'■■itf:; ^'•^■'-fii CORNELL UNIVERSITY THE FOUNDED BY ROSWELL P. FLOWER for the use of the N. Y. State Veterinary College 1897 Cornell University Library RF 46.W95 A text-book of the diseases of the nose 3 1924 000 323 554 Cornell University Library The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924000323554 A TEXT-BOOK DISEASES OF THE NOSE AND THROAT BY JONATHAN WEIGHT, M.D. DIRECTOR OF THE DEPARTMENT OF THE LABORATORIEB, NEW YORK POST-GRADUATE MEDICAL , SCHOOL AND HOSPITAL HARMON SMITH, M.D. SUHQEON TO THROAT DEPAHTMENT OF THE MANHATTAN EYE, BAB, NOSE AND THROAT HOSPITAL; CLINICAL PROFESSOR OF LARYNGOLOGY AND RHINOLOGY, CORNELL UNIVERSITY MEDICAL SCHOOL ILLUSTRATED WITH 313 ENGRAVINGS AND 14 PLATES LEA & FEBIGER PHILADELPHIA AND NEW YORK 1914 Entered according to the Act of Congress, in the year 1914, by LEA & FEBIGER, in the Office of the Librarian of Congress. All rights reserved. PREFACE. It seems to the authors that the exceptional feature in this text-book of laryngology is the emphasis they have laid upon the etiology and path- ology of disease. They have attempted to deal with nasal, pharyngeal, and laryngeal morbid processes from this standpoint, which necessarily involves also an extended consideration of the normal histology and physiology of the mucous membranes of the upper air passages. No logical and scientific discussion of disease can be carried on from any other basis. Much of this work in etiology and pathology rests on original investigation pursued for many years in the laboratory and the clinic by one of them. While in the various text-books of laryngology hitherto issued there has been some attempt to treat fully this aspect of the subject, the authors feel that the larger space they have devoted to it is entirely warranted, but they have sought to avoid any curtail- ment of other interests; and the symptomatology and diagnosis, the topical and the operative treatment of diseases of the upper air passages have not been neglected in the attempt to give due consideration to their causes and consequences. In preparing the present work for the press, the authors desire to express in the preface their indebtedness to many colleagues to whom in the text also reference has for the most part been made. Naturally every such work is built on the foundation laid by others, but while fully appreciating this they have made no attempt to go further into the Uterature and history of the subjects connoted under the differ- ent headings than was absolutely necessary, for two reasons. First, such excursions add enormously to the journey through our specialty in its most recent development and are themselves incomplete and not altogether adapted to the impartial and judicial expressions of opinion. Second, one of the authors has recently, from the press of the same publishers, issued a second edition of his History of Laryngology and Rhinohgy, in which this aspect of it is fully developed. They would be lacking in courtesy if they did not express their appre- ciation of the care Dr. J. G. Callison has given to the preparation of a full table of contents and an elaborate index. J. W. H. S. New York, 1914. CONTENTS. CHAPTER I Office Equipment and Methods of Examination 17-59 Office Equipment, Fixed 17 Office Equipment, Movable 24 Position of Patient 30 Rhinoscopy 30 Pharyngoscopy 31 Transillumination 31 X-ray 33 Location of Foreign Bodies 33 Laryngoscopy 34 Dorsal Decubitus 36 Bronchoscopy 40 Esophagoscopy 41 Gastroscopy 42 Special Instruments 48 Anesthesia, Local and General 50 Laws Governing Use of Cocaine 50 Suspension Laryngoscopy 52 Instruments and Measures Employed for the Treatment of the Upper Air Passages 54 CHAPTER II. Embryology AND Anatomy of the Nose: Its External Deformities and their Correction 60-76 Embryology of the Nose 60 External Nasal Deformity 63 CHAPTER III. Anatomy, Histology and Physiology of the Internal Nose . 77-99 Anatomy of Internal Nose 77 Minute Anatomy of Nasal Mucosa 82 Bloodvessels and Contractile Elements 82 Contractile Elements of Stroma 85 Elastic Elements 85 Smooth Muscle Cell 86 Epithelium 87 Glands 90 Leukocytes 92 . Connective Tissue 92 Bone Structure 93 The Lymphocytes 93 Physiology of the Nose 94 Action of Epithelial Cells . 99 VI CONTENTS CHAPTER IV. Simple Inflammation of the Nasal Mucosa . . . 100-124 Acute Rhinitis 100 Acute Rhinitis in Infants ■ . . • • ^^^ Membranous, Croupous, Pseudomembranous and Fibrinoplastic Rhinitis . . 108 Chronic Rhinitis 108 Intumescent Rhinitis 115- Hypertrophic Rhinitis 115 CHAPTER V. The SBQUBKae of Chronic Rhinitis .... 125-190 Nasal Polypi and Accessory Sinus Disease 125 Edematous Polypi and Polypoid Degeneration 125 Histology 127 Bone Cysts of Middle Turbinate 130 The Accessory Nasal Sinuses and their Inflammatory Diseases 133 Anatomy of the Sinuses ; . . . 133 Maxillary 133 Frontal Sinus 135 Sphenoid Sinus 137 Ethmoid Sinuses or Cells 138 Acute and Chronic Inflammations 138 Chronic Catarrhal Sinusitis 142 Maxillary 142 Ethmoids and Sphenoid 143 Acute Empyema of Maxillary Sinus 143 Acute Empyema of Frontal Sinus 149 Acute Ethmoidal Empyema 151 Acute Sphenoidal Empyema 153 Chronic Empyema of the Accessory Nasal Sinuses 154 Chronic Empyema of Maxillary Sinus 155 Chronic Frontal Sinus Empyema ' 163 Chronic Sphenoidal Sinus Empyema 175 Hypophyseal Tumors 177 Chronic Empyema of Ethmoidal Cells 178 Optic Neuritis Resulting from Involvement of the Nasal Sinuses 179 Relation of the Optic Nerve to the Sphenoidal Sinus and Posterior Ethmoidal Cells with a Description of the Process of Involvement 180 Direct Infection 181 Ocular Manifestations in Relation to the Different Accessory Sinuses . 183 Treatment of Ethmoidal Sinus Disease 184 Mucocele 189 Hydrops Antri 190 CHAPTER VI. The SequeljE of Chronic Rhinitis. (Continued) . . 191-218 Deviations and Spurs of the Nasal Septum 191 Septal Perforations 211 Hematoma 214 Abscess 215 Synechia 216 Epistaxis 216 CHAPTER VII. Atrophic Rhinitis 219 Rhinoliths and Foreign Bodies in the Nasal Passages , 228 CONTENTS vii CHAPTER VIII. Nkuroses of the Nose 231-242 Disturbances of Olfaction 231 Anosmia 232 Hyperosmia 233 Parosmia 233 Reflex Neuroses of Nose 234 Vasomotor Rhinitis 235 Hay Fever, Rose Cold, Asthma 236 Rhinorrhea 240 Discharge of Cerebrospinal Fluid from Nose 241 CHAPTER IX. Nasal Neoplasms 243-269 Benign Nasal Neoplasms 243 Adenoma 243 Angeioma (Bleeding Septal Polyp) 246 Fibroma 247 Osteoma 248 Papilloma 248 Myxoma 249 Chondroma 249 Rhinosporidium Kinealyi 250 Malignant Nasal Neoplasms 256 Spindle-cell Sarcoma 258 Osteosarcoma ^ 259 Osteochondrosarcoma .' 259 Epithelial Tumors . 260 Adenocarcinoma 260 Columnar Celled Epithehoma 261 Teratoma 262 CHAPTER X. The Anatomx, Embryology, and Histology op the Pharynx . . 270-290 Topographical Anatomy of the Pharynx and its Structures 270 Embryology of the Pharynx 272 The Minute Anatomy of the Mucous Membrane and its Structures 277 Faucial Tonsil . 277 Pharyngeal Tonsil 278 Lingual Tonsil 281 Racemose Glands 281 Lymphoid Tissue 282 Histology of a Lymph Node 283 Lipoid Material 284 The Lymphatics 288 Bloodvessels of the Tonsil 288 Tonsillar Bacteria 288 The "Function" of the Tonsil 289 CHAPTER XI. The Inflammation of the Pharynx .... 291-325 Acute Inflammation of the Throat 291 Membranous Tonsillitis 298 Quinsy 298 Ludwig's Angina 306 Postpharyngeal Abscess 313 Chronic Pharyngitis 316 Atrophic Pharyngitis 318 Lateral Phaaryngitis 319 viij CONTENTS CHAPTER XII. Chronic Hypebteophy of the Pharyngeal, Faucial, and Lingual Tonsils and of the Uvula 326-376 Hypertrophy of Faucial Tonsil 338 Anesthesia 341 Adenectomy 360 Aural Conditions Resulting from Nasal and Postnasal Obstruction .... 365 Scarlet Fever and Diphtheria 366 Inflammation of Lingual Tonsil 367 Keratosis of the Tonsil (Mycosis Tonsillaris) 370 Bone in Tonsil 372 Tonsillohths 372 Acute and Chronic Inflammation and Elongation of the Uvula 373 Deformities of Uvula 374 Removal of Uvula • . . 375 CHAPTER XIII. Inflammations of the Buccal Cavity .... 377-405 Catarrhal Stomatitis 377 Stomatitis Aphthosa 377 Gonococcal Stomatitis 378 Vincent's Angina '.....,. 379 Inflammations of Pharynx with Systemic Symptoms and Dermatoses . . 382 Diphtheria 382 Intubation of Larynx 397 Tracheotomy 402 Sequelse of Diphtheria and its Treatment 402 Influenza 403 CHAPTER XIV. Buccal Lesions IN Dermatoses: Buccal Drug Lesions: the Keratoses and Mycoses: Glanders, Anthrax, etc.: Differential Diagnosis . 406-428 Mouth Lesions in Dermatoses . . . ' 406 Herpes 406 Impetigo Herpetiformis 408 Pemphigus 408 Drug Eruptions on Mucous Membrane 411 Mercury 412 Urticaria 413 Lichen Ruber Planus 414 Submucous Hemorrhages 414 Erythema 414 Lupus Erythematodes or Erythematosus 415 Scleroderma 41g Keratoses of the Mouth and Pharynx 4ig Erythema Migrans (Geographical Tongue) 418 Black Tongue, or Melanoglossia 418 Eczema 418 Pityriasis Lichenoides 418 Thrush 418 Ulcers 418 Actinomycosis 419 Blastomycosis 423 Sporotrichosis 424 Trychophyton, Herpes Tonsurans, or Ringworm 424 Mycosis Fungoides 424 Leptothrix Bucealis 424 Glanders — Malleus 424 Anthrax 42g Differential Diagnosis of Lesions Showing False Membrane in Throat . . '. 426 Abscess ' 427 Macroglossia 428 CONTENTS ix CHAPTER XV. TuMOEs OF Tongue, Oropharynx, anij Nasopharynx . . 429-447 Tumors of Tongue 429 Ranula 429 Benign Tumors 429 Malignant Tumors 429 Epithelioma 429 Sarcoma 431 Benign Tumors of Oropharynx 43I Papilloma 43I Adenoma 432 Fibroma 432 Fibromyoma and Myxochondroma 433 Teratoma 433 Branchial Cysts 433 Hemangioma 434 Lymphangiomata 434 FibroHpoma 434 Fibromyxoma, Fibrochondroma, Fibrolymphadenoma 434 Chondroma and Osteoma of TonsU 434 Malignant Tumors of Oropharynx 435 Sarcoma 435 Carcinoma 436 Sarcoma of Tonsil and Oropharynx 437 Epithelioma of Oropharynx 438 Epithelioma of Tonsil 438 Nasopharyngeal Tumors 439 Benign 439 Malignant 445 Sarcoma 445 Epithelioma 446 Pharyngeal Neuroses 447 Paralyses 447 Hyperesthesia, Anesthesia, Paresthesia 447 CHAPTER XVI. Anatomy of the Larynx: Histology of the Laryngeal Mucous Membrane 448-461 Anatomical and Surgical Consideration of the Larjmx 448 Cartilages 448 Thyroid 448 Cricoid 448 The Epiglottis 448 The Arytenoid Cartilages 449 Ligaments and Membranes 449 Muscles 449 The Cricothyroid 451 The Posterior Crico-arytenoid Muscle 451 The Lateral Crico-arytenoid Muscle 451 The Arytenoideus Muscle 451 The Thyro-arytenoideus Muscle 451 Blood-supply 451 The Superior Larjoigeal Artery 451 The Inferior Laryngeal Artery 453 Minute Anatomy of Laryngeal Mucosa 453 Mucous Membrane 453 Epithelium 453 Racemose Glands 457 Connective Tissue . . • 457 Lymphatics 458 Intralaryngeal Bloodvessels 459 Nerve Endings 459 X CONTENTS CHAPTER XVII. Acute and Chronic Laeyngeal Inflammations . . . 462-469 Acute Inflammations of Larynx 463 Simple Chronic Laryngitis 465 Atrophic Laryngitis 467 Tracheitis 468 CHAPTER XVIII. Benign Laryngeal Neoplasms 470-503 Benign Epithelial Neoplasms 472 Benign Connective-tissue Neoplasms 488 Fibroid Neoplasms 488 Singer's Nodules 489 Edematous Laryngeal Polypi 491 Cysts 491 Glandular Cysts 491 Connective-tissue Cysts 491 Lymphangiomata 492 Tophi 492 Fibroma 492 Fibromyxoma 492 Fibro-angeioma 493 Lipoma 493 Lymphoma 493 Chondroma 495 Amyloid Tumors and Amyloid Degenerations of the Laryngeal Mucosa . 496 Thyroid Tumors in Larynx 497 Prolapse of Laryngeal Ventricles 497 Symptoms of Benign Laryngeal Neoplasms (Connective-tissue Type) . 497 Treatment 502 CHAPTER XIX. Malignant Laryngeal Neoplasms .... 504^544 Transformation of Benign into Malignant Growths 504 Internal and External Laryngeal Cancers 505 Epithelioma 507 Adenocarcinoma 512 Malignant Connective-tissue Tumors • , 512 EndotheUoma 512 Sarcoma 513 Metastatic Growths 513 Coexistence of Cancer with other Disease of the Larynx . 514 Symptoms of MaMgnant Disease of the Larynx 5I4 Extrinsic Laryngeal Cancer 517 Treatment other than Surgical 522 Extirpation by Operative Treatment 523 Neoplasms of Trachea 526 Papillomata 527 Fibromata 527 Ecchondromata and Chondroosteomata 528 Strumas 528 Adenomata 528 Lipomata 528 Lymphomata 528 Carcinomata 528 Sarcoma 528 Operations on the Larynx 529 CONTENTS xi CHAPTER XX. The Throat in Gbnbeal Diseases: Syphilis: Tubeeculosis . . 545-585 Syphilis 545 Primary Chancre of the Mucous Membranes of the Upper Air Passages 546 Secondary Lesions, the Mucous Patch 646 Tertiary Stage, the Gumma . . . . 546 Differentiation in the Microscopical Appearances of Syphihs from that of other Lesions 647 Diagnostic Value and Demonstration of the Spirochseta Pallida in Lesions and Secretions 548 Tuberculosis of Nose and Throat 562 Nasal Lupus and Tuberculosis 684 CHAPTER XXI. The Nose and Throat in General Disease: Rhinosclbroma: Dippbk- ENTiAL Diagnosis op Syphilis, Tuberculosis, Scleroma, and Cancer of Nose and Throat 586-601 Rhinoscleroma 686 Differential Diagnosis of Syphihs, Tuberculosis, Scleroma, and Cancer of the Nose and Throat 690 CHAPTER XXII. The Nose and Throat in General Diseases (Continued) . 602-608 Leprosy 602 Typhoid Fever 603 Cholera 606 Anemia 606 Leukemia and Pseudoleukemia 606 Hemophilia, Purpura, Scurvy 606 Rachitis 606 Acromegaly 606 Gout 606 Chicken-pox, Smallpox, Vaccinia 606 Rheumatism 607 Scarlet Fever or Scarlatina 607 Measles, Rubeola 608 CHAPTER XXIII. Laryngeal Neuroses 609-634 Central and Peripheral Nerve Supply .of Larynx 609 Cerebral Cortex 609 Corona Radiata and Internal Capsule 611 The Medulla and Floor of the Fourth Ventricle 611 The Origin of Motor Filaments of the Vagus Nerve 613 The Vagus and the Laryngeal Nerve 614 The Action of the Intralaryngeal Muscles 616 Dilators of the Glottis 616 Closers of the Glottis 616 Tensors of the Vocal Cords 616 The Sensibilities and Reflexes of the Larynx 616 Respiration and Phonation 617 Disturbances of Sensation 617 Anesthesia ...'.' 617 Paresthesias 618 xu CONTENTS Disturbances of Sensation: Hyperesthesia of the Larynx 618 Neuralgia 618 Disturbance of MotiUty 618 Larjmgeal Spasm 618 Ictus Laryngis, Laryngeal Vertigo, Laryngeal Epilepsy 619 Spasms and Contractors of the Laryngeal Muscles 620 Incoordination 620 Laryngismus Stridulus or Spasmodic Croup in Children 620 Laryngismus Stridulus in Adults 622 Spasm of Postici Muscles 623 Hysterical Aphonia 623 Laryngeal Paralysis 624 Laryngoscopic Appearances and Diagnostic Symptoms of Complete and Partial Larsmgeal Paralysis 627 Paralysis of Individual Laryngeal Muscles 632 Paralysis of the Openers of the Glottis 632 ' : of the Closers of the Glottis 633 Paralysis of the Thyro-arytenoideus and Crico-arytenoideus Lateralis . 633 Paralysis of the Transversus 633 " 1 of the External Tensor, the Cricothyroideus 634 CHAPTER XXIV. Foreign Bodies in the Labtnx and Bronchi and their Removal. Fractures and Wounds op the Larynx and their Treatment. Anomalies and Cicatricial Stenosis of the Nose and Throat and Operations for their Relief. Diseases op the Esophagus . . 635-654 Foreign Bodies in the Larynx and Bronchi 635 Fractures and Wounds of the Larynx 637 Dislocations of the Cartilages of the Larynx 637 Fractures of the Larynx 637 Wounds of the Larynx 637 AnomaKes of Development in the Anatomy of the Nose and Throat 638 Anomalies of the Nose 638 Anomalies of the Naso- and Oropharynx 639 Prominence of the Tubercle of the Atlas and of the Vertebral Muscles . 639 Anomalies of the Larynx in the Anterior Cervical Region 640 Laryngocele . 640 Cleft Palate 640 Hare-lip . 646 Laryngeal, Pharyngeal and Palatal Stenoses, Webs, Adhesions or Bands Fol- lowing Syphilitic Involvement 647 Stenoses of Larynx 647 Webs in the Larynx 648 Bands and Adhesions in the Larynx 648 Adhesions and Deformities of the Soft Palate 648 ; of the Esophagus 652 Diverticula 652 Cardiospasm ' . 652 Strictures 653 Malignant Tumors 653 Cancer 653 DISEASES OF THE NOSE AND THROAT. CHAPTER I. OFFICE EQUIPMENT AND METHOD OF EXAMINATION. Fixed Ofl&ce Equipment. — ^Illumination. — Experience has demon- strated that the most reliable light with the greatest illuminating intensity is a Welsbach gas light with a finely woven mantle, a mica chimney, and a Mackenzie condenser attached. The spiral image frequently projected by the electric light is avoided. The penetration for deep laryngeal work and distant operative work upon the sphenoid with electric light is insufficient properly to illuminate these remote areas. The light should be attached to a movable arm bracket, so that the bull's-eye of the condenser may be lowered or raised to the level of the patient's ear when sitting. It is most conveniently situated on the right of the patient, as in this position the operator's right hand does not obstruct the source of illumination. Should there be disturbances of vision in the left eye of the operator or should he be left-handed, the position of the light should be reversed. Cabinet. — This should be of enamel-ware, with glass top and fittings for sprays and bottles containing solutions for topical application. The smaller instruments constantly in use are placed on the glass top. It should be upon the left of the operator, as then the specula and tongue depressors constantly used for examination purposes are within easy reach of the left hand, which is employed for examination while the right remains free for operative measures. The cabinet should also have a receptacle for absorbent cotton and several drawers for small dressings and bandages. The type of cabinet to be used depends largely upon the individual requirements of the operator, and somewhat upon whether be combines otology with laryn- gology. The necessity for the convenient presence of many mstruments depends upon whether the physician has an assistant or an office nurse. In the absence of these, it is well to have a cabinet fitted with many drawers to contain the instruments necessary for examination and minor surgical operations. If the office space is small, the drawers should open at the end of the cabinet, otherwise they will be constantly hitting the knees of the patient and operator when opened. 2 18 OFFICE EQUIPMENT AND METHOD OF EXAMINATION Fig. 1 Movable arm and bracket, with Mackenzie condenser. Fig. 2 Office cabinet. FIXED OFFICE EQUIPMENT 19 Patient's Chair. — This chair should combine three features, which are essential to effective Operative work. These are comfort to the patient, inflexible back projecting well forward, and a revolving superstructure. To insure the comfort of the patient, it is necessary to have ample space upon the seat of the chair, arms on the sides to which the patient can cling during the tension incident to treatment or operation, and a back Fig. 3 White's modification of Phillips' ofBce chair. which comes in contact with the shoulders and upper part of the spinal column, and a head-rest attachment. As an aid to the operator, the necessity for the inflexibility of the back is of paramount importance, otherwise the patient will extend the head backward beyond his reach. The superstructure of the chair should revolve on its axis in order to determine labyrinthine involvement of the ear, which is evidenced by rotary nystagmus following rotation. A chair devised by Dr. Wendell Fia. 4 Doctor's stool. Fig. 5 Accessory office table. FIXED OFFICE EQUIPMENT 21 C. Phillips and modified by Dr. Francis White meets these conditions admirably. This chair should also be of enamel-ware. Doctor's Stool. — This should be a large revolving-top stool, with a receptacle for waste cotton situated between its legs. Accessory Table. — An enamelled table with one or more glass shelves should be placed to the right of the operator. This table holds the instruments necessary for any operation performed under local anes- thesia in the office. Upon it rests also the sterilizer, which is within ^'o- 6 easy reach and to which can be transmitted the instruments used in the examination of the patient as well as those used in the opera- tion. The other shelves may be employed for dressings, electric ap- paratus, or other paraphernalia frequently employed in the treat- ment of cases. To the patient's left there should also be a dental cuspidor, swinging on an axis, so that when unemployed it may be pushed to one side out of the way. Compressed Air. — ^This is best furnished by a water or electric pump placed in the cellar, with a sixty-gallon air tank for storage. From this tank a lead pipe may be run to the office, where it is connected with a pressure register and controller. The pressure in the tank is ordinarily too strong for nasal sprays, and should be reduced to ten pounds to the square inch. The pharynx and larynx can stand twenty pounds without harrn. The nebulizer requires forty pounds properly to disintegrate the oily substances Dental cuspidor. most frequently used in them. The Pynchon and Hubbard regulating air tank is of great value in controlling the force of the air current, as you turn into this auxiliary tank only sufiicient air to make the gauge register the ten pounds or more required. A small portable air tank will meet this requirement very satisfactorily. The hand pump and air receptacle is equally effi- cient, but requires more attention than one has time to give to it. Electric Apparatus.- — ^Although cauterization of the nasal mucosa has lessened in popularity, there are so many conditions requiring its use that a suitable machine for its application and control is indispensable. 22 OFFICE EQUIPMENT AND METHOD OF EXAMINATION The electric motor with controller may be used for cautery, trans- illumination, and vibratory massage, while the addition of a suction pump enables one to employ it for evacuation of the sinuses, massage of the membrana tympani, or pressure for sprays. There may also be attached to the motor a drill for the removal of angular septal spurs or for entrance into the maxillary or frontal sinuses (Ingals' method). This composite apparatus is now manufactured by all the electric instrument houses. Fig. 7 Wappler's direct electric current controller with suction pump. High-frequency Apparatus. — Employment of the high-frequency cur- rent and violet rays has now a fairly stable position in the therapy of throat and nose diseases. Fulguration. — Fulguration is a high-frequency current in the form of a short hot spark. The current may be taken from a high-frequency coil of the transformer type of high power, from an induction coil and Oudin resonator or from a high-speed static machine. The small portable high-frequency coils are not sufficiently powerful for effective results in moist cavities where destruction is required. The electrode consists of a hard-rubber handle with a thumb-break switch and a long hard-rubber tip with a wire running through the centre and just pro- jecting beyond the end of the rubber insulation. A piece of soft-rubber tubing over the end of the electrode will prevent the current jumping to the palate, tongue, and epiglottis or adjacent structures.' The ful- guration spark will reduce hypertrophied tonsils and other lymphoid ' Law, Journal of Advanced Therapeutics, February, 1911. FIXED OFFICE EQUIPMENT 23 masses, and it is particularly valuable in overcoming supra-orbital and trifacial neuralgias. It is being largely employed in the removal of papillomata and fibromata of the nose and larynx) . Fig. 8 Wappler's violet rays and fulmination apparatus. Position and Technique for Fulguration in the Larynx. — The patient is placed in the same position as for examination by the direct method, and the same procedure of anesthetization is employed. After the laryngeal speculum is in place the patient is permitted to free the lungs of the chloroform vapor before the electrode is placed directly on the growth. The current is then turned on and held until the point touched becomes white from burning, when it is turned off and the electrode removed. If the current is on, either during entrance or withdrawal of the electrode, it will short-circuit with the metallic laryngeal speculum. A specially insulated wire has been devised by Law to obviate short- circuiting, and it has materially lessened this undesirable occurrence. Several applications may be made at each sitting, but too large an area must not be treated at one time. The greatest difficulty arises from an inability to obtain a dry surface to which the spark may be applied, as a moist surface tends to diffuse the spark. No edema or other unfavor- able symptoms follow this method unless the fulguration has been excessive. 24 OFFICE EQUIPMENT AND METHOD OF EXAMINATION When a good spark has been applied, the light is transmitted through the laryngeal -box and is easily observed externally by the assistant. Sterilizers. — ^A sterilizer is indispensable and should be within easy reach of the surgeon. The gouree of heat may be either gas or elec- ts Pynohon's sterilizer and instrument dryer. tricity. Gas is a quicker and less expensive method than electricity, although it is more uncomfortable in hot weather. The style of the sterilizer may be determined by individual preference. An additional dry chamber for drying instruments after operation will preserve them longer from rust. Fig. 10 Fig. 11 Fig. 12 Bosworth's tongue depressor. Tiirck's tongue depressor. Frankel's tongue depressor. Movable Office Equipment. — ^Instruments. — Tongue Depressors. — The fenestrated tongue depressor of Bosworth is the most universally em- ployed, but for posterior rhinoscopy, Frankel's depressor possesses unusual merit. A great many prefer wooden spatulse to any metallic MOVABLE OFFICE EQUIPMENT 25 instrument, but in the experience of some they have proved too elastic properly to depress an obstinate tongue. There has been devised by Alexander a depressor, one extremity of which is small and adaptable to use in children, while the other is large and fitted for adults. There is no fenestra in either extremity and its tip curves somewhat down- ward, which enables a good forward and downward depression of the tongue to be obtained. Fig. 13 Alexander's tongue depressor. Nasal Specula. — There are many varieties, all of which tend to meet the individual requirements of the operator and the necessities of each case. The fenestrated speculum of Bosworth in two sizes, one for adults and the other for children, meets the demand for ordinary examina- tions. They should be made with a flexible spring and not strong enough to dilate the nostril too widely, which will cause pain. Bosworth's nasal specula. The bivalve speculurii of Hartmann is opened by hand-pressure, which is regulated with a spring holding the handles apart. This pre- vents unpleasant distention and will meet the requirements of varying sized nostrils. It also holds aside the vibrissas in the nostril, which offer obstruction to perfect illumination of the nasal chambers. 26 OFFICE EQUIPMENT AND METHOD OF EXAMINATION Yankauer has also devised a self-retaining speculum which greatly facilitates operative work. Fig. 15 Hartmann bivalve speculum. Fig. 16 Fig. 17 Foster's nasal speculum. Yankauer self-retaining speculum. Head Mirror. — This should consist of a mirror four inches in diameter, with aluminum back for lightness, a large hole in the centre for the use of the examining eye, and. should be attached to a broad band of Fig. 18 T^' i soft leather, so that it will not irritate the forehead. The attachment of a double ball-and-socket joint enables the operator to raise the mirror upon the head when not in use. MOVABLE OFFICE EQUIPMENT 27 Electric Head Mirrors. — ^A number of these are in use, and in the examination of the ear render good service; but for the examination Fig. 19 Phillip's electric head mirror. Fig. 20 The improved electric pharyngoscope. (Hays.) of the nose and throat they are inadequate both in the field of illumina- tion and in intensity. For bedside examination they meet every require- ment. Their source of light is obtained from dry batteries, which 28 OFFICE EQUIPMENT AND METHOD OF EXAMINATION require frequent renewal and which lose their power whether in use or not. The Pharyngoscope. — This instrument was perfected by Hays, and is admirably adapted to the bedside examination of the larynx, and can be effectively used in some cases for the examination of the larynx when ordinary measures fail.' Fig. 21 Laryngeal and nasopharyngeal mirrors. The tube is placed in the mouth and its end carried just beyond the curvature of the tongue. The lips are closed and the patient instructed to hum "mo," when a good picture of the larynx is obtained. The image of the larynx is somewhat reduced. The necessity for its use is limited. Holmes has modified the principle of the pharyngoscope for Fig. 22 Fig. 23 Wilde's nasal forceps, smooth. Fig. 24 Michel-Frankel's rhinoseopio mirror. Wilde's nasal forceps, mouse-tooth. the examination of the nasal chambers, particularly for detection of secretions escaping from the sphenoidal sinus and posterior ethmoidal cells. It is also of advantage in examining the entrance to the Eustachian tubes. ' Simpson, Transactions of the American Laryngological Association, 1912. MOVABLE OFFICE EQUIPMENT 29 Laryngeal and Nasopharyngeal Mirrors. — ^These mirrors should vary in size from to 5. The larger ones are employed in the examination of the larynx and the smaller for the examination of the nasopharynx. For the examination of the nasopharynx Frankel hias devised a small Fig, Pomeroy 's haSal forceps mirror working on an axis, which moves through an are of a circle, and is controlled by a thmnb lever attached to the handle. It is well adapted to this purpose. Fig. 26 Knight's nasal forceps. Forceps. — Several varieties should be at hand, of such nature that the removal of packing, pledgets of cotton, and foreign bodies may be easily accomplished. Fig. 27 Laryngeal applicator. Applicators. — Short malleable, triangular-pointed applicators are indis- pensable for use in topical applications and for probing. Laryngeal applicators should have the bent angle fixed and the extremity con- structed so that the cotton cannot easily be detached. 30 OFFICE EQUIPMENT AND METHOD OF EXAMINATION Position of Patient. — ^The patient should assume a natural position with the head neither flexed nor extended. The aid a patient attempts to render the examiner is only a complication and makes difficult what would otherwise be easy. The shoulders of the patient should be about the same level as the shoulders of the examiner, which position offers the easiest and most normal view of the pharynx, nasopharynx, and larynx. The examination of the attic of the nose necessitates slight extension of the head. The back of the examining chair tilts slightly forward, and this with the head-rest brings the body sufficiently forward for easy examination. For direct examinations the positions necessary are described under other headings. Fig. 28 Posterior rhinoscopic image. Rhinoscopy.— inferior.— Upon dilating the anterior nares with the nasal speculum and throwing the reflected light into the nasal chamber, attention should be directed (1) to the nasal septum. This should present a perpendicular plane surface to the floor of the nose. Deviation from this plane should be noted as well as any pro- jectmg angles of bone or cartilage. (2) The inferior turbinated body is noted and its relation to other structures, likewise its turgescence, color, approach to the nasal septum, and possible obstruction to free nasal respiration. (3) The middle turbinated body is also considered. It should not impinge against the septum and there should exist proper PLATE r A. Transillumination AA^hen Antra are Uninvolved. B. Transillumination with Left Antrunn Packed with Gauze, the Shado^A^ being Less Intense than in Cases of Empyema. C. Transillumination of Right Antrum by the Retromaxillary method. D. Transillumination of Antra Demonstrating Empyema of the Right Side. TRANSILLUMINATION 31 space between it and the inferior turbinated body. The spaces beneath each turbinate should be free and distinctly .outlined. (4) Growths, such as polypi, fibromata, or cysts, should be recorded. Posterior Rhinoscopy. — For this purpose a tongue depressor is neces- sary to prevent the posterior part of the tongue from obstructing the view. This is accomplished best by placing the point of the depressor well behind the tongue — not touching the pharyngeal wall — and pressing downward and forward. Pressure exerted directly from above down- ward on the tongue will not give satisfactory results, and will not offer the space requisite for posterior rhinoscopy. When the tongue is properly depressed the small rhinoscopic mirror is warmed and introduced to one side of the uvula and behind the soft palate, with the mirror directed upward and forward; then by lowering or raising the handle a view of the structures in the nasopharynx may be obtained. Frankel's rhino- scopic mirror is particularly useful for this work. The examiner now sees the posterior ends of the three turbinates — superior, middle, and inferior. In anterior rhinoscopy only the inferior and middle can be seen. It should be noted if there is hypertrophy of the posterior tips, also if any tumors are attached. The posterior border of the septum nasi is also seen, and it is frequently thickened to such an extent that it offers obstruction to nasal breathing. The vault of the nasopharynx and entrance to the Eustachian tubes also come into view. Adenoid vegetations are to be noted, and particularly if of suflScient size to warrant removal. Pharyngoscopy. — ^With the tongue held down the observer notes the tonsils, their size, condition, and attachments, the lateral pharyngeal walls and constrictors. There is frequently seen a reddish, inflamed, cord-like structure running up one or both sides of the pharynx toward the Eustachian tubes. This inflamed condition is known as lateral pharyngitis, and often gives rise to severe constitutional symptoms, to pain on swallowing and earache. The posterior wall of the pharynx is examined for inflamed follicles, retropharyngeal abscess, and other lesions of the mucous membrane. Transillumination. — For this purpose the apparatus consists essentially of a small electric lamp, 1 to 3 candle-power, mounted on a stem, and provided with a guard so perforated that the light may be thrown in the required direction. Though occasionally used externally over the larynx to determine infiltrations of the cartilages, its chief employment is in diagnosticating morbid conditions of the frontal and maxillary sinuses. Placed under the supra-orbital ridge for the former and in the buccal cavity with the patient's lips closed for the latter locality, the current is turned on in a perfectly darkened room, and from the resultant penetration of the light, internally for the larynx and externally for the nasal sinuses, conclusions are drawn. This method of examination is employed as an aid in the diagnosis of empyema, cysts, fibrous and malignant growths, bony growths, such as dentigerous cysts, exostoses and foreign bodies in the sinuses. Used alone for diagnostic purposes, it is frequently misleading, for an 32 OFFICE EQUIPMENT AND METHOD OF EXAMINATION unusually thickened bone, or a thickened lining membrane of the cavity from previous inflammation or present purulent conditions, will lessen the transmission of light. Such a;n error of diagnosis was clearly demon- strated in a case under our care, where the supra-orbital nerve had been cut for neuralgia, which had resulted in a fibrosis over the frontal sin us. This prevented the transmission of light, and led several experienced observers to the conclusion that a frontal empyema existed. It was only after more careful investigation of the previous history that we definitely concluded that the sinus was neither the cause of the pain Fig. 29 Fig. 30 Birkett's frontal sinus illuminator. Coakley's transillumiiiator for the sinuses. nor responsible for the shadow. The radiograph also coincided with the transillumination. A complete recovery resulted from the treatment of the neuralgia. The presence of an opaque fluid in the sinus will give a shadow upon transillumination. When it is one-sided the diagnosis from transillumination alone can be relied upon more than where both sides are involved and an equal shadow is given. The intensity of the shadow is no index to the amount of involvement. In cases of mucocele, where the bony walls have been thinned by long-pressure, less shadow is given than in cases of acute empyema, where, in addition to the contained pus, there is an inflammatory thickening of the lining mucosa. For the PLATE II X-ray Picture of Accessory Sinuses. LOCATION OF FOREIGN BODIES 33 examination of the frontal sinuses the double transilluminator of Birkett facilitates the diagnosis by the comparative shadow of the two sides; particularly, is this so in one-sided empyema. In the use of the trans- illuminator too great an intensity of light is to be guarded against, for with the modern Tungsten lamps, sufficient intensity may be obtained to penetrate any involvement of the sinuses other than osseous. In one-sided empyema it is well to get just sufficient illumination to show plainly through the uninvolved side, then it will not show at all on the affected side. In its application to the maxillary antra it is essential to determine the existence of dental plates, for the presence of these will invariably give a shadow which is of course misleading. When applied to the frontal sinuses the same angle of approach should be employed on both sides, as a varying angle will throw the light through the bone on one side and through the skin on the other, thus bringing about an illumination which is no indication of the internal involvement of the sinuses. X-ray. — Photographic plates prepared from outlines secured by the use of Rontgen rays, as in transillumination, are to be relied upon only as an accessory to other clinical facts in making a positive diagnosis. In sinusitis it bears out in the majority of instances the clinical diag- nosis, and in addition to this a lateral view outlines the distance between the inner and outer plate of the frontal sinuses, and likewise gives a definite knowledge of the anteroposterior diameter of the sphenoidal sinus. For operative purposes, these two facts alone are of material aid. Involvement as shown by the x-ray alone does not warrant external - operative procedures upon the sinus. It may, however, justify explora- tory puncture of the antra and possibly internal exploration of the frontal sinus. Further than this, it would seem unjustifiable to proceed upon the x-ray indications alone. In the employment of the x-ray it is essential to have both front and lateral views taken, as one will fre- quently elucidate the complication of the other. In cases where external frontal operation is considered, it will often show a septum of bone walling off a cavity situated laterally and far out over the orbit, which if not explored by the operator will subsequently act as a focus of infec- tion and prevent proper healing. These remote cavities when unexplored are the most frequent sources of recurrent empyema. In the internal operative measures the distance between the inner and outer plate of the frontal sinus is of great importance to the operator, also the angle of curvature of the internal plate; for unless these two are known, the approach to the sinus is fraught with the danger of perforating the inner plate. If the distance between the two plates is definitely known, one can gauge the opening made into the frontal sinus with accuracy and take advantage of the room afforded by the anatomical conditions. Location of Foreign Bodies. — The x-ray has proved invaluable in bronchoscopic and esophagoscopic work, and while many foreign bodies have not been definitely located by the x-ray, owing to the shadow cast by the heart, aorta, ribs, and vertebrae, yet such a large percentage have been located by this means that no one should fail to avail himself 3 34 OFFICE EQUIPMENT AND METHOD OF EXAMINATION of this method, provided the circumstances permit his doing so. Biirger' reports 78 positive findings with the x-ray in 100 foreign body cases. Radiographs when taken from several varying positions are more accu- rate in locating a foreign body than fluoroscopic examination. How- ever, with the aid" of the fluoroscope, one can see the body move in various directions during forced expiration and inspiration, which will sometimes enable the object to be located. Owing to the movement of the ribs, diaphragm, and other anatomical structures within the chest, at the time the radiograph is taken their shadows may obscure it. It is the practice of opeiators to examine with the fluoroscope all cases in which the radiograph has failed to locate the body. Errors of loca- tion are to be kept in mind by the operator. Fig. 31 Laryngoscopio image. Laryngoscopy.— Jmiwed.— This is accomplished with the use of the laryngoscopic mirror, which is warmed sufficiently to prevent conden- sation of the breath, and with the patient's tongue held well forward with the left hand, the mirror is passed in with its shank clinging closely to the left cheek, and when just beneath the soft palate it is turned with 'von Brilnings: Die direote Laryngoskopie und CEsophagoskopie, 19X0. DIRECT LARYNGOSCOPY 35 the mirror surface toward the larynx, and the palate and uvula are gently elevated on its upper margin. The mirror is then fixed at an angle which reflects the structures of the larynx. It should be held in one position and not moved from side to side, as this irritates the pharynx and causes pharyngeal intolerance. The handle may be raised or lowered to bring into view the different aspects of the larynx. Attention is first drawn to the base of the tongue, where frequently there appears a lymphoid structure called the lingual tonsil. Here also a venous plexus exists, which if congested will produce a varix which may be annoying. The second structure is the epiglottis, which often is the seat of tuberculous malignant or syphilitic lesions. Thirdly, the false vocal cords, or ventricular bands, beneath which lie the true cords, and between the two on either side, is the ventricle of Morgagni. The true cords are attached posteriorly to the arytenoid cartilages, between which is a space known as the interarytenoid space. Notice should also be taken of the movement of the cords upon the patient's saying "ah," and if they move symmetrically, or if one or both are incapable of adduction. In singers suffering from hoarseness or voice fatigue, careful attention should be given to the position of the cords upon phonation; whether they are convex in their centres and come in contact at one point, or whether concave; also, whether there are vocal nodules on the surfaces or borders of the cords. The subglottic region must be taken into consideration, and the probability of a growth being below the cords. The trachea can often be seen as far down as the bifurcation and its topography studied. Use of Cocain in Throat Examination. — A spray of cocain solution (2 to 4 per cent.) will sometimes, in rebellious patients, be of service in allaying pharyngeal irritation, and in thus securing a better examina- tion of the pharynx and larynx. Very often, however, this exaggerates rather than allays such disturbance, and in the use of indirect laryngos- copy it should be employed only as a last resort. In direct laryngoscopy it will usually be found desirable thoroughly to anesthetize the parts with cocain. In indirect laryngoscopy the sucking of ice or, better, the use of a bromide of potassium gargle at intervals preceding the patient's next visit will frequently overcome the embarrassments arising from a rebellious throat. Direct Laryngoscopy.— The patient may be examined either sitting in a low chair specially devised for the purpose, such as Briinings' (Fig. 32), or lying recumbent upon a table. Sitting Position.— Adults only can be examined in this position. The patient sits in a low chair with the head extended and the chest and thorax held well forward by the curvature of the back of the chair, so that the mouth, larynx, and trachea are brought into nearly a direct line (Fig. 33). The examiner stands in front of and slightly to the right of the patient. With the thumb and little finger of the left hand the lips are elevated away from the teeth to avoid injury from the tube in its passage. With the remaining fingers of the left hand the examining spatula is directed downward until the tip of the instrument engages 36 OFFICE EQUIPMENT AND METHOD OF EXAMINATION the tip of the epiglottis upon its under surface, when the operator ele- vates the handle of the spatula with the right hand and makes forward pressure against the epiglottis. The employment of a mouth gag in the examination of the larynx is unnecessary, as the spatula acts in this capacity. Before the introduction of the instrument the light is turned on so that the eye of the examiner may follow the tip of the instrument throughout its passage into the larynx. When the larynx alone is to be examined the instrument may be introduced until it just engages the epiglottis. The direct examination of the larj-nx in children with a spatula especially devised for the purpose by Kirstein has been sup- planted by the direct methods of Killian and Jackson, with the patient in a recumbent position. Fig. 32 Briiiiings' chair. Bursal Vccuhltus.—Boycc Position (Fig. 34).^The patient lies upon the back, with the shoulders extending from four to six inches beyond the head of the table, so that the head and neck are freely movable and under the control of the assistant assigned to this work. The head is extended on the occipito-atlantal joint, while the mouth, larynx, and trachea are brought into a direct line. The cervical vertebra? and the instru- ment to be passed should be in the same horizontal plane. This definite relation between the cervical vertebra and instrument must be main- tained by the special assistant, who also administers general anes- thesia. In order to do this properly, he must sit at the head of and to the right of the patient, with his left foot supported upon a stool, twenty- DIRECT LARYNGOSCOPY 37 six inches lower than the top of the table. His left hand rests upon his left knee, and grasps the patient's head firmly at or in front of the bregma, bending it backward and exerting a certain degree of upward pressure. His right forearm and hand are extended under the neck of the patient, and the jaws are held apart by a metallic thimble upon the Fig Direct laryngoscopy and bronchoscopy in the upright position in Brunings' chair. right forefinger, specially designed by Boyce for this purpose. The use of the mouth gag is unessential. For the introduction of the laryn- geal speculum, it is only necessary to open the jaws slightly, and if this instrument alone is used, neither thimble nor mouth gag are essential. The greatest difficulty in passing a laryngeal speculum is due to over- 38 OFFICE EQUIPMENT AND METHOD OF EXAMINATION extension of the head backward, and frequently slight flexion of the head upon the breast will materially aid the introduction of the instru- ment. Fig. 34 Direct laryngoscopy. Dorsal decubitus. Boyce position. Fig. 35 Fig. 36 Thimble gag. Bite block for bronchoscopy and esophagoscopy. Masker's Lateral Position.— "In this instance the patient's head and shoulders are supported by the table instead of the assistant's hand and DIRECT LARYNGOSCOPY 39 arm. He is laid flat upon his back on- the table and the head is turned on the left cheek, with the chin flexed sHghtly upon the breast. The muscles holding the larynx are thereby relaxed and the ligaments at the base of the tongue loosened. The larynx, not having any tension upon it, remains movable and will adapt itself more easily to the intro- duction of the instrument. The distance also between the entrance at the mouth and the larynx is shortened." A speculum has been specially devised by Mosher for use in this position. It cons'sts of a combination of tongue depressor and mouth gag, and is so constructed that while the operator holds it in his left hand, he still has his right free for examina- tion. There is no hood, so that the wall of the pharynx is seen and the operator's eye does not get the cramped feeling which comes from looking long through the tube spatula. The fulcrum for the leverage of this speculum is the left upper bicuspid teeth. Fig. 37 Mosher' a laryngeal spatula and mouth gag. Technique. — "The jaw is slightly opened by a mouth gag; the operator kneels at the head of the patient on the left side. Either reflected light from a head mirror or the Kirstein forehead light is used. The speculum is introduced at the left angle of the mouth and pushed straight back until the base of the tongue is passed; at this point the mouth gag must always be removed, for if left in it interferes with the view. When the base of the tongue is passed the upper flange of the speculum falls naturally into place against the bicuspid teeth. The speculum is now pushed farther in, and at the same time the tip is carried forward by elevating the handle. In this way the epiglottis is brought into sight 40 OFFICE EQUIPMENT AND METHOD OF EXAMINATION and the end of the speculum carried down behind it. At this point the arytenoids and the posterior half of the vocal cords come into view. In order to bring the anterior commissure into the field the assistant is told to push backward on the larynx; as he does so the anterior part of the cords can be seen. In inspecting the cords and the pyriform sinus the tip of the speculum is allowed to fall behind the arytenoid and then is carried down back of the cricoid. On raising the handle of the speculum again the cricoid cartilage is carried forward. Following this last maneuver the upper inch and a half of the esophagus opens up into a funnel."^ The direct method of examination of the larynx can in many instances be employed successfully where the indirect is practically impossible. This is particularly so in infants and young children. While Kirstein's method of examination of children's larynges meets every requirement, in isolated cases it is accomplished only at the expense of great dis- turbance to both examiner and patient. It is also necessary to make the examination too quickly to be always accurate. The direct method enables one to determine the presence of foreign bodies and neoplasms in the larynx, irrespective of irregular anatomical formations. The epi- glottis in some cases assumes such shape that it is practically impossible to see the entire larynx with the laryngoscopic mirror, and only the anterior commissure and possibly the anterior third- of the cords come into view; while with the laryngeal speculum the anterior and the pos- terior parts of the larynx, as well as the upper part of the esophagus, the usual site of malignant involvement, are brought clearly into view. For purposes of removal of sections for microscopical examination and for the removal of small neoplasms of the larynx, direct laryngoscopy offers safe methods, even in the hands of the comparatively inexperienced, and it is far easier to learn to remove neoplasms from the larynx by the direct method than by the indirect method. Bronchoscopy. — Here, as in the examination of the larynx, the sitting, the recumbent position of Boyce, and the recumbent lateral position of Mosher are likewise employed for examination as well as for operative procedures. The laryngeal speculum is introduced first. After a clear view is obtained of the opening and closing of the larynx during respira- tion, the bronchoscopic tube, selected to meet the requirements of the age of the patient, is introduced through the slide speculum, and during inspiration is advanced between the vocal cords into the trachea. The eye of the operator must be held constantly at the opening of the bron- choscope, and kept there during its descent downward to the foreign body, otherwise the instrument may override it at any point. If the foreign body has not been previously located by the a;-ray in either the one bronchus or the other, it is advisable to explore the left bronchus first, for although it is longer and narrower than the right, it is straighter and more liable to be the recipient of the foreign body. Briinings, however, claims that foreign bodies show a preference for the right ' Mosher, Boston Medical and Surgical Journal, February 6, 1908. ESOPHAGOSCOPY 41 bronchus. The bronchial tree, although it extends outward at an angle to the trachea, is thoroughly flexible, and will come into direct line with the upper end of the trachea and larynx, with but slight pressure from the instrument. Each division of the bronchial tree must be examined until there remains practically no possibility of the existence of a foreign body in that locality. After definitely determining the absence of the body in the left bronchus, the instrument is withdrawn and introduced into the right, which is shorter, larger, and at a greater angle to the axis of the trachea than the left. The examination here is pursued in a similar manner to that of the left. Esophagoscopy. — The passage of a bougie previous to the introduction of the tube is strongly advocated by Gottstein and others to ascertain the depth of a foreign body, to determine the width of a stenosis, or to locate disease in the cervical portion of the esophagus. This pro- cedure is deemed unnecessary by Briinings. Esophagoscopy should be done preferably in the morning and when the stomach is empty. As this is frequently impracticable, irrigation of the esophagus or preparation to use the stomach tube during opera- tion should be made. Disinfection of the mouth and esophagus are unnecessary. Fig. 38 V.MUfLLfff&CO Schema showing relation of the cricoid cartilage (the circle) to the posterior hypopharyn- geal wall, in the recumbent patient, observer looking down the esophagus. The pyriform sinuses are at the positions marked X. The same positions are applicable here as for the other two examina- tions. It is more essential, however, that the cervical vertebrae and the esophagoscope should be in the same horizontal plane in this pro- cedure than in the two former, otherwise the end of the instrument will strike the greatest curvature of the cervical vertebrae and not enter with ease into the lumen of the esophagus. A scheme devised by Jackson suggests to the mind of the operator an easy method of entrance into the esophagus. The introduction of the tube is facilitated by its pas- sage through the extreme right angle of the mouth, particularly if the wisdom or molar teeth are out on this side, or if they are not out here, and are lacking on the left, the left side should be selected. The pyriform sinus opposite to the side. selected for the introduction of the tube is the one to be approached. If the larynx is held forward by an instru- ment designed for the purpose, the esophagus opens up before the eye of the operator. The examination of the esophagus is particularly easy until the constriction of the diaphragm is reached, which it is often necessary to overcome with general anesthesia. 42 OFFICE EQUIPMENT AND METHOD OF EXAMINATION Contra-indications. — Aortic aneurysm, cirrhosis of the Hver, uncom- pensated heart lesions, embarrassed respiration from stenosis, phthisis, and emphysema. In extreme cases these contra-indications must be disregarded, inas- much as mortality in esophagostomy for foreign bodies is from 10 to 20 per cent. (Briinings). Gastroscopy. — Gastroscopy is justifiable in any condition where suspicion of stomach involvement is of such gravity as to warrant the administration of a general anesthesia. Its most frequent use is for diagnostic purposes, for any foreign body of sufficiently small size to enter the stomach will in all probability pass through it into the intes- tinal tract. Complete general anesthesia is essential for proper investi- gation of the stomach. Many varieties of instruments have been devised, both rigid and elastic. Under proper anesthesia there is no difficulty in passing a straight inelastic tube, provided there is no constriction intermediate between the mouth and the stomach to prevent its passage. The distal illuminated tube is the best instrument for gastroscopic work, for the tube is of necessity of such length that the proximal illumi- nation is insufficient in intensity to carry to its distal end. The objection brought against the distal illuminated tube is that the light bulb becomes heated and throws off vapor, also that it becomes smeared with secre- tions and blood, which necessitate constant wiping. The first of these objections is erroneous so far as the experience of the majority of operators has been expressed. The second objection can be readily overcome by more or less frequent wipings of the lamp. In the living subject the stomach remains in an almost vertical position, and presents to the eye of the examiner two walls in apposition. There have been methods devised by Briinings and Janeway that will dilate the stomach with oxygen or air and thus afford a view of the entire walls of the stomach. Jackson has demonstrated that the stomach is movable through a wide arc, varying from 6 to 12 centimeters, also that the diaphragm can be dragged from side to side. The eye of the operator should follow the passage of the tube both through the esophagus and into the stomach, and if this is carried out the use of the lens system is rendered super- fluous; but after gaining entrance into the stomach it may be added, if desired, although it will require gastric distention. The first examina- tion should be made of the walls of the stomach before dilatation takes place, so that it may be palpated with a probe and wiped with a swab and otherwise examined by degrees, until a definite conclusion relative to the walls is obtained. Jackson^ says there is no human being with a normal spine and a normal esophagus into whose stomach a straight and rigid gastroscope cannot be readily and safely introduced, provided (1) the patient is fully anesthetized, (2) an open tube of light construc- tion is gently passed by sight; (3) the patient's head is held in the Boyce position; (4) the operator is a skilful esophagoscopist. ' Laryngoscope, September, 1911. GASTROSCOPY 43 Instruments. — Innumerable varieties have been advocated by their designers and adherents, all of which have possessed more or less merit, but those most frequently employed at the present time are Killian's, Jackson's, and Briinings', while Kirstein, Mosher, and others have devised special instruments for specific purposes. For comprehensive description it is necessary to take the instrumentarium up under separate headings, and only cursory mention can be given; for further reference the books of Jackson and Briinings on the subject of tracheobron- choscopy, esophagoscopy, and gastroscopy are recommended to the student. Illumination. — The same illumination is adaptable to the examination of the larynx, trachea, bronchi, esophagus, and stomach, and the selec- tion depends upon the individual preference of the operator. Kirstein's head lamp was one of the first successful electric illuminators, and with it Killian and others performed very effective work. The illumination, however, was insufficient for use in the longer tubes, and very inferior to the present instruments for this purpose. Fig. 39 Kirstein's head lamp. Jackson was the first to present the distal illuminating tube, which consists of a tiny electric bulb on the end of a projector, which is directed through a separate groove on the side of the tube until the light is just disengaged near its tip. The source of light is from a battery designed for this purpose. The broncho-electroscope devised by Brunings consists of two parts: first, the illuminating part or the electroscope, which comprises the burner, condenser, and reflector, and second, the mechanical part, con- sisting of the tube holder, handle, and a spring which limits the revolution of the lamp. Kohler's apparatus is a modification of Briinings', and is highly praised by those who have used it. 44 OFFICE EQUIPMENT AND METHOD OF EXAMINATION Laryngoscopic Spatidw. — One of the first efficient spatulse was tliat of Kirstein, ^vhic•h consisted of an open plate with a hood at the proximal end . Fig. 40 Briiniiigs' broncho-clectrosnnpe. Fig. 41 Kirstein's laryngoscopic spatula. 46 OFFICE EQUIPMENT AND METHOD OF EXAMINATION Jackson employed both tubular and separable specula for the examina- tion, first of the larynx, and with the separable speculum he was able to pass the bronchoscopic tube through the larynx with very satis- factory distal illumination at the time of passage. In both Jackson's instruments distal illumination is employed. Mosher's open speculum has its most efficient use in the examination of the larynx and upper part of the esophagus.^ Briinings also has some variations in his autoscopic spatula which are of more or less merit. Fig. 44 Briinings' bronchoscope. Fig. 45 'j'l'^j! Jackson's bronchoscope. Bronchoscopes. — Killian, von Schrotter, Ingals, Jackson, Briinings, and others have modifications of the same principle, viz., a long tube of varying size and length, with sufiicient illumination either proximal or distal to locate the foreign body and illuminate it sufficiently to permit its removal. The telescopic tubes of Briinings enable one to extend the same rigid tube to the extremity of the bronchus without removing it, which is a great advantage Jackson's bronchoscopic tube has a separate drainage canal, which enables the operator to maintain a dry, clean condition at the distal end of the tube. Ingals' light carrier served a good purpose before the Jackson tubes were in general use and before proximal illumination became so effective, but now it is not so important. Laryngoscope, June, 1909. GASTROSCOPY 47 Esophagoscopes. — Einhorn's instrument consists of a long straight tube in which is fitted a mandarin for introduction, and of a distal electric illumination. Jackson uses the long bronchoscope for esophageal work, as does Briinings. Mosher also employs the same instrument for upper esopha- goscopy as for laryngoscopy. Kirstein employs the same style of straight tube as for bronchoscopic work, with a window cut in its upper surface. Gastroscopes. —Mikulicz devised a long tube with a bend of 150° at the junction of the ventral and middle thirds to accommodate itself to the curve of the vertebral column, but which, according to Jackson, limits the rotation in the stomach to 180°. Fig. 46 tTaokson's esophagoscope. The present-day gastroscope is an elongated esophagoscope and Jackson's instrument is 70 cm. long for adults. Modifications in length and size to meet the requirements of the age of the patient are to be found in any of the tables relating to the subject. Length op the Esophagus at Diffekent Ages. FBOM StABK. Compiled by Mosheh Birth 1 year 2 years 5 years 10 years 15 years Adult Teeth to cricoid. To bifurcation. 2| in., 7 cm. 4 in., 10 cm. 4 in., 10 cm. 4 in., 10 cm. 4 in., 10 cm. 5^ in., 14 cm. 6 in., 15 cm. 4f in., 12 cm. 5i in., 14 cm. 6 in., 15 cm. 6i in., 17 cm. 7 in., 18 cm. 9 in., 23 cm. lOJ in., 26 cm. To cardia. Whole esophagus. 6| in., 18 cm. 81 in., 22 cm. 9 in., 23 cm. lOJ in., 26 cm. 11 in., 28 cm. 13 in., 33 cm. 151 in., 40 cm. 4 in., 10 cm. 4i in., 12 cm. 5i in., 13 cm. 6| in., 16 cm. 7 in., 18 cm. 7i in., 19 cm. 10 in., 25 cm. Diameter op the Esophagus at the Four Constkiotions. Transverse Anteroposterior Constriction. diameter. diameter. Vertebra. Cricoid 1 in., 23 mm. f in., 17 mm. Sixth cervical. Aortic 1 in., 24 mm. | in., 19 mm. Fourth thoracic. Left bronchus 1 in., 23 mm. J in., 17 mm. Fifth thoracic. Diaphragm 1 in., 23 mm. 1 in., 23 mm. Tenth thoracic. 48 OFFICE EQUIPMENT AND METHOD OF EXAMINATION Special Instruments. — For laryngoscopic, bronchoscopic, and esopha- geal work. Fig. 47 Safety-pin closer. Upper figure, the safety-pin closer with the receiving ring flat for introduction through the tube. Lower figure, the ring turned upward to aright angle and the safety-pin closed by the ring. Mosher's two varieties of safety-pin closers appear to embrace all the mechanical requisites for the safe conduct of the pin through either the bronchi or the esophagus. A description of them is unnecessary, as the figures indicate their method of employment. Fio. 48 Safety-pin catcher. Rigid safety-pin catcher for the lower pharynx and the upper esophagus. Upper figure, full-length side view. Lower figure, the method of grasping and closing a safety-pin. Coins and buttons are sometimes difficult to grasp, particularly when they are located transversely in the bronchus or esophagus. It then has to be turned to one side so that the instrument can be passed behind it in order to grasp it. Fig. 49 Coin and button tube. The upper figure is a full-length side view of the tube, with the hook pushed down a httle beyond the tube. The lower figure shows the method of grasping a button with the tube. Jackson's forceps, fitted to a universal handle, offers all that is to be expected in a forceps for the removal of specimens for examination or for the removal of neoplasms. SPECIAL INSTRUMENTS 49 Fig. 50 Brunings has also devised a number of different-sized and shaped forceps, some of which can be employed for the removal of specimens and other purposes, such as the re- moval of neoplasms. Any of the von Schrotter instru- ments can be fitted to a universal handle, so that specimens or neo- plasms may be removed from the bronchus, larynx, or stomach. For foreign bodies hooks, blunt and mouse-toothed forceps, and nearly every conceivable instrument have been employed to meet the individual Fig. 51 Jackson's laryngeal forceps. Mosher's forceps for direct intubation. Extractor in place. requirements of the cases. In certain instances the ingenuity of the operator would be taxed to devise an instrument not yet constructed Fig. 52 Mosher's forceps holding intubation tube. to remove the foreign body. The peculiarity of its shape, its size and location are factors governing the character of the instrument necessary for its safe removal. Fig. 53 Mosher forceps demonstrating how the tube can be raised to facilitate introduction. Mosher has devised an instrument by which the O'Dwyer intubation tube can be safely and easily introduced into the larynx, and in the 4 50 OFFICE EQUIPMENT AND METHOD OF EXAMINATION hands of those inexperienced with the previous methods of intubation, it is probably the safer and more rehable procedure. Anesthesia. — The necessity for anesthesia varies in frequency in- versely with the skill of the operator. According to Jackson, there is no necessity for any anesthesia of the larynx for diagnostic purposes in either children or adults; none for the removal of foreign bodies or papillo- mata in children and infants; and none in bronchoscopy or esophagoscopy of children. Local Anesthesia. — Local anesthesia is employed for the removal of foreign bodies in the trachea and bronchi of adults; for removal of specimens or neoplasms from the adult larynx; for bronchoscopy and tracheobronchoscopy, but only to the larynx or lower down, when it is necessary to overcome coughing induced by the instrument passing the bifurcation; then it is necessary to apply the cocain by means of a specially constructed spray apparatus. General Anesthesia. — In Bronchoscopy. — It is employed in broncho- scopy for the difficult removal of a foreign body, for the closure of open safety-pins, and for the removal of foreign bodies lodged in the trachea. Anesthesia is to be employed in partial stenosis of the bronchus, but it is unwarranted unless there is a tracheal tube in place. In laryngoscopy, by direct method it is indicated for children, for excitable and hysterical patients and for the removal of laryngeal neoplasms in the adult. In esophagoscopy it is usually necessary for excitable children, for diagnosis in spasmodic or organic stricture, and in cardiac spasm of the stomach. In gastroscopy, general anesthesia is desirable to render the diaphragm limp so that it can be dragged about without hindrance. Rules Governing the Use of Cocain. — 1. Cocain should never be used in infants or small children. 