate forceps may be more efficient in some cases. In these manipulations, however, care should be taken not to lacerate the membrane, and to avoid pushing RHINOLITHS. 213 the foreign body still deeper in the fossa. When the for- eign body is deep-seated, a method which I have found effective is to pass a piece of slender wire along the floor of the nose as far back as the pharynx, withdrawing the end out of the mouth with forceps, A tampon of cotton or linen being securely attached to it, and drawn up be- hind the palate into the posterior nares, it is pulled through the nasal cavity along with the foreign body. In a case in which a pebble could not be grasped, I passed two wires, one above and one under it, into the mouth, then tied a long piece of strong tape between the two ends, thus forming a loop with which the foreign body was withdrawn as a cork is pulled out of the body of a bottle. Fig. 59- Bent tip curette. (Inventor's name could not be ascertained.) KHINOLITHS. Rhinoliths are calcareous concretions, varying in size from a millet-seed to an almond, formed by the accumula- tion of the alkaline constituents of the secretions (princi- pally phosphate of lime) around a foreign body in the nasal passages. They sometimes originate from a small mass of desiccated mucus. A gouty diathesis is thought by GrsBfe to be favorable to their formation. Symptoms. The symptoms occasioned by the presence of rhinoliths resemble those of a foreign body. At first, how- ever, its presence is hardly noticed, its effects becoming per- ceptible when it has attained a sufficient size. A nasal dis- charge, which gradually thickens, presents itself, and, as the inflammation of the surrounding mucous membrane becomes more and more marked, obstruction to nasal respiration 214 DISEASES OF THE ANTEKIOR NASAL CAVITIES. takes place with its accompanying symptoms, nasal voice, anosmia, etc. Headache is a frequent symptom when the calculus is large. What part of a rhinolith presents itself, generally appears black ; it can thus be mistaken for a necrosed bone, being partially buried, like the latter, in the mucous membrane. Its gritty surface may also cause con- fusion with dead bone, but the horrible odor emanating from the latter is of course absent. Treatment. An ordinary dressing forceps generally suffices to dislodge a rhinolith, but at times the mucous membrane surrounding it has to be first detached, an operation readily done with Professor Gross' curette, the spoon-shaped end being pushed between the stone and the membrane. When it is very large, a diminutive lithotrite has to be used to crush it and extract it piecemeal. MAGGOTS IN THE NOSE. The fetid odor accompanying certain catarrhal affections of the nose, occasionally attracts flies and other insects. When these penetrate the nasal cavity and deposit eggs within them, maggots are hatched, this process being assisted by the heat of the surrounding surfaces. The mucous membrane is destroyed by them, and the cartilage and bones become necrosed. This condition, however, is seldom met with in this country, occurring principally in India and in Central and South America. Symptoms. Itching in the nose is the first symptom. For- mication and a gnawing sensation are then experienced, both increasing markedly. Occasional hemorrhages occur, accompanied by a profuse muco-purulent discharge. Great cephalagia is usually complained of. Convulsions and coma occur in fatal cases. Treatment. Inhalations of chloroform, as proposed by MAGGOTS IN THE NOSE. 215 Dauzat, are fatal to the maggots, and their destruction is the cure of the affection. Pure chloroform may be injected into the cavities when inhalations are not effective, a pro- cedure harmless to the membrane. CHAPTER XII. DISEASES OF THE POSTEKIOE NASAL CAVITY. ACUTE POSTERIOR NASAL PHARYNGITIS. (Synonyms: Acute Catarrh of the Naso-Pharynx ; Acute Retro- Nasal Catarrh ; Acute Post-Nasal Catarrh.) Etiology. Acute inflammation of the posterior nasal cavity may occur primarily as a concomitant symptom of acute rhinitis and be due to the same causes, but it most fre- quently presents itself as a complication of that affection and of acute pharyngitis. It is sometimes caused by the inhalation of dust or other irritating particles, through me- chanical action, and is a frequent accompaniment of a number of diseases of childhood, such as diphtheria, measles, scarlatina, etc. A scrofulous diathesis seems to predispose to it. The irregular climate of this country renders it of frequent occurrence, and, although its symptoms are seldom of sufficient intensity to require medical aid, it assumes great importance as the precursory stage of the so-called post-nasal catarrh. Pathology. Hypersemia of the glandular tissue may take place as a result of peripheral irritation, as by cold, etc., the impression being transmitted through the sympathetic system, and causing a sudden contraction of the local blood- vessels soon followed by dilatation and engorgement, but I doubt whether in the naso-pharynx this occurs as uni- versally as it does in the anterior nasal cavities, in which the vascular supply is very great, with a correspondingly important vaso-motor innervation. I am more inclined to (216) ACUTE POSTEEIOE NASAL PHARYNGITIS 217 consider inflammation here as due, in the majority of cases, to contiguity of tissue, and as a complication of an inflam- matory process in a neighboring part. Tn some individuals, especially those of a scrofulous tem- perament, a preternatural sensitiveness of the naso-pharynx causes it to become easily influenced by conditions which would in others bring on acute rhinitis, and a localized hypersemia is engendered which either disappears or forms the initial step to further pathological changes. Symptoms. When the affection occurs as a complication of acute rhinitis, the symptoms of the latter, as regards obstruction to breathing and copious secretion, are so marked, that those occurring in the posterior cavity are generally overlooked. When the latter is solely affected, however, as is frequently the case in scrofulous subjects, the first symptom is a sensation of dryness or parchedness behind the soft palate, accompanied by a feeling of con- striction, especially marked during deglutition, which some- times becomes painful. A thick, starch-like secretion soon begins, and after a couple of days this becomes still thicker, assuming at the same time a purulent character. The dis- charges are hawked into the mouth or swallowed. The voice becomes shallow or thick, and sometimes quite nasal. Pain at the top of the head is frequently complained of. Hearing is sometimes compromised through participation, in the inflammatory process, of the mucous lining of the Eustachian tubes. These symptoms are generally well marked in affections such as diphtheria, scarlatina, etc., of which it is a frequent accompaniment. When the inflam- mation is marked, bleeding often occurs. Examined rhinoscopically, the parts appear congested and somewhat thickened, and masses of the discharge described are seen clinging to the degressions and crypts of the lining membrane. 218 DISEASES OF THE POSTERIOR NASAL CAVITY. Prognosis. Acute inflammation of the posterior nasal cavity may rapidly disappear, but in the majority of cases, it is the primary manifestation of the chronic condition. Treatment. As is the case with acute rhinitis, cases of this character seldom apply for treatment. When inflam- mation of the anterior and posterior cavities occur simul- taneously, the treatment of the former suffices for both conditions, the one following the course of the other. When the posterior cavity is alone involved, however, the remedies are best applied directly to the parts by means of the in- sufflator devised by Dr. A. H. Smith, Fig. 26, or that shown in Fig. 61. The powder recommended on page 69 will be found very effective when the case is seen early, the local hypera3mia being influenced in the same manner as in acute rhinitis. When the parts appear dry and parched, as they do at the very start of the trouble, a solution of bicarbonate of sodium (gr. v-3j) will be very grateful to the patient, and in some cases arrest the attack at once. An atomizer with a curved tip must be used for the purpose, such as that in Fig. 60. A solution of sulphate of sulpho-carbolate of zinc (gr. v-3j) is also very effective when the secretion is pro- fuse, by causing contraction of the superficial blood-vessels and the glandulae. A four per cent, solution of cocaine is doubtless as effective here as in acute rhinitis, especially when there is pain. CHRONIC POSTERIOR NASAL PHARYNGITIS. (Synonyms: Chronic Catarrh of the Naso-Pharynx ; Follicular Dis- ease of the Naso-Pharyngeal Space ; Post-Nasal Catarrh ; Retro* Nasal-Catarrh.) The almost universal prevalence of post-nasal catarrh in this country has given rise to much speculation among CHRONIC POSTERIOR NASAL PHARYNGITIS. specialists, and many are the views advanced as to its etiology. The scope of this work not permitting their enu- meration, I will but state those which I have personally entertained for some time, and which close observation and satisfactory results in a large number of cases, have led me to consider as the true one. Etiology. Chronic inflammation of the naso-pharynx may be due, firstly, to repeated attacks of acute posterior nasal pharyngitis occurring independently or simultaneously with acute inflammatory affections of the anterior nasal cavities; secondly, to chronic inflammatory processes in the neigh- boring parts, the anterior nasal cavities or the pharynx; thirdly, to the presence in the anterior nasal cavities of turgescences, hypertrophies, polypi and other growths and septal deviations, and all conditions which interfere me- chanically with the performance of the physiological func- tions of the nose and with the anterior flow of discharges; fourthly, to a scrofulous diathesis, or a pseudo-scrofulous state of the system occurring as a result of a number of diseases, among which scarlatina, diphtheria, measles and smallpox are the principal. Pathology. A fact of great importance in connection with the pathological consideration of this affection, is the slow- ness with which glandular tissue enters resolution after having undergone an inflammatory process, as compared with other tissues. An acute inflammation of either the anterior nasal cavities or the pharynx having implicated the naso-pharynx, the profuseness of glandular elements in the latter cause it to retain, as it were, the inflammatory process much longer than the parts primarily inflamed. If the anterior cavities undergo a renewed attack before the naso-pharynx has fully recuperated from the preceding, the congestion of the glandular tissue is increased in proportion, '220 DISEASES OP THE POSTERIOR NASAL CAVITY. and the chances of entire resolution are diminished. Re- newed attacks decrease these chances more and more, until chronicity is established. This, it seems to me, is the course of events in the majority of cases of post-nasal catarrh in this country. The irregular climate and other causes, most of which have been enumerated in the chapter on the dif- ferent forms of rhinitis, cause frequent attacks of acute rhinitis, and a few succeeding attacks are sufficient in most individuals to establish a chronic post-nasal inflammatory process. In the second category of the causes enumerated, the process is the same, the post-nasal affection being merely a part of the general trouble. In the third category, the chronic inflammation induced by the presence of hypertrophies, growths, etc., is in itself sufficient to cause by continuity of tissue, a catarrhal state of the naso-pharynx, this being further aggravated by the constant passage over it of more or less irritating dis- charges, which cannot, through the mechanical interference offered by the abnormal formations, be freely evacuated anteriorly. In the fourth, the proclivity to inflammation peculiar to the scrofulous diathesis is the starting point of the trouble, while the recuperative powers are not sufficiently strong to cause resolution. Symptoms. In mild cases of post-nasal catarrh, the prin- cipal symptom generally complained of, is an increased dis- charge of mucus, a "dropping," as the patients term it, of starch-like, gluey lumps of thickened mucus, which adhere tenaciously to the surface upon which they are expecto- rated, after having been "hawked" into the mouth. This may occur several times, or only once daily, or less often. During the presence of the mass in the naso-pharynx, a CHRONIC POSTERIOR NASAL PHARYNGITIS. 221 feeling of fullness is experienced, the voice may be muffled or deadened, and acquire the nasal twang. After a year or more of this condition, the discharges begin to assume a purulent character, oyster-like, muco-purulent lumps taking the place of those described. These are occasionally streaked with blood, or present a brownish appearance which betokens its presence. Instead of being inodorous as before, these discharges may assume a somewhat offen- sive odor, especially if they have remained for any length of time pent up in the cavity. The hawking necessary to dislodge them is much more frequently resorted to, and habit being added to necessity, the patient is greatly an- noyed and becomes a disagreeable companion. This is fur- ther aggravated, in some cases, by the extension of the in- flammatory process to the lower pharynx and the larynx, which renders an occasional "hemming" a source of mo- mentary relief for the patient. Dull pain on the top of the head is often complained of, while frontal headache is also present if the anterior cavities are affected. In some cases the memory seems to be dulled. The mouths of the Eusta- chian tubes are sometimes implicated, and the hearing may become compromised. In aggravated cases, the discharges assume a decidedly purulent character, forming hard, con- crete scabs, which emit a fetid odor, and frequently present the shape of the surfaces from which they became detached. The efforts of the patient to discharge these masses, which have become almost dry by evaporation of their watery con- stituents, by hacking, coughing, scraping, etc., now become more frequent. This maintains the soft palate in a con- gested condition, and after a time its volume becomes in- creased, causing drooping, and the symptoms of elongated uvula are added to the others, a coated tongue, general congestion of throat, nausea, a hacking cough, etc., while 222 DISEASES OF THE POSTERIOR NASAL CAVITY. dyspepsia may be engendered by occasional, unavoidable swallowing of the discharges. Patients of this kind gen- erally present an anaemic appearance. Examination of the parts by means of the rhinoscope generally reveal the presence of masses of secretion of a color and character varying with the stage of the affection, and adhering tenaciously to the walls of the cavity. These being eliminated by means of the atomizer or Hall's syringe (using a solution of bicarbonate of soda, 3J-OJ), if the mem^ brane is yet in the early stages of the affection, but little, if any difference will be observed, as compared with the normal state; immediately after the cleansing operation, the membrane may appear somewhat congested, but after a short while, this passes away, and the membrane appears even paler than usual. In the second stage, the irregulari- ties of the surface may appear more marked, or the con- trary may be the case, the crypts and depressions being filled out, as it were, and appearing as if flush with the sur- rounding parts. A rough, granular aspect is often presented, the edges of the Eustachian tube openings presenting the same appearance. In advanced cases, the naso-pharyngeal wall generally presents a shrunken appearance, its dry, glist- ening surface contrasting markedly with the moist appear- ance of the earlier stages. A sensation of great dryness, which extends to the lower pharynx, is a source of great annoyance to the patient. Prognosis. Chronic post-nasal catarrh cannot be consid- ered as dangerous to life in itself, but there is no doubt that its presence so undermines the system as to reduce markedly its resisting power to disease, rendering it sus- ceptible, therefore, to affections to which otherwise it would not be liable. As a focus of inflammation, it is a dan- gerous neighbor for the surrounding parts, the pharynx, CHRONIC POSTERIOR NASAL PHARYNGITIS. 223 larynx, arid the lungs even, being constantly exposed to contamination through continuity of tissue. The disease principally affects young people, frequently disappearing about middle life. Treatment. The therapeutic measures to be adopted vary, of course, with the cause of the trouble in each individual case. The cause must first carefully be sought for, and eradicated if possible, the success of the treatment depend- ing upon the effectiveness with which this is accomplished. In other words, turgescences, hypertrophies, polypi, deviated septa, etc., must be cured in order to render a complete recovery possible. Any diathetic condition must also receive attention. The abnormal conditions which may be met with in the anterior nasal cavities have been described; the reader is therefore referred to the chapters containing them for the means to be adopted. While the treatment for the anterior primary trouble is progressing, the naso-pharynx may also receive attention. Cleanliness is of course an important desideratum, as is the case in all affections accompanied by abnormal secretion. The proper performance of this part of the treatment, how- ever, is not always easy. Ablutions through the nose are not satisfactory ; they do not effectively cleanse the naso- pharyngeal membrane of the discharges which adhere tena- ciously to them. The cleansing must be conducted pos- teriorly, the tip of the instrument used being introduced behind the soft palate. The patient must be taught the manipulation, so as to enable him to conduct it several times daily if necessary. In cases in which the discharges are not difficult to remove, the atomizer is the most satisfactory instrument. In my office, I employ Sass' tubes (Fig. 17) which throw a rather coarse spray and cleanse the cavity effectively and rapidly. The straight tips of these instru- 224 DISEASES OF THE POSTERIOK NASAL CAVITY. ments, however, prevent their introduction behind the soft palate, and they cannot be used effectively by the patient, the frequent approximation of the velum palati to the pharynx preventing the passage of the spray. The instru- ment represented in Fig. 60 is the one I usually prescribe Fig. 60. Post-nasal atomizer. for patients, an ordinary perfume atomizer with a long tip curved upward. The patient readily learns how to intro- duce its point behind the soft palate, the curved end being so rounded as not to wound the soft membrane of the parts. When the crusts are detached with difficulty, Hall's CHRONIC POSTERIOR NASAL PHARYNGITIS. 225 syringe is required, employing as a tube that shown in Fig. 30, which also represents exactly the latter's position in the nose, when used. The cleansing solution recommended for anterior nasal affections, pages 75 and 118 having given greater satisfaction than others tried ; I also employ them for the naso-pharynx. The first is indicated in the first and second stages of the disease, while the second solution can be employed in the third, when fetor forms an element of the symptoms. In some cases, the treatment of the primary cause, and the salutary effects of either of the solutions employed in the naso-pharynx, are sufficient, after a period varying from six months to one, two, and occasionally three years, to bring about a comparatively healthy condition of the parts, although relief is experienced from the start. In the majority of cases, however, the treatment must be pushed with more vigor, and local applications in the form of powders, glycerites, or solutions may be used with advantage. Powders are especially beneficial when the discharge is copious and not inclined to form scabs. When the anterior cavities are large, the auto-insufflator (Fig. 27) can be used most conveniently by the patient, who can, by means of sudden blasts, distribute the powder over the surface of the vault. Few patients, however, have such roomy noses; the majority of cases require an insufflator with which they can medicate the parts through the mouth, and the use of which they can readily learn. The little instrument shown in Fig. 61 has proven very satis- factory for the purpose. It consists of a hard rubber tube, the tip of which is bent upward and flattened. The other end is also turned upward, to prevent the escape of the powder into the bulb when the instrument is accidentally held per- 15 226 DISEASES OF THE POSTEKIOK NASAL CAVITY. pendicularly ; the portion pointing upward is curved and connected with the tube of a rubber bulb. A hole through the upper surface of the tube serves for the introduc- tion of the powder. When the instrument is used, the powder is introduced and the hole is closed with the end of the index finger, the thumb being under. The instru- ment is then passed into the mouth, the tip introduced Fig. 61. Author's posterior auto-insufflator. behind the soft palate, and a slight compression of the rubber bulb with the left hand, will drive the powder to the desired spot. Patients learn the manipulation without diffi- culty, although the first two or three trials cause slight retching in some cases. The cheapness of this instrument places it within the reach of even poor patients. For office purposes, when medicines which do not require exact dosage are employed, I use Dr. A. H. Smith's powder insufflator (Fig. 26), using the curved tip. CHEONIC POSTEEIOR NASAL PHARYNGITIS. 227 In the early stages of the affection, a powder composed of one-quarter of a grain of nitrate of silver to three grains of bismuth, closely triturated, applied night and morning after cleansing, has proven very effective. After a couple of weeks, the silver nitrate can be increased to one- half grain to the powder. In using this medicine, however, the danger of argyria should be remembered; it is best to cease its use after one month, and resort to some other agent for some time. Oxide of zinc has seemed to me to keep up the action of the nitrate of silver most satisfactorily, one grain being used with three grains of sugar of milk at each application. After one month, the use of the silver can be resumed. Calomel is especially effective when the affection is due to a scrofulous diathesis, one grain with three of bismuth applied twice daily having proven efficient in a number of cases. When the case has so far progressed that the discharges have become muco-purulent, boracic acid, one grain wifh as much bismuth, has been found very useful. It modifies the character of the discharge after a few weeks' steady use, after which the treatment for the first stage can be substi- tuted. In some cases, an astringent, such as tannic acid, either used pure or with equal parts of bismuth, exerts a powerful influence upon the membrane, but it cannot be borne by every patient, occasionally increasing the inflam- mation. In these cases, the addition of powdered bella- donna, half a grain to the powder, or one-eighth of a grain of morphia, added to each application, prevents too active stimulation and promotes the absorption of inflammatory products. In cases in which desiccated crusts are discharged, liquid applications alone should be used, after cleansing the parts very thoroughly. A preparation which has been of great 228 DISEASES OF THE POSTERIOR NASAL CAVITY. benefit in such cases is the glyeerite of carbolized iodo- taniiin, described on page 76. Here, however, it should be used at half strength, four ounces of glycerine being added, instead of two. For its application, the instrument repre- sented in Fig. 62, an appropriately curved wire mounted in a wooden handle, is used. Its tip, which is somewhat rough- ened, serves for the attachment of a piece of cotton wool. It can be used with facility by the patient, who should be taught the manipulation as it is described page 44. The sulphate of copper solution (gr. iij-lj) is another val- uable agent, which, alternated now and then with the for- mer, sometimes advances markedly the favorable result Fig. 6a. Posterior pharyngeal applicator. Sulphate of zinc (gr. v-3j), acetate of lead (gr. v-j) or chlo- ride of zinc (gr. iij-3j) may also be used advantageously, according to indications. Warm vaseline administered with the atomizer, strongly recommended by Glasgow, of St. Louis, has also proven satisfactory in my hands. In the majority of cases of aggravated post-nasal catarrh, internal treatment is of the greatest importance. When scrofula is an element of the trouble, syrup of the iodide of iron, administered as in scrofulous rhinitis, syrup of^ the hypophosphites, or tonic doses of bichloride of mercury (gr. 4 1 ?), iron, quinine, and strychnia, may be used, according to the necessities of the case. The hydrated chloride of cal- HYPERTROPHIO POSTERIOR NASAL PHARYNGITIS. ciuin, ten or more grains three times daily, as recom- mended by Cohen, has given excellent results in a number of cases. Agents which are partly eliminated through the glands of the throat and nose, when taken internally, are some- times very serviceable in assisting the curative measures by modifying the character of the discharges. Of these, cubebs is, in my opinion, the most effective. It may be ad- ministered in the form of powder, three grains being given in syrup of ginger and water, after meals; or, the oleosin may be employed, fifteen drops on a lump of sugar also three times a day and after meals. Ammoniacum in very small doses (gr. j.-iij) is much lauded by Beverly Robinson, administered with an expectorant such as ipecac or carbonate of ammonia. In cases in which the stomach rebels against cubebs, it may be used as an excel- lent substitute. The presence of malaria in the system interferes greatly with the progress of the case, apparently neutralizing the therapeutic measures. The exhibition of quinine is of course indicated, and should be continued until all traces of the malaria have completely disappeared. HYPERTROPHIC POSTERIOR NASAL PHARYNGITIS. (Synonyms : Adenoid Vegetations at the Vault of the Pharynx; Adenomata of the Pharynx.) Etiology. Hypertrophy of the glandular tissue of the naso-pharynx occurs principally in childhood and adoles- cence. It is seldom seen after the age of thirty, and does not seem to be due to any special diathesis, although, as shown by Lowenberg, a lymphatic temperament seems to predispose to it. The origin is probably traceable in all 230 DISEASES OF THE POSTERIOR NASAL CAVITY. cases to a catarrhal state of the naso-pharynx, the causes of the latter being therefore the primary etiological factors. Heredity is undoubtedly an element in many cases. In this country, it seems to be oftener prevalent among females than males. Pathology. The analogy between the glandular tissue of the vault of the pharynx and the tonsils, which caused Luschka to term the former the "pharyngeal tonsil," ren- ders it probable that the liability to hypertrophic changes to which the tonsils are susceptible in some persons, exists also in the pharyngeal tonsil, and that a continued or often repeated inflammatory process may also act as an exciting cause. The inherent deficiency of recuperative powers peculiar to lymphatic glandular tissue being an important element in the pathology of this, as it is in simple chronic inflammation, the hypertrophic process is but a result of the continued hyperplasia. Microscopically, the growths consist mainly of the adenoid tissue of His, which contains quantities of lymph cells, some conglomerate glands and follicles, and is freely supplied with blood-vessels. Symptoms. The most prominent symptom of glandular hyperplasia is due to the interference with the passage of the sound waves through the posterior nasal cavity which the growth occasions. It consists of a peculiar deadness of the voice, a want of resonance which causes it to sound as if the words were spoken into a tumbler held horizontally with its rim close to the mouth. This muffled condition of the voice is accompanied with a nasal intonation, resembling somewhat the "nasal twang" but it is deprived of the ringing character which the latter sometimes possesses; the patient is said to talk "thick." As a rule, the nasal respiration is not impeded, but when the growths are large, a feeling of obstruction is experienced, especially marked during inspi- HYPERTROPHIC POSTERIOR NASAL PHARYNGITIS. 231 ration, and when an accumulation of mucus diminishes the lumen of the cavity. When the growths are very large, however, respiration through the nose is rendered difficult, and the patient is obliged to breathe through the mouth, to the detriment of the pharynx and larynx. The discharge is not, as a rule, as important an element of the case as in simple posterior chronic nasal pharyngitis. It is usually that described when speaking of the first stage of the latter affection, a thick, whitish, gluey substance, which is sometimes tinged with blood. Occasionally, it as- sumes a purulent character, and scabs are formed which desiccate in situ, and are usually "hacked" into the mouth and expectorated, leaving the underlying surface somewhat abraded, with a tendency to bleed. Aural complications are frequently present, due in some cases to pressure upon or occlusion of the mouth of the Eustachian tubes, and in others to extension of the catarrhal inflammation into them. The appearances of the growths vary greatly in different cases. In some they resemble a cushion, extending from the posterior nares along the roof and upper part of the naso-pharynx to within a short distance above the level of the soft palate, more or less deep crypts and depressions rendering its surface irregular. In others they present the form of rounded bodies resembling small pink beans, which hang in clusters from the roof of the cavity and hide from view the upper portion of the posterior nares. Frequently the mass is greater on one side of the cavity than on the other, and is sometimes sufficiently large to press upon the mouths of the Eustachian tubes and even to obliterate their openings. Their color is light pink, which becomes red when subjected to manipulation with the probe, or by the use of cleansing solutions. When the rhinoscope cannot be used, as in children for 232 DISEASES OF THE POSTERIOR NASAL CAVITY. instance, the examination can be conducted with the index finger passed behind the soft palate. As indicated by Meyer, of Copenhagen, the sensation communicated to the finger when the grape-like or fimbriated variety is met with, is that experienced when the finger is applied to a mass of earth-worms. In the cushion-like variety, a soft, smooth surface is felt, which contrasts with the comparative hard- ness of the surrounding parts. Prognosis. The natural tendency of these growths is to undergo absorption towards the thirtieth year. Left to themselves, therefore, they will gradually disappear. Although this may seem to render therapeutic measures unnecessary, the impaired enunciation and the danger to the hearing, besides other complications which might arise, are sufficient to warrant the employment of active treat- ment. Treatment. Eemoval of the growths by surgical means is the only effective procedure. When the vegetations are not large, galvano-cautery may be used with advantage. A suitably bent electrode, with a small loop presenting a burn- ing surface about as large as a pea and covered by a hood, to prevent burning of the surrounding parts, is passed behind the soft palate and located against the most promi- nent portion of the growth. The current being then turned on, the white-hot metal is left in contact with the mass a couple of seconds. The electrode is then moved slightly, and another cauterization is applied, this procedure being repeated three or four times, without removing the instru- ment. Slight bleeding generally follows the operation, which is painless and not followed by disagreeable after-effects. After a few days, it can be renewed until the exuberant tissue has been destroyed. The instrument represented in Fig. 44, used with the HYPERTKOPHIC POSTERIOR NASAL PHARYNGITIS. 233 curved tip, is very convenient for the extirpation of large growths by snaring. Introduced with the loop hidden in the tube, the tip is placed behind the mass which is to be cut off. The loop being then formed by separating the rings, it encircles the mass, which can then either be Fig. 63. Author's post-nasal cautery loop in position. gradually or suddenly cut off. The operation presents the advantages of being easily performed and of being abso- lutely free from all danger. For suitable cases, the straight end may be used by passing it through the anterior nares. It is only applicable, however, in the fimbriated variety of vegetations, the cushion-like masses not being seizable by 234 DISEASES OF THE POSTERIOR NASAL CAVITY. the loop. The cautery snare can also be used, but the proximity of the Eustachian tubes renders its use more dangerous than other less complicated methods. The in- strument shown in Fig. 64 can be used with advantage in any case, but its manipulation requires care. The extremi- ties of the blades are cup-shaped and sharp, and when they are introduced into the vault, the part seized is cut off. In pillow-like vegetations the sharp end is pressed into the mass, and when the blades are approximated, a piece is pared off, leaving a deep furrow. Considerable bleeding follows in some cases, but this stops after a few moments. Fimbriated tumors can be grasped with ease, and generally Fig. 64. Cohen's post-nasal cutting forceps. bleed but slightly if at all. The rhinoscope should always be used to guide the instrument. Several operations are necessary, at five or six days' interval. Guye, of Amsterdam, uses his finger-nails to scrape the growths away, a method which presents advantages in chil- dren. Capart, of Brussels, uses a curette, connected with the end of the finger by means of a double cylinder, which also acts as a finger shield. NASO-PHARYNGEAL POLYPUS Etiology. Polypi located in the naso-pharynx are rarely met with. They usually occur between the ages of five and twenty-five, and are more frequently developed in males NASO-PHAKYNGEAL POLYPUS. 235 than females. Morell Mackenzie believes them to be due "to an irregular evolution, during the growing period, of a tissue which, under normal conditions, is exceptionally abundant on the under surface of the base of the skull;" a fact rendered probable by the predilection of the growths for the time of life during which development takes place, and their tendency to spontaneous absorption after the de- velopment has been accomplished. Pathology. Naso-pharyngeal polypi, like the fibrous growths occurring in the anterior nasal cavities, arise from the peri- osteum or from connective tissue, and present the same pathological characters as similar growths in other situa- tions : fibrous tissue, closely interlaced or grouped in bun- dles of various sizes, interspersed with small vessels whose coats are easily torn. Symptoms. The early symptoms of naso-pharyngeal polypus are those of an advanced case of adenoid vegetations in the naso-pharynx, just described more or less embarrassed nasal respiration, nasal voice and profuse mucoid discharges. As the case progresses, the symptoms become more accentuated until respiration through the nose becomes impossible, and the voice so altered as to be almost unintelligible. The dis- charge increases in quantity and is frequently sanguinolent, the blood arising not only from the tumor itself, but also from the surrounding parts, which are compressed. If the polypus grows downward, deglutition becomes difficult, and nausea, cough, shooting pains in different parts of the head and chest may occur through reflex irritation. When the polypus advances toward the anterior cavities, hearing soon becomes impaired through pressure upon the Eustachian orifices, and frequent cephalalgia, especially located on the top of the head, is complained of. As the tumor grows, it penetrates into the nearest cavity, making room for itself 236 DISEASES OF THE POSTERIOR NASAL CAVITY. by displacing and destroying bone and cartilage through pressure, sometimes sending prolongations on all sides, and distorting the features fearfully in some cases; the more frequent disfigurement is a separation of the nasal bones, which induces the characteristic " frog face." Fibrous polypi are dark pink or red, and usually covered by a net- work of vessels which grow larger as they approach the seat of implantation. They are usually attached by a moderately broad base, the diameter of which is that of the growth for some distance. They are hard and resisting. Prognosis. A naso-pharyngeal polypus growing after the twentieth year, is not likely to attain sufficient size to cause a fatal issue. As the process of growth ceases, that of the tumor ceases also, and it may even be completely ab- sorbed. Earlier in life, if left to itself, the growth steadily increases until the patient succumbs. Treatment. If seen early the evulsion of a naso-pharyn- geal polypus cannot be said to be difficult. The hardness of the mass and its tendency to copious bleeding when lacerated, preclude the use of the forceps, although these are used by some surgeons, who employ a strong, curved instru- ment which is passed behind the soft palate. The snare, galvanic or cold, is in my opinion the best instrument at our disposal. If sufficient time be taken for the operation, but little if any blood is lost, and the pain to which the patient is subjected is trifling, while cocaine, applied thor- oughly to the parts, renders the operation painless. A curved canula is required if the operation is to be performed through the mouth, while the ordinary straight tube can be used through the nasal cavities. The selection of either depends, of course, upon the position of the tumor and its shape. When the polypus grows from the roof of the cavity and hangs downward, the operation is best performed through NASO-PHARYNGEAL POLYPUS. 237 the nose, the loop being adjusted as near as possible to the seat of implantation by a finger passed behind the soft palate, and held there until firm grasp is obtained. One hour at least, should be employed to gradually penetrate the growth if the cold snare is used, while somewhat less time is needed with the cautery snare, which cauterizes the cut surface. When the tumor grows upon the posterior surface of the vault, pointing towards the posterior nares, the operation through the mouth will alone enable the loop to sever it close to its point of attachment. Here, again, the finger should be used to apply the wire to the proper posi- tion. When the growth is sessile and cannot be grasped, a curved transfixing needle can be passed through it, its in- troduction being conducted with the assistance of the rhi- noscope. ' When the polypus is almost penetrated by the loop, it should be -secured with a curved volcella forceps, to pre- vent its falling into the larynx when detached. Large growths with numerous attachments require more space than the natural openings for their extirpation, and either of the operations of Rouge or Oilier, which have already been alluded to, may be required; or, the soft palate may be divided and the hard palate trephined, as practiced by Nelaton. Other operations of even greater magnitude have sometimes to be resorted to. Electrolysis has occasionally succeeded in destroying naso- pharyngeal polypi. Cohen's needle, which is covered by a non-conducting material, is the most convenient instrument for the purpose. It should be connected with the negative pole of a moderately strong battery, the positive pole being placed over the sternum. Each application should be re- newed every other day, the sittings lasting from ten minutes to one-half hour. 238 DISEASES OF THE POSTERIOR NASAL CAVITY. Injections of iodine or ergotine may be used to en- courage absorption, or actual cautery or caustic acids may be employed to induce suppuration and shrinkage. PLATE v. PLATE V. FIGURE 1. Male, ast. 21; anterior view of extensive osteo-enchondroma of sep- tum, occluding completely left nasal cavity ; mass reduced with dental engine. Case referred by Dr. C. S. Turnbull. FIGURE 2. Lateral view of above. FIGURE 3. Male, set. 24 ; posterior view of assymetrical nasal cavities of above case; complete stenosis of the left narium. FIGURE 4. Male, set. 44; anterior view of deviation of septum to right, causing partial occlusion of cavity. Case referred by Dr. M. O'Hara. FIGURE 5. Lateral view of above, showing concavity of septum anteriorly, and a convexity posteriorly, due tc 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 tinder the mucous membrane ; asthma relieved. FIGURE 7. Male, set. 48 ; relaxation of soft palate, causing symptoms of elongated uvula ; astringents found useless ; amputation of uvula. FIGURE 8. Female, t. 22 ; elongation of uvula, causing cough, expectoration, etc., and general symptoms of phthisis ; amputation ; complete relief. FIGURE 9. Female, ast. 27. Position of mouth in forcible separation of jaws during tonsillitis ; further examination impossible ; diagnosis established by character of pain, color of tongue, odor of breath, and odynphagia. FIGURE 10. Male, set. 28 ; hypertrophy of the tonsils ; amputation with tonsillo- tome. FIGURE 11. Appearance of tonsils in above case during an attack of tonsillitis fNoTK-^Represented as seen by gas-light. By day -light, the red color appears much paler.] late V. C.E. Sajous,Pinxit Burk & M c Fetnd^e. Lith. Phils CHAPTER XIII. ANATOMY AND PHYSIOLOGY OF THE PHAKYNX. ANATOMY. THE PHARYNX. As generally considered, the pharynx is that portion of tne pharyngeal cavity situated between the naso-pharynx, or posterior nasal cavity, which extends to the level of the soft palate above, and the laryngo-pharynx, which begins on a plane with the greater cornua of the hyoid bone and extends to the lower border of the cricoid car- tilage below. In contra-distinction to the naso-pharynx and the laryngo-pharynx, it is sometimes called the oro- pJiarynx. In the adult it extends about two inches per- pendicularly and presents to the eye of the observer a more or less concave surface, with a slight central and per- pendicular convexity, well marked in aged individuals. Its breadth is about one and a half inches. The side of the pharynx is connected with the posterior half arch, which extends from the posterior aspect of the soft palate on each side, and is formed by the fold of mucous membrane covering the palato-pharyngeus muscle. These folds are sometimes called the posterior pillars of the fauces, on ac- count of their resemblance to the pillars of an archway, and in contra-distinction to the anterior pillars or anterior half arch, or palato-glossal folds, which are formed by the palato-glossus muscle, and extend from the anterior aspect of the soft palate to the side of the tongue. The mucous membrane lining the pharynx proper ad- (239) 240 ANATOJVTY AND PHYSIOLOGY OF THE PHAKYNX. heres closely to the constrictor muscles, which in turn are separated from the cervical vertebra and the strong apo- neurosis which covers them, by cellular tissue. Laterally, it overlies the carotids and the internal jugular veins, the pneumogastric and eighth pair of nerves, lymphatics, and ganglia. Its epithelium is of the squamous variety, and compound follicular glands are distributed over its surface Vessels. The arteries which supply the pharynx are de- rived from the ascending pharyngeal branch of the external carotid, and the ascending palatine branch of the facial artery. A few twigs from the internal maxillary may also be found. Nerves. The nervous supply is derived from the pharyn- geal plexus and branches of the pneumogastric nerves and the spheno-palatine ganglion. THE SOFT PALATE. The soft palate, or velum pendulum palati, is a movable, curtain-like musculo-membranous fold suspended from the posterior border of the hard palate. During nasal res- piration it stands some distance from the pharynx, and the interval between it and the latter is termed the isthmus, already alluded to. Its border, which hangs free across and above the base of the tongue, forms the upper part of the arch, and is subdivided into two smaller archways (the anterior and posterior pillars already described) by the uvula, a nipple-like protuberance suspended in the middle, and possessing also free mobility. The soft palate is connected with the surrounding parts by means of the tensor palati, levator palati, palato-glossi and palato-pharyngeus muscles, and is covered anteriorly and posteriorly by mucous membrane. Its anterior surface is freely supplied with racemose glands. The uvula con THE TONSILS. 241 tains the azygos uvulge muscle which draws it up to com- pletely close the isthmus, and is also covered by a com- paratively thick layer of mucous membrane. THE TONSILS. The tonsils are two almond-shaped bodies lying between the anterior and posterior pillars, one on each side. Each tonsil is about nine lines long and six lines wide, and its thickness is usually so limited in the normal condition as to render its examination very difficult. Its surface, which is invested with pavement epithelium, is studded with from twelve to fifteen depressions, the lacunae-, which penetrate deeply into the surface of the gland, and are covered by reduplications of the mucous membrane, thickly furnished with follicles. In the spaces between them are quantities of small lymphatic glands. The tonsil is in relation exter- nally with the superior constrictor muscle, behind which lies the external carotid artery, from which it receives a branch, sometimes quite large, the tonsillar artery. Physiology. The physiological functions of the oro- pharynx are principally concerned in the process of deglu- tition. The contraction of the constrictor muscles, under- neath, propels the bolus down in the direction of the OBSO- phagus, while the follicular glands serve to lubricate it so as to facilitate its passage to the stomach. The soft palate acts as a valve which closes t.he isthmus tightly during deglutition, to prevent the ascent of the bolus of food into the posterior nasal cavity. In phonation, it also holds an important position, its proximity to the pharynx giving or depriving the voice of nasal intonation (see page 21). The uvula serves the purpose of closing up tightly what interval might exist between the edge of the soft palate and the pharynx, when the former is raised and adapted against the latter. 10 CHAPTER XIV. PHAKYNGOSCOPY. PHAKYNGOSCOPY is the term applied to the optical exami- nation of the pharynx. The mouth being widely opened and the light directed into it, the part which will appear, if respi- ration is continued as it was before the mouth was opened, i.e., through the nose, will be the anterior surface of the soft palate, its lower border, including the uvula, being closely adapted against the base of the tongue, so as to form a direct channel for the passage of the air current on its way from and to the lungs, behind. If now the tongue is depressed with a tongue-depressor such as that shown in Fig. 11, the edge of the soft palate will cease to touch the base of the tongue (unless the former be elongated) and the patient will breathe partly through the mouth and partly through the nose. The soft palate will appear in full view, its light pink color contrasting somewhat with the redder aspect of the pillars and the posterior walls of the pharynx, which, however, can only partly be seen. If the patient is now directed to breathe forcibly through the mouth, the soft palate will be seen to rise and adapt itself closely to that part of the phaiynx which may be considered as the dividing line between the naso-pharynx and the oro- pharynx. The latter will then appear, bounded above by the outline of the soft palate, laterally by the posterior pillars, and below by the base of the tongue. In the normal state, the pharynx is pinkish, streaked with patches of a lighter hue. Thin blood-vessels may be seen crossing it from side to side or obliquely, while its surface is studded with minute monti- (242) PHARYNGOSCOPY. 243 cules about the size of a pin's head, formed by the under- lying glands. The anterior and posterior pillars, when normal, should appear sharply denned, and be of a pale- yellowish pink hue. The uvula is of the same color. The tonsils are usually seen with difficulty when they are not hypertrophied. When they are visible, their upper half only can generally be brought to view, the lower half being below the level of the tongue. Their surface is irregular and marked by a number of depressions, the lacunaB or crypts. CHAPTER XV. INSTKUMENTS USED IN CLEANSING AND MEDICATING THE PHARYNX. CLEANSING of the pharynx, soft palate and tonsils, prior to the application of remedies, is almost as important as in the nose. The most effective instrument for office use is Sass' direct tube '(Fig. 17), the pneumatic power being fur- nished by an air compressor (Fig. 18 j. In order to expose the pharynx to the spray, the tongue must be depressed, the tongue depressor being held with the left hand while the Sass tube is held with the right. Two-thirds of the tongue being depressed, the patient is directed to breathe entirely through the. mouth during the application, so as to force the soft palate upward, and expose as much as possible of the pharynx and its adjacent parts. The surfaces having been thoroughly irrigated, a large piece of absorbent cotton, held in the grasp of a forceps, can be used to mop the moisture from the membrane, the medicinal application being made immediately after. When the patient has to be entrusted with the local treat- ment of the parts, an atomizer is required which can be manipulated easily and independently of an air condenser. The hand and ball arrangement is here most convenient, but as one hand is required to operate the rubber bulb and the other to hold the bottle, an arrangement such as that shown in Fig. 65, in which the tongue-depressor is connected with the atomizer, becomes necessary. The apparatus generally sold, in which the spray tube is in contact with the tongue- depressor, should not be employed; it gags the patient if (244) PHAEYNGEAL ATOMIZER. 245 introduced deeply into the mouth, and if it is not, the spray impinges upon the portion of the tongue beyond the tongue- depressor, and does not reach the pharynx. For the application of solutions to limited portions of the pharyngeal cavity, the cotton pledget and the brush are mostly employed. For cotton pledgets, the instrument shown in Fig. 66, is, in my opinion, the most satisfactory Fig. 65. Author's pharyngeal atomizer. in every way. Its grasp is very safe, while the simplicity of its construction renders its cleansing easy. For the patient's use, the instrument represented in Fig. 67 can be recommended on account of its simplicity and slight cost. He should be carefully shown its mechanism and directed to bring the clasp ring as closely to the end as possible, when the cotton pledget, made as described on page 45, has been inserted between the claws. 246 INSTRUMENTS USED IN TREATING THE PHARYNX. The brush, however, is to be preferred when the applica- tions have to be made by the patient. It should be flat, about one-half inch in width, and examined before each application, to ascertain that no loose hair is likely to become detached and cause annoying symptoms, such as cough, nausea, ete. Fig. 66. Cohen's pharyngeal cotton holder. In making an application to the pharynx with the pledget or brush, care should be exercised to not take up too great a quantity of the fluid used. If this precaution is not observed the solution is liable to run down along the pharyngeal wall to the larynx, where it may cause spas- modic cough and irritation, followed by annoying sensa- Fig. 67. Tumbull's cotton holder. tions of some duration. The applications are best made from below upward, a horizontal line being first drawn across the lower limit of the application, to arrest any rivulet of the solution that may form above, through the compression exerted by the instrument against the surfaces treated. INSUFFLATORS. 247 For the application of powders, the scoop insufflator (Fig. 25) or Dr. A. H. Smith's instrument (Fig. 26), may be em- ployed, the straight tip being adjusted. While applying powders in this locality, the bulb of the insufflator used should be compressed lightly and repeatedly, the applica- tion being divided into a series of light puffs, which, com- bined, cover the entire surface. The patient should be directed to breathe through his mouth during the applica- tion, and to avoid swallowing some time after, so as to insure the dissolution of the powders in situ. Inhalations of medicated steam are very useful in affections of the pharynx and tonsils. The inhaler shown in Fig. 28, the low cost of which places it within the reach of even poor pa- tients, may be used, or a more complicated instrument, such as the steam atomizer, represented in the chapter on ** instruments used in treating diseases of the laryngeal cavity," which projects the medicated steam through the horizontal glass funnel shown, may be employed. CHAPTER XVI. THERAPEUTICS OF THE PHAEYNX. As stated iii Chapter XV, cleansing of the pharynx and the adjacent parts prior to the application of remedies, is almost as important as in the nose. It enables the medicament to come in direct contact with the diseased surfaces, this being further assisted by drying the latter with absorbent cotton immediately before each application. If these precautions are neglected, the secretions reduce the strength of the solution used, if the former are thin and watery, while the medicinal agent does not reach the part at all if the discharge is thick, its density preventing the contact of the solution and all action upon the underlying membrane. Gargling is sometimes effective in cleansing the posterior oral cavity of superabundant healthy or unhealthy secre- tions; but as generally practiced, this operation is very in- effectual when the posterior wall of the pharynx is to be reached. As usually done, a mouthful of the solution used being taken into the mouth, the head is thrown backward, and the fluid gravitates no farther than the soft palate; this adapts itself closely to the base of the tongue, while a current of air, which passes through a slit between them, is forced through the liquid, producing the gurgling noise heard. In diseases of the soft palate and tonsils, much benefit sometimes follows this popular way of gargling, through the fact that the latter are rotated forward while the gargling is performed ^ but when the disease implicates the pharyngeal wall, the latter being completely closed off, (248) THERAPEUTICS OF THE PHARYNX. 249 no benefit whatever is procured. Properly conducted, garg- ling is productive of excellent results. The patient having thrown his head backward, should partially swallow the liquid, i.e., arrest it just as the act is to be completed, and air being allowed to pass through it (as in the ordinary method) for a few seconds, to prevent the second move- ment of deglutition, the head is suddenly tilted forward, causing the fluid to regurgitate into the mouth. After a few trials the patient will generally succeed in gargling effectively. As to the agents to be employed in gargles, they should be limited to those which, if accidentally swallowed, would cause no deleterious effects. The cleansing solutions described on page 53 can be used for the pharyngeal cavity as well as for the nose, none of them possessing sufficient medicinal activity to even disturb the stomach in the one dose. The bicarbonate of sodium and the biborate of sodium solutions are in my opinion more effective than the others. To them may be added chlorate of potassium (3J-OJ) which, in acute troubles espe- cially, is invaluable. Medication. The agents employed in the treatment of the pharynx do not differ from those employed in the nasal cavities. The reader is therefore referred to the chapter on the therapeutics of these parts for their enumeration and a detailed account of their properties. CHAPTER XYII. DISEASES OF THE PHARYNX. ACUTE PHARYNGITIS. (Synonyms: Acute Sore Throat; Acute Catarrh of the Pharynx; Angina Catarrhalis.) Etiology. Exposure to cold or damp is the most frequent cause of acute pharyngitis, especially in persons in whom in-door life and sedentary habits have diminished the resist- ing power against external influences. Rheumatism and syphilis, a scrofulous diathesis, and a liability to herpetic eruptions, predispose to it, while prolonged treatment with debilitating agents such as mercury, iodide of potassium and alkalies in general, seems to exert some influence in rendering the pharynx liable to the disease. It may occur as a complication of an inflammatory process in an adjoin- ing part, such as acute rhinitis, tonsillitis, etc. It is most frequent in young people, although it frequently occurs in old age. Pathology. The brunt of the inflammatory process is not, as usual, evenly distributed, being greater in some parts of the membrane than in others. It principally involves the glandular structures, their action being interfered with by the engorged blood-vessels. After a time the glands become over-stimulated and their secretion much increased and starchy, this process retrograding as the disease disappears. Symptoms. In the majority of cases of acute pharyngitis, the general symptoms are so slight that they are hardly perceived, a feeling of lassitude, slight headache, and super- (250) ACUTE PHARYNGITIS. 251 ficial heat, being the usual train of sensations experienced. The local symptoms are more marked, however. At first a feeling of dry ness and stiffness, most marked when degluti- tion is performed, is noticed, these symptoms increasing until pain becomes, sometimes, quite severe. As a rule the voice is veiled, and a feeling as if a foreign body were there causes the patient to hawk frequently. After a few days the expectoration increases, a thick mucus taking the place of the normal secretion. In severe cases, the sys- temic disturbance is much greater; a chill marks the onset of the attack, and high temperature, reaching as high as 103 Fahr., is present. The local inflammation being greater in proportion, deglutition is very painful, and all the symptoms are proportionately more severe. In these cases, extension of the inflammation to the laryngeal cavity becomes a formidable complication, there being danger of oedema and death. The cervical glands are often swollen and painful to the touch. Examination of the pharynx reveals an irregularly dis- tributed redness, or patches of congestion implicating, in the majority of cases, the posterior pillars and the posterior aspect of the soft palate. Dilated blood-vessels may be seen coursing over the inflamed surfaces, while slight elevations mark the seat of the inflamed follicles. In severe cases, the anterior pillars, the uvula and the tonsils are also involved, the redness being greater and more evenly distributed. The tongue is generally furred when the affection is severe. Prognosis. In the great majority of cases, the affection lasts but six or seven days, but it usually leaves the parts weakened and subject to renewed attacks. Death, although occurring exceedingly rarely, may follow a very severe attack through extension of the inflammatory process to the larynx. 252 DISEASES OP THE PHARYNX. Treatment. The introduction of cocaine has added a val- uable agent to our list of remedies for the treatment of this affection. A four per cent, solution applied every two hours with a brush, after having cleansed the parts with chlorate of potassium solution and dried them, has several times succeeded in cutting an attack short in six or seven hours. Wine of coca, given internally, a wineglassful every two hours, also assists materially in hastening resolution. Coca lozenges, each containing five grains, may replace the wine when the latter cannot conveniently be taken. These preparations induce contraction of the vessels of the mem- brane, thus relieving the engorgement. When they cannot be procured, the next best remedy is perhaps opium, which also stimulates the vaso-motors when taken in small doses; three to five drops of the tincture being given every hour three times, then every two hours. Tincture of belladonna, two drops taken in the same manner, can be administered instead when an idiosyncrasy prevents the use of opium. Guaiac is also a valuable preparation, internally as well as locally, especially when the affection occurs in a rheumatic individual. One drachm in a half glassful of milk, used as a gargle and swallowed every three hours, generally succeeds in arresting an attack after three or four doses. It may also be administered in conjunction with steam, a drachm being placed in a teacupful of hot water. The cup being covered with a towel folded into a cone, the mouth is placed over the upper opening, and the steam is inhaled as long as it is generated. The inhaler (Fig. 28) may be used with advantage. When the affection is due to hepatic engorgement, a saline purgative is, of course, of primary importance, followed with phosphate of sodium, a teaspoonful night and morning for a few weeks, which acts as a gentle stimulant to the liver. PLATE vi PLATE VI. FIGURE 1. Male, set. 23 ; acute pharyngitis ; saline purgatives ; wine of coca ; two per cent, spray of cocaine. FIGURE 2. Male. set. 44 ; simple chronic pharyngitis ; mild purgation every other day. using podophyllin; nitrate of silver solution (gr lx-j) three times per week, alter- nating every other week with copper sulphf (gr. x-^j) solution. Case referred by Dr. Weaver, of Norristown. FIGURE 3. Male, set- 21 ; folliculous pharyngitis; galvano-cautery to follicles, followed by application of copper sulph. sol. (gr. v-^j) ; attention to stomach and bowels. Case referred by Professor S. W. Gross. FIGURE 4. Male, set. 67; atrophlc or dry pharyngitis; nitrate of silver sol. (gr. x-^j) daily ; oleo-resin of cubebs internally. FIGURE 5. Normal appearance of pharynx, uvula and palatal folds e, Soft palate. A Posterior pillar. f, Uvula. p, Anterior pillar, n, Posterior wall of pharynx. FIGURE 6. Male, set. 23; tuberculosis of pharynx; morphia insufflations; cocaine (not known at that time) would now be used. Case referred by Professor William H. Pancoast. FIGURE 7. Male, set. 28 ; retro-pharyngeal abscess ; abscess opened. Case referred by Dr. L. Webster Fox. FIGURE 8. Male, set 29 ; syphilitic ulceration of pharynx and soft palate ; mercury and iodide of potassium; local applications of iodoform and morphia; afterwards cauterized with mitigated stick. FIGURE 9. Male, set. 20; adhesion of soft palate to posterior wall of pharynx, following syphilitic ulceration ; perforation of soft palate, enabling patient to breathe through the nose. [NoTB. Represented as seen by gas-light. By day-light, the red color appears much paler.] Plate VI. C F, Sajous, t,r,dge Lith.Phi,a. SIMPLE CHRONIC PHARYNGITIS. 