2. Its use should be avoided, if possible, in all cases, such as papillo- mata, in which frequent sittings are necessary. 3. The patient should never know the name of the drug. 4. The amount used should be the minimum. 5. Solutions may be applied by: (a) Spray. (6) Syringe. (c) Painting syringe (Briinings). (d) Applicator carrying cotton or gauze, saturated but not dripping with solution. 6. The stomach should always be empty, not only because the tendency to retching and vomiting are thus lessened, but because, as proved by Briinings, absorption of cocain is thus lessened. Additional anesthetics are bromides, morphin, and heroin. These drugs unquestionably aid either the local or general anesthesia. Atropin as advocated by Ingals lessens the secretions, which materially facilitates operative procedures, while adrenalin will occasion less absorption of the cocain by bleaching the mucous membrane. ANESTHESIA 51 Jackson^ claims ether to be the best general anesthetic, to which can be added chloroform occasionally, if the necessity arises for relaxation. Brunings, on the other hand, prefers chloroform, as the secretions are much less than when ether is employed. He has designed a special sponge syringe for the application of cocain. In our clinic at the Manhattan Eye, Ear, and Throat Hospital the following method of local anesthesia has been successfully employed, and has been favorably advocated for this particular work by Dr. F. W. White. First cleanse the mucous membrane of all mucus by syringing the pharynx and larynx with a solution of bicarbonate of soda, or diluted Dobell's solution. Owing to the presence of a small amount of carbolic acid in the Dobell solution, a slight anesthetic effect remains for some time after using it. When the mucous membrane is cleansed of its mucus it more readily takes up the cocain and very much less is required to produce proper anesthesia. To one dram of a 20 per cent, solution of cocain add one minim of epinephrin. Then with a laryngeal syringe one drop is allowed to fall upon the base of the tongue and another upon the under surface of the epiglottis. This will produce slight reflex coughing, after which the patient should expectorate and not swallow the solution. In case coughing does not occur the patient should be instructed to make the attempt and to expectorate that which is raised, for by this act the cocain is disseminated to adjacent parts of the larynx and base of the tongue. After a lapse of three or four minutes the second application is made. This time the patient is instructed to say a (not ah), very gently, and while the cords are in apposition a drop of the solution is allowed to fall upon them. If coughing does not occur the patient should be instructed to force the cough as before. After this second application the tip of the syringe is carried high up on the pos- terior pharyngeal wall and one drop of the solution is drawn from one side to the other and allowed to trickle down the posterior wall. As it is seen to pass the level of the base of the tongue the patient is instructed to expectorate. Within two or three minutes the application is repeated during the act of phonation. At this time cough will probably not occur; if it does two drops are permitted to fall directly into the trachea while the cords are abducted. This will undoubtedly create a reflex cough. When it has ceased the base of the tongue, the laryngeal surface of the epiglottis and posterior wall of the pharynx are tested to see if they are anesthetic. If not the same procedure is gone through with as directed above. To anesthetize the trachea one or two drops of the solution is allowed to fall as nearly as possible into its centre, which usually suffices for the passage of the tubes, even as far as the right or left bronchus, and it eliminates the disagreeable necessity of making the deep applications by means of a spray or applicator. The one irritable spot after passing the cords is the bifurcation of the trachea. The advantages of the use of the syringe under the guidance of the laryngeal mirror are these: 1 Jackson, International Clinics, 1911, vol. ii, series 22. 52 OFFICE EQUIPMENT AND METHOD OF EXAMINATION 1. No irritation of the mucous membrane is produced by cotton swabs. 2. If a foreign body is present it is not disturbed by the applicator. 3. The pathological aspect of the mucous membrane is not altered by local application. 4. There is less fright on the part of the patient, and the time of anesthesia is lessened. 5. The procedure is executed under the indirect vision of the laryngeal mirror. Suspension Laryngoscopy. — This method was devised by Killian, and consists in holding the lower jaw, tongue, and epiglottis away from their contiguous parts by means ^i°- 5* of a spatula suspended from a horizontal bar called a gallows, the lower end of which is fixed to the operating table by screws. Instruments. — 1. An operating table, the top of which can be made horizontal, and the head of which may be raised or low- ered to meet the requirements of the operator. 2. The gallows, or stand, which consists of a vertical portion at- tached to the table, from the upper end of which projects the horizontal portion over the sub- ject to be operated upon. This arm may be raised or lowered by means of a screw arrangement attached to the lower end. It can also be moved backward and forward by means of another screw. The horizontal part is notched at intervals to accom- modate the swinging spatula and to prevent its slipping. 3. The Hook Spatula. — At one end of a 32-cm. shaft there is a loop or bow which if viewed from the front presents to the left, thereby leaving a free entrance into the throat upon the right side. On the lower end of the loop is a small plate with the plane parallel to that of the spatula. By moving the loop this plate is brought nearer to or farther away from the spatula, by which the mouth can be opened or closed as the plate rests against the upper incisor teeth, which, with the head hanging, are, of course, below the lower incisors. A small ridge is located upon this plate, which passes posterior to the incisor teeth, and by means of a screw it can be made to press against the teeth, thereby rendering Killian's gallows for suspension laryngoscopy. SUSPENSION LARYNGOSCOPY 53 the jaw immovable. The opposite or upper end of the shaft is curved forward, and by means of this curved portion it is suspended from the horizontal portion or gallows. The spatula is situated at right angles to the shaft, from which it may be separated to accommodate different sized spatulse as required by the varying cases. There are two forms of spatulse, of which there are four sizes in each and all of them are V-shaped upon cross section. Operative Procedure. — Subjects with short thick necks are difScult to examine, and for practice it is advisable to select a patient upon whom the ordinary methods of direct laryngoscopy have been practised previously. Those without upper incisor teeth are the easiest to examine and it may be accomplished frequently without the use even of cocain. The difficulties met with by the direct method of examination are also experienced here. Thorough local anesthesia must be obtained after the manner described previously, to which may be added a hypodermic injection of morphin and scopolamin. In young subjects these two drugs are contra-indicated. The patient is then placed upon the oper- ating table so that his shoulders are just in line with the end of the table and the head freely movable and under the control of the assistant. The operator is seated at the head of the patient and introduces the spatula carefully far back into the phraynx while the assistant adjusts the horizontal piece at the proper height and hangs the tongue spatula in place. A mouth gag and tongue forceps may be used if the patient will not open the mouth and protrude the tongue in accordance with the request of the operator. A Kirstein lamp is employed for illumina- tion. The screw that is fixed upon the spatula is now employed to open the mouth almost to its maximum, when the interior of the larynx is brought into view. The posterior commissure, the trachea, the pyri- form sinuses, and occasionally the upper part of the esophagus are clearly visible, while both hands remain free for operative work. The anterior commissure is not so easily seen, which is one of the arguments brought against the employment of this means of examination. Lateral Introduction of the Spatula. — ^When it is found impossible to introduce the spatula with the head directly extended, either from an uncontrollable tongue or because of the loss of one or more teeth in the wrong place, the spatula may be introduced with the patient's head turned to the right or to the left. It is then introduced on the upper side of the mouth and the tongue pressed upward, by which a clear, but narrow view of the larynx may be obtained. It is only justifiable when the other way is associated with much difficulty. Operative procedures in the larynx and upon the structures under direct vision are easily accomplished, while upon the more remote struc- tures it may be performed with the bronchoscope or esophagoscope, just as described under their respective heads. The necessity for a skilled assistant to hold the head and the avoidance of the very tirespme procedure of holding the instrument with the left hand for a long time, while employing the right in operative measures, are sufficient arguments in favor of this method for examination and operation. The adverse 54 OFFICE EQUIPMENT AND METHOD OF EXAMINATION criticism might embody the pain experienced by the patient incident to long suspension, possibly some pressure paralysis, and the inability to view the anterior part of the larynx with ease. Fig. 55 Position in operating with the help of the suspension laryngoscope. INSTRUMENTS AND MEASURES EMPLOYED FOR THE TREAT- MENT OF THE UPPER AIR PASSAGES. Douches. — Except in a limited number of conditions of the upper respiratory tract, douches should not be employed. This statement applies principally to douches administered through the anterior nares and flowing back into the postnasal space. The postnasal douche, however, when properly given, is one of the most valuable means we have at command for overcoming postnasal catarrhal conditions and for cleansing the nares throughout. The postnasal douche consists of a small barrelled syringe with a long postnasal tip attached. This tip should be curved gently upward at its distal extremity for about one-half inch. The openings should be anterior and posterior in the flattened oval tip and not on the sides, so as to permit the solution passing forward and backward, but not laterally, into the Eustachian tubes. Dobell's solution one part and two parts hot water make the most agreeable cleansing agent, while a 10 per cent, solution of argyrol added to the remaining part of the Dobell solution after one syringeful has been employed gives the best results in catarrhal colds. In empyema of the sinuses the Douglass douche is the most valuable INSTRUMENTS FOR TREATMENT OF UPPER AIR PASSAGES 55 when properly employed, as it emits a large flow of water, which flushes without exerting undue pressure. The gravity douches, where the flow comes from a suspended fountain syringe, or from the various styles of bottles and metallic receptacles on the market, are unreliable as regards the quantity of pressure exerted; whereas with the Douglass douche both the doctor and the patient can regulate by hand pressure the force of the flow of the solution through the nares. Fig. 56 J> Fig. 57 The postnasal douche. To employ the Douglass douche properly the nasal tip is introduced from one side, while the patient bends well forward over a receptacle. The head is flexed upon the chest, and breathing continues through the mouth during the administration of the douche. If this is carried out properly the solution will fill the entire nares, flowing from one side to the other, behind the septum, and in addition to flushing out the contents of the nasal fossse will create a cer- tain evacuating force in the adjacent sinuses. The initial douche should begin on the un- affected side so as to carry out the discharge that has come into the nostril from the dis- eased sinus of that side. After one or more douches upon the healthy side the reverse douching may take place. The small glass Birmingham douche has been so universally used that everyone is familiar with its char- acter and the conditions for which it is rec- ommended. While in a few instances it may have overcome certain nasal disturbances, upon the whole it has probably been abused and has brought about pernicious conditions in excess of the good that it has done. The evils resulting from the use of any of these douches are: Eustachian catarrhal conditions, sometimes purulent infection of the middle ear, a highly sensitive nasal mucosa, which will become turgescent shortly after the douche and. give more obstruction than existed previous to its employment. It also washes away the normal nasal secretion which itself acts as a protective influence against infection. It also tends to produce a habit which grows on the individual the more it is used and finally neces- sitates constant douching to overcome the dryness and uncomfortable sensation which results. Douglass' douche. 56 OFFICE EQUIPMENT AND METHOD OF EXAMINATION Solutions. — The remedies suggested for use in nasal catarrhs and other disturbances of the nose, producing similar symptoms, are without number. Glycothymolin has been upon the market for a number of years and has rendered itself familiar to the majority of people, par- ticularly in closely settled districts where gases and dust apparently tend to dry the mucosa more than in rural communities. There are a number of alkaline antiseptic tablets, such as Seller's, Dobell's, etc., which are in convenient form for the use of both patient and physician. The most desirable solution for postnasal employment is the liquid Dobell solution well diluted. It should be in the proportion of one part Dobell solution to two parts water Fig. 58 Fig. 59 The de Vilbiss spray. The Davidson spray. Sprays.— There is no doubt in the minds of the majority of throat specialists that sprays have been long abused, particularly when used in the nose. The pharyngeal and laryngeal mucous membranes are better able to withstand the trauma of a spray than the nasal mucosa, and it has been observed by many employing sprays in the nose that a marked hyperemia occurs in from one to two hours after the spray is first administered, and that instead of permanently overcoming the turgescence which exists it only does so temporarily and later induces an exaggeration of the previously existing condition. At one time the throat specialists felt it incumbent upon them to be surrounded by a great number and variety of sprays, but keen observation on the part of those looking to the future welfare of the patient has determined that the less sprays are employed in the nose the better the ultimate results obtained. However, for the laryngeal and pharyngeal conditions the spray is an almost indispensable method for the application of medica- INSTRUMENTS FOR TREATMENT OF UPPER AIR PASSAGES 57 ments. It is not certain, however, that the solutions sprayed into the throat always reach the larynx, for much of it stops at the epiglottis. The cotton-wound laryngeal applicator is the surest method of applying solutions to the larynx. Solutions, particularly nitrate of silver, should never be sprayed into the larynx, except in very diluted form, as it almost always induces a spasm, which while not dangerous is sufficiently alarming to the patient to render it objectionable. The postnasal spray has been almost entirely supplanted by the postnasal douche. For the application of silver nitrate the bent cotton-wound applicator is prefer- able, as it obviates any excess of solution falling into the larynx, provided the application is made after the excess is removed. The three most universally used sprays are the de Vilbiss, which has its spraying parts made of metal and can be boiled; the Davidson (Fig. 59), which has its parts made of hard rubber and will carry silver solutions without corroding the tips, and the glass spray, which can be rendered anti- septic and will also carry silver solutions without corroding it. The glass sprays are so fragile that they are being constantly broken through manipulation. A number of other sprays are on the market, which have one or more things to recommend them, but these are not of sufficient importance to be substituted for those mentioned. Insufflations. — At one time medicated powders were blown into the nasopharynx and larynx for the majority of abnormal conditions which came under the observation of the specialist, but in later years these insufflations have been less and less employed until at the present time few are being used except orthoform for the relief of pain in tuberculosis or cancer. Powder blowers both for the nose and throat have been constructed after various models, and are used both with a hand bulb and with a compressed air apparatus. They have been constructed of such shape as will most conveniently convey the powder to the part affected. When snuffs containing certain medications were being used more than at present, there seemed to be a tendency on the part of sufferers to form pernicious habits. Unprincipled manufacturers of drugs soon began mixing small quantities of cocain with these powders, which contributed still more to fix the habit. Recently the dangers attendant upon this practice have been brought forcibly to the attention of the laity as well as to that of the profession, and strenuous laws have been enacted to prevent such practices; consequently the use of all such powders has diminished. Inhalations. — Steam laden with some of the balsamic vapors tends to lessen the irritation of the mucous membranes and to hasten their activity in throwing off the products of inflammation. For a number of years the compound tincture of benzoin added to the boiling water of a croup kettle has been recognized as of considerable merit, but in the more modern appliances for the inhalation of medicated steam, benzoin alone has proved too irritating, and has induced cough in irri- table throats; consequently a less irritating substance has been employed, or if benzoin is used it has been diminished in quantity and likewise has had added to it some non-irritating substance. A prescription 58 OFFICE EQUIPMENT AND METHOD OF EXAMINATION universally employed now, particularly in the special hospitals for nose and throat cases is: ^ — 01. pini pumilionis 3ii Menthol g™. v Tr. benzoin oo 3j Milk magnesisE q. s. ad giv Sig. — 5i to Oj boiling water. This has proved of benefit in bronchial, sinus, and tracheotomy cases. The old-time croup kettle still possesses the same merit that years of use have awarded it, but in recent years several new inventions have been presented which combine utility with convenience. Maws' earthen- ware inhaler will hold the heat for a long period while giving off through its specially arranged mouthpiece steam laden with the medication used therein. Taking advantage of the principle of the "thermos bottle," Fig. 60 Maws' inhaler. there has been constructed a vacuum inhaler which will hold its steam over a period of twelve or fourteen hours if, after the mouthpiece for inhalation has been removed, a separate stopper is inserted to keep the heat within. This arrangement is particularly useful in travelling, as one can keep a steam inhalation on hand during a sojourn overnight on a train. It also enables a patient to have a steam inhalation at the bedside, without the necessity of rising each time to obtain boiling water to make it. There are a number of mechanical devices for nebulizing medicated solutions, which have a certain amount of value in tracheal and bronchial affections. It is necessary, however, to have a reservoir of compressed air, which should afford a pressure of from forty to fifty pounds. These nebulizers are ordinarily a part of the stationary outfit of a specialist's office, and while they may not be of particular value, are yet acceptable to the patient and are at least productive of a favorable mental impression. INSTRUMENTS FOB TREATMENT OF UPPER AIR PASSAGES 59 A number of solutions have been advocated for use in these nebulizers, the majority of which have some oily substance as a base, such as albolin Fig. 61 Fig. 62 Vacuum bottle inhaler. Office nebulizer. or viridol, to which has been added menthol, eucalyptus, thymol, cam- phor, and such other substances of volatile nature as may render the vapor soothing to the mucous membrane. CHAPTER II. THE EMBRYOLOGY AND ANATOMY OF THE NOSE: ITS EXTERNAL DEFORMITIES AND THEIR CORRECTION. THE EMBRYOLOGY OF THE NOSE. In the true vertebrates the olfactory organ has usually the form of a pair of pits. In all the vertebrates these organs are formed from a pair of thickened patches of the epiblast, on the under side of the forebrain immediately in front of the mouth. Each thickened patch of epiblast soon becomes involuted as a pit, the lining cells of which become the olfactory or Schneiderian epithelium. The surface of this epithelium is usually much increased by various foldings. They subsequently become very pronounced, serving greatly to increase the surface of the olfactory epithelium. At a very early stage the olfactory nerve attaches itself to the olfactory epithelium (Balfour). The bony external walls are made up of the extension of the fronto- nasal processes. The invagination of the olfactory pits on each side of each lateral portion is subdivided into an outer and an inner nasal process. The latter are prolonged backward as laminae which finally fuse and form the nasal septum. On the mesial wall of the nasal fossa a small blind pit of epiblast becomes invaginated and extends backward into the nasal septum. This forms the rudiment of Jacobson's organ, which ultimately becomes partly inclosed in a curved cartilaginous plate derived from a cartilage of the nasal septum (Gray). Vestiges of this are sometimes found in the ridges on the nasal septum in adult man. It is highly developed in certain animals, but it is rudimentary in man. It is lined by olfactory epithelium, and up to the fourth or fifth embryonal month it is supplied by a twig of the olfactory nerve, which later disappears (Kolliker), and the cavity is shut off from external communication as from further development. The maxillary sinus, beginning as a depression of the lateral wall of the nasal capsule before the fourth month of embryonal life, reaches its full development by the eighth or ninth year. The frontal sinus is an outgrowth of a depression in the upper anterior part of the lateral wall of the nose of the embryo seen at the fourth or fifth month and in its evolution, which is somewhat complicated, it is closely connected with that of the anterior ethmoidal cells. At the second year of life it has arisen only to the level of the frontal bone. At seven years it has penetrated the frontal bone as a direct offshoot THE EMBRYOLOGY OF THE NOSE 61 from the labyrinth below, with which it communicated by the infun- dibulum. This, direct evolution of the frontal sinus is sometimes com- plicated by its coalescence with a preexisting cell in the ethmoid region, which unites with the cavity coming up from below and has a common outlet in the infundibulum. Sometimes, however, the cavities remain separate, the outer one plainly starting from an ethmoid cell and having no outlet, or there may be septa partially dividing the common cavity due to incomplete coalescence. This irregularity in the development of the frontal sinus has a practical bearing on operative procedures and the diagnosis of conditions for which they are performed. The sphenoidal sinus also arises from the lateral masses of the nasal capsule at the fourth month and pushes itself posteriorly into the body of the sphenoid bone, or rather this develops around the cavity and the sinus is fairly well formed by the eighth or ninth year. During the same period the anterior and posterior ethmoidal cells have grown from mere depressions of surface cells in the fourth month of fetal life to the complicated cavities of the ethmoid bone (Killian) . In the seventh month of embryonal life there has already occurred in the regions of the turbinated bones extensive ossification of the carti- laginous lamellae. Though a fourth turbinate bone is not usually seen in the adult, it is very frequently present, and there are often traces of a fifth and even a sixth turbinate observed. They are all alike developed from the lateral lamellae of the nasal capsule in embryonic life, and probably in their adult developed form of three turbinate bones repre- sent the recession and suppression of structures more highly developed and more numerous in the phylogeny of man. In many of the lower animals this multiplication of the turbinates is observed. The irregular projections and outlying islands of bone in sagittal sections of the tur- binates represent probably more complex branches, providing in the lower animals a larger expanse of nasal mucosa for olfaction and other functions necessary to the survival of lower forms of life, which have undergone retrogression as unnecessary in the course of man's evolution. Killian shows the existence in embryonic life of five chief furrows or depressions with six corresponding ridges in the lateral lamella, and with the exceptional existence of a fourth and a fifth, even a sixth, so-called turbinate bone in adult life. The evidence seems fairly clear from human morphology alone, but the complications observed in the embryonic development of the accessory sinuses would seem to make any arbitrarily selected number of turbinates the original form impos- sible. Killian finds reason to believe that though the ethmoid cells may have been supplied with olfactory nerve filaments before their secondary development, the other sinuses were not supplied with them. The latter existing as slight depressions at the periphery of the lateral masses are from the beginning at a distance from the central nerve supply, while the former lie directly in the olfactory tract in their primary state. In their further expansion the olfactory twigs do not follow them. (For further remarks on the embryology of the nose, see the Embryogeny of the Pharynx.) 62 EMBRYOLOGY AND' ANATOMY OF THE NOSE The external nose is commonly described as made up of bone, fibro- cartilage, and of various muscles, to which they give attachment, covered Fig. 63 Seen from below. Lower lateral cartilage. t-^Sesamohl cartilages Fig. 64 Cartilages of the nose. (Gray.) by integument richly supplied by bloodvessels. The bones entering into the framework of the nose are the nasal bones held firmly in place by the buttresses of the nasal processes of the superior maxilla, forming Fig. 65 Bones and cartflages of septum of the nose. Right side. (Gray.) the arch of the nose. It is important to remember that the septum takes no part in the support of this nasal arch and that the contour of EXTERNAL NASAL DEFORMITIES 63 the bony nose is in no way destroyed by any defect or disease of the nasal septum proper. The lateral and sesamoid cartilages fill in the lower contour of the lateral wall of the external nose, the alar edge of the nostril being largely made up of cellular tissue, while the septum is terminated by a thick fibrocellular band beneath and closely incor- porated with the integument stretching from the tip of the median border of the lower lateral cartilage to the anterior nasal spine of the superior maxillary bone. The lower movable cartilages are governed by the actions of the slender muscles, which tend to constrict or dilate the opening of the nostrils, the compressors, levators, and dilators of the alse of the nose. The arteries of the nose, the lateralis nasi from the facial, the lower artery of the septum from the superior coronary supply the nose below, while above the arterial supply is derived frord the ophthalmic and infra-orbital. EXTERNAL NASAL DEFORMITIES. Etiology. — Traumatism. — From the statistics obtained from thirty- seven operators comprising observations upon fifteen hundred patients operated upon for external nasal deformity by the injection of parafiin alone, it appeared that the majority of the deformities resulted from traumatism. Traumatic injury results from either the mishap of the individual or from the intent of the other party inflicting the injury; in either case the septum is usually crumpled upon itself and the nasal bones flattened out upon the superior maxilla. In the early stages of Fig. 66 Fig. 67 McKernon's hollow rubber nasal splint. Simpson-Bernay's intranasal splint. traumatic injury directly after the accident, the nasal bones can be readjusted and held in position by either hollow rubber splints within the cavity or by several Bernay sponge-splints, fashioned after the Simpson form, placed one upon the other in each nostril, until ample support is given the tissues to maintain them in proper relation. These have to be renewed every other day until the bones have set. It is well to grease with vaselin both the hollow splint and the Bernay sponges before introduction, so that hemorrhage will be lessened and pain 64 EMBRYOLOGY AND ANATOMY OF THE NOSE reduced to a minimum upon removal. An external support can also be given by placing several dry Simpson splints against the nasal bones externally on either side and a few strips of adhesive plaster over them from one cheek to the opposite brow in lamellated fashion, until firm pressure is instituted, when the splints can be moistened and the pressure increased to the degree desired. Traumatic injuries resulting in abscess or hematoma have to be treated for these conditions first before measures can be taken to straighten the deformity. Syphilis. — Next in order of frequency, as a cause of external nasal deformity, is syphilis by involvement of the nasal bones or of the alse of the nose or by necrosis of the bony maxillary buttresses against which the two nasal bones rest. The most difficult conditions to overcome in syphilitic involvement are the adhesions, which flatten the nose against the face and also unite intimately the skin and mucous membrane of the nose after the destruction of bone and cartilage. Abscess of the Septum. — ^This is a condition which results either from infection, syphilis, traumatism, or operative procedure, and often pro- duces the "saddle-back" nose by removing the cartilaginous support of the nose below the nasal bones. Lupiis. — ^The deformity following this condition usually involves only the alae and tip of the nose and is the direct result of loss of tissue. Scalds and Burns. — Many deformities occur as a result of scalds from steam or hot water, while the burns may be either thermal or chemical, the latter being the severer of the two. Burns from alkalies are usually deeper and more extensive than those from acids. Fig. 68 Adams' nasal ferceps. Methods of Correction. — Old Fractures. — It is necessary in these cases to administer a general anesthetic and break away the overriding nasal bone from the nasal process of the superior maxilla. This can sometimes be accomplished by protecting the blades of an Adams nasal forceps with pieces of rubber tubing and placing the one blade in the nostril and the other externally over the nasal process of the superior maxilla, and with a firm lateral motion breaking up the osseous union at this point. After the two sides have been treated in the same manner, hollow nasal splints made of hard rubber are inserted into each nostril for internal support and two small rolls of bandage are placed on the outer side of the fractured bone, and are held in position by crossed strips of adhesive plaster. When the bony union is so firm that undue trau- matism is likely to result from this procedure, it is better to make slight incisions over the point where the nasal bone overrides the nasal process EXTERNAL NASAL DEFORMITIES 65 of the superior maxilla, and with the sharp chisel and mallet break away the nasal process, after which a couple of stitches in the superficial incision is made and the treatment continued as in the other case. Berens has devised an operation by which the nasal processes may be chiselled away from incisions made within the nose. This, of course, has an element of danger from infection, but in those cases cited by Berens,^ no untoward symptoms resulted. In deformities in women this method will prevent any external scarring, although scars resulting from the two small external incisions become almost invisible after a year or so. Where the nasal bones have been flattened out over the superior maxilla so that there is not only widening but depression of the nose, the bridge splint of Carter is applicable, a description of which will be given under the head of "saddle-back" nose. It is generally accepted now that the internal support rendered by hollow rubber splints or Bernay's sponge splints may be obtained better from the employment of the bridge splint, as there is no downward pulling by strips of adhesive plaster placed over the external nose. "Saddle-back" Nose. — ^This deformity results from the following causes in frequency in the order mentioned: Traumatism, syphilis, abscess of the septum, operations, and lupus. 'There are certain depres- sions of the dorsum which are congenital and which may detract from the personal appearance of the individual, but which cannot be con- sidered as deformities. Such cases frequently apply to the specialist for a remedy of the defects of nature, which he is justified in overcoming, providing the matter is of serious import to the individual. Subcutaneous Injections of Paraffin. — ^This method of overcoming nasal deformities of the saddle-back order is a thoroughly justifiable procedure in those cases where the depression is of a gently curved nature and not angular; where the skin is loose and easily elevated from the underlying structures; where the nose is not too broad and not flattened out against the face by a separation of the nasal bones; and where there is some under- lying cartilaginous or bony support for the injected paraffin. The contra-indications to operations for overcoming these deformities by paraffin injections are: syphilitic cases where some activity is still present; diabetic and nephritic cases where the tissues are of low vitality; where there is a predominance of scar tissue which is poorly nourished and which cannot stand any more strain upon the blood-supply; where there is complete destruction of the cartilaginous or bony septuru; where the skin is adherent to the underlying tissues and the tension is so great across the deformity that the injection of paraffin cannot elevate the depression. Paraffin Mixture. — After a number of years of experimenting a paraffin having a melting point of 110° to 115° F. has been adopted by the majority of those employing this method for correction of deformities. Its preparation is best left to a chemist who takes the ordinary commer- cial paraffin with a melting point of about 140° F., and to this adds 1 Annals Otol. and Laryngol., September, 1904. 66 EMBRYOLOGY AND ANATOMY OF THE NOSE petroleum jelly in sufficient quantity to bring its melting point down to the desired temperature of either 110° or 115°. This preparation is then properly sterilized, and in the liquid state it is poured into sterile tubes which are sealed and stoppered under aseptic precautions. Fig. 69 Harmon Smith's paraffin syringe. Instruments for Injection. — In the early injections, liquid paraffin was considered the best form in which to employ it, and various ingenious devices were presented by different authors to keep the paraffin in a liquid state while it was being injected. Quinlan, Eckstein, and Downie Fig. 70 Onodi's paraffin syringe. devised various water jackets and electric heating apparatus to preserve the liquid condition of the paraffin for the space of time necessary to make the injection. After various experiments, however, it was deter- mined that it was better to inject the paraffin' cold instead of hot, as in ' Tubes of paraffin properly prepared may be obtained from C. N. Leigh, Chemist, 158 IWadison Avenue, New York City, N. Y. EXTERNAL NASAL DEFORMITIES 67 SO doing the danger of embolus was materially lessened. The first syringe of this kind was devised by Harmon Smith, by means of which a cylin- drical thread of solid paraffin could be forced out through the needle by employing the mechanical force of a screw piston. Following the same mechanical idea, Onodi and Beck have devised syringes which meet the same requirements. There is little if any advan- tage of one syringe over the other so far as the results are concerned, and here, as in the selection of other instruments, the personal equation must determine the one to be employed. Fig. 71 Beck's paraffin syringe. Preparation of the Patient. — Scrub the nose and adjacent areas with green soap and water, then sponge off with pure alcohol. The forehead and face are covered with a sterile towel and the shoulders and arms with a sterilized gown. Preparation of Instrument and Operator. — ^The paraffin syringe and needle should be boiled. The paraffin which comes in sterilized tubes should be again boiled in a metal cup, which can be placed in any sterilizer, the bottom of the cup being raised sufficiently to prevent the paraffin from scorching. The paraffin is drawn up into the syringe in a liquid state, after which the syringe is dropped into a receptacle of cold steril- ized water, which soon solidifies it. The hands of the operator and the assistant are both sterilized. Method of Injection. — No anesthetic is necessary, although some operators prefer to inject cocain prior to the operation. The patient sits on a stool, so that when the head is tilted backward the nose is about the height of the operator's elbow, with the arms hanging by the side. The operator stands on the left of the patient, and the assistant stands behind and slightly to the right of the patient. The assistant grasps the nose firmly with the balls of his thumbs pressed against the 68 EMBRYOLOGY AND ANATOMY OF THE NOSE nasal bones at the junction of the nasal bone and superior maxilla and with the proximal extremity coming together over the root of the nose. In this way pressure is exerted along both sides of the nose, and will prevent the entrance of the paraffin into the areolar tissue around the eye, and will also prevent its getting into the circulation, should the needle penetrate a small vein. The injection is always made from above downward, as this is in the direction away from danger, and toward nature's natural barrier, which is the adherence of the skin and cartilage to the tip and alse of the nose. Before introducing the needle, which is curved, it is immersed in hot water, and the piston turned several times until the paraffin comes out in a hard cylindrical thread. The first few turns of the piston usually sends forth an interrupted stream of paraffin mixed with some oil and water, but in a few turns all of the oil and water will have been expelled, and the paraffin remains a solid block within the cylinder of the syringe. At the point of injection the skin is lifted up with firm pressure and the needle introduced beneath the skin and into the areolar tissue above the periosteum. The point of the needle is carried just beyond the depression, when the injection is begun slowly and is continued as the needle is gradually withdrawn. The injection is frequently discontinued and the paraffin moulded to meet the 'requirements of the case. During this time a second assistant holds the syringe in place, or the first as- sistant relinquishes his pressure and holds it while the results are noted. It should never be the object of the operator to overcome the deformity at one injection; however, in many instances only one injection is neces- sary. When anemia of the surface occurs further injection should cease, as this is the danger signal that the tissue will stand no more. The needle is carefully withdrawn and hemorrhage, if any, is controlled with adrenalin, after which a dressing of collodion is applied. If con- venient for the patient to do so, rest in bed is advisable for the remainder of the day, and ice-cloths should be applied. When the paraffin melts at 115° F. and is injected cold, it enters the tissue as a hard mass and cooling sprays are unnecessary. A second injection should not be made sooner than a month afterward, for nature is having all it can do to take care of this first injection during this time, and any additional demand may result in necrosis. Accidents. — The discussion under this head will be limited to those accidents resulting from injecting paraffin for the correction of nasal deformities. Embolus. — There are three authenticated cases on record of throm- bosis of the eye vessels immediately following the injection of paraffin for nasal deformity: 1. Amaurosis of the left eye, caused by thrombosis of the ophthalmic vein, reported by Leiser in 1903.^ 2. Amaurosis of the right eye, caused by thrombosis of the arteria centralis retinae, reported by Hurd and Holden in 1903.^ ' Berliner klinisohe Wochensohrift, 1903, pp. 13. 2 New York Medical Record, July 11, 1903. EXTERNAL NASAL DEFORMITIES 69 3. Amaurosis of the left eye, with temporary hemiplegia of a mild character which disappeared in a few days, reported by Thomas H. Huntington, in November, 1904. Fig. 72 Fig. 73 Showing nasal deformity before its cor- rection by paraffin injection. Showing nasal deformity after its cor- rection by paraffin injection. Fig. 74 Fig. 75 Showing nasal deformity before its correc- tion by paraffin injection. Showing nasal deformity after its correc- tion by paraffin injection. 70 EMBRYOLOGY AND ANATOMY OF THE NOSE Errors of the kind mentioned are absolutely preventable by the employment of the rules and regulations cited for the proper technique in the injection of solid paraffin. When these methods have been strictly adhered to, no untoward results have followed. Distribution to Undesirable Locations. — All of the reported instances where paraffin has entered undesirable localities not intended for injec- tion have been when the injection was made with a semiliquid sub- stance, with the needle pointing upward, and with insuflScient precaution in regard to pressure. With a solid paraffin, a screw syringe, with the needle pointing toward the tip, and with the fingers of an intelligent assistant to aid in the procedure there will be no lodgement in any other locality than the one desired. There may be one exception to this statement, and that is where considerable scar tissue exists at the site of the deformity, and the precaution to elevate this with a bistoury is not properly accomplished before the operation. Then, of course, the paraffin will go in the direction of least resistance. Shifting of Paraffin Subsequent to Operation. — Unquestionably there are instances where paraflSn has shifted after its injection, even though it has remained in place for many months afterward. In each instance however, it has been injected in either a liquid or semiliquid state and employed in improperly selected cases. If injected beneath the skin drawn tightly over a depressed nose, the paraffin will work out to either side in the direction of least resistance. If injected also in large quantities into the cheek or forehead in due course of time it seems to gravitate to areas where there are quantities of loose areolar tissue such as surrounds the orbit or exists beneath the jaw. When injected in small quantities over the dorsum of the nose in properly selected cases it forms ultimately for itself a berth of connective tissue which holds it in place, and while some absorption may occur in the course of years it is insufficient to give material evidence of its disappearance. Microscopical appearance of paraffin in the tissues has been definitely determined by an accident which occurred two years subsequent to the injection in one of our own cases, and which permitted the examina- tion of a piece of tissue. The permanency of paraffin in the tissues depends largely upon the melting point of the paraffin and its state at the time of injection. The colder the paraffin at the time the more lasting it will be in the tissues, likewise the better anchorage insured. Cold compresses after the injection is important also, as it favors the anchorage of the paraffin and a collodion dressing over the entrance of the needle as a precaution against infection through this opening. Operations. — For depressed deformities of the nose Carter has devised an operation in which a mechanical splint, known as the bridge spHnt, plays an important part. He divides these deformities into two classes: first, those without loss of bony tissue, in which cases there is an addi- tional callous formation around the displaced fragments, and second, those in which a portion or all of the bony framework of the nose has been destroyed through disease or trauma. In recent fractures the fragments are properly placed and held in position by the administration EXTERNAL NASAL DEFORMITIES FiQ. 76 71 Microscopical appearance of paraffin in the tissues of the nose. Low power. Piece removed from nose of patient two years after injection. Fig. 77 Microscopical appearance of one of the islands of paraffin under high power, showing the endothelial lining of the cavity. 72 EMBRYOLOGY AND ANATOMY OF THE NOSE of a splint to be subsequently described. In old fractures wbere there has been overriding of the nasal bone with separation in the median line, it is necessary to mobilize thoroughly all the tissues and to employ a part of the nasal process of the superior maxilla to aid in bringing the nose to its proper height. A specially devised chisel and chisel forceps are employed for breaking away the nasal bones and nasal processes of the superior maxilla which is done subcutaneously after the method of Berens. Further mobilization of the tissue is accomplished by the use of Adams' forceps, one blade being placed inside the nose and the other covered with rubber tubing on the outside. When the septum is badly deviated a submucous operation is done several days before the other for the employment of the bridge sphnt. "After proper coap- tation of the broken fragments a No. 14 iron- ^iG. 78 dyed silk is passed through one of the holes in the hard-rubber splint and knotted. The other end is threaded into a large curved needle which is passed from within the nose through the cartilaginous dorsum just below its attachment to the nasal bone. • This pro- cess is repeated on the opposite side. The bridge is then supported and the wings ad- ^(t''^' justed with a thumb screw to give the proper Carter's bridge splint. Support to the base of the nasal triangle. The sutures are then run -through the fenes- trse in the bridge corresponding vertically to the other exit from the nose, and drawn tight enough to lift the dorsum into its proper position. There should only be sufficient tension to support the bridge." The bridge is held in place for about ten days and the nasal cavities cleansed daily with pledgets of cotton soaked in Dobell's solution and the alee and nasal fossae kept well greased with vaselin. The conclusions drawn after five years' observation are that the method should not be attempted where there is insufficient bony framework to support the nose after the removal of the bridge. But in these cases bone trans- plantation can be accomplished and the bridge splint will then act as a valuable agent in perfecting the result. Operations for Nasal Deformities Attended by Loss of Bone. — In con- ditions of this character the application of either the bridge splint or the subcutaneous injection of paraffin are inadequate to overcome the deformity. To meet this condition Carter devised an operation whereby the outer part of the ninth rib is transplanted into the subcutaneous tissues of the nose which act as a bony support; one end of the splint rests upon the frontal bone and the other upon the cartilaginous tip. The rib is selected as the best bony structure because of its shape, being slightly bowed to give the nose the normal curve which characterizes it. The rib is also richly supplied with minute nutrient vessels which favor its nutrition. Carter's description is as follows: "The skin over the nose and over the right side of the chest corresponding to the ninth rib is prepared for an aseptic operation. A curvilinear incision (con- EXTERNAL NASAL DEFORMITIES 73 vexity downward) about three-fourths of an inch long is made down to the bone over the nasofrontal process. Through this incision the skin and subcutaneous tissues over the dorsum and sides of the nose are elevated with a long, thin, two-edged knife, curved on the flat. Above this incision the periosteum over the nasofrontal process is elevated for about one-fourth of an inch. This wound is then covered with sterile gauze. The ninth rib, at about its middle, is then exposed, and a portion Fig. 79 Bone transplantation for nasal deformity. two inches long is shelled out of its periosteum and removed. I then split this section of rib in its transverse diameter. All of the medullary tissue is then carefully scraped from the outer half and the thin strip of compact bone is shaped to suit the deformity. If the medullary tissue is not removed from the transplanted bone, it has been found that it causes irritation and an aseptic fever, the graft being more apt to slough out. It is desirable to transfer the bone to the nose as quickly 74 EMBRYOLOGY AND ANATOMY OF THE NOSE as possible and that too without placing it in any solution. The strip of bone is inserted into the wound in the nose previously made for its reception, the lower end reaching nearly to the tip of the nose, and the upper being carefully anchored under the periosteum over the nasofrontal process. This latter procedure is greatly facilitated by turning up the curved flap made at the time of the original incision. The wound is closed with horsehair sutures and dressed with sterile gauze. If the case is progressing satisfactorily the dressing is not disturbed for a week." Operations in Total Destruction of the Nose. — In some cases, only that portion of the nose remains which is attached to the nasal bones, the whole anterior cartilaginous portion having been destroyed by syphilis, lupus, or trauma. To overcome this unsightly deformity it is necessary to make a plastic flap from the soft tissues of the arm rather than from the tissues of the brow or cheek. The finger has also been e^nployed to replace the destroyed portion by being grafted on to the freshly prepared tissue remaining of the nose, and the arm held to the head in plaster bandages until union has taken place, when the finger is amputated and fashioned in such manner as to resemble somewhat the lost member. However, these finger implantations are usually as unsightly as the original deformity. An ingenious method of transplantation in a case where the whole of the nose was destroyed was performed by Carter in the following manner: A piece of rib, the length of the destroyed portion, was grafted into the soft tissue of the left arm about midway between the shoulder and the elbow, where it remained for two weeks and became a part of the tissue. A flap was then outlined including the bone to assume the shape of the tip of the nose, and the upper end of the flap was elevated and attached to the freshly prepared tissues remaining of the nose. The arm was then bound by plaster to the side of the head until the circulation was established, which occurred at the end of about two weeks, when the flap was severed from the arm and shaped to resemble the nose. After detaching the flap the tip became blue from bad circulation, but leeches were placed on the tip of the nose which sucked the bad blood out and also drew into it a fresh supply of arterial blood from above, and thereby the flap was saved. The tissues assumed the best resemblance to a nose we have seen from any of these trans- plantations and now the patient has sensation even as far down as the tip. The vestibule on either side of the median raphi was preserved so that at a little distance the patient seems to have a natural nose, though slightly irregular in character. In lupus, rodent ulcer, and burns, where the destruction is of one ala or the tip of the nose, plastic operations are necessary, in which cases the flap may be obtained from the cheek nearest to the deformity or from some portion of the forearm. It is an impossibility to build up the destroyed part from tissue of the nose adjacent to the deformity. It must be taken from some region as the cheek, forehead, or arm. Many external deformities of the nose consisting of excessive bony projections with unusual depressions have been overcome by removal EXTERNAL NASAL DEFORMITIES 75 of the exostoses subcutaneously, and placing the removed bone in the depressions. Such work has been developed particularly by Roe, a description of which is found in the Medical Record, July 1, 1905. Collapsed alee are difficult to remedy whether due to the destruction of the cartilage of the alee, to the loss of its resiliency, or to the deterio- rating function of the muscle which elevates it, which often follows prolonged obstruction on one side because of the lack of inspiratory effort suflficient to exercise the muscle. Many methods have been advo- cated for the restitution of the function of alar dilatation, but the operative procedures which have been tried have resulted in cicatricial formation sufficient ultimately to pull the ala back into a fixed position, which was worse than its original condition. It has been noticed that in the subcutaneous injection of paraffin, additional stretch of the tissues near the tip of the nose has pulled out the ala, so that breathing has been facilitated, but without a deformity near the tip of the nose it is an unjustifiable procedure to inject it for this purpose. A column of paraffin has also been injected from the dorsum near the tip toward the Fig. 80 Mucocutaneous incision. MacKenty's operation. angle of the ala laterally, which in a few instances has proved of benefit, but it also results in an external bumpy condition which detracts from the appearance of the nose. The only operative procedure which has proved of much lasting benefit is that advocated by MacKenty in the New York Medical Record, November 25, 1911. An incision is begun on the septal side of the collapsed ala high up, and just within the skin line near the mucocutaneous junction of the nose and carried downward, outward and upward into the ala. The superficial and subcutaneous tissue is elevated until the bony ridge of the nasal floor is reached, when the periosteum is likewise included and this elevation is carried for a short distance beyond the ridge. The bony ridge is now removed trans- versely, including the diameter of the entrance downward until the floor of the nose and the entrance are on the same plane. The instru- ments necessary for this purpose are a small thin gouge such as Good's, a thin chisel, and bone forceps. The base of the septum next to the ridge upon the nasal floor is likewise chiselled away until only one-third of its thickness remains. The fat areolar tissue attached to the flap 76 EMBRYOLOGY AND ANATOMY OF THE NOSE is removed, leaving only skin and mucous membrane. The nasal floor will now lie about one-half to two-thirds of a centimeter below its original plane and the flap will be too short to cover the denuded area. A certain amount of contraction in healing is to be expected and to lessen this it is necessary to leave a bared area either upon the floor or the septum, and as the object is to gain the greatest possible trans- verse diameter, this can be obtained best by leaving this bared area on the septal side. The flap is incised on the septum and carried backward Fig. 81 Fig. 82 Mucocutaneous elevation from septum and floor of nose. MacKenty's operation. Flap stitched in place. MacKenty's operation. and downward in the nose toward its floor to the extent of denudation. It is then lowered upon this new floor, made by the chiselling away of the bony ridge, where it is stitched in place with fine iodized catgut and held there with packings of vaselined gauze. The gauze should be removed at the end of the third day, and the nose cleansed gently and a stopper-like plug of greased (vaselined) gauze reinserted. The sutures should remain in place for a week, at which time they are removed and the patient should be advised to keep the nostrils well greased with vaselin nose cream. CHAPTER III. THE ANATOMY, HISTOLOGY, AND PHYSIOLOGY OF THE INTERNAL NOSE. ANATOMY OF THE INTERNAL NOSE. Description. — The nasal cavity is divided into two more or less equal divisions by a median partition, the septum. Each of these divisions has an entrance anteriorly known as the vestibule, and an outlet posteriorly called the choana. The floor is formed of the palatal processes of the superior maxilla and palate bones. The roof is formed anteriorly by the nasal bone and nasal process of the superior maxilla, medianly by the cribriform plate of the ethmoid, and posteriorly by the under surface of the body of the sphenoid. The outer wall is formed by the inner surface of the superior maxilla, the lateral mass of the ethmoid, the vertical plate of the palate bone, the internal pterygoid plate of the sphenoid, and the three turbinated bodies. Surgically this is the most important boundary of the nasal cavity. From it the three turbinates project with the corresponding meati beneath them, and hidden by these structures are the outlets of the adjacent sinuses. The inferior turbinated body is the largest under normal circumstances, and tapers at both extremities. It occupies the lowest position upon the external wall, is about three-fourths of a millimeter above the floor of the nose in the adult, but approaches the floor nearly to contact in infants. The inferior meatus is just below the inferior turbinate and conforms in size to the structure above, being also more roomy in the middle. Into this meatus empties the tear duct at about 25 millimeters within the nasal entrance. Removal of the anterior extremity of the inferior turbinate will often admit ample air for respiratory purposes owing to the increased size of the inferior meatus just within the nasal cavity; but its removal will also occasion uncontrollable dripping of the nose during a coryza or weeping, which has its embarrassing features. The middle turbinate is smaller than the inferior, and is attached to the lateral mass of the ethmoid, curves inward, downward, and outward. The anterior part is hook-shaped, under which the middle meatus forms a cavity called the recess of the middle meatus, which extends upward within close proximity to the floor of the frontal sinus. The free border of the middle turbinate is thickened especially at its anterior extremity, in which an air cell (bulla ethmoidalis) is often found lined with normal mucous membrane like the normal ethmoidal cell. In certain conditions this cell may become cystic. 78 ANATOMY, HISTOLOGY, AND PHYSIOLOGY OF INTERNAL NOSE The middle meatus lies between the middle and inferior turbinates, and when the middle turbinate is removed there is brought into view the processus uncinatus, the hiatus semilunaris, the bulla ethmoidalis, the infundibulum, the ostium maxillare, and the openings of the anterior ethmoidal cells. The processus uncinatus springs from the anterior portion of the lateral ethmoidal mass near the upper part of the anterior border of the middle turbinate. It then passes backward and downward to end below and behind the ostium maxillare. The external surface is concave and forms the lower border of the hiatus semilunaris. The bulla ethmoidalis is formed by the projection of one or more of the middle ethmoidal cells and is not of uniform size. It is smooth and rounded, and lies just above the processus uncinatus. Fig. 83 a b c d e f Outer wall of internal nose, illustrating turbinated bodies and nasal fossae, a, superior turbinate; b, agger nasi; c, superior meatus; d, middle turbinate; e, middle meatus; /, inferior turbinate; g, inferior meatus. The hiatus semilunaris is a narrow, half-moon shaped groove, lying between the bulla ethmoidalis and the processus uncinatus. Its anterior extremity reaches into the recesses of the middle meatus, while its posterior part grows shallower until it ceases to be a groove. In the front part of the hiatus semilunaris the infundibulum opens and some of the anterior ethmoidal cells; and behind these is the opening of the maxillary antrum (Fig. 84). The superior turbinate, which is ordinarily situated highest upon the lateral wall, is a thin projection of bone from the lateral body of the ethmoid. It is seen normally by posterior, but not by anterior rhinos- ANATOMY OF THE INTERNAL NOSE 79 copy. The superior meatus is of very small dimensions and into it open the posterior ethmoidal cells, and occasionally the sphenoidal sinuses. The spheno-ethmoidal recess, if it exists, is a space above and behind the superior turbinate and below the sphenoid. Into it open the sphenoidal, sinus and possibly one of the posterior ethmoidal cells. Ductus naso- frontalis is the outlet of the frontal sinus into the middle meatus, and terminates in the infundibulum. Fig. 84 c d e f m n Outer wall of internal nose, illustrating openings of sinuses with turbinated bodies removed, a, anterior ethmoidal cells; 6, posterior ethmoidal cells; c, sphenoidal sinus; d, superior turbinate; e, recessus sphenoidalis ; /, maxillaiy antrum; g, inferior turbinate; h, frontal sinus; i, frontonasal duct; k, infundibulum; I, bulla ethmoidalis; m, hiatus semi- lunaris; n, processus uncinatus; o, lachrymal duct. The septum forms the inner wall of the nasal cavity. It consists of the thin perpendicular plate of the ethmoid above, the vomer below, and the triangular cartilage in front. There is hardly ever symmetry in the septum of the adult, and Morell Mackenzie found in nearly 77 per cent, of 2000 skulls examined that asymmetry existed. A ridge is often found upon the septum commencing at the lower and posterior part of the triangular cartilage near the nasal floor, and running obliquely backward and upward toward the sphenoid. The majority of thickenings and deviations are found upon the anterior two-thirds and nearer the floor (Figs. 85 and 86). The mucous membrane lining the cavity of the nose is called Schneiderian or pituitary. It is highly vascular and inseparably united with the periosteum and perichondrium over which it lies. It is thickest and most vascular over the turbinated bones and next in thickness over the septum. It continues throughout the accessory sinuses where it is 80 ANATOMY, HISTOLOGY, AND PHYSIOLOGY OF INTERNAL NOSE thin and pale, contrasting strongly with that lining the nasal fossae proper. The upper one-third of the nasal chamber is known as the olfactory region, where the epithelium is non-ciliated and columnar, and to this locality are distributed the filaments of the olfactory nerve. Fig. 85 Septal irregularities. (Zuckerkandl.) Fig. 86 Septal irregularities. (Zuckerkandl.) The blood-supply of the nose is derived largely from the sphenopalatine branch of the internal maxillary artery which enters the cavity by the sphenopalatal foramen. Its internal branch, known as the posterior nasal, sends a supply to the meati, the turbinated bodies, the ethmoidal PLATE III The Arterial Supply of the Septum Nasi (Ballenger). A, a. ethmoidalis anterior; B, a. ethmoidalis posterior; C. aa. nasales posteriores septi; D, anastomosis "witH a. palatina nnajor. The Arterial Supply of the Lateral Wall of the Nose (Spalteholz). A a. meningea anterior; B, a. ethmoidalis anterior; C, a. ethmoidalis posterior; D, aa. nasales posteriores laterales ; E, palantinse major et minores. sphenopalatina; F, aa. ANATOMY OF THE INTERNAL NOSE 81 cells, the maxillary and frontal sinus. Its internal branch, known as the artery of the septum, courses along the septum to the incisor foramen (Plate III, Fig. 1). The septum is also supplied by the anterior ethmoidal Fig. 87 Nerve supply of the septum nasi, a, N. ethmoidalis anterioris; b, N. olfactorii; c, N. nasopalatinus ; d. canalis incisivus. (After Spalteholz.) Fig. 88 Nervesiof the lateraljwalliof the nose, a, ganglion sphenopalatinum; 6, rami nasales pos- teriores'superiores laterales; c, rami nasales posteriores inferiores laterales; d, Nn. palatini; e, Nn. olfactorii; /, rami nasales interni N. ethmoidalis anteriores. (After Spalteholz.) 