253 SIMPLE CHRONIC PHARYNGITIS. (Synonyms: Chronic Catarrh of the Throat; Chronic Sore Throat; Relaxed Throat.) Etiology. Eepeated attacks of acute pharyngitis are the most prolific factors in the production of simple chronic pharyngitis. The causes of the former are therefore those of the latter. In addition to these, however, may be added alcoholism and debauchery, prolonged exposure to dry heat, the constant inhalation of smoke and inordinate smoking, a disturbed state of the digestive apparatus, and hepatic tor- pidity. Posterior nasal pharyngitis is also a frequent cause, through extension of the inflammatory process from above downward, or to the contact of the secretions which descend from the diseased surfaces. Pathology. As is the case in chronic rhinitis, frequent in- flammatory manifestations, whether due to cold or to other causes, gradually reduce to permanency the abnormal con- dition of the vascular supply accompanying an acute attack. Here, however, the membrane yields to the expanding action of the congestion, and after frequent repetition of the in- flammatory process, it does not return to its normal position over the underlying tissues, but remains swollen, falling back in folds. When an acute attack (which now represents an exacerbation of the disease) has subsided, the glandular elements, being over-stimulated, pour out an excess of secre- tion, its character depending upon the gravity and duration of the affection. Symptoms. The symptoms of the affection are more than prone to manifest themselves by exacerbations than as con- tinued suffering. Dryness and parchedness, relieved momen- tarily by a sip of water or other beverage, is usually the first source of annoyance, culminating in a spicy and raw 254 DISEASES OF THE PHARYNX. sensation extending in some cases to the vault. The voice is usually somewhat hoarse and lowered in pitch, and is easily tired. Frequent hacking and coughing is indulged in to clear the throat of accumulated masses of thick, tenacious mucus, which are sometimes tinged with pus or blood. After a few days, these symptoms become somewhat less severe, a stage of comparative comfort being enjoyed until another slight exposure or imprudence, a day's constipation or an injudicious meal, bring on another exacerbation. The membrane may or may not seem congested, but instead of the smooth appearance of health and the sharply- defined anterior and posterior pillars, the membrane appears as if formed of unevenly distributed folds, and presents a granular appearance. The posterior pillars are sometimes thickened sufficiently to cause complete obliteration of the recess between them and the pharynx proper. The uvula is generally implicated and elongated, this being due not so much to the disease itself as to the constant hacking and scraping indulged in to clear the throat. The tonsils are involved in the majority of cases. Prognosis. Although in no way dangerous to life, chronic pharyngitis is persistent, and is likely to become aggravated unless the initial causes be avoided, and an uninterrupted and prolonged treatment be submitted to. Treatment. In this affection, general treatment is of the utmost importance. In the majority of cases hepatic tor- pidity, evidenced by the coated tongue, maintains a local congestion of the pharynx, and attention to the liver will give relief when all local measures will fail. Podophylin, calomel or Hunyadi water, in small, but often repeated doses, have been productive of best results in my hands. Gastric disturbances, when present, should be carefully attended to, while abstinence from habits which tend to maintain the trouble should be enjoined. FOLLICULOUS PHARYNGITIS. 255 Of the local remedies, the application of which should always be preceded by careful cleansing, nitrate of silver, forty grains to the ounce, is in my opinion the most effective, this conclusion having been reached after trying a large number of other agents. As stated in the chapter upon therapeutics of the nasal cavities, nitrate of silver causes contraction of the blood-vessels, thus diminishing the local congestion, while it stimulates the absorbents also, inducing therefore, absorption of the inflammatory products. Weak solutions, on the contrary, of ten, fifteen, or even twenty grains to the ounce, only stimulate the superficial blood-vessels and increase the inflammatory process. Ap- plied once daily with the brush (taking care, to not take up too much of the solution, lest it run into the larynx) it will in a very short time produce great relief, and if continued sufficiently long in conjunction with the internal treatment, will cure the affection. Sulphate of copper, ten grains to the ounce, applied in the same manner, is effective in some cases, but the applications must be continued during a long period. Occasionally, cases are met with in which astringents, in whatever form or strength they may be administered, increase the inflammation. Soothing applica- tions are therefore indicated. Vaseline, rendered liquid by exposure to heat, and applied with the brush three or four times daily, is generally very effective, or the O cosmoline, the specific gravity of which is sufficiently low to enable it to be used in the atomizer, may be employed. FOLLICULOUS PHARYNGITIS. (Synonyms : Follicular Pharyngitis ; Granular Pharyngitis ; Clergy- mans' Sore Throat ; Speakers' Sore Throat.) Etiology. The great prevalence of this affection among persons who, in their avocations, are obliged to use their 256 DISEASES OF THE PHARYNX. voice extensively, such as clergymen, lawyers, singers, hucksters, etc., makes it evident that one of its causes, and probably the most important, is extensive use of the vocal apparatus, under certain unfavorable conditions. Whether this be due to an inherent liability of the membrane to become influenced in that manner by over use of the vocal powers, or to some defect in the method of delivery, is difficult to ascertain, but it is probable that both play an important part in its causation. The continued oral breathing in more or less dusty atmospheres doubtless adds greatly to these primary causes. Scrofulous and rheumatic individuals seem to be more predisposed to it than others, while anemia is a frequent accompaniment in marked cases. The affection is usually seen in young and middle aged people, although old age cannot be said to be exempt. It is a frequent complication of chronic affections of the nose and naso-pharynx, the contact of the irritating secretions being most probably the exciting cause, while the hacking and coughing accompanying these affections tend to aggra- vate it. The inhalation of irritating substances, smoke and dust, are also frequent causes. Pathology. The principal pathological conditions charac- terizing this affection in addition to the vascular engorge- ment and tissue changes of chronic pharyngitis, consists in a blocking up, as it were, of the mouths of the follicles. Their products accumulating more and more, each follicle finally becomes metamorphosed into a foreign body, which, becoming encysted, as it were, remains in that state indefi- nitely, irritating the surrounding parts. How this condition is brought about by extensive use of the voice seems to me explainable : the follicles are overtaxed by the unusually great amount of lubrication required, and this being frequently repeated, an inflammatory process is gradually induced. FOLLICULOUS PHARYNGITIS. 257 External irritants and purulent discharges from the naso- pharynx cause inflammation of the mouths of the follicles, which gradually causes their closure. Symptoms. The onset of the affection is usually charac- terized by an occasional sensation of dryness in the pharynx and larynx, which continues for a short time. At the end of a few days, perhaps after a prolonged conversation, the same symptom recurs, to follow the same course as the preceding attack. This is repeated several times at vary- ing intervals, each attack becoming longer, until a constant malaise of the entire throat is experienced, which in time gradually increases in intensity. This process may take a few weeks, perhaps a few months, and frequently two or three years. The voice becomes slightly hoarse upon the least exposure or exercise in speaking, preaching, or sing- ing, and if the exercise is continued any time, a sensation of great fatigue in the parts is experienced. A short hack- ing cough is usually present, accompanied by a disposition to clear the throat frequently and to expectorate. When the disease has progressed for some time, pain, or a sensa- tion akin to it, and resembling that produced by the pres- ence of a foreign body, a pin, a fish bone, etc., is com- plained of, which frequently leads the patient to believe that he has actually swallowed some sharp object. In some cases, a sensation of rawness or scratching is experienced, which becomes painful when deglutition is performed. Hawking, expectorating and coughing become almost per- manent in bad cases, the discharge generally consisting of tough, glairy mucus, contaminated with muco-purulent masses or scales, if a nasal affection is also present. The cough is provoked by a tickling sensation in the larynx. The voice loses its timbre, becoming veiled in addition to the hoarseness; these symptoms, however, disappear tem- 17 258 DISEASES OF THE PHARYNX. porarily when "hemming" is practiced. Elongation of the uvula is often induced by the hawking and the continued congestion. Inspection of the parts reveals the striking characteristic of the affection, a number, more or less great, of rounded projections, reddish in color, with white apices, standing out like pimples, from the surface of the membrane. A few only may appear, distributed unevenly over the entire mucous surface, including the pillars; they may be sepa- rated or coalesced into clusters of three or four. Enlarged vessels are generally seen coursing between them, appearing in some cases to terminate in them, or, if veins, to start from them. In some cases, these enlarged follicles burst and discharge a thick, cheese-like substance, which escapes from a minute opening at the apex of the growth. At times it adheres tenaciously to the mouths of the follicles, forming small, ill-smelling patches of irregular shape, which can be peeled off without difficulty. This exudative form (termed so in contradistinction to the other variety, which is called the hypertrophic form) of the affection, is most frequently located upon the anterior and posterior pillars and the tonsils, where the secretion occasionally assumes a calcareous character. The base of the tongue is sometimes implicated, its glands and follicles becoming inflamed and hypertrophied. Prognosis. Follicular pharyngitis can generally be cured by an appropriate treatment, conducted systematically over a prolonged period. Left to itself, it does not present any danger to life, but it may encourage the development of other affections of the larynx and naso-pharynx through the permanent congestion maintained. Treatment. -The treatment of this form of pharyngitis is essentially surgical, while any dyscrasia, such as scrofula, syphilis, rheumatism, herpetism, etc., should be treated with FOLLICULOUS PHARYNGITIS. 259 appropriate remedies. The state of the digestive apparatus should be carefully inquired into and appropriate remedies administered. The liver will frequently be found torpid, constipation being often complained of, and the tongue showing by a yellowish fur the evidence of hepatic engorge- ment. Mild purgatives are always advantageous in these cases, followed up by the administration of phosphate of sodium, one drachm night and morning. Cascara sagrada is an excellent aperient in these cases, from fifteen to twenty drops of the fluid extract being taken when required. The object of the surgical procedure is, both in the hyper- trophic and exudative forms, to destroy each enlarged and engorged follicle, and thereby the circuitous inflammation which its presence maintains. This may be done by means of a number of methods, which I will describe in the order of preference. Galvano-cautery has by far given the best results. Besides being a painless means, it gives rise to no disagreeable after- symptoms and does its work effectually. A small loop twisted at the tip so as to form a miniature corkscrew, is the most effective instrument, penetrating deeply into the follicle and emptying it of its contents when withdrawn, while not creating enough local disturbance to give rise to annoying symptoms. After cleansing the pharyngeal wall thoroughly, each engorged follicle should be touched sepa- rately, six or seven being cauterized at each sitting. Hardly any discomfort is caused during the operation, a slight sore throat, lasting a couple of days, representing about all the after-effects. A few days later the cauterizations are re- newed, and repeated as often as required. In the exudative form, a pair of long, fine forceps should previously be em- ployed to dislodge the layer of cheesy matter. After each sitting, the burnt spots present a white appearance, with a 260 DISEASES OF THE PHARYNX. small inflammatory areola. When the white scab disappears a red spot is left, which in turn is replaced by a small cica- trix. The relief is almost immediate and is lasting. When the superficial vessels are large and present evidences of varicosity; the larger ones had better be cauterized in the same manner. Actual cautery is also very efficient. A good-sized sharp piece of wire, mounted upon a wooden handle, is heated to a red heat in the fire of an alcohol lamp and applied to each follicle, the manipulation being conducted and repeated as with galvano-cautery. The fire of an oil lamp or gas should not be employed, the carbonaceous deposit which is often formed at the end of the wire retarding greatly the resolu- tion of the burnt follicle if accidentally introduced into it. A small incision into each follicle, and then touching the spot with solid nitrate of silver melted on the end of a probe { is another method much in vogue at one time, but which has become almost obsolete on account of the pain occa- sioned and the somewhat severe after-effects. Nitrate of silver, applied without incision, is effective when the follicles are seen in their early stage of formation, i.e., when merely a small red elevation is visible. An instrument such as that used for actual cautery may be employed. Its tip, being heated over an alcohol lamp, is applied against the nitrate of silver crystal, enough of which will adhere for two or three applications. It is best, however, to renew the coating of silver for each application. The resolution of the parts in this method of treatment, does not take place as rapidly as in the others described, and more time should elapse between the sittings. Morell Mackenzie recommends London paste, preferring this agent to all others. The preparation being rubbed up with sufficient water to make a thick cream, is applied to two or three follicles at each sitting, and in some MEMBKANOUS PHARYNGITIS. 261 cases to one only. The patient should then gargle with cold water, to remove any excess of the caustic. I have found this method more troublesome and painful than the others, without increased benefit. The follicles once destroyed, the chronic inflammation existing in the membrane proper should receive attention. The local treatment recommended in chronic pharyngitis will be found as advantageous in the . f olliculous variety. MEMBRANOUS PHARYNGITIS. (Synonyms : Membranous Sore Throat ; Aphthous Sore Throat ; Croupous Pharyngitis ; Herpes Pharyngis.) Etiology. Membranous pharyngitis usually occurs in per- sons of weak constitution. Exposure to the influences of infectious matter, or close contact with persons suffering from septic affections, such as diphtheria, scarlatina, etc., are among the frequent causes of the complaint, while cold may also excite it primarily, especially in persons who have already suffered from it. Pathology. The affection consists of an acute superficial inflammation of the mucous membrane, characterized by the exudation of a whitish substance which coagulates over its surface in the form of thin patches, which are fre- quently mistaken for those seen in diphtheria. In the latter affection, the exudation involves the entire thickness of the membrane, while in membranous pharyngitis it is limited, as stated, to the surface. Symptoms. Membranous pharyngitis is usually ushered in by a chill or creeping sensations in the back, a slight head- ache and soreness in the throat. Deglutition soon becomes painful, and a thick ropy mucus is expectorated with some difficulty. The tongue is usually furred, the skin is hot, and the pulse is sometimes quite high. 262 DISEASES OF THE PHARYNX. Seen in the first stage of the affection, the mucous mem- brane of the pharynx and all the adjoining parts appears quite red, the redness being still greater over certain limited areas or spots, especially around the tonsils. After a short time these areas become covered with a whitish ex- udation, which spreads over the membrane and forms patches. These can be easily detached with a suitable instrument, dif- fering entirely in this peculiarity from diphtheria, in which the false membrane can only be torn away with great effort, causing sometimes copious hemorrhage. The appear- ance of the false membranes of the two affections differ also in a marked manner. In diphtheria it is of a dirty yellow, with somewhat everted edges and surrounded by a dark-red areola; in membranous sore throat, the exudation is perfectly white, with sometimes a tint of pink or gray. Its surface is even, and the areola, if any exist, is hardly discernible. Prognosis. The prognosis of this affection is favorable in almost every case, its duration being, at the longest, of two weeks. Extension of the false membrane to the larynx, however, may cause death by obstructing mechanically the passage of air; but such an accident is extremely rare. Treatment. A mild aperient is usually indicated in these cases, the salines being preferable. Pain should be com- bated by anodynes, while the asthenic nature of the affec- tion should be antagonized by quinia and general tonics. Wine of coca is exceedingly valuable in this affection, a wineglassful every two hours tending greatly to diminish the local pain, while bracing the system. Locally, lime- water used with the atomizer and as a gargle, can be employed with advantage to keep the throat clear of pseudo-mem- brane, which necessitates its use every hour. Chlorate of potash lozenges, gr. v to each lozenge, can also be em- ATKOPHIC PHARYNGITIS. 263 ployed. A plan which I have used with great success, especially in children, is first to detach the false mem- brane by spraying or with a pledget of cotton, then to paint the underlying mucous membrane with a ten-grain solu- tion of permanganate of potash every three hours, giving wine of coca internally. The affection is generally cut short in a couple of days. ATKOPHIC PHARYNGITIS. (Synonyms : Pharyngitis Sicca, or Dry Pharyngitis.) Etiology. Atrophic pharyngitis generally occurs as a sequel of chronic or folliculous pharyngitis, or as a result of continued exposure to dust, smoke, the emanations of certain irritating substances, and to the prolonged contact of irritating dis- charges from the posterior nasal cavity. Sleeping with open mouth is also an occasional cause. Shurly, of Detroit, as- cribes the disease to organic derangement of the stomach or allied organs in most cases. In old people it frequently occurs as an expression of the general senile debility. Pathology. The principal feature of this affection is the state of inactivity of the glands and follicles, brought on by the pressure exerted by inflammatory products upon them, and through which the mucus necessary to keep the parts lubricated is not generated. Dryness necessarily ensues and the desiccated condition of the pharyngeal surface causes contraction, which in turn induces pressure upon the under- lying tissues. These, with the greater part of the vascular supply and glandular elements, are absorbed, reducing the membrane to half its normal thickness. Symptoms. The prominent symptom of this affection is an intense dryness of the pharynx, extending sometimes to the naso-pharynx. A sensation of stiffness is experienced, 264 DISEASES OF THE PHARYNX. with a frequent tendency to deglutition, prompted by an unconscious desire to lubricate the parts. Eating and drink- ing is generally followed by momentary relief, while de- glutition is sometimes performed with difficulty through the impaired action of the constrictor muscles, which become rigid and stiff in the affected portions. Swallowing "the wrong way" is a frequent accident through the impaired action of the epiglottis, which occasionally takes part in the inflammatory process and the impaired sensitiveness of the pharynx. A dry cough is occasionally present through implication of the larynx. Upon examination, the membrane of the pharynx appears perfectly dry and lustrous, with perhaps small, muco-puru- lent masses adhering to its surface with tenacity. These may originate in the posterior nares, or from erosions on the surface of the membrane, caused by the irritating action of foreign particles, which remain on the surface through lack of secretion to wash them away. The outline of the bodies of the underlying vertebrae can generally be discerned when the disease occurs in an old subject. The dryness can frequently be seen extending to the posterior nares and the larynx. The membrane is somewhat paler than normal. Prognosis. In young people the affection can generally be cured, but in middle aged and old subjects, temporary relief only can be furnished. Treatment. The first indication in the treatment of this affection is to keep the membrane free of discharges by cleansing it as frequently as possible, while the liquid em- ployed should contain an agent having a tendency to main- tain the parts in a moist condition. A saturated solution of chlorate of potassium is, in my opinion, the best solution for the purpose. It may be used as a gargle if the patient can ATROPHIC PHARYNGITIS. 265 gargle properly, or it may be used with, an atomizer, in both cases as frequently as possible. Any hurtful habit should be corrected, the mouth being tied up at night if necessary. A slightly stimulating application every day is the next requisite, to increase the nutrition of the membrane by inducing the formation of new blood-vessels. Too stimulating a remedy should be avoided, the inflammation resulting being more harmful than beneficial. The ten-grain solution of nitrate of silver has served me more satisfactorily than any other agent for the purpose, applied with a cotton pledget. Iodine, in an equal quantity of glycerine, as recommended by Fauvel, of Paris, is also an efficient remedy, but less so than the other. In young people this treatment, when carried out faith- fully, generally gives rise to favorable results in from one to four months. In persons of mature age, internal treatment should be added, to stimulate the secretory function of the mucous membrane or that of the salivary glands. Jabo- randi, in the form of the hydrochlorate of pilocarpine, gr. , three times a day, is perhaps the most effective remedy. Iodide of potassium, gr. iij, and chlorate of potassium, gr. v. are sometimes preferable, especially where there exists some catarrhal affection of the nasal cavities. Fifteen drops of the oleo-resin of cubebs on sugar, is another agent possess- ing much merit. Shurly lays much stress upon general treatment to suit the systemic disturbance acting as cause. Galvanism is recommended by him, the positive pole being applied to the pharynx. Daily sittings are necessary for about two weeks, after which they can gradually be di- minished. Muriate of ammonia, administered in tablets con- taining gr. iij each, is advantageous to keep the pharyngeal wall moist. In aged people, continued local treatment is necessary to insure comfort, a cure being doubtful, if at all possible. CHAPTER XVIII. DISEASES OF THE PHAKYNX (Continued). TUBERCULOUS PHARYNGITIS. (Synonyms : Tuberculosis of the Pharynx ; Consumption of the Pharynx.) Etiology. Tuberculous pharyngitis generally presents itself as a complication, either of tuberculosis of the lungs or the larynx, or of both, rarely preceding them. Its etiology is the same as that of tuberculosis occurring in other parts, a sub- ject which will be treated under the head of tuberculous laryngitis. The same will be the case as regards the pa- thology of the affection. Symptoms. The early symptoms of a case of tuberculous pharyngitis are generally those which present themselves in the early history of acute pharyngitis. Deglutition becomes very painful, especially if any irritating substances, such as strong liquors, vinegar or condiments are swallowed. As the disease advances these symptoms increase in in- tensity; the pulse becomes rapid, the temperature high, and the tongue covered with a whitish fur. Soon after the begin- ning of these symptoms, the ulcerative process makes its appearance. A shallow, grayish ulcer, with indistinct out- line, presents itself on the pharyngeal wall, pillars, or soft palate (most frequently the latter in the cases seen by me), gradually increasing in depth and giving rise to a slimy yellowish discharge. The pain becomes continuous, with exacerbations when swallowing; it is of a sharp, lancinating character, and frequently extends to the ear. The throat is parched and dry. The ulcerative process extends with more (266) TUBERCULOUS PHARYNGITIS. 267 or less rapidity, but in most cases, five or six weeks are sufficient to create enough local disturbance to render ali- mentation by the mouth impracticable. When the soft palate is greatly ulcerated, liquids are often forced into the nose. Prognosis. The prognosis of tuberculous pharyngitis is as unfavorable here as in the tuberculous manifestations in other parts, with the difference that on the whole its course is more rapid. Six months represent the maximum of life in the cases reported, while in the majority, death occurred in from six to ten weeks after the first local manifestation. Treatment. Judging from its effects in tuberculous laryn- gitis, we doubtless have in cocaine an agent of the greatest value in the treatment of tuberculosis of the pharynx. The excruciating pain which accompanies it, can, with a ten per cent, solution, be kept at bay, and the patient receive the benefit of an amount of alimentation which the suffering occasioned by deglutition would otherwise cause him to refrain from taking. It should be applied sufficiently often to prevent all pain, after cleansing the ulcerated surface with a borax spray (gr. v-lj). Cauterizations with nitrate of silver, in the solid form or solution, have, in my hands, proven more hurtful than beneficial. I have obtained more satisfactory results, as far as contributing to the patient's comfort is concerned, by sedative applications. Steam inhala- tions, with succus conium, a dessertspoonful in a half pint of water at 130 Fahr., or inhaling the steam of hot infusion of belladonna, hyoscyamus, or opium, have proven very valuable in diminishing pain and facilitating deglutition. Morphia, given internally, or applied locally, gave rise to so much dry- ness of the parts that I had to abandon its use. When deglutition becomes impossible, Bryson Delavan's feeding bottle, described later on, may be used to great ad- vantage, or the patient can be fed by the rectum. 268 DISEASES OF THE PHARYNX. > SYPHILITIC PHARYNGITIS. (Synonyms : Syphilis of the Pharynx ; Specific Chronic Pharyn- gitis; S3 r philitic Sore Throat.) Etiology. As in the nasal cavities, syphilitic manifesta- tions may occur as a result of direct contamination or as a symptom of the secondary or tertiary periods of syphilitic infection. Primary syphilis in this location is more fre- quently met with than in the nose, contact with an infected subject, in kissing or biting, using table utensils or glass, spoon or fork, etc., improperly cleansed after having been used by a syphilitic individual, and certain loathsome prac- tices, rendering the pharyngeal cavity more exposed to direct infection. Secondary syphilis of the pharynx is met with in the majority of cases of constitutional syphilis, the pre- dilection of this region to become affected by the systemic dyscrasia, being probably greater than any other portion of the system, after the vulva and anus. Tertiary lesions are of frequent occurrence, and may present themselves, as in the nasal cavity,- as long as thirty years after the primary infection, although six or seven years represent about the interval between the primary and tertiary manifestations. Syphilitic pharyngitis may also be hereditary. Pathology. The remarks on the general pathological mani- festations of syphilis occurring in the mucous membrane made under the heading of syphilitic rhinitis, are also appli- cable to syphilitic manifestations of the pharynx. Symptoms. The symptoms of syphilitic pharyngitis vary according to the stage of the disease. In primary syphilis, the subjective symptoms are usually so slight as to be over- looked at first. After a few days the glands under the angle of the lower jaw become painful to the touch, and examination of the throat reveals one or more reddish SYPHILITIC PHAEYNGITIS. 269 or whitish abrasions, with slightly elevated edges. These almost always heal spontaneously, but they may, as was the case in Diday's patient, be followed by phagedaBnic ulceration. Their differentiation from tuberculous ulcera- tion is somewhat difficult. Secondary lesions may present themselves in two forms, as an erythema, and in the form of mucous patches. They are apt to be located symmetrically, on both sides of the pharyn- geal cavity. Erythema usually begins by a diffuse redness of either the entire cavity or only a portion thereof. The symptoms of an ordinary sore throat are then experienced, with dryness and pain, and sometimes slight pyrexia. After a few days, sometimes only twenty-four hours, clearly out- lined patches show themselves, located on the tonsils and anterior pillars, the pharyngeal wall, or the soft palate, and coalescing at times so as to form an almost continuous chain of blotches, which present in color the ordinary aspect of catarrhal inflammation. The larynx generally becomes in- volved, cough and hoarseness being added to the other symptoms. Mucous patches generally make their appear- ance upon the anterior pillars and the soft palate ; they may be found, however, in any other portion of the pharyiigeal and oral cavities, the sides of the tongue being a favorite site for them. At first they appear as mere circumscribed, regularly defined, oval elevations, which soon become dark red, then slightly excavated, afterwards changing in color to a whitish gray. The subjective symptoms are more accentuated than when erythematous patches are present, the dysphagia especially being greater. Tertiary manifestations do not present the same degree of symmetry as those of the second period. The soft palate and one of the tonsils are generally the first invaded, the ulcerative process spreading rapidly. In almost every case, 270 DISEASES OF THE PHARYNX. the first local trouble is the formation in the layers of the membrane, of one or more gummous tumors, which form small nodular swellings ; these may remain inactive for some time, or proceed at once to soften, suppurate, and give rise to a deep-seated ulceration. The ulcer formed is cup-shaped, with an irregular, sharply cut and jagged edge, and covered by an ichorous yellowish discharge. When situated in the soft palate, it is quite likely to cause perfora- tion. Located on the posterior wall of the pharynx, adhe- sion of the soft palate is liable to take place, the parts heal- ing together. The ulcerative process may create great havoc in all the parts, the cicatricial contraction which generally follows often limiting the isthmus markedly, and sometimes closing it up altogether, as was the case in a subject under my observation. The subjective symptoms are not com- mensurate with the degree of local mischief, although some- times great pain is experienced; deglutition is always diffi- cult and in some cases liquids can alone be swallowed ; slight cough is usually present, due to involvement of the larynx in the general congestion. The tumefaction of the soft palate prevents its apposition against the wall of the pharynx, and the voice acquires the nasal twang. Prognosis. The prognosis of syphilitic pharyngitis as re- gards life, can only be unfavorable when the disease occurs as a manifestation of tertiary syphilis. The liability of the ulcerative process to penetrate deeply into the tissues, mena- cing bones, cartilage, and blood-vessels, creates dangers which, although seldom realized, are nevertheless to be feared, and thwarted if possible. In debilitated persons, and in those in whom the disease has existed in its active form for a long time, death may take place by exhaustion. Treatment. The constitutional treatment recommended in syphilitic rhinitis is as valuable in syphilis of the pharynx, SYPHILITIC PHARYNGITIS. 271 and often suffices to induce prompt recovery. Local cleans- ing is of the greatest importance, and should be practiced several times in either of the three stages of the disease. I have used with much success in these cases, the permanga- nate of potash solution described on page 118. It is not only an effective detergent, but the slight stimulation which it produces tends to hasten resolution. Besides these qualities, it is an excellent disinfectant and soon changes the character of the secretions. In the primary stage, but little if any other local medication is necessary ; a weak astringent such as a five grain solution of sulphate of zinc or acetate of lead may be used to perhaps hasten the recovery, which almost always occurs spontaneously in a week or so, In secondary symp- toms, a solution of nitrate of silver (gr. xxx-lj) has given me the greatest satisfaction, applied with a camel's hair pencil to each blotch after thorough cleansing. lodoform is also very useful, but its unpleasant odor renders it very ob- jectionable to the patient. Tincture of the chloride of iron, fifteen minims in a drachm of glycerine, is also very effi- cient, painted over the mucous patches three times daily. In the tertiary form, the mitigated stick (composed of one part of oxide of silver and nine of nitrate of silver) is, in my opinion, more effective than any other application. It should be applied carefully to the ulcerations and some distance around the margin, after careful spraying. Acid nitrate of mercury is another valuable remedy, used in the same manner. lodoform can also be used with good effect. Powdered astringents such as alum, tannin, etc., can be used with benefit by insufflators, their constringing action upon the blood-vessels decreasing the intensity of the in- flammation. CHAPTER XIX. DISEASES OF THE PHARYNX (Continued). RETRO-PHARYXGEAL ABSCESS. Etiology. The formation of an abscess in the posterior wall of the pharynx may occur as a complication of acute pharyngitis, or be due to inflammation of the connective tissue and lymphatic glands between the pharyngeal walls and the vertebra, or of the latter themselves. It is most frequent in the early months of life, although it may occur" at any age. Scrofula and syphilis are predisposing causes of the idiopathic abscess, which is the most common form. It occasionally follows scarlatina, erysipelas, diphtheria, and other exanthemata. It is often caused by traumatism, falls against some sharp instrument which penetrates the opened mouth, swallowing spicules of bone, etc. Necrosis of the vertebrae is a frequent cause of retro-pharyngeal abscess. Symptoms. The early symptoms of the formation of a retro-pharyngeal abscess are but seldom characterized by systemic disturbance. A slight chill or occasional chilly sensations may be experienced, with some headache. The local symptoms are usually those which first attract atten- tion, and these vary according to the location of the abscess. It may be located sufficiently high and be hidden behind the soft palate, and require the rhinoscope to ascertain its out- line ; it may be situated opposite the larynx, and only be seen in its entirety with the laryngoscope; again, it may 'be located on the side, behind the posterior pillar. In the majority of cases, however, its situation is in the posterior wall of the pharynx, facing the oral cavity, and on either (272) RETKO-PHARYNGEAL ABSCESS. 273 side of the median line. When the abscess is situated high up, a sensation as if a foreign body were located in the vault is experienced, accompanied by difficult deglutition and some interference with the respiration through the nose. Pain of a dull, throbbing character, but occasionally very sharp and lancinating, may be felt, accompanied by head- ache and tinnitus. The speech becomes nasal and devoid of resonance, the consonants being accompanied by a sound of " escaped air" through the nose. When opposite the larynx, dyspnoea is a marked symptom, coming on -in spasmodic attacks which endanger the patient's life ; swal- lowing becomes very difficult and dangerous, owing to the occasional passage of food into the larynx, and this is likely to occur frequently unless great care be taken. This danger is further increased by the interference presented by the bulging surface to the free motion of the epiglottis. When the abscess is in the posterior wall of the pharynx, respira- tion is not interfered with until it has attained great size. In addition to the local symptoms, there is swelling of the neck on the side of the tumor, and the cervical glands may be enlarged and painful. The head is drawn to one side or forward in some cases, and can only be raised with great difficulty. As the formation of pus proceeds, fever and pyrexia are generally present, the pulse being weak and easily compressed. Left to itself, the abscess generally bursts spontaneously, a mass of pus being suddenly evacu- ated into the mouth or throat, sufficiently great sometimes, to asphyxiate the patient. At times the pus burrows under the tissues and forms an opening at some remote point. If near the larynx, oedema may be caused by penetration of the suppuration into the ary-epiglottic fold. The tongue being depressed, a tumid swelling, red and dusky in color, is seen to project into the pharyngeal cavity, 18 27-4 DISEASES OF THE PHARYNX. the view being more or less complete according to its location. The surrounding parts, the pillars and uvula, are usually inflamed and swollen, especially on the side of the abscess. With the finger, fluctuation can generally be felt almost from the start, although weeks are sometimes passed before the accumulation of pus is sufficiently great to cause rupture. The symptoms of retro-pharyngeal abscess resemble, in some particulars those of croup. Cough, however, is absent, a marked feature of the latter disease, while the voice is rarely affected. Again, it is often confounded with and treated for acute tonsillitis. (Edema of the larynx has also been mis- taken for it in the adult. The propriety of always examining the throat carefully in croup and otber diseases in which the larynx and pharynx are implicated, is here well exemplified, the life of the patient depending greatly upon a proper recog- nition of the trouble. Prognosis. When the abscess is caused by caries of the vertebrae, the prognosis is unfavorable, death taking place in the majority of cases. In the other forms of abscess, it is rarely fatal except by accidental causes, such as asphyxia by the sudden escape of pus into the larynx, etc. Treatment. The only treatment is the evacuation of the contents of the abscess by an incision with a bistoury or by withdrawing the fluid by means of a trocar and aspirator. When the former means is employed a small vertical in- cision high up (as recommended by Dr. MacCoy, of Phila- delphia), and not at the point of greatest tension, avoids the danger of suffocation by the sudden flow of a large quantity of pus which a free incision would occasion. After the ten- sion of the abscess has been relieved, the incision can be somewhat extended, but only to a limited extent, lest par- ticles of food penetrate into it during the act of deglutition. TUMOKS OF THE PHARYNX. 275 The abscess can be emptied gradually by digital compres- sion, the pus being worked out by gently sliding the finger upwards over it, so as to bring the fluid to the level of the incision. The discharge continues for some time, the cavity growing smaller and smaller until the wound is healed. In using the aspirator, a straight trocar pushed in at right angles with the growth is liable to wound the posterior wall of the abscess, or to pierce the vertebrae, an accident which may take place in the most careful hands, owing to the resistance which is sometimes offered to the penetration of the trocar point, and the suddenness with which it enters the cavity of the abscess. A trocar shaped like that shown in the cut, can be introduced from below, and the operation Fig. 68. Retro-pharyngeal abscess trocar. can be performed without the least danger, while a ten pei cent, solution of cocaine applied freely over the abscess and the surrounding parts will prevent all pain. TUMOKS OF THE PHARYNX. Although tumors in the pharyngeal cavity are rarely met with, almost every variety of growth may be found there. Cases of sarcoma, nbro-sarcoma, fibroma, osteoma, enchon- droma, adenoma, papilloma, cysts and lupus, have been reported. These growths may originate in the pharynx proper, or penetrate into it from the surrounding parts. Their most frequent location is on the lateral walls, involv- ing the palatine folds, and extending to the surrounding 276 DISEASES OF THE PHARYNX. parts. They present the same properties, in shape, den- sity and color, as in the nose. Aneurism of the internal carotid artery has also been seen in this location, a globular mass protruding into the pharyngeal cavity. Symptoms. The presence of pharyngeal tumors is usually not recognized until they have attained sufficient size to in- terfere with deglutition or with respiration. As in retro- pharyngeal abscess, the symptoms vary according to the location of the growth. Outside of carcinoma and lupus, which are ulcerative and very painful, and gradually spread to the surrounding parts, all the other varieties named are characterized by obstruction to both deglutition and respira- tion, pain being usually very slight. Pharyngeal tumors may be mistaken for retro-pharyngeal abscess or hypertro- phied tonsils. Palpation, however, in connection with a careful examination, will serve to % establish the true diag- nosis. ' Treatment. The treatment consists in extirpation, when practicable. This may be done by means of the knife, the snare or galvano-cautery. Electrolysis may also be em- ployed, especially when the tumor is not of hard consist- ence. PARALYSIS OF THE PHARYNX. Etiology. Paralysis of the pharynx, which implies paralysis of its muscles, may occur as a result of general disease with local expression, such as diphtheria, or syphilis, or be due to a cerebral affection implicating the nerves which supply the pharynx. The paralysis may be limited to one con- strictor muscle, or involve them all ; it may involve one side of the pharynx or both, and if the latter be the case, it is generally more marked on one side than on the other. It is an occasional complication of hemiplegia, being limited to FOREIGN BODIES IN THE PHARYNX. 277 the same side. It frequently occurs as a precursor of death in febrile diseases. Symptoms. The most marked symptom is the difficulty of deglutition, the greatest efforts being required to force the food down the oesophagus. Liquids are generally swal- lowed with less difficulty, but their frequent passage into the larynx, especially when the epiglottis is also paralyzed, renders their use dangerous. When the soft palate is in- volved, the food may be forced into the posterior nasal cavity, through the efforts of the tongue to assist deglutition. Treatment. The central causes should be carefully sought for and treated. Strychnine hypodermically and general tonics are almost always indicated. Arsenic is especially valuable when the affection is a sequel to diphtheria. Elec- tricity serves the double purpose of assisting in the diagnosis and restoring motion. When the paralysis is of central origin, an interrupted current will cause contraction of the muscles, but this contraction will not occur if atrophy of the muscles is the principal pathological element of the case ; the cure will then be rendered much more difficult, if at all possible. Therapeutically, electricity should be applied with both electrodes over the muscles for about ten minutes every other day. FOREIGN BODIES IN THE PHARYNX. The two classes of objects which are most frequently found in the pharynx, are, firstly, those presenting sharp points or asperities, such as needles, pins, tacks, fish-bones, fragments of meat, bone, bristles, etc., which the contractions of the constrictors in deglutition force into the pharyngeal walls, and, secondly, those whose dimensions do not allow their passage into the oesophagus, such as pieces of meat, bread crust, false teeth, coins, etc. 278 DISEASES OP THE PHARYNX. Symptoms. Objects which are long and narrow, such as pins, needles, fish-bones and bristles, are generally caught transversely, and are found sticking into the sides of the pharynx in almost every case, at times as high up as the tonsils ; tacks, being of small size, are rarely caught by the constrictors, this being only possible providing its long axis be antero-posterior, while passing behind the larynx. As a general thing they do not reach as far as that region, but fall on either side of the epiglottis into the pyriform sinus, where they are generally found. Bodies which are arrested on account of their size, are usually found either behind the larynx or above it, and resting upon the epi- glottis, which they sometimes hold down. Small objects, such as buttons, pebbles, etc., generally slip into the glosso- epiglottic fossae or into the pyriform sinuses. The symptoms vary greatly according to the nature of the foreign body. When a small, sharp object is impacted in the pharynx, the sticking sensation which it gives rise to is markedly increased by deglutition; or, it may be felt in two places at once, the latter being often- the case when a needle, for instance, is swallowed. Large bodies, by holding the epiglottis on the larynx, may cause death before assistance can be obtained. Lodged in one of the pyriform sinuses they do not give rise to as much dis- comfort as in other locations, and may remain there for a long time without interfering with the functions of the surrounding parts. Localized spots of irritation, such as inflamed follicles, when situated low down on the pharyngeal wall, frequently give rise to the sensation produced by a foreign body. This sensation may also be caused by a piece of bone or a crust of bread, which, when swallowed, scratches the membrane, leaving an abraded spot. Again, a foreign body may have FOREIGN BODIES IN THE PHARYNX. 279 become impacted, then swallowed or ejected, and the patient still continue to experience the sensation that it gave rise to before being ejected. These facts, to which may be added the imaginary foreign body of hysterical women, are of im- portance, and should be remembered when measures to ex- tract it are to be resorted to. Prognosis. Sharp objects, by being forced into one of the large arteries of the neck, may cause death by hemorrhage, while, as we have seen, asphyxia may be caused by a large foreign body. In the great majority of cases, however, the object can be withdrawn without trouble, the patient re- covering very soon. Treatment. The laryngeal mirror is of great assistance in ascertaining the position of the impacted body. The nature, shape and density of the object swallowed being ascer- tained, it may be looked for in the portion of the pharynx, in which, as explained above, it is most likely to become located. A satisfactory examination of the parts is not always obtainable, however, owing to the marked conges- tion generally present and the quantity of saliva secreted. The index finger can then be used to advantage, by pass- ing it into the pharynx and examining each part as it is reached ; the right finger should be used for the right side of the throat, and the left for the left side, so as to always have its palmar surface against the membrane. The finger may not only be used for the exploration, but also to grasp the foreign body and withdraw it. The recess between the nail and finger is well adapted for the entrance of the shaft of a pin, for instance, and once in position can be held firmly by resting the palmar side of the finger against the nearest surface while drawing it out, the pin being thus held tightly in its position. When the object is too large to be grasped in this manner, the finger should be held on 280 DISEASES OF THE PHARYNX. the foreign body until a pair of forceps, introduced by slip* ping them along the finger can be fastened on to it. The most convenient instrument for the purpose is Seiler's tube forceps shown in Fig. 69. The flexible tube shaft can be conveniently adjusted to any suitable shape, thus facilitating its introduction in any part of the pharyngeal cavity. When, through the presence of a large foreign body, the patient's death appears imminent, tracheotomy must be per- formed at once, or if the necessary instruments are not at hand, the trachea can be opened with a penknife, and main- tained so until the foreign body can be withdrawn. This extreme measure, however, is rarely necessary, and there is Fig. 69. Seiler's tube forceps, usually sufficient time to pass the finger in the throat and extract the offending object. After a foreign body has been extracted, there remains for a time a sensation as if it were yet there, and it is some- times difficult to persuade the patient that there is not an- other foreign body in his throat. This might possibly be the case, however, and a careful examination should always be made. CHAPTER XX. DISEASES OF THE TONSILS AND UVULA. TONSILLITIS. (Synonyms: Quinsy; Amygdalitis ; Cynanche Tonsillaris ; Angina Tonsillaris; Angina Faucium.) Etiology. Inflammation of the tonsils is a common affec- tion in young people, especially between the ages of twelve and thirty. As age advances, it becomes of less frequent occurrence, presenting itself very rarely after the fiftieth year. Exposure to cold and damp is the most prolific cause of tonsillitis, especially when the subject has already had it. Hypertrophy of the tonsils predisposes to it, as do also the rheumatic and scrofulous diatheses. It is an occa- sional complication of scarlatina, variola and measles. It may be caused traumatically by the action of caustic acids, an impacted foreign body, external injury, etc. Pathology. The inflammation may be deep-seated and in- volve the parenchyma of the organ (parenchymatous tonsil- litis) or be merely superficial (erythematous tonsillitis). In the former case the affection is likely to manifest itself principally in one tonsil, while in the latter, the inflam- matory process generally involves both equally. "When the inflammation is deep-seated, an abscess generally occurs, which increases in size until opened. Repeated frequently, parenchymatous inflammation of the tonsils soon induces hypertrophy. The brunt of the inflammatory process is sometimes located in the crypts of the tonsils (folliculous tonsillitis), a soft, cheesy exudation being poured out from the follicles and forming a number, ten to fifteen, of small patches, representing the number of crypts affected. (281) 282 DISEASES OP THE TONSILS. Symptoms. A chill, more or less marked, is generally the first symptom experienced. Pains in the legs and back, headache and fever, characterize an attack of more than ordinary intensity. A sense of dryness and stiffness in the throat, with diminution of secretion, is soon noticed, and dysphagia soon sets in. The sufferings of the patient now become quite severe; the dryness of his throat tends to in- duce frequent deglutition in order to cause lubrication of the parts and this is accompanied by so much pain that the features are distorted at each effort. Inflammatory infil- tration of the muscles of the jaws renders opening of the mouth difficult and painful, arid in marked cases the teeth can hardly be separated. The tongue is coated with a thick white fur, and the breath is generally intolerably fetid; speech becomes almost unintelligible, as much from the inability to move the jaws as through the interference pre- sented by the swollen tonsils to the passage of air, and the inflammatory paresis of the soft palate. The hearing is frequently obtunded on account of the extension of the in- flammation to the posterior nasal cavity and the Eustachian tubes, this being occasionally complicated with abscess of the ear. As the disease progresses, the local pain becomes more and more severe, being sharp and lancinating, and frequently extending to the ears ; deglutition, even of the saliva, is so excruciating, that the patient prefers to allow it to dribble out of his mouth. In parenchymatous tonsil- litis with tendency to abscess, the suffering is very great, and the relief is proportionately marked when the latter 'opens of its own accord, or with the assistance of the sur- geon's knife. The cervical glands are enlarged and hard- ened, and the entire anterior portion of the neck occa- sionally appears puffed up and swollen. The impossibility of opening the patient's mouth soon TONSILLITIS. 283 after the early symptoms of the affection renders examina- tion of the inflamed tonsils very difficult, and the diagnosis has frequently to be made without the benefit of this source of information. The inability to separate the jaws, the fetid breath and the coated tongue, and the comparatively slight systemic disturbance, are pretty sure evidence of the trouble, with which other affections could hardly be con- founded. When the diagnosis is uncertain, much informa- tion can be gained by introducing the index finger into the mouth as far as the tonsils; the organ will feel hard and prominent, while pressure upon it will increase pain in- tensely. The presence of pus can at the same time be ascertained, as indicated by Stoerk, by placing the fingers of the other hand behind and below the ramus of the lower jaw, and compressing the tonsil between the finger in the mouth and those outside. In tonsillitis with folliculous ex- udation, the organ is generally soft to the touch, while a strong light thrown in between the partly opened jaws, will reveal white spots which contrast markedly with the sur- rounding redness, and are frequently mistaken for diphthe- ritic patches. The differential diagnosis between them, however, can be established without great difficulty by intro- ducing the end of a probe (appropriately curved near the extremity for the purpose) into each crypt. Diphtheritic pseudo-membrane is leathery and resisting, while the fol- licular exudation is so soft that the end of the probe will easily penetrate through it, into the crypt, and generally detach a small portion of cheesy substance. The color of the latter differs also, being much whiter than in diphtheria, the membrane of which has a blackish tint. Prognosis. Death, as a result of tonsillitis, very rarely takes place. Rupture of the tonsillar abscess and asphyxia- tion by the escaping pus; pyaemia, which may occur in a 284 DISEASES OF THE TONSILS. debilitated constitution; extension of the inflammation to the larynx with oadema as a sequel, are, however, dangers which should be borne in mind. Treatment. We fortunately possess, for this affection, a remedy which has certainly not been overestimated, and which, in my hands, has not as yet failed to cut an attack short if administered early. In erythematous as well as parenchymatous and folliculous tonsillitis, guaiacum can be termed a specific. The method which I usually follow in administering it, is to prescribe the ammoniated tincture, one teaspoonful in a half glassful of milk, and to order the patient to first gargle with a mouthful of the solution, then to swal- low it. Enough of the powder to cover a penny is then placed far back on the tongue, the sufferer being directed to keep it there as long as possible. When the fever is high, tincture of aconite root, in drop doses every hour, is most effective, assisting at the same time in diminishing the local congestion. In erythematous tonsillitis, lozenges containing two grains of the resin of guaiac are generally sufficient to avert the inflammatory process. When the affection has progressed for some time, i.e., more than two or three days, guaiac is no longer useful. Of late I have been using injections into the inflamed masses, of a ten per cent, solution of cocaine, using an or- dinary hypodermic syringe with a long needle. The pain is not only greatly reduced locally, but also in all the adjoin- ing parts. It seems to curtail the duration of the attack, and to prevent suppuration. The injections should be ap- plied at least twice daily. Great relief may be obtained, when the tonsils are much inflamed, by free depletion, a long, sharp bistoury being used to make a series of cuts. Five or six stabs are generally sufficient to cause quite a flow of blood. In most cases, TONSILLITIS 285 however, this procedure can only be conducted with great difficulty, on account of the half-closed mouth. When suppuration cannot be arrested, warm applications not only hasten the formation of the abscess, but they also decrease the pain. Water, used as a gargle, as hot as it can be borne, is very efficient ; warm poultices, applied externally over the tonsils, also produce a sedative effect; the in- halation of steam, medicated with opium, belladonna, conium, or benzoin, can also be employed, but the suction necessary in ordinary inhalers, entails some pain. This can be avoided by using a steam atomizer on the principle of that shown in Fig. 79. As soon as fluctuation can be distinctly felt by internal and external digital pressure, it is better to evacuate the abscess than to allow it to open itself, lest it burrow in the surrounding parts and cause dangerous complications. The best means to accomplish this, is to apply the index finger of one hand over the seat of fluctuation, the point of the bistoury being slipped alongside and pushed into the tonsil, beneath the tip of the finger resting over the abscess. The patient's head should be tilted forward so as to enable the pus to run out of the mouth instead of in the larynx or oesophagus. In folliculous tonsillitis, the general indications are the same. The guaiac treatment can also be used with advan- tage when the patient is seen early. Generally, however, the case is not seen until two or three days after the onset of the affection. The treatment recommended by Bosworth, of New York, has also proven of the greatest value in my hands, two drachms of tincture of the chloride of iron in two ounces of glycerine being given in drachm doses every two hours, without water. It makes a nice golden-brown mixture, which is quite palatable. It acts as a local astringent in passing over the inflamed tonsils, decreasing 286 DISEASES OF THE TONSILS. markedly the local congestion while modifying the action of the follicles. Frequent gargling with lime water is very effective in removing the exudation, and if used every half hour or so, its accumulation can be prevented, thus contributing greatly to the patient's comfort. Untreated, an attack of folliculous tonsillitis generally lasts from six to ten days. HYPERTROPHY OF THE TONSILS. Etiology. Hypertrophy of the tonsils is generally met with in children and young persons, being rarely seen after the fortieth year, on account of the tendency of these organs to disappear gradually after the age of thirty. A scrofulous diathesis predisposes to it, while certain diseases, such as diphtheria, scarlatina, etc., may also cause it, sometimes almost spontaneously. Repeated inflammatory processes, such as successive attacks of acute pharyngitis, in which the tonsils are involved, occasionally act as a cause. In some cases, the hypertrophic process cannot be traced to any distinct etiological factor, the subject being apparently in perfect health. Pathology. As in hypertrophy of the glandular tissue of the naso-pharynx, the lymphatic element which forms an important part in the anatomy of the tonsils, is probably causative in the maintenance of the early inflammatory process which forms the primary step to the hypertrophic changes. When these have progressed for some time, the epithelial layer is greatly thickened, and the mucosa under it is permeated with lymphatic cells and new tissue elements. The size of the tonsils is principally increased by the pro- liferation of new connective tissue, interspersed with bundles of fibrous tissue, while their density or hardness depends HYPEKTKOPHY OF THE TONSILS. 