6 82 ANATOMY, HISTOLOGY, AND PHYSIOLOGY OF INTERNAL NOSE branch of the ophthalmic artery (see Fig. 110), which enters the nasal cavity with the nasal nerve. The posterior ethmoidal cells, the roof of the nose and upper part of the septum also receive arterial supply from the posterior ethmoidal branch of the ophthalmic artery (Plate III, Fig. 2). The veins form a dense plexus in the mucous membrane, the deeper ones being especially large and frequently approach the structure of a cavernous- tissue. This is found developed most largely in the whole of the lower turbinated structure and in the posterior border of the middle turbinated bone. The lymphatics are abundant and large and are in communication with the lymphatic spaces which enclose the branches of the olfactory nerve, and these spaces again communicate with the subdural and subarachnoid spaces of the cranium, so that the lymphatics of the nasal mucous membrane may reasonably be carriers of infection from the nose to the meninges. The innervation of the nose is from the olfactory bulb sending filaments to the upper one-third of the nasal mucosa through the cribriform plate; from the sphenopalatine ganglion sending fibers to the superior, middle, and inferior turbinated structures and septum; and the external twig of the nasal nerve to the anterior part of the outer wall of the nasal chamber (Figs. 87 and 88). Ths Minute Anatomy of the Nasal Mucosa. — The Bloodvessels and the Contractile Elements.^The thickness of the mucosa over the turbinate bones is given as 4 to 9 mm., but very little information is gained thereby, since the thickness even over the inferior turbinate varies greatly at difi^erent points, at different ages, in different individuals, and above all it is influenced by the previous existence of inflammation, while in different parts of the nose the variation is still greater — in the ethmoid cells it may be very little more in thickness than the vertical diameter of a single epithelial cell, since in those situations there is scarcely more than a single row of epithelium to be made out. If we accept the state- ment of Schiefferdecker, who gives the measurement of the columnar epithelial cell as from 30 to 70^ in its long diameter with 6/i for the length of the cilia, we may estimate the thickness of the covering in the normal sinuses at scarcely more than twice or thrice this for the whole thickness of the mucosa; in other words, very much less than even 1 mm. While the vertical diameter of the columnar ciliated cells may be reduced to 13.5yu in the sphenoidal sinus, the length of the cilia remains constant. The arterioles of the nasal mucosa are derived from the sphenopalatine artery which supplies the nasal mucosa from the choanse to the vestibule, and they include the vascular distribution to the accessory sinuses. After leaving the sphenopalatine foramen it divides into an external branch, the posterior nasal artery, which supphes the lower olfactory region and the respiratory region, and into an internal twig, the nasopalatine, which supplies the upper olfactory region and the septum. These anastomose with the ethmoidal artery, the external nasal, the septal, the palatine, and with the arteries of the lower part of the nasolachrymal duct. This network occupies the deepest layers of the mucosa and the periosteum. ANATOMY OF THE INTERNAL NOSE 83 The veins of the nasal mucosa form anteriorly at the pyriform orifice a thick network of vessels which empty into the facial veins by the channel of the anterior nasal vein. In the ethmoidal region they com- municate with the venous plexus of the dura mater and with the superior sinus in thefalx cerebri. Around the lachrymal duct they find an exit into the orbital veins and into those of the face around the orbit. Pos- teriorly the superficial veins communicate with those of the palate and pharynx below. Above they empty into the vein which accompanies the sphenopalatine artery (Zuckerkandl). Fig. 89 Section through erectile tissue of inferior turbinate body. (Zuckerkandl.) We see by this distribution of the radicle arteries and veins that there exist, by the agency of the latter, sanguiniferous channels of infection to the cranial and pharyngeal cavities and there are various physiological, pathological, and experimental facts which seem to indicate that infec- tion is carried thither by the bloodvessels whether the lymph channels carry it or not. These deeper arteries and veins often lie in such juxta- position to one another whether in bony canals, as in the sphenopalatine foramen and the ethmoidal cells, or close to the bone and cartilage, as 84 ANA TOMY, HISTOLOGY, AND PHYSIOLOGY OF INTERNAL NOSE on the septum and along the turbinated bones, that the vasomotor dilatation of the artery opening the afferent blood channel at tlje same time compresses and narrows the venous efferent vessels, thus mechan- ically contributing to the passive congestion of the capillary and caver- nous blood spaces of the erectile tissue.' The arterioles have, pro- portionately to their size, more of the muscular layer than they have in regions of the body unsupplied with erectile tissue. From their deep situation they tend to pursue a corkscrew course toward the surface and the venous sinuses. These latter in the deeper layers are wide spaces in adult life, much enlarged in a mucosa when it is the site of inflammatory change. This is so often the case that it is difficult to judge what is abnormal. The more superficial network consists of vessels not so large as the deeper channels of the erectile tissue. The latter varies much in different individuals. Its development has a close relation with the beginning of sexual life, since it is only seen in its full extent after adolescence is well established, and it atrophies in old age. It is found along the lower border of the inferior turbinate bone, especially posteriorly. It is also seen on the lower border of the middle turbinate at its anterior extremity and lower border. It is fre- quently fairly developed on the posterior border of the septum, forming some of the tissue going to make up the tubercle of the septum seen at the upper part posteriorly on each side of the vomer. The venous sinuses are irregular in shape. Their long axes are said to be directed vertically to the surface and the underlying bone, the direction of the axis of the erectile tissue as a whole being anterior posterior. Some of the arterioles supplied with muscle fibers are said to open directly into the venous sinuses, before they are split up into capillaries. The radicle veins are supplied to a much less degree than the arteries with a muscle layer, and this holds true of the venous sinuses. The capillaries are distributed everywhere through the connective tissue of the mucosa. Tiny capillary twigs are in contact with the basal layer of the gland epithelium, and it is possible to see direct diapedesis of the white cells through the capillary walls and between the gland cells into the lumina of the acini. There is every reason to believe that in this way the bloodvessels may empty the serous and leukocytic elements of the blood directly into the glands. Not only is there evidence of this direct communication of the sanguineous vessels with the glands, but the same phenomenon is observable in the relationship of the surface epithelium to the capillaries. In numerous places the latter may be seen at the lower border of the basal epithelial cells. Vasomotor dilatation, therefore, means not only an exudation of the serum of the bloodvessels into the stroma and a consequent swelling of it, but simultaneously there is a direct discharge into the glands and on the surface of the mucosa. Around the diicts of the glands, whose mouths usually lie in some sulcus of the surface epithelium, there is at these openings a more or less thick network of capillaries. In many places this is very ' Wright, Amerioan Journal of the Medical Sciences, May, 1895. ANATOMY OF THE INTERNAL NOSE 85 well-marked, as Zuckerkandl pointed out. A vasomotor dilatation of these capillaries would mean a considerable constriction of the gland outlets. This would cause the dilatation of the acini. As the vasomotor excitement subsides the superficial capillaries cease to cause this obstruct- ing compression and a free vent is afforded to the seromucous gland contents, temporarily blocked up. Contractile Elements in the Stroma. — ^This leads us naturally to a consideration of the contractile elements in the stroma of the mucous membrane. These are the elastic tissue and the smooth muscle fibers. The elastic tissue varies much in quantity and distribution, and in appearance as revealed by stains in the sections made for microscopic examination. There are two phenomena in man which are active in the development of the nasal erectile tissue. One he exhibits in common with the other animals, and it applies to other primary and secondary sexual charac- ters — the advent of adolescence. The erectile tissue of the nose, like that of the sexual organs, like the cock's comb, rapidly grows in volume at this period. The other influence in the development of the erectile tissue in man is peculiar to him — due to his artificial environment; it is peculiar to the nasal mucosa also as distinguished from other sec- ondary sexual characters. I refer to the frequent coryzae so often seen at this time. There can be no doubt that this predisposition in adolescence to acute rhinitis is due to physiological vasomotor excitement. There can be but little doubt that this reacts again in such a way as to exag- gerate the development of the venous sinuses of the nasal erectile tissue, because man, of all animals, is artificially clad and lives in an artificially regulated temperature most of the time. Venous sinuses are present in the nasal mucosa of certain other animals, but there is not in other animals either the degree of venous dilatation nor the wide distribution of erectile tissue seen in the nose of man. The Elastic Elements. — It is quite impossible to obtain samples of adult human nasal mucosa which do not exhibit evidences of present and preexisting inflammation. These alter, as we know, the distribu- tion and the state of the contractile elements of the mucosa so that it is practically impossible to draw a line betweeji their physiological and their pathological conditions, especially in its respiratory regions. The intima coats of all the bloodvessels above the size of capillaries, inclusive of the venous sinuses, are supplied with elastic fibers which lie just under the endothelium and give a blue-black reaction to the Weigert stain and its modifications. Singular to say, the most constant and the most richly supplied locality of the connective tissue is the peri- osteum close to the bone, and the deeper layers of the stroma intimately connected with it. Thick interlacing bundles are always demonstrable,^ running in an irregular way, parallel with the planes of the bone. Every- ' Whether we are warranted in calling only those fibers elastic which show the tinctorial reactions and the configuration ascribed to elastic fibers has been described elsewhere by Dr. Wright (New York Medical Journal, February 12 and April 9, 1910), and lack of space forbids. the intrusion of the discussion here. 86 ANATOMY, HISTOLOGY, AND PHYSIOLOGY OF INTERNAL NOSE where in properly stained sections of the mucous membrane separate blue-black threads, in a wavy course may be seen running either parallel to the surface of bone and epithelium or obliquely between the two — never vertically or in a straight line connecting the two. Some of the finer of these threads may be seen to be continuations of the terminal fibrils of some of the connective tissue and smooth muscle cells. Mechan- ically it is scarcely possible of conception that to be efiicient such elastic bands should not be anchored in the tissues at each end. The breaking up of such connection is doubtless a sequence of inflammation and degeneration of the stroma cells. The loss of resiliency thus brought about must be an important factor in the pathological changes to be described later. Nearly always demonstrable is a thin special layer of fibers, following the surface irregularities just under the epithelial layers. Occasionally one sees straight so-called "telegraph line" fibers especially in the periosteum and the walls of the bloodvessels. They are probably certain fibers which for some reason are stretched straight in the tech- nique of their fixation for microscopical examination. The intima of the venous sinuses is very thick and the longitudinal and transverse elastic fibers always stand out as sharp landmarks in sections of the erectile tissue stained to show them. It is true that one can observe appearances as if the base of the gland cells exuded a homogeneous substance. In this may frequently be seen the elastic fibers of the stroma, but around them there is no special elastic fibrous network. Smooth Muscle Cell. — We have spoken of the smooth muscle cell of the bloodvessels. Both in the adult and in the infantile nasal mucosa separate smooth muscle cells, or cells having the form ascribed to them, may be seen. Often one end of such cells may be seen entangled in the muscular coat of some bloodvessel; but though these stroma smooth muscle cells are more abundant in the vascular layers, there appear to be some of them which are free from any direct connection with blood- vessel walls. They may appear singly or associated with one or two others running parallel. It is probable that they owe their embryo- genetic origin to those around the bloodvessels, and are separated from them by the ingrowth of indifferent connective-tissue cells in the course of the evolution of the mucosa. In the basal line between surface epithelium and stroma they probably do not exist; certainly they are not to be found free in the superficial stroma, except around the ducts of the racemose glands, and there they may exist pretty close to the surface. Occasionally a cell resembling a smooth muscle cell may be seen in the basal line of the stroma under the glandular epithelium. There are various reasons to suppose that these contractile elements in life carry a surface tensile electric charge which forms the quality of living tissue we recognize as tonicity. We see how admirably they are arranged to subserve the function of the general expansion and con- traction in the volume of the erectile nasal mucosa. Along the surface of the erectile bodies are horizontal furrows in the mucosa, accordion pleats as it were, present even in fairly normal conditions, but much exaggerated in chronic inflammation, forked and divided until they form ANATOMY OF THE INTERNAL NOSE 87 the mulberry hypertrophies or even papillary masses to be referred to later. This reduplication of the surface permits of the wider distention of the venous sinuses normally, while the great vascular congestion accompanying repeated attacks of acute inflammation and the long continuation of chronic inflammation results in the "mulberry" and papillary hypertrophies alluded to— an exaggeration of a normal con- figuration which subserves a functional activity. The rest of the mucous surface when normal, is for the most part smooth. The Epithelium. — Whether the surface layers are of the columnar type or of the pavement variety the basal layers of the epithelium except in the olfactory regions are of cuboidal shape, approaching closely that of some of the fixed connective-tissue ceUs, with which they mingle when, as often happens, there is no limiting membrane between them. In the latter case, which oftener obtains in chronic inflammation, it is difficult to tell where epithelium leaves off and stroma begins, the zone being an indeterminate one of lymphocytes, polynuclear, and cuboidal cells. Fig. 90 Mucosa of middle turbinate region showing basal membrane channeled and fibrillated. (Altered from Schiefferdecker.) The basal membrane is often spoken of as homogeneous, but with proper fixation and sectioning, fine lines may often be seen running in a sense horizontal to the surface. It scarcely can be doubted that these are minute lymph spaces. The basal line is frequently broken by the eruption of leukocytes into the lower layers of epithelial cells (Fig. 90). Indeed, they frequently find their way thus to the surface. A capillary wide enough to admit the passage of a single red cell only may often be seen running parallel with the surface in the basal membrane. The basal line of the epithelium in a general way is less distinguishable and less sharply differentiated in proportion to the degree of involvement of the mucosa in a previous inflammatory process. This loss of the limiting membrane may be local or it may be noted over large stretches of surface. At these points the leukocytes wander with greater freedom into the epithelial layers, but practically everywhere isolated leuko- 88 ANATOMY, HISTOLOGY, AND PHYSIOLOGY OF INTERNAL NOSE cytes may be seen occasionally between the epithelial cells or even phagocyted by them. Stohr, who drew attention to similar phenomena in the tonsil, has described the wandering of leukocytes through the surface epithelium of the gland ducts, from the areolar stroma. We have seen leukocytes passing direct from the capillaries, skirting the base of the gland epithelium into its layers, so that there seems nO doubt this leukocytic exudation takes place, not necessarily from some clump of leukocytes in juxtaposition to the limiting membrane of the epithelium, and that they find their way to the surface not through preexisting stomata, but between any of the cells of the epithelium. The presence of a basal membrane in the olfactory regions has been noted by Ebner and others, but its existence has been denied by still others, while most observers admit it cannot be demonstrated in the mucosa of the acces- sory sinuses, and it is not recognizable in infants at birth. The varying accounts of the presence of the basal membrane, of its thickness, and of its structure are doubtless due to constant variations in the thing itself. It probably belongs to those fluid semipermeable membranes which we have been accustomed of late years to conceive of as the microchemical layer which limits cell structure itself. Its colloid state gives rise to various physicochemical changes accompanying the absorption and extrusion of nutritional and corpuscular elements. It probably is an evanescent state of living matter in a semifluid form, which is revealed to us practically in the form of an artefact when seen in section. This accounts for its occasional fibrillation, its perforation by corpuscular elements, the irregularity of its presence in inflammatory states, etc. Without such a conception a homogeneous membrane as depicted by some authors is incomprehensible; with such a conception, many physiological and pathological phenomena are explicable. It is seen perforated under goblet cells in the epithelium to admit material for excretion; the leukocytes pass freely through it. All argues, therefore, not for the existence of a membrane in life in the old sense of the word, but for the existence in many places of a colloid state of the protoplasm favorable for its caniculization by nutritional currents and for giving passage to corpuscular elements. In the nose there are no papillae in the normal basal line of the epithelium. Leukocytes are described as more marked in the sub- epithelial stroma than deeper down, but it is always difficult to tell how much is due to a transient or a chronic inflammatory process. The surface epithelium of the nasal mucosa is described as ciliated columnar epithelium in the respiratory parts of the nose posterior to the vestibule and non-ciliated above in the olfactory regions where its various layers act as supporting cells for the cells of olfaction. This description is more accurate for children than for adults. In adult life the flat-celled epithelium is a common form in the respiratory tract, Oppikofer stating that in 200 cases exclusively columnar epithelium was found in less than 20 per cent, over the turbinated bodies. In the majority of the cases it is of a mixed type. It is idle to attempt to decide how much of this is due to the metaplasia of pathological processes. ANATOMY OF THE INTERNAL NOSE 89 We shall find the same phenomenon in the larynx. In children the prevailing type behind the vestibule of the nose is the columnar cell, ciliated below and non-ciliated above; but in adults the character of the epithelium will depend upon the environment to which it has been subjected. The flat epithelium is more often seen in men who are exposed to the weather and to the impact of dust than in women. It will be found more often in the anterior more exposed portions of the nasal chambers than posteriorly. This applies almost exclusively to the respiratory portions of the nasal chambers, the surfaces of the inferior turbinate bodies, and the lower borders of the inferior turbinates. The patches of one or the other type are irregularly scattered, apparently due to the way the inspired air current with its burden of dust and its lower temperature strikes the surface. It is true that this metaplasia is found on the inferior borders of the inferior turbinate and not infre- quently at the posterior ends of the inferior conchae, but these are, par excellence, the localities most subject to inflammatory changes, attrition against the neighboring walls and the drip of secretions from above. In the accessory cavities of the nose, when free of inflammatory conditions, we find a thin lining of columnar cells with ciha well developed and a very thin subepithelial stroma between the surface of the mucosa and that of the bone. In the nose, Ebner speaks of the thickness of the epithelial layers as varying between 40m and 90^. Beaker ceUs are everywhere to be noted in the areas of columnar epithelium, both of the olfactory and of the respiratory regions. In the olfactory region the cells are long and cylindrical, not, as a rule, supplied with cilia; between them are seen the bipolar cells of olfaction with a nucleus and nucleolus at the centre and directly continuous below with the twigs of the olfac- tory nerve, ending at the surface in a short stiff -pointed process, as described by recent authors. Near the base of these cells are wedge- shaped cells which are called "support cells," the idea being they are meant to fill in the interstices left between the terminal olfactory cells and the cylindrical epithelium of the part. Ebner describes the limits of the distribution of the olfactory epi- thelium as covering the superior turbinate bone and the lamina cribrosa, extending downward from the latter not more than 2 to 2.8 cm., with a corresponding limit on the septum and on the lateral walls. Others have traced the olfactory cells as low as the middle of the middle tur- binate body. The olfactory membrane is of a yellow-brown color, easily discernible by the eye, but there are wide individual variations in its distributions. It evidently does not enter any of the accessory sinuses. While the epithelium in the olfactory region does not regularly show cilia, there are occasionally patches of this discernible frankly within the olfactory zone. Likewise olfactory epithelium is occasionally seen within the ciliated territory, and in fact the line between the two is said to be an irregular or wavy one. In the olfactory region the basal membrane is for the most part absent. In man the olfactory mucous membrane is said to vary between 50jli and lOOyu. It is much thicker in the lower animals than in man, where it is for the most part supplied 90 ANATOMY, HISTOLOGY, AND PHYSIOLOGY OF INTERNAL NOSE by a single layer of epithelial cells with the intervening olfactory cell, though the short wedge-like cells referred to above as supporting cells are described as representing the basal layers. Ebner makes the statement that in the olfactory regions the con- nective tissue contains elastic tissue only exceptionally. The connective- tissue cells in the upper portion contain the yellow pigment granules ftirnishing the color alluded to. In the embryo, the Jacobson organ, which is rudimentary in adult man, according to Kolliker, is supplied with a branch of the olfactory nerve, but it disappears later. In animals the organ is developed and lined by the elements of the olfactory mem- brane. In man when present it exists simply as a furrow or horizontal recess on the lower part of the septum. It is well developed in the. sheep. Glands. — The Bowman glands are the prevailing type in the olfactory region, consisting practically of a straight tube from the outlet to the fundus, which reaches well below the line of the basal epithelial cells. The tubular glands, secreting a much less viscid fluid, than the racemose glands below, are lined with a more cubical and less granular epithelium. These cells are smaller and the glands themselves are of less dimension in every measurement, except that the ducts are wider. They are the analogue on the mucous membrane of the sweat glands of the skin in structure and function. As compared with the racemose gland in an embryogenetic sense it is a less completely evolved structure, and like the surface of which it is an invagination, it secretes a watery fluid less rich in mucin. These straight glands are sparingly present even low down in the respiratory region. Their contents often show yellowish pigmented granules. They often present at their lower or fundal extrem- ities straight horizontal branching extensions of a smaller diameter or simply slight local dilatations of the fundus. While it may be true that these cells secrete a peculiar fluid aiding in the function of olfaction, its watery character is specially adapted to extend it by capillary action over the olfactory surface and to cause it to drip down as sterile irrigation for the respiratory region below. This, it would seem, may be the extent of its specific adaptation of function. It is not bactericidal in action, except in the sense that it furnishes a poor culture medium for bacterial growth. The racemose glands of the nasal mucosa, especially of the respiratory region, differ in no way so far as we know from the structure of racemose glands elsewhere. We have noted the peculiarities in the structure of the Bowman glands as placing them in another category, both as to structure and function, from the racemose glands. The character of the epithelium differs. That of the racemose glands is bottle-shaped, that of the Bowman glands is more cuboidal. It is true both kinds of epithelium may be seen in the racemose glands as well as in Bowman's glands. This is especially to be noted in the border zone between the olfactory regions and the respiratory regions. Whether this betokens an absolute difference in structure or is an evidence of a vicarious func- tion of the gland cell in this region is a matter of opinion. The bottle cells are apt to have the nucleus at the periphery and to be filled with ANATOMY OF THE INTERNAL NOSE 91 a homogeneous or finely granular secretion rich in mucin, while the cuboidal cells exhibit a more central position of the nucleus and a coarsely granular state of the cytoplasm. Often both kinds of cells are present in the ducts, and the cells of the latter may also be provided with cilia. There is a space about 1.5 cm. wide just above and posterior to the upper limit of the nasal vestibule, which, according to Schiefferdecker, is free of glandular elements in the stroma. Beyond this the tissues all gradually take on the structure of the nasal mucosa. In the vestibule both the sebaceous and the sweat glands are well developed, the latter exceptionally so, being somewhat modified in form and having large outlets. Just back of the borderline of the vestibule begin the racemose glands of the mucosa, and in this situation they are surrounded by con- siderable elastic tissue, a continuation of that of the skin, though it becomes finer and less developed in passing backward. In the vestibule the subepithelial stroma, the elastic tissue and the perichondrium are intimately mingled together and intimately bound to the cartilage. The glandular supply in the respiratory regions is made up of clusters of racemose glands. Not infrequently gland acini are embedded in or are more or less surrounded by the cavernous sinuses in the erectile tissue, but, as a rule, the two structures are separate, the gland acini in a general way lying more superficially than the cavernous sinuses. They vary greatly in their distribution in the mucosa, some sections crowded with them, others showing little gland structure in relatively large areas of stroma. In the accessory sinuses the glands are very few, isolated and incompletely developed even in the antrum of Highmore. In the latter cavity they are more abundant around the naso-antral opening than at the fundus. In these cavities the separate acini are apt to undergo cystic dilatation. While beaker or goblet cells are fre- quently seen, we have never been able to observe them in the abundance reported by some observers. They vary greatly in frequency in different localities, and doubtless the frequency with which they are demonstrated in sections depends not only upon the method of fixation of the specimen, but upon the physiological state of the mucosa from which the specimen is taken. When the cells collapse after discharge of their contents at the surface, they are scarcely recognizable until they again dilate. They are regarded as resulting from a peculiar physiological transformation of ciliated columnar epithelial cells. In the epithelial covering of the surface when the type of cell is cylin- drical there are often seen not only invaginations resembling Bowman's glands, but rosettes of glandular epithelium around a central cavity. These structures have been described as intra-epithelial glands. They were doubtless the appearances which induced some of the earlier writers to describe them as taste buds, comparing them to those of the tongue. While such structures as taste buds connected with the nerves have been noted in the olfactory regions of fishes, they have not been found in man. Probably the intra-epithelial glands above referred to are expressions of a tendency, embryogenetic in origin, for the epithelium of the surface to form glands by invagination. 92 ANATOMY, HISTOLOGY, AND PHYSIOLOGY OF INTERNAL NOSE It is necessary to bear in mind the distribution of the bloodvessels and smooth muscle cells around the ducts, to which reference has been made, and to remember that there is no special arrangement either of the smooth muscle cell or of the elastic fibers around the fundus of the gland. While the gland has a regulating apparatus at its outlet, it has to depend on the pressure of the -stroma around its fundus and upon the general resiliency, tonicity, and engorgement of the lymph spaces for the expulsion of its contents. The trigeminus nerve branches supply the glands as well as the surface of the mucosa both of the olfactory and of the respiratory regions. Leukocytes. — Leukocytes are more abundant just under the epithelium, and this greater abundance of the leukocytes in the subepithelial lymph spaces is described as the adenoid layer. This is never well defined, nor is it always easy to say they are more abundant in this layer than elsewhere. As the surface is more exposed to irritations of various kinds, we are more inclined to look upon the so-called adenoid layer as the pathological or perhaps the physiological response of the tissues. At places it is often very marked, but sometimes it is also very marked around glands and bloodvessels in the mucosae even of children. Indeed, it is impossible to know from our own observations or from the uncer- tain tone of writers on histology how much of it we are to ascribe to essentially pathological states. As a matter of fact, the normal mucosa of adults is more or less of a hypothetical structure. The fixed connective- tissue cell processes are loosely interlaced and make a wide-meshed web in whose spaces there are leukocytes, mononuclear lymphocytes, and polynuclears, eosinophiles and mast cells seen under varying conditions of physiological and pathological states. Lymph follicles are occasionally though rarely seen under the epithelial line, but whether they are normal structures, as Zuckerkandl and Schiefferdecker agree, we do not pretend to say. Connective Tissue. — ^This loose stroma, apt to be distended with serum and cellular elements at every vasomotor disturbance or with every transient inflammation, becomes more dense under the surface epithe- lium, and around the cavernous sinuses and the racemose glands, where it is described by many as a limiting membrane. Even where it seems homogeneous, or at least provided with interstices between its fibers too small to admit cellular elements, properly fixed sections will usually show, under the high powers of the microscope, minute lymph channels along which the fluids flow by capillary attraction. At the level of the periosteum the connective tissue again becomes gradually more dense, so that some authors describe two layers to the periosteum and peri- chondrium. As a matter of fact, for the most part there is no very sharp line between periosteum and stroma. The layers of the periosteum nearest the bone are ma,de up of fibro- blasts and osteoblasts, the latter more or less cuboidal or polyhedral cells, which secrete lime salts. Here and there along the edge of the turbinated bone structure an osteoclast may be seen hollowing out a little cavity in the edge of the bone by the absorption of bone salts. ANATOMY OF THE INTERNAL NOSE 93 It is a polynuclear giant cell apparently made up of the coalescence of osteoblasts and the inclusion of their nuclei in a single cell body, when their function changes from that of bone-salt formation to that of bone- salt absorption. In this metabolism of the cells the formation of salts of the fatty acids plays an important part and tinctorial reactions for soap are obtained with the proper technique (see Figs. 106, 107, 108). Fig. 91 t.f '/(^^^ Section through the inferior turbinate bone" and soft parts covering it. (After Schiefiferdecker.) Bone Structure. — The structure of the turbinated bones may be described as made up of cancellous sheets of bone held in thin scrolls between periosteal leaves of connective tissue (Fig. 91). The amount of bony tissue and its topography is constantly varying under the influence of the bone builders and bone destroyers — the osteoblasts and osteoclasts. Strands of fibrous tissue from the periosteum shoot into the depressions left in the bony surface by the absorptive action of the osteoclasts. They accompany the vascular channels into Haver- sian spaces and there form numerous gulfs and bays of connective tissue. The osteoblasts, on the other hand, are constantly building spicules and promontories of bone projecting into the fibrous tissue. This bony tissue of the turbinate bodies is probably more abundant in middle life than in adolescence or in old age. In the later periods of life there is an atrophy of all the structures of the turbinate bodies — more marked in the soft tissues, but apparent also in the bone. The Lymphatics. — The lymph channels beginning close under the epithelium through whose interstices, as we have seen, they are in direct anatomical connection with the surface, are divided into a deep and a superficial network by most authors, but the limits are ill-defined. They communicate with one another around the posterior border of the septum. They are said to communicate through the cribriform plate 94 ANATOMY, HISTOLOGY, AND PHYSIOLOGY OF INTERNAL NOSE with the subdural and subarachnoid spaces of the meninges; they com- municate with the lymph channels of the skin at the lower edge of the nasal bones and at the edge of the nostrils. Along the free edge of the turbinated bones they are most abundant, especially at the posterior border of the inferior turbinate body. There are horizontal channels along the upper part of the septum and the lateral walls of the nasal chambers, which mark fairly well the lower limits of the olfactory region. These collect from vertical channels the lymph supply of the mucosa. These channels unite into two posteriorly, one directed outwardly toward the lateral wall of the pharynx around the Eustachian tube, the other toward the floor of the nose. The lymph channels of the respiratory mucosa are more complex, but their general direction is downward and backward to the pharynx, joining with the channels from above to empty in the lateral pharyngeal lymph spaces. While it seems probable that the lymph spaces perforate the bone in the ethmoidal cells, making communication thus between inner and outer surfaces, it is not at all certain that this occurs in the other sinuses; but it seems probable that the chief communication is by way of the lymph channels leading through the mucosa of the natural outlets in or near the hiatus semilunaris. Those lymphatics having their exit externally through the interstices of the alar cartilages and at the introitus are connected with lymph glands in the parotid region, and the channels to them run as high as the lower border of the orbit, some as low as th? lymph spaces of the lips, while others accompany- the facial vein to the anterior cervical regions. The posterior internal lymph current is directed through more or less superficial retropharyngeal channels and glands, while others having penetrated the muscles and their aponeuroses lie in the deeper cervical fascia from the base of the skull to the lower border of the con- strictors of the pharynx. The intimate and direct connection of all these regions with the lymphoid structures, especially of the fauces, has been repeatedly deinonstrated. Colored particles injected into the nasal mucosa have been demonstrated in the excised tonsil, but this also has been the result of injection of carmine and other granules into more distant regions. It may be said in this connection that while the anatomical connections above mentioned have been repeatedly demon- strated, we find a better indication as to the natural intra vitam direction of lymph currents from clinical data. The anatomical possibilities are too complex, experimental postmortem injections are too artificial, experimental intra vitam injections are of too limited a scope satisfac- torily to establish the natural lymph current paths of this or any other region. THE PHYSIOLOGY OF THE NOSE. The respiratory region of the nose includes chiefly that part of it lying below the lower border of the superior turbinate and above the lower border of the inferior turbinate, but, as a matter of fact, the THE PHYSIOLOGY OF THE NOSE 95 inspired air is diffused by eddies in the current set up by irregularities peculiar to each individual and by the return of air expired from the lungs, so that practically all the mucous surfaces in the nasal chambers proper come in contact with it, though the olfactory region is much sheltered from the direct impact of the entering air. Disse showed the inferior meatus is scarcely at all developed at birth and the infant breathes mostly through the middle meatus. The relative proportions gradually change until at seven years they are of the adult type so far as their relativity is concerned. They simply grow after this. The functions of the intranasal structures are fourfold: To warm the inspired air. To moisten the inspired air. To filter the inspired air. Olfaction. The efficiency of each one of these processes depends to a very large extent upon the regulation of the vascular apparatus. The dilatation of the bloodvessels when it is not carried to the point of rendering the amount of air-supply to the lungs insufficient, renders the air, when it reaches the pharynx, not only warmer and moister and freer of dust and bacteria, but by filling the unnecessary space in the respiratory region of the nose it directs a more copious supply of it toward the olfactory regions. The internal configuration of every nose, even of those we would pronounce normal, varies so greatly that every nasal chamber is a law to itself. Anterior and posterior rhinoscopy are often incapable of furnishing us with trustworthy information as to the efficiency of the nasal chambers in the performance of these functions. The statements of the patients are still more untrustworthy. Some fail to appreciate even extreme grades of nasal obstruction. Others complain of it when manifestly it does not exist. The clinical experience, the common sense of the physician and his ability to judge of the patient's temperament are more important guides to the* appreciation of how these functions are in reality being performed than the help his tech- nical skill or the instruments of precision at his disposal furnish him. We have noted how the vascular supply is regulated not only at its entrance and exit by the large nasal bloodvessels, but by the contractile elements in the nasal mucosa itself. We have seen how the relation of the capillaries- to the surface and the glandular epithelium facilitates the exudation of the fluid and some of the corpuscular elements of the blood from the vessels to the epithelial surfaces. It remains to point out briefly, as we have exhaustively done elsewhere,^ the part played by the exudation of the serous part of the blood into the lymph spaces in the physiological swelling of the mucous membrane, especially in the erectile-tissue regions. The simple filling of the capillaries and the venous sinuses with blood is not sufficient to account for the smooth turgescence of the mucosa in physiological action nor for many points which we shall subsequently 1 Wright, New York Medical Journal, October 28, 1911. 96 ANATOMY, HISTOLOGY, AND PHYSIOLOGY OF INTERNAL NOSE take up in the study of the pathological states of the mucous membrane. The dilatation of the lymph spaces is coincident with the dilatation of the sanguineous channels. A stretching of the stroma and an oblitera- tion of the lymph spaces would ensue if there was no transudation from the bloodvessels at the time of their expansion. The flow of lymph along its channels would be impeded. An increase in the blood-supply would mean a decrease in metabolism rather than an increase in it. For various reasons, largely of a physicochemical nature, there is evi- dently a flow of serum and doubtless a diapedesis of leukocytes, accom- panying the vascular turgescence, from the bloodvessels into the stroma, and through the glandular epithelium into the lumina of the racemose and tubular glands. The discharge of a mucoserous fluid from the latter through their ducts to the surface takes place chiefly when the vascular turgescence diminishes, because as we have seen there is not only a network of capillaries but a supply of smooth muscle cells con- stricting the mouth of the ducts. It is impossible and it would be inadvisable here to dwell upon the physiochemical changes above alluded to. More familiar to the clinician in coryza is the dryness which initiates the vasomotor dilatation, the subsequent watery flow from the nose which ensues during turgescence and the copious thick mucous dis- charge which follows the subsequent vasomotor collapse. Nothing could be imagined more likely to act as a nasal bacterial detergent than this familiar exaggerated physiological sequence of events. The flow of watery secretion from the tubular Bowman glands above the territory swept by the inspired bacteria- and dust-laden air is constantly going on during intranasal quiescence. When exaggerated by vasomotor excitement a considerable amount of sterile watery fluid irrigates the surfaces, and this is supplemented by the drastic flow of viscid mucus from the glands as an additional cleansing. Manifestly this is not only an act of surface irrigation and surface scrubbing, which can be only feebly imitated by artificial sprays and douches, but it is a dredging of the stroma channels which the art of man is incapable of imitating. One of the early methods of filtering air of its bacterial contents in the laboratory for examination was to pass it through cylinders whose inner surfaces were coated with gelatin presenting a moist viscid surface. Upon this, bacteria from the passing air current are deposited by virtue of the law of gravitation. No bacteria can rise from a moist surface except the blast of air is sufficient to tear off with them droplets of the moisture. The finer the caliber of the cylinder in proportion to its length, the more efficient is the air-filter. Thin sheets of air passing over the mucous surfaces of the respiratory tract of the intranasal structures deposit at least three-fourths of their bacterial contents on them and the flow of secretions carries them to the pharynx by means of the gutters in the nasal architecture, helped by the cilia which line them and which wave along the current in an anterior posterior direction. It must be remembered that these cilia do not wave free in the air, but immersed in secretions which cover the surfaces. THE PHYSIOLOGY OF THE NOSE 97 _ The richest bacterial flora is found in that part of the nose which lies anterior to the columnar ciliated epithelium not only because of that being the first moist surface the inspired air meets, not only because of the coarse moist vibrissse which are absent in children and many females, but because in addition to these reasons there is the added and chief explanation of the absence of cilia and of the flowing intranasal current of liquid secretion. The vestibule contains a much greater nuniber of bacteria, as it does of dust, than the internal stretches of the respiratory channels, but the internal nasal passages themselves are by no means sterile even in so-called normal noses.' Fig. 92 Fig. 93 Bacteria in ten liters of laboratory air before passing through the nose. . Bacteria in ten liters of laboratory air after passing through the nose. It will be readily understood that the expanse of surface over which the inspiratory air current goes not only thus acts as a filter, but the same principles on which its eflSciency as a filter rests largely govern its efficiency in warming and moistening the air current — all three thus preparing the air for the sustenance of Jife and robbing it of many of its dangers. Naturally even at the best, it is not a perfect and sufficient device against infection nor against the injurious effects of cold and desiccation of the surface, but it is an important adjuvant in the general defense of the organism against the inimical factors of its environment. Not only are air forms and non-pathogenic varieties of bacteria found in normal nasal chambers, but a number of observers have noted the occasional occurrence of those bacteria regularly associated with infec- tious diseases. The most common are the streptococci, but diphtheria bacilli, influenza bacilli, the pneumococcus and even the tubercle bacillus have been described as present in the nasal secretions of those not ' In regard to this question the reader is referred to the following: Wright, New York Medical Journal, July 27, 1889. Park and Wright, ibid., February 5, 1898. In the latter will be found a bibliography of the literature of the subject. 7 98 ANATOMY, HISTOLOGY, AND PHYSIOLOGY OF INTERNAL NOSE affected with the diseases they represent. This is especially apt to be the case during the prevalence of epidemics of influenza, diphtheria, etc., and tubercle bacilli have been found in the nasal secretions of attendants upon tuberculous patients though they themselves were free of manifestations of the disease. Olfaction, the function which almost exclusively occupied the atten- tion of anatomists and physiologists alike when they came to deal with the anatomy and physiology of the nose before the advent of modern rhinology, rests upon a phylogenetic differentiation of the nasal epi- thelium whereby certain cells in the ectoderm side by side with other cells push out processes which, joined together as non-medullated nerve fibers, have formed in the course of evolution connection with the cerebral ganglia. Complicated and extensive in some of the lower animals, the olfactory function and the olfactory anatomy are in the course of regression in man. In civilized man other nasal functions are vastly more important in the struggle for existence. Zwaardemaker' analyzed the sense of smell in man, differentiating it fundamentally into nine classes which severally represent odors from: 1. The ethereal oils. 2. Aromatics. 3. Fragrant and balsamic substances. 4. Musky and amber odors. 5. Asafetida. 6. Empyreumatic or pine tar. 7. Tallow or fatty acid smells. 8. Narcotic — opium — bzeena. 9. Fecal odors. By means of his olfactometer,^ substances representing these odors are used in different dilutions, thus testing the acuity of smell. Little of practical value has resulted from these investigations. They are spoken of here for the sake of completeness and the reader is referred to the original publications of Zwaardemaker. From various facts to be detailed in the consideration of the distur- bances of olfaction, it seems probable that the function of smell is influenced by chemical changes set up in the pigment which is contained in the olfactory cells as described in what has preceded. We are learning that the pigment granules which are seen in certain body cells are intimately connected with the labile chemistry of the fatty and lipoid elements of the tissues which are responsible for so much of the vital metabolism of the body. The absence or scantiness of this pigment in the olfactory region is associated with a weakness in the power of smell. This is seen in white animals and in albino sports. We are reminded in this connection of the fact that albinos in the human race suffer from disturbances of vision and that blue-eyed cats are always deaf according to Darwin. How much value this chain of observations may have it is now impossible to say. It is interesting, if not suggestive. ' Archiv f. Laryngologie und Rhinologie, etc., Band iii, 1895; Zwaardemaker and Renter, ibid.. Band iv, 1896; Zwaardemalcer, ibid., Band xv, 1904. ' See Fig. 180. THE PHYSIOLOGY OF THE NOSE 99 The Action of the Epithelial CiUa. — ^There is a physiological act per- formed by one structure of the nasal mucosa which is of great importance and one upon which sufficient emphasis has hitherto not been laid What we have had to say of the action of the cilia has its chief nasal appli- cation in the physiology of the accessory cavities of the nose, but it has also a great significance for the trachea and the bronchi below. We know that one of the chief functions of the mucosa of dependent cavities like the maxillary sinus or the bronchial tree is to provide a mechanism whereby foreign matter can be prevented from entering, as in the respi- ratory current of the bronchi — or can be promptly removed if by chance it is introduced, as dust from the accessory nasal sinuses. Such a provision we find in the cilia of the columnar cells which line these passages. While from the nose and the larynx the cilia are in many places lost by the end of adolescence, that is not the case in the trachea or in the sinuses. They persist in spite of much which is inimical to their existence. Were it not so, the accessory cavities in the course of time and the lungs in the course of a very short time would be filled by atmospheric dust if by nothing else. Their efficiency in preventing the lodgement of bacteria must also be an important element in the immunity of mucous surfaces to infection. The inhibition of ciliary movement is probably largely responsible for deaths from pneumonia after prolonged anesthesia. In the maxillary sinus their efficiency can be demonstrated by a simple experiment. If the maxillary sinus of a dog is opened on its external surface, or, if not too badly damaged, the human maxillary sinus is used for the same purpose at operation, the sprinkling of a few grains of carmine powder on the mucous membrane will be followed by its prompt appearance in the nasal chambers themselves, waved out through tJhe natural openings by the cilia with which the mucous membrane is supplied. CHAPTER IV. SIMPLE INFLAMMATIONS OF THE NASAL MUCOSA. ACUTE RHINITIS. Etiology. — ^The etiology of coryza is obscure. Unassociated, as it frequently is, with any specific disease germ, it evidently has a number of factors in its etiology, of which, even when associated with the influenza bacillus the bacterial agent is a minor factor. Unquestionably the vasomotor system is largely involved after the onset of symptoms, and there is good reason to suppose that disturbance in the sympathetic nervous system is the change which initiates an attack of rhinitis. It seems evident also that certain systemic conditions, but especially certain habits of daily life, render the sympathetic nerve tissue concerned in the process more liable to the molecular change which initiates or pre- cipitates an attack of cold in the head. Exposure to the vicissitudes of the weather at all hours of the day and night, without protection of a roof or of excessive clothing, away from the environments of modern civilization, we know practically banishes the ordinary cold from even large bodies of troops undergoing great fatigue and deprived of proper food. The sympathetic nerves thus rapidly acquire a resistance to the effects of cold and wet which they rapidly lose when men return to closed houses and superfluous clothing. These latter then may be looked upon as the primary predisposing causes. Those who are sub- jected to these predisposing causes differ widely in the frequency with which they catch cold. The secondary predisposing causes are less definite. Certain systemic conditions such as are frequently noted in persons often afflicted with rheumatism and acidosis seem to accompany a predisposition to cold catching in people living in the artificial conditions of modern life. Adolescence is another of the secondary predisposing causes. It can hardly be denied that a history of exposure to cold and wet and draughts seems to indicate this factor as the exciting one in the vasomotor storm which initiates a cold in the head. The presence of the influenza bacillus is a common observation of bacteriologists who examine healthy nose and throat secretions during epidemics of the disease, and that it may also be present in attacks of rhinitis which present none of the severer systemic symptoms of influenza is also well known. The same may be said for certain other pathogenic micro- organisms, such as the streptococcus, the diphtheria bacillus, etc. For the present we will not consider those phases of inflammation of the nasal mucosa peculiar to the preponderating presence and manifest influence of these germs. Certain biochemical changes take place on ACUTE RHINITIS 101 the surface of mucous membranes and within their stroma and in the general systemic conditions which may render persons more hable to infectious disease when they have a cold in the head, but these considera- tions will be taken up when we discuss such afPections (see Chapter VI) . Pathology. — The pathology of coryza presents the greatest interest from a point of view which regards it as a process of abnormal bio- mechanism — not as a lesion but as a change in metabolism. The first physical change is sometimes described as a shrinking in volume and a paleness of the nasal mucosa, supposedly due to a contraction of the vascular channels. Whether this is what takes place primarily or not may be left to conjecture. The first change commonly noted is a swelling and redness of the mucosa and a check to the flow of nasal secretions. Fig. 94 The effusion of serum and the dilatation of a lymph space in a severe case of acute coryza. This latter condition may only last a few hours, but it is sufficiently constant to bring it under common observation. The swelling of the mucosa during these first few hours seems to be due to engorgement of the bloodvessels, but this engorgement is more or less intermittent, the frequent change in the volume of the nasal mucosa being accom- panied by sneezing. Within a few hours or perhaps a day or two, the sweUing of the mucosa becomes more constant, the nasal secretion becomes superabundant and watery. This is the stage of effusion of serum from the bloodvessels into the stroma and through the surface epi- thelium. In Fig. 94 may be seen the representation of a section through the serum-soaked stroma at such a stage. In this case the effusion of serum was so great as. to produce a paleness of the surface and large 102 SIMPLE INFLAMMATIONS OF THE NASAL MUCOSA cavities in the stroma containing serum as represented. The engorge- ment of the superficial capillary network and perhaps the contraction of the smooth muscle fiber around the ducts of the racemose glands prevent the discharge of their viscid mucin contents during this early period of a coryza. As the vascular congestion subsides, as the radicle arteries contract and the radicle veins open, as the congestion of the superficial capillaries around the gland ducts diminishes, the gland contents are discharged by the resiliency of the elastic stroma in which their acini are buried. The discharge thickens. Gradually the elas- ticity and contractility of the stroma force the extra serum out of the meshes of the loose areolar tissue. Probably this cannot occur until some change occurs in the biochemistry of the fluids or of the vascular channels, whereby endosmosis takes the place of exosmosis. That the resiliency of the tissues is at least an adjuvant in the absorption of the fluid and corpuscular exudates is also probable. After many repeated and prolonged attacks of acute rhinitis, after the conditions have become chronic, much of the resiliency of the stroma is lost. It becomes water- logged — or, as the term is in rhinology — polypoid. With the effusion of the serum and probably preceding it, there is an increased diapedesis of leukocytes from the bloodvessels and this continues for some time, even after the subsidence of the vasomotor storm. While large numbers of lymphocytes aud polynuclears are discharged from the surface and the glands, while probably also large numbers again enter the efl^erent blood and lymph currents, a certain number remain behind to become fixed connective-tissue cells. We can scarcely doubt the assertion that a mucosa, or any other tissue, once the site of an acute inflammation never entirely regains its former structure. Though imperceptible, changes doubtless occur whereby a little of the elastic fiber is damaged, the meshes of the stroma lose a little of their contractility, the glands are a little dilated. There remain a few more areas of round-cell infil- tration around the bloodvessels or under the epithelium, the venous sinuses become permanently a' little larger, or at least, like the stroma meshes, their walls lose a little of their elasticity. Such changes in tissue structure insignificant perhaps after one or two attacks of acute rhinitis, become marked and permanent after many. Membranous Rhinitis. — ^This is a condition not infrequently seen in the dispensaries, either in the noses of the patients or in those of the doctors and attendants upon them, in which a membrane is present over the septum and the turbinated bones and which is accompanied by severe inflammation with considerable discomfort and slight rise of temperature. There is some glandular involvement, but on the whole the patient is not seriously sick and usually quite able to go about his ordinary duties. In the membrane and on the surface in a large proportion of cases, over one-half, the diphtheria bacillus is found. In the remaining cases the streptococcus alone may be present. The inflammation as a rule lasts several weeks and is rather rebellious to local treatment. It is unknown what the exact relationship is which this affection bears to clinical diphtheria. It is unknown whether it is due to the lack of viru- ACUTE RHINITIS 103 lence of the accompanying organism in its relation to the individual patient, or whether it is due to the patient's resistance to an otherwise virulent organism which is responsible for the absence of any grave systemic disturbances. The sharp localization of the membrane in these cases to the nasal chambers is also a phenomenon which is as yet unexplained. There are some cases which present a gradation to typical diphtheria in the local appearances. In such cases the mem- brane may be seen on the back of the soft palate or covering part of the uvula. These latter cases of course should be carefully quarantined, even though they present no clinical picture of diphtheria. As for the purely intranasal cases belonging to this category, they usually elude a quarantine for which the medical attendant can assign no reason which is satisfactory to the lay mind. Symptoms. — The symptoms of acute rhinitis may be conveniently divided into three stages which merge one into the other. First stage: The prodromal or dry sta,ge. Chilly sensations are experi- enced inconsistent with the temperature of the surroundings whether out-of-doors or in the house, and this chilliness may even approach a distinct chill followed by fever varying from 1° to 2°. Alternate waves of heat and cold extend up and down the spine, spoken of as "creepy sensations," associated with a general feeling of malaise. There is a tightening sensation within the nose referred to the region between the eyes, and occlusion of the nose rendering respiration difficult. Pres- sure over the ethmoidal and frontal regions externally will elicit more or less tenderness. Itching and burning is felt in the nasopharynx. A long inspiration irritates the nasal mucosa, and will often produce sneezing, which phenomenon is more pronounced in some people than in others, due to a varying sensitiveness of the mucosa, also to a greater pressure of the turbinated bodies against the septum in those cases where the septum and turbinates are normally near together. The conjunctiva is reddened, the vessels of the cornea are congested, the lids itch and burn, and the eyeballs ache. Headache is a frequent symptom, and is more pronounced in those cases of septal deformity which obstruct the outlets of the sinuses. There is thirst, dryness of the throat, anorexia, and repeated efforts at swallowing. Both taste and smell are impaired, and there is fre- quently a ringing in the ears, or at least a fulness. Intranasal examination shows an intensely reddened mucous membrane, swollen and dry, which may at times appear granular. Second stage: Exudation. There is an outpouring of serum and mucus as the membrane tends to disgorge its inflammatory products, also lachrymation and frequent nasal dripping both anteriorly and pos- teriorly. The intensity of the pressure symptoms abate somewhat. The temperature, if any, remains about the same for the first part of this stage, with probably some tendency downward. In cases of one- sided obstruction the soreness over the sinus may become more marked, owing to the secretions damming up behind the obstruction. The discharge is clear, thin, non-viscid and watery, leaving but little stain 104 SIMPLE INFLAMMATIONS OF THE NASAL MUCOSA on the handkerchief. Taste and smell remain impaired, though the taste is slightly reestablished. Hearing is somewhat affected and the ears feel distinctly "stopped up," which sensation is emphasized by swallowing. It is during this stage that infection of the Eustachian tube occurs. Efforts at blowing the nose drives air in the direction of least resistance, carrying with it the infective material of the naso- pharynx. During this stage the sinuses are likewise often affected, although they may not give any symptoms until later. The discharge is irritating and excoriates the alse of the nose and the upper lip. "Cold sores" or herpes appear on the lips, which are painful and unsightly. The tongue is coated and the breath hot and feverish. The eyelids are swollen and congested, and the facial aspect is a dull one. Chilliness and pains in the limbs usually disappear with the advent of the discharge. Indigestion and constipation are often present. Third stage: Mucopurulent and terminal. The serum is thickened with leukocytes and epithelium. This exudate clings closely to the mucous membranes and is dislodged with difficulty. The effort to get it out of the nose may induce ear trouble, particularly in children, and those with one-sided occlusion of the nares. The temperature returns to normal, the headache is better, and the tenderness over the sinuses has gone, provided the course of the cold has been uneventful and without complications. Breathing is easier, smell and taste return, lachrymation ceases though the necessity for frequent use of a handker- chief remains. The discharge is often bloody, due to abrasions of the mucous membrane. Sometimes the color is yellow, with possibly a greenish tinge. The course of an ordinary uncomplicated untreated cold is about ten days. The possibilities from sequelae and complications are without number and indeterminable. The many cases of chronic empy- ema, bronchitis, rhinorrhea, otorrhea, etc., may have had their inception in a simple neglected cold. Complications. — In those suffering from frequent attacks of rhinitis there are few who escape involvement of some of the adjacent mucous membranes. Pharyngitis, tonsillitis, laryngitis, tracheitis, and bron- chitis often follow in this sequence, and the severity of these conditions depends upon the lowered resistance and the systemic tendency of the individual. In lithemic patients colds assume greater severity and the complications are graver than in those free from this and other constitutional diatheses. Eustachian tube infection is also a frequent concomitant of colds, and in' some individuals it follows with more or less regularity. One side is predisposed to infection more than the other, and it is usually upon the side of the greatest nasal obstruction to respiration. Sinusitis with the ordinary cold is usually not a serious complication. It may be accompanied only by discharge of a serous character or it may be mucopurulent, but, while painful, it usually disappears when the tissues have assumed their normal state, thereby permitting drainage to take place. Acute rhinitis in itself occasions little disturbance, but it renders the nasal mucosa more liable to subsequent attacks which may finally lead to more serious results. ACUTE RHINITIS 105 Sequelae. — There may be chronic rhinitis, rhinorrhea, sinusitis, otitis media, and the chronic catarrhal conditions of the larynx, trachea, and lungs which follow in the wake of prolonged inflammation. Tie&tment.— Prophylactic. — Proper clothing, both for adults and chil- dren, is one of the most important measures in preventing cold. All who live in the overheated houses of the city are entirely too warmly dressed while indoor . and insufficiently dressed while out. Flannels which absorb and hold moisture keep the skin at its lowest resistance and prevent the action of its vasomotor system. The adoption of "linen mesh" has done much toward lessening the danger from flannels, but in the very young and the aged where the vasomotor conditions are at a minimum, moderately thick flannels are advisable. Adults having indoor occupations should have but little change in the weight of their winter and summer undergarments, and should depend largely upon overcoats and external coverings of different degrees of warmth to meet the varying atmospheric changes. Cold sponging or even a cold plunge is 6ne of the best preventive measures against colds. This method cannot be adopted by all people, and must be confined to those whose skins react well after such procedure, for if the patient remains cold and chilly, and the skin is blue and does not react, the cold plunge or even the cold sponge is inadvisable. Another condition which renders the plunge inadvisable is in those suffering from rheumatism of either an arthritic or muscular type. The feet should be properly protected against dampness, and rubbers, which should be worn in wet or snowy weather, should be removed upon entering the house, for if they are kept on the feet will perspire and chilliness will ensue. Patients suffering from acute coryza should take particular care not to come in closer contact than necessary with others, nor should their handkerchiefs be used by others, as is frequently done by children. The handkerchiefs should be sterilized immediately after limited use in a 5 per cent, solution of formalin. Local. — ^As a cold relieves itself by exudative processes, this physio- logical action should be aided by whatever artificial means are at com- mand. In nature's attempts at a cure, without committing ourselves to former conventional ideas in regard to inflammation, we may look upon the hyperemia as supplying serous and corpuscular elements to remove soluble and insoluble protein offending material which has appeared in the tissues in their reaction to disturbances, with the exact nature of which we are unacquainted. It is unreasonable in theory and unwise from the practical stand-point of experience to use cocain and adrenalin, which interfere with this method of nature. It is far more rational and in practice more efficacious to use hot drinks and vapors, or the sweat box proposed by Briinings and Killian, to favor the hyperemia. This consists of a box in which the heat is supplied by a number of electric-light bulbs. When the head is thrust into it, provision being made to protect the eyes from the light and to supply the patient with air, the current is turned on and regulated by the comfort of the patient. The patient will usually find it more practicable to accom- 106 SIMPLE INFLAMMATIONS OF THE NASAL MUCOSA plish this by throwing a towel over his head and breathing into the upper air passages vapor from a steam kettle. Until the nasal discharge becomes thicker and mucopurulent, nasal sprays and douches should be avoided. When the discharge becomes thick and abundant, as is usually the case after the first forty-eight hours, the best plan is then to irrigate intranasally with warm alkaline solutions from behind for- ward with the postnasal syringe and thereby bring away from the Eustachian tubes and the regions anterior to them the products of inflammation thrown out in the nasal chambers. The best solutions for this purpose are either Dobell's solution one part, hot water two parts, or Seller's solution one part, hot water three parts, or a hot normal saline solution. Two syringefuls of any of these solutions injected postnasally are sufficient to cleanse the nose of its collected mucus. Following this, one syringeful of a warm solution of 1 per cent, argyrol should be injected, which is non-irritating, and yet slightly antiseptic and stimulating to the mucosa. This is then followed by a spray of albolene one ounce, menthol five grains, or a mixture of: I$— rAoidi carbol TUj Acidi boraci gra. x Zinci oleo-stearati q. s. ad Sj which is dropped into the nose with a medicine dropper. The irrigation together with the subsequent medication should be emploj'ed at least twice daily. Irrigations given through the anterior nares are inadvisable, as by this means infecting material is carried back into the Eustachian tubes or the nasopharynx, which might otherwise escape involvement. The Berming- ham nasal douche and others of its kind when employed in acute rhinitis are dangerous. Strong local astringents of nitrate of silver or chloride of zinc are harmful. Soothing irrigations with slight stimulation are productive of much more good. Internal. — In the early stage, Dover's powder, ten grains to adults before retiring, together with a hot mustard foot bath and a hot lemonade, will do much toward abating the severity of the attack, and if combined with calomel, followed by a saline laxative next morning, it will frequently abort a cold. Quinin has long been employed empirically, but from a consideration of its physiological action it is hard to determine by what method it influences favorably the outcome of rhinitis. It is recognized as one of the most powerful antiseptics, but a solution of at least 1 in 500 is required to destroy microorganisms. A few grains daily by the mouth are not likely to reach the nasal mucosa in sufiiciently strong solution to sterilize it, and considering the disturbing influence upon digestion and its tendency to produce tinnitus and headache, it seems inadvisable to employ it. The oil of cinnamon in 20-minim doses in milk, every hour for three hours, which is reduced to every two hours after this for six hours, is one of the most harmless agents we have at com- mand for the control of cold. The skin and kidneys are assisted in their action materially by taking one dose of Burney Yeo's mixture: ACUTE RHINITIS 107 I^— Tr. opii TUx Vin. ipecac x(iv Sp. aether, nit gj Liq. ammon. acet giij Aq. camph ad Biss Rhinitis and coryza tablets are of value in some instances, but must be taken frequently until the effects of the belladonna is obtained to be effective. The Turkish bath is a dangerous procedure owing to the fact that sufficient time for proper cooling of the skin surface is not permitted before the patient enters the outside air, and many cases of simple cold are converted into a graver form by such indiscretion. The patient should be put to bed and made comfortably warm with bed- clothing, but the ventilation of the room should be properly main- tained. Inhalations. — ^Steam inhalations, medicated with the oil of pine mixture, or oil of eucalyptus, 20 drops to the pint of water, is not only soothing to the mucous membranes, but apparently aids in the exudation which is essential to throwing off inflammatory products. The method of application is described in the chapter on Sprays, Douches, and Inhalations. Acute Rhinitis in Infants.^-The symptoms are virtually the same as in adults, but if uncomplicated, it runs a shorter course. Treatment. — Prophylactic. — Avoid bathing or dressing the. child in close proximity to a steam or hot-water heater, or in the direct current of warm air from the hot-air furnace. Also avoid getting soap in the nose during bathing, as the alkalinity of the suds will frequently induce an inflammation which ends in a cold. Too much covering and too warm clothing in the house will expose the child to too great cold when taken out. It has been a fallacy existing in the minds of mothers and nurses that infants to be healthy must be constantly bundled up even when in a house heated to about 80° F., which mental state is gradually being overcome by the observance of some children having better health when not so encumbered. The hot bath should be followed by a cool sponge, unless there is some constitutional condition which renders it unwise. Attention to diet and digestion will materially lessen colds. Local. — Place the baby on its back, and with a small wick of absorbent cotton moistened in warm milk, to each ounce of which three grains of sodium chloride or boric acid has been added, gently work it in and out of the nostrils repeatedly, until they are clear of the mucus. Then with a medicine dropper run into each nostril a few drops of a 1 per cent, solution of argyrol. This should be done twice a day for four days; if argyrol is continued longer it will irritate the mucous membrane. After the argyrol solution, one or two drops of albolene or plain oleo- stearate of zinc may be dropped into the nostril. Constitutional. — ^Liquor potass, acetatis, two to five minims in water, may be given twice a day, or a small dose of sweet spirits of nitre. Small doses of Dover's powder are also suggested, but opium in any form in infants should ordinarily be avoided. 108 SIMPLE INFLAMMATIONS OF THE NASAL MUCOSA Membranous, Croupous, Pseudomembranous, and Fibrinoplastic Rhinitis. — ^All of these appellations are applicable to one and the same disturbance, varying only in degree and slightly in symptoms. Symptoms. — Nasal discharge, slight temperature, obstructed breathing, disturbances of smell, taste, and hearing, disordered digestion and lachrymation all occur in membranous rhinitis. An exudate consisting of leukocytes, fibrin, a few red-blood corpuscles, and mucus forms upon the nasal septum or upon the anterior and inner surface of the inferior turbinate, which it is difficult to remove. The general appearance and the malaise with slight temperature arouses the suspicion that it may be a case of nasal diphtheria, but Klebs-Loffler bacilli are not so frequently found upon culture examination. The fibrinoplastic form is only an additional thickness of fibrin in a lamellated fashion upon the mucosa, and the area involved is more extensive. When removed there is some tendency to bleed. These membranes may form a cast of the internal nares and completely block the passage of air. Isolation is advisable until a diagnosis is established. Treatment. — Local. — The excess of membrane should be removed as gently as possible so that abrasion of the mucous surface is avoided. In the simpler forms this can be accomplished by syringing or mopping the surface with an alkaline solution, such as Dobell's solution and water. Peroxide of hydrogen and water in equal proportion should be applied and a second douching performed. After drying the surface an applica- tion of Loffier's solution is made (Kyle). In the fibrinoplastic variety it may be necessary to pull away the membrane with forceps, after which bleeding may occur. It is well to keep the surfaces well oiled in the intermediate stages between treatment, and for this purpose the following preparation is of material value: I^ — Gum camphor gr. iv Menthol gr. iv Zinci oleo-stearati q. s. ad gj Constitutional. — Tonics combining iron, arsenic, strychnin, and gentian should be administered. Attention should be directed to diet and general hygiene, and a grain of calomel should be administered every third night, followed by a mild saline laxative the next morning until the bowels are freely evacuated. CHRONIC RHINITIS. Etiology.— Repeated attacks of acute rhinitis being the antecedents of the structural changes of chronic rhinitis, we must assume for its etiology the factors which enter into that of acute rhinitis. The per- sistence and the intensity with which these factors exist tell largely for the production of the various lesions of chronic rhinitis. Certain kinds of dust, such as that encountered in the occupation of stone-cutters, cement-workers, hostlers, seem, in their persistent influence, to be CHRONIC RHINITIS 109 specially apt to produce chronic inflammations of the nasal mucosa. Those who in addition are compelled to face violent wind, such as drivers or motormen, complain of symptoms due to nasal lesions. Wind and cold alone seem to have no influence. It is difiicult to go farther in placing in an etiological category the systemic factors in the etiology of chronic rhinitis than has already been done for acute rhinitis. Pathology. — ^The clinical divisions of nasal disease, multifarious as they are, with the exception of infections, true tumors, coryza, and some of the neuroses, are fundamentally due to the exaggeration of chronic inflammatory processes in some one or more of the constituents of the nasal mucous membrane. The epithelium and the glands, the fibrous stroma and the juices which permeate it, the periosteum and the bone which it covers, the bloodvessels and their muscular and fibrous coats may one or more of them be so specially affected as to present the classical picture of a cartilaginous spur or a bony cyst, of an edematous polyp or a mulberry hypertrophy; but whatever may be the clinical name which gives emphasis to the lesion, it is always associated with other changes in the minute structure of the elements of the mucosa than those alone upon which the naked-eye description is founded. We may speak therefore first of the epithelium. We have already, in the chapter on the Normal Histology of the Nasal Mucosa, pointed out how impossible it is to draw any line between the normal and the abnormal. In one sense none exists in the nasal mucosa. This is especially true of adults. Every case of chronic rhinitis sufficiently severe to cause symptoms will present a nasal epithelium in which metaplasia has occurred. In the respiratory regions at least the existence of unmodified cylindrical ciliated epithelium over any considerable area of the respira- tory regions is a rare microscopical phenomenon. Not only are the cells modified in type, shorter and more cuboidal, but the number of layers has markedly increased. The basal line may be indistinguishable and the new connective-tissue cells and the epithelium with leukocytic infiltration are mingled together along a zone representing it in such a way that it is often difficult to differentiate them. Usually there is no tendency to the formation of papillse at the borderline observable in the nasal mucosa, but in some of the far-advanced lesions of chronic rhinitis it is well marked. There is an increase in the volume of the connective tissue, but this is often more apparent than real. There can usuaUy be plainly seen in the neighborhood of bloodvessels new connective-tissue cells, and the periosteum is much thicker in some places than in others; but the bulk of the stroma increase is due not to proliferation of the connective tissue alone, but to the dilatation of the lymph spaces and the filling of the meshes of the stroma with serum and corpuscular elements, lymphocytes, and polynuclears. This is apt to be speciaUy well marked in the super- ficial or subepithelial layers, the deeper stroma alone showing increase in the fibrous connective-tissue strands. The coagulation of the fibrin incidental to the fixation of the specimen for examination in sections makes a mass of fibrinous threads indistinguishable from the real fibrils no SIMPLE INFLAMMATIONS OF THE NASAL MUCOSA of the connective-tissue cells except by special staining, but when this is resorted to the scantiness of new connective-tissue cells and their fibrils will be noted when compared to the general increase in bulk. The mucoid degeneration of the stroma, called myxomatous, occasion- ally seen elsewhere in fibrous tumors and chronic hyperplasias, practically never occurs in the nose, nor are the branching stellate embryonic connective-tissue cells, characteristic of the condition, ever seen there in their typical form. The capillaries are apparently not increased in number nor specially altered in distribution. In old-standing lesions the cavernous sinuses are manifestly enlarged even to the extent of forming blood-cysts (Fig. 95). Fig. 95 Cross-section through posterior turbinate body, showing large cavernous dilatation of a venous sinus in the erectile tissue. That this dilatation of vascular walls is due to some weakening in the contractile elements which compose them seems likely, but the microscopical evidence of the disintegration of the elastic fibers in them we have not been able to make out. In the connective-tissue outside of the vessels the pathological state of the elastic fiber is quite apparent. The elastic fibers in a fairly normal mucosa, as that of infants, run in wavy lines in which most of the fibers show as continuous threads and bands. Here and there one can be seen continuous with the process of one of the indifi'erent connective-tissue cells. In chronic inflammation there is, perhaps as part of the process of repair, a great increase in granular substance in the tissue which takes the specific stain for elastic fibers in the sections and is probably a cell exudate, known as elastin. Much of this granular detritus, however, is quite evidently made up of the disintegrated elastic fibers themselves; they become swollen, and in the technique demonstrating them they are seen as dissevered joints of what had been a continuous fiber. Thus disintegrated it is quite evident that their function of contractility is lost. In later stages much, of this material is absorbed and the unorganized elastin exuded from the cells as well as the detritus of the elastic fibers is relatively and absolutely less in the fibrous tissue. CHRONIC RHINITIS 111 The smooth muscle cell is not appreciably altered nor absolutely diminished in amount either in bloodvessel wall or in the stroma. Whether a more critical examination than is possible with the present state of histological technique will continue to bear this out cannot be asserted. Certainly there is not the evidence of muscle-fiber disintegration present in chronic inflammation of the mucosa which the elastic fiber shows in the stroma, but the technique of demonstration of the latter is much more sharp and conclusive than that of the smooth muscle. The existence of a nose without irregularities due to thickened bone or cartilage in its internal framework is almost unknown in the adult. Yet in a general way it may be said that these are much exaggerated in nasal chambers which are the seat of marked chronic inflammations of the mucosa. It is difficult to separate cause and effect. Chronic inflammation is primarily responsible for perichondrial and periosteal activity, and the increased metabolism of these layers results in local cartilage and bone formation. The cartilaginous septum attempting to grow in one plane becomes bent and distorted by deviations and spurs. In these as well as along the lower border of the turbinated bones new bone formation is easily discernible.. The cavities of the ethmoid, especially those well forward in the middle turbinate, occa- sionally, in women, grow into large cyst cavities whose genesis is due to the exaggerated local metabolism of chronic inflammation. There are some of these changes it is necessary to take up more in detail as repre- senting certain clinical conditions. Symptoms. — It occurs as a result of recurrent or prolonged attacks of acute rhinitis which may or may not be influenced by underlying con- stitutional conditions. It is not a disease of age or sex; it is found in children as well as in adults. Highly .arched palates and septal defor- mities often add and possibly engender rhinitis which becomes chronic, and those suffering from catarrh of this character are affected with recurrence of acute rhinitis at intervals of more or less frequency. Appearance of Mucous Membrane. — ^Very seldom does the mucosa appear as intensely red as in acute rhinitis, but, on the contrary, it is pale, pendulous, and covered with yellowish tenacious mucus. This may be plastered upon the septum and turbinates, or strung across the inter- vening space in a cobwebby manner. It may also form in crusts of • varying size which are at times greenish yellow or intermixed with blood, so that they form scabs which upon detachment leave an ulcerated bleeding surface beneath. If these are frequently detached or picked at, as is often done, the ulceration may extend to perforation, and a large part of the cartilage of the septum may be destroyed in this manner. The inferior fossa of the nose will fill with this discharge, and upon saprophytic change emit a disagreeable odor. The mucous membrane is puffy and easily contracted by astringents in the first stages of the disease, but in the later yields less and less to their influence. Upon pressure with a probe an indentation will follow which will regain its contour quickly in the early stages, lessening in its activity with the progress of the disease. The discharge in some cases assumes a 112 SIMPLE INFLAMMATIONS OF THE NASAL MUCOSA watery character, and under these conditions the mucous membrane appears pale and anemic. This condition is seen more in the old. The swollen mucosa is not confined to any particular, location, but favors the anterior tips of the middle and inferior turbinates, and the posterior of the inferior turbinate, and the septal mucosa may be likewise involved. Even the tip of the nose externally may become red and enlarged, due possibly to disturbances of circulation. Subjective Symptoms. — There is frequent necessity for blowing the nose, which feels occluded most of the time on one or both sides, and this feeling is exaggerated upon lying down. The stoppage alternates from one side to the other, or there may be intervals of stoppage with others of comparative freedom of respiration. A quick change from freedom to closure based upon no appreciable fact is often experienced. When going from a hot to a cold atmosphere the freedom of respiration will be favored, and vice versa. One can often see a puffiness occurring in the nostrils of a patient coming into the office from the outside cold if the examination is made immediately upon entrance. A vasomotor disturbance appears to be present in all these cases. There is a postnasal discharge necessitating frequent hawking and clearing of the throat. This discharge is continuous during sleep and is unquestionably swallowed in large part, giving rise to bad digestion, foul breath,, and pharyngitis. A part falls into the larynx, which it is necessary to get up in the morn- ing, and which produces a "husky" voice. Persons suffering with this disease have an unpleasant nasal quality to their voice, and in singers it occasions a lessening of resonance, sadly affecting its quality. The head tones are almost impossible of accomplishment, and the necessity for frequent hawking produces a form of laryngitis which makes the singer uncertain of proper tone production. Mental hebetude and frontal headaches with local tenderness between the eyes over the root of the nose is often associated with this disease. The eyes are frequently affected, and the lachrymal duct overflows, owing to constriction in the nasal part of the duct. Taste and hearing are both affected, and Eustachian catarrh is found in more or less extent to exist in nearly all of these cases, giving rise to impaired hearing and tinnitus. The necessity for breathing through the mouth not only produces a dry, irritable pharynx, but gives a dull expression to the face not always in accord with the mental acumen of the patient. Olfaction is impaired to some extent and may extend even to the loss of smell. It occurs with more frequency and from less disturbing influences, such as dust, irri- tating gases, etc., in these cases than in the normal nose. Patients so afflicted are incapable of performing their full quota of either mental or physical work, and tire easily at either. Treatment. — Constitutional.— CaxtixA consideration should be given to the possibility of underlying constitutional disturbances, such as lithemic conditions, Bright's, auto-intestinal intoxication, acidity of the stomach, and constipation. No local treatment will be of any per- manent benefit with any of these constitutional conditions remaining unattended to. In those patients whose occupation submits them to CHRONIC RHINITIS 113 unceasing irritation of the mucosa, such as quarrymen, hostlers, motor- men, and chemists, but little hope of benefit can be expected so long as they continue in their occupation. Proper clothing, food, and bathing should be advised. Local. — Medicinal. — Postnasal irrigations with warm saline solutions, followed by a 2 per cent, warm argyrol solution, is a most efficient way to remove the secretions from the nasal chamber. It is inadvisable to place in the hands of a patient nasal sprays or douches, as with the first only temporary comfort is gained and the mucosa is injured more or less by the impact of the spray, and with the latter Eustachian catarrh is more than apt to follow its use. Sprays and douches indiscriminately employed in this class of cases or the snufiing of salt water has seemed to afford no permanent relief. The spraying, douching, salt-water snuffing habit is responsible for more chronic catarrhal conditions of the nose and Eustachian tubes than anything else known to the specialist. After cleansing the nose with the postnasal douche as mentioned, a pledget of cotton wet with a nitrate of silver solution, five grains to the ounce of water, is introduced into both nostrils along the line of the septal surface of the inferior turbinate and allowed to remain in place for five minutes. After removal another syringeful of the alkaline Fig. 96 Schadle's chromic acid applicator. solution may be injected to neutralize some of the disagreeable effects of the silver. An application then of a nose cream, consisting of menthol five grains, eucalyptus fifteen minims, and vaselin one ounce, is smeared over the surface. This treatment is necessary twice a week. The vaselin nose cream is given the patient in a compressible tube, to be applied to the nostrils night and morning by smearing it over the mucous surfaces with the tip of the little finger as far within as the nostril will permit. In children this can be applied with a camel's-hair brush. Should this method not tend to overcome the condition after a reason- able time, a stronger astringent will have to be employed. Fused nitrate of silver on the tip of an applicator and applied in a line from behind forward, along the inferior border of the inferior turbinated bone, will frequently be as strong an astringent as is necessary, and in the young works sufficiently well. During adolescence extreme caution should be exercised not to shrink the swollen turbinate too much, as at this period physiological changes occur which produce turgescence of the tissues and their puffiness is normal, and interference at this stage may result in subsequent dryness of both the nose and pharynx. Argyrol in a 25 per cent, solution may be applied locally by the physician upon pledgets of cotton, or it may be given to the patient in a 10 per cent. 114 SIMPLE INFLAMMATIONS OF THE NASAL MUCOSA solution to be dropped into the nose at night with a medicine dropper. Tannic acid and glycerin, ichthyol, 10 to 20 per cent, solution, chloride of zinc, 10 grains to the ounce of water, have all been employed locally with apparent benefit. Surgical. — It has been recommended by Kyle to puncture the mucous membrane down through the periosteum at several points along the most pendulous parts of the swollen membrane, which will occasion an inflammation, and from the resulting fibrosis the turgescence will be reduced. He also recommends several linear cuts along the surface of the greatest congestion which will not only permit of the free extrava- sation of the serum, but in the contraction resulting from the healing a diminution of the exudate will ensue. Local application of fused chromic acid has been employed to bring about the same result, and it is highly recommended by Schadle. To insure the fused acid remaining upon the tip of the applicator, he has devised an instrument consisting of a web of platinum wire at the tip of an applicator which holds the drop of chromic acid within its meshes. Spurs and deflections should be corrected if they exist as one of the first surgical steps toward over- coming the condition. One or the other of these septal deformities is generally found associated with this condition, whether as a cause or a result it is difficult to determine. Theii* correction, however, produces one of the most satisfying results in nasal surgery, for thereby the mechanical irritation is removed and the suction force of deflected air- currents is overcome. Ballenger lays great stress upon the influence of counter air currents in the nasal chamber, which produce hyperemic conditions in certain locaHties and anemic conditions in others. Fig. 97 Goldstein's chromic acid applicator for submucous cauterization. Pierce recommends the submucous application of fused chromic acid, which is applied after the tissues are elevated by a trocar. Goldstein has rendered this easier of accompHshment by employing a trocar in which is fitted a stilette, upon the end of which the chromic acid is fused and after the introduction of the trocar along the periosteum to the extent desired, the stilette is advanced so that just the tip with the HYPERTROPHIC RHINITIS 115 fused acid extends beyond its point and can be withdrawn along the line of elevated tissue. Formerly the galvanocautery was universally employed for the reduc- tion of the congested tissues of the inferior turbinate bone, but it has given rise in many instances to subsequent dryness which is as much of a disturbing factor as the previous congestion, and has therefore been abandoned by the majority of specialists. Punctures at varying intervals along the line of greatest turgescence will accomplish almost as much in the way of reduction and is less disastrous in the destruction of the mucous surface. A broad, flat electrode should never be used for this, as too wide a path of eschar results; but a sharp-pointed electrode is advisable, and a line should be followed from behind forward, across the extent of the swollen tissues, one-third of which is cauterized at each sitting, and the interval between treatments should be about one week. After cocainization the electrode should be introduced cold to the farthest point of turgescence and a backward and forward movement begun before the current is turned on, and this motion should be continued during the time the current is on and until the electrode has cooled off, otherwise the eschar will be pulled away with the electrode and no benefits will result from the procedure. In the experience of the writer a V-shaped piece of the superfluous tissue can be removed by means of an ethmoidal forceps, which should include all tissues down to the bone. In the healing processes following, contraction will take place sufficiently to reduce the mucosa of the turbinated body to nearly its normal state. If one of these removals is insufficient a second or even a third may follow. It is absolutely unwarrantable to remove the entire turbinated structure, as a dry nose and pharynx with Eustachian catarrh results. The submucous removal of the turbinated bone as advised and recommended by Yankauer is not essential in this class of cases, but applies preferably to hyperplastic conditions. The cautery and caustics should be used only with the greatest caution on the middle turbinated tissues, as a few cases of fatal meningitis have followed such procedures. Intumescent Rhinitis. — This form of rhinitis is merely a symptomatic condition of simple chronic rhinitis, characterized by sudden turgescence of one side with more or less freedom of respiration on the other, which without apparent cause will suddenly shift to the opposite side. The underlying conditions and the associated symptoms are the same as in chronic rhinitis, except that some benefit is derived from having one side open at a time for breathing. The treatment is the same as for chronic rhinitis. HYPERTROPHIC RHINITIS. While chronic rhinitis even when not presenting the classical features of atrophic rhinitis is not necessarily accompanied by any considerable hyperplasia of the various elements of the nasal mucosa, it usually is. There is an appreciable increase in the volume of the soft parts in addi- tion to local hyperplasias of the cartilage. Some of this increase of 116 SIMPLE INFLAMMATIONS OF THE NASAL MUCOSA volume is doubtless due to the thickening of the epithelial layers and the increase in the amount of leukocytic infiltration of the stroma. The chief increase in volume, however, is an increase in the fibrous con- nective tissue of the turbinate bodies. The vascular dilatations, the swelling of the venous sinuses in the erectile tissue contribute also to the increase in volume, yet the chief hyperplasia is the fibrosis. In chronic rhinitis the first functional activity of the mucosa to be impaired is its contractility, its resiliency. As we have seen, there may be just as much or even more elastin present taking specific stains, but it is in granular form; the efficient fibers have been broken up. It seems not so clear what damage has been done to the smooth muscle cells. Fig. 98 Fig. 99 - p^* s/ /" Mulberry hypertrophy of posterior end of inferior turbi- nated body. Section through hypertrophy of inferior turbinated body showing development of papillary condition evolved from glandular and surface structure. When, however, the fibrous connective tissue has been increased so that the fibrous prolongations of the cells are thickened and predominate over the cell body and the nucleus, when the elastic fibers have become damaged in the stroma and in the vessel walls, the smooth muscle cell, even though not displaced and degenerated, cannot do its part in adding to the resiliency and contractility of the tissues. If the functional resiliency of the tissue be impaired, we have then not only an increase in volume, in itself causing obstruction to the air current, but a lack of normal contractility as well. When the venous sinuses are thus gorged with blood and the stroma and its covering epithelium are stretched, the respiratory passages are greatly narrowed or entirely blocked. When the local blood-pressure is relaxed by the contraction of the radicle arteries and the opening of the efferent veins, the swollen surfaces collapse, but the subepithelial stroma having lost its uniform contractility, the surface instead of assuming a smooth consistency is thrown into pleats; HYPERTROPHIC RHINITIS 117 ridges and depressions cross one another in such a way that over the posterior ends of the inferior turbinated bodies and over the erectile tissue in general we have produced a mulberry-like surface shown in Fig. 98, the direct result of a loss of normal contractility of the mucosa. The process so initiated may be halted at this stage of mulberry hyper- trophy or it may go on to the exaggerated forms seen in Figs. 99, 100, and 101. Finally this becomes in this way a papillary surface indis- tinguishable by the naked eye from a true papilloma, a growth depending upon an entirely different pathological principle for its development. In Fig. 100 f-'v^ The structure of the posterior end of the inferior turbinated body, showing the hyper- plasia of the surface epithehum and the dilatation of the venous sinuses. The glands (a) are unaffected, but are here much exaggerated in size to show their presence. Camera lucida X 100. these mulberry growths or papillary hypertrophies the surface epithelium shows increased metaplasia, the basal line is usually obliterated, strands of fibrous tissue run up into the papillary projections, the glands are to some extent encroached upon and obliterated, though they may seem more abundant than usual because their acini are dilated. The venous sinuses, as intimated, are dilated and probably increased in number, owing to the dilatation of veins to the dimensions of sinuses. The peri- osteum is thickened and osteophytes are deposited along the lower borders of the turbinate bones. In these papillary hypertrophies the gland ducts are sometimes widely 118 SIMPLE INFLAMMATIONS OF THE NASAL MUCOSA dilated and the acini with their different lobes become a part of the papillary surface. The borderline between these growths and those which most histologists would call an adenoma does not exist. A certain amount of gland-cell proliferation exists in these growths plainly of inflammatory origin, while in those typically adenomatous it is the prevailing feature. While we are not prepared to say that the genesis of all benign adenomata is an inflammation, we know nothing in the facts antagonistic to such a statement, and that some at least are of such origin we are entirely convinced. Fig. 101 The structure of the papillary edematous hypertrophy of the posterior end of the middle turbinated body, showing the involvement of the glands. At a is seen the dilatation of a glandular duct helping to make the papillary surface. Camera luoida X 10. In addition to the forms which chronic rhinitis gives to the nasal tissue already mentioned under the clinical designation of septal devia- tions and spurs, nasal polypi and polypoid degeneration, papillary hypertrophies and adenomata, other exceptional vagaries of nasal hyper- plasia have been noted. Fig. 102 represents a pedunculated tumor examined for Dr. W. F. Chappell. It consists of an hyperplasia of the mucous membrane, having its origin from the posterior end and lateral attachment of the inferior turbinate to the wall of the choana, and contains erectile tissue and lymph follicles beneath the epithelium. HYPSRTBOPHiC Ml Ml f IS 119 Again ossification of the connective tissue of the turbinate around an arteriole was seen in a specimen from a case of Dr. John D. Richards. Occurrence. — Hypertrophic rhinitis is seen chiefly in males, and is more frequent after twenty-five years of age than before. It is more frequent in climates where the changes of temperature often occur from just below the freezing-point to just above it, and vice versa. It is more common on the sea-coast than inland. We have spoken of the causes of coryza and of chronic rhinitis, and what has been said of them may be held to apply to chronic hyperplasia of the mucous membrane. Any environment of the individual, climatic or occupational; any systemic Fig. 102 Lymph nodes in pedunculated mulberry hypertrophy of posterior border of inferior j turbinated body. dyscrasia which causes frequent contraction and relaxation of the tissue of the turbinated bones, especially in the region of the erectile tissue, is apt to produce an increase in the bulk of the soft parts of the internal nose. This has been held to apply to a form of hypertrophy described as frequently seen in prostitutes induced by the congestion of erectile tissue from sexual excitement. Symptoms. — ^The patient may complain of continued nasal obstruc- tion, though he is apt to declare that at times he can breathe perfectly through the nose. It is a matter of comparison. A certain amount of the power of the erectile tissue to contract is always retained, and wheii 120 SIMPLE INFLAMMATIONS OF THE NASAL MUCOSA this at times allows more air to go through the nose than at others the patient believes it to be the normal state of affairs, when, as a matter of fact, the air passages are never as free as they should be. Tinnitus aurium and a certain amount of deafness are apt to be present. The discharge may at times be excessive and thick, but unless there is some involvement of the accessory nasal sinuses, this is not a marked feature, though frequent blowing of the nose is indulged in by the patient to clear away an obstruction not due to secretion but to hyperplasia of the tissues. Such as there is, it is apt to be thick and easily forms crusts, which, however, never reach the dimensions seen in typical atrophic rhinitis. As in other forms of rhinitis, smell, taste, and hearing are impaired, as a rule, somewhat in proportion to the length of time the trouble has existed, and this it is difficult to estimate from the symptoms. Headaches, mental hebetude, nasal voice, bad breath, indigestion, the dropping of postnasal secretion into the pharynx, and many other symptoms are ascribed to hypertrophic rhinitis, or to catarrh if the patient has learned from others that he is a victim of it. If the diagnosis has not been made for him the category of symptoms he ascribes to it is small. Together with frequent sneezing, it may be stated that those specifically mentioned above comprise about all that can reasonably be thought to be due to an uncomplicated state of hypertrophy of the nasal mucosa. Purulent nasal discharge, nasal hemorrhage, hoarseness, neuralgias, eye symptoms, may all be present, dependent upon sinus disease, varices, laryngitis, pressure or cartilaginous spurs; but simple hypertrophy of the mucosa causes neither these nor the ridiculous catalogue of ills detailed often at such length by the patient. One is tempted to make the statement sweeping enough to include most of the so-called reflexes ascribed to the condition by many rhinologists, but the etiological nexus of symptom and nasal lesion and systemic state is often so complex that the most skeptical observer finds difficulty in justifying his disbelief in the intranasal hypertrophy as the chief or primary factor. A very large share of all the sensations a human being is capable of feeling has been ascribed to an intranasal cause not only by the patient but by rhinologists themselves who are largely responsible for the patient's mental attitude. The history of this phase of rhinology is well known to the older practitioners. Nasal reflex neuroses, accessory sinus troubles, tonsillar hypertrophy, are chapters in which human credulity is exhibited both by patient and practitioner at its worst. Local Appearances. — There is, as a rule, not so much to be learned by anterior as by posterior rhinoscopy. The membrane may be pale and translucent. There is more or less mucus to be seen clinging as a semifluid or crust material to the mucous membrane of the septum and turbinated bones. The use of the probe shows indentations in the mucosa not immediately effaced. The anterior tip of the middle tur- binate body may show distinct enlargement. The application of cocain and adrenalin, while it may diminish the turgescence and cause pallor of the surface to some extent, does not markedly shrink the mucous membrane down on its bony and cartilaginous supports and leave the HYPERTROPHIC RHINITIS 121 meatus a large space for the passage of air between turbinate body and septum. One must realize here, in the consideration of the symptom- atology as in that of the pathology, that not only do all different degrees of thickening of the mucosa present themselves in practice, but it is almost never the case that there is not, with the greater or less thickening of the mucous membrane which is seen to limit the breath way, some deviation or irregularity of the nasal septum which accentuates it. It will not infrequently be noted that the lower border and posterior end of the middle turbinated bone is tilted inward and upward, so that throughout more or less of its length it impinges on the internal or septal wall of the nasal fossa. This displacement is probably brought about through expulsive efforts in blowing the nose, during which the blast of air passing the posterior surface of the soft palate without impinging on the inferior turbinate bodies which lie in its lee, as it were, strikes the hood of the middle turbinated bone and forces it in the direction indicated. The resiliency of normal structure restores it to its proper position, but the weakening of the elastic elements in the manner detailed in remarks on the pathological histology causes it to yield permanently to the force repeatedly applied. It is true that the deviation or thickening of the septum is responsible for some of this contact. The application of adrenalin is necessary in order to gauge just how much and how firmly the one surface impinges on the other. It is possible that the pain which is at times coincident with this firm contact of the surfaces is the result of the pressure, but the periostitis which accompanies the chronic inflammation is probably the more constant factor in these cases, inasmuch as the pain is at times present without an appearance of undue pressure, while the firm contact is frequently noted without the coincidence of any symptom which can be reasonably ascribed to it. Posterior rhinoscopy will not infrequently reveal the swollen mulberry hypertrophies of the posterior ends of the inferior turbinate (Fig. 98). Sometimes these present a smooth surface but enormously distended with serum, so that they hide the posterior edge of the septum and impinge upon one another in the middle line. The posterior edge of the middle turbinates is not as a rule enlarged, but one is often able to note that an abnormal amount of space exists between the lower surface of the middle turbinate and the upper surface of the inferior turbinate, due to the mechanism of forcible expiration already referred to. This space is sometimes partially occupied by the so-called tubercle of the septum. This projection is not due to any considerable extent to a thickened process of bone, but to the abnormal development of the erectile tissue which exists to some extent in this situation normally. Treatment. — General. — ^We have already indicated sufficiently the regimen of a systemic nature which it is wise to pursue in these cases. Local Treatment. — Medicinal. — ^There is no medicinal agent which will cure a true hyperplastic rhinitis, but there are many lotions which will ameliorate the disagreeable symptoms. Postnasal irrigation with a warm Dobell solution, followed by a, 2 per cent, warm argyrol solution, will 122 SIMPLE INFLAMMATIONS OF THE NA&AL MUCOSA remove the discharge and reduce in a measure its constant formation. The turgescent membrane will also shrink slightly, though in the true hyperplastic stage this is almost inappreciable. Topical applications of fused silver nitrate, fused chromic acid, or nitric acid will often shrink the tissues sufficiently to give slight temporary relief. Also some of the submucous applications of fused chromic acid, as mentioned under Chronic Rhinitis, will reduce the hyperplasia. However, surgery is the only sane method of procedure. Thermocautery is inadvisable as the extent of the cauterized area adequate to meet the desired end is of necessity too extensive and too destructive to the mucous membrane to warrant its employment Surgical. — Removal of the superfluous membrane is the object of any procedure under these conditions. To accomplish this many different methods have been devised, all of which have their merits and advocates. In the majority of instances it is not necessary to remove the entire turbinated bone to overcome the obstructive condition, hence the use of the spoke-shave as formerly advocated by a great many operators seems unwise. The same may be said of the large swivel spoke-shave of Ballenger, when employed for the entire removal of the turbinated bone. Redundant parts of the structure as the posterior and anterior tip may be removed with the snare most advantageously, and it is adaptable to the removal of either. Cocainization should be thoroughly accomplished before any surgical attempt at removal is made, but the use of adrenalin is inadvisable when the snare is to be employed, as the shrinkage obtained thereby offers no advantage in enabling the operator to engage the snare, and the danger of postoperative hemorrhage in cases where it is employed offsets any of the advantages that might accrue from it. A straight snare employing the mechanical force of a screw, which enables the operator to detach the projecting turbinal slowly, is best adapted to the removal of the posterior tip, such as the Jarvis snare. The loop of the snare should not be too long and the wire should be sufficiently heavy not to break in the process of removal. Where there is an excess of fibrous tissue it is sometimes difficult to cut through it, in which case the operator has to resort to the employ- ment of scissors. If the loop is too long the end of the screw portion upon the stilette is reached before the loop is drawn jvithin the sheath of the snare, which may occasion considerable embarrassment to the operator. When the anterior tip is to be removed, an initial cut with the scissors along the attachment of the turbinate is made, into which a part of the loop may be inserted, and the distal extremity of the loop placed at that portion of the under surface of the turbinate embodying the pendulous portion desired to be removed. The turbinate scissors of Jackson are well suited to the removal of pendulous parts of the turbinate, and are of sufficient strength to cut through hyperplastic tissue and bone with ease. The curved scissors of Holmes, which of necessity have to be constructed for the right and left middle turbinates, are probably the best cutting instruments devised for the removal of the middle turbinated structure, but even in this case the snare HYPERTROPHIC RHINITIS 123 still holds supremacy. An operation devised by Yankauer, which has for its object the removal of the underlying bone and the preserva- tion of the mucous membrane, has many ardent advocates, but in true hyperplastic conditions the preservation of the membrane, which has but little functioning power, seems hardly to warrant the expenditure of time and patience incident to performing this operation. The opera- tion as advocated by Yankauer^ is as follows : The parts are cocainized and adrenalized and an elliptical incision is made above and, below the hypertrophied area, meeting anteriorly and posteriorly. The hyper- trophied mass is dissected out with elevators and scissors down to the bone. Enough of the bone is removed with forceps to bring the edges of the wound in apposition. After the removal of the bone the edges of the wound are brought together by sutures of No. catgut at about one-fourth inch apajt, beginning posteriorly and working forward. The nose is then packed with gauze or wicking, impregnated with aristol powder, which is removed after forty-eight hours. The sutures are Fig. 103 Holmes' middle turbinal scissors. absorbed in from four to five days. The difficulty lies not so much in the removal of the tissue as in the placing of the sutures, and for this a number of delicate instruments have been devised which facilitate the procedure. A description and illustration of these are given in the article as cited above. The saw has been frequently used in the removal of the hypertrophied middle turbinates, but there are other means more efficient and which result in less traumatism to the parts. V-shaped pieces of the hypertrophied structure may be removed from the anterior and inferior border of the turbinate, and in sufficient number to reduce a great part of the redundant membrane. This will obviate the removal of the entire body. Grunwald's ethmoidal forceps are of material value in this method of operating. They will cut into the bony structure unless the hypertrophy of the soft parts is excessive. Packing of some kind is necessary after all these operations to prevent synechise forming 1 Laryngoscope, February, 1907. 124 SIMPLE INFLAMMATIONS OF THE NASAL MUCOSA between the cut surfaces and the septum, and we have found that a small sliver of Bernay's sponge cut after the model of Simpson's splint to. be one of the best packings, particularly if both sides of the splint are well coated with vaselin before introduction. No packing should be left in longer than forty-eight hours, and if the operation has been of small extent twenty-four hours' duration is to be preferred. The dry pharynx and dry, scabby condition of the nares following complete removal of the inferior turbinate has occasioned greater caution than was formerly observed on the part of operators in the last few years, and more regard is now paid to the judicious preservation of mucous membrane, however well laden with fibrous elements. Just sufficient space should be gained to obtain free respiration, otherwise the disagree- able results ensuing will be quite as annoying as those due to the previous obstruction. CHAPTER V. THE SEQUELAE OF CHRONIC RHINITIS. NASAL POLYPI AND ACCESSORY SINUS DISEASE. Among these we may enumerate the cKnical conditions of edematous polypi and polypoid degeneration: accessory sinus disease, both polypoid and suppurative; bony cysts of the middle turbinate bone, mucocele, and finally atrophic rhinitis. The latter will be taken up as a separate subject, because of its peculiar histological, etiological, and symptomatic features. Suppuration of the accessory sinuses, with the exception of a few remarks on the histology of the altered mucosa of the sinus, will also be given special consideration. AH of these belong to the same pathological syndrome of chronic inflammation. Its different manifesta- tions, due to its localization chiefly, constitute clinical entities which are too often unintelligibly treated because their common bond of histology and etiology is not recognized. Edematous Polypi and Polypoid Degenerations. — Pathology and Etiology. — The former term is given to the common nasal neoplasm, which may be so small as to escape detection on a cursory rhinoscopic examination, or it may be so large as to fill the whole nasal chamber, distort the septum, and project into the nasopharynx. The latter term is applied to a diffuse condition of the mucosa presenting, the same histological features as the nasal polyp. Nearly alt nasal neoplasms present more or less of the edematous. loose fibrillar structure charac- teristic of the nasal polyp. Any part of the mucosa of the nasal chambers or their adnexa may serve as a point of origin. It is more commonly an affection of the middle fossa of the nose. The mucosa over the middle turbinate may give origin to one or very many localized polypi. Those that present in the nasopharynx are said to spring from the hiatus semi- lunaris at the opening of the maxillary sinus or just within that opening, but any or all of the cavities may be full of masses or clusters of polypi, often flattened or deformed by pressure against the bony walls. The pressure on these in exceptional cases may be so great as to cause their absorption. The nasal bones may be raised so as to obliterate the con- figuration externally of the nasal arch, and rarely the patient may thus have from a benign neoplasm the so-called frog face, characteristic of a malignant growth. There is regularly a tendency for the growth to recur after removal, especially in the cases of multiple polypi, by far the most common form. This is more or less true even if applied in those cases where operative measures for extirpation have been most thorough. The glands are often dilated into veritable cysts, one or more 126 THE SEQUELS OF CHRONIC RHINITIS cavities often occupying much of the tissue shown in cross-section, as seen in Fig. 104. That the condition is often dependent upon other factors than that of an antecedent inflammatory change is certainly true. It is said that certain occupations, peculiarly that of hostlers, are prone to excite the condition. The most striking affiliation it has is with hay fever and asthma and with accessory sinus suppuration. It was formerly claimed that nasal polypus is the common cause of hay fever and bron- chial asthma. That the conditions are frequently associated and that they complicate and aggravate the condition of each is well recognized. Both, however, very often exist separately. When they are associated the history of the neurosis usually antedates the history of the local existence of nasal polypus. Their frequent coincidence is due to the fact that they depend upon a common vasomotor neurosis. The vascular dilatation alluded to in the description of acute coryza is attended bj" Fig. 104 Cross-section through an edematous polyp, showing glandular cysts and their contents. distention of the lymph spaces in the nose in hay fever. Lasting for a month or more, accompanied by repeated severe daily or even hourly exacerbations, the serum escapes from the capillaries of the nasal mucosa and distends the stroma spaces until after one or many yearly attacks the nasal mucosa has lost its resiliency in the damage done to the con- tractile elements. The elastic tissue and the unstriped muscle fiber of the stroma no longer able to contract, the status of the nasal polypus and polypoid degeneration is set up from what seems a pure neurosis by the same mechanism we have detailed for the sequelse of a chronic inflammation. In rare cases, at some one or more localities, a local vasomotor neurosis seems to exist which seems allied to some of the bullous skin eruptions. Serum is suddenly exuded under the epithelium of the nasal mucosa, which results in a bleb usually circumscribed in area, but often quite large. When touched with a snare or a knife these rupture and the watery fluid escapes, the apparent tumor disappears; what was supposed to be a nasal polyp is no longer seen. It is probable NASAL POLYPI AND ACCESSORY SINUS DISEASE 127 then that the vasomotor mechanism present in acute and chronic inflam- mation is that part of it which is specially responsible for the serous effusion resulting in the growth of nasal polypus in the nose. This links the morbid processes of a more or less central neurosis, of in- flammation and of polyp formation in a chain of events in which the sequence becomes intelhgible when compared with the gross and minute changes in the nasal mucosa and with the clinical symptoms. Histology. — The structure of the tissue may therefore be defined as follows: While it may be accompanied by fibrous hyperplasia, by epi- thelial metaplasia at the surface, and by glandular proliferation or vascular dilatation it is essentially a serous effusion. Fig. 105 'i '-"^ kvi •p h '». s.,7 ^*(> A' o swt # IV/- Edematous nasal polyp, showing coagulated fibrin fibrils, with circumvasoular infiltration of leukocytes. In Fig. 105 will be seen widely dilated spaces whose walls, made up chiefly of fibrin threads, have entangled in the meshes various forms of leukocytes which have, to all appearance, issued from the bloodvessel. A nasal polyp may contain any or all of the constituent parts of the mucous membrane from which it springs, but though there may even be a relative increase of some of them — ^the leukocytes or fibrous connective tissue for instance — ^there is practically always an increased effusion of serum in the polyp. This may be so marked that there is little else to be distinguished than the fibrin coagulated from the serum chiefly in fixing the tissue for microscopical examination. As represented in Fig. 105, it will be seen that the serum is issuing from the bloodvessel, that 128 THE SEQUELM OF CHRONIC RHINITIS being evidently the origin of the large number of leukocytes whose abundant diapedesis is being favored by the outflow of the serum. No areas typical of myxoma are ever found in these polypi. It is a singular fact that careful histological analysis has shown that the internal nose where myxomata were supposed to abound by less critical observers is almost the only locality where the tissue never shows that particular form of cell degeneration. Here seems the proper place for remarks on the histology of inflam- mations of the mucosa of the accessory nasal sinuses. All we know of the pathological histology of inflammations of the mucosa of the accessory sinuses is derived from analogous conditions in the nose and from tissue removed at operations. This represents the final stages of a long pre- existing process. It is usually so much mutilated and in such small fragments that one can only remark that it presents itself under two aspects histologically. Both conditions, that of serous effusion and the formation of polypi and that of dense infiltration with the cellular products of inflammation, may be observed in the tissue removed from the same diseased cavity. This is the origin of the edematous polypi of the maxillary sinus just as it has been described in what has preceded for the edematous polypi of the nasal chambers, proper. Indeed, the statement has been made that many of the nasal polypi have their place of attachment within the hiatus semilunaris. There is one obser- vation to be noted in regard to the edematous and granulomatous frag- ments of mucosa removed from long-standing chronic inflammation of the sinuses, and that is the persistence of the cilia on the surfaces. Wide- spread and extreme lesions may exist in the subepithelial stroma, but the delicate cilia of the one or two-layered columnar epithelium remain in tissue removed from the sinuses. A like severity and chronicity of the inflammatory affections of the nasal structures themselves are scarcely ever seen without a complete abolition of the cilia. In edematous inflammations of the nasal sinuses resulting in polyp formation, as well as those in which the gross appearance of polypi is not observed, pieces of bone often become necrotic and come away with the mucosa at operations. Considerable destruction from pressure often ensues in the delicate bony framework of the ethmoid region, and is seen on the firmer walls of the maxillary frontal and sphenoid sinuses. These necrotic areas, whether resulting from pressure or from the exten- sion of severe inflammation, sometimes lead to perforations of bony plates, such as the os planum of the ethmoid or the posterior bony wall of the frontal sinus whereby dangerous communications are established with the orbital or cranial cavities. While this condition of bone necrosis is the marked feature of syphilis of the nose, it is not by any means absent in these chronic polypoid and septic conditions of the nasal chambers and their accessory cavities. The so-called polypoid degen- eration may extend over the whole mucosa of the sinuses or a limited portion only. While there are many cases of hay fevfer which find a common factor of neurosis in the etiology of nasal polypi, there are many cases of nasal NASAL POLYPI AND ACCESSORY SINUS DISEASE 129 polypi, perhaps the majority of the eases, in which no such etiological factor can be said to exist. They are in these cases one of the results of a simple chronic inflammation of the mucous membrane. Therefore, edematous nasal polypi are localized projections from the surface of the mucosa of small portions of epithelium and their subjacent stroma. A localized effusion of serum may be so immediately under the epithelium that it is raised in the form of a translucent blister. Usually, however, it carries with it a certain amount of fibrous connective tissue and often one or more gland acini. These latter are usually dilated into smaller or large cyst cavities when there is a relatively small amount of fibrous connective tissue and a large amount of edematous infiltration. These cyst cavities may occupy the larger part or even the whole of the polyp. There may be a few capillaries included in the stroma, but these are very small if present. The sparse and widely separated strands of connective-tissue fibrils have their interstices filled with fibrinous threads or granules, and with many lymphocytes, plasma cells, and eosinophiles, red cells, and polynuclear leukocytes. The fluid expressed from such a polyp does not coagulate on boiling with acids and gives the reaction for mucin. Thus obtained it is not especially rich in leukocytes. The epithelium shows a tendency to the formation of papillae. Symptoms. — Either in the form of pendent tumors or in that of poly- poid hypertrophy, so called, this form of pathological change of the mucosa is seen chiefly in adult life, and is more common in men. It is rarely seen in children, though cases have been reported in patients under twelve years of age. Its etiological factors have been discussed. They differ scarcely at all from those of the forms of chronic hypertrophic rhinitis, with which, indeed, the condition is so frequently associated. Their association with hay fever and asthma already alluded to will be more exhaustively considered under captions dealing with those affec- tions. The subjective symptoms, with the exceptions just indicated, are exclusively