287 upon the degree of organization which these tissues have reached. Symptoms. The increased volume of the tonsils may be hardly noticeable, or their increase in size may be so great as to cause them to touch. One organ alone may be hypertro- phied, but, as a rule, both are involved in the process. Mod- erately enlarged, the tonsils generally occasion but little if any trouble. In many cases their presence is unknown until they have attained sufficient size to offer mechanical impedi- ment to the physiological functions of the pharynx. In chil- dren their presence often occasions a diseased condition of the surrounding parts, without in themselves presenting ac- tive symptoms. Their volume diminishing the lumen of the pharynx, the passage for the respired air is diminished in pro- portion, and the patient keeps his mouth open and breathes through it to compensate for the deficiency of the current inhaled through the nose. A catarrhal condition of the latter is engendered through the accumulation of secretions on account of the limited air-blast to discharge them, while the mouth and throat are kept dry and exposed to the action of what foreign particles may be present in the atmosphere. The features 'sometimes acquire a silly expression, the voice is muffled and devoid of resonance, snoring and disturbed sleep and dysphagia are complained of, while all the other subjective and objective symptoms of a chronic catarrhal inflammation of the nose and throat may be present, com- plicated in some cases with impaired hearing, through in- volvement of the Eustachian tubes. Frequent recurrences of acute tonsillitis are the rule. The obstruction to free respira- tion rendering an imperfect action of the thorax obligatory, its development is not properly accomplished, and deformity of the chest results in many cases, that form called " pigeon- breast" being the most common. Imperfect oxygenation is 288 DISEASES OF THE TONSILS. a natural consequence, and the child attains his maturity, in a weak state of health, to be easily influenced by all causes of disease. Infants are in some cases unable to take the breast, sucking being rendered very difficult. In some cases the lacuna are almost continuously filled with masses of cheesy secretion, which decomposes in situ and evolves a very fetid odor, contaminating the breath and the inspired air. When the tonsils become enlarged in grown subjects, the deleterious effects are not so marked, the pharyngeal cavity being much more spacious and only influenced me- chanically when they have attained a very large size. Then the subjective symptoms described may take place, the most frequent complication being posterior nasal pharyn- gitis and folliculous pharyngitis. Acute tonsillitis, especially the folliculous variety, is also common in these cases. Prognosis. As already stated, enlarged tonsils generally return to their normal size after the thirtieth year. In them- selves, they therefore offer no likelihood of proving dangerous to life, and it is only through the complications which they induce that their presence can present an unfavorable prog- nosis. Treatment. Active treatment for the reduction of hyper- trophied tonsils is always indicated when they are sufficiently large to occasion complications or to interfere with proper respiration through the nose. In adults, however, the likeli- hood of their spontaneous disappearance should be remem- bered and the treatment should be more medicinal than surgical, unless frequent attacks of tonsillitis renders sur- gical procedures peremptory. Eepeated attempts to reduce hypertrophied tonsils by means of astringents, have, in my hands, failed to produce anything but a very slight diminution in their bulk. Nitrate HYPEKTKOPHY OF THE TONSILS. 289 of silver solution instead of causing a decrease in their size, seemed to cause an increase, a fact theoretically explained by the stimulation induced by this agent and its tendency to encourage the formation of new elements. The solid stick, however, a portion of which is dissolved on the end of a heated wire, which is then introduced into the lacunae, may be used with good effect. Powdered alum and tannin, equal parts, applied with the insufflator, seemed to be productive of what benefit was obtained by means of astringents. Iodine and ergotine did not seem to affect the glands at all. When, for some reason or other, the tonsil cannot be am- putated, the best method, in my opinion, is that of Donaldson, of Baltimore, who makes small incisions into it and inserts Fig. 70. Tonsil bistoury. a crystal of chromic acid into each cut. Gralvano-cautery is also effective when the tonsils are soft, a few deep cauteriza- tions in each tonsil being repeated about twice a week. Morell Mackenzie recommends London paste, applied once or twice a week, according to circumstances, over different parts of the organ. The treatment, although effective, is very painful and tedious. Amputation of the tonsils can be performed by means of the bistoury, the tonsillotome, the wire snare, and the gal- vano-caustic snare. The operation with the bistoury can be employed very satisfactorily in adults, but not in children, on account of the resistance which the latter usually offer, and the danger of cutting the surrounding parts. An ordi- 19 290 DISEASES OF THE TONSILS. nary probe pointed bistoury, with a long shaft, may be used for the purpose. The tongue being depressed by an assistant, a volcella for- ceps is fastened on the tonsil and held with the one hand ; with the other, the bistoury is introduced under the tonsil and a couple of sweeps from below upwards are made until it is cut half-way through. The instrument is then with- drawn and placed over the organ, and an incision is made from above until the first cut is reached. As generally per- formed, i. e., cutting down from above until the tonsil is detached, there is always danger of cutting the parts below the level of the tongue, especially when, as frequently hap- pens, the tonsil extends far down. The operation by the tonsillotome presents none of the Fig. 71. Mathieu's tonsillotome. dangerous features of that of the bistoury, and can be per- formed without assistant. Mathieu's tonsillotome, shown in Fig. 71, is a very convenient and satisfactory instrument Its oval fenestrum encircles a large tonsil accurately and its fork raises the organ from its bed. Approximation of the thumb and finger-rings then causes penetration of the cutting blade through it, and the piece comes off adhering to the fork. For my own use, I had constructed the instrument repre- sented in Fig. 72, which is so disposed as to be applicable to any degree of hypertrophy. It is somewhat smaller than Mathieu's, and the general conformation of the blades is preserved ; but, instead of being furnished with a side-shaft HYPERTROPHY OF THE TONSILS. 291 for the fork, the spear which takes the place of the latter is attached to the main shaft by means of a thumb-screw. The lower edge of the spear is straight throughout one-half of its length, then oblique, and rests in a grooved guide- screw which passes through a slot in the shaft and is fast- ened to the blade. When in action, it perforates the tonsil and draws it out without causing the jar occasioned by the sliding-screw of Mathieu's. A spear is made to replace the fork, to avoid the difficulty generally experienced in sepa- rating the cut-piece from the latter; it holds it sufficiently to prevent its dropping into the throat, and can be easily withdrawn when partly in the tonsil, should a calcareous concretion be met with. The thumb-ring is screwed on the main shaft, bringing it in a direct line with the finger-rings. By this arrange- ment the equilibrium of the instrument is maintained during the operation, whether operating on the right or the left tonsil. The main shaft is not continuous with the blade-rings, as in Mathieu's ; they are separate, and the latter are furnished with rods which fit and move easily in longitudinal grooves extending an inch and a half along the side of the shaft. By this arrangement any size of blade or ring can be ad- justed to the shaft, in each case the rings fitting tightly around the tonsil, a desideratum for a neat operation and an even surface. As represented in Fig. 72, the instrument is ready for the operation. When the thumb-ring and finger-rings are approximated, the spear enters the tonsil and the beveled end of the main shaft slips under a small spring situated near the grooved guide-screw, from which a pin, reaching down to the blade, protrudes. The spring being raised, the pin is lifted out of the hole in the blade, setting it free, and 292 DISEASES OF THE TONSILS. the knife, following the motion of the fingers, cuts through the tonsil. One of the annoying features of tonsillotomes in general is the difficulty attending their cleansing. In this instrument, traction on the blade-rings with the left hand will cause them to slip half-way out of the shaft, until a pin, pro- rig. 72. Author's tonsillotome. Fig. 73- Smaller sizes of blades. Fig- 74 Blade and rings separated. jecting from the lower surface of one of them, becomes en- gaged in a "safety" groove near the end of the knife. The finger-rings are now pushed away from the thumb-ring, causing the blade to occupy the position it held before the operation. The rings being thus allowed to slip farther out, they become disengaged from the shaft, leaving the HYPERTROPHY OP THE TONSILS. 293 blade exposed. The tip of the spear is now turned aside by lifting it out of the grooved guide-screw and the piece of tonsil taken off. Each exposed part can be cleansed thoroughly and readjusted in a few seconds. If necessary, the whole instrument can be taken apart by merely un- screwing the thumb-ring. The operation with the tonsillotome is very simple. The tongue being depressed with the left hand, the instrument is introduced flat-wise into the mouth until the two rings are on a level with the tonsil. A slight turn of the in- strument on its axis will then bring the ring over the tonsil, against which it should be pressed gently. The fingers and thumb-rings being then approximated, the tonsil is perforated by the lance and cut off. The pain pro- duced is generally .slight and lasts but a short time. Bleeding usually follows, but it almost always stops after a few seconds, especially if a gargle of ice-water is used. Oc- casionally it lasts longer, stopping spontaneously in ten or fifteen minutes. Profuse hemorrhage occurs in perhaps one out of every five hundred operations, while an alarming flow does not occur in one out of a thousand. It has been my misfortune to meet with two such cases ; in one, a medical student, seven consecutive hemorrhages at from three to fifteen hours' intervals, occurred, pressure alone, of all the means employed, acting satisfactorily. In the second case, a boy of seventeen, the bleeding occurred two hours after the operation, and torsion of the tonsillar artery was re- sorted to with success. Before I had these two cases, I was inclined to consider the danger of hemorrhage as overrated ; since then, I have come to the conclusion that I was wrong, and that the likelihood of its occurrence should be borne in mind, especially since a number of cases are on record in which a fatal result could not be prevented. Hemorrhage 294 DISEASES OF THE TONSILS. is more to be feared in adults than in children ; the vessels being larger, the clots cannot as rapidly cause occlusion, while the less elastic arterial walls are collapsed with greater difficulty. In my two cases of profuse hemorrhage, the tonsils were exceedingly hard to penetrate, a fact which led me to believe that the cut arteries were maintained open by the surrounding fibrous elements adhering to them. I am therefore inclined to consider hemorrhage more likely in hard than in soft tonsils. Prior to operating, I now introduce into the parenchyma of the tonsil, with an hypodermic syringe, as much as I can of a ten per cent, solution of cocaine ; its constricting action upon the blood-vessels renders the organ compara- tively exsanguine, preventing almost entirely the usual slight bleeding, and limiting the likelihood of subsequent hemorrhage. The slight pain incident upon the operation is also prevented. Dr. Mackenzie's tanno-gallic acid gargle is an excellent mixture for the prevention of secondary hemorrhage. It is composed of six drachms of tannic acid and two drachms of gallic acid in an ounce of water; half a teaspoonful of this mustard-like liquid being slowly sipped at short intervals, it penetrates into the cut surface, assisted by the act of deglu- tition. Amputation by the snare is a rather slow process as compared with that by the tonsillotome, but what danger of hemorrhage may exist is much diminished. The loop being passed over the tonsil, the wire is gradually drawn home, fifteen to twenty minutes being employed. In some cases the growth is sessile, and cannot be grasped; a long needle may be used to transfix it, as in large anterior nasal hypertrophies (see Fig. 36). The galvano-caustic snare is manipulated in the same manner but the operation can be performed more rapidly. Cocaine is of great assistance in RELAXATION OF THE SOFT PALATE AND UVULA. 295 these operations and should invariably be employed as indicated above. In some cases, the enlarged tonsil is found adhering to the sides of the pillars with which it is in contact. It should be detached before the operation, by slipping the end of a probe between pillar and tonsil until these are separated. The after-treatment of these operations is of the greatest simplicity. The cut surface heals in a few days, without causing, in most cases, the least systemic disturbance. Highly seasoned articles of food should be avoided, as well as hot liquids. Systemic treatment is important in many cases. Scrofula should be met with appropriate remedies, such as the iodides, hypophosphites, and general tonics. Anemia, which is a frequent result of hypertrophic tonsils of long standing, through imperfect oxygenation of the blood, is best treated with Rabuteau's pills of iron, permanganate of potash or arsenic. In short, all existing abnormal conditions should receive proper attention. RELAXATION OF THE SOFT PALATE AND UVULA. (Synonyms : Elongated Uvula ; Relaxed Throat ; Relaxed Throat and Uvula.) Etiology. Relaxation of the soft palate and uvula is gen- erally due to chronic catarrhal inflammation of the posterior nasal cavity and of the pharynx. In the former, the relaxa- tion is not only due to extension, by continuity of tissue, of the inflammatory process, but it is mainly caused, in my opinion, by the constant hacking and scraping to which these cases become accustomed in their efforts to clear the vault of offending discharges. A relaxed and weakened condition of the system, through loss of tone of the muscular power, 296 DISEASES OF THE TONSILS. is also a frequent cause, the azygos uvulae and palatal muscles taking part in the general debility, and allowing the palate and uvula to drop perpendicularly on the base of the tongue, where they are kept congested by the efforts of the patient to dislodge a supposed foreign object. Gastric affections, immoderate smoking and drinking, are also frequent causes, while cerebral affections and diphtheria, by causing paralysis of the soft palate, may cause it to appear relaxed. Pathology. In elongation due to catarrhal inflammation, there is at first mere congestion, the blood-vessels being engorged and the cellular tissue somewhat oedematous. Gradually, there is inflammatory infiltration, which finally becomes organized, and the enlargement, which at first was fugitive, is made permanent. The relaxation may implicate the soft palate and the uvula, or the latter only. Symptoms. A tickling, irritating sensation, which induces frequent fits of coughing, is experienced in the majority of cases. A feeling as if a foreign body were in the throat causes the patient to make violent efforts, by hacking, to clear his throat. Nausea is a frequent symptom, most marked on rising, the upright position causing the uvula to rest against the base of the tongue. Upon lying down, it falls back upon the posterior wall of the pharynx, and maintains a constant irritation, which soon establishes a chronic inflammatory process. Snoring is usually marked, and the sleep is disturbed by the obstruction presented to normal respiration by the relaxed palate, which acts like a valve, allowing the air to pass downward, but interfering with its expulsion. When the uvula is very long, it may cause spasm of the glottis, and, according to Bosworth, genuine spasmodic asthma. The tongue is usually coated at the base by a yellowish-green fur, which resembles that caused by hepatic engorgement. In some cases, the hacking RELAXATION OF THE SOFT PALATE AND UVULA. 297 cough, the irritable throat, and the increased salivary secre- tions affect the patient's health greatly, and he may appear as if suffering from a much more formidable affection. Treatment. When the relaxation involves the soft palate only, astringents are sometimes, quite effective, but they must be used in strong solution. Alum is about the most effective agent we possess ; in the proportion of gr. xx-lj ; it may be used as a gargle every two or three hours, generally with the happiest results. Ferric alum, sulphate of zinc, and tannin, may also be used with good effect in solutions of gr. xv-! j. When this does riot succeed, or when the Fig. 75- Author's uvulatome. relaxation is limited to the uvula, ablation of the latter is the only satisfactory measure. This may be accomplished with a pair of long, curved scissors, the uvula being steadied with a pair of suitable forceps. This procedure, although apparently easy, is sometimes quite difficult, owing to the constant up and down motion of the uvula. Again, the scissors, in closing, allow the organ to slip out of its grasp, after cutting perhaps half-way through it. A much more satisfactory instrument is that shown in Fig. 75. It consists of a pair of strong scissors with the 298 DISEASES OF THE TONSILS. handles slightly beiit. Its lower surface is armed with a pair of toothed claws, the stems of which are united, and are connected with the handles by means of two little arms. These being attached loosely, the claws have free longitu- dinal motion, being guided by the pivot-screw of the scissors, and kept in position by a cap which not only serves that purpose, but also approximates the toothed edges of the claws by the resistance it offers to their outer edge, as they are drawn backward by the approximation of the handles. The instrument being held with the palm of the hand directed toward the operator, that is to say, with the thumb and finger passed through the rings from below upward (the bend being just sufficient to prevent them from inter- fering with the line of vision) it is introduced closed into the mouth. As soon as the point has reached the uvula, the rings are separated, and the organ hangs between the teeth of the claws. The rings being now approximated, the claws close on the uvula before the blades touch it, hold it fast, and bring it forward by bending it at its base. The scissors cutting it in that position, the cut surface is oblique and posterior. When food is swallowed, the horizontal surface obtained with other instruments is exposed to the bolus, and scraped and kept sore by it for several days. With the posterior oblique surface obtained with this instrument, the bolus only touches the anterior surface of the stump, the cut surface resting against the pharynx. The healing pro- cess is more rapid, and a better stump is obtained; slipping of the uvula between the blades is impossible, and the cut is always complete. A ten per cent, solution of cocaine, applied just before the operation, renders it almost painless, and prevents the slight bleeding which usually occurs. The after-effects of the operation are slight local pain, increased by the act of RELAXATION OF THE SOFT PALATE AND UVULA. 299 deglutition. Well-seasoned food, hot liquids, and smoking, should be avoided. An occasional application of a four per cent, solution of cocaine during the day limits markedly the unpleasant after-effects and promotes resolution of the cut surface. CHAPTER XXL THE LARYNX. ^ ANATOMY. THE larynx may be considered as an expansion of the upper portion of the trachea or windpipe, which lies between the pharynx, of which it forms the anterior wall, and the lower portion of the base of the tongue. Its superior aperture slants toward the pharynx, and is covered by a leaf-like lid, the epiglottis, which is attached to its anterior margin and closes from before backward. The larynx is connected with the surrounding parts by muscles and ligaments, the former of which serve to elevate it during deglutition and phonation. It forms in the neck, the promi- nence generally called " Adam's apple." Although the larynx is in shape an expansion of the trachea, its framework is not like that of the latter, com- posed of cartilaginous rings, but its walls are formed by two broad plates of cartilage, which meet anteriorly and are widely separated posteriorly, thus forming a triangular space between them, with its base facing the pharynx. United in this manner, they form the thyroid cartilage, called go on account of its resemblance to a shield. The anterior angle of the thyroid cartilage is hardly more than an inch from above downward, a deep depression in its superior margin diminishing its perpendicular diameter greatly. Posteriorly, however, this diameter is much greater, each wing being furnished with two perpendicular horns DV cornua, one above and the other below, the former being somewhat longer and thinner than the latter, which is short (300) ANATOMY. 301 and thick. The upper horns are connected with the hyoid bone above by means of ligaments. The two lower horns might be called the pillars of the thyroid cartilage, as they form its posterior support, resting upon the two facets of the cricoid cartilage, immediately below. The cricoid cartilage, called so on account of its resem- blance to a seal ring, separates the thyroid cartilage from the trachea, its seal or broad portion being turned towards the pharynx. On each side of the seal is a small promi- nence, which in turn is furnished with a small hollow facet. In the two facets thus formed, rest the inferior cornua of the thyroid cartilage, which are held in place by means of a capsular ligament, so disposed as to allow approximation of the two cartilages anteriorly. While the sides of the seal-like portion of the cricoid car- tilage support the inferior cornua, its upper border becomes the resting point of two other cartilages, the arytenoid cartilages, which stand some distance from the median line. Each cartilage is pyramidal in form, its antero-posterior diameter being much longer at the base than its lateral, and resembles greatly in shape the pointed paper hats made by children. Like the cornua of the thyroid, the arytenoid cartilages rest upon facets, to which they are secured by ligaments, in such a manner as to be freely movable; rest- ing upon these facets, as they do, only by a small portion of their inferior surface, near the middle, they can be piv- oted upon their support like the needle of a marine compass, and even be slipped up towards the median line. In the rotatory faculty of the arytenoid cartilages, we have the mechanical basis for the adduction and abduction of the vocal bands, wrongly called the vocal cords (not being rounded cords as the name would imply), which are two thin but strong bands of yellow elastic tissue, covered on their 302 THE LARYNX. surface by a thin layer of mucous membrane, and attached anteriorly to the retiring angle of the thyroid cartilage near its lower border, and posteriorly to the anterior angle of the base of the arytenoid cartilage. The manner in which ap- proximation and separation of the vocal bands is accom- plished is as follows: Abduction. The posterior aspect of the seal of the cricoid cartilage presents two shallow depressions, one on each side of the middle line, which serve for the attachment of the posterior crico-arytenoid muscles, whose fibres are directed upward and outward and are inserted at the posterior angle of the arytenoid cartilage. When these muscles contract, they approximate these posterior angles, and the anterior angles of the arytenoid cartilages are rotated around, sepa- rating their extremities. The vocal bands being attached to the latter, are also widely separated, the triangular open space between them being called the glottis. Adduction. To approximate the vocal bands, we have another set of muscles, the lateral crico-arytenoidei, whose broad attachments are on the upper border of the narrow or ring portion of the cricoid, while their fibres, which are directed upward and backward and somewhat inward, are also inserted at the posterior angle of the aiytenoid. Con- traction of these muscles causes the antagonizing action to that of the posterior crico-arytenoidei, and by pulling the posterior extremities of the arytenoid cartilage outward, they cause approximation of the bands. In death, or when both sets of muscles are paralyzed, the muscles are neither com- pletely approximated or separated; they remain half way, in the so-called "cadaveric" position. The lateral cricoid-arytenoid muscles are not sufficient, however, to cause approximation of the whole length of the bands. A delicate piece of soft cartilage which is imbedded ANATOMY. 303 in each vocal band and attached also to the anterior angle of the arytenoid cartilage, called the vocal process, limits the action of the bands, and when the lateral crico-arytenoidei alone act, their points come together with the portion of the cords anterior to them, leaving a triangular opening behind. In order to close this, when necessary, there is another muscle, the arytenoideus, composed of three sets of fibres, two oblique and one horizontal, which is attached to the internal surface of each arytenoid cartilage, and which, by contracting, approximates the cartilages by causing them to slide upward, upon their facets, thereby approximating that part of the vocal bands containing the vocal processes and consequently the entire length of the bands. The vocal bands are thus opened by the posterior crico- arytenoidei, partially closed by the lateral crico-arytenoidei, and completely closed by the arytenoideus ; thus making three sets of muscles concerned in opening and closing the glottis. Extension. Extension of the vocal cords is produced by the tilting upward of the cricoid cartilage upon the thyroid, the articulation of the inferior cornua of the thyroid car- tilage and the cricoid serving as fulcrum. The part of the seal upon which the arytenoid cartilages are attached being much higher, comparatively, than the location of the fulcrum, when the anterior portion of the cricoid cartilage is raised, the upper border of the seal is forced back, drawing the arytenoid cartilages with it, and stretching the vocal bands which are attached to them. The muscles which accom- plish this purpose are the thyro-cricoidei, composed of two fasciculi on each side, which are attached to the external surface of the thyroid cartilage near its lower edge, and, being directed forward and downward, are inserted upon the external surface of the cricoid. When these muscles contract they draw the cricoid cartilage upward under the 304 THE LARYNX. thyroid, stretching slightly, at the same time, the anterior portion of the trachea. Relaxation. Relaxation of the vocal bands after the thyro- cricoid muscles have extended them, is accomplished by the thyro-arytenoidei or vocal muscles, each composed of three fasciculi, mainly by approximating the arytenoid cartilages and the thyroid cartilage. The first or straight fasciculus is composed of flat horizontal fibres which are closely connected with the vocal band, and are inserted into the inferior bor- der of the arytenoid cartilage. The second is triangular in shape, the base of the triangle being attached to the ante- rior surface of the arytenoid cartilage, while the third fasci- culus is also triangular in shape, the apex being attached to the infeiior border of the arytenoid, while its base is inserted at the point of common origin in the retiring angle of the thyroid cartilage, sending diverging fibres to the sides of the cavity from origin to insertion. The vocal bands are thus extended by the contraction of the tkyro-cricoid muscles, and relaxed by the contraction of the thyro-arytenoideij a perfect equilibrium being maintained between the two sets of muscles so as to insure absolute steadiness in the production of tones. Another impor- tant set of muscles is that which causes the descent of the lid of the larynx, the epiglottis, and which contracts, and even closes in some cases, the upper aperture of the larynx. Depression of the Epiglottis. The epiglottis is maintained raised some distance from the laryngeal aperture principally by a ligament which connects its upper surface with the base of the tongue, the alosso-epiglottic ligament. The ordi- nary position of the epiglottis during respiration is to stand a certain distance above the larynx, but when food or drink is swallowed, it is closed upon the larynx to prevent the ANATOMY. 305 ingression into it of the liquids or solids taken. This is accomplished by the thyro-epiglottideus, a small muscle which is inserted on each side of the epiglottis, and attached to the inner surface of the thyroid cartilage. Its contraction causes the epiglottis to adapt itself closely to the aper- ture of the larynx, which it closes securely. Contraction of the Laryngeal Aperture. The muscles which contract the aperture of the larynx, and are capable of closing it completely in case of loss of the epiglottis, are the superior aryteno-epiglottidei, which arise from the apices of the arytenoid cartilages, and curving around in the fold of mucous* membrane forming tlje edge of the laryngeal aperture, the ary-epiglottic fold, into which the greater por- tion of their fibres are lost, are finally inserted at the base of the epiglottis. Their contraction causes approximation of the upper portion of the laryngeal cavity and holds the office of the epiglottis when this is gone. In order to further secure the integrity of the larynx during deglutition, a third mechanism enters into play. Immediately below the edge of the laryngeal aperture and a short distance above the vocal bands, are the ventricular bands, sometimes called the false vocal cords, which extend from the receding angle of the thyroid cartilage to the anterior surface of the aryte- noid cartilages, parallel with the true vocal cords. They are formed by the superior tliyro-arytenoid ligament and some muscular fibres. Just before the epiglottis conies down on the larynx, the ventricular bands are approx- imated, the cushion of the epiglottis, a pad-like thickening upon its under surface, filling the gap between it and the ventricular bands and closing the slit between the latter effectively. Lubrication of the Vocal Bands. Between the ventricular band and the vocal band on each side, is an elliptical 90 306 THE LARYNX. space, the rent ride, which extends antero-posteriorly from the thyroid to the arytenoid cartilage, and forms a sort of pocket between the ventricular band and the wall of the larynx. Into it opens the laryngeal sac, an upright cavity, which is really but an extension upward of the ventricle, about the size of a small bean. The mucous membrane lining this sac is thickly studded with small racemose glands, which are constantly pouring out a glairy mucus that keeps the cords lubricated. The ventricle being situated between the internal wall of the larynx and the ventricular band, it is in a favorable position to be compressed, this being accomplished by the contraction of the inferior anjteno-epifjlottideus (compressor sacculi laryngis of Hilton), which arises from the anterior angle of the arytenoid car- tilage, and is inserted into the margin of the epiglottis, after having passed over the sac, through the ventricular band. The larynx is united with the surrounding parts by means of muscles and ligaments. The former, which are called the extrinsic muscles (in contradistinction to those which unite the different parts of the larynx together the intrinsic muscles), move the larynx up and down in the throat during phonation and deglutition, and maintain it steady during the emission of sound. Elevation is accomplished principally by the thyro-hyoid muscles, which are attached to the hyoid bone and to the upper portion of the thyroid cartilage. These are prin- cipally instrumental in insuring the steadiness of the larynx, which they raise during phonation. In the production of low tones, the larynx is depressed by the sterno-ihyroid muscle which connects the sides of the thyroid cartilage with the sternum. The Laryngeal Mucous Membrane, The different parts ANATOMY. 307 described, comprising the framework and muscular supply of the larynx, are, throughout their entire extent, covered with mucous membrane. Between the epiglottis and the tongue, it forms three folds, the glosso-epiglottic folds one exactly in the middle, forming the glosso-epiglottic ligament, before alluded to, and two lateral, which form between them two shallow fossae into which foreign bodies frequently become impacted. On each side of the epiglottis the mucous membrane forms another fold, the pharyngo-epiglottic fold which unites the epiglottis to the pharynx. This forms on each side the upper limit of another cavity, the pyriform sinus, much deeper than the glosso-epiglottic fossae, which are also frequently invaded by foreign bodies. The upper border of the larynx is formed by a redupli- cation of the membrane called the ary-epiglottic fold. The membrane is here loosely attached to the underlying parts, especially in the region of the arytenoid cartilages, which are thus enabled to rotate freely. Over the ventricular bands it is somewhat more adherent, but again becomes loose in the ventricle. The laxity of the membrane in these situations renders them more liable to oedema than other parts. It adheres firmly to the vocal cords, forming a sharp edge at their border, then continuing obliquely downward to the trachea. The epithelium is principally of the ciliated variety. The vocal bands, however, are covered along the edge and a short distance beyond, by pavement or tesselated epithelium, the cells being especially large. The posterior surface of the epiglottis and the inter-arytenoid space are also lined with pavement epithelium. Arteries. The larynx is supplied by branches of the xnperior and inferior thyroid arteries. The superior laryngeal which is derived from the former, penetrates into it by 308 THE LARYNX. passing through the thyro-hyoid membrane. The middle laryngeal, also a branch of the superior thyroid, passes over the thyro-cricoid membrane and unites with its fellow, after having sent a branch into the laryngeal cavity. The inferior laryngeal, a secondary branch of the inferior thyroid, sends a branch to the posterior crico-arytenoid muscle, while another meets with a branch of the superior laryngeal. Nerves. The nervous supply of the larynx is derived from the superior and inferior or recurrent laryngeal, both branches of the pneumogastric. The former is a sensory nerve almost exclusively, supplying motor nerves only to the ihyro-epiglottidean, ary-epiglottidean, and crico-thyroid muscles. The recurrent laryngeal is exclusively a motor nerve and sends branches to all the muscles of the larynx, with the exception of the three enumerated. PHYSIOLOGY. The principal physiological function of the larynx is the production of voice. During respiration the vocal bands are separated, this separation being especially marked during the inspiratory act, when the posterior crico-arytenoid muscles approximate as closely as possible the posterior processes of the arytenoid cartilages, thus abducting the vocal bands to their utmost extent. In expiration, however, these muscles cease to act, and the vocal bands are main- tained separated by the current of expired air which forces them apart. If now a sound is to be emitted, in connection with the expired current, another set of muscles is brought into play, the lateral crico-arytenoidei, which pull the pos- terior processes of the arytenoid cartilages outward, and cause adduction of the vocal bands, leaving a mere slit between them. The air impinging upon the edge of the bands, causes them to vibrate, just as the tongue of a PLATE vii. PLATE VII. ANATOMY OF THE LAKYNX. A. Thyroid cartilage. b. Cricoid cartilage. C. Arytenoid cartilage d. Cartilage of Santorini . Crico-thyroid membrane. f. Vocal band. a. Arytenoideus muscle. A. Lateral crico-arytenoid muscle. i. Posterior " " j. Epiglottis. k. Vocal process FIGURES I TO 9. m. Cartilage of Wrlsberg. n. Aryteno-epiglottic fold. o 1 Upper fasciculus of thyro-arytenoid muscle. 02. Middle " " " " 3 . Lower " " " p. Ventricle of the larynx. q. Laryngeal sac. r. Ventricular band *. Superior aryteno-epiglottic muscle. t tf fl. Two fasciculi of thyro-cricoid muscle. w. Superior thyro-arytenoid ligament. ABDUCTION AND ADDUCTION. FIG. i. POSTERIOR VIEW. Vocal bands abducted by con- traction of posterior crico-aryte- noids (arytenoideus cut off). FIG. 2. LATERAL VIEW. Section of larynx showing rela- tion of adductor and abductor muscles. FIG. 3. POSTERIOR VIEW Vocal bands adducted partially by contraction of lateral crico- arytenoids (arytenoideus not hay ing acted). FIG. 4. FIG. 5. HORIZONTAL SECTION OP LARYNGEAL FRAMEWORK, ABOVE VOCAL BANDS. Vocal bands in abduction. Vocal bands in partial adduction. EXTENSION AND KELAXATION. FIG. 6. LATERAL SECTION. Relaxation of vocal band through contraction of thyro- arytenoids and relaxation at thyro-cricoids. FIG. 7. LATBKAL SECTION. Interior of larynx. Flaps raised to show lary ngeal sac, and the rela- tion of muscles with the mucous membrane. FIG. 9. ANTERIOR SECTION. Interior of larynx and relation of muscles. FIG. 8. LATERAL SECTION. Extension of vocal band by elevation of the cricoid cartilage through contraction of the thyro- cricoid muscles and relaxation of the thyro-arytenoids. FIG. 10. INNERVATION OF THE LARYNX. Posterior section of neck and upper part of chest showing the course of the pneumogastric nerves, their branches, and their relations. Lateral half of trachea and quarter of larynx cut off. A tf A\. Pneumogastric nerve. B ty B 1 . Superior laryngeal. C. Right recurrent laryngeal. D. Right lung. E. Left recurrent laryngeal. F. Branch of superior larvngeal a. CEsophagus. b. Aorta. C. Pulmonary artery. d. Trachea. e* (Upper) Internal jugular vein cut off. e. (Lower) Bronchi. f. Arytenoid cartilage. a. Subclavian artery. A. Common carotid artery. t. External " " i. Internal " k. Base of cranium. m. (Upper) First cervical verte- bra. TO. (Lower) Arytenoideus muscle. . Pharynx cut off from upper ' attachments. o. Epiglottis. p. Hyoid bone. q. Thyroid cartilage. r. Cricoid cartilage. . Thyroid gland. U. Thyro-cricoid muscle. V. Cervical vertebrae. x tf y. Muscles of neck S. Innominate artery FIG. ii. ARTERIES AND VEINS OF THE ANTERIOR PORTION OF THE NECK. Vessels of the neck, showing those in danger of being severed in making artificial opening into the larynx and trachea, and their connections. a. Trachea. b. Cricoid cartilage. C. Thyroid cartilage. d. Thyroid gland. e. Crico-thyroid membrane. f. Thyro-hyoid membrane. 0. Hyoid bone. h. Aorta. t. Innominate artery. j. Common carotid artery. k. Superior thyroid artery. 1. Anterior jugular vein. m. Crico-thyroid artery, n. Internal jugular vein. O. Thyroid plexus. p. Right inferior jugular vein. q. Left inferior jugular vein. T. Crico-thyroid vein. t. Superior thyroid vein. t. Middle thyroid vein. u. External jugular vein. v. Subclavian vein. ar. Right and left innominate vein, y. Superior vena cava. C.E. Sajous, Pi nx.it & WFetndge, l/tfi Phil a PHYSIOLOGY. 309 clarionet is caused to vibrate by the breath of the player. The pitch of the note produced depends upon the tension of the vocal bands, which in turn depends upon the degree of displacement backward of the arytenoid cartilages, induced by the action of the thyro-cricoid muscles upon the cricoid cartilage. If now another note is to be sounded, say one tone higher, the thyro-cricoid muscles contract a little more, increasing the tension of the bands in proportion. If, on the contrary, a lower note is to be given, the thyro-arytenoid muscles contract and approximate the vocal processes of the arytenoid cartilages to the thyroid cartilage, while the thyro-cricoid muscles relax to an equal degree. Although their tension is decreased, the vocal bands are thus held steadily between the two antagonistic sets of muscles, and a note can be prolonged without change of pitch as long as the expiratory breath lasts. For the clear production of the voice, absolute integrity of the vocal bands and muscles must exist. A slight con- gestion of the mucous membrane of the former, by thick- ening their edges, interferes with their proper vibration, and hoarseness is produced, while great congestion may cause complete loss of the voice, by rendering vibration impossible; again, their approximation and vibration may be prevented by the presence of a tumor or paralysis of some of the adductor muscles. Inflammation of the muscles may also compromise greatly the production of voice through the paresis induced by the inflammatory infil- tration. CHAPTER XXII. LARYNGOSCOPY. LARYNGOSCOPY is the term applied to the optical exami- nation of the larynx. This is accomplished with the assist- ance of the laryngeal mirror, sometimes called " laryngos- cope," and either natural or artificial light. The laryngeal mirror employed in this country consists of a plain, round mirror, varying in diameter from one-half to one inch, and mounted in a metallic frame. To the edge of this frame, a strong wire stem, about four inches in length is attached, at an angle of about 120 ; this, in turn, is either securely Fig. 76. Laryngeal mirror. connected with a small handle, or left free so as to be intro- duced at will into a universal handle, an ordinary handle perforated longitudinally, and furnished near its extremity with a thumb-screw, which can be tightened down upon the stem when this is introduced. Different sizes of laryn- geal mirrors are furnished, and are numbered according to their size, No. 1 representing the largest size mirror, one inch in diameter; No. 2, the second in size, being three quarters of an inch in diameter, and No. 3, which is only one-half inch in width. When possible, the largest mirror should be used, its surface reflecting a greater number of luminous rays, and, therefore, illuminating the parts more (310) LARYNGOSCOPY. 311 brightly. In some cases, however, the smaller mirrors can alone be used, their limited diameter enabling them to be introduced without touching the surrounding parts. In chil- dren, for instance, a mirror larger than No. 2 can but very seldom be used, the narrowness of the pharyngeal cavity otherwise causing the walls to come in contact with the circumference of the frame. We have seen in the chapter on anatomy, that in order to completely uncover the laryngeal cavity, it is necessary to raise the epiglottis from its semi-recumbent position, and that the glosso-epiglottic ligament unites it to the tongue. Protrusion of the latter, therefore, causes elevation of the epiglottis, the parts behind and below it thus be- coming visible. For a laryngeal examination, this is indis- pensable. The tongue must not only be protruded, but it must be held so, either by the patient or the physician. When the patient is first seen, he is frequently inclined to withdraw the head when the mirror is being introduced, but as soon as it has been applied once or twice, the slight degree of apprehension leaves him, and he holds his head steadily. In the first examinations, therefore, it is preferable to hold his tongue for him, a clean towel being interposed between fingers and tongue. Later on, he is shown how to grasp the organ between his index finger and thumb to hold it, not to "pull it, lest the fresnum be wounded by the lower incisors. He should use his right hand if the mirror is held in the right hand by the observer, or vice versa, the object being to avoid the impediment which the patient's hand would offer were they both on the same side of the mouth. The tongue being withdrawn, the next step is to adjust the light so that the central rays will impinge upon the spot just above the level of the surface of the tongue. The laryngeal mirror, held like a penholder, is then exposed 312 LARYNGOSCOPY. over the light a couple of seconds, with the glass surface downward. This is to heat it slightly, so as to avoid the condensation of the watery portion of the breath which would take place upon it, if it were cold, thus blurring it completely. Its posterior surface is then placed upon the back of the other hand so as to ascertain that it i$ not Fig. 77. The laryngeal mirror in position. sufficiently hot to burn the patient, after which the mirror is quickly introduced into the mouth, the long axis of the instrument being first perpendicular, then brought to the norizontal by raising the handle as the instrument is ad- vanced in the oral cavity. In this manner the surface of the mirror is in relation with the surface of the hard palate LAKYNGOSCOPY. 313 until in position, thus greatly diminishing the likelihood of touching the base of the tongue, and avoiding gagging and nausea. As soon as the uvula is reached, the back of the mirror is placed against it, and it is pushed upward and backward, adjusting at the same time the surface of the glass (by depressing the handle slightly) so as to cause the image of the laryngeal cavity to appear in it. If no ob- struction is presented, an unruly or over-sensitive tongue, a depressed epiglottis, etc., the upper border and interior of the larynx and the upper portion of the interior of the trachea will be seen, and if the patient be breathing quietly, the edge of the vocal bands will appear in the abducted posi- tion, looking like little white shelves, about three-quarters of an inch long, which are approximated at one end and diverge from above downward (in the mirror) forming a V upside down. If now the patient is requested to say ah, ah, the vocal bands will be seen to rotate suddenly upon their anterior attachment and come together, the A being replaced by two parallel bands with a slight slit between them. Their width will appear greater than when they were separated, the greater part of their surface being then hidden under the ventricular bands, their edges merely appearing. As represented in the mirror, the image appears to the observer as if he were standing behind the larynx and looking into it, this being in reality the position of the mirror, which also stands behind and above the larynx. The observer sees it, therefore, as if he were in the mirror's place. The anterior commissure or the apex of the A formed by the abducted vocal bands being anterior in relation to the throat, it is therefore seen in the upper portion of the mirror, while the widest portion of the A i g near its lower margin. Beginning at the upper portion of the image, the first 314 LAKYNGOSCOPY. object seen is the epiglottis, its curled border varying greatly in shape with different individuals, but generally presenting the shape of a Cupid's bow, with the concavity downward. Its color is yellowish pink, with arborescent blood-vessels strewn over its surface. Starting from each side and curving inwardly as they advance, are the ary-epi- glottic folds, which form the upper border of the laryngeal aperture, and are united posteriorly by the wter-arytetwid fold, formed by the arytenoideus muscle and its overlying membrane. At the point of junction of the inter-arytenoid fold with the ary-epiglottic fold on each side, may be seen a little knob, formed by the diminutive cartilage of Santorini, which surmounts the apex of the arytenoid cartilage. A little higher up towards the epiglottis, another but some- what larger knob may be seen on each side, this being the eminence caused by the cartilage of Wrisberg, a perpendicular strip of cartilage, which seems to support the walls of the larynx. The four knobs are enclosed in the ary-epiglottic folds, which are rather more pink in color than the epi- glottis, and devoid of arborescent vessels. Going deeper into the laryngeal cavity, we now come to the ventricular bands, whose posterior insertions about correspond with the interval between the cartilages of Wris- berg and Santorini. Their anterior commissure is hidden by a more or less prominent nodule, the cushion of the epi- glottis, which projects from the internal surface of the latter, and serves, when it is depressed, to close what interval may be left between them. The ventricular bands generally present about the same color as the ary-epiglottic folds, which surround them. Below the ventricular bands and parallel with them, appear the vocal bands, contrasting by their bright white color, with the pink hue of the surrounding parts. Their anterior com- OBSTACLES TO LARYNGOSCOPY. 315 V missure is also generally hidden by the cushion of the epi- glottis, while the posterior extremities are attached imme- diately below the cartilages of Santorini. If the mirror is slightly rotated on its axis and turned somewhat, a dark recess will be seen belfoeen the ventricular band and the vocal band of the side examined; this is the aperature of the ventricle of the larynx. Below the vocal bands, the tracheal rings are brought to view, five or six being gen- erally seen, while in some cases the entire trachea and a small portion of the right bronchus may be examined. OBSTACLES TO LAKYNGOSCOPY. In many cases, a laryngoscopic examination is accom- panied by great difficulty. A peculiar conformation of the epiglottis, enlarged tonsils, an over-sensitive throat, etc., are obstacles which often have to be overcome before a satisfactory examination can be conducted. An overhanging epiglottis is the most frequent cause of interference; the depression may be slight, and cover but a small part of the anterior portion of the laryngeal cavity, or it may be so great as to allow only its posterior border to appear. In these cases a satisfactory examination can only be obtained by raising the epiglottis while the mirror is in position. Several instruments have been invented for the purpose, but they can very seldom be used without causing the patient to retch and gag. The application of a four per cent, solution of cocaine to the posterior surface of the epiglottis, however, renders its manipulation possible, and any curved probe, or the instrument shown in Fig. 69, turned downward, may be employed to raise it against the base of the tongue. The probe is, of course, held with the left hand if the mirror is held with the right. Two or three successive applications 316 LARYNGOSCOPY. of cocaine, at a couple of minutes' interval, are sometimes necessary to render the epiglottis completely asensitive. An over-sensitive pharynx is probably the obstacle most frequently met with. The mirror is hardly in the mouth but that the patient begins to manifest all the symptoms of a coming emesis, a result which occasionally takes place. A spray of cocaine, however, is very effective in mastering superficial sensitiveness. If an atomizer be not at hand, it can be applied with the brush or cotton pledget, the brunt of the application being made over the base of the tongue. After two or three examinations with cocaine, the parts become much more tolerant and the laryngoscope can generally be borne without trouble. "When cocaine cannot be had, gargling with ice-water, a thirty- grain dose of bromide of potassium, morphia, etc., will sometimes succeed in allaying the irritability for a short while. In some cases it is utterly impossible to examine the throat without the assistance of cocaine. When this agent cannot be had, training the parts to the p'resence of a foreign body by the introduction, two or three times a day for a week or so, of the handle of a spoon or some other blunt object, will generally succeed in diminishing their sensibility sufficiently to render an examination pos- sible. An elongated uvula sometimes interferes with the ex- amination, by bending anteriorly, then upward, around the lower margin of the mirror, through the pressure exerted by the latter upon it and the underlying pharyngeal wall. This can be overcome, in most cases, by quickly passing the mirror below the tip of the uvula, then raising the latter upon its metallic or posterior surface until the proper posi- tion for the instrument is reached. Enlarged tonsils some- times prevent the introduction of the mirror in the pharyn- OBSTACLES TO LAKYNGOSCOPY. 317 geal space, rendering the use of a smaller mirror necessary. An unruly tongue occasionally renders a view of the mirror, when this is in position, almost impossible. It should in that case be held by the observer, a tongue-depressor being used in connection with the towel employed. The handle of the instrument can be held between the thumb and the tongue, while the index finger under the latter serves as the supporting point. Care should be taken not to exert pres- sure on the portion of the tongue lying on the lower teeth, lest the fraenum be cut or crushed. CHAPTER XXIII. INSTRUMENTS USED IN CLEANSING AND MEDICATING THE LARYNX, WHEN cleansing of the laryngeal surfaces is indicated, this being by no means as frequently the case as in diseases of the nose or pharynx, Sass' laryngeal tube (Fig. 17) may be employed. It is useful to remove masses of purulent Fig. 78. Lcntz's atomizer. secretion which adhere tenaciously to the mucous membrane. For general purposes, however, an atomizer, such as that shown in Fig. 19, with a tip turned downward, or the instru- ment represented in the annexed cut, which, notwithstanding its single bulb, produces a continuous flow, is preferable, the spray being much lighter and presenting no mechanical force to irritate the parts. (318) ATOMIZEES. 319 When an atomizer is to be used, the tongue should be withdrawn and held by the patient, so as to raise the epiglottis and uncover the larynx as much as possible. The bottle is held with one hand, while the other is used to work the bulb, unless an air-compressor be employed, when the tongue can be held by the physician, so as to maintain the head in a steady position. The tube being introduced into the mouth, the patient is directed to take long breaths and to make his respiration as soft as *he can ; this is to diminish as much as possible the resistance which the respiratory current presents to the spray, thus preventing its access to the larynx during expiration. During inspiration, the pene- tration of the spray into the trachea being reduced to a minimum, the liability to cough is decreased. When it is desirable to reach as much of the vocal bands as practicable, the patient is requested to make a sound, which will cause the bands to come together, exposing their entire surface. A couple of minutes, at the longest, are sufficient, in most cases, to thoroughly cleanse the laryngeal surfaces, or at least to so soften the mucoid or muco-purulent masses as to cause them to be easily expectorated. Impediments are often encountered which render the use or the atomizer very difficult. A thick, rebellious tongue, an over-sensitive throat, retching, caused by the least ap- proximation of the point of the tube to the papillae at the base of the protruded tongue, and an overhanging epiglottis, are some of the difficulties met with. To subdue a rebel- lious tongue, the tongue depressor may be used to advan- tage, the organ (held by the patient) being forced down in the centre. Over-sensitiveness of the throat and the base of the tongue can be much reduced by swabbing the parts with a four per cent, solution of cocaine, the anaesthesia lasting sufficiently long to enable the operator to treat the parts effectively. 320 INSTRUMENTS USED IN TREATING THE LAKYNX. For the application of solutions in small quantities, I prefei the cotton pledget to either the sponge or the brush; it is cleanly and soft, and can be thrown away after each applica- tion. The only feature which somewhat militates against its use, is the liability of small films to become detached and to cause irritation in the larynx by remaining there. This can be obviated, however, by passing the cotton pledget over the light used for illumination, which will cause what films are not closely adherent to the pledget proper to burn off. I have found the instrument shown in Fig. 22 (which is shown in Fig. 79 in the position it occupies when held in Fig. 79 Laryngcal cotton forceps in position. the larynx) most convenient. Any size of cotton pledget, folded as described on page 45, may be used with it, so that a large as well as a small surface can be thoroughly treated. The manipulation of this instrument in the larynx is much the same as for the posterior nares. The laryngoscopic mirror, held with the left hand, should be used to guide the applications ; the forceps being introduced with its curved surface lying horizontally, is quickly turned 'on its axis, the tip being over the laryngeal cavity. The point to be touched POWDEE INSUFFLATORS. 321 is then well noted in the mirror, and the tip is suddenly low- ered and applied to {he desired spot, the forceps being then quickly, but gently, withdrawn. This manipulation presents some difficulty at first, but this is overcome after repeated trials. When the application is to be made to a larger area, or to the entire surface of the larynx, a large piece of cotton is used, and when the pledget is introduced into the laryngeal cavity, it is left there an instant, when muscular contraction will squeeze and deplete it of its solution. Cotton pledgets should at no time be full of the fluid used, lest the latter run down in a stream along the internal wall of the trachea and produce considerable distress and coughing. For the application of powders, the scoop insufflator, shown in Fig. 25, with the tip turned downward, is the most con- venient instrument when a fixed quantity is to be employed. The manipulation is the same as for the atomizer, the tongue being held out by the patient, so as to raise the epiglottis, and the mirror being used to guide the application. When the powder is to be applied to or above the vocal bands, the patient is requested to make a sound, and the powder being blown out just as he does so, the agent used covers the supra-glottic surfaces without falling into the trachea, while the vocal bands are thoroughly covered. When the powder is to be distributed evenly over the entire surface, this can be done by dividing the single insufflation into a series of small puffs, changing the direction of the tip of the insuf- flator each time, and holding it as high as possible over the larynx. The mucous membrane is thus covered with a thin film of the remedy. When a spot of ulceration is to be treated and the powder is to be limited to it, the tip of the insufflator should be approached as closely as possible over it, and a slight puff will cover it thoroughly. For the insufflation of remedies not requiring exact dosage, 21 322 INSTRUMENTS USED IN TREATING THE LAEYNX. such as iodoform, Dr. A. H. Smith's insufflator (Fig. 26) is by far the most convenient, the tip being turned downward. The two hands being necessary for its manipulation, the mirror cannot be used; but as the remedies employed in that manner are diffused over the entire laryngeal surface, the assistance of that instrument is not required. Steam inhalations are of advantage in the treatment of laryngeal affections when the patient can remain at home. If, on the contrary, he is obliged to go in the open air, they are more hurtful than beneficial, offering positive danger sometimes, and especially in cases of subacute laryngitis. The sudden transition to which the inflamed parts are sub- jected, by the exposure to widely different degrees of tem- perature, readily explain the manner in which an acute inflammation can be brought about. A popular method of administering steam inhalations is to half fill a pitcher with warm water, using it pure or medicated with some diffusible agent, and to surmount the vessel with a towel folded cone-shape, with the apex of the cone turned upward. The patient having introduced his mouth and nose in the opening formed above, inhales deeply as long as an appreciable amount of steam is generated. The inhaler described on page 50, and shown in Fig. 28, presents many advantages for the administration of pure or medi- cated steam. One-half pint of water being poured into the can, this is placed on the stove or on an alcohol lamp until the water is heated to the desired temperature, this being noted on the thermometer which protrudes through the stopper. If a medicinal agent is used, it is dropped in through the mouth of the instrument, the rubber stopper being then adjusted so as to close the aperture hermetically. The patient should then introduce the mouthpiece, which is covered with rubber tubing to prevent burning of the lips, STEAM ATOMIZER. 323 into his mouth and breathe through it, the inspiratory cur- rent being drawn from the instrument through the lower valve, while the expired column of air is driven out into the surrounding atmosphere through the upper valve. This can be continued for two or three minutes, or more, if the patient is not fatigued. For office practice, pieces of rubber tubing, an inch long, can be kept on hand so as to supply a new mouthpiece covering for each patient. This is not only a measure of cleanliness, but also of prudence. Another instrument used for administering steam inhala- tions, is the steam atomizer shown in Fig. 80. The steam Fig. 80. Codman & ShurtlefTs modification of Siegle's steam atomizer. is formed in a little boiler supported over an alcohol lamp, and while passing out through a horizontal glass tube, over the end of another but perpendicular tube which dips in the medicament used, it produces a vacuum in the latter which causes the medicinal agent to ascend and to mix with the steam current. It is a very convenient instrument, but is rather difficult to keep in perfect order. It is employed in the same manner as the preceding. CHAPTEK XXTY. THEKAPEUTICS OF THE LAEYNX. CLEANSING of the laryngeal mucous membrane is of great importance before the application of local remedies, in chronic catarrhal affections. In acute affections, it but stimulates the inflammatory process and should therefore be avoided In chronic laryngitis, as well as in the laryngeal manifesta- tions of tuberculosis and syphilitic laryngitis, it forms a prominent part of the treatment, not only relieving the sur- faces of the secretions which prevent the contact of the remedy used, but also exerting a marked influence in limit- ing the ulcerative process. In the treatment of laryngeal affections, a greater amount of circumspection is necessary in choosing cleansing instru- ments than for the nasal cavities and pharynx. If the presence of chronic disease, accompanied by copious dis- charge, renders their use necessary, not only to wash away the discharges, but also to expose the mucous surfaces to the action of the more active agents used in the treatment, Sass' laryngeal tube produces the strongest spray, and is therefore to be theoretically preferred; but the mechanical power which serves so well for the removal of secretions is frequently more than the inflamed surfaces can bear. The comparatively large atoms of fluid act somewhat like foreign bodies, and latent inflammation may be turned into active inflammation, and the application, therefore, do more harm than good. Lennox Browne, of London, considers the use of the spray in the larynx as unphysiological and foreign to the natural function of the organ. I am not pr<3- (324) MEDICATION. 325 pared to advocate this opinion in its entirety, for I believe that with proper choice of instruments as regards the density of the spray produced, and a careful determination of the degree and kind of inflammation present, the atomizer is a valuable instrument. In other words, I consider it as being of great assistance in the treatment of laryngeal affections, if used intelligently. When a strong spray such as Sass' is not well borne by the patient, or the membrane betokens, by its diffuse redness, a subacute inflammation in addition to the chronic state, atomizers, such as those shown in Figures 19 and 78, may be tried, their spray being much lighter and presenting no appreciable mechanical force. I have always been able to use either of these instruments, even when a considerable degree of subacute congestion existed. As to the selection of the kind of cleansing solution to be used, the remarks made on the subject when speaking of the nasal cavities, can be here repeated. When there is profuse discharge, dependent simply upon a relaxation of the membrane, its mere admixture with an alkaline liquid will be sufficient to wash it off. If the secretion is tjhick, however, a solvent will facilitate its separation from the seat of production. Bicarbonate of sodium and biborate of sodium (gr. iv-3j) or the solutions on pages 75 and 118 may be used, according to indications. MEDICATION. Taking the solutions usually recommended for the treat- ment of nasal affections as a basis, laryngeal solutions should be at least twenty-five per cent, weaker, lest irritation be pro- duced. The proportions recommended for the nose, in this work, however, are weaker than those generally employed, and astringents, stimulants, alteratives, and sedatives can 326 THERAPEUTICS OF THE LARYNX. be used in the proportions given in the chapter on thera- peutics of the nasal cavities, the drugs being also the same. In the choice of agents to act as diluents with more potent drugs in the form of powder, preference should be given to substances capable of being easily dissolved in the laryngeal mucus. Bismuth, which is frequently recommended, does not possess this property, and remains a long while on the spot to which it was applied, acting in a certain manner like a foreign body, producing cough and retching, and, conse- quently, irritation. Pulverized acacia is probably the most satisfactory agent we possess for the purpose; it is bland and soothing, and covers the membrane with a uniform coat which separates it from the air current for awhile, during which the active principle of the powder is absorbed. Escharotics are also used in the larynx, chromic acid being manipulated with the greatest ease and at the same time being very effective. CHAPTER XXY. DISEASES OP THE LARYNX. | SUBACUTE LARYNGITIS (Synonyms : Simple Catarrhal Laryngitis ; Catarrhal Laryngitis ; Erythematous Laryngitis.) Etiology. Exposure to cold is the most frequent cause of subacute laryngitis: a sudden change from heat to cold, such as going from a warm room into the open air insufficiently clothed, exposure to draughts, wet feet, etc. It is for that reason very common during fall, the system being relaxed by the preceding warm weather and therefore more prone to become influenced. Local irritation by irritating vapors, tobacco smoke, dust, etc., are also frequent causes. It is sometimes due to over-exertion of the voice, in loud sing- ing, for instance, when the singer has had no training in the proper use of his vocal organ. It is often present in army officers, after manoeuvre or drilling. Subacute laryngitis is a frequent complication of acute rhinitis and occasionally of acute bronchitis. Persons leading sedentary lives are more subject to it than those accustomed to out-door exer- cise. Rheumatic and scrofulous individuals seem to be more predisposed to it than others. It may also occur as a symp- tom of scarlatina, measles, and the exanthemata. Pathology. In subacute laryngitis the inflammatory pro- cess is confined to the superficial layers of the mucous mem- brane, and does not at first involve the submucous tissue and sometimes the muscles, as in acute laryngitis. After it has lasted for some time, however, it may penetrate these parts, the inflammatory infiltration spreading to them. (327) 328 DISEASES OF THE LARYNX. Symptoms. The first symptom usually experienced, is a pricking sensation, as if a pin were sticking in the throat. Slight chilliness may occur, but in the majority of cases it does not. Hacking is indulged in to relieve the larynx of a supposed foreign element which cannot be dislodged. The voice soon becomes hoarse, and a slight burning pain is ex- perienced, which extends sometimes along the pharynx. Slight dyspnoea is present in most cases, and is sometimes the most annoying feature of the trouble. As the case advances, the hoarseness becomes greater and greater until the voice is sometimes entirely lost, the patient being obliged to speak in a whisper. Deglutition is at times quite painful. There is usually a coarse, barking cough, which is, after a few days, accompanied by expectoration. This expectoration, at first gluey and viscid, soon assumes a muco-purulent character, and becomes sufficiently purulent in some cases to cause apprehension in the belief that the lungs are seriously involved, thoracic pains, caused by the muscular exertion in coughing, serving to increase the fears of the patient. Examined with the laryngeal mirror, the entire larynx ap- pears congested, the ventricular bands and inter-arytenoid com- missure appearing especially red. The vocal bands are more or less congested also, and small vessels are distinctly seen coursing over them. The epiglottis usually takes part in the general inflammation, arborescent vessels and diffuse redness covering its anterior and posterior surfaces. Prognosis. The prognosis of subacute laryngitis is gen- erally favorable, but it may be suddenly developed into the acute affection and assume formidable proportions. Its duration is from a few days to a couple of weeks. Fre- quently repeated, subacute laryngitis may conduce to chronic laryngitis. SUBACUTE LARYNGITIS. 329 Treatment. The most important requisite in the treatment of this affection is absolute rest. The use of the voice, how- ever slight it may be, naturally increases the local con- gestion, aggravating the symptoms. The patient should remain at home, and avoid atmospheric transitions such as going from one room to another of a different temperature, sitting by an open window, etc. Frequently, an attack of subacute laryngitis can be suddenly cut short by a deriva- tive purgative, castor oil being the most effective; although a "popular" remedy, its effects are some time so gratifying that it should not be considered as obsolete. Aconite in drop doses every hour, to control the fever and diminish the local congestion, when administered early, also succeeds at times in checking the affection. When the malady has existed for some time, wine of coca, a wineglassful every three hours, generally succeeds in bringing about a favor- able change in from thirty-six to forty-eight hours. In the subacute laryngitis of actors or other persons who have to use their voice extensively, it is especially beneficial, by depleting the congested parts of superabundant blood, and diminishing the sensitiveness to the contact of the air cur- rents. A fine spray of a two per cent, solution of cocaine applied alone, also has a beneficial influence, but this becomes much more marked with wine of coca internally. Pulverized cubebs, ten grains every three hours, is a favorite remedy. Camphor packed into a little glass tube and inhaled, is occasionally sufficient to arrest an attack in the earliest stages. I have not found local applications with brush or cotton pledget, of astringents, detergents, etc., of value in these cases, and cannot therefore recommend them. The me- chanical irritation, even when powders are used, does, in my opinion, more harm than good, and since I have aban- 330 DISEASES OF THE LARYNX. doned them and resorted to general treatment, I have had better results. Morphia is a remedy of apparent value in these cases, but I have not found it so, the drug probably increasing, by checking to a degree the intestinal action, the laryngeal congestion. ACUTE LARYNGITIS. (S}^Bonyms : Acute Catarrhal Lar3 r ngitis ; Acute Catarrh of the Larynx.) Etiology. Acute inflammation of the larynx is but rarely met with. It may occur traumatically or idiopathically, traumatic acute laryngitis being the commoner of the two. The accidental inhalation of hot water (a frequent occurrence in children), flame, caustic vapors, etc., the presence or violent extraction of a foreign body, the deglutition of caustic acids, accidental or with suicidal intent, and wounds penetrating the laryngeal cavity, are the most frequent causes of the traumatic variety, while the idio- pathic may be due to exposure to cold, and occur as a sudden complication of an acute attack ; it may find its initial cause in a chronic catarrhal inflammation, such as that occurring in syphilis, presenting itself in that case as a sudden exacer- bation of the trouble. Pathology. Acute laryngitis differs from the subacute variety, in that the inflammatory process, instead of being superficial, extends to the submucous tissue and to the muscles. In traumatic laryngitis, inflammatory infiltration takes place suddenly in the majority of cases, and the dyspnosa is caused by the mechanical impediment to respi- ration. The pathological process of idiopathic laryngitis also culminates in submucous infiltration in most cases, but it is likely that paralysis of the motor muscles and ACUTE LARYNGITIS. 331 spasm, are elements of importance in the production of the most marked symptom, dyspnoea. / Symptoms. Traumatic laryngitis, due to the inhalation of steam, fire or caustic vapors, or the deglutition of hot water, usually sets in at once, the infiltration of the submucous areolar tissue causing marked swelling of the ary-epiglottic folds and ventricular bands. Dyspnoea soon becomes of such intensity that the other symptoms, those of subacute laryn- gitis, are overlooked; and if the patient is not soon relieved by one of the means indicated under the head of treatment, death by asphyxia is likely to occur. Acute inflammation, as a result of the presence of a foreign body, is generally de- veloped suddenly, some time after the object has been in the larynx, the acute symptoms occurring as a result of the ulcerative process due to pressure; when the foreign body is sharp, however, the acute symptoms may present them- selves early, as a result of the solution of continuity of tissue. In this manner, the violent extraction of a foreign body and wounds penetrating the laryngeal cavity, may also cause acute laryngitis. Idiopathic acute laryngitis, occurring as a sudden compli- cation of subacute laryngitis, is at times so rapidly fatal that no warning of the oncoming issue is given. The patient retiring with a laryngeal inflammation just sufficient to give rise to slight hoarseness, for instance, may be found dead in the morning. These cases are fortunately very rare, and are more likely due to spasmodic contraction of the vocal bands than to submucous infiltration. As a complication of syph- ilitic ulceration, infiltration sets in much less rapidly, the symptoms gradually increasing in intensity. The early objective symptoms vary with the causes; in carbolic acid poisoning, for instance, the parts may at first appear white, etc. Soon, however, the inflammatory process 332 DISEASES OF THE LARYNX. assumes the general form, and the intense redness of the entire larynx is discerned in the laryngoscope. If the caustic substance has only come in contact with its upper border, the epiglottis and the ary-epiglottic fold may present the greatest degree of congestion, while the ventricular bands and the vocal bauds appear comparatively free. As the ease progresses, the swelling increases, until the vocal bands hardly appear beyond the edge of the ventricular bands. The surrounding parts are almost always inflamed also, especially in traumatic laryngitis. Prognosis. Acute laryngitis, complicated with oedema, is usually fatal if left to itself, the traumatic variety, unless very slight, presenting the greatest danger. Occasionally, the inflammation recedes after having reached a certain height, but the possibility of this occurrence should not influence the treatment. Treatment. The necessity of acting promptly is self-evident. The danger being due to infiltration, and thus causing swell- ing and obstruction to respiration, the first step is to ascer- tain, by means of the laryngoscope, the degree of infiltration. The respiration should not be taken as a criterion, as the oedema may be quite severe in the upper part of the larynx at first, without presenting much obstruction to the passage of air, and suddenly kill the patient by obstructing the laryn- geal aperture unexpectedly. If the degree of infiltration is limited, and not making rapid headway, a general deriva- tive treatment or depletory measures may be of service. A hot mustard foot-bath, followed by free diaphoresis, avoid- ing at the same time all drinks, may prove veiy beneficial by drawing the blood to the periphery and diminishing the local pressure. Tincture of belladonna, five drops every hour until its physiological effect becomes marked, by contracting the laryngeal blood-vessels is also valuable, in counteracting ACUTE LARYNGITIS. 333 the infiltration. Local applications in the form of powders or solutions, with brush or cotton pledget, should be strictly avoided, their mechanical irritation doing more harm than the agent applied does good. Steam may be inhaled with benefit, and the atmosphere of the room of the patient should be rendered moist by either boiling water or slacking lime in it. The steam atomizer shown in Fig. 79 may be used with advantage for the inhalations. Although I have had no opportunity of treating a case since the discovery of cocaine, it seems to me that a twenty per cent, solution of this drug, applied with a fine spray atomizer, would produce a marked effect in depleting the infiltrated parts. Sprays of alum or sulphate of zinc (two to five grains to the ounce), are recommended by Cohen. Leeches may be used advan- tageously, five or six being applied externally some distance from the thyroid prominence. When the oedema is marked, or when the dyspncea is evi- dent and on the increase, surgical measures should be re- sorted to. The swelling must be scarified and relieved of some of its contents. With the assistance of the laryngeal mirror the procedure is very easy. The ordinary pocket-case curved bistoury may serve efficiently for the purpose, its blade, as far as to within a line of the point, being surrounded by string, to prevent cutting of the parts anterior to the larynx. The tongue being drawn out, the epiglottis will generally be seen standing erect and swollen. This, however, had better not be punctured, lest the patient object to further cutting. The mirror being introduced, the knife is passed around the side of the epiglottis and its point is caused to penetrate the external border of the ary-epiglottic fold, thus causing the blood and serum to flow into the pyriform sinus, instead of the laryngeal cavity. If possible, the other side had better be treated in the same way. Laryngeal lancets, 334 DISEASES OF THE LAKYNX. especially adapted for oedema, are generally recommended, but being very seldom used, they are usually not at hand when wanted, and it is best not to depend on them. One scarification is usually sufficient to deplete the parts effect- ually, the relief being immediate. A second is seldom re- quired. In some cases the symptoms are so urgent that even this procedure is not sufficiently rapid to save the case, and tracheotomy has to be performed. Traumatic laryngitis is sometimes followed by one or more abscesses near the seat of injury, in which the cartilages may become implicated. The pus should be evacuated by free scarification. Convalescence after an attack of acute laryngitis is gen- erally quite slow. The voice remains hoarse for a time and becomes easily fatigued. It is frequently followed by chronic laryngitis, which predisposes the patient to renewed attacks of the acute variety. (EDEMA OF THE LAEYNX. (Synonyms: (Edema Glottidis; (Edematous Laryngitis.) Etiology. Besides occurring as a complication of acute laryngitis, oedema of the larynx may present itself without previous local inflammatory manifestations. The larynx may become the seat of dropsical effusion in diseases character- ized in their advanced stages by dropsy, such as Bright's disease, cirrhosis of the liver, cardiac affections and phthisis ; or suddenly, by exposure to cold when the system is in a weakened condition. (Edema may also be caused by the administration of the preparations of iodine, especially when the affection for which such a preparation is given is located in the throat. I have seen two such cases, in one of which the use of iodide of potassium had to be stopped (EDEMA OF THE LARYNX. . 335 definitively, after three trials, each, causing marked dyspnoea, which ceased as soon as the administration of the drug was discontinued. (Edema of the larynx may become chronic, occurring in that case as a concomitant symptom of syphilitic or tuber- culous laryngitis and cancer. The acute form may assume chronicity, with a tendency to exacerbation. Pathology. The laxity with which the laryngeal mucous membrane is attached to the underlying tissues furnishes a ready explanation for the facility with which it becomes in- filtrated and distended. In diseases in which obstruction to the blood current becomes an important element, the laryn- geal submucous tissue offers but little resistance to the serous effusion which can here produce almost instantaneous distention, a result not produced in other parts, the limbs, hands, abdomen, etc. Symptoms. ^Occasionally, oedema of the larynx is so rapidly fatal that symptoms can hardly be said to have existed. When occurring in the course of dropsical affections, no other symptom may present itself other than dyspnoea. In most cases, however, local symptoms are evident: heat and pain, a sense of constriction around the throat, dryness, and im- peded respiration, principally during inspiration. As the disease progresses, the symptoms become more marked, dyspnoea is more evident, the expiration as well as the inspiration being impeded. These symptoms may consti- tute an exacerbation which gradually declines, or the case may proceed from bad to worse until death takes place. The appearance of the laryngeal membrane differs from that described under the last heading, only in color. Instead of being fiery red, resembling somewhat the surface of a ripe tomato, it is pale, at times almost yellow, watery, and translucent, appearing much like an oedematous prepuce. 336 DISEASES OF THE LARYNX. Prognosis. (Edema occurring as a secondary manifesta- tion of another disease, is more likely to recur than that due to a local inflammatory process, unless the original cause can be eradicated. Treatment. Local applications, derivatives, and even de- pletory measures are of doubtful value in this variety of oedema. The distended folds of membrane must be scarified freely and the serum evacuated. The manipulation described under the last heading may be resorted to, or the finger may be introduced into the mouth and used as guide for any pointed instrument that may be at hand. The incisions must be free, and, as already said, should be made as much as possible on the edge of the ary-epiglottic folds, so as to cause the serous discharge to flow into the pharynx, instead of the larynx, thus avoiding asphyxiation by flowing liquid. After the incision, the fold shrinks suddenly; the relief is immediate, and in the majority of cases, lasting. If the dyspnoea is not relieved by the scarifications, subglottic oedema is likely to be present also, and tracheotomy is the only resource. CHRONIC LARYNGITIS. (Synonyms : Chronic Catarrhal Laryngitis ; Chronic Laryngeal Catarrh.) Etiology. Chronic inflammation of the vocal bands may result from repeated attacks of subacute laryngitis in con- nection with acute pharyngitis, but in the majority of cases it assumes the chronic form from the first, unpreceded by acute symptoms. As pointed out under the heading of hyper- trophic rhinitis, it is a frequent complication of this affec- tion, the chronic catarrhal inflammation extending by con- tinuity of tissue to the larynx, which is itself made subject to all the exacerbations which the nasal disease undergoes. CHRONIC LARYNGITIS. 337 A more frequent connection between the two diseases, how- ever, is the irritation kept up by the post-nasal discharges, which either drop into the larynx, or trickle down along the posterior pharyngeal wall until the inter-arytenoid commis- ture is reached ; here they accumulate to a degree, and main- tain the posterior portion of the larynx in a constant state of irritation, which is further aggravated by the coughing and hacking induced. This cause of chronic laryngitis is insisted upon by Bosworth, and I can well confirm his opinion. A fact which I have frequently noticed in this connection, is that the amount of chronic laryngeal inflam- mation is in proportion to the degree of purulence of the discharges; purely mucoid secretions are tolerated by the laryngeal membrane without harm, but as soon as they become muco-purulent or purulent, local congestion is en- gendered, followed frequently by erosions. These cause hoarseness, cough, and expectoration (the sputa being formed principally by the nasal discharges), and the presence of phthisis is suspected. When hypertrophic rhinitis is pres- ent and sufficiently marked to prevent free respiration through the nose, oral breathing is another aggravating feature, the air reaching the larynx without being warmed, moistened or purified of its extraneous substances. Gastric disturbances, especially those caused by debauchery, are frequent causes of chronic laryngitis, as evidenced by the hoarseness of drunkards. Hepatic torpidity is another cause, well known to singers, who find great difficulty in producing clear tones when " bilious." Excessive use of the voice, either in screaming or singing, when continued for a certain period, finally causes the temporary congestion, which exists at the time, to assume the chronic state. In hucksters, for instance, hoarseness is almost universal. In singers, a prolonged use of the voice, even frequently re- 22 338 DISEASES OF THE LARYNX. peated, is tolerated without harm under certain conditions, i.e., when the singer has received judicious training and uses his voice within its normal compass ; but if he has not, his efforts to produce as high a note as possible and give his voice a volume which it does not possess, strain the muscles, and produce in them an inflammatory state which soon be- comes chronic and extremely difficult to eradicate. The continued inhalation of air containing much dust or other irritating substances, which accompanies many occu- pations, is another frequent cause ; marble cutters, street sweepers, and colliers being probably the most affected. Pathology. The epithelial layer of the vocal bands is generally thickened and the superficial vascular supply in- creased. The hypertrophic process may involve the entire mucous membrane, but in the majority of cases, it is located in the posterior portion of the cavity, gradually extending to the other parts. The muscles are frequently the principal location of the inflammatory process, undergoing in some cases, hyperplastic induration. The principal cause of the hoarseness, however, lies in the thickened condition of the vocal bands, or rather of the membrane covering them; their vibration is devoid of the regularity and freedom necessary, for the production of a pure tone, and the note is cracked or irregular. When the muscular tissues are involved, the pitch can only be altered with great difficulty, the extension and relaxation of the bands being interfered with according to the degree of inflammation. Implication of the arytenoideus is a frequent cause of aphonia, which sometimes occurs in the course of the affection. Symptoms. The symptoms of chronic laryngitis consist principally in an alteration of the purity of the voice. The hoarseness is not always continuous, however, but generally occurs after the voice has been used a short time. In some CHRONIC LARYNGITIS. 339 cases, the contrary is the case; the voice, at first, is quite hoarse, but after a few words or phrases, it becomes clearer and clearer, until it has returned to its normal condition. This does not last long, however; the voice soon becomes tired and resumes its hoarseness. Its pitch is usually lowered. Cough, provoked by a tickling, itching sensation in the throat, is present in the majority of cases, and is accom- panied by more or less expectoration, according to the cause of the trouble. There is seldom pain, a feeling of heat and constriction being more frequently complained of. Complete loss of voice is not a rare occurrence, but it generally returns after a few days' rest. Left to itself, the disease, in some cases, becomes aggra vated. General symptoms, such as fever, pyrexia, emacia tion, gastric and intestinal disorders, supervene. Locally, the abrasions become active ulcerations, and a purulent, fetid expectoration, often streaked with blood, violent and harassing cough, pain extending to the ears, and dysphagia, render confusion of the disease with the local manifestations of tuberculous or syphilitic laryngitis quite possible. Chon- dritis or perichondritis may occur and bring on a fatal termination. Viewed with the laryngoscope, the larynx presents a con- gested appearance, marked in proportion to the degree of active inflammation. The epiglottis is also congested, en- larged vessels coursing over its posterior surface. The out- line of the prominences of Wrisberg and Santorini is some- what obscured, and they present the same color as the surrounding parts. The general redness is not so great as in acute or even as in a marked case of subacute laryngitis, but the thickened appearance of the membrane and its irregular surface presents quite a marked contrast with the 340 DISEASES OF THE LARYNX. former. The vocal bands are more or less congested, ac- cording to the stage of the disease ; they may present only a slight pinkish appearance or be as red as raw beef, cream- like, stringy mucus adhering to them, and forming films when they are separated. In phonation the bands appeal- relaxed ; their edges, which are thickened, do- not appear to come accurately together, and an elliptical opening is occa- sionally observed between them. This want of parallelism is due to paresis of the laxors of the vocal bands, through inflammatory infiltration. Prognosis. In the majority of cases of chronic laryngitis, when local ulceration and chondritis are not present, the prognosis is quite favorable. When the case is of long dura- tion and the muscles have become markedly infiltrated by inflammatory products, which have to a certain degree become organized, hoarseness is likely to remain after all the other symptoms have disappeared. Treatment. The maintenance of local cleanliness is of the greatest importance in this affection, and superficial erosicns and ulcerations will often disappear under the frequent ap- plication of a detergent spray of borax (gr. iv-lj) to which a few drops of cologne have been added. In the fetid variety, permanganate of potash (gr. j-lj) may be used, its stimulating properties tending to limit the ulcerative process. For office use, Sass' laryngeal spray tube is probably the best instru- ment, its dense spray offering slight and gentle mechanical force for the removal of the secretions. For the patient's use, the laryngeal atomizer, shown in Fig. 78, is a conve- nient instrument. Its spray is continuous and sufficiently large to bathe the parts thoroughly. The frequency with which the parts should be cleansed depends entirely upon the amount of secretion ; twice a day is usually sufficient, however, the patient being directed to CHEONIC LARYNGITIS. 