those of nasal obstruction. Sometimes the patient complains of a sensation ascribable to pendent masses causing a valve- like or intermittent obstruction to respiration. There may be an exces- sive discharge of glairy mucus. The patient may give a history of having blown small bits of the tissue from his nose. Sometimes the condition • is so exaggerated that the nasal bones have been displaced and the patient has the frog face more often indicative of malignant disease. On anterior rhinoscopy, pearly translucent masses may be seen occluding the nares or even slightly protruding from the vestibule. The use of adrenalin has no effect in causing their disappearance, or even diminution, though collapse of the adjacent mucosa may be secured which allows a more just appreciation of the situation and extent of the neoplasms. Their site of attachment cannot often be assuredly made out, but for the most part the examining probe, if not the vision, locates it in the neighborhood of the upper part of the middle meatus, and from our knowledge of the pathology we know the polyp very often springs from the lip of the hiatus semilunaris or even from within the ostium of the maxillary sinus. When pendent masses are cleared away and portions 130 THE SEQUELS OF CHRONIC RHINITIS of the middle turbinate are removed, edematous buds may be seen projecting from the ethmoid cells or from the free mucosa of the whole upper region of the nose. Postrhinoscopy may show a like condition. Large masses are seen projecting from the choanae into the nasopharynx, or that cavity may be entirely taken up by a single enormous polyp whose attachment is to the mucosa well within the nose. We have seen an instance of a polyp which had for years occupied the whole of one nasal chamber, causing by pressure a great concavity of the septum and the absorption of both turbinate bodies, which were reduced to comparatively small ridges of tissue. It projected into and filled the nasopharynx. It was removed without great difficulty through the pharynx, and when uncoiled to its greatest length measured over five inches and it had a transverse diameter in places of two inches. Usually, however, the polypi range in size from that of a pea to that of a walnut. Translucent and red- veined, they often form a striking and nearly always an unmistakable picture within the nose or in the postnasal mirror. If the condition has lasted for any great length of time it is nearly always bilateral. Indeed, it is rare to find polypi on one side and the other nasal chamber presenting no appearance of a water-logged mucosa at all. Treatment. — So far as is possible, attempts must be made to establish free ventilation in the upper regions of the nose. This is to be accom- plished by the thorough eradication not only of the base of the polyp, but of the immediate area of the mucosa and its underlying periosteum and bone from which the polyp springs. While the exact mechanism upon which depends the efl^usion of serum into the stroma is unknown, we have every reason to believe that it is associated with structural changes in the depth of the mucous membrane and in its underlying periosteum. The means whereby the removal of the polypoid masses and the eradication of tissues from which they spring can be accom- plished is taken up after we have considered the diseases of the accessory nasal sinuses, in connection with ethmoid disease upon which the existence of nasal edematous polypi so often depends (see p. 145 et seq.). Bone Cysts of the Middle Turbinate. — ^It sometimes happens that in a mass of nasal polypi there will be seen a smooth globular swelling of the anterior end of the middle turbinate bone. From the mucosa of the inside or of the outside of it there may originate the pendent masses of nasal polypi. They may form a cavity in which purulent matter or more rarely the glairy material of a mucocele lies. It is to the extension of inflammatory processes that we must ascribe the formation of the curious and somewhat rare pathological structures known as bony cysts of the middle turbinate. Spurs and deviations of the septum are more frequent by far in males. On the contrary, about 75 per cent, of the cases of bony cysts of the middle turbinate reported in literature occurred in females from twenty-five to fifty years of age. In normal growth and development, the accessory cavities of the nose, including the ethmoid cells, are increased in volume in adolescence by NASAL POLYPI AND ACCESSORY SINUS DISEASE 131 the location and activity of osteoblasts on the external surface of the bone, whether it be the superior maxilla or the fragile lamella of an ethmoid cell. These have the faculty of absorbing and precipitating Fig. 106 A row of osteoblasts derived from the fibroblasts of an epulis of the upper jaw. j5 oil-immersion lens. bone salts from the circulating fluids, probably by a biochemical process in which the fats and fatty acids are concerned. These seem to appear in the cytoplasm of a cell as a result of metabolic changes in its proteids. Fig. 107 1^ 'Hif'^'Jfe^ TO The transition stage from osteoblasts to osteoclasts. Same case as Fig. 106. Yj oil-immersion lens. This we recognize in certain pathological conditions as fatty degenera- tion. In the process of the precipitation of lime salts, whether the lipoid substances are the result of proteid change or are themselves 132 THE SEQUELS OF CHRONIC RHINITIS absorbed from the environment, it seems certain that the appea,rance of these bodies in a fibroblast of the periosteum is the essential chemical change whereby it becomes an osteoblast or bone builder. On the contrary, on the concave surface of the interior of these bony cavities, there are giant cells, apparently formed by the coalescence of the osteo- blasts or fibroblasts so as to form a single cell body with a number of nuclei. These giant cells or osteoclasts have the faculty of withdrawing and taking up into solution the bone salts of the sinus walls. Thus internally the walls are being excavated in numberless places by the bone dissolvers, the sum total of their action finding a manifestation in the enlargement of the cavity. It is well to bear in mind this double simultaneous action of osteoblast and osteoclast on different surfaces of the same bony lamella. The action of the osteoclasts alone would remove the bone, as probably happens in the atrophy of age. The action of the osteoblasts alone would result in the formation of a localized thickening, as we see along the lower border of the inferior turbinated bones at times or in the bony thickenings of the septum; but the two together, exerting their functions on opposite surfaces of the walls of a small depression in the lateral nasal masses of the embryo, hollow out the accessory cavities. Fig. 108 Section of the wall of a cyst in a middle turbinate bone, showing fully formed osteo- clasts absorbing the inner wall. yV oil-immersion lens. The formation of a bony cyst is but a continuation of this physiological process of development. Aroused again to action by the disturbing nutritional influences of chronic inflammation, the osteoclasts and osteoblasts exerting their functions on opposite surfaces of the walls of a small preexisting cavity in the anterior end of the middle turbinate bone, the result is a bony cyst, which may or may not communicate with a larger cavity of the ethmoid or with the middle meatus. It may be filled with much purulent secretion, or it may be empty. In either case it is lined with columnar epithelium continuous with that of other surfaces in the labyrinth of the ethmoid, bone, or, such com- munication having existed in prenatal life, it may in subsequent develop- ment have been cut ofl^ from its fellow epithelium. It may have preserved ACCESSORY NASAL SINUSES 133 its cilia or these may have been lost in the course of the pathological disturbances. Such we believe is the pathogenesis of a bony cyst, but why it occurs chiefly in young women, though also observed in men, we do not know. Bony cysts seen usually in females in adult life give rise to symptoms of nasal obstruction. They press firmly on the septum, but the impact of bony structure on this region in this condition has not been noted to cause pain any more frequently or any more severe than other con- ditions of intranasal hypertrophy. It is one of the reasons which may well lead us to doubt if the factor of intranasal bony pressure is so important in the etiology of pain referred to the face and especially to its nasal territory. These rare neoplasms are seen as bulbous smooth masses projecting at the anterior end of the middle turbinate bone against the septum. The probe reveals the fact that a comparatively moderate thickness of mucous membrane covers a surface of bony hardness. Sometimes the nature of the condition is not apparent until the bony wall is perforated. The use of the snare, rongeur, and bone curette usually accomplishes a cure of the condition revealing, however, sometimes a purulent or mucoid involvement of the ethmoidal sinuses. Mucocele is a condition in which a closed bony cavity near the anterior ethmoid cells or one or all of the cells themselves and even the frontal sinus become filled with a glairy material evidently due to the degenerar tion or the exaggerated secretion of the surface epithelium. The bulla of the ethmoid enlarged by the process just alluded to may be distended or at least filled by this glairy material, which is largely an exaggerated product not only of the gland cells but of those Cells known as beaker cells so abundant in certain areas of the mucous membrane in this region. The conditions of mucocele may be combined with their localized bone-cavity dilatation, and the whole trouble is to be dealt with by a technique which, together with that for nasal polypi, will be described in the section dealing with operations on the accessory nasal sinuses. THE ACCESSORY NASAL SINUSES AND THEIR INFLAMMATORY DISEASES. From what has preceded the reason why this subject should be taken up as a sequel of intranasal inflammation is apparent. It is necessary, however, to devote some space to a special consideration of the surgical anatomy' of the cavities before proceeding to a study of their diseases. Anatomy of the Sinuses. — Maxillary. — In the body of the superior maxilla of the adult is a large sinus of pyramidal shape, having for its base the outer wall of the nasal cavity; its apex, the outer extremity of the malar bone; its floor, the alveolar process of the superior maxilla; its roof, the floor of the orbit; its outer wall, the facial surface of the superior maxilla; and its inner wall, the zygomatic surface of the superior I We are indebted to the excellent work of Dr. Harris P. Mosher for much of the sub- stance of our remarks on the anatomy of the accessory nasal sinuses. 134 THE SEQUELS OF CHRONIC RHINITIS maxilla. It varies in size and shape in different individuals and in the sexes, being respectively larger in men. The two sides also vary in size and interior arrangement. The floor is sometimes on a level with the floor of the nasal cavity and, again, it may be above or below it. Occasionally, a complete septum of bone will wall off a separate chamber, and virtually form two antra upon the same side. It opens by one or more ostia into the middle meatus of the nose, over which hangs the middle turbinated body, which under certain pathological changes completely obstructs these openings. Fig. 109 Maxillary sinus. (Zuckerkandl.) It is lined by a thin ciliated epithelium and is drained by the action of the cilia in the direction of the ostium. Owing to the proximity of the roots of the teeth, which occasionally penetrate into the cavity of the antrum, caries is one source of empyema. It has been estimated by some observers to be responsible for about 50 per cent, of the cases of antral empyema, while others estimate it as low as 5 per cent. The second bicuspid and the first molar are in closest proximity to the floor of the antrum, and in proportion to the increased size of the antriun an additional number come into intimate relation with the floor. The thinner the alveolar floor the greater the predisposition to infection from dental "caries." Teeth which have not emerged from the alveolus or which have become impacted in the upper jaw have occasioned inflammatory conditions of the mucous membrane of the antrum which ultimately resulted in empyema. The base of the pyramid which is also the outer wall of the nasal fossa and is frequently called the inner wall of the antrum, is composed of bone ACCESSORY NASAL SI MUSES 135 varying in thickness from one-eighth of an inch at the floor to that of a sheet of paper above and also of mucous membrane without bony support at its upper third. The ostium, which is the natural opening of the sinus is situated just behind the uncinate process and empties into the hiatus semilunaris and thence into the middle meatus of the nose, is situated high up on the wall of the sinus at about its central point and just below the attachment of the middle turbinate. In about 20 per cent, of cases a second ostium is found which may open below the other or just behind the bulla ethmoidalis. The roof of the antrum is normally composed of a thin lamina of bone with its covering of mucous mem- brane, but in old people the bone often becomes absorbed in places, leaving nothing but the membrane, thus bringing the contents of the orbit and the antrum into close contact. 1"1G. 110 Frontal sinus, anterior and posterior ethmoidal cells and sphenoidal sinus and arteries of the septum. Frontal Sinus. — ^There are two frontal sinuses in normal subjects, a right and a left, separated by a median partition which corresponds to the sagittal suture of the head. This partition often deviates from the normal and may have an opening through it connecting the 136 THE SEQUELAE OF CHRONIC RHINITIS two sinuses, or it may be absent entirely, thereby presenting one sinus for the two sides. The sinuses are never exactly equal in size, and in rare instances the sinus may be absent on one side. The bony wall dividing the two sinuses is rarely in the median line, and is never perpendicular, but leans to one side or the other. In accordance with recent studies it has been demonstrated that the frontal sinuses are ethmoid cells, and each represents a terminal cell of the ethmoid laby- rinth which are situated between the two tables of the frontal bone. The anterior table forms the orbital ridge and the posterior table forms the bony support for the anterior lobes of the brain. The posterior wall is composed of a vertical and horizontal part. The sinus aspect is roughened by the numerous septa which spring from it and its cranial surface is also convoluted by the brain. The cranial wall is extremely thin, but is composed of compact bone and is about one millimeter in thickness. The floor of this pyramidal-shaped cavity is the roof of the orbit, and at the posterior internal angle of the pyramid is the outlet of the sinus known as the frontonasal duct, which extends into the hiatus semilunaris and out into the middle meatus of the nose. To compre- hend more clearly the channel through which secretions of the frontal sinus pass into the nasal chamber it is necessary to keep in mind that upon the external wall of the nasal chamber, when the middle turbinated bone is removed, are two ridges: first, anteriorly the ridge of the unciform process, and second, posteriorly the ridge of the bulla ethmoidalis. Between the two is a semilunar groove, the hiatiis semilunaris, and behind the bulla is a groove not so well marked which terminates blindly, called the groove of the bulla. The hiatus semilunaris widens as it ascends, and its wider extremity is called the infundibulum, and into this the naso- frontal duct opens. In a small proportion of cases (6 in 150, Mosher) the frontal sinus empties through its nasofrontal duct into the posterior groove, or groove of the bulla. In the lower part of the hiatus semilunaris the maxillary antrum opens and higher up the majority of the anterior ethmoidal cells open. "The bulla ethmoidalis, therefore, holds the key to the drainage of the frontal sinus, the maxillary sinus, and most of the anterior ethmoid cells." (Mosher.) The lining of the sinus is vascular, but not well supplied with mucous glands. The arterial supply is from the sphenopalatine and anterior ethmoidal arteries. The nerves are also ethmoidal, coming from the ethmoidal branch of the nasal nerve. Size. — The height in very large sinuses reaches from one and one-half to two inches, which reduces itself to a minimum when the sinus is nothing more than an anterior ethmoidal cell. The outward prolongation varies in length from one to two inches, while the depth extends up to five-eighths of an inch. There may be many incomplete or partial septa of bone which will often wall off infection, particularly if they run obliquely to the median partition. These septa occasionally become complete and form a sepa- rate sinus within the larger one, and when infected often present surgical problems of serious moment. ACCESSORY NASAL SINUSES 137 It is not uncommon to have an ethmoid cell "mound" into the frontal sinus, which cell is called the frontal bulla. Through such a cell catheter- ization of the sinus is often accomplished and in order to enlarge the nasofrontal duct one or more such cells must be sacrificed. The pulley of the superior oblique muscle is attached to a fossa upon the outer exposure of the floor of the sinus. The notch for the supra-orbital nerve is also situated about one inch from the median line and upon the external border of the anterior wall of the sinus. The Sphenoidal Sinus. — In the body of the sphenoid bone is a quadri- lateral cavity with a median partition which seldom divides it into two equal portions. The sinuses vary in size, the left being larger in the majority of instances. The sinus of either side may be so small as to hold only a drop of liquid or large enough to contain two and a half drams; the average sinus contains one-half drams in the adult. Absence of the sinus has been reported by several observers. Prolongations of the sinus into the lesser wings as well as into the greater wings enlarge its fluid content capacity. The muGOus membrane is similar to that lining the nasal cavity, though thinner, and the lymphatics com- municate with the deep lymphatics of the neck and those at the base of the brain. The quadrilateral outline of the sinus is composed of two surfaces, superior and inferior; two walls, external and posterior, and the anterior face. The internal wall is the median partition dividing the sinuses. Superior Surface. — From before backward we have a portion of the lesser wing, the optic groove and olivary eminence, the sella turcica, the posterior clinoid processes and the back of the saddle. This surface is in relation anteriorly with the posterior ethmoid cells and posteriorly with the basilar groove. The bony structure of this surface is very thin, and in many instances it is so thin that the dura cannot be removed without detaching the wall with it. Relations. — The dura, optic nerves, ophthalmic arteries in the optic canal, optic chiasma, pituitary gland and the coronary sinus. The Inferior Surface. — ^This surface is in relation with the nasopharynx and through a small foramen in its structure runs the pterygopalatine nerve. The thickness of this surface varies from one-eighth to three- eighths of an inch, and it is difiicult to remove in the operative procedures for lowering the wall anteriorly. From this surface springs also many of the fibromata and myxomata of the vault. The arterial supply is from the pterygopalatine and vidian arteries. Relations. — The middle lacerated foramen containing the internal carotid artery and the vidian nerve in a wide sinus is found on the floor. It is the motor nerve of the sphenopalatine ganglion. The External Wall. — From before backward is found the optic canal; the sphenoidal fissure, the large cavernous sinus and the internal carotid artery. Outside of the cavernous sinus, anteriorly, is the foramen rotundum in which runs the superior maxillary nerve, and posteriorly the foramen ovale through which runs the inferior maxillary nerve. Relations. — The cavernous sinus is the most important relationship, within which are the internal carotid artery, the motor nerves of the 138 THE SEQUELS OF CHRONIC RHINITIS eye, and the first branch of the fifth. This wall should not be curetted, as the proximity of the internal carotid artery and the ophthalmic render such procedure unjustifiable. The structure of this wall is very fragile and when diseased progressive ocular troubles, violent pain, epileptiform attacks, meningitis, and brain abscess frequently result. Posterior Wall. — This wall is intracranial, and hollowed out by the basilar groove. In this groove lies the basilar artery, the medulla oblongata, and the pons. The occipital sinus may extend fully to the posterior wall, and if involved might give the symptoms of occipital headache, vertigo, vomiting, epileptiform attacks, involvement of the nerves of the eye, alteration of the fundus, and possibly involvement of the meninges. The Anterior Face. — This is divided into an outer part which comes in contact with the posterior ethmoid cells, and an inner which is free and forms the upper and back wall of the nose. The ostium, which is the natural outlet of the sinus, is situated nearer the upper than the lower border of this face. It is ordinarily one-eighth of an inch from the top and one-fourth of an inch from the bottom of the anterior face. It usually measures one-eighth of an inch vertically and one-sLxteenth of an inch transversely. This opening cannot be seen in the greatest number of cases until the middle turbinate has been removed. The ostium is situated about two and a half inches from the nasal spine or two and three-eighths inches from the lower border of the lateral car- tilage of the nose. The Ethmoidal Sinuses or Cells. — They are divided into two groups, an anterior and a posterior. They vary in size and number from two to six or more and are embodied in the lateral mass of the ethmoid bone. The anterior group empties into the hiatus semilunaris, and the posterior into the superior meatus of the nose. Their entire inner wall is overlaid by the middle turbinated body and a part of the middle meatal wall. Their outer wall is formed by the inner wall of the orbit and they extend anteriorly to the inner canthus of the eye, and posteriorly to the sphe- noidal cavity, and occasionally even around and behind it. Hajek divides the ethmoidal labyrinth into four lamellse between which the cells develop. The first lamella is made by the unciform process, which is defective above and consequently does not extend upward to the cribriform plate. The second lamella is that of the ethmoid bulla, which does extend entirely through the labyrinth. The third lamella gives attachment to the middle turbinate, and the fourth to the superior turbinate. The classification according to drainage into the anterior and posterior is by far the better for surgical consideration. One or two cells develop in the lamella of the bulla and result in the swelling known as the bulla ethmoidalis. Acute and Chronic Inflammations. — Under the heading of the path- ology of edematous nasal polypi, we have spoken of the essential identity of the histology of the mucosa found in cases of sinus inflammation with that of edematous hypertrophies of the mucosa of the nasal chambers proper. It may be well to say in addition that less in the sinuses than ACCESSORY NASAL SINUSES 139 in the nasal fossae do we find an hypertrophy whose bulk is due to proliferation of the fibrous tissue or other histological elements of the mucosa. It is always a serous effusion. Etiology. — The acute inflammations of the accessory sinuses may be a part of the lesion produced by the initial shock of taking cold. Indeed, it probably usually is not to be considered as an extension of an infection, but the sinuses are as entitled to be considered the primary seat of the disturbance as are the nasal fossae themselves. At what stage in the evolution of an acute sinusitis bacteria infiuence the etiology is far from clear. Many cases of chronic sinusitis have presented a pus, when the cavity has been opened aseptically, which was sterile. On the other hand, there is fair reason to believe that in the chronic cases bacteria, the streptococcus, the staphylococcus, the pneumococcus, often add a gravity to the symptoms which warrants us in regarding them as etiological factors. Even in the most virulent cases, with high temper- ature and the systemic signs of sepsis, there is unquestionably an ante- cedent change in the mucous membrane and its secretions which have afforded these frequent denizens of healthy noses an opportunity for maleficent activities. Almost invariably cases of chronic sinusitis present conditions of the septum such as spurs and deviations combined or not with intranasal hypertrophy of the soft parts, which have evidently interfered with the proper aeration and drainage of the nose. It is true that spurs and deviations are exceedingly frequent in noses which cause their possessors no trouble of any kind, but the prevalence of marked abnormalities in cases suffering from chronic sinusitis reaches a higher ratio than it does in those not thus affected. The lymphatics and the bloodvessels communicate for the most part only along the network of the mucous membrane in its extension between the sinuses and the nasal chambers and not through the bone proper. It is along the mucous membrane that the chronic inflammation spreads by continuity, and when bacterial infection is a prominent feature in the process it is probable the same route is traversed, and not that through the bony structure. A severe coryza terminating in resolution and a restoration of the struc- ture of the intranasal mucosa to a fairly normal condition often takes place when the mucous membrane of the accessory cavities remains charged with the products of inflammation, because at the hiatus semi- lunaris or at the ostium of the ethmoid cells the lymphatics and the bloodvessels are compressed by perhaps only a slight exaggeration of a long-standing obstruction. Not only are the contents of the cavity of the sinuses retained in them, but the efferent vessels, t,hemselves cannot carry away absorbed detritus, while the afferent vessels cannot supply the parts with proper nutrition or proper protection in the circulating fluids. Were there free interchange of this kind through the bony walls, we should not expect an occluded ostium to be the important factor in the etiology of sinus disease which clinical experience teaches us it is. Nasal polypi, while frequently growing in the sinuses on mucous surfaces beneath which the changes of chronic inflammation have already taken place, doubtless sometimes have their origin from the 140 THE SEQUELS OF CHRONIC RHINITIS mucous surfaces of the nasal chambers, and, by the mechanical obstruc- tion they ofi'er to the escape of the contents of the cavities, form in this way a link in the etiology; but as they are usually phenomena secondary to underlying stroma changes, they are to be looked upon more ration- ally as a part of rather than as a cause of processes which are manifested by the presence of pus in the accessory nasal sinuses. These then may be considered as the intranasal etiological factors of sinus suppuration, and we believe they form the preponderating ones in all but exceptional instances of purulent sinus disease. Foreign niatter in the maxillary and sphenoid sinuses has been found post- mortem and its evident origin was from the stomach; but while it is possible, we suppose, for stomach contents to reach these cavities under other conditions than the death agony, we are much inclined to doubt if any cases of sinusitis have ever arisen from the intrusion of vomited matter. The teeth roots in the antrum of Highmore, once looked upon as almost the sole source of antral suppuration, are now known to account for only a small proportion of maxillary sinus disease. Both as foreign bodies in the antrum and as furnishing a nidus around the alveolus whose bony wall is perforated or softened, a few cases are undoubtedly solely due to causes of a dental nature. Very many cases of pus in the maxillary sinus present this condition as a sequence to purulent disease of the ethmoids. It is probable that the constant presence of pus on the mucous membrane finally induces the emigration of leukocytes from its own meshes, and a suppurative condition of the mucous membrane is thus secondarily set up. Suffice it to say that such a sequence of events accounts for the considerable number of cases of suppurative disease of the maxillary antrum which do not yield to treatment either by drainage or curetting of the mucous membrane of that cavity. It is impossible to answer the natural though hypothetical question. Do such cases of maxillary antrum suppuration recover without treatment except such as is directed toward a cure of the suppuration in the other cavities? We are free to say we do not believe that this has ever been put to the test of experiment in such a clear-cut way that an assured answer can be given. With the tendency toward intranasal surgical treatment of the ethmoid and sphenoid region we doubt not that the answer will be forthcoming. The point is a practical one, for, given the coexistence of suppuration in the upper row of sinuses and of thie maxil- lary antrum in any case, it would be of advantage surely to know if the lower cavity would undergo spontaneous cure after the trickle of pus from the regions above has abated. There are reasons founded on observations of cases in our experience to suppose that it does. It is a matter of observation also that the ciUa are preserved on the cells covering extensive areas of extremely edematous stroma. There is no reason to suppose that when the action of these cilia is permanently abolished a maxillary sinus will ever serve as anything but a pus pocket unless there is dependent drainage, but there is every reason to believe that it is only in very rare instances indeed that this cilial action is permanently abolished. There is every theoretical reason to avoid ACCESSORY NASAL SINUSES 141 curetting or prolonged packing of this cavity. We bring in these con- siderations here to emphasize the point that the health of the maxillary sinus is impaired just in proportion to the extent that the cilia with which the epithelial cells of its surface are supplied have lost their efficiency. It is important to keep in mind this point in the etiology of sinus disease. So long as the natural passages are unobstructed, so long ap disease has not abolished or temporarily restrained the action of the cilia, the accessory nasal sinuses will remain healthy. On the extent to which these conditions can be restored will depend the prognosis. Symptoms of Acute Catarrhal Sinusitis.— MaxiZZa/-!/ Sinus.— The patient complains of a stuffy sensation in the nose and head as from an exagger- ated cold. The voice sounds dead and non-resonant as though one had been diving and the nostrils were filled with water. Pain is experienced upon the affected side on chewing, clamping the teeth together, or having them tapped with a metal tongue depressor. There is excessive discharge from the nose, and the middle meatus is filled with a thick, viscid, mucoid matter. Pressure on the part of the face corresponding to the antrum elicits a sense of soreness if not of pain. The eye may feel heavy, and this may be associated with excessive lachrymation. The mucous membrane over the middle and inferior turbinates is reddened, puffy, and covered with a tenacious glairy mucus. The velvety smooth anemic appearance of chronic empyema is not present. Frontal Sinus. — Pain is experienced upon pressure made under the inferior orbital ridge and over the bridge of the nose. There is excessive secretion from the nose, which is associated with the symptoms of acute coryza, such as sneezing, lachrymation, and headaches, which are more pronounced when stooping over. Dizziness occurs occasionally upon suddenly rising from a stooping to the upright position. The appearance of the mucous membrane is the same as in a chronic coryza. Ethmoidal Cells. — Pain results from pressure over the anterior eth- moidal region along the inner margin of the orbit. There is both anterior and posterior nasal discharge of a thicker nature than that from a simple coryza. The appearance of the mucous membrane and the other general symptoms are the same as in frontal sinus involvement. Sphenoidal Sinus. — Postnasal "dropping," pain behind the eyes of a dull, indeterminable character, and the symptoms of an acute cold are the pronounced symptoms. Visual disturbance is rare in the acute stages. Diagnosis. — Transillumination (Plate I) is not of much value insofar as if not positive it does not exclude the presence of catarrhal involvement. If the cilia of the maxillary sinus have become inactive, or the ostium closed from pressure or mechanical obstruction, sufficient discharge may have accumulated to give a shadow, otherwise the sinus will trans- mit the light with almost the same intensity as if unaffected. The prolonged nasal discharge with exaggerated symptoms of coryza leads one to suspect sinus involvement, particularly if local pain upon pressure is definite. Prognosis. — Favorable, particularly if deviations of the nasal septum and obstructive hypertrophies of the turbinates are not present, or 142 THE SEQUELAE OF CHRONIC RHINITIS if present are corrected. Occasionally the acute catarrhal condition becomes chronic, and this in turn may become an infected one and terminate ultimately in empyema. Treatment. — The same treatment is applicable to acute catarrhal conditions of all the sinuses. Shrink the turgescent mucosa with a 2 per cent, solution of cocain first, which is applied on cotton pledgets moistened and squeezed out flat before applying. Second, apply in the same way pledgets moistened in a solution of adrenalin 1 to 8000 made up in aqua rosse. Leave each of them in place for five minutes. Irrigate the nostrils with a solution of one quart of hot water to which has been added two teaspoonfuls of salt. For this purpose the Douglass nasal douche is the best, but a gravity syringe with a nasal tip may also be employed. The irrigation should be from the well side around the septum and out through the affected side. To irrigate with the Douglass douche the head should be flexed on the chest, the mouth kept open while breathing continues, and gradual pressure exerted on the bulb so as to preserve a continuous and gentle flush. Sudden pressure or an attempt to swallow will force the solution into the Eustachian tube. Any irrigation is attended with some danger to the Eustachian tubes, but care and gentle manipulation will reduce this to a minimum. Hot compresses over the eyes or antrum will lessen the pain. Internally a brisk cathartic and some of the coryza remedies, as "coryza" tablets, "rhinitis" tablets, or the following prescription will materially hasten the disappearance of the symptoms: 1$ — Cinchonidiae gra. ij Ex. belladonna gr- n; Ex. suprarenal gland gr. j Camphor monobromat gr. ss One capsule every three hours. The treatment for cold together with the local shrinking and douching are the therapeutic measures which should be employed. The use of the sweat-box of Briinings, as recommended by Killian, has already been referred to in remarks on the treatment of a simple coryza. Prophylactic Measures. — Correction of all deviations of the septum; hypertrophies of the turbinates and irregularities of diet and hygiene, tending to favor colds, should be instituted. Chronic Catarrhal Sinusitis. — Maxillary. — Symptoms. — ^The manifesta- tions of pain and discomfort are of longer duration and are less exagger- ated in the chronic form than in the acute. The discharge may have become less, owing to complete stoppage of the outlet of the sinus, or it may have changed to a more gelatinous character, which if visible in the meatus will appear in greater quantity and be expelled in larger masses. Upon holding the head between the knees there wifl be less outpouring of mucus, and if the Bier suction pimip is used a thick mucosity will be sucked out. Irrigation of the nose, even after shrinking with cocairi and adrenalin, may not bring forth results, thus demonstrating ACCESSORY NASAL SINUSES 143 the increased density of the discharge or the greater obstruction to the outlet from either pressure or granulations. In these cases transillumination may show quite a marked shadow, due to the retained secretions. Diagnosis. — Definite conclusions as to the character of the disturbance is now more certain, as tenderness is more marked, transillumination is definite, and the discharge, if in evidence, is characteristic. Prognosis. — ^The prognosis is favorable, particularly if a counter- opening is made for drainage in the inferior fossa of the nose. The only danger is from infection. Treatment. — Overcome local pressure against or adjacent to the ostium. Shrink the tissues with cocain and adrenalin, and irrigate, as in acute sinusitis, with the Douglass douche or endeavor to pass a cannula into the normal opening, and irrigate through it with an alkaline solution. Should these fail, puncture the wall of the antrum in the inferior fossa and irrigate through this. (For method, see Chronic Empyema of Maxillary Sinus.) The internal medication is the same as in acute sinusitis. Steam inhalations of the oil of pine solution (see formula, p. 58) , materially lessen pain and often induce discharge, which is thinned by the additional mucus thrown out by the membranes from the stimulating effects of the pine and steam. Frontal Sinus. — Here also tenderness is less marked and headache less intense than in the acute form except upon iDcnding forward. The drainage obtained by gravity may evacuate the sinus temporarily and afford relief. Transillumination will, at times, give a positive result, and at others be uncertain, in accordance with the ability of the sinus to empty itself. There is a sensation of greater pressure around the eye and over the root of the nose, and the fulness in the head is continuous. Prognosis. — Favorable unless infected. Treatment. — Irrigations after shrinkage together with the same internal treatment as for coryza. ' If at the end of a week the symptoms have not abated, it may become necessary to remove the anterior end of the middle turbinate, and irrigate directly into the frontal sinus with a cannula. It is always expedient to attempt this under cocain prior to removing the turbinate, for it is possible, in some instances, to locate the hiatus or the opening into the middle meatus and irrigate without surgical procedure. Ethmoids and Sphenoid.— The symptoms are simply exaggerated for the chronic condition, and if irrigation after shrinkage does not effect a cure, recourse must be had to operative measures, just as for empyema. Acute Empyema of the Maxillary Sinus.— There is but little difference in the symptoms experienced by the patient in acute empyema and acute catarrhal sinusitis. The same nasal stoppage— continuous dis- charge— headaches, either local or general, soreness upon pressure, either externally upon the teeth, or within the nose against the lateral wall. Mental hebetude and disinclination to pursue either physical or mental 144 THE SEQUELS OF CHRONIC RHINITIS labor are prominent symptoms in both conditions. There is a sense of sohdity to the head as though filled with water, which is quite charac- teristic and the vocal resonance has a peculiar nasal quality to it at marked variance with the normal. Sudden jarring or movements of the head will cause an indefinable pain which is exceedingly unpleasant. Continuous blowing the nose fails to free the nostril of the offending matter, and the sensation of stuffiness remains after repeated efforts. The eyes are heavy, bloodshot, and ache upon use. There is a sore- ness manifest when pressure is exerted upon the eyeballs from above downward. Little changes are noticeable in the fundus from acute empyema. The throat is frequently affected by the discharge flowing into the nasopharynx and dropping into the larynx, which often results in acute pharyngitis and laryngitis. Fever is sometimes present in a small degree, and rigors not infrequent, but both are attributed, in most instances, to the coryza the patient has at the time. Digestion is often impaired owing to the quantity of discharge swallowed and likewise to the lack of exercise on the part of the patient due to the malaise. Sweats and flashes of heat and cold are experienced during the early stages of empyema, and are likewise attributed to the coryza, but they are in reality due to septic absorption. Examination and Diagnosis. — The turbinates will be swollen, red, covered with a purulent secretion, and in close contact, ordinarily, with the septum. The fossae and spaces between the turbinates and the septum will be filled with the purulent exudate mixed with mucus. There may not be evidence of great discharge upon looking into the nose, which impression will be shortly corrected by free irrigation with a hot normal saline solution and the use of the Douglass douche. Before irrigating, the tissues may be slightly retracted with cotton pledgets wet in cocain 2 per cent, and adrenalin 1 to 8000 and applied for a few minutes against the turgescent turbinates. This is the picture of one class of cases only. In the second variety the examiner will observe an intensely red mucosa, puffy and edematous, with no appearance of discharge whatever in the nares. There may be slight redness and puffiness over the antrum externally, but this is not common. The intranasal tissues should be reduced by cocain and adrenalin, and the patient should be directed to hold the head between the knees for five minutes, when, upon examination, a thin streak of whitish or yellowish pus will be seen to extend from about the region of the ostium maxillare down over the inferior turbinate, and possibly fill both middle and inferior fossae. This expedient may also fail to determine the presence of pus, and the use of Bier's suction pump may then be necessary to furnish the desired evidence. Should these fail, and the other symptoms be suffi- cient to warrant the belief that pus does exist, a cannula bent at the proper angle (Fig. Ill) may be introduced into the antrum through its ostium, and the sinus irrigated with a hot normal saline solution. Before attempting to pass the cannula, the middle meatus should be properly ACCESSORY NASAL SINUSES 145 cocainized and adrenalized. In a limited number of cases this measure is successful. In acute conditions, whether the presence of pus is sus- FlG. Ill ^ ^ '■»„ Killian's cannula for entrance into the maxillary sinus. pected or not, further attempts at determining the diagnosis by entering the antrum should be abandoned unless there is some very active indi- FiG. 112 Abrahams' sharp-pointed, hollow antrum needle. cation for surgical interference, such as extreme pain, signs of general sepsis, fears of j'purulent involvement of the middle ear, etc. Under Fig. 113 Instrument in place beneath inferior turbinate entering sinus. • these conditions, when the methods of examination for the detection of acute antral suppuration have failed, it is then expedient to cocainize and adrenahze the inferior meatus well up under the inferior turbinated 10 146 THE SEQUELS OF CHRONIC RHINITIS bone and introduce a sharp-pointed hollow needle, as Abrahams' (Fig. 112) or the Myles trocar, through which the antrum may be irrigated and definite conclusions drawn as to the presence of pus. Some authors advocate the use of the dental drill to gain entrance through a tooth socket, but unless a tooth has previously been with- drawn or one suspects a certain tooth to be the cause of the trouble it seems unwise to sacrifice a tooth to such a procedure when other measures are simpler. The operation for going through the canine fossa as a means of diagnosis seems unwarranted in acute cases. Transillumination. — If one side only is involved and the walls of both antra are of about equal thickness, the shadow of one side as com- pared to that of the other is of value in determining the presence of fluid; but unless taken in conjunction with other symptoms it is of no value. Method. — The examining room is made entirely dark. The small electric bulb is placed well in the mouth and brought against the hard palate in the median line. All dental plates and foreign substances should be removed from the mouth and nares, as a tooth plate or even pledgets of cotton in the nose will give shadows when transillumination is employed. If one side appears darker than the other, and the shadow under the eye is absent on one side, a certain amount of inferential evidence is obtained. The light should then be removed. from one side to the other to confirm the original impression. Often the pressure and heat of the bulb will elicit a tenderness on one side and not on the other which, if on the dark side, is of diagnostic value. The candle power of the bulb, which is mounted upon a sufficiently long stem, should be low — not more than one to three — in order to get the best results. Too strong light will penetrate a moderately thick layer of pus in the antrum. It should, however, be of sufficient brilliance to contrast the opacities with the transillumined areas. For the diagnosis of acute antrum empyema it is hardly necessary to employ the a;-ray, and the application of this method of diagnosis and its limitations will be taken up under a separate heading. Empyema has to be differentiated from cysts, mucocele, and tumors of both a benign and a malignant character. The history of the case, the char- acter of the transillumination, and the presence of pus obtained by the methods enumerated usually make the diagnosis reasonably clear. Treatment. — Irrigations with hot normal saline solution after proper shrinkage of the congested tissues should be tried for a week or more before surgical measures are employed to relieve the condition. This statement should be governed largely by the judgment of the physician, for if an empyema is causing severe pain, and the constitutional symptoms give evidence of septic absorption, and the tissues within the nose or those externally over the antrum seem to indicate pus under pressure, immediate operative measures are indicated. Puncture of the antrum in the inferior meatus with a hollow needle or trocar, followed by an irrigation of hot saline solution, has frequently ACCESSORY NASAL SINUSES 147 produced most satisfactory results and has been the starting-point of a speedy recovery. An irrigation by such means may be employed daily Fig. .114 Myles' back-cutting trocar or punch. for several consecutive days without inducing either great pain or irri- tation, and it apparently frees the lining mucosa of the destructive action of the pus upon the ciliated epithelium and permits natural drainage to be. resumed. Excessive hypertrophy or turgescence of the middle Fig. 115 Enlarging antrum perforation anteriorly. turbinate overhanging the ostium maxillare should be removed, and this ordinarily means the removal of the anterior one-third of the tur- 148 THE SEQUELS OF CHRONIC RHINITIS binate. Septal deviations making pressure or obstructing the natural drainage of the sinus must be considered as subject to possible correc- Fiu. 116 Curtiss gouge for antrum. tion, provided other measures fail; but if interference is avoidable it should be left untouched until the acute empyema has been overcome. Fig. 117 Abrahams' pyramidal and olive-shapedjantrum drills. Drainage through Inferior Meatiis. — This may be obtained in acute cases, without sacrificing any part of the inferior turbinate, by the use of Fig. 118 Enlarging antrum perforations with dental trephine. Myles' back-cutting trocar or punch (Fig. 114). After cocainizing and adrenalizing the inferior meatus well up under the inferior turbinate ACCESSORY NASAL SINUSES 149 anteriorly, the trocar is introduced within the meatus about one inch from the ala and its point directed upward and outward just beneath the attachment of the inferior turbinate, and with steady, firm pressure the antrum is easily entered. By withdrawing the punch the flange cuts backward and removes a small portion of the inner antral wall. This cavity can be enlarged either backward or forward by employing punches that have their cutting flanges directed either anteriorly or posteriorly, and as many entrances can be made as is necessary to give free drainage to the sinus and also to permit of con- tinuous subsequent irrigation through the opening with a large cannula. Freer drainage may be obtained by removing a segment of the inferior turbinated bone about one-half inch from its anterior extremity (Fig. 115), and through the space so obtained entrance is made into the antrum either by a gouge or grooved chisel and the use of a mallet; or by Curtis' gouges; by Abrahams' pyramidal and olive-tip drills; by the dental trephine, or by hand drills. Fig. 119 Tilley's hand drill. It has been demonstrated that the removal of the anterior third of the turbinate, as was formerly practised, has resulted in removing the control the patient has over the nasal and conjunctival secretions excited by coryza or weeping, and the discharge will run out without notice, and at inopportune times. The method of removing a segment from the middle of the external wall of the inferior nasal meatus presents ample space for entrance and serves every purpose requisite to obtain proper drainage. Acute Empyema of Frontal Sinus. — Symptoms. — Here also the general symptoms vary but little from the acute catarrhal involvement. The intensity of the headache and the general malaise are more marked. There may be a slight rise in temperature which becomes higher in the afternoon. Pain is experienced upon local pressure, when made just under the orbital ridge at the inner angle and just over the ridge near the median line, which varies from a slight soreness to an exquisite tenderness. The region over the area involved may appear red and associated occasionally with slight edema. The eye on the affected side appears watery, often streaked with engorged bloodvessels, and may protrude slightly downward and outward, although this is seldom the case. The upper lid is frequently edematous and there is slight ptosis. Examination of the nasal chamber will reveal the presence of pus in the middle meatus and a variable sized stream coursing over the inferior turbinate. This condition is not constant, for in many instances the pus is retained under pressure and evidence of its presence may 150 THE SEQUELS OF CHRONIC RHINITIS not be obtainable even by the employment of the three methods recom- mended for its evacuation, viz., shrinking with cocain and adrenalin and placing the head between the knees for five minutes; use of the Bier suction pump after shrinkage; or hot saline irrigations with the Douglass douche. The mucous membrane is puffy, turgescent, and often edematous in appearance. It has not assumed that soft, velvety, slightly anemic appearance seen in the chronic cases. The middle turbinate is the one most often involved and is ordinarily found pressing against the septum, although the inferior turbinate may give evidences of a similar turgescence. The patient experiences discomfort if not pain upon jarring or on leaning over, and the head has a sense of fulness and the voice a lack of resonance, which is characteristic and at variance with somewhat similar symptoms experienced with a cold. TH&gTiosis.^- Transillumination (Plate I). — If one side only is involved the shadow obtained on that side as compared to the other is of value, but errors entering into this method of diagnosis are many. A thickened sinus wall will lessen the intensity of the transmitted light; scar tissue or fibrous thickening over the region externally is misleading. A case illustrative of this came under our observation in which both trans- illumination and x-Ta,y showed marked involvement of the right frontal sinus associated with extreme tenderness on pressure and intense pain of a lancinating character at intervals. Upon the indications of these symptoms the man had been advised to have an external frontal sinus operation, but upon more careful inquiry we ascertained that five years previously he had had his supra-orbital nerve cut for neuralgia and for the intervening space had had no pain except for the two months previous to coming to the hospital. Fulguration over the nerve and large doses of phenacetin relieved the pain temporarily, and the same treatment has been applied at intervals of about three months for two years since with equally gratifying results. The scar tissue resulting from the operation still gives a marked shadow on transillumination. Peri- osteal thickening and varying density of the sinus walls are also produc- tive of shadows which are misleading and without other corroborative evidence transillumination is without definite value. For proper com- parison of the two sides the Birkett double transilluminator is of special value (Fig. 29). In its application the intensity' of the light should not be too strong; the approximation should be beneath the orbital ridge, and at such an angle that the rays penetrate the sinus and not the skin and soft tissues over the sinus. Treatment. — It is best first to try hot saline irrigations every three hours after having reduced the turgescence of the mucosa by the application of cocain 2 per cent, and adrenalin 1 to 8000 in aqua rosee. This will, in the majority of instances, result in a cessation of the purulent exudate. Should a week, or possibly two weeks (if there is no fever and no pressure symptoms), elapse, and there appears little if any abatement in the symptoms, operative measures are warranted. The advent of ACCESSORY NASAL SINUSES 151 marked fever, 101-2° F., or evidence of pressure eroding or distending the bony walls should be the signal for immediate operation. It is sometimes possible to pass a small cannula into the frontal sinus and irrigate it directly; but it is usually difficult and often results in inflammatory irritation of the exit, so that more harm is done than good. If the cannula passes easily into the sinus an argyrol irrigation (20 per cent, solution) should follow the saline. Fig. 120 ,. . . . ■, ; 1 "^rji ■; Mi'Tis ' ", '■ ' . ■ '!. I 'I ll'l'?' '.. I ,HI!'I|' |i 'III ;i|l lUEl E.AMAROYHCOCmCAGa. Ballenger's swivel turbinotome. Operative Measures. — ^The anterior third of the middle turbinated bone should be removed by first cutting its attachment anteriorly with a pair of curved nasal scissors (Fig. 103) and then passing a snare loop into this incision and carrying its posterior portion back to the point at which it is desirable to limit the removal, the whole constituting ordinarily about one-third of the body. This will remove all that is necessary to uncover the hiatus semilunaris into which the frontal sinus empties. This portion of the turbinate may also be removed with the Ballenger swivel spoke-shave (Fig. 120) or entirely with scissors. Any of these methods are very satisfactory. Ordinarily the removal of this piece offers sufficient drainage and permits the passage of a cannula directly into the sinus; but should it be inadequate, the bulla ethmoidalis must be broken down by a curette and the entrance into the infun- dibulum established by pinching away sufficient material to render the opening patulous. Even where free access is had to the sinus by surgical means, it is necessary to shrink the tissues with cocain and adrenalin before irriga- tion is effective, or before the cannula is introduced. At least once a day it is advisable to employ some mild astringent after irrigation, so that drainage can be established. Argyrol 20 per cent, solution, zinc chlorid 10 grains to the ounce, alumnol 20 grains to the ounce, enzymol full strength, and lactic acid bacilli held in suspension, ha.ve been employed with varying success by many operators. Argyrol seems to result in less discomfort to the patient, and is equally satisfying in results. Acute Ethmoidal Empyema. — ^The symptoms vary but little from those incident to frontal involvement. Local tenderness is elicited upon pressure upon the inner upper angle of the orbit. Sneezing, headache, lacrimation, malaise, and the other symptoms associated with an exag- gerated cold are experienced by the patient. Discharge is profuse, and 152 THE SEQUELS OF CHRONIC RHINITIS continuous blowing fails to relieve the sense of stuffiness and the sensa- tion of the presence of a foreign body. Examination. — ^The mucosa of the middle turbinate and the regions adjacent to the hiatus semilunaris are hyperemic and puffy. There is a streak of pus running over the inferior turbinate and a mucopurulent collection upon the middle turbinate and between it and the septum. In ethmoidal empyema the pus is hardly ever retained for a long period, and probably gives less trouble than involvement of any of the sinuses. This may be accounted for by the thinness of the ethmoidal walls, which would readily yield before great internal pressure could take place. It is difficult to determine from the appearance of pus in the nose which of the sinuses is involved, and particularly is this difficulty experi- enced in determining between frontal and anterior ethmoidal involve- ment. Treatment. — Therapeutic. — Shrink the tissues as in frontal empyema and irrigate frequently with the same solutions. In applying the solu- tions of cocain and adrenalin the pledgets should be shoved up under the middle turbinate. Operatite. — If the middle turbinate is not too large and affords any operative space between it and the external wall of the nose it is unneces- sary to sacrifice it in order to uncap the ethmoidal cells. When the operative field is cocainized the bulla ethmoidalis is broken into with a curette, then the outer walls of the cells are cut away from before back- ward with a Griinwald ethmoidal punch. It is better to employ a sharp- cutting instrument, which leaves no tags of mucous membrane, than a dull instrument, for all macerated tissue remaining becomes enmeshed with the granulation tissue springing from the cut surfaces and prevents drainage. The curette should only be employed to break down the outer wall of the cells and not to remove the lining membrane of the cells, although it may be diseased. When the ethmoidal tract has been sufficiently uncovered to facilitate free drainage a light packing with vaselined gauze should be introduced and left in situ until the following day, when irrigations should be resumed. If there is a tendency to the formation of granulations they should be controlled by the applica- tion of fused nitrate of silver, and if this is ineffective they should be removed with cutting forceps. If the middle turbinate is left undis- turbed it is more essential to keep the ethmoidal tract free from granu- lations than if it is removed. In cases where the middle turbinate is large and offers small space between it and the outer wall of the nose it becomes necessary to remove it to obtain sufficient drainage. In many instances this is accomplished with ease by the wire snare without addi- tional surgical measures; but if the anterior portion is very much rounded and difficult to engage in the snare loop, it is advisable to sever it from its attachment by means of curved scissors or narrow-bladed ethmoidal forceps, and the snare loop is then engaged in this incision. It may also be removed entirely with scissors, spoke-shave, or forceps. After remo\'ing the turbinate the ethmoidal cells should be uncapped as pre\iously described. The subsequent treatment consists in irrigation ACCESSORY NASAL SINUSES 153 and local application of nitrate of silver, argyrol, chloride of zinc, etc., to keep down granulations arid facilitate drainage. Acute Sphenoidal Empyema. — Symptoms. — Headache in sphenoidal involvement is referred mostly to the region behind the eyes, but the occipital and even the parietal regions are often complained of. Postnasal "dropping" and a constant desire to swallow are more marked than in other sinus involvement. The other symptoms simulate a severe coryza. Examination. — Anterior rhinoscopy may not reveal any evidence of pus, but upon the use of the postnasal mirror a stream jnay be seen running down the posterior nasopharyngeal wall. If the Holmes rhino- scope is employed a small stream of pus may be seen to exude from the region of the ostium sphenoidale. Very little discharge from the sphenoid finds its way into the anterior nares, but drops into the nasopharynx and is swallowed. This pften gives rise to digestive disturbances. Treatment. — Therapeutic. — Irrigation both anteriorly with the Douglass douche with hot saline solution, and posteriorly with the postnasal syringe. A cannula can occasionally be passed with moderate ease into the sphenoidal sinus through its ostium, and if accomplished with ease it is advisable to irrigate the cavity through the cannula and follow it with some of the solutions of argyrol, etc., as recommended in frontal and ethmoidal involvement. Fig. 121 Smithiussen-Pynchon sphenoidal forceps. Operative. — First locate the ostium, by means of a probe, and if suc- cessful in this a curette can be guided by its under surface to the ostium, which is then enlarged by downward and forward strokes of the instru- ment, until sufficient room is obtained to permit of the use of the sphenoidal forceps (Fig. 121). However, in the majority of instances, ample room is unobtainable between- the middle turbinate and the septum to pass the instruments without injury to the septal mucosa, and it is then necessary to remove the middle turbinate, which will give free observation as well as surgical access to the anterior wall of the cavity. The ostium should be enlarged from above downward until 154 THE SEQUELS OF CHRONIC RHINITIS ample drainage is secured. This does not necessitate lowering the anterior wall to the floor of the cavity, as is recommended in chronic empyema, but only sufficiently to permit of a large-sized cannula entering with ease, so that irrigation may be effectually carried out and good drainage obtained. The same solutions for subsequent irrigation should be employed as in frontal and ethmoidal empyema as well as the same astringents. Granulations are to be taken care of in the same manner. Chronic Empyema of the Accessory Nasal Sinuses. — There are a number of symptoms in addition to those enumerated under acute empyema which are common to involvement of any or all the sinuses. Symptoms. — Nasal. — ^The two conditions always present are discharge and obstruction, either unilateral or bilateral. The discharge may vary in character from a thick mucopurulent to a thin, foul, bloody pus, varying in color from a canary to a greenish yellow. The sensation of obstruction is always experienced by the patient, whether the nasal mucosa is hypertrophied, atrophied, or polypoid. Both taste and smell are affected, and the sense of smell is often lost either temporarily or permanently. The odor of the discharge may be apparent to the patient and not to the observer, which condition has been frequently considered of value in diagnosis. The quantity of discharge varies, and frequently in cases where there is apparently greatest bone involvement the dis- charge is moderate or scanty. The discharge flows almost equally into the postnasal space and into the anterior nares, and when it flows posteriorly it often occasions inflammation of the pharyngeal bursa, which condition is known as Tornwaldt's disease. There may also occur inflammation and even abscess of Luschka's tonsil. Where the pus extends into the larynx it produces cough, particularly at night and ultimately a chronic laryngitis. We often see atrophic laryngitis follow chronic sinusitis together with bronchorrhea, asthma, and even bronchopneumonia. Head. — Headache, occurring with more or less periodicity each day, is a common symptom, while faceache and neuralgia are almost always experienced during some period of the course of a case of sinusitis. Ears. — Tinnitus is quite common, and ordinarily begins with the acute stage. Vertigo is occasionally experienced, particularly on rising quickly. Earache and otitis media are very common, and are due to frequent efforts at blowing the nose, also to the irrigations being im- properly employed. Otitis media suppurativa is frequently associated with sinus empyema, and is probably, the result of direct invasion by the organisms producing the empyema. Cutaneous manifestations are eczema of the alse and upper lip and erythema, which may occasionally result in erysipelas. Ocular. — Invasion of the orbit may result directly from the pus breaking through from the frontal, ethmoidal, or maxillary sinus; by infection of the lacrimal duct and extension to the eye; or by inflammatory extension resulting in orbital cellulitis. Optic neuritis occurs in a large majority of cases, and will be discussed under its own heading. Gastro-intestinal disturbances such as indigestion, vomiting, diarrhea. ACCESSORY NASAL SINUSES 155 etc., are frequently present and are due to the swallowed pus. General ill health, as nervousness, loss of weight, loss of appetite, fever, irrita- bility, neurasthenia, and even melancholia, or meningeal irritation have been reported frequently as occurring in the course of empyema of the sinuses. Chronic Empyema of the Maxillary Sinus. — Symptoms. — The symp- toms enumerated for acute empyema may be exaggerated in character, or, as happens in some instances where free drainage occurs into the nose, may be of much less severity. In pus retained long in the maxillary sinus a bad odor is not infrequent, depending upon how long the secre- tions have been retained and upon whether there is necrosis of the bony walls. Pus from this sinus is ordinarily of a light canary color, which frequently differentiates it from that of other sinuses. Pain over the face, neuralgic disturbances, and cacosmia are almost always experienced. The discharge is more in evidence in the early morning hours than in the afternoon and evening, as exercise seems not only to tend to empty the sinus, but to excite the mucous glands to a greater activity, which thins the character of the pus. During the acute exacerbations grafted upon old chronic conditions, redness, pufSness, and tenderness of the cheek and lower eyelid occur almost invariably. The examination of the nostril on the affected side will show the mucosa over the inferior tur- binate to be puffy, soft, and velvety looking, and less hyperemic than in the acute catarrhal or empyematous involvement. There will be evi- dences of purulent secretion running over the inferior turbinate and collecting in the inferior fossa. Should this not be present at the first view, after the nasal tissues have been shrunken with cocain and adren- alin, if the patient's head is lowered to his knees and held there for the space of five minutes, there will often appear a thin stream of pus flowing over the inferior turbinate. Should this fail, the other measures as recom- mended under acute empyema, the Bier suction pump and hot saline irrigation, will in the majority of instances give the desired evidence. In some cases it becomes necessary, however, to puncture the antrum with a hollow needle, such as Abraham's or Myles', and force the pus out by injecting air through the needle or irrigating it with a hot saline solution. In doing this, caution should be exercised, as in rare cases death has followed the procedure. Diagnosis. — Transillumination. — In conjunction with other positive symptoms, transillumination, if positive, is of considerable value. If negative it renders no assistance to the examiner. Barring anatomical irregularities the same deductions may be drawn from transillumination in chronic involvement as were described under Acute Empyema (see Plate I). The instrument most universally employed in America is the Coakley lamp (Fig. 30), which consists of a small electric bulb over which may be placed a glass tube to protect the patient against the possibility of the bulb breaking and also against burning. All dental plates and foreign, bodies should be removed from the mouth, as well as any packing that may be in the nose, as they will give shadows which are misleading. The room being darkened, the light is then advanced 156 THE SEQUEL JE OF CHRONIC RHINITIS well into the mouth and held in the median line against the hard palate. In an uninvolved sinus of normal proportions there will appear a red glow over the cheek, another semilunar red area just beneath the lower eyelid. This is called a "tache." A third red area occurs in the location corresponding to the lower border of the nasal bone, which is less intense than the others. The pupil also reflects a red glow and simulates in appearance a cat's eye in the dark. The patient experiences a sensa- tion of light. When the sinus is involved the glow over the cheek will be almost entirely abolished, the "tache" beneath the eye will be absent, and the transmission of the light through the pupil will either be absent or lessened, and the patient experiences no subjective sensation of light. Positive evidences from transillumination may be obtained from other conditions than empyema, such as thickened bony walls, entire absence of the sinus, invasion by neoplasms, and permanent thickening of the lining membrane of the sinus from former inflammatory conditions. Occasionally the same negative evidences will be obtained where the sinus wall has been thinned, as from the presence of a mucocele, or if the sinus has been recently emptied of pus. X-ray examination will be taken up under a separate heading. X-ray Examination in the Diagnosis of Sinus Involvement (Plate 11).^ Radiographs when skilfully taken and critically interpreted are of un- questionable value in the diagnosis of sinus disease; moreover they are indispensable in guiding the operator both in the internal and in the external methods of operating. Without other determining factors one should be guarded in the conclusions drawn from a radiograph alone, however positive it may appear, and should never perform a radical operation based solely upon its reading, Radiologists have become expert in interpreting the lights and shad- ows of an x-ray plate, but there are many conditions, other than pus, which will give the same evidence. Chronic inflammatory processes, fibrous thickenings of the mucosa of the sinus from previous purulent involvement, periosteal thickenings, rarifying osteitis, irregularity in the thickness of the sinus walls, mucocele, tumors, and many other changes qualify the conclusions to be drawn from a radiograph. When the empyema is unilateral and other symptoms definitely determine the presence of pus, although the evidence may come from one sinus and the x-ray show that an additional sinus is involved, the operator may rely with some certainty upon the findings even though the clinical evidences of pus in both sinuses are not present. The radiograph shows air spaces dark, and if the same spaces are filled with fluid it is of a milky or opaque appearance, very easily determined after careful study of a number of pictures. The readings of a radiograph belong largely to the radiographer, who becomes expert in its interpretation just as the ophthalmologist does in the use of the ophthalmoscope. When the radiograph is transcribed to paper the dark air spaces become white and the purulent sinuses dark. Unilateral empyema is far easier of interpretation than a pansinusitis, as the unaffected side offers opportunity for comparison. Unscientific and ineffective work ACCESSORY NASAL SINUSES 157 in radiography lead to false conclusions and these are detrimental rather than of aid to the operator. One of the greatest values of the radiograph to the operator is the determination of the size of the sinus, the presence or absence of septa walling off separate cavities, and the determination of the distance between the inner and outer plates of the frontal sinus. Radiography has become a science of its own, and in it there are many original workers who have not only developed perfect means of photo- graphing the sinuses, but have perfected themselves in reading the lights and shadows with accuracy. Treatment. — ^Treatment of chronic empyema of the maxillary sinus must of necessity be more or less surgical, for the therapeutic measures available for the cure of sinusitis must of necessity have been exhausted during the acute stages, or if perchance the patient has not had the advantage of douching and has consulted the physician for chronic empyema for the first time, therapeutic measures will usually be of little avail. Daily irrigation through the natural orifice in a chronic case will usually be of no benefit, although a few operators have recom- mended it, and provided entrance can be gained by a bent cannula to the sinus, it may be attempted. Occasionally it is successful. Intranasal Operations. — Where the inferior turbinate is sufficiently small and stands away from the outer wall of the nose sufficiently far to give drainage, should an opening be made from the inferior fossa into the antrum, it is unnecessary to remove a portion of it to obtain adequate entrance into the antrum. After proper cocainization and adrenalization of the parts, entrance may be gained into the sinus by means of a Myles trocar, which initial opening can be enlarged by employing repeatedly his anterior and posterior cutting instruments until the opening assumes the desired size. Abrahams' two burrs, pyramidal and olive-shaped, may also be employed to drill an opening sufficient for purposes of irrigation and drainage. The curved gouges of Killian and others may be advantageously employed, but they are more effective when a segment of the inferior turbinate has been removed prior to their use. If the inferior turbinate is hypertrophied, or even if it is small but in close contact with the wall of the sinus, it becomes necessary to remove a portion in order to obtain proper drainage. In the experience of most operators it has proved more advisable to remove a middle segment from the turbinate than to remove its anterior extremity. Yankhauer has advised making the opening into the sinus not only down to the floor of the nasal fossa, but also to extend it upward to the ostium maxillare, which procedure prevents the rapid filling in of the artificial opening. There are also some operators who prefer making the opening from the ostium downward only to the inferior turbinate, confining it thereby to the middle fossa of the nose. They claim that drainage necessarily takes place normally in the antrum against gravity, upward toward its ostium; consequently a restoration to normal of the function of the cilia would thereby empty the antrum as successfully from an opening made high up on its wall as if it depended entirely upon gravity for its drainage. 158 THE SEQUEL JE OF CHRONIC RHINITIS After-treatment. — If the opening into the sinus has been made suffi- ciently large to admit the introduction of a good-sized cannula, it is safe to intrust the irrigation of the sinus to the patient, who frequently becomes adept in its introduction, and can irrigate with the same facility as the physician. Daily irrigation of the sinus through the cannula should be carried out by the patient and it should be followed by an injection of 10 per cent, argyrol. Additional douching should take place with the Douglass douche twice daily to bring away the pus which accumulates in the nasal fossa. The ability of the patient to irrigate the sinus should not prevent him seeing the physician every second or third day after the operation for about ten days, as granulations will spring up around the artificial opening and tend to obstruct the natural outflow of pus. These granulations must be cut down with either fused nitrate of silver, chromic acid, or with punch forceps. Ingals has devised a small gold tube that can be introduced into the artificial opening, through which pus can drain and the sinus may be irrigated with ease, but in the maxillary sinus it has hardly been necessary to employ it, as the opening can be kept patulous by the frequent use of nitrate of silver and dilatation with graduated probes. Alveolar Operation. — ^When a tooth has been removed just beneath the antrum, or if the tooth is supposed to be the cause of the difficulty and is so diseased that it has to be removed, it has been considered by some operators advisable to make an opening through the tooth socket into the antrum by means of a hand drill constructed for the purpose. Into this opening it was customary, formerly, to insert a gold tube, through which pus drained from the antrum into the mouth, frequently for years, it either being swallowed or expectorated by the patient. While some of the cases have made speedy recoveries, it has, in the face of more modern and more efficient operative measures, ceased to be employed. Canine Fossa Operation. — Both Caldwell and Luc designed an opera- tion of similar character at about the same time, and to give equal credit to both authors it has been designated the Caldwell-Luc operation. Whereas the operation may be performed under local anesthesia, it is by far better in the majority of instances to employ ether. The patient is prepared as for any surgical procedure, in addition to which the nares should have been freed from all polypi, the teeth put in good order, and the mouth rendered as aseptic as possible. Before beginning the opera- tion a post-nasal tampon of adequate size should be introduced and held firmly in place by grasping the end of the nasal string in the same forceps with the one extending from the mouth. An incision is then made at a little below the gingivolabial fold and well up above the alveolar processes of the teeth, beginning near the median line and extending well out toward the first molar tooth. This incision is carried down through the periosteum to the bone, after which the tissues are raised with a periosteal elevator well up above the canine fossa until the area for entrance into the cavity is exposed sufficiently for operative measures. In the region of the canine fossa a medium sized gouge is ACCESSORY NASAL SINUSES ■ 159 employed for gaining the initial entrance. The ordinary mastoid mallet is the best for use in this instance. The original opening is enlarged with Hajek's bone forceps and the wall removed to a level Fig. 122 Fig. 123 Caldwell-Luc operation. Gingivolabial incision. Caldwell-Luc operation. " Packing in sinus. Fig. 124 with the alveolar floor of the nose and forward until it approaches the nasal wall of the cavity. Care must be exercised not to carry the upper opening sufficiently high to involve the infra-orbital branch of the trigeminus nerve. When the opening is of sufficient size to permit the introduction of the little finger with ease, and the borders are smoothed of all projecting spiculse of bone, so that they will neither injure the intruding finger nor catch the gauze packing left after the operation, the contents of the sinus are removed with blunt-pointed grasping for- ceps and not curetted. The object is to free the sinus of polypi and granulation tissue without injuring the mucous membrane, however much diseased it may have become, for if the bone is entirely denuded of its covering, granulations will spring up in nature's effort to protect the bone and will subsequently occasion more disturbance than if the diseased mucosa is left in situ. When the sinus is first opened there will be con- siderable bleeding and it is unnecessary to attempt to control it, as it will not stop until all the polypi and granulations have been properly removed, after which the sinus may be packed with gauze soaked in ad- renalin and the bleeding almost completely overcome. When hemor- rhage has been sufficiently controlled for the operator to see the nasal wall of the antrum, he may begin the opening from the antrum into the Grtlnwald's bone forceps. 160 THE SEQUELJa OF CHRONIC RHINITIS nose by the use of a curette, protecting the structures of the nasal fossa by the introduction of his Uttle finger into the nostril and curetting against it. This opening may be enlarged by bone forceps, and it_ m the judgment of the operator it is deemed advisable to remove a portion of the inferior turbinate, a middle segment may be taken out with the ethmoidal punch forceps or the anterior third removed. The lower part of this opening should be carried as low as the floor of the nose and sufficiently well forward and backward to permit of the introduction of the index finger, which sized opening in the majority of instances will insure permanent drainage. The antrum then should be inspected in all its angles and recesses to see that it has been properly cleansed and that there is no septum of bone walling off a separate cavity which might act as a focus of subsequent infection. The sinus may then be packed loosely with a ribbon of gauze (ordinary sterile gauze well vaselined being preferable to iodoform), and one extremity carried out through the opening into the nose. The vaselin gauze is much easier to remove than any of the others and produces less hemorrhage when removed. The gingivolabial wound is then sutured with interrupted sutures of chromatized catgut, over which wound a small roll of gauze is placed and is held in position by the muscular power of the lip. The mouth should then be thoroughly cleansed with a solution of listerin and water, and kept as aseptic as possible for the next few days. After-treatment. — The patient should be put to bed and ice com- presses kept over the side of the face, which, in a measure, prevent the edema and discoloration that often result from the operation. Liquid diet should be given for a few days and a brisk cathartic administered on the following day, for in spite of the nasal tampon there is consider- able blood swallowed which if kept in the stomach and bowels is likely to upset the general system. The packing should be removed through the nose at the end of twentyrfour hours, and the sinus irrigated with a hot normal saline solution. The roll of gauze under the lip should also be removed and a fresh one substituted. There will be paralysis of the upper lip on the side of the incision for some weeks subsequent to the operation. Daily irrigations of the nostril and antrum should be carried out by the physician for at least a week after the operation, after which time the patient may take the matter in hand. Local swabbing within the sinus with chlorid of zinc, 10 grains to the ounce, argyrol 20 per cent, solution, or alumnol, 20 grains to the ounce, should follow each daily irrigation. All granulations tending to spring up around the opening should be cut down with fused nitrate of silver. Mmntages of the Operation.— Free and permanent drainage is ob- tained at one time without submitting the patient to successive minor «ntrn^''- P™f ^"^^^^^ j^ ^'^^w of the angles and remote places of the and elclnt^ , granulations and polypi can be successfully and efRciently removed. No deformity follows the procedure and recovery takes place m the majority of instances in from one to two months following the operation. Unless necrotic bone is definite^ determined in the sinus, the curette should not be used witJ^^W upon ACCESSORY NASAL SINUSES 161 its walls. Great care should be exercised to determine if the bone is necrotic or .merely denuded of its epithelial covering, as "bare" bone will give to the probe a sensation similar to necrotic bone. The operation known as the Ballenger-Canfield consists of an incision made just within the vestibule on the outer wall of the nose, exposing the anterior wall of the maxilla through which an entrance is made with gouge as illustrated in Figs. 125 and 126. Fig. 125 Fig. 126 Incision for Ballenger-Canfield operation. Opening tor Ballenger-Canfield operation for maxillary sinus. Denker's Operation. — ^This operation has for its object the union of the antrum and nasal fossa by means of obliteration of the bony wall dividing the two. An incision is made through the mucous membrane and periosteum down to the bone, extending from the second molar tooth to the frenum. The tissues including the periosteum are elevated by means of the periosteal elevator until the canine fossa is well exposed. By means of a curved blunt periosteal elevator the mucous membrane is then elevated from the outer wall of the nasal cavity down to its floor, as well as from the under and outer surface of the inferior turbinate. The antrum is now entered through the canine fossa by means of a gouge and mallet, and this opening is enlarged into the nasal fossa with bone-cutting forceps. It is sometimes necessary to use a chisel and mallet so as to carry the line of removal along the floor of the nose and as near to the floor of the antrum as is possible in the ana- tomical conformation. The nasal wall of the antrum is removed suffi- ciently far backward to insure a permanent large opening, and in the 11 160 THE SEQUELS OF CHRONIC RHINITIS nose by the use of a curette, protecting the structures of the nasal fossa by the introduction of his little finger into the nostril and curetting against it. This opening may be enlarged by bone forceps, and if in the judgment of the operator it is deemed advisable to remove a portion of the inferior turbinate, a middle segment may be taken out with the ethmoidal punch forceps or the anterior third removed. The lower part of this opening should be carried as low as the floor of the nose and sufficiently well forward and backward to permit of the introduction of the index finger, which sized opening in the majority of instances will insure permanent drainage. The antrum then should be inspected in all its angles and recesses to see that it has been properly cleansed and that there is no septum of bone walling off a separate cavity which might act as a focus of subsequent infection. The sinus may then be packed loosely with a ribbon of gauze (ordinary sterile gauze well vaselined being preferable to iodoform), and one extremity carried out through the opening into the nose. The vaselin gauze is much easier to remove than any of the others and produces less hemorrhage when removed. The gingivolabial wound is then sutured with interrupted sutures of chromatized catgut, over which wound a small roll of gauze is placed and is held in position by the muscular power of the lip. The mouth should then be thoroughly cleansed with a solution of listerin and water, and kept as aseptic as possible for the next few days. After-treatment. — The patient should be put to bed and ice com- presses kept over the side of the face, which, in a measure, prevent the edema and discoloration that often result from the operation. Liquid diet should be given for a few days and a brisk cathartic administered on the following day, for in spite of the nasal tampon there is consider- able blood swallowed which if kept in the stomach and bowels is likely to upset the general system. The packing should be removed through the nose at the end of twentyrfour hours, and the sinus irrigated with a hot normal saline solution. The roll of gauze under the lip should also be removed and a fresh one substituted. There will be paralysis of the upper lip on the side of the incision for some weeks subsequent to the operation. Daily irrigations of the nostril and antrum should be carried out by the physician for at least a week after the operation, after which time the patient may take the matter in hand. Local swabbing within the sinus with chlorid of zinc, 10 grains to the ounce, argyrol 20 per cent, solution, or alumnol, 20 grains to the ounce, should follow each daily irrigation. All granulations tending to spring up around the opening should be cut down with fused nitrate of silver. Advantages of the Operation. — Free and permanent drainage is ob- tained at one time without submitting the patient to successive minor operative procedures. A view of the angles and remote places of the antrum is obtained and granulations and polypi can be successfully and efficiently removed. No deformity follows the procedure and recovery takes place in the majority of instances in from one to two months following the operation. Unless necrotic bone is definitely determined in the sinus, the curette should not be used with force upon ACCESSORY NASAL SINUSES IGl its walls. Great care should be exercised to determine if the bone is necrotic or .merely denuded of its epithelial covering, as "bare" bone will give to the probe a sensation similar to necrotic bone. The operation known as the Ballenger-Canfield consists of an incision made just within the vestibule on the outer wall of the nose, exposing the anterior wall of the maxilla through which an entrance is made with gouge as illustrated in Figs. 125 and 126. Fig. 125 Fig. 126 Incision for Ballenger-Canfield operation. Opening for Ballenger-Canfield operation for maxillary sinus. Denker's Operation. — This operation has for its object the union of the antrum and nasal fossa by means of obliteration of the bony wall dividing the two. An incision is made through the mucous membrane and periosteum down to the bone, extending from the second molar tooth to the frenum. The tissues including the periosteum are elevated by means of the periosteal elevator until the canine fossa is well exposed. By means of a curved blunt periosteal elevator the mucous membrane is then elevated from the outer wall of the nasal cavity down to its floor, as well as from the under and outer surface of the inferior turbinate. The antrum is now entered through the canine fossa by means of a gouge and mallet, and this opening is enlarged into the nasal fossa with bone-cutting forceps. It is sometimes necessary to use a chisel and mallet so as to carry the line of removal along the floor of the nose and as near to the floor of the antrum as is possible in the ana- tomical conformation. The nasal wall of the antrum is removed suffi- ciently far backward to insure a permanent large opening, and in the 11 162 THE SEQUELM OF CHRONIC RHINITIS act of so doing the mucous membrane of the nasal fossa is lifted up by the blunt point of the rongeur. When ample space is obtained for viewing the entire inner surface of the antral cavity the contents are removed with blunt forceps, and in accordance with Denker's recom- mendation thorough curettage is carried out. The large flap of mucous membrane which has been detached from the outer wall of the nasal fossa and the under surface of the inferior turbinate is now incised longi- tudinally from behind forward to the junction of the skin and mucosa within the vestibule, and a perpendicular incision is made down from the anterior extremity to the floor of the nose. This leaves a triangular- shaped flap with its base attached to the floor of the nose, which is then Fig. 127 The Denker antrum operation : a, the area of bone removed in the Kuster and the Caldwell- Luc operations. In the Denker operation additional bone is removed from 6 to the pyriform aperture. (Ballenger.) pushed into the antrum cavity and held by gauze packing. The bony part of the inferior turbinate which has been denuded is now removed with forceps and the whole cavity packed with a ribbon of vaselined gauze, one extremity of which is brought out through the nose for drain- age. The gingivolabial incision is now closed with interrupted sutures of chromatized catgut, and the subsequent treatment is the same as that recommended in the Caldwell-Luc operation. This operation has many advantages insofar as it institutes perfect antral drainage and affords ample opportunity for investigating any of the small recesses which may retain septic material. It is, however, a more extensive operation and apparently is unnecessarily destructive of bony parts, which might upon certain occasions result in external facial deformity. ACCESSORY NASAL SINUSES ' 163 Chronic Frontal Sinus Empyema. — Symptoms. — In addition to the symptoms common to empyema of all the sinuses, such as local tender- ness, headache, discharge, and general constitutional manifestations, there may be added that of recurrent puffiness of the upper lid, occasional vertigo, recurrent headache of more or less regular periodicity, supra- orbital neuralgia, periods of marked mental hebetude, and occasional evidences of septic absorption, which is characterized by a peculiar pallor, muddy complexion, irritability of temper, and gastro-intestinal disturbances. There will also occur acute exacerbations grafted upon the chronic condition, which will produce redness and swelling over the frontal region and upper eyelid, the loss of smell and taste, laryngeal and tracheal inflammatory conditions. Eustachian tubal disturbances, and likewise disturbances of vision. In some instances of long standing or where the pus is held under pressure there will be considerable mental depression, even to the extent of hypochondria or melancholia. Inatten- tion and mental dulness are very frequent in these cases. It is the general opinion of all observers that alcohol and smoking tend to exag- gerate them. During these stages of acute exacerbation, symptoms of meningeal irritation are frequently present, and such a condition should be called to the attention of members of the family, as the operator has often been blamed for a meningitis following radical operation, which existed prior to the procedure. Appearance within the Nose. — ^The nasal mucosa has a soft, velvety appearance, which is slightly anemic and in marked contrast to the acute inflammatory or infective conditions. Over the inferior turbinate and also over the under and inner surface of the middle turbinate there will be a collection of purulent or mucopurulent secretion, which when wiped away will reappear. It is difficult to ascertain from the location of this pus which of the anterior set of sinuses is involved. Many diag- nostic points have been suggested to determine whether this pus comes from the frontal, ethmoidal, or maxillary, but unless the maxillary is examined by puncture and irrigation it cannot be excluded as a source of pus, as. the evidences of pus in the middle fossa and over the two turbinates will be of little diagnostic value. The mucosa over the middle turbinate appears soft and boggy and it is ordinarily in contact with the septum. Between it and the outer wall of the nasal fossa there may appear small polypi or the mucous membrane itself may be polypoid in character. These polypi frequently spring from the neighborhood of the hiatus semilunaris and may be outgrowths from either the anterior ethmoidal cells or from the hiatus. The discharge is most likely to take an anterior direction if the anterior sinuses alone are involved. In many anatomical specimens one finds a natural drainage from the frontal directly into the antrum, in which case if the frontal were involved the antrum would act as the natural receptacle of the pus from above. Treatment. — In the vast majority of instances it is impossible to pass a cannula directly into the frontal sinus with any degree of certainty, and the traumatism induced by this passage, without preparing a way for it, results in greater tumefaction of the adjacent tissues than the 164 THE SEQUELS OF CHRONIC RHINITIS mere outpouring of pus would produce; hence it is advisable to remove the anterior portion of the middle turbinate as the first step toward inducing proper drainage of the sinus. This itself will frequently bring about a favorable result, particularly if the turbinate has been puffy and pressing against the outlet of the sinus, but as the tissues are already cocainized, it is best to break down the bulla ethmoidalis which encroaches upon the groove from behind. This procedure enlarges the lower extremity of the hiatus semilunaris, and if there are no obstructing granulations above the sinus will drain very well by gravity, and if not a cannula can be passed directly into it and irrigations instituted. Many operators prefer also to chisel away the uncinate process, which then removes both the anterior and posterior limits of the hiatus semilunaris. In a few cases this procedure is all that is necessary, but if at the end of two weeks there is no evidence of reduction in the quantity of discharge from the sinus as well as improvement in the symptoms incident to the retention of pus therein, further operative procedures must be begun. Previous to enlarging the nasofrontal duct the a;-ray should be taken to determine the distance between the anterior and posterior wall of the sinus to ascertain if there is sufficient room to warrant intranasal enlarge- ment of the duct. There have been several operations devised which are perfectly safe in the hands of one acquainted with the anatomical relations, provided there be ample space to permit of instrimientation between the anterior and posterior wall. Fig. 128 Good's frontal sinus operation. Good's Operation. — After proper anesthetization thp anterior extremity of the middle turbinate is removed and the bulla ethmoidalis is broken down by means of a curette. A frontal sinus probe is then passed up through the hiatus semilunaris, infundibulum, and nasofrontal duct into the frontal sinus. This gives the direction of natural drainage of the sinus and likewise gives some idea of the size of the curette necessary to form a sufficient opening for the introduction of the rasp employed ACCESSORY NASAL SINUSES 165 for enlarging the duct. A small curette on a curved handle is introduced upward through the hiatus semilunaris, and curettage takes place from before backward, as well as upward until the frontal sinus is reached. Then the curved rasp, with its cutting border anteriorly and its smooth side toward the septum, is introduced and the anterior part of the duct, infundibulum, and hiatus are rasped away until a sufficient open- ing is gained for the introduction of a large cannula, through which irrigation may be carried on. The posterior wall of the hiatus, infun- dibulum, and duct are left untouched as well as the walls of the frontal sinus. It is well to chisel or bite away with bone forceps the uncinate process, as it will interfere with the proper introduction of the catheter and also offer obstruction to the drainage of the sinus. After the detritus is all cleared away the fragments of mucous membrane and bone should be cut away cleanly with ethmoidal punch forceps, the frontal sinus irri- gated with a hot saline solution, and the operative field lightly packed with a strip of vaselined gauze. This packing should be removed on the following day and the sinuses irrigated once daily through a cannula, followed by some of the solutions mentioned, as argyrol, enzymol, etc. The patient should be instructed also to douche the nose twice a day Fig. 129 EZ- ammmmmiiimmM} Good's curved rasp. with the Douglass douche and a saline solution. Granulations incident to the operative procedure should be kept down with fused nitrate of silver or chromic acid, which if unsuccessful should be followed by cutting forceps. This operation has proved a great success in the hands of many observers, and has many features to recommend it. Ingal's Operation. — Here, as in the operation of Good, it is necessary to ascertain if there is proper space for the introduction of the instrument between the posterior and anterior plates of the frontal. The anterior part of the middle turbinate is removed and the bulla ethmoidalis broken down. There are three pilots or probes essential to the opera- tion. These vary in length and size to meet the varying sizes of the duct and the hiatus. Their distal ends are malleable so that they may accommodate themselves to the irregularities of the duct. After a selected pilot or probe has entered the frontal sinus, a hollow burr (Fig. 131, B) is threaded over it and attached to the shafting of an electric motor. The probe is thus used as a guide or pilot to the burr. The burr itself is on a flexible tube and the whole is then guided to place by a stiff-looped guard (Fig. 131, ^) which serves to keep the burr, when in motion, far enough anteriorly to open the way to the frontal sinus by enlarging the natural opening. The canal below the revolving burr may 166 THE SEQUELS OF CHRONIC RHINITIS be protected by the shield (Fig. 131, C), which is slipped over the hollow revolving tube shafting of the burr. Pressure may also be exerted Fig. 130 SHARP « SMITH C^niimiiiii]|illl!lilPlii||1l1>F]|illlllPimllli]|ii 'iiiiiiiiiiiiiiinlli iiiliiiiaiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii II iiiiiiiiiiiMiiiiiiiiiiiiiiiiiiiiii Hilling iiiiiiiiiiMiiiiiiiiliiiuiiiiiiii;]iii][iiiiiiiiiiiwi"„imll{[iip[||][ ~UM.iii.ii,ii»Miiniiiiniiiiiiii ili!'!:!'?l!' ''!l::!il!:!!fi!:i:!l!!'g!!gr'';'g':';g^^^ Ingals' flexible pilots or probes. Fig. 131 ""^ P Ingals' hollow burr for frontal sinus operation. Fig. 132 Ingals' frontal sinus operation. ACCESSORY NASAL SINUSES 167 through the guard on the burr to force it upward. (See Fig. 132.) A gold drainage tube (Fig. 133) with a cup-shaped lower extremity and flaring springs at the upper end, which are held together until introdufced into the frontal sinus by means of a soluble capsule, is now introduced into the opening made by the burr. To prevent the capsule from disin- tegrating before the tube can be properly introduced, it should be dipped in melted paraffin, which will insure its lasting for a sufficient length of time to get it in place. This tube is left in situ from one month to two years, in accordance with. the progress of the case. The patient can be taught to irrigate the sinus through the tube, and if left in situ it affords ample drainage to prevent pressure pain. Occasionally it becomes loose in its position, and this indicates that the opening would probably remain patulous if the tube were removed. This operation is frequently modified so that entrance is gained into the frontal sinus by means of the hand drill or the Good curved sinus rasp, after which the gold tube may be inserted. The electric burr has been considered dangerous by a good many observers, and while it may act with uniform satisfaction in the hands of one thoroughly familiar with its use, it is unwise to recommend it for general employment. Fig. 133 Gold drainage tube for Ingals' operation. A, applicator; B, gold tube without capsule; C, gold tube with capsule. External Operations. — Experience is beginning to teach that a great many of the external operations for empyema of the frontal sinus may be avoided by careful internal operative measures followed by persistent treatment. This treatment not only consists in irrigation which is followed by medication as previously recommended, but by keeping down all granulation tissue with either fused nitrate of silver, chromic acid, or cutting forceps, thus permitting free evacuation of the sinus between irrigations. Ventilation and drainage are the two essential factors for the cure of sinusitis, and these may be obtained with equal facility in those cases in which the internal operation has been recom- mended, as by the external method. When, however, there is high temperature, symptoms of septicemia, evidences of extravasation of pus into the orbital tissues, symptoms of meningeal irritation, or any of the most highly exaggerated symptoms enumerated under the head of symptoms of chronic empyema, the external operation is advisable. It is also advisable where insufiicient drainage has been obtained through the intranasal method, and treatment has been persisted in oyer a period of a year or more without success. However, in the experience of the writer there have been several cases where a complete cure has been 168 THE SEQUEL/E OF CHRONIC RHINITIS effected even at the expiration of eighteen months to two years of intra- nasal treatment. One other condition in which the external operation is essential is that of a recurrent acute exacerbation in a patient pre- viously operated upon, associated with edema of the upper lid, pain, temperature, and dizziness which comes on with more or less periodicity where there is no evidence of pus between attacks. These manifestations usually indicate a walled-off partition in the frontal sinus which acts as a focus of infection, lighting up whenever the patient's resistance is lowered below normal. Opinions still are at variance relative to when and under what circumstances the external operation should be per- formed, but in the minds of the most conservative operators the external operations should be the last and not the first attempt to relieve the condition, except in such circumstances as just enumerated. Jansen's Operation. — This operation consists in making a curvilinear incision just below the overhang of the orbit extending from the supra- orbital notch around the inner canthus of the eye and down on the side of the nasal bone. The tissues together with the periosteum are liberated from this incision downward, exposing the inner angle and roof of the orbit, and upward above the supra-orbital ridge. By means of a gouge and mallet the frontal sinus is entered from below the overhang and the roof of the orbit is entirely removed by means of bone forceps or until sufficient space is obtained for proper curettement of the sinus above. The nasofrontal duct is enlarged by breaking down any ethmoidal cell that may "mound" into the sinus and also the bony surroundings anteriorly and laterally. Jansen recommends thorough curettement of the sinus, even to the removal of the diseased mucous membrane. This operation relies principally upon external drainage, although a large part of the discharge may find its way into the nose through the enlarged duct and infundibulum. It was formerly considered that the orbital fat would tend to fill in the cavity made by the removal of the roof of the orbit, but how far this is true is a matter of conjecture. The operation is peculiarly applicable to very small sinuses; if the sinus is of any size, or if there are septa of bone dividing it into the various cavities, the operation is inadequate to furnish either proper drainage or a proper view of the interior of the sinus. It was employed extensively until the introduction of the Killian operation. The Ogston-Luc Operation. — Ogston first employed the method about ten years before Luc made it popular. It consists in making a curved incision along the inner third of the supra-orbital ridge through the eyebrow from the supra-orbital notch to a point opposite the inner canthus. The tissues are elevated above and below the incision until the anterior wall of the sinus is exposed. With a gouge or trephine entrance is gained into the sinus externally and the opening enlarged with bone forceps. The nasofrontal duct is enlarged by curetting and the inner part of the supra-orbital rim is sometimes destroyed. The ethmoidal region and the orbito-ethmoidal cells are not reached, which is an argument against the operation. Drainage is instituted by means of a tube or a wick of gauze inserted from the sinus down into ACCESSORY NASAL SINUSES 169 the nose, and the external wound is closed. This drainage-tube or gauze is replaced on the second day after withdrawing the original packing through the nose. Some operators also leave the external wound open for a few days, after which it is closed by sutures. Kuhnt's Operation. — This operation has for its object the removal of the entire anterior wall of the frontal sinus, which permits the soft parts covering it to be pressed down into the cavity until they become adherent to the posterior wall. This obliterates the cavity entirely, but in order to do so the orbital ridge is frequently removed and the whole anterior face is flattened out at that point. The external deformity following it renders it entirely unjustifiable, except in extreme instances, where the sinus may extend nearly to the hair line of the forehead. The Killian operation affords equal advantages without the subsequent deformity, and it is to be advised in its stead. Watson Williams' Osteoplastic Operation. — ^The author of this operation advocates, in addition to the surgical procedures incident to all operative measures upon the sinuses, the bacteriological examination of the pus contained in the sinus, and if streptococci predominate, 20 to 30 c.c. of antistreptococcic serum should be injected the day before operation. The incision follows the eyebrow toward the root of the nose, thence downward along the midline of the dorsum of the nose sufficiently far to permit the nasal bone to enter entire into the osteoplastic flap. The skin and soft tissues are then elevated for about one-fourth of an inch, where the periosteum is incised corresponding to the curvilinear skin incision, and the periosteum is elevated with the soft tissues until the anterior surface of the frontal sinus has been exposed, the extent of which has been previously determined by the a;-ray. The anterior wall of the sinus, above the periosteal incision, is then completely removed. A second incision about three-fourths of an inch in extent is made along the inner and lower margin of the lachrymal groove, which exposes the lachrymal duct, and the duct is then turned to one side out of the way, and entrance is made into the nasal passage through the bottom of the lachrymal groove. A fine curved saw is then passed through the nose and out of the opening in the groove, and the nasal process of the maxillary bone divided. Watson Williams' saw, devised for the purpose, is probably the best instrument to employ, although the Gigli saw will serve the same purpose. By means of the saw another division is made extending from the frontal sinus down to the lachrymal groove, dividing the bone from behind forward and leaving the soft tissues intact. The nasal bone is then divided by means of a saw, following the initial incision along its dorsum, just to the outside of the septum. The osteoplastic flap thus formed is then turned outward giving free access to the fronto- nasal passage and ethmoidal cells.. The ethmoidal labyrinth may be followed backward even to the sphenoidal sinus with every operative movement under supervision. Watson Williams recommends that the sinus be cleared of polypi and of the pyogenic membrane covering the bone and all septal ridges. The floor of the sinus is then removed to within a few millimeters of the orbital margin, and when necessary the inner 170 THE SEQUELS OF CHRONIC RHINITIS wall of the orbit together with the ethmoidal cells should be cut away. The osteoplastic flap is then examined to see if it may possibly contain any small ethmoidal cell, which if present is removed together with the pyogenic membrane along the infundibular surface. The flap is then replaced and sutured, and a rubber drainage tube extending from the deepest and farthest removed angle of the sinus is carried through the nasofrontal duct into the nose. This tube is removed at the end of two or three days and is not replaced. Douching is not instituted until four or five days after the operation, which should even at that time be performed with care. Killian's Operation. — The operative area together with the eyebrow is thoroughly sterilized, but the latter is not shaved. Fig. 134 Killian's frontal sinus operation. Cutaneous incision. First Step. — A curvilinear incision is made through the soft tissues down to the periosteum, beginning at the temporal extremity of the brow and carried through the hair line to the root of the nose, where a curved angle is made and the incision is carried obliquely downward and outward to just below the base of the nasal bone. Transverse cutaneous incisions are made superficially across this original incision to enable the operator to coapt the flaps after the operation with greater accuracy. The soft tissues are then elevated from the periosteum and the external plate of the frontal bone is uncovered up to the superior limit of the sinus, which limit has been determined by a previous a;-ray picture. The soft tissues below are also turned downward and outward until the floor of the sinus is exposed nearly to the supra-orbital notch as well as the ethmoidal area at the inner and lower angle of the orbit. The eye is protected by a pad of moist gauze so that the instruments ACCESSORY NASAL SINUSES 171 requisite to control the hemorrhage and for retracting the tissues do not injure it. Second Step. — Periosteal Incisions. — ^The first incision is made through the periosteum parallel to the supra-orbital margin and five to six millimeters above and extends from the temporal end of the eyebrow to the beginning of the root of the nose at its central point. A second periosteal incision is made by beginning at a point just internal to the attachment of the superior oblique muscle and following the line of cutaneous incision to its extremity. The periosteum is then elevated above the first incision to uncover the entire anterior frontal wall over the extent of the sinus, and below the second incision the periosteum is turned downward until the inner and superior third of the orbit is exposed. The periosteum over the bridge of bone included in these two incisions is left in situ for the purpose of nourishment. Fig. 135 Killian's frontal sinus operation. Periosteal incision. Third Step (Fig. 136).— The sinus is now entered by means of a gouge or V-shaped chisel such as KiUian's (Fig. 137) above the superior periosteal incision, and sujfBcient bone is chiselled away to permit of satisfactory probing of the sinus. If an a;-ray has not given an idea of the extent of the sinus it is well to leave the mucous membrane in place temporarily, and a probe is introduced through the opening between the mucous membrane and the wall of the sinus and a definite idea obtained of its extent and outline before entrance is made into the cavity. 172 THE SEQUELS OF CHRONIC RHINITIS Fourth Step. — ^The outer plate of the sinus wall is now removed by means of bone-cutting forceps or chisel and mallet until the limits of the sinus above the upper periosteal incision have been obliterated. All angles should be thoroughy investigated and transverse ridges and septa of bone should be curetted away so that the inner surface of the Fig. 136 Eillian's frontal sinus operation. Removal of bone. . sinus will present no obstacles to proper drainage. Hemorrhage is apt to be severe until all granulation tissue has been thoroughly removed, after which packing with gauze soaked in adrenalin will overcome any oozing that may be present. The superior border of the bridge of bone should be smoothed down carefully and great care maintained not to fracture it, as upon this bridge rests the subsequent outcome of the case as regards external deformity. It was formerly advised by Killian, Killian's gouge chisel. and the plan was followed by many other operators, thoroughly to denude the sinus of its lining mucous membrane, but in the light of more extensive experience it has been found best to leave this membrane in situ, as it affords a better covering for the bone than the granulations which would spring up if the bone were entirely denuded. ACCESSORY NASAL SINUSES 173 Fifth Sfep.^-Th.e periosteum has already been elevated and retracted from the nasal bone, from the frontal process of the superior maxilla, from the lachrymal groove and from the orbital portion of the frontal bone toward but not up to the supra-orbital notch. A small-sized Killian V-shaped chisel is placed at the junction of the nasal bone, with the frontal process of the superior maxillary bone just external to the inferior peri- osteal incision, and is driven upward by means of a mallet until a groove is formed, which will prevent the splintering of these bones by the succeed- ing efforts to gain entrance into the frontal sinus from "below. The upper margin of this groove forms the lower end of the supra-orbital bridge. The chisel is again placed at the lower end of the suture between the nasal bone and the frontal process of the superior maxillary bone, and is driven through the frontal process toward the lachrymal bone, care being used not to injure the lachrymal sac. The groove thus formed prevents the downward breaking of the frontal process during its resec- tion. Entrance is now made into the frontal sinus from below, which is best accomplished by beginning just above the last-made groove, where the bone is thinnest and can be perforated without injury to the under- lying mucous membrane of the nose, which must be preserved for use as a flap. After an opening has been gained, bone forceps may be employed to remove with ease the greater part of the process of the superior maxilla. The rest of the bone constituting the floor of the sinus may be removed with ease; its inner periosteal lining, if possible, may be retained to enter the flap of mucous membrane made from the nasal mucosa. After this area has been properly uncovered the flap of mucous membrane is made by perforating the nasal mucosa with a pointed scalpel at the edge of the nasal bone, and the incision is then continued by means of a blunt-pointed bistoury upward and backward below the cribriform plate and then downward. This flap is tongue-shaped, and is turned outward to be used to cover those parts of the wound facing the nasal cavity. If the flap is properly preserved it will aid in establishing a permanent communication between the frontal sinus and the nose. When this is done and the tissues are retracted a good view may be obtained of the anterior end of the ethmoidal labyrinth. Sixth Step. — Remove with a snare the middle turbinated bone through the nose. The anterior and posterior ethmoidal cells, if diseased, should be removed with forceps through the wound. If the sphenoid is involved its anterior wall can be cut away with Williams' or SkiUern's forceps. The forceps of Griinwald and Hartmann are also recommended for removal of the ethmoidal labyrinth, and better results will follow the removal of these tissues with sharp-cutting instruments than if the area is curetted. The remaining portion of the frontal floor which cannot be removed from below can now be safely reached from above. Kiflian formerly removed the entire frontal floor from above, but at the present time he does not follow this course. The limitations of the removal of bone to be kept in mind are the lower part of the lachrymal groove below, the anterior ethmoidal vessels behind, the attachment of the trochlear muscle and the supra-orbital notch above. The surface 174 THE SEQUELJE OF CHRONIC RHINITIS of the entire operative field must be smoothed either with forceps or curette, otherwise the gauze drainage will catch on some of the projecting points and granulations will spring up from the macerated areas which will tend to prevent proper drainage of the sinus. Seventh Step. — Irrigate the wound with a noiunal salt solution and properly dry with gauze packing, after which iodoform is blown into the wound. The posterior postnasal tampons are then removed and a narrow strip of iodoform gauze is loosely packed along the ethmoidal labyrinth, the end of which projects out into the nasal orifice. A second gauze wick is run from the temporal extremity of the frontal sinus into the nasal chamber through the nasofrontal duct and out through the nasal vestibule. The wound is then sutured, care being exercised to bring the two lips into exact coaptation guided by the transverse cuts Fig. 138 Beck's plastic flap frontal sinus operation. previously made at right angles to the primary incision. Horsehair, silkworm gut, silk, and metal sutures have all been tried by the different operators, with ardent advocates for each. The metal sutures seem to offer the most aseptic material for suturing the wound. They do not come into contact with any of the infective area. Finally the whole eye and external wound are covered with dressings of moist boric acid gauze, which is bandaged more or less tightly. After-treatment. — ^The patient is now put to bed and made to lie upon the sound side for the next few days. He is forbidden to blow his nose, as by so doing he is liable to blow air into the tissues and produce an emphysema. The nasal secretions are drawn into the throat, which can be expectorated. No irrigation should be used. The gauze packing is removed on the second day and the sutures on the fifth, provided ACCESSORY NASAL SINUSES 175 the appearance of the wound gives favorable indication for their removal. Granulations tend to spring up rapidly which at the end of the second week should be kept down with a strong solution of nitrate of silver. In the after-care of these cases Luc recommends the daily removal of the crust and secretions forming in the nasal cavity. He does this by the introduction of a tampon of cotton soaked in peroxid of hydrogen or a weak solution of iodin. It has been found by many operators that to keep the nasal mucosa well greased with "vaselin nose cream" (see formula) will materially aid in the expulsion- of these crusts. The deformity that results in some of these cases consists in a depression above the bony a,rch, which can be overcome in most instances by the sub- cutaneous injection of paraffin. There is scarcely ever any deformity below the bridge. Secretions of a mucopurulent character continue to exude for several months subsequent to the operation, and in some instances the discharge of pus continues in spite of the radical pro- cedure. Secondary operations are not infrequent, and upon entrance into the sinus there will be found a focus of infection usually walled off by an overlooked septum of bone at the outer extremity of the sinus. Upon the whole this operation has been the most satisfactory of the external methods, and results in less deformity and more cures than any advocated up to the present moment. Chronic Sphenoidal Sinus Empyema. — Symptoms. — The symptoms in this condition vary from that of the acute involvement only in an exaggerated intensity of headache and of pain behind the eyes and referred to the parietal and suboccipital regions. The eye symptoms also are more numerous and complicated than in infection of the other sinuses. A discussion of this will appear under a separate heading. The discharge is frequently foul in character, and its dropping into the pharynx and larynx often induces inflammatory conditions in these places. That which is swallowed also produces digestive dis- turbances of more marked character than in the acute involvement. Both pain and volume of discharge are intermittent in character, which tends to indicate that the sinus will fill up with pus until distended, which will occasion pain, and then from the pressure within will burst . out through the ostium, evacuating a quantity of pus at one time, after which the pain lessens. Upon the examination of the region of the sphenoid by means of the postnasal mirror or the Holmes pharyngoscope granulations and even large polypi may be seen to occupy the region in and around the ostium sphenoidale. Probing the sinus will often give evidence of bare bone, which sensation simulates that of necrotic bone, but from this symptom alone curettement of the walls of the sinus is unjustifiable. Transillumination is of no advantage in the determina- tion of involvement of the sphenoid, but the a;-ray will often add further facts to the'Dther symptoms indicating sphenoid involvement. Treatment. — ^The same treatment is applied here as in the acute empyema, only the anterior wall must be lowered to a greater extent than formerly described — that is, the ostium must be enlarged down- ward—otherwise the opening will soon granulate up and the drainage 176 THE SEQUELS OF CHRONIC RHINITIS will not be sufficient to overcome the disease. When the middle turbinate is removed, or in cases of atrophy where the turbinate does not intercept the vision, free access to the sinus is obtainable. Instruments for operating upon the sphenoidal sinus do not meet entirely the requirements of the procedure. Andrews has a combination of probe, cannula, and knives which are of material advantage in making entrance into the sinus. Watson Williams has also devised a sphenoidal sinus cutting forceps with a bayonet-shaped point for entrance into the Fig. 139 Watson Williams' sphenoidal sinus operation. ostium which cuts downward and forward against the ring-shaped piece fixed to the shank. With this instrument the wall of the sinus may be lowered to meet the requirements of the case. It is inadvisable to employ either a chisel or gouge in lowering the wall, as no man can rely absolutely upon his dexterity in handling an instrument the point of which is directed against such remote and dangerous localities so far removed from the point where the power is applied. Here, as in the other sinus operations, granulations are apt to spring up and ACCESSORY NASAL SINUSES 177 undo all that has been done in the way of ventilation and drainage; consequently particular care must be exercised to keep them down. Hypophyseal Tumors. — ^Involvement of the pituitary body, either by true hypertrophy, tumor, or cystic degeneration, produces a class of symptoms peculiar to this disease. A general description of the symp- tomatology can best be derived from general text-books or from Cush- ing's^ book on this subject. A few of the special symptoms directing the attention of the rhinologist to the existence of the condition are enlargement of hands and feet, possibly of ankles and wrist, but seldom of the arms and legs. The head may be enlarged, but disproportionately to the size of the face, which becomes very much enlarged, particularly the superior and inferior maxillary bones. The nose and ears are often enormously hypertrophied, with sometimes thickening and drooping of the eyelids. Headache is frequent and the patient is disturbed with persistent somnolence. Vision is occasionally disturbed, owing to pro- gressive atrophy of the optic nerve. The hypertrophy of the bones of the face continues until a condition is reached known as leontiasis ossea. Treatment.^ — Gushing has instituted treatment both by the hypodermic injection of pituitary extracts, by transplantation of the pituitary body taken from healthy animals, and by the administration internally of the whole gland. Definite conclusions relative to the abatement of symptoms following this method of treatment cannot yet be drawn. Operation. — ^Numerous methods have been devised by which the sella turcica can be approached, and after trying various methods Gushing has evolved what he terms "the trans-sphenoidal approach, with sublabial incision and submucous septal resection." A prelimi- nary tracheotomy is performed through which the administration of warm ether is most easily accomplished. A tracheotomy also permits of packing the laryngopharynx to prevent blood and secretions gaining entrance into the lungs. When the jaws can be opened ether may be given through a hollow tongue spatula or through a mouth gag, to which is attached a hollow tube to the tooth piece, and tracheotomy may thus be avoided. Urotropin to the extent of sixty grains is administered twenty-four hours previous to the operation to guard against possible meningeal infection. The patient is placed in the moderate Rose posi- tion, with the shoulders slightly, elevated and the head extended back- ward. Adrenalin, 1 to 1000 on pledgets of cotton, is packed in the nostril during the first part of the operation. The upper lip is then elevated with the mucoperichondrium for a considerable distance on either side of the frenum until the septal cartilage is reached, when a submucous resection of the cartilage and bone of the septum is performed. The septum is removed and the mucous membrane held apart with retractors or bivalve speculum so that the anterior surface of the sphenoid cavity is exposed. The walls of the sphenoid are then removed by pinching forceps or curette and the lining of the cavity likewise removed, so that the protrusion of the sella turcica into the sphenoidal cavity may be ' Harvey Gushing, The Pituitary Body and its Disorders. 