341 inhale through the mouth while using the instrument. In order to render a cure possible, all general conditions or dis- eases bearing influence upon the etiology of chronic laryn- gitis, must be eradicated. All affections of the nose or pharynx should be appropriately treated. The bowels fre- quently need attention and I have seen cases much benefited by simple measures directed to them. Friedrichshall water is probably the best alkaline water at our disposal, its salines producing, besides the derivative action, beneficial local action. Gastric and hepatic disturbances should be met with appropriate remedies, .while any underlying diathesis that may be present should also receive attention. Due care, as regards general hygienic measures, diet, etc., should also be exercised. Local applications, after cleansing, are best made with the atomizer, the cotton pledget being only used to touch spots of ulceration with the stronger agents. For the general con- gestion I have not found strong solutions produce a benefi- cial effect, weaker ones giving rise to less irritation. Before resorting to these, however, the spots of ulceration should first receive attention. A sixty-grain solution of nitrate of silver, as advocated by Seiler, has been most serviceable in my hands, and a few applications generally suffice to cause their disappearance. Of late, I have partially anaesthetized the larynx with a ten per cent, solution of cocaine to make these applications, and have been able to locate them with greater accuracy. A small piece of cotton only should be used, which, having been adjusted to the .end of the forceps and dipped in the solution, should be lightly squeezed be- tween the folds of a towel to prevent dripping. With these precautions, no danger of spasm need be feared. A strong solution of sulphate of copper (gr. xxx-!j) is also very efficient in those cases, but not so much so as nitrate of 342 DISEASES OF THE LARYNX. silver. Chloride of zinc (gr. x-lj) is effective when the ulcer- ations give rise to much discharge, accompanied with fetor. Any of these applications should be made about twice a week. For the treatment of the general surface of the larynx, 1 have noticed that a two per cent, solution of cocaine, used two or three minutes three times a day, produced great relief : after its application the membrane presents a paler appear- ance, the effect of the drug upon the blood-vessels being to contract them. Mild solutions of alum (gr. iij-3J), applied in the same manner, are also beneficial. An excellent remedy in some cases is the O cosmoline, applied in the form of spray with the atomizer shown in Fig. 78. It covers the membrane with a thin film, which protects it effectually for a time. Applied immediately after the astringents, it seems to enhance their action. CHAPTER XXVI. DISEASES OF THE LARYNX. (Continued.) TUBERCULOUS LARYNGITIS. * (Synonyms : Consumption of the Throat ; Laryngeal Phthisis.) Etiology. The opinion still entertained by the majority of observers, is that tuberculous laryngitis is a secondary mani- festation of tuberculosis of the lungs. That it may be pri- mary is still a mooted question, owing to the impossibility of always ascertaining the presence or absence of lung dis- ease when the laryngeal affection declares itself. The fact, however, that in a small number of cases reported the laryn- geal affection had reached an advanced stage before the presence of the pulmonary trouble could be detected, seems to indicate a likelihood that tuberculous laryngitis can occur primarily. Males are more predisposed to it than females, owing probably to the greater degree .of exposure to which the former are subjected, while age seems also to bear great influence as a predisposing cause, the fifteen years between the ages of twenty and thirty-five presenting a much greater proportion of cases than other periods of life. Pathology. The tubercular deposits or miliary tubercles in the membrane, are described as small spherical elevations, which appear in greater or less numbers through its surface ; in the epiglottis, they are principally lodged beneath the membrane in the depressions or cavities of the cartilage. In a small proportion of cases of pulmonary tuberculosis, the laryngeal tubercles undergo the same pathological process as those in the lungs, and if, as is almost always the case, (343) 344 DISEASES OP THE LAEYXX. one lung only is involved, the first manifestations in the larynx will generally appear on the same side. As the ulcerative process continues, tissues and cartilages may gradually become involved and destroyed. Symptoms. The early symptoms of the affection are so in- sidious as hardly to be perceived. After a time, slight hoarse- ness is noticed, which is usually ascribed to the co-existing pulmonary trouble; a feeling of heat and dryness is expe- rienced in the throat, accompanied by pain of a lancinating character, shooting occasionally to the ears. Deglutition becomes painful if the ulcerations involve the border of the epiglottis and the ary-epiglottic folds, but as a general thing, dysphagia only occurs later on. As the disease pro- gresses, the hoarseness increases, and frequently the patient becomes completely aphonic. The pulse, temperature, and other general symptoms are those of pulmonary phthisis, but emaciation takes place more rapidly than in the latter affec- tion, the odynphagia causing the patient to abstain from food as much as possible. When the disease has reached an advanced stage, dyspnoea supervenes, and that, added to the already difficult respiration occurring as a result of the pulmonary affection, causes the patient to suffer greatly. Tracheotomy is sometimes required. The cough incident upon the lung trouble, which under ordinary circumstances is not painful, becomes excruciatingly so in this affection, the pain continuing a good while. The sufferings of the patient continue to increase until death comes to his relief. Upon examination in the early stage, the membrane of the larynx and the surrounding parts generally appears pale, a yellow tint pervading what pink may have remained. In some cases this pallor is so marked that the parts look perfectly blanched. A characteristic symptom occurring in the majority of the cases in which the affection first shows TUBERCULOUS LARYNGITIS. 345 itself in the larynx proper, are pyriform swellings of either of the arytenoid prominences or sometimes both, looking like rounded cushions, which enlarge at the expense of the laryn- geal aperture. They generally present the pale hue of the surrounding parts, but may appear quite red and occasionally livid. The mechanical impediment which they offer to the closure of the epiglottis, renders deglutition difficult, and liquids are prone to cause considerable annoyance by running into the larynx and causing violent coughing and gagging. The vocal bands may appear hardly influenced by the disease for a considerable time after the early manifestations, but they generally show evidences of involvement very soon after, or simultaneously with them. They may appear highly inflamed and fiery, but they frequently do not present even the slightest redness, and spots of ulceration, forming inden- tations upon their thickened edges, may occur in such number, as to cause a dentated appearance, the free borders of the bands resembling the edge of a curry-comb. The voice, in these cases, becomes impaired almost with the out- break of the local trouble, and is soon lost. Active inflam- mation, involving the entire larynx, is generally present, how- ever, and small spots of ulceration, at first appearing like mere abrasions, with a grayish surface, may be met with in any part of the cavity, but most frequently over the aryte- noid commissure, where they are usually covered by the secretions emanating from the diseased lung. These ulcera- tions gradually deepen and spread, the inflammation in- creasing at the same time. The general shape of the 1'arynx may become completely altered, and the vocal bands, or what may be left of them, become hardly discernible amongst irregularly distributed swellings and ulcerated surfaces. In a small proportion of the cases, the ulcerative process begins in the membrane of the epiglottis, and rapidly spreads to 346 DISEASES OF THE LARYNX. the surrounding parts, involving sometimes the base of the tongue and the palatine folds. The epiglottis in these cases becomes infiltrated and swollen, and assumes the shape which causes it to be termed "turban" epiglottis, owing to its re- semblance to a Turk's turban. In many instances, the first local evidence of the affection is a grayish prominence in the laryngeal aspect of the arytenoid commissure, often mis- taken for a papilloma. It may be rounded or resemble pointed crests. I have seen it present a fimbriated appear- ance and involve the entire laryngeal surface of the ary- tenoid commissure. These papillary excrescences are not limited to this locality, however, but may be developed in any portion of the mucous membrane. Prognosis. Although a number of recoveries have been reported, even in cases in which the affection had advanced considerably, we can hardly hope to do much more than retard its progress, and thereby prolong for a few months the life of the patient. When the epiglottis is the first part of the larynx involved, the fatal issue is likely to occur at an early date. Treatment. Although the number of well authenticated successful results reported is not large, the possibility of recovery under appropriate treatment is sufficiently demon- strated to place the practitioner under the stress of consider- able responsibility. In this affection, more perhaps than in any other, the life of the patient is, to a certain degree, in his hands; by his assiduous care he can certainly prolong it for a short time at least, and perhaps cure the disease. To Dr. F. H. Bosworth, of New York, the profession is in- debted for the practical demonstration of this fact, and, although I can only add one successful case to several re- ported by him, it certainly serves to show the value of his suggestions, and to encourage renewed efforts in subsequent TUBERCULOUS LARYNGITIS. 347 opportunities. The general outline of the treatment followed by him is as follows : (1) the thorough cleansing of the parts preparatory to the more special application ; (2) the appli- cation of such mild astringents, alteratives, or resolvents as may be indicated; (3) the application of an anodyne to re- lieve pain or irritability, and to correct irritation caused by the previous remedies ; (4) the application of iodof orm as a specific in its action on ulcerations of mucous membranes. For cleansing purposes, Sass' spray tube, used gently, is the most satisfactory instrument, the adhesive nature of the sputa requiring some slight mechanical force for its removal. I have generally found a solution of borax (gr. iv- 3j) most agreeable to the patient as a detergent spray, its disinfecting qualities being an important feature. The larynx being thoroughly cleansed, the anodyne is next in order; cocaine in this connection is of the greatest value, and a two per cent, solution, used with an atomizer throwing a fine spray, is not only exceedingly soothing, but it facilitates greatly the subsequent steps. If cocaine cannot be obtained, a five or ten grain solution of morphia, as recommended by Bosworth, may be used, a little bicarbonate of sodium being added to give it an alkaline reaction. The application of an astringent comes next; this should also be used with the atomizer, to avoid as much as possible the contact of instru- ments. I have found nitrate of silver (gr. ij-5j) more satis- factory than tannin (gr. x-lj), or sulphate of zinc (gr. v-lj), producing less irritation. In some cases, however, the latter will perhaps be better borne. In using iodoform, I prefer the method proposed by the late Dr. Elsberg, i.e., dissolving the drug in ether. I use a saturated solution, which is also applied by means of the atomizer. Powders cause an un- comfortable sensation of dryness, which lasts sometimes a couple of hours, while the cotton pledget, the brush or the 348 DISEASES OP THE LARYNX. sponge render mechanical irritation unavoidable. The atom- izer reaching the desired spot as well, it should receive the preference. This treatment, which should be repeated at least every other day, is generally tedious to both patient and physician, but the relief furnished certainly repays the trouble. For the patient's use, I have of late prescribed the two per cent, solution of cocaine, to be used with the atom- izer, just before eating, and sufficiently between meals to subdue pain. The effect produced is so satisfactory, that the patients are generally anxious to use the solution more Fig. 81. Bryson Delavan's alimentation bottle. frequently than directed to. Another convenient way to administer the cocaine, is to have it put up in the form of lozenges, gr. i to the lozenge, one being used as often as re- quired. Deglutition being facilitated, the sufferer is better nourished, while the diminished suffering is a source of great satisfaction. When deglutition becomes impossible through extensive ulceration, Bryson Delavan's alimentation bottle, shown in Tig. 81, may be employed to great advantage. A flexibe catheter of small size, replaces the ordinary stomach tube, and is introduced not into the stomach, but simply SYPHILITIC LARYNGITIS. 349 below the pharyngeal constrictors, or beyond the seat of the difficulty. Cough is also greatly decreased. The general treatment is that indicated for the co-existing pulmonary trouble, tonics and stimulants forming the principal feature. Should the dyspnoea become alarming, tracheotomy may become necessary. When it is performed, a temporary favor- able reaction seems to take place, but unfortunately it is only of short duration. SYPHILITIC LARYNGITIS. (Synonyms : Syphilis of the Larynx ; Specific Laryngitis.) Etiology. Syphilitic laryngitis most frequently occurs as a manifestation of the tertiary period, from three to thirty years after the primary infection. As a complication of the secondary stage of syphilis, it may present itself from a few weeks to one year after. Primary syphilis of the larynx is extremely rare. Syphilitic laryngitis is more frequent in men than in women, this being explained by the fact that the former being more exposed, the throat is more fre- quently congested, and becomes an easier prey to the ravages of the affection. The influence of climate is shown by the greater frequency of the disease during winter than at other times of the year. It may also be due to heredity. Pathology. The pathological manifestations of syphilis in the larynx are extremely varied, and comprise the great majority of lesions that the disease can present. In secondary syphilis, the local lesion may consist of mere hypersemia of short or prolonged duration, giving rise to the symptoms of simple laryngitis; this hypersemia may be complicated with more or less deep ulcerations which heal spontaneously, or with coiidylomata, which may undergo ulceration or disappear of their own accord. In tertiary 350 DISEASES OF THE LARYNX. syphilis, hyperaemia is also the first manifestation, followed by ulceratiou, either starting on the surface or beneath the membrane, and progressing rapidly. It occasionally extends to the cartilages, and is liable to cause stenosis by the cica- tricial contraction which follows resolution, when this takes place. Grummata are also of occasional occurrence. Symptoms. In secondary syphilis of the larynx, the symp- toms are usually confined to those manifested in the course of an attack of simple acute pharyngitis, superficial ulcera- tion of the mucous membrane or mucous patches, if they occur, increasing the local soreness and the inflammation. The voice is generally affected early, a peculiar, low-pitched hoarseness accompanying ordinary speech when the vocal bands are implicated. Pain in the surrounding parts and odynphagia are more or less prominent symptoms, according to the location of the laryngeal cavity presenting the ulcera- tion. A short, hacking cough, with more or less expectora- tion of stringy mucus or muco-pus, is usually present. The suffering, in any of its features, is not to be compared with that of tuberculous laryngitis. Examined laryngoscopically, the appearance of the larynx at first resembles so much that of subacute laryngitis that a differential diagnosis can only be established with great diffi- culty. Even if a clear history of syphilitic infection can be obtained, the true etiology of the manifestation can only be suspected, since the laryngeal inflammation can also be due to the ordinary causes of subacute laryngitis, without at all involving the general specific intoxication. A feature which assists greatly in the differentiation of the two affec- tions when it is sufficiently marked, is the irregularity of the congestion in syphilitic laryngitis; it occurs more in spots, which seem to bulge out from the surface. These elevations may be numerous on one side of the larynx, while on the SYPHILITIC LAEYNGITIS. 351 other they may be quite scarce, the vocal bands on the most affected side presenting more congestion than that on the other. This irregular appearance is by no means seen in every case, and, in the majority, further developments are necessary to establish a positive diagnosis. When mucous patches appear, their concurrence with patches under the tongue or other parts of the oral cavity, serves to differ- entiate the condition from any other. They most frequently appear upon the ventricular bands, the inter-arytenoid space and the epiglottis ; they present the same appearance as in other localities a regular outline with a slight inflamma- tory areola around them, and a whitish surface covered with a yellowish secretion. As a rule, and especially under appro- priate treatment, they disappear after a week or two, leaving a reddish spot which gradually vanishes. Occasionally, they become irregularly covered with granulations, which some- times assume sufficient size to require removal by surgical means. Condylomata are occasionally met with ; they re- semble small, yellow pimples on an elevated base. They generally disappear of their own accord. Tertiary ulcerations usually present themselves on the epi- glottis first, its edge or its oral surface being their favorite site. They then make their appearance in the laryngeal cavity and the trachea. Here, again, a certain amount of difficulty presents itself in the differentiation, but in this case, tuberculous ulceration and carcinoma are the local lesions with which it is likely to be confounded. In tubercu- losis, however, the pulmonary symptoms, almost always present, assist materially in the differentiation, while the ana3mic appearance of the pharynx and the soft palate, and frequently of the larynx itself, furnish further evidence ; to these may be added greater local pain and dysphagia. In carcinoma, the pain is of a lancinating character, and 352 DISEASES OF THE LARYNX. usually very sharp, while in syphilis it is dull and continu ous. The cachectic appearance of the skin, when present in cancerous individuals, is also of some assistance. Tertiary ulcerations differ from those of the secondary period in that they are deep instead of superficial, the pathogenic process beginning in the deep layers of, or beneath the membrane, and presenting elevations which finally break down. The ulcer formed is thus deep-seated from the start ; it extends rapidly, both in breadth and in depth, seldom, however, in- volving the surrounding cavities or organs. A peculiarity of syphilitic ulcerations, is that they fre- quently occur symmetrically on both sides, a spot of ulcer- ation occurring on the ventricular band on one side, for instance, being often followed by another on the other ventricular band Their edges are ragged and sharp cut. and a deep red or purplish areola surrounds them. Their surface is covered with a greenish-yellow discharge, which is secreted profusely and contains shreds of necrosed tissue. A fetid odor is usually emitted, which renders the breath of the patient offensive. The epiglottis is often completely destroyed ; when the ulceration extends to the other car- tilages, these become partially or entirely necrosed, and are expectorated either whole or in pieces; the latter may endanger the patient's life by falling into the glottis and causing asphyxia. Blood-vessels may become implicated in the ulcerative process and severe hemorrhage ensue. The ulcerative pro- cess is rapid and destructive, and if the disease is not arrested until the ulcerations have made much headway, the cicatricial contraction of the excavated tissues causes further deformity of the larynx, and bands of cicatricial tissue so limit the glottis or other parts of the laryngeal cavity as to interfere greatly with respiration, and some- times to cause complete stenosis. SYPHILITIC LARYNGITIS. 353 The subjective symptoms resemble, at the start, those of an attack of subacute laryngitis. Aggravation soon takes place, however, accompanied by local heat and pain, especially marked during deglutition; the expectoration assumes a purulent character and is quite profuse, being at times streaked with blood ; the voice becomes hoarse, and complete aphonia follows, if the ulcerative process involves both vocal bands or the inter-arytenoid commissure. As the destruction of tissue and cartilage continues, these symptoms increase in virulence, deglutition becoming almost impossible. Prognosis. Under proper treatment, syphilitic laryngitis, even when far advanced in the tertiary period, is almost always curable. After the latter, however, considerable de- formity generally occurs, compromising, in many cases, the physiological functions of the larynx, and endangering the patient's life. Treatment. In secondary laryngeal manifestations, the local treatment principally consists in frequent detergent sprays, to keep the laryngeal surface as free as possible from unhealthy secretions. This of course only applies to cases in which there is ulceration. A borax spray (gr. iv-Ij) applied three or four times daily, not only contributes materially to the patient's comfort, but advances the recovery. Astringents are recommended by some authors, but I have found them more irritating than beneficial. If the superficial ulceration seems stubborn, a sixty-grain solution of nitrate of silver, applied with a very small cotton pledget to each spot, after partially anaesthetizing the larynx with cocaine, will soon cause them to disappear. Although the tendency of secondary syphilis of the larynx is to undergo spontaneous resolution, when the diagnosis is rendered positive by the mucous patches and the other evi- dences described, a mercurial treatment is indicated, not for 28 354 DISEASES OF THE LABYNX. the secondary manifestations, but to prevent as much as pos- ble the tertiary stage of the affection. The red iodide of ' mercury, administered in doses of one-sixteenth of a grain three times daily, may be prescribed, and alternated, when ptyalism occurs, with iodide of potassium, ten grains night and morning. After continuing this treatment for six weeks or two months, Rabuteau's pills of carbonate of iron are of advantage if anaemia is present, one being taken after meals. In tertiary syphilis of the larynx, internal medication is of primary importance. The system must, as soon as possible, be placed under the influence of an anti-syphilitic treatment, to check, in' the briefest time, the ulcerative process. Mer- curial inunctions, practiced three times a day, a piece of mercurial ointment as large as a cherry being rubbed into a different part of the body each time, is rapidly effective. The ulcerations show marked improvement after a few days, after which the inunctions may be reduced to twice a day. When ptyalism becomes evident, the mercury is replaced by iodide of potassium, which should in turn be given in large doses, beginning with ten grains, and gradually increasing at the rate of one grain per day until twenty grains are ad- ministered three times a day. While the drug is being used, the urine must be watched, and if it becomes scanty or its specific gravity becomes abnormally increased, prudence must be exercised lest oadema of the larynx occur. The larynx should be frequently and carefully examined, and if it shows unusual puffiness or the patient complains of dyspnoea, the iodide must either be decreased or discontinued as the case may be. This step is seldom necessary, however, and when the maximum dose of the salt has been administered, it can be continued as required, and decreased as it was increased, one grain per day. To prevent gastric disturbance, the iodide SYPHILITIC LARYNGITIS. 355 can be administered with tincture of cinchona bark. The salt should be dissolved in a little water by the pharmacist, prior to mixing it with the tincture, to insure proper solu- tion. Local applications are also very important, not only to assist the healing process, but to dimmish the suffering. Cleansing solutions of borax (gr. iv-lj), bicarbonate of sodium (gr. v-Sj) are very useful to detach the layers of pus which cover not only the ulcerations, but the adjoining parts. When this has been done thoroughly, a spray of four per cent, solution of cocaine is used to counteract the slight in- flammatory exacerbation set up by the spray, and to slightly anaesthetize the larynx prior to the next application, which should be made at once. lodof orm is generally recommended, but I have not found it as effective as a one hundred and twenty grain solution of nitrate of silver, applied to each ulceration only, with a curved probe, covered at the tip with a thin film of cotton. The laryngoscope should, of course, be used. When the practitioner finds this measure difficult, iodoform may be used with the insufflator (Fig. 25). When cicatrization follows upon extensive ulceration, the adhesions formed may be of such a nature as to render tracheotomy and the permanent wearing of a tube necessary. Cicatricial bands not admitting of dilatation, they should be divided when such division can restore the function of a part. An incision through a web connecting a portion of the edges of the vocal bands, for instance, will restore the voice and free respiration. Frequently, the motion of the epiglottis is restrained by a band passing from its edge to the ary-epiglottic fold; an incision through this band not only restores free motion to the epiglottis, but renders de- glutition, which before was performed with difficulty, per- fectly easy. The larynx is placed under the influence of a 356 DISEASES OF THE LARYNX. ten per cent, solution of cocaine, and the cicatricial tissue is severed. To prevent reunion of the cut edges, a probe must be passed between them every day until they are com- pletely healed. PLATE -vin. PLATE VIII. LAEYNGOSCOPICAL APPEABANCE OF THE LAKYNX, NOKMAL AND DISEASED.* FIG. i. IN ABDUCTION. J. Epiglottis, r. Ventricular band. /. Vocal band. z. Trachea. m. Cartilage of Wrisberg. d. Cartilage of Santorini. g. Inter-arytenoid com- missure. FIG. 2. IN PARTIAL ADDUCTION. Omega-shaped epiglot- tis concealing anterior portion of larynx. FIG. 3. IN COMPLETE ADDUCTION Depressed epiglottis concealing two-thirds of larynx. FIG. 7. ACUTE LARYNGITIS. Female, set. 24. Acci- dental deglutition of aq. ammoniac. Spontaneous resolution. Case refer- red by Dr. M. Hanly. FIG. 4. CHILD'S LARYNX. I 1 . Glosso-epiglottic fold. 12. Palato- " " J. Epiglottis. V. Pyriform sinus, jr. Inter-arytenoid com- missure. w. CEsophagus. y. Posterior wall of phar- ynx. FIG. 6. SUBACUTE LARYNGITIS. Female,set.47. Infiltra- tion ; threatening oedema. Absolute rest. Jaboran- di. Solution of buchu and uva ursi. FIG. 5. SUBACUTB LARYNGITIS. Female, opera singer, set. 25. Rest, cocaine 2 percent, spray, coca wine internally, saline purga- tives. FIG. 8. CEDEMA OF LARYNX. Complete closure of the glottis. FIG. 10. CHRONIC LARYNGITIS COMPLICATED WITH PA- RALYSIS OF THE ARYTE- NOIDEUS. Male, set. 28. Locally, aac (gr. iv-Sj.), alterna- ting with nitrate of silver. Sol. (gr. 6o-Sj. ) iodide of potassium internally; electricity afterwards. FIG. 14. FIBROMA OF RIGHT VO- CAL BAND. From Mackenzie. FIG. ii. PAPILLOMA OF LARYNX. Male, set. 22. Stone-cut- ter. Removed with for- ceps, and cauterized base with galvano-cautery. FIG. 12. PAPILLOMA OF LARYNX. Female, set. 5. Trache- otomy. Extirpation with forceps and snare. FIG. 9. CHRONIC LARYNGITIS. Female, aet. 36, opera singer. Coppersulph. sol. locally, coca wine inter- nally and lozenge No. i. Case referred by Dr. Kyte. FIG. 15. ABDUCTOR PARALYSIS, RIGHT SIDE, DURING IN- SPIRATION. Female, set. 48. Strych- nia and iodide of potas- sium. Electricity. Fig. 16. PARALYSIS OF ABDUC- TION, ADDUCTION, AND RELAXATION OP RIGHT SIDE. BAND IN CADAVE- RIC POSITION. SHOWN IN ATTEMPTED PHONATION. Female, set. 61. Due to pressure of goitre upon right recurrent. FIG. 20. TUBERCULOUS LARYN- GITIS. Male, set. 50. Sprays morphia, iodoform, and ether. Case referred by Prof. S. D. Gross. FIG. 13. FIBROMA OF LEFT VO- CAL BAND. Male, aet. 63. Removed with forceps. FIG. 18. BILATERAL ABDUCTOR PARALYSIS OF SEVEN YEARS' STANDING. Male, set. 47. Treat- ment proved useless. Patient refuses tracheot- omy. FIG. 19. TUBERCULOUS LARYN- GITIS. Female, set. 24, sprays, morphia, etc. Case re- ferred by Prof. S. D. Gross. FIG. 17. PARALYSIS OF THYRO- ARYTBNOID MUSCLES. Female, set. 35. Singer. Rest and electricity. FIG. 21. TUBERCULOUS LARYN- GITIS. Male, set. 27. Same treatment as Fig. 20. Case referred by Dr. Valette. FIG. 22. SYPHILITIC LARYNGITIS. Male, set. 24. Mercuri- als and iodides, nitrate of silver locally. Case re- ferred by Dr. Mercur. FIG. 23. SYPHILITIC LARYNGITIS. Female, set. 27. Mercu- rials, iodides. Case re- ferred by Dr. Minich. FIG. 24. CANCER OF THE LARYNX. Epithelioma of left ventricular band. From Mackenzie. * Represented as seen by gas-light. By day-light, the red color appears much paler. Plate Y/I1 C-E. Sajous, Pin Ait Burkt M c Fetn