12 178 THE SEQUELM OF CHRONIC RHINITIS determined. The floor of the pituitary fossa is then removed. A trans- verse incision is made in the dura surrounding the pituitary gland by means of a "knife-hook," and such extirpation of the tumor is made as is deemed advisable to overcome the condition. In cases of cysts it is only necessary to incise the cyst wall and evacuate the fluid contents. Hemorrhage is controlled by pressure with pledgets of cotton soaked in adrenalin or peroxid of hydrogen, after which they are removed, the speculum is withdrawn, the mucous flaps of the septum are replaced and held in position by packing or Bernay sponge splints, and the wound beneath the lip is sutured with catgut sutures. CofSn has devised a much simpler operation, and for the rhinologist it offers ample room for safe approach to the pituitary gland. Under cocain and adrenalin anesthesia a perpendicular incision is made through the septal cartilage and the mucous membrane of both sides about three-fourths of an inch from the columnar cartilage. The lower third of the septum is then removed, or as much as it is deemed necessary to remove, for obtaining a good view of the anterior surface of the sphenoidal cavity. The mucous membrane together with the bone and cartilage, wherever encountered, is bitten away by the use of cutting forceps, and it is in the use of these forceps, which lessen hemorrhage, that Coffin's operation differs from that of West, who employs knife and chisel for the same purpose. If insufficient room is obtained by the removal of the septum, which enables the operator to operate on one side of the nose while the illumination is directed on the other, the middle turbinate, together with the ethmoidal tract, may be removed on one side to enable the operator to obtain a better view of the anterior surface of the sphenoid. The walls of both sphenoid cavities, together with its septum, are removed; the mucous membrane covering the protrusion of the sella turcica into this cavity is taken away, hemorrhage is controlled by gauze or cotton packing soaked in adrenalin, and the bony covering of the sella turcica is broken away with the curette. As much as is necessary of the pituitary body is then removed and light gauze packing is introduced for the control of hemor- rhage. Coffin has employed this method successfully in two cases. The last case has made a satisfactory recovery. Chronic Empyema of Ethmoidal Cells. — Symptoms. — Griinwald divides empyema of these cavities into (1) closed suppuration, and (2) open suppuration. Closed Suppuration. — ^When the orifice of the cell is shut off by granu- lations, by pressure of the middle turbinated body, or by inflammatory sweUing surrounding its exit, there will be pain over the root of the nose, the forehead, and lower margin of the orbit. Inspection of the nasal chamber will frequently reveal a dilatation of the anterior end of the middle turbinate, which is often found upon operation to be cystic. Pus when retained in this way frequently becomes fetid, and when the turbinate is removed and the cell broken into, the discharge is often greenish, streaked with blood, and of a peculiarly disagreeable odor. The headache incident to involvement of the ethmoid is of a drawing. ACCESSORY NASAL SINUSES 179 dull, and indefinable character, which tends to make the patient wish to compress with thumb and finger the external area of the ethmoidal region or press against the' orbit at its inner angle. Pressure in this location, while painful during the process, results for some reason in amelioration of the pain for a limited period. Open Suppuration. — ^This is the condition most frequently found, and it may be overlooked where polypi or atrophic rhinitis exists. The amount of discharge may be comparatively small, and there may be periods when there is none at all. The same symptoms, neuralgia, mental hebetude, depression and melancholia may be present as in frontal sinus or sphenoidal sinus suppuration. The patient is also peculiarly susceptible to colds, and in fact may be said to have a continuous cold with now and then an acute exacerbation. The discharge consists of inspissated mucus, mucopus, and crusts. The sense of smell is always rendered less acute and in the majority of instances it is lost except for certain odors. In acute exacerbation of chronic ethmoidal disease, headache is of a very severe type and may be referred to the occiput and mastoid process, which are also the locations, to which the pain is referred in sphenoidal involvement. These localized headaches should suggest the examination of both the sphenoidal cavity as well as of the ethmoidal cells. When the pus has free exit the patient may not have his atten- tion directed to the condition at all except by the use of more handker- chiefs than would otherwise be used in an ordinary cold, and over a longer period. The patient may consult the physician for disturbance of olfaction or for inflammatory conditions of the pharynx, Eustachian tube, and larynx; There is an unpleasant taste in the mouth in the morning, due to the secretion collecting in the choana during the night, and during the day there is a continual hawking, spitting, and drawing from the nasopharynx. The orbital manifestations will be spoken of under a separate heading. Examination of the nasal mucosa will fre- quently reveal numerous small polypi or a polypoid condition of the mucous membrane over the middle turbinate. Between the turbinates and the septum and on its under surface greenish-yellow crusts will be formed, which after removal will present erosions of the epithelium of the mucosa, which often bleed. In many instances lack of attention to the underlying suppurative condition will result in polypus formation until the whole nostril and postnasal space will be filled with polypi, varying in size from that of the end of the thumb to a small pea. The largest ones are frequently attached by a long pedicle of an inch or more in length. As many as three hundred separate polypi have been removed from a single nostril. Optic Neuritis Resulting from Involvement of the Nasal Sinuses. — The most striking and impressive results in surgery are those which restore sight to a patient who has been temporarily deprived of it. A number of cases are on record in which almost complete blindness has been overcome by operations upon affected accessory sinuses. No one has contributed more both to the description of the symptoms incident to optic neuritis from sinusitis and offered a greater number of solutions 180 THE SEQUELS OF CHRONIC RHINITIS for its cure than Onodi. Following in his footsteps are to be mentioned Posey, Holmes, Loeb, CofBn, and others who add a long list of cases in which the neuritis has been entirely overcome by operative measures. Other symptoms of involvement of the sinuses are often found wanting, and the neuritis results as frequently from latent empyema as from pressure incident to the open acute or chronic conditions. As there are so many other causes for neuritis, the oculist must arrive at his conclusions by the exclusion of all causes save empyema; but when the neuritis does not yield to the treatment for the. more common causes no time should be lost in bringing the patient to a rhinologist for definite diagnosis, even to the extent of exploratory operative work. Fig. 140 Showing occasional relation of optic nerve to sphenoidal sinus. (Onodi.) 1, optic nerve; 2, optic canal; 3, sphenoidal sinus; 4, anterior ethmoidal cell; 5, ethrnoidal bulla; 6, left frontal sinus; 7, right frontal sinus; 8, internal carotid artery; 9, superior meatus; 10, middle meatus ; 1 1 , inferior meatus; 12, left frontal lobe; 13, superior longitudinal sinus; 14, genu of corpus callosum; 15, caudate nucleus; 16, lateral ventricle; 17, fornix; 18, choroid plexus; 19, splenium of corpus callosum; 20, falciform process; 21, occipital lobe; 22, straight sinus; 23, cerebellum; 24, optic thalamus; 25, pons. Relation of the Optic Nerve to the Sphenoidal Sinus and Posterior Ethmoidal Cells, with Description of the Processes of Involvement. — It has been demonstrated by numerous anatomical sections, prepared by Onodi and Loeb, that the optic nerve very frequently runs through the sphenoidal sinus, sometimes with and sometimes without its bony protecting sheath. In other instances the nerve runs along the ethmoidal labyrinth in such close contact that inflammatory conditions of the cells affect the nerve either by the pressure resulting from swelling or by direct infection after the paper-like bone has been destroyed by ACCESSORY NASAL SINUSES 181 necrosis. ^ The nerve is likewise occasionally found in close proximity to a projection backward of the frontal sinus, and necrosis of the superior wall or roof of the maxillary sinus may also permit of the nerve becoming involved either by pressure or infection. The bony sheath of the nerve inferiorly is frequently the roof of an ethmoidal cell, and it stands to reason that pus under pressure or even inflammatory involvement of the cell may produce sufficient pressure to involve the nerve. The nerve may be affected either by trauma arising from inflammatory or infectious disease of the nasopharynx, sphenoidal sinus, or ethmoidal cells. It is sometimes injured by operative procedures upon these sinuses, and it has been noted by Watson Williams that complete blindness has resulted from an operation upon the sphenoidal sinus where the optic nerve passed through its superior part. The nerve is also subject to trauma due to fracturing in the region of the sphenoid or to any hyperostosis of the wing of the sphenoid which will occasion a narrow- ing of the optic foramen. Tumors in the region of the optic nerve, abnormal bone developments, premature ossification at or near the optic foramen, have all been known to produce blindness by the involvement of the nerve itself. Direct Infection. — ^When the nerve, in passing through the sphenoidal sinus or posterior ethmoidal cells, has a dehiscence of its bony sheath, or if the bony sheath has been disintegrated by septic processes, the nerve will then come in direct contact with the pus of the sinus, and may be thus infected. Infection is also transmitted to the nerve through the veins and arteries. It is questionable if the lymphatics play any part in the transmission of infection in this location. Pressure upon the nutrient vessels to the nerve often give slight visual disturbance, so that inflam- matory conditions in or around the nerve may affect it when infection is not transmitted. Symptoms. — Blurred vision, exophthalmos, divergent strabismus, and blindness are some of the ocular manifestations which may result from sinus suppuration, and which cause the patient to consult the oculist. Upon persistent inquiry into the history of the case the patient will confess to having had a severe cold extending over many months, asso- ciated with headache, dizziness, and often local tenderness, with slight fever and possibly with chills, which he attributes to the cold, but which are in reality a beginning sinusitis. Upon examination of the nasal fossae the mucous membrane will present that pale, velvety appearance which characterizes the presence of pus in the underlying sinuses. Pus or mucopus may be present, although it is not visible in the nasal fossae in the greater number of cases where the ocular symptoms have pre- dominated. In the experience of the majority of operators the empyema associated with optic neuritis is ordinarily of a latent character, and gives little evidence of its presence upon rhinological examination. Often so undecided is the rhinologist in regard to the presence of an empyema that it. becomes a serious question as to the advisability of exploring the ethmoidal and sphenoidal regions when no other evidence is present than the optic-nerve involvement. In the experience of the writer. 182 THE SEQUELS OF CHRONIC RHINITIS however, those cases in which the greatest improvement has resulted had little or no other evidences of empyema; but so marked was the improvement after operation that it appears justifiable to state that where the oculist has eliminated all other causes for optic neuritis the rhinologist should operate upon the sphenoidal sinus and posterior ethmoidal cells, irrespective of other evidences of empyema. One case coming under the writer's observation showed such marked improvement after operation that it deserves brief mention here: E. T. v., of Grenada, Nicaragua, male, aged forty years, referred June 13, 1909, by Dr. Edgar Thomson. The father had gradually become blind at middle age and subsequently developed locomotor ataxia. Other specific history was indefinite. Nine months previous to examina- tion he had contracted a heavy cold, which was followed by a swelling of the right upper eyelid. It was at this time he noticed a gradual diminu- tion of vision. He consulted a specialist in Nicaragua, and was put upon mercurial injections without benefit. Later he was given potassium iodid in increasing doses, with no improvement. The eye examination showed R. V. zero, L. V. faint light perception. Both optic nerves were pale, but the bloodvessels were fair-sized. There was an old central choroiditis in the left eye. The left visual field appeared about normal. Examination by a neurologist revealed no central lesion, but a Wassermann test was positive. The mucous membrane over the middle turbinated body on the right side was pale and puffy, and pressed against the septum. The inferior turbinated body was slightly less anemic, but equally puffy. There was no evidence of pus in either nasal fossa. The left side presented similar conditions, but less marked in degree. The sphenoidal sinus was probed without obtaining any evidence of pus, but the bony wall appeared to give evidence of necrosis, although a denuded bony wall in the sphenoidal sinus will give a similar tactile impression, so that a definite conclusion as to its being necrotic is impos- sible. In consultation with Dr. Thomson it was decided that an opera- tion was advisable, as antisyphilitic treatment had been pushed with vigor without any apparent benefit. Under cocain anesthesia the middle turbinated bone was removed, the posterior ethmoidal labyrinth freely opened and the anterior sphenoidal wall lowered from the ostium nearly to its floor. Two days later the left side was operated on after the same manner, and on both sides some evidence of latent empyema of the posterior ethmoidal cells was present. The granulations subsequent to the operation were held in check by applications of fused nitrate of silver. One month after the operation the patient was able to observe light in the right eye and count the fingers with the left. Two months later he was able to count the fingers with the right eye and had 4/100 vision in the left eye. Three months later the vision had increased so that he could count the fingers with more distinctness with the right eye and had 12/200 vision in the left eye. Four months later the right eye showed 2/200 vision, the left eye 18/200 vision. ACCESSORY NASAL SINUSES 183 Ten months after the operation a letter was received written by the the patient, in which he stated that his vision had continued to improve, and that he could read the larger print of a newspaper with ease. Con- sidering the fact that when he entered the hospital he could hardly differentiate light from darkness, could not tell by sight when the nurses entered the room, and had to be led wherever he went, and that as a result of the operation he was able to regain his sight to the extent of reading a newspaper, and go wherever he wished, it appears a most justifiable procedure to have operated in spite of the apparent absence of empyema. Because there are instances of optic neuritis incident to empyema of the sinuses it does not follow that in all sinus involvement there is disturbance of the optic nerve. In the extensive and systematic investigation pursued by Coffin in the examination of several hundred cases of empyema it was found that only 1 per cent, of the cases showed any disturbance of the optic nerve, but that 90 per cent, had some con- traction of the visual field. This might lead us to the conclusion that in those cases, where the optic neuritis was predominant there might have been some anatomical displacement of the nerve which rendered it peculiarly susceptible to the trauma incident to pressure or to infection from continuity. Ocular Manifestations in Relation to the Different Accessory Sinuses. — Maxillary. — ^While empyema of the maxillary sinus alone is infrequently the cause of ocular complication, there are yet a few conditions which result therefrom, such as blurred vision, conjunctival suffusion, and orbital cellulitis. Optic neuritis as a result of involvement of the antrum alone is extremely rare, and only a few cases have been reported. As pus under pressure in the antrum will usually break in the direction of least resistance, it ordinarily evacuates into the nasal chamber rather than into the orbit. Frontal Sinus. — ^As empyema of the frontal sinus is almost always associated with empyema of the anterior ethmoidal cells the two may be considered together. Abscess within the orbit results frequently from necrosis of the antero-inferior wall of the frontal sinus, as well as from necrosis of the outer wall of the anterior ethmoidal cells. The most frequent orbital complication is that of abscess resulting from the con- dition just mentioned. Facial erysipelas has been known to follow the erosion of the skin externally where the orbital abscess has been neglected. Permanent fistulae have resulted from the same neglect. The Sphenoidal Sinus and Posterior Ethmoidal Cells. — ^The eye com- plications incident to involvement of these two regions may likewise be considered together, as they are more or less inseparable in their involvement. Optic neuritis and other symptoms incident to pressure on or infection of the optic nerve result most frequently from involve- ment of these two regions, as they are both in close proximity to the course of the nerve. Some of the other eye conditions following involve- ment of this location are: reduced visual field associated often with scotoma, choked disk, congestion of the retinal veins, papillary stasis, atrophy and chemosis, ptosis and strabismus due to the paralysis 184 THE SEQUELAE OF CHRONIC RHINITIS of the ocular muscles, unilateral and bilateral hemianopsia, cavernous sinus phlebitis, exophthalmos, and thrombosis or abscess and blindness. Neglected cases have resulted even in the destruction of the eyeball; but even more serious for the surgeon than this is that unnecessary enucleations of the eyeball may be performed when accessory sinus empyema has been overlooked as the underlying cause of the eye trouble. This subject has been elaborated by Onodi, Loeb, and Posey to such an extent that to cover the ground in a short article is impossible. For the correction of these conditions, the operations as recommended for the suppurative conditions of the accessory sinuses are the same, care being exercised, in the case of the posterior ethmoidal and the sphenoidal sinuses, to avoid, if possible, further injury to the optic nerve, as there may be anatomical displacement of the nerve within or without its sheath. Treatment of Ethmoidal Sinus Disease. — In order to avoid repetition of remarks which apply as well to the subject of the treatment of nasal polypi as to that of the treatment of ethmoidal sinus trouble, we will go here a little more extensively into the former subject than might otherwise seem necessary. Fig. 14 r bajous snare. The nasal polypus is a symptom of an ethmoiditis insofar as the ethmoidal turbinated bone at least is practically always involved in a pathological process whether there is a deeper ethmoidal trouble or not. But clinically, although this is the underlying pathological and etiological connection with ethmoiditis, the nasal polypus often presents itself as a separate entity, and hence in the consideration of its treatment it is desirable to so deal with it before taking up the therapy of the underlying cause, an osteitis or an empyema of the ethmoid cavities. If a polypus is single and pedunculated it may be removed without the employment of local anesthesia, and some operators have advocated this procedure; but to allay the fear of the patient as well as to reduce the discomfort incident to the introduction of the snare loop it is advis- able to cocainize slightly the nasal mucosa and likewise the area of attachment of the polypus. The snare is the instrument best adapted to the removal of a single polypus, and the selection of the instrument depends upon the individual preference of the operator. The Jarvis, Wright; Blake, and Krause snares are three types most universally em- ployed. Into the Krause snare may be fitted the loops of varying sized wire, already rolled and prepared, after the Yankauer method, which greatly expedites matters and often prevents pricking the finger with the tip of the wire preparatory to fitting the loop into the stilette. The prick of a snare wire, while in itself irritating, also subjects the operator ACCESSORY NASAL SINUSES 185 to danger of infection, especially in cases of suppurative disease. Not infrequently it results in a very sore wound for several days. The Wright snare has the advantage of a lever and ratchet attachment, which enables the operator to draw with one hand upon the loop with precision, accuracy, and continuous traction without moving the end of the snare away from the location of the polyp, which is apt to be Fig. 142 Wright's snare. the case when the sliding finger grasps of other snares are employed. The Blake snare is small, easily handled, and the loop crosses itself so that it is not pulled into the cannula of the snare and may be employed successively for the removal of a number of polypi without rethreading the wire. The wire to be used should not be too fine and yet not sufficiently heavy to produce any difficulty in drawing it into the Fig. 143 Blake's snare. cannula. No. 5 piano wire is about the size which meets the requirements of the ordinary condition. In the introduction of the loop over the polypus it should hug the septal wall until the upper extremity of the loop is carried well upward into the attic of the nose, when the under part of the loop is carried away from the septum to the outer wall of the nose beneath the polypus and thence upward to the 186 THE SEQUELS OF CHRONIC RHINITIS location of its attachment, while at the same time it is gradually retracted to smaller dimensions. It is better to draw the loop tightly around the pedicle of the polypus and tear it away from its attachment than to cut directly through it. As each polypus is removed another will come into view, which must be removed in the same manner. The number to be removed at one sitting depends entirely upon the patient and his ability to endure cocain and operation. When the polypus slips back- ward from sight it may frequently be brought into view of the operator by requesting the patient to close the opposite nostril and blow forcibly. If the polypus is large, covered with blood, and projects into the post- nasal space, it is sometimes necessary to grasp it with tenaculum forceps and to fit the loop directly over it while drawing it forward. In some cases polypi have grown to such dimensions that they occupy almost the entire postnasal space, and then it is extremely difBcult to engage them in a loop. It becomes necessary to introduce the forefinger into the postnasal space and to fit the wire around the polypus, having threaded the snare with loop ample to reach from the tip of the nose well into the nasopharynx, and then when the polypus is properly en- gaged draw the wire through the cannula until the loop is sufficiently small to insure the polypus' not becoming disengaged. Fig. 144 c ME^FOWiTZ Ballenger's ethmoturbinate knives. Polypoid Degeneration of the Middle Turbinate and Ethmoidal Polypi. — In these cases, where it appears necessary to remove the middle tur- binate together with the ethmoidal labyrinth, Ballenger has devised a right and left cutting knife which will remove the turbinate together with the larger portion of the ethmoidal tract at one sweep of the knife. After thorough cocainization the short blade of the knife is introduced up well behind the middle turbinate with the longer cutting blade extended toward the outer wall of the nose. The initial cut or introduction is made by pressure outward and upward at the extremity of the knife; then the force is exerted forward until the cutting instrument has passed through the ethmoidal area, then outward and downward. The pressure upon the handle of the knife will consequently be made in opposite directions to these, as the blades of the instrument are on a shank at an angle to the handle. In the hands of Ballenger this procedure has been successful. In the experience of the writer it has been successful with the exception of profuse hemorrhage, so much ACCESSORY NASAL SINUSES 187 so that it has often seemed inadvisable to employ it when other methods accomplish the purpose with less bleeding. A procedure more univer- sally in use is that of removal of the middle turbinate by means of either scissors, forceps, or snare, and then with Luc's ethmoidal forceps the polypi and diseased ethmoidal cells are pulled away in masses. A bowl of sterile cold water is kept near at hand, so that following each grasp of the forceps the small polypi and polypoid degeneration of the lining of the ethmoidal cells may be quickly washed away, and successive grasps can be made before hemorrhage occurs in sufficient amount to obstruct the field of operation. The area may be packed several different times during one sitting with gauze soaked in adrenalin and cocain, and the same procedure repeated until the whole labyrinth has been entirely cleared out. The remaining fragments of mucosa, macerated cells, and small polypi should be removed with sharp cutting forceps, so that no tags or detritus will remain after the operation is completed. If the posterior ethmoidal cells are involved, one will frequently find the sphenoid involved as well, and during the course of the operation the Fig. 145 Luc's forceps. surgeon will occasionally find that he has opened up the anterior wall of the sphenoid in his work upon a large posterior ethmoidal cell. Particu- larly is this so if the anterior wall of the sphenoid has been softened by empyema of long standing. These operative procedures may all be" best accomplished under local anesthesia with the patient sitting in the office chair; but in timid patients, or in those unable to endure cocain, general anesthesia may be administered; but the operator must keep in mind the different angle of the ethmoidal area when the patient is lying on his back. He must not direct his instruments upward at the same angle as he would with the patient sitting. If the operation is perfornied under general anesthesia a postnasal plug is necessary, as the bleeding is more profuse than under local anesthesia, and tends to flow backward into the nasopharynx. This postnasal plug should be removed imme- diately after the operation, for if left in place it often causes an otitis media. Mosher's Method of Exenterating the Ethmoidal Labyrinth.— After proper anesthetization of the upper third of the nasal chamber a curette with 188 THE SEQUELS OF CHRONIC RHINITIS a long shank is pressed against the large anterior ethmoidal cell if present; if it is not present, against the area of the anterior end of the middle turbinate, until entrance is gained into a cell which represents the anterior end of the ethmoidal labyrinth. The external guide to this location is the inner canthus of the eye, and to obtain a similar location within the nose it is well to measure on the curette the distance from the inner canthus of the eye to the lower end of the alar cartilage at the posterior end of the vestibule, and when this same distance is gained within the nose, it will be found that the curette enters well into the olfactory cleft. If easy entrance is not obtained upon the first attempt the operator should carry the point of the curette a little higher up and a little more posteriorly, where access will be easily gained. With the bowl up and the cutting edge downward the curette is carried backward and down- ward until the "bulla ethmoidalis" has been entered and destroyed. This procedure destroys the anterior end of the middle turbinate, which should then be either cut or snared off. This now presents the anterior portion of the labyrinth open for operation. If a probe is employed, easy access to the frontal sinus is obtained. By this time the anterior ethmoidal cells have all been exenterated, and to remove the posterior it is only necessary to continue curetting backward through the attach- ment of the middle turbinate to the posterior part of the labyrinth. The direction of the destruction is backward and downward, always keeping to the outside of the middle turbinate. What remains of the middle and superior turbinate is then removed by forceps or snare. The final step in the operation is to uncover the front wall of the sphenoidal sinus and to recognize the posterior ethmoidal cell which, because of its extensive limits, leads one to suspect that one is in the sphenoidal sinus rather than in an ethmoidal cell. After the removal of this area the cavity is packed with vaselin gauze, which is removed on the following day. External Operation. — Orbital abscess and cellulitis result more fre- quently from ethmoidal suppuration than from empyema of any other sinus; particularly is this so in children. When the pus has broken its bony confines and gained entrance into the orbit it is possible in some instances to operate intranasally and to direct the flow of pus into the nose, and thus to secure adequate drainage. The writer has performed this operation successfully in several cases, and the subsequent results have been all that could be desired; but in others external operation has been ultimately necessary, and, as a general statement, it may be said that when the orbit is invaded by pus it is wisest to do the external operation in the first instance. Technique. — Under general anesthesia and after a postnasal plug has been introduced a curvilinear incision is made, beginning just over the supra-orbital notch. It is carried forward to the junction of the nasal and frontal bone and thence downward to the nasal process of the superior maxilla. The tissues, together with the periosteum, are then elevated outward and downward until the inner third of the orbit has been ' properly uncovered. With a sharp curette, entrance is then gained into ACCESSORY NASAL SINUSES 189 the ethmoidal tract, attention being given to the necrosed area, easily observable when it has been uncovered by the presence of a small exudate of pus at that location. From this entrance any soft necrotic bone is removed with bone-cutting forceps, and the anterior end of the ethmoidal Fig. 146 External ethmoidal operation. labyrinth is entered and all diseased tissue removed. The middle tur- binate should then be removed through the nose, and the whole area should be drained into the nasal chamber. Unless the cellulitis of the orbital tissues is very extensive the external wound may be closed and drainage may be established through the middle meatus. Hot boric acid dressings should be kept over the external wound for the first Fig. 147 Moure's double external ethmoidal operation. twenty-four hours after operation and irrigation of the nasal chamber may be begun about five days after operation. Mucocele. — Occurrence. — The frontal sinus or ethmoidal labyrinth seems the most frequent location, though the antrum is often affected. 190 THE SEQUELAE OF CHRONIC RHINITIS Symptoms. — Some disturbance of vision ordinarily causes the patient to consult an oculist, who finds the eyeball projecting downward and outward; not infrequently the optic nerve is disturbed, and in one case of mucocele of the sphenoid optic neuritis resulted. Pain. — Until infection of the cavity occurs little or no pain is experi- enced, although a dull headache is complained of in some cases. Local tenderness is not the rule, and its absence may be regarded as a diagnostic point against empyema, with which it is often confused. There is no involvement of the skin over the swollen area; on the contrary the skin appears normal. At the inner angle of the upper eyelid and over the brow, even to the root of the nose, the swelling is very noticeable. Pal- pation gives evidence of an elastic, semifluctuating mass, and it is often attended with the characteristic egg-shell crackling sound, due to pressure on fragile bone. Catarrhal discharge from the nose of an abundant charac- ter may be experienced, but examination will sometimes give no evidence of its origin. Occasionally pus or mucopus may appear in the affected side and lead to the supposition of sinus empyema. If a bulging middle meatus is seen and puncture is made into it there will be a gush of viscid mucoid material which is sometimes mixed with pus. Hydrops antri results in a gradual, persistent distention of the antral walls, without pain, until the walls are so thinned that the familiar egg-shell crackling is elicited on pressure. Often the walls do not with- stand the pressure, and the tumor bulges into the nasal cavity, producing stenosis. Puncture of the antrum will evacuate either a clear, watery fluid or it may be amber colored. Treatment. — ^When of the frontal or ethmoidal sinus it is almost always necessary to perform an external operation, but in a limited number of cases the internal eradication of the ethmoidal labyrinth, or free entrance into the frontal sinus through the nasofrontal duct, will suffice. Should more thorough operative measures be necessary the same procedure is followed as for ethmoidal or frontal empyema, except that in the frontal involvement the Jansen or Ogston-Luc operation is all that is necessary, while the Killian operation is unnecessary. The deformity which results from external operative measures is by no means equal to that which will follow the progress of an untreated mucocele. CHAPTER VI. THE SEQUELAE OF CHRONIC RHINITIS (Continued). DEVIATIONS AND SPURS OF THE NASAL SEPTUM. Deformity of the bony part of the septum, producing asymmetry, occurs in 78.5 per cent, of cases of adult skulls, which is an average deduced from the examinations made by Morell Mackenzie, Lowenberg, Scheier, Zuckerkandl, and Collier. Some irregularity of either the bony or cartilaginous septum is found in nearly every adult. These irregularities may be due to traumatism, bad breathing in childhood, or other mal- formations tending toward the exertion of pressure upon the nasal septum during its growth. It has even been claimed that deviations may be congenital, though Zuckerkandl states that they rarely occur before the age of seven; but small 'projections from the cartilaginous septima have been observed even before this age. The spurs, ridges, or crests may be cartilaginous or bony, and usually occur along the line of union of cartilage and bone. Etiology and Pathology.^ — ^The upper jaw of civilized man is phylo- genetically in a state of recession. The long succession of centuries since it was used in the acts of defence and offence, the scarcely less extended period of time since prolonged and forcible mastication was necessary in the preparation of food for deglutition and digestion, has resulted in a recession of the maxillary development of the face which has thrown its internal architecture in many individuals out of that symmetry which is necessary for efficiency in the functions the nose as well as the jaws have to perform. This asymmetry of development, in accordance with the biological law of the genetic regression of structure, is marked much more in late adolescence and adult life than in infancy by the distortion of the cartilaginous septum and by the narrowness of the nasal fossae and the height of the palatal arch. Less frequently we have similar manifestations of a tendency to regression in analogous deformities of the bony septum. These evidences of maxillary regression are less common, though by no means absent, in those races of men still leading an uncivilized life. They ase less frequently seen in the negro than in the white man. These being the evolutionary factors in the etiology of septal spurs and deviations they are reinforced, so far as the cartilaginous septum is concerned, by the injuries the nasal septum receives from blows during infancy and adolescence. The septal cartilage is sharply bent by the exertion of the force of a fall or blow in the plane of its surfaces. A certain amount of repair takes place in its subperichondrial cells at the site of the greatest strain — the convexity of the bent surface. 192 THE SEQUELM OF CHRONIC RHINITIS Redundant cartilage is thrown out and a so-called septal spur is the result. It seems very probable that the increased nutrition which bone and cartilage receive as the result of chronic inflammatory processes extending from the mucosa to the perichondrium and periosteum, leads not only to the general growth of the cartilaginous septum, which, being held in a firmer bony framework, bends and is deviated, but to the local growth of ridges and thickenings both of the cartilaginous and the bony septum. Microscopical examination of these adventitious cartilaginous and bony hyperplasias shows but little variation from the normal histology in the former, but in the cases of the bony deposits the surface is apt to present irregular spicules of bone and not infre- quently unorganized deposits of lime salts. The periosteum and peri- chondrium are thicker and the mucosa itself is thinner over these convexities, and the latter is more firmly attached to the underlying . structure. Spurs, whether exostoses or ecchondroses of the nasal septum, give rise to obstruction and irritation which frequently warrant their removal; but in many cases, even of those who come under the rhinologist's observation, they cannot be accurately regarded as giving rise to any symptom whatsoever. The vast majority of men have them, and some- times they are discovered accidentally as existing unnoticed in extreme development. They have been classified as to shape and extent in various ways. They may be vertical or horizontal or oblique. They may be more or less sharp-pointed and pyramidal, or they may be long crests or ridges of tissue. Even when confined to the cartilaginous septum they are reasonably sure to contain foci of bone cells, repre- senting an ossification of the cartilaginous tissue. They are almost constantly combined with deviations of the cartilaginous septum, which may be slight or extreme, but of which, in forming a judgment as to what is to be done, the practitioner must always take account. They may not in themselves give rise to sufficient obstruction or nasal dis- comfort to cause the patient to seek the physician's care, but they are frequently associated with tinnitus aurium and catarrhal deafness, most accentuated on the side in which they present. Even when it cannot be definitely established that they are the cause of the ear symptoms it may be desirable to remove them in order to secure a free road for the use of the Eustachian catheter. They may be apparently the cause of intranasal irritation, producing sneezing and vasomotor intumescence. Finally, they may obstruct nasal drainage and be a predisposing cause not only in the onset of an acute inflammation of the accessory nasal sinuses, but in chronic suppuration they may be the essential reason that inflammation of the sinuses has not undergone a spontaneous cure after an acute inflammation. Deviation of the septum is a condition whose pathology has been described as an overgrowth in answer to a stimulation which normally ceases when the complete skeletal growth of the individual has been attained. It is seen in the majority of the white race and in a certain not inconsiderable percentage of the individuals of other races. The DEVIATIONS AND SPURS OF THE NASAL SEPTUM 193 stimulation of physiological growth is apparently sometimes reinforced in adolescence, and perhaps in adult life entirely replaced by pathological overnutrition due to inflammations starting in the mucous membranes as chronic rhinitis. There is no doubt in our minds that the essential factor in the causation both of septal spurs and of septal deviations is of this natiu-e in very many cases, but in a large proportion of cases there is the added factor of trauma. The cartilaginous structures are injured on the convexity of the septum when it is bent by the impingement of a force on the end of the nose in such a way that it is expended chiefly in the f)lane in which the septum lies. We are not speaking at present of the severe and crushing traumatisms which at once break up the resiliency or dislocate the septum. To these we shall refer elsewhere. But while these severe injuries are manifestly frequently followed by septal distor- tions and displacements, it is to those of less violence that we must ascribe an important influence in the etiology of the average spur or deviation. Whether the force applied is very severe or only moderately severe, the layer of cells on the convexity of the resultant bend of the flexible cartilaginous plate undergo a strain, which determines hyperemia and hypernutrition. As a result we have the formation of a deviation due to general overgrowth, it is true, but the general overgrowth radiates from the greatest thickness of the septum. Sections across this line show the deposit of overgrowth on the convex surface and it is especially at this point we are most liable to find the ossification — the frequent accompaniment of fibrous and cartilaginous repair processes elsewhere. As with the spurs, the septal deviations differ markedly in contour and in the situation of their most pronounced development. The deviation may be a dislocation of the septal cartilage from its intermaxillary articulation. This may or may not^be associated with further distortion behind it, but it results always in the projection of the thin edge of the septal cartilage from behind the columna of the external nose which may thus constitute something of a disfiguration. The whole septal cartila'ge may be more or less bowl-shaped on the concave side and correspondingly bellied out into a smooth symmetrical convexity on the other side. Usually, however, this condition is com- plicated with more or less of a ridge representing the septal intermaxillary articulation. This projects sharply into the nasal chamber enlarged by the concavity of the deviation. A common form of deviation is one represented by a sharp bend or sulcus of the cartilage parallel and tolerably close to the floor of the nose. Vertical incision by saw or knife to remove the apparently thick spur on the convex side is very apt to result in a perforation in this form. Another form of deviation is one which runs obliquely upward and backward. The rarest form is one running in the inverse sense — that is, from the region of the tip of the nose downward and backward. Variation from this classification is less frequent than the combination of two or more of its forms associated with septal spur or thickening. We have had in mind chiefly the deviations of the cartilages of the nasal septum, but when these are extensive more or less of the anterior border 13 194 THE SEQUELS OF CHRONIC RHINITIS of the vomer or even of the os planum depart from the median hne. Usually this is slight; sometimes, however, the whole vomer is distorted from a vertical or horizontal plane. This is rare, and is usually asso- ciated with other anomalies in the development of the cranial bones, occasionally due, when present, to some rachitic tendencies in early youth. Treatment. — ^While it may occasionally sufBce to remove a septal spur without an operation which also includes a submucous resection of the septum so as to bring it all in a straight line, this is now less frequently done than before the brilliant successes of the latter were attained. . Treatment of the Nasal Spur. — Local anesthesia should be induced by the application of cocain crystals mixed with just sufficient adrenalin chlorid to make a paste, which is rubbed over the surface four or five times with an applicator. After waiting about ten to fifteen minutes anesthesia is sufficiently advanced to prevent pain during the operation. Present-day surgery requires the preservation of all healthy mucous membrane, particularly if the area from which tissue is to be removed is one subjected to the drying influence of inspired air; hence a flap of mucous membrane must be preserved sufficient in size to cover the area from which the spur or ridge is to be removed. If the ridge, spur, or crest is not too angular, or the mucosa too thin, a vertical incision through the mucous membrane and perichondrium is made in front of the projection. These membranes are raised by a blunt elevator in such manner that the whole periphery and surface of the cartilage and bone to be removed lies free in a pocket opening only anteriorly. This is only accomplished with patience and dexterity; but if successful an adequate flap attached above, below, and behind can be obtained which will become fixed by primary union to the underlying surface from which the bone or cartilage has been removed. The next step is to remove the cartilaginous or bony projection. If of cartilage, a spoke-shave or a heavy Ballenger swivel knife can be placed behind the spur and with a sharp forceful jerk forward the projection completely removed. A more effective way is to employ a chisel either curved, such as Spratt's, or angular, as Ballenger's, and with a few gentle taps of a lead mallet the growth can be reduced. While doing this it is necessary to employ some self-retaining speculum, such as Yankauer's, which will enable the operator to use both hands. The saw is to be condemned in this procedure, as not enough anteroposterior motion is obtainable to make it available, and it endangers the mucous membrane. Formerly when no regard was had for the mucous membrane the saw was a most effective instru- ment for the removal of spurs, and even now it may be employed in cases where the projection is large and situated far back on the vomer, for the time necessary to preserve uninjured a flap of mucous membrane in this locality and the attendant difficulty hardly warrant the effort, and the possibility of subsequent dryness here is of little consequence. Bosworth's nasal saw has been satisfactorily employed for many years, and if not too thin and flexible, it is as serviceable as any other. DEVIATIONS AND SPURS OF THE NASAL SEPTUM 195 Fig. 148 Nichols' spoke-shave for septal cartilage. Fig. 149 Spralt's septal chisel. Fig. 150 I L- li '> jW ■""A""*'"*!'? Ballenger's septal chisel. Fio. 151 Bosworth's septal saw. Fig. 152 Miai's septal saw. 196 THE SEQUEL Jl OF CHRONIC RHINITIS Mial's saw, with reversible blade, is shorter, double toothed, and cuts more easily through very dense bone. Both varieties are made to cut either from below upward, which is preferable, or from above downward. ^ After-treatment. — One-half of a Bernay sponge modelled after Simp- son's splint, or so much as is necessary to produce slight pressure when moistened, is well greased with vaselin and placed against the flap of mucous membrane and then moistened with Dobell's solution. The next day this is removed and cleansing with some alkaline solution followed by the local application of white vaselin, to which has been added a little eucalyptus and menthol, is performed twice daily. IJ — Adrenalin gr- sV Phenol, Menthol, Boric acid ... aa gra. ij Oil rose geranium lU iv Vaselin-pura gj Deflections, associated as they are more or less regularly with nasal spurs, give rise to approximately the same symptoms. One nostril is more occluded than the other by the deviation, although there often appears an hypertrophy of the inferior or middle turbinate on the opposite or concave side, which also interferes with breathing, due to suction or vacuum hyperemia. The mucous membrane is red, puffy, and covered with tenacious mucus. Cob-webby secretions stretch across the nasal chamber and strings of mucus may be observed hanging down in the nasopharynx. Upon forced inspiration the ala of the side toward which the deflection occurs will be seen to collapse, producing a valve-like action, and obstructing still further the breath way. Epistaxis is frequent, and is due to the dried secretions from the apex of the deflection, being forcibly blown out or picked away. Sometimes the deflection within will influence the shape of the nose externally. The Surgical Correction of Deviations of the Septum. — ^Tbe desire to perfect the internal architecture of the nose does not warrant operative procedure unless the faulty construction is associated with some of the major deleterious symptoms already enumerated. In many patients a very marked deviation produces no objectionable subjective symptoms, and under such conditions an operation is unwarranted. There are both cartilaginous and bony obstructive deviations which are impossible to correct by the submucous operation, although these instances become more exceptional as each modification and new instrument overcomes what had been previously considered an insurmountable difflculty. The chief difficulty to overcome has been the reduction of the resiliency of the cartilaginous septum to such a degree that when once adjusted in the middle line it can be made permanently to remain there. So difficult is it to secure this that on the advent of the submucous operation, which consists essentially in the excision of the deformed structure, all other methods of operating became infrequent. There are some conditions. DEVIATIONS AND SPURS OF THE NASAL SEPTUM 197 however, which can be remedied by other means than submucous excision. Where a marked angular deviation of the cartilage is encountered the Sluder operation may be employed with gratifying results. This consists in three parallel longitudinal incisions through the mucous membrane Fig. 153 Sluder's septum operation. and cartilage of the side of the convexity. The first incision above the ridge, the second along the ridge, and the third below. The bend of the cartilage is now pushed over so that the upper piece overrides the lower. The resiliency of the three pieces is overcome. The pieces thus adjusted are then held in position for three days by a hollow splint or a Bernay Fig. 154 Sluder's septum operation. sponge cut after the Simpson form, or until union has taken place in the new position. When the cartilage is bent in a cup-like manner with a marked concavity on one side and a corresponding convexity on the other the Gleason operation^ has been of service, and this is particularly available in children. ' Laryngoscope, August, 1903. 198 THE SEQUELM OF CHRONIC RHINITIS This operation consists in making a U-shaped flap the thickness of the cartilage and mucoperichondrium of both sides. The saw is inserted below the deflection of the convex side, and first an oblique and then a vertical direction taken until the entire deflection is included in the Fig. 155 Gleason's septum operation. flap. The arms of the U may be extended by the use of the bistoury. The flap is then forcibly pushed through from the convex to the concave side, and is held in position by its bevelled edges. To reduce the resiliency of the flap, it is necessary to force it sufficiently far to the concave side Fig. 156 Septal incisions for the Asch operation. to break the bony attachment above, if bone is included, or to overcome the elasticity of the cartilage, if cartilage alone is included. A nasal tube is inserted to give support only, care being taken to prevent uiidue pressure. DEVIATIONS AND SPURS OF THE NASAL SEPTUM 199 The Watson operation is based on the same principles. In deviations horizontal to and close to the floor of the nose, sometimes defined as dislocations of the septal cartilage from its articulation with the inter- maxillary suture, a bevelled incision is made from the concave side downward through all tissues into the convex side in such a curve that the cartUage may be pushed into the concave side until the thin bevelled edges are back to back and are held in place by compress or splint. Fig. 157 Asch's straight septum scissors. The Asch operation, which was much in vogue in this country before the submucous operation was perfected, consists in a crucial incision made across the area of greatest deviation by means of a specially devised instrument. With a pair of Steel's septum forceps the bases of the triangles made by the crucial incision, which is carried through mucous membrane and cartilage, are forcibly bent. Further efforts to destroy their resiliency may be made by forcing them sharply into the concave side by finger or rigid probe. Perforated hollow hard-rubber splints are inserted into one nostril or into both. These are removed from time to time for cleansing and the nostrils are irrigated by mildly Fig. 158 Asch's angular septum scissors alkaline antiseptic solutions (Dobell's), or sterile salt solution. This is kept up for several weeks. Roe's operation is practically on the same principle, but with more elaborate instruments. Instead of hollow splints he used iodoform gauze packing, which is allowed to remain in the nostril for several days without removal. While the Sluder, the Gleason, and the Watson operations are easily 200 THE SEQUELM OF CHRONIC RHINITIS accomplished in the adult by means of local anesthesia, the Asch and Roe operations must be performed under general anesthesia. Some operators still choose the Asch operation in children, because of the fear of removing cartilage from the undeveloped nose of the child. It is in children that the Asch operation is very difficult, because of the intractability of the child, when the subsequent treatment is undertaken, — to remove the splints and to disinfect the nose. We very strongly, for these reasons and for others, deprecate the practice of operating on the nasal septum of any but adults. Except as the immediate result of violence, the cartilaginous septum is usually straight in children until after puberty at least. It is usually practicable to defer the performance of the more violent operations and of the submucous operation until, at least, the age of self-control is reached, when the latter procedure may be carried out by local anesthesia. -On the whole, we think that with few exceptions, which we have emphasized, the submucous operation as now practised in this country and in Germany is the operation of choice for the deviated nasal septum. Submucous Resection of the Septum Nasi. — ^The indications for operation have been enumerated; the contror-indications are syphilis, unless by medi- cation complete control of the disease has been obtained for a year or more; diabetes; Bright's disease; hemophilia; children under twelve; the old with atheromatous arteries; active tuberculosis. To the last class of cases some exceptions can be made in those with a moderately advanced condition, when nasal respiration is important. The credit of the sub- mucous resection in its last development is due to no one operator, but to suggestive technique and ingenious construction of instruments by many different surgeons to meet the difficulties arising at each step of the procedure. Position of Patient. — In the majority of instances the upright position is best suited for the purpose of the operator, but for the patient the recumbent or semi-upright position is attended with less discomfort. If the operation is performed in the hospital, which is by no means essential, the head of the operating table can be raised so as to bring the patient's head within easy reach of the operator while standing, and at the same time relieve the dizziness and nausea sometimes experienced by the patient. A dentist's chair will answer this purpose, but the prefer- ence is for the upright position. It is essentially an ofiice operation, provided adequate equipment is at hand. Anesthesia. — "Coeain mud" (Freer) has proved more effective in lessening pain, reducing hemorrhage, and preventing cocainism than any other form of local anesthesia employed. To a small amount of powdered coeain crystals is added just enough adrenalin solution (1 to 1000) to form a paste. This is applied with a cotton-wound applicator over the two sides of the septum in the area involved in the deviation. After a few minutes an injection of 0.5 per cent, sterile coeain solution, to which one drop of adrenalin (1 to 1000) has been added to the half dram, is made beneath the mucous membrane and perichondrium along the line of the vertical incision, and also over the bony ridge posteriorly on both DEVIATIONS AND SPURS OF THE NASAL SEPTUM 201 sides. This injection is made with a long, thin needle, and an effort is made to force the membranes away from the underlying cartilage and bone, which "pouting" condition will materially aid in its liberation with the submucous elevators. Again waiting five minutes a second application of the cocain paste is rubbed over the field of operation, and a pledget of cotton moistened with adrenalin (1 to 1000) solution is flattened out over both sides of the septum, including the area involved, and is permitted to remain in place for five minutes. It has now been fifteen minutes since the first application of cocain, and this time in nearly every instance complete anesthesia is produced. Should there be much hemorrhage the effect of the anesthesia is lessened, and further appli- cations upon the cotton-wound applicator are necessary. It is also advisable to make an application between the flaps of mucous membrane to the vomer before its removal, as here the greatest pain is experienced during the entire operation. Fig. 159 Freer's septal mucous membrane incision. Incisions.— The Freer "open-flap" method is employed to meet ex- treme posterior bony deviations and sharp-angled crest deformities. It consists of a vertical incision beginning high up on the septum above the deviation and extending downward toward the floor of the nose follow- ing the angle of vertical deflection. This is made with one of Freer's right-angled knives, which are right and left to meet the requirements of the case. A second incision is then made from the bottom of the first and brought forward horizontally either along the crest of the deviation, if it is sharp and angular, or along the floor of the nose if the deviation is gentle, to terminate almost at the mucocutaneous junction, and a little upturned at its anterior extremity (Fig. 160). This enables the operator to raise a flap of mucous membrane with a broad anterior attachment. The cartilage and bone are then removed piecemeal by means of many small instruments specially devised for the purpose. The argument in favor of Freer's method is the advantage gained by open 202 THE SEQUELS OF CHRONIC RHINITIS vision in the removal of bony projections situated far posteriorly, and the freedom of operation not obtainable through elevations made by the Hajek and Menzel incisions. This large anterior flap also obviates anterior perforations, which are more objectionable than the posterior one. Hajek's incision is a curvilinear one, situated well anteriorly along the free border of the triangular cartilage. Anesthesia at this point is Fig. 160 Freer's septal mucous membrane flap. only obtainable by the hypodermic injection of cocain solution, 0.5 per cent., or by Schleich's method. Killian's incision is just posterior to Hajek's, and is well out upon the mucous membrane of the septum. Yankauer's Incision^ is devised to overcome the objections presented by the one practised by Freer and it has, in the experience of many operators, proved more satisfactory than any of the others. Begin the incision well anteriorly upon the mucous membrane over the cartilage, about 1 cm. from the dorsum of the nose, and carry it vertically downward Fig. 161 Freer's angular cartilage knives. to the point where the mucous membrane of the nasal floor meets the skin of the vestibule, thence outward along the mucocutaneous junction half-way to the outer nasal wall. This incision permits free elevation of the mucous membrane so that the flap from the septum can be reflected ■ Yankauer, Laryngoscope, April, 1906, Fig. 4. DEVIATIONS AND SPURS OF THE NASAL SEPTUM 203 upon the outer wall of the nose, and the space obtained is equal to the size of the nostril. If the deviation includes only cartilage and is well anterior, there will not be the necessity for such an extensive incision as when it is farther back in the nose. Fig. 162 YANKAU KILL! AN HAJEK Hajek's, Killian's, and^Yankauer's incision for resection of the nasal septum. Elevation of Mucous Membrane with Perichondrium and Periosteum. — It is advisable to employ a thin, flat, sharp elevator to start the flap and to begin the elevation at the upper portion of the incision; when an entrance has been made a thicker, blunt elevator may be used and the separation carried well back before the descending process is begun. The tissues can be elevated easiest from the perpendicular plate of the ethmoid, and it becomes more difflcult as the apex of the deviation is approached. When the elevation has been carried to a point behind the greatest projection, Yankauer's blunt hook elevator can be passed behind and brought forward by careful down- ward and forward pressure and frequently accomplish what may have been considered an impossible feat. The elevation should always be carried at least one-half inch above and beyond the involved area and sufficiently below to permit of the removal of the crest. Some operators (Ballenger and Hurd) prefer heavy, blunt elevators for raising the tissues, and there are several of these which meet admirably all the requirements of the case. Kurd's elevator is one with which rapid and safe work may be accomplished. It has one extremity blunt and the other thick, flat, and sharp on the surface. The blunt end is employed 204 THE SEQUELS OF CHRONIC RHINITIS after the mucoperichondrium has been started with the other. The oise of small, sharp elevators, as compared with thick, blunt ones, is a matter Fig. 163 Elevation of the septal mucous membrane Fig. 164 CUT EDGES OF LEFT MUCOPERICHONDRIUri SURFACE OF RIGHT MUCOPERICHON'M "ANTERIOR cur EDGE OF CARTILAGE. Anterior edge of septal cartilage in the submucous operation. Fig. 165 r Yankauer's submucous hook for septum operation. Fig. 166 Hurd's submucous elevator. of individual preference. Freer prefers to utilize the smaller, sharper instruments, although more deftness and care are necessary to accomplish DEVIATIONS AND SPURS OF THE NASAL SEPTUM 205 the same result. It has been demonstrated that the periosteum is only continuous over a suture when bone comes in contact with bone, as at the junction of the perpendicular plate of the ethmoid with the vomer; and along this line of union it is not difficult to elevate the periosteum with the mucous membrane; but, when bone and cartilage come in contact, as the cartilage of the septum and vomer, the periosteum covers only the bone and is not continuous with the perichondrium. When the liberation comes to this point it is necessary to incise the periosteum along the crest or articulation if it is to be included in the flap. This anatomical condition was first described by Freer. ^ Incision through Cartilage and Liberation of Mucoperichondrium of Opposite Side. — The line of penetration should be slightly within the original muco- perichondrial incision, so that if the membranes of the opposite side are cut or torn there will be tissue upon the original side of incision to cover it over. Ballenger "and others penetrate the cartilage with a small, sharp scalpel, utilizing the index finger to determine when the blade has penetrated the cartilage. This method is quite universally employed, and with but little practice there appears to be small danger of cutting the membrane of the opposite side. To overcome this danger, however, it has been advised by many to employ a sharp curette, or spoon, in order to cut away sufficient cartilage to introduce a small elevator. After the cartilage has been penetrated the same steps are necessary to remove the 'mucous membrane with perichondrium and periosteum over a similar area on that side. When the Hajek incision is made, the mucocutaneous membrane is dissected away from the anterior border of the cartilage with a sharp-pointed knife. The blunt elevator follows the sharp one in the same manner as before, and is passed upward, parallel with the ridge of the nose, and brought downward and forward. Removal of Cartilage. — ^With a moderate amount of surgical skill and dexterity, there is no more effective instrument for this purpose than Ballenger's swivel knife. It is introduced between the flaps, which are held aside by Metzenbaum's flexible septal speculum or by Kurd's speculum devised for this purpose, and the incision carried upward and backward until the entire cartilaginous deflection has been encom- passed, when it is brought downward to the vomer and then forward along the crest. This circumscribed incision enables the entire piece of cartilage involved in the deviation to be removed with ease and expedition, and the piece taken out from between the flaps with a pair of dressing forceps. There are those who condemn the use of the Ballenger knife, but with any delicacy of manipulation and ordinary precaution it is perfectly adapted to the purpose for which it was intended. Yankauer and others advocate biting away the cartilage with cutting forceps, and Freer dissects out the cartilage with some of his small knives designed for this purpose. If the swivel knife has not removed a sufficient quantity of the cartilage above to permit of the mucous membrane flap assuming a perpendicular position, more can be removed with the biting •1 Journal Ophthalmology and Oto-laryugology, April, 1907. 206 THE SEQUELS OP CHRONIC RHINITIS forceps. The cartilage should not be removed completely up to the dorsum of the nose, but at least one-quarter to one-half inch of this should remain for support. Fig. 167 Metzenbaum's adjustable, flexible, septal speculum. Blades can be bent and adjusted to conform to the deflection. Fig. 168 Hurd's submucous nasal speculum. Fig. 169 Removal of septal cartilage with Ballenger swivel knife. Mucosa represented as cut away to permit action of swivel knife to be shown. DEVIATIONS AND SPURS OF THE NASAL SEPTUM 207 Fig. 170 After removal of septal cartilage. Fig. 171 Elevation of septal ridge with chisel. FiQ. 172 Foster-BaUenger bone forceps. 208 THE SEQUELS OF CHRONIC RHINITIS Removal of the Perpendicular Plate of the Ethmoid. — This may be punched out with heavy bone-cutting forceps, such as the Foster-Ballenger bone forceps, or with any of the heavier forceps with cutting fenes- trated blades. Those with sharp edges in approximation are not so good. With a broad duck-billed forceps oval on the surface the bone Fig. 173 Hajek's septal chisel. may be firmly grasped and twisted off, but it has the attendarit danger of extending the fracture to the cribriform plate. It is inadvisable to employ a chisel for this purpose, as the direction of the point is of necessity toward a dangerous locality, and a misdirected blow would possibly result seriously. Fig. 174 Kurd's ridge forceps. Removal of the Crest and Remaining Portions of the Vomer. — Probably the easiest, quickest, and most effective way of removing the crest is to employ either the curve-pointed chisel of Good or the V-shaped chisel of Hajek, and although the tissues consisting of mucous mem- brane, perichondrium, and periosteum are attached, the bone can be DEVIATIONS AND SPURS OF THE NASAL SEPTUM 209 fractured without injury to the tissues and Hberated from its bed with- out tearing them. The V-shaped end is engaged between the folds of the flap and directed downward and backward, when a few gentle blows from the mallet will be sufficient to drive the chisel in, so that fracture occurs either from the driving force or it may be induced from leverage by depress- ing the handle of the chisel. The fractured piece is then grasped with dressing forceps and detached by a twisting, tugging movement. Another method which is particularly applicable to cases, when ossification is not perfect, is to employ the ridge forceps of Hurd or Carter, which have a powerful grasp with the jaws directed downward, the borders of the blades shove aside the attached tissues, and the crest is broken away by twisting from side to side. Fig. 175 Carter's ridge forceps. Ballenger prefers to use the Asch septal forceps and fracture the vomer before attempting to remove it. He places the forceps on the outer side of the flaps and just above the floor of the nose, then twists the forceps in their longitudinal axis. The posterior part of the vomer can be broken away, if deviated, by means of heavy dressing forceps, or preferably by heavy spoon-billed forceps. The curved border of these forceps shoves the tissues away from the bone. In all these procedures, except that of Ballenger 's, the flap should be held apart either by Hurd's, Metzenbaum's or some speculum devised for the purpose and meeting the personal preference of the operator. Dressings. — Before the flaps are permitted to fall together for permanent coaptation the interior of the pouch should be swabbed with peroxid of hydrogen, followed by alcohol, as there are occasionally small fragments of bone or cartilage which will be withdrawn upon the swab, and the peroxid of hydrogen and alcohol tends to sterilize the wound and also to control hemorrhage. The flaps are now brought together in the median line and a Simpson splint of Bernay sponge is well greased on both sides with white vaselin, inserted into each nostril and moistened with Dobell's solution until gentle pressure is brought to bear against the flaps. It is necessary, in some instances, to employ more than one splint to the side, both to cover the anteroposterior space and,' in large nasal chambers, the lateral space. All broken points should have a part of the splint impinge against it, as it effectually controls hemorrhage. By 14 210 THE SEQUELS OF CHRONIC RHINITIS the pressure they exert, effusion of blood and serum between the flaps is also avoided. The splints are left in situ twenty-four hours, wh&n they can be removed with less pain and bleeding than any other form of pack- ing, provided they have been well greased. If bleeding is profuse at the time of removal the outer part of the splint can be peeled off and the inner part attached next to the septum allowed to remain, which procedure will lessen the discomfort from pressure and at the same time control the hemorrhage. Should there appear a tendency to "ballooning" of the .flap with blood the splints should be replaced. In nearly every instance splints can be safely left out after the second day. Many operators prefer to use strips of vaselined gauze and pack the nares tightly with this, but more bleeding follows its removal, the patient suffers more pain, and the pressure is by no means so uniform as when the Simpson splint is used. It has also been advocated to employ thrombokinase upon the bleeding-points for the control of the hemorrhage, and leave the nose unpacked with anything; but the danger from hematoma outweighs the consideration of comfort. After the splints have been permanently removed it gives relief to shrink down the congested tissues with a 2 per cent, solution of cocain and a 1 to 8000 solution of adrenalin chlorid, followed by a free irriga- tion of hot water, to which a little sterile salt solution has been added. The Douglass douche is best suited for this purpose, but. it should be used with care and discretion, to prevent Eustachian dis- turbances. Sequelae. — Hematoma occasionally follows the operation where lateral pressure upon the flaps has been insufficient and bleeding has occurred into the pouch. The blood must be let out at the site of the incision made for elevating the mucoperichondrium and pressure instituted upon the lateral walls by means of one or more Simpson splints to the side. They should be removed on the following day and fresh ones substituted. Faulty technique is not entirely responsible for abscess either in the way of asepsis or antisepsis, for the nasal chamber cannot be made surgi- cally clean. Each operation should be preceded by an antiseptic nasal douche, such as Dobell's, and all instruments should be surgically clean^ and by these means the danger of abscess decreased; but frequently the infection enters apparently some days after the operation, and against this contingency there is no safeguard. All packing should be removed from the nostrils within forty-eight hours, and new packing substituted if necessary, as the altered nasal secretions are abundant and offer a very good medium for the culture of microorganisms. Daily douching with slightly antiseptic alkaline solution beginning forty-eight hours after the operation is also advisable, and this should be followed by the free use of liquid oleostearate of zinc, with boric and carbolic acids added: IJ — Phenol. gr. j Acid boric gra. x Zinc stearate 5j Minerol gvj Vaselin'alba 5ij SEPTAL PERFORATIONS 211 When either a tear or a cut occurs through the mucoperichondrium of either side just opposite to one another a perforation is almost certain to result. This may be obviated in many instances by uniting one of the sides by means of Yankauer's sutures, or by the introduction opposite the cuts and within the mucoperichondrial pouch of a piece of the car- tilage of the septum previously removed. Patience, skill, dexterity, and good judgment all go hand in hand toward making a good submucous resector. Operators noted for skill and effectiveness in other fields of nasal or laryngeal work are often failures as submucous operators. Falling bridge has been reported as a sequence to stibmucous resection, but it must be rare, as in our experience a very large clinical observation has failed to note a single instance. In operating upon very young patients, or where abscess has followed with chondritis, it is reasonable to expect a falling of the tip of the nose. Also a blow upon the nose shortly after an operation might make it sink in; but all of these conditions are more to be regarded as accidents than as probable sequelae. SEPTAL PERFORATIONS. Etiology. — Syphilis is probably responsible for the greatest number of perforations of the septum, and it does not confine itself to cartilage but involves bone as well. Atrophic or perforating ulcer results from some projection of the cartilage into the current of inspired air, which not only dries the apex, but likewise a certain violence is inflicted upon the mucosa by the impact of the particles of dust in the air. A crust forms which is the source of constant irritation, and the patient either ejects it by blowing the nose or picks it away with the finger or handkerchief. In each instance some epithelium is detached with the scab. Traumatic perforations are usually due to surgical procedures or to infection following accident. Acute irijectious perforations may follow scarlet fever, typhoid, or erysipelas. Tuberculous and lupoid ulcerations are seen frequently in large clinics. It is possible that lues may play an important part as an associated factor in these cases. Symptoms. — Epistaxis ordinarily brings the patient to the observation of the physician, for pain is not complained of. Picking the nose is almost always acknowledged. Stuffiness and difficult respiration is frequent, and the crusts sometimes expelled are large, dry, and blood-tinged. Odor is frequently present, particularly if the case is of syphilitic origin. Often the patient is unaware of the perforation until acquainted with the fact by the examiner. Sibilant respiratory sounds are frequently noted if respiration is forced, as from running. Treatment. — It has been suggested by some operators to cut out entirely an ulcerating area when perforation seems imminent (Hajek), but others condemn the plan and would leave to nature the act of outlining the destruction (Thomson). Cleansing the ulcerated area with peroxid and the application of mild astringents, like argyrol 20 per cent., chlorid of zinc 20 grains to the ounce, ichthyol 10 per cent., and balsam of Peru 212 THE SEQUELS OF CHRONIC RHINITIS will, in many instances, prevent the ulceration forming a perforation. Instructions must be given to the patient to cease blowing the nose forcefully, and to desist from picking it. A nasal cream of vaselin, menthol, and eucalyptus given into the hands of the patient and applied gently with the ball of the finger three times a day will prevent scab formation: ^ — Camphor, Menthol aa gra. iv 01. eucalyp TUx Zino stearate 5J Minerol 3vj Vaselin alba 3ij When perforation has occurred, and the edges are not cicatrized, the application of fused nitrate of silver is one of the best methods of control- ling epistaxis and hastening cicatrization. Fig. 176 Goldstein's plastic flap operation. Operative Measures, Goldstein's Plastic Flap. — ^After cocainization the periphery of the perforation is pared. The mucoperichondrium is then elevated for about half an inch encircling the perforation, and a ring of cartilage is removed around the perforation for about a quarter of an inch. Then a flap of mucous membrane is outlined larger than the perforation desired to be covered and removed from the most suitable location adja- cent to the perforation and tucked in between the elevated membranes of the two sides of the cavity, a pedicle of sulEcient size for nourish- ment being left on the side from which it is removed. Ballenger's mucosa swivel knife is of aid in making the flap. When the flap is in place three or four stitches hold it in position, and are to be removed on the third day. SEPTAL PERFORATIONS 213 Oodlsmifh's operation consists in preserving in normal salt solution the cartilage removed from a submucous resection, trimming it to fit the Fig. 177 Goldstein's plastic flap operation. Fig. 178 Hazeltine's plastic flap operation. 214 THE SEQUELS OF CHRONIC RHINITIS opening, and placing it between the membranes of either side. In the newly made or anticipated perforations the patient's own cartilage may be employed, but in old perforations freshly removed cartilage from another patient will often meet the requirement. Simpson's splints are placed on either side to hold the membranes in place until removed after forty-eight hours. Too much pressure is undesirable. The wound heals by granulations, and in due course of time the cartilage is absorbed and a membranous formation remains over the opening. Burt R. Shurly has advocated dissecting a piece of cartilage the size of the opening and adjacent thereto and fitting it into the separated edges of the opening and holding it in place by splints of Bernay sponge. He reports one successful case of such character.' Fig. 179 Hazeltine's plastic flap operation. Hazeltine recommends making an anterior flap sufficiently large to cover two-thirds of the opening on one side and a posterior flap of similar dimensions on the other, and attach them to the opposite prepared edge of the opening with two or three sutures. As a result of this procedure a granulating area is left anteriorly on one side and posteriorly on the other, but the opening is completely covered over with the membranes of the opposite sides. Hematoma. — Following the submucous resection and as the result of blows, blood will often balloon the mucosa of the nasal septum without finding egress. If it results from a submucous resection the blood should be evacuated from the original incision, and Bernay sponges applied ' Transactions American Laryngological Association, 1912. SEPTAL PERFORATIONS 215 on both sides to create pressure. The Simpson spHnt of Bernay sponge is preferable, and should be well vaselined before introduction, and after- ward moistened thoroughly with a 1 to 8000 solution of adrenalin. If the hematoma is traumatic an incision should be made perpendicularly at the anterior part of the swelling, and after the blood has been evacuated similar treatment instituted. If there are any loose fragments of bone or cartilage detected by probing they should be removed. If there are tendencies toward suppuration it is well to put in a small piece of rubber tissue for drainage, and the pocket should be irrigated with saline solution onee daily. Should the hematoma be of extremely small size it may become absorbed, and this can be hastened by hot antiseptic compresses externally and hot irrigations of the nose internally. Abscess. — ^It may result from an infected submucous operation, from an infected hematoma, or from infection following trauma, such as is incident to boxing, or in children from falling upon the nose. The invading germ may gain entrance through some break in the continuity of the mucosa and infect a small blood-clot which has resulted from the injury. It also occurs in some of the acute infectious diseases, likewise in syphilis and tuberculosis. . Symptoms. — Nasal obstruction is the most prominent and quite secondary to pain. The effort to blow the nose is ineffectual, and in the "pressure stage" elicits pain. The history of the case usually directs the observer in diagnosis, but gumma must be borne in mind when endeavoring to eliminate other possibilities. . Prognosis. — ^The prognosis is ordinarily good and only a few days will, in children, often restore the nasal functions; but in adults, if much damage has resulted before the pus is evacuated, a falling in of the nose anterior to the nasal bones may result. Perforation from destruction of the mucosa, either from pressure or infection, is also frequently reported. The disfigurement may not be noticed for some time after the abscess has properly healed. A chondritis is the most probable underlying cause of deformity. Treatment. — Under cocain anesthesia a free perpendicular incision is made just anterior to the bulging mucosa and pressure made with the finger on the opposite side. Occasionally there will be two pockets, one above the other without communication, in which instance both must be opened. A Simpson splint is placed on both sides and moistened in order to institute pressure, and in long-standing cases a small drainage tube of rubber is introduced into the opening for about a quarter of an inch. In every instance the patient must be seen daily and the opening probed apart and the cavity irrigated with normal saline solution. Very careful surgical attention should be given these cases, as meningitis has been reported as probably following the invasion of infection through the cribriform plate. The danger of deformity also should not be minimized. St. Clair Thomson' recommends making the incision for ' Diseases of the Nose and Throat, p. 147. 216 THE SEQUELA!: OF CHRONIC RHINITIS evacuation of the pus through the inferior border of the swelling from behind forward, which will prevent the pocketing of pus. Synechias. — These are bands of fibrous tissue between the septum and turbinates, and are the results in most instances of operative procedure or the use of the galvanocautery. In prolonged turgescence of the mucosa, as in measles, scarlet fever, etc., these bands of tissue have been known to result, and it is always soothing in these diseases, as well as prophylactic, to douche the nose with a mild antiseptic solution and follow it with a few drops of albolene to keep the tissues soft. Frequent colds, sneezing, snuffling, disturbances of respiration, and hyperesthetic turgescence of the mucous membrane are complained of. Symptoms simulating hay fever have been relieved by removing a synechia. A segment of the band of tissue should be removed with a Griinwald punch and not with scissors, and a piece of greased Bernay sponge inserted between the cut edges. This should be removed daily if irritating to the patient, or every other day if not, until the edges are healed and the turbinate shrunken down to normal proportions. Careful attention to the nose after operations will prevent adhesions, particularly if all granulations are either cut off with scissors or burnt down with fused nitrate of silver or chromic acid. Epistaxis. — This rarely. occurs in infants, but its frequency increases gradually until it reaches its maximum at the period of puberty. It is very frequent for a year or two after this is established. After adolescence it is seen in its gravest form in advanced life, when it is often a symptom of internal organic disease. It is more commonly seen in males than in females. The lesions of chronic disease of the liver, of the kidneys, of the heart, of the arteries, are among those which most frequently give rise to the symptom. These diseases, as is well known, are accom- panied by high tension in the general arterial system. Just as at puberty we see a certain number of cases, so in women at the climacteric the same phenomenon is observed. Occasionally it is seen as the result of violent or long-continued exertion, of states of high excitement, and as the result of the extremes of cold and of heat. Whether it ever occurs from these causes alone is uncertain, inasmuch as high tension in the arterial system and general disease of the walls of the bloodvessels is more frequent than is realized. It is also seen in various forms of cardiac disease, especially in mitral stenosis; it is seen in chronic bronchitis accompanied by emphysema or in any affection causing obstruction to the venous circulation, such as mediastinal growths and tumors of the neck. In various affections of the blood, such as chlorosis, anemia, leukemia, hemophilia, malaria, and purpura it is one of the most striking features. It is also a common symptom in various acute diseases of infectious type, such as whooping cough, pneumonia, and especially in typhoid fever and in smallpox. It is seen in measles, German measles, in influenza, in scarlet fever, typhus fever, and erysipelas. It is occasionally a serious complication of diphtheria. It is said to occur in children suffering from acute rheu- SEPTAL PERFORATIONS 217 matic fever. It is frequently a weakening incident of exposure to rarefied air in balloon ascents and at mountain altitudes. It is seen in vicarious menstruation. It occurs in states due to poisoning from drugs, such as phosphorus, less frequently from quinin, and the salicylates. It is a symptom of fracture of the base of the skull, inasmuch as blood finds its way from the region of the fracture through the nasal passages. In addition to these causes of a general nature, traumatism plays perhaps a still more frequent role in the etiology. It is a result of opera- tions; it is due to blows and falls, and frequently results from ulcer of the septum and from angeiomatous tumors; it is seen in atrophic rhinitis; it is a symptom of adenoid growths. Its most severe form is seen in the rapidly growing sarcomata of the nasal passages. It is very much less frequently seen in syphilis, and when it occurs in syphilitic granuloma the bleeding is not so violent as that coming either from the benign angeiomata of the septum or the malignant sarcomatous tumors. Less frequently it is due to foreign bodies or worms or leeches in the nose. It may be the result of paroxysmal sneezing of a purely nervous character or from that of hay fever or influenza. The ulcerations of glanders are occasionally marked by it and it is seen in acute and chronic rhinitis. Examination. — Upon first inspection the nostril is usually filled with a blood-clot from which there is continuous oozing and which prevents detection of the bleeding area. In the majority of instances, either in spontaneous hemorrhage or in that from injury, the blood comes from the bleeding area of the septum known as Kiesselbach's. To obtain a proper view it is necessary to flush out the blood-clot and temporarily to control the hemorrhage by pledgets of cotton soaked in a mixture of 2 per cent, cocain solution and adrenalin, 1 to 8000. Often the bleeding area is either so far back or so situated beneath the turbinals that it does not come into view even after removal of the clot. Treatment. — In many instances it is advisable to let the bleeding con- tinue up to a certain limit, as it may be nature's method of relieving blood-pressure. This, however, should be governed by circumstances, and in the old or nervously inclined the hemorrhage should be stopped irrespective of the good that it might accomplish and other methods instituted to reduce arterial tension. In young boys and girls where hemor- rhage follows slight injuries or results from overexercise, pressure with the thumb and finger upon the alae over the lower cartilaginous portion of the septum will often be all that is necessary to overcome it. The injection of vinegar, lemon juice, and other acids, or the use of iron, alum, and gallic acid, have been replaced by the use of adrenalin, peroxid of hydrogen, and thrombokinase. It is not only necessary to check the hemorrhage, but to preserve the mucous membrane from injury as well. If the bleeding spot can be definitely determined, fused nitrate of silver upon an applicator and applied after cocainization is one of the best methods of controlling the hemorrhage. When the slough comes away a second attack will often occur. Hence the application should take place at inter- vals of two or three days until the ulcerated area is completely healed. The galvanocautery and other cauterizing methods are not only uncertain 218 THE SEQUELS OF CHRONIC RHINITIS in their action, but frequently create inflammatory conditions which are quite disturbing. If it appears necessary to control the hemorrhage by internal pressure first cocainize the area with a 2 per cent, solution of cocain and insert either the whole or a part of one of Simpson's splints of Bernay sponge, having previously greased it well with vaselin. This should be removed on the following day and if necessary a second thinner piece should be inserted. If constitutional disturbances are factors in the cause of the hemorrhage, treatment must be directed to these. In anemic cases iron should be administered internally The lactate of calcium has been recommended in 20-grain doses for the purpose of increasing the efficiency of the general coagulability of the blood. CHAPTER VII. ATROPHIC RHINITIS. RHINOLITHS. FOREIGN BODIES. Etiology. — Most modern observers who have devoted attention to the histology of the lesions of atrophic rhinitis, believe it is primarily a bone disease. In the consideration of the etiology, various predisposing factors have been urged, some of them with considerable plausibility, others with noiie. General systemic malnutrition in children, sometimes dependent on syphilis, seems warranted from the number of cases observable in this class, often seen in two or more children of the same parents. Sex quite evidently is a determining factor as a very large majority of the cases occur in females. Puberty also is clinically observed to have a determining influence on the advent of the symptoms. These factors are observable in the apparent etiology of those cases of chronic rhinitis with crust formation and the typical ozenic odor. In regard to the latter, while we speak of a typical ozenic odor, it seems probable, from the state of opinion as to the bacteriology of the disease, that there is no specificity about it. Large numbers of bacterial forms, swarming in a lipoproteid excretion of the mucous surfaces, set up chemical changes in which the volatile and non-volatile fat derivatives are concerned which give rise to the odor. While space forbids a discussion of the many theories advanced in regard to the etiology, it may be well to say that syphilis, long regarded as an etilogical factor from the point of view of heredity, has recently been investigated in its relationship to ozena by the Wassermann reaction. Negative results were almost uniformly obtained when complement fixation was tested for in the serum of the blood of ozenatous subjects. How far this can be regarded as conclusive in negation of the idea of a syphilitic hereditary factor in the etiology of true ozena it is too early yet to decide.^ Excluding the cases of active tertiary nasal syphilis, as we do in modern rhinology in speaking of ozena, there is little warrant for the belief that hereditary syphilis has more to do with the etiology of atrophic rhinitis than that the syphilitic dyscrasia, like the tuberculous dyscrasia, is the cause of a lowered state of general vitality. Like tuberculosis, atrophic rhinitis is the disease of poverty. It occurs in the well-to-do just as phthisis does, but it is a disease of malnutrition, the usual cause of which, as we know, is poverty. 1 A reference to the modern history of atrophic rhinitis in Dr. "Wright's History of Laryn- gology, second edition, will introduce the reader to the exhaustive literature discussion of the points involved in the etiology, entirely too extensive for review in a text-book. 220 ATROPHIC RHINITIS There is an affiliation of atrophic rhinitis with accessory sinus disease by virtue of the fact that the process itself occasionally extends to the mucosa of these cavities. There are also certain cases in which a chronic discharge from the posterior ethmoidal and sphenoidal sinuses exists with crust formation. In the former category of cases surgical treat- ment of the sinus accomplishes nothing — in the latter category of cases eradication of the sinus affection cures the ozena. In the majority of cases of atrophic rhinitis with ozena the sinuses are not involved in any way, even in advanced stages. Frequently the openings of the sphenoidal sinus can be perceived by anterior rhinoscopy, owing to advanced atrophy; their mucous membrane may be seen free of crust or other discharge. Atrophic rhinitis sometimes exists in one nostril, when there is marked deviation of the septum. The concavity on the one side shows abundant crusts and an atrophic mucosa. Straightening of the septum regularly cures the condition. Atrophic rhinitis not infrequently follows extensive operative destruction of intranasal structure. These undisputed phe- nomena lend some plausibility to the theories and observations advancing, as an etiological predisposing factor, the congenital roominess of the nasal chambers. The arguments and facts usually adduced in support of such theories have not sufficed to convince the majority of rhinalogical observers of their tenability. Finally a certain amount of atrophy, without crusts, is the physiological accompaniment of old age. There is plainly a shrinking of both bone and mucosa. Pathology. — ^There is hardly any histological lesion which could serve as a common cause for changes in the mucosa of all these cases except that of a bone lesion which has interfered with the nutrition of the soft parts. The periosteum and the bone itself is affected in them all, and while there is no satisfactory evidence in the bone itself of inflammatory action, the process is manifestly associated with a preexisting chronic inflammation of the mucosa in a sufficient number to suppose that in these at least the bone atrophy is due to it. An analogous bone lesion may be supposed to exist in the other cases. It must be confessed, after all is said, the etiology and even the succession of histological changes are far from satisfactorily understood or accurately known. In this form of nasal inflammation the epithelial metaplasia is more marked, and it is constantly present. As we have seen, even in fairly normal nasal chambers, the cylindrical epithelium is in places frequently replaced by flattened cefls. In atrophic rhinitis this is universal. Yet so far as we know there is no stickle-cell formation such as is sometimes seen in the epithelial metaplasia of other morbid processes. There is a tendency to cornification of the surface layers. There is beneath the epithelium an infiltration of the stroma with a relatively much increased number of round ceUs. These are marked around the ducts of the acinous glands. There is a steady encroachment on the epithelial structures of the glands by these round cells and a lowly organized fibrous connective tissue which finally all but destroys all traces of glandular structure. The same may be said for the bloodvessels. Whether cavernous sinuses in these cases have ever been much developed RHINOLITHS. FOREIGN BODIES 221 at puberty or not is a question. At any rate the bloodvessel walls have been, to a large extent, obliterated by the fibrosis and the round-cell infiltration. That in this process of cell degeneration there is the pro- duction of considerable fatty detritus is probably true, but to the extent one would infer from the accounts of some observers is certainly not our experience. This proteid decomposition evidently finds its way to the surface with the copious discharge of serum, which takes the place of the normal viscid fluid of the glands, and there the rapid evaporation of water and volatile matter leaves behind 'in the form of crusts a lipoproteid precipitate, which rapidly ferments and is split up into fatty acids by various bacteria. A large number of these have been found, and several have been described as specific in the disease; but neither the bacilli of Loewenberg, Perez, Pes Gradenigo, nor the diphtheroid bacillus, all of which have been urged as etiological factors, have been accepted as of any significance in the causation of the lesions. It seems probable that in the sense that there is an antecedent hyper- plasia of the periosteum in atrophic rhinitis, we may say that hypertrophy is followed by atrophy in certain cases of nasal inflammation; but it seems quite certain that while this preexisting periosteal hyperplasia may be present in the larger number of cases of typical atrophic rhinitis with ozena, this is the only element in the mucosa which is hyperplastic. That this is always affected primarily must also be acknowledged as more or less hypothetical. However, the most significant change in structure is this thickening of the periosteal layer. Inasmuch as the distribution of nutrient arteries to bone and to mucosa lies in this element of the mucosa, and inasmuch as it seems to be fibrosis which ultimately destroys the glands and the bloodvessels of the mucosa itself, it is a fair conjecture that it is in the periosteum and the perichondrium — for the septal cartilage also becomes thin and even in places absorbed — ^we must seek for the root of the changes which give this nasal disease unique characteristics. The histological featiu^es of the disease seem to justify us in calling it a fibrosis, but the clinical features which accompany it justify us rather in calling it a mystery. There is no analogue to it elsewhere in the body. This may give us a clue to its essential nature. There is no other region in the body where we have a very thin plate of bone covered on both sides by a vascular secreting mucous membrane and separated from the bone on each side by a thin layer of periosteum which carries its nutrient bloodvessels. Often present in early childhood, associated with puberty in women, the symptoms ceasing for the most part after middle life, not beginning, except in the rarest cases, after adolescence, appar- ently not necessarily preceded by a condition of chronic inflammation or by hypertrophy, conceiving of it as initially a fibrosis of the layers of connective tissue next to the bone and cartilage is a matter of some difficulty, yet after all that seems the most reasonable hypothesis purely from an histological stand-point. In describing the changes in the elastic fiber in cases of chronic hyper- trophic rhinitis, we followed them to the point when in the later stages the elastin detritus begins to be absorbed. This we presume may be 222 ATROPHIC RHINITIS looked upon as the initial stage of atrophy; at least in those cases in which a marked atrophy was evident clinically and pieces were removed for examination it was invariably seen that the elastic fiber and even the elastin detritus had almost entirely disappeared, there being some hint of it perhaps still visible in the thickened periosteum. On the other hand the smooth muscle fiber persists in the stroma to a late stage. Indeed it is chiefiy in a stroma in a late stage of chronic inflammation that one occasionally sees a muscle cell or perhaps two or three around the acinus of a gland. The thought has occurred to me that possibly there is a mutation of a connective-tissue cell to a contractile form in answer to the physiological demand for the expulsion of gland contents rendered difficult or impossible by the disappearance of elasticity from the stroma. Inasmuch, however, as many histologists have protested against the assumption that what we call an elastic fiber is any more elastic than the indifferent connective-tissue fiber, it is not worth while to indulge too much in theoretical deductions. Finally, in extreme cases of atrophy everything that looks like muscle ctell or an elastic fiber has disappeared with the glands and the larger bloodvessels, and there is left only tissue resembling more or less organized granulation tissue between the horny epithelium and the shrivelled bone. The structural changes wrought in the mucosa are evidenced in the vitiation of the secretions. The absorption of bone and cartilage are responsible for a change in the external configuration of the nose when the disease has begun in early childhood, before the facial bones are fully developed. Whether it has begun in childhood or at puberty the roominess of the nasal chambers is dependent upon atrophy of the scroll bones and of the mucosa covering them. How to account for the disappearance of the crusts and the secretions in those cases in which it continues after middle life remains a subject for histological research. A restoration of the glands and bloodvessels anatomically seems biologically improbable, yet there is a return to a secretion on the surface of such a nature that its evaporation is not rapid enough to prevent it from carrying away with it those non-volatile ingredients which formerly were left behind as crusts of dried secretion. The atrophy of age is of the same structural nature, so far as the glands and bloodvessels and the periosteum are concerned, and it seems probable that in those cases which recover from their terrible affliction of f oul- smefling nasal crusts the senile stage of the mucosa is reached and its condition suffices to remove the trouble. In this view then we may believe that a fibrosis of unknown origin in the periosteum and perichondrium induces, by shutting off the proper nutrition of the tissues, a state of vicious lipoproteid metabolism in the mucosa, the waste products of which, washed out with the serum and lymph of the tissues, produce the crusts on the surface. These vary with the concentration of the solid constituents of the secretions. Sometimes they are not sufficiently con- centrated to remain as a deposit on the surface. We may thus account for cases of atrophy without crusts or excessive odor. The approach of age slows down the activity of all metabolic processes, and tends thus BHINOLITHS. FOREIGN BODIES 223 automatically to cure the ozena of atrophic rhinitis and leave behind only the structural atrophy. We are fully aware, in the present state of our knowledge, how likely this hypothesis is to prove insufficient on critical ana,lysis or even erroneous when more complete objective knowledge is attained. Symptoms. — ^As, has been stated the disease manifests itself most fre- quently about the time of puberty, but the period of greatest frequency may be more accurately defined as stretching from fourteen to twenty years of age. It is true a considerable percentage of cases is seen in which the disease began in early childhood. These form the basis for Bosworth's statement that atrophic rhinitis is essentially a late stage of suppurative rhinitis. It is in these cases that the crusts seem no less abundant than at a later stage, but there seems in addition a greater abundance of foul fluid, thick discharge. Occasionally such a condition of intranasal disease .is found in two or more children of the same parents. Hereditary syphilis as an underlying etiological factor has been postulated for these cases, but we are not aware that the existence of syphilis in the parents has been established with sufficient frequency "or with sufficient accuracy fully to support this assumption. It is rare to find a history of the symptoms of atrophic rhinitis beginning after the patient is twenty-five. Occurring usually in women (about 75 per cent, of the cases) its period of inception covers fairly well the period of puberty in girls. The symptoms subsiding after forty, suggests that in women the menopause has something to do with the etiology; but undetermined as this is we note the fact here simply as a part of the symptomatology. It is almost invariably the case that the patients seem to suffer from a considerable degree of enfeeblement of the general system manifested by anemia or emaciation. It is rarely seen in vig- orous, well-nourished pers.ons. Headaches, loss of appetite, nausea in the morning, the complaints of their associates that there is a bad odor to the breath, make the life of these young women and girls a burden. Unable to appreciate the bad smell themselves, they imagine it more universally noted by others than it is. Tormented by the thought of their offensiveness to the opposite sex at a time in which they wish to appear most attractive, these poor victims, often oversensitive, are the objects of a well-deserved compassion. Although ample room for free respiration is apparent upon examination of the nares, the patient constantly experiences a stuffy feeling and a sense of obstructed breathing, which is partially due to the mass of excretion collected upon the surface of the turbinates and the intermediate meatus, and partially to the absence of sufficient normal mucus upon the secreting membrane to moisten the inspired air. Smell, taste, and hearing are impaired just as in other forms of chronic rhinitis, and both mental and physical activity are lessened. The victim is constantly hawking and spitting, also making frequent attempts to draw from the naso- pharynx the excretions collected in the posterior choanaj. Blowing the nose is not of such frequency as in other forms of chronic rhinitis, where the discharge is thinner. The facial aspect of the patient is characteristic, 224 ATROPHIC RHINITIS but is of two kinds. In the first one sees the flabby, flattened, thick, heavy features with nostrils directed outward, and eyes far apart with which ozena is most commonly associated. The other is where the nose is small, sharp in outline, with thin nostrils, slight curvature of the dorsum, and with thin, closely adherent integument over the bony parts. In this class there seems to be an absence of nourishment for the mucous mem- brane and the underlying bone, but odor, except of a catarrhal character, is not often present. In both instances the tip of the nose is slightly upturned. An excessive quantity of yellowish or greenish-yellow exudate may collect in the nasal meatus, which changes, and can be easily evac- uated by douching. The exudate may dry and form scabs or crusts on the entire inner aspect of both turbinates and also collect along the septal mucosa. These are difficult to remove, and in doing so, either by the effort of the patient or physician, abrasions of the underlying mucosa result and superficial ulcerations occur. These crusts may even reach the size of entire casts of the inner nose, and they often are mixed with blood from the abraded mucosa. The real ulceration of the mucous mem- brane of the septum occurs from the endeavors of the patient to remove with the finger the offending crust from its attachment, which effort will- frequently produce an ulceration extending through the entire cartilag- inous septum. Sometimes the crusts are flaky and cover very superficially the entire mucosa of the nostril. The quantity and character of the crusts bear but little relation to the odor emitted, as in many instances the most disagreeable odor is experienced in cases with but little crust formation. Ozena is found always in those cases of idiopathic origin, frequently in those with sinusitis underlying the condition, and occasionally in those careless of nasal hygiene. In all cases the odor is due to saprophytic infection of the retained exudate. Syphilitic ozena has the characteristic odor of dead bone ; that of essential atrophic rhinitis has a peculiar sweetish, sick- ening quality, indescribable, but unmistakable when once experienced. Appearance of the Internal Nose. — The first inspection would indicate an excessive width of passage-way for inspiration; the mucous membrane is pale and tightly. adherent to the shrunken bony supports; there- clings to the membrane crusts of dried mucus, blood, epithelium, and pus, which may cover the entire surface of the turbinates or only parts of it, and which, when removed, leave a shining fibrous-looking membrane which will not pit on probe pressure. The entrance into the sphenoidal cavity can be frequently seen in these cases, as well as an extensive view of the nasopharynx. Spurs and deviations may be present, and an atrophic condition may exist in one naris and a fairly normal condition in the other. The atrophy is always on the concave side. Appearance of the Nasopharynx and Oropharynx. — Festoons of blackened crusts are seen clinging to the nasopharynx, plaques of this may extend down the posterior wall of the nasopharynx to the larynx. It is very unusual to note any considerable enlargement of the lymphoid tissue of those regions. Such as are seen are in the form of red nodules showing through a glazed and thinned pharyngeal mucous membrane. A certain amount of pharyngeal atrophy regularly accompanies the nasal lesion when BHINOLJTHS. FOREIGN BODIES 225 the latter is well advanced. Complications on the part of the ear are in our experience surprisingly infrequent, though crusts may be seen cling- ing to the periphery of the Eustachian cushions and in the fossa of Rosenmiiller. Appearance of the Larynx and Trachea.— Cases of tracheal ozena have been reported in which there was said to be no existing and no history of an antecedent nasal atrophy. This statement should be received with some reserve. Crusts and foul discharges are seen on the posterior laryn- geal wall, and this is often accompanied by a thickening of the epithelium, so that a condition of chronic laryngitis with pachydermia exists. The crusts in these cases are seen chiefly in the early morning. As the day wears on they seem to be expelled and the inference is that they form only during sleep, the discharges trickling into the larynx and trachea from the posterior nares and drying upon the walls. There are numerous cases in which i;he evidence is conclusive that this is the correct inter- pretation for the larynx, these patients suffering from hoarseness and even aphonia, but not from cough. This point is to be noted. The con- dition seems to be due to a lack of sensibility of the laryngeal mucosa occurring in an ozenic patient. In the trachea we are not so sure that this is always the correct view. Black crusts are seen clinging to the tracheal walls when the larynx and pharynx are free. We have never seen a case of tracheal ozena with a normal nose. We entertain the opinion that in the rare cases in which nasal crusts have been reported as absent, intranasal atrophy of the mucosa exists; but the discharge, always fluid enough to flow or be blown from the nose, at night trickles to the trachea and dries there, perhaps inducing inflammatory changes there of a second- . ary nature and dependent upon the irritation of the ichorous discharge from the nose — a sequence of cause and effect we see well illustrated in the laryngeal pachydermia referred to above. When the oropharynx and the larynx are free from the crusts which exist in the nasopharynx and in the trachea we are disposed to believe it is due to the motility of the former regions. Prognosis. — ^The meager success which has followed almost any form of treatment justifies the conclusion that the majority of cases are essentially incurable, and that while susceptible of relief from the most distressing of the symptoms through appropriate measures the disease is, as a rule, self-limited. To this there are some exceptions. The atrophic rhinitis attendant upon a deviated septum — that is, a unilateral atrophic rhinitis with ozena — will be at least much improved by the correction of the septal deformity. Atrophic rhinitis associated with and probably due to the desiccation of discharges from a chronic sinusitis will markedly improve or disappear on the correction of the condition which gives rise to the discharge from the sinuses. A syphilitic ozena which is reallly not essen- tially due to atrophy of the mucosa, but to dead bone associated with dried discharges, will be cured by medication. Thus far the classification has not included cases dependent for their atrophy on deep-seated periosteal or perichondrial change. They are symptomatic. There is another class of cases, the typical atrophic rhinitis with ozena and usually 15 226 ATROPHIC RHINITIS with crust formation, which are in no way improved, but rather damaged by the intranasal operations spoken of; they in no way yield to anti- syphilitic treatment. Persistent and judicious treatment ameliorates the symptoms, but the anatomical conditions remain and the symptoms return when the treatment is suspended. This state lasts for a consider- able period of years, and while it may cease to be excessively annoying before the patient reaches forty years of age, it rarely ceases to be a burden until a later period, whatever the treatment. Treatment. — ^The object of treatment in atrophic rhinitis is to cleanse the mucosa of the excretion adherent to it and to stimulate what remaining mucous cells there may be by proper medication. To effect this purpose it is often necessary to irrigate with moderate force several times daily. Any hot alkaline solution will meet this indication when given either from a fountain syringe or from the Douglass douche. Sprays, the small Bermingham nasal douche, or others of a similar kind, are absolutely ineffectual in dislodging the crusts. A method most frequently employed in the large clinics where atrophic conditions form a considerable part of the diseases treated is first to irrigate the nose with a quart of hot water to which a half-dram of salt has been added. The Douglass douche is usually employed for this purpose. Following this, one doucheful of hot water, to which has been added a tablespoonful of peroxid of hydrogen, is passed through the nostrils. If the mucosa is not entirely cleansed by this process it is swabbed with the cotton-covered applicator with a stronger solution of peroxid of hydrogen until the mucous membrane is entirely cleansed of all secretion. Into the tissues is then rubbed one of two strengths of Mandl's solution in accordance with the length of time the atrophic condition has existed, and also in accordance with the length . of time the patient has been treated: No. 1. I^ — Potass, iodid 3ij lodin gss Glyc 5v No. 2. I^ — Potass, iodid giv lodin gv Glyc. 5v No. 1 is employed for the milder cases and No. 2 where greater stimulation is required. In another class of cases where underlying sinus trouble is coexistent a solution of sea-water may be employed to which one drop of car- bolic acid to the ounce is added. This same solution is also given to the patient to be used at home. The chlorin and bromin of the sea- water affects very favorably the diseased mucous membrane in. this class of cases. Nearly every stimulating drug has been used to induce reestablishment of the functions of the mucosa, but a return to normal is absolutely out of the question. "Where proper cleanliness has been observed and sufficient time and attention has been given to the RHINOLITHS. FOREIGN BODIES 227 care of the nose, marked improvement has resulted, even to the extent of the disappearance of crust formation. One case in our experience came daily for treatment, with the exception of Sundays and holidays, for two years, and under very rigid and persistent efforts all crust formation and odor disappeared, and while the mucosa presented a smooth fibrous appearance there were no crusts and no odor for at least one year after cessation of treatment. How long this favorable result obtained is not known, as the patient disappeared at this time from observation. 10 to 20 per centi of an aqueous solution of ichthyol, following the cleansing irrigation, has in many instances been very effective. In the past few years argyrol, 25 per cent., has apparently been productive of better results than the ichthyol or the iodin solutions. Many practitioners still employ Lugol solution and other preparations of iodin. Into the hands of the patient should also be entrusted a nose cream, to be used frequently during the day, composed of: If — Iodin gr. j Oleo zinci stearatis g j This -if applied within the nose with a camel's-hair brush will keep the mucous surfaces oiled and the crusts can be more easily detached. 15 to 20 minims of the pure culture of the lactic acid bacillus, injected into the nose with a medicine dropper after proper cleansing, first recommended by Blau, has been tried by a number of experimenters with varying success. In a series of fifty cases so treated by the author, improvement was obtained in 40 per cent, of the cases, but whether the improvement was due to regular and systematic cleansing of the nose or to the efficacy of the lactic acid bacillus was never definitely determined. The odor was lessened in a reasonably large percentage of the cases, but inability to enforce regular attendance for a sufficient length of time to formulate definite clinical conclusions was impossible in the class of cases coming for treatment. Pledgets of cotton saturated in a solution of enzymbl and applied locally are productive of the same results as the use of ichthyol, argyrol, etc. Cold paraflan subcutaneously injected over the turbinated bone and septum nasi lessens materially the tendency to crust formation, and also reduces the dry, scabby condition of the nasopharynx, so often experienced by atrophic rhinitis cases, by reducing the volume of the inspired air. A paraffin that melts at 110°, injected with any of the many forms of the screw-piston syringe, as is described for the correction of "saddle- back" nose, is the procedure to be employed. The substance per se can have no direct influence upon the secretion of the atrophied mucosa other than a temporary stimulation due to inflammatory conditions induced by the presence of a foreign substance. The injections should take place at ten-day intervals to permit the tissues properly to care for the foreign substance. Whatever the method of treatment, the question of securing the cooper- ation of the patient in cleansing the nose at home will come up. Few can spare the time or money to attend the clinics or come to the doctor's 228 ATROPHIC RHINITIS office with requisite regularity and frequency to secure the best results. Men and children seldom have the dexterity or the patience to learn the use of the postnasal syringe, but young women can often be taught to employ a rubber-tipped postnasal syringe of some kind with safety and benefit at home. An alkaline solution of some kind copiously used twice or thrice daily followed by a thymol spray at home, supplemented by a ^ — Thymol gr. iij to x Alcohol q. s. Aquae 5j' visit thrice or twice or even once a week to a physician for the more thorough removal of the intranasal discharges, will frequently be effica- cious and practicable in cases unable to have daily attention from a specialist, and will give the patient much relief from her sufFerings. Internal Treatment. — Whereas the general health of the patient afflicted with atrophic rhinitis is usually not good, there are certain underlying conditions of the disease which can be influenced by proper internal medication. Arsenic in the form of Fowler's solution, iron with strychnin, gentian and phosphorus, either in cod-liver oil or in hypophosphites, should be administered in all cases. The hypodermic injection of the caco- dylate of soda, as advocated by the French physicians, is said materially to aid in the upbuild of tissue essential to the improvement of these cases. Lung gymnastics and outdoor exercise regularly and systematic- ally employed will accomplish much in bringing about a restitution of the functions of the nasal mucosa. Natier^ of Paris, has strongly ad- vocated lung gymnastics in the care of atrophic and ozenic cases, and cites instances wherein such procedure has resulted in material benefit to the patient. RHINOLITHS AND FOREIGN BODIES IN THE NASAL PASSAGES. Rhinoliths, or the deposit of bone salts around some foreign body, however minute, are frequently observed and reported as occurring in the nose. These objects have a black appearance as seen in the nasal fossae, are rough on the exterior, and give a grating sound to the probe touching them. They are usually movable, but are sometimes wedged in between turbinated bones and the septum, and are held firmly in a mass of granulation tissue; behind them cholesteatomatous masses may exist, forming the condition described occasionally as caseous rhinitis. The most varied objects acting as nuclei are found on section across these concretions; sometimes they may be only inspissated mucus. It is probable that they never occur except as deposits made around such a centre. They consist of the salts of calcium and magnesium. They may reach such a size that it is necessary to break them up with a forceps before they can be removed. ' Transactions of the American Laryngological Association, 1911-1912. RHINOLITHS AND FOREIGN BODIES IN NASAL PASSAGES 229 Almost every object capable of introduction into the nose of the human infant has been found in the children's nasal passages. Shoe buttons, having a convenient handle, are probably the most frequent articles requiring removal, but beads and bits of stone, coal, wood, beans, peas, insects, etc., testify to the enterprise if not to the judgment of the young of the human species. These may remain in the nose for years and often do so for months. Prolonged stay in the secretions of the nose results in the deposit on them of the salts of lime, with which they may be com- pletely covered, so that whether we call the object simply a foreign body or a rhinolith really depends on the length of time it has been an intra- nasal inhabitant. The crowns and roots of the teeth of the upper jaw are not infrequently found in the nose and in the maxillary sinus, whither they have found their way by displacement in the physiological process of growth or in the pathological processes of inflammation. Symptoms. — Symptoms of a foreign body in the nose vary in proportion to the size and character of the body. Small inanimate objects frequently remain in the nose with no other symptom than an increased amount of one-sided discharge, which in some instances is without fetor. However, a one-sided catarrh in a child should be regarded as suspicious of the presence of a foreign body. In cases of peas and beans the heat and moisture will frequently make them swell and become considerably greater in size than when introduced. After a reaction has set in following the acute manifestation the discharge becomes mucopurulent, fetid, and blood-stained. Often there is hemorrhage from one side of the nose, labored breathing, snoring, headache, sometimes earache, and many other phenomena of a reflex character such as winking the eye. It is often difficult to make a proper examination owing to the intractability of the child. Cocain should be used sparingly in chil- dren; an examination that cannot be performed under persuasion will be imsuccessful when force is employed. It is better to give a general anesthetic than to risk the chance of injuring the nasal tissues by the sudden movement of the child's head in the process of extraction. In infants and very young children chloroform can be administered to produce primary anesthesia. By the use of the probe such objects as buttons, beads, pebbles, etc., are easily determined, but soft objects as peas, beans and the like do not give a definite sensation to the probe. It may help to diagnose it from diphtheria in that diphtheria is usually bilateral. Children present, as the most prominent symptom, a unilateral nasal discharge, mucopurulent and ichorous in character, excoriating the vestibule, alae nasi, and upper lip. Inspection will occasionally reveal a black object buried in purulent granulation tissue, or, if recently intro- duced, plainly revealed to view without these products of local irritation. Not infrequently the object will be entirely hidden from view, either by granulation tissue and thickened secretion or by the swollen mucosa in front of it. The object usually lies in the inferior meatus, but may be lodged in the middle meatus or between the inferior turbinate and the septum. 230 ATROPHIC RHINITIS Treatment. — Cleansing the nose by a spray and the application of cocain and adrenalin will not only serve to reveal the nature of the condition, but will prepare the field for its removal. This is iiot infrequently a matter of some difficulty. Local anesthesia usually suffices, but sometimes it may be necessary to anesthetize the little patient. A small, stiff, spoon- shaped loop of wire mounted firmly in a handle, with the loop end of it slightly curved so that it can be introduced over the object, will always be efiicient in removing it unless it is too large to permit of the introduction of the instrument beyond. A wire snare will sometimes be more suitable, as the loop of thin wire will require less space. Sometimes the object must be pushed into the pharynx, when precautions are to be taken against its falling into the larynx. Unless the object present a small projection like the eye loop of a shoe button, a nasal forceps is not a suitable instrument to use, though in large rhinoliths a stout pair of forceps or rongeurs may be necessary to reduce the size of it before re- moval; but owing to the limitation of intranasal space, the forceps in any case can rarely be used without considerable laceration of the soft parts. Parasites. — Flies and other small insects, maggots, screw-worms and various larvae have been found in the nose, particularly in those cases where there has been ozena or syphilitic necrosis. Presumably the odor arising from these conditions has attracted the fly, which either in passing through the nose or during its temporary sojourn deposited a sufficient quantity of eggs to fill the nostril with worms in the course of a few days. Cases of screw-worm have been reported by Goldstein, Foster, and Steele. Within a space of twenty-four hours after the infection by the fly there occurs a fulness and pain between the eyes, increasing in severity, asso- ciated with nosebleed and an extremely offensive discharge. Formi- cation is also present and extremely distressing. Upon examination the nose seems to be alive with worms, and from one to three hundred have been extracted. The treatment is simple and eflScient. Douche the nose with a hot normal saline solution and then administer whiffs of chloroform, which kill the worms immediately. Calomel fumes will also kill them, but it takes several hours to do so, during which time the worms may multiply in great numbers. A douche of mercury bichlorid, 1 to 10,000, is also effective, but it is extremely irritating to the healthy mucosa. Chloro- form is by far the most effective, and should be inhaled for a short space following the irrigation, once a day for three days to insure the death of all the worms developing from larvae unaffected by the first administration. . CHAPTER VIII. NEUROSES OF THE NOSE. It is difficult to define the general subject. It is very questionable if we can identify any subjective sensation and dignify it by the importance of a name such as nasal neurosis unless we include those more or less manifestly dependent upon a recognizable lesion. Pure hysteria, in- sanity, and mental obsession occasionally furnish instances in which various complaints are referred to the nose when nothing abnormal can be detected by the examiner. Much more frequently are these psychical disturbances present to a greater or less degree in patients who have had something, usually of a trifling nature, wrong with the nose. The most familiar examples are those individuals chiefly seen in the dispensaries, though sometimes seen among women or others who have money to spend which they have not earned, who lust after nasal treatment often of a bloody and painful kind. We have seen a number of such cases in which the obsession had arisen to such a height that they have beset public clinics for years with importunities that have long since worn out the patience and put the credulity of the most enthusiastic rhinolo- gist to shame. We have seen in private practice a woman, the wife of a high-placed official, who had travelled from one end of the country to the other, seeking operators to remove pieces of her nasal 'septum, until she had only a mere protuberance on the floor of the nose posteriorly to represent a former septum. We have seen occasional cases in dispensaries who have only escaped such an experience because they were without money. . From these extreme cases down to the idle lady of our waiting- rooms, all gradations of this neurosis or mental obsession are seen. It is possible to enumerate a long list of mental aberrations in regard to nasal states from records to be found in literature. The woman re- ported by John N. Mackenzie, who sneezed when she saw an artfficial rose which she took for a real one, presented a state which has been satisfactorily explained in the analysis of responses to stimuli which owe their efficiency to former association with more direct influences, and it is possible that many such incongruous phenomena may be ex- plained by psychical analysis. At present they defy intelligent classi- fication and discussion. Suffice it to say this mental attitude of the patient should never be lost sight of in the treatment of nasal disease. DISTURBANCES OF OLFACTION. It may very well be that certain instances of these are placed among the pure nasal neuroses only because we are unable to ascertain the histological state of the olfactory nerves, but we may find justification 232 NEUROSES OF THE NOSE for it with the remark that molecular disarrangement doubtless is the cause of many things which cannot be classified on an histological basis. Anosmia. — Anosmia, we have every reason to believe, is associated with gross or minute lesions of the olfactory nerve and its terminal filaments. It is seen in a variety of nasal disorders largely of an inflamma- tory nature. Severe coryza and sinus disease, influenza, atrophic rhinitis, very often have it for a symptom to a greater or less degree. Inasmuch as the sense of taste in some cases of anosmia is entirely abolished, and inasmuch as it is always more or less impaired, it has been argued that the sense of smell in itself is an essential part of the sense of taste. So far as we know this is a question which has not yet received careful scientific analysis. Anosmia has been called respiratory when it has arisen from the lack of access of the odor-laden air to the olfactory region on account of the obstruction of polypi and other lesions of the nose. Essential anosmia is the term applied to loss of smell arising from lesions of the olfactory tract itself. In chronic hypertrophic rhinitis it is often impossible to know whether an essential anosmia exists from extension of the inflam- mation or whether the anosmia is due to obstruction to the respiration. Instances have been reported of rupture of the olfactory filaments from jars and blows, and it has been said there may be an actual olfactory neuritis. Olfaction has been reported as weakened in negroes when they have lost their skin pigment, as sometimes happens. The correlation of this with the observation that white animals have a feebler power of olfaction and less pigment in the cells of the organ of olfaction in the nose and that dogs have deeply pigmented olfactory mucous membranes is well known. Syphilis, tabes dorsalis, cerebral tumors, and abscesses have all been noted as causes of essential anosmia, which has also been ascribed to tobacco poisoning, malaria, lead poisoning, to astringent and irritating nasal douches and vapors, and foul smells. Some cases of loss of smell were once ascribed to distant lesions by means of reflex action. Taste or at least the finer shades of gustatory differentiation are lost in complete anosmia, but not infrequently the essential qualities, such as bitter, sweet, sour, etc., are retained. In the section on nasal function will be found the division which Zwaardemaker has arbitrarily made in his analysis of the sense of smell. By means of his olfactometer he asserts he is able to measure the acuity of the olfactory organ in de- tecting and difi'erentiating them. It is possible that a careful study of this subject might reveal interesting clinical and pathological facts, not to mention phenomena of a broader biological application. The prognosis in essential anosmia is not good, but it may be expected to recede when due to respiratory obstruction if the latter is removed even after many years of loss of smell. Two years' abolition of olfaction due to lesions of the nerve organ is an extent of time after which not much can be expected in the way of restoration of function, though we have seen a case in which the sense of smell began slowly to return a year and a half after it had been lost in the course of a severe attack of non- DISTURBANCES OF OLFACTION 233 obstructive influenzal rhinitis. The improvement continued for a year, and finally the patient ceased to complain of any interference either with smell or taste. In such a case, however, it may well be doubted, without careful objective measurement and record, whether there is a real restora- tion of function or whether the apparent improvement is not due to the habit the patient has formed of disregarding the former standard of odors and savors. Fig. 180 Zwaardemaker's olfactometer. Treatment. — The application of flat copper electrodes to the olfactory mucous membrane from behind the palate under the guidance of the postnasal mirror was used in our case, which improved. It had at least the practical advantage of greatly impressing the patient with the resources of the medical art and with the dexterity of its practitioners. Tonics, including strychnin, are conventionally administered in such cases. The hysterical anosmias are to be recognized as a part of the mani- festations of the psychical state, and treatment is to be directed to that. Hyperosmia. — Hyperosmia is said to exist in certain persons, which means that some have the power of smell more highly developed than others. It is probably also more acute at certain times in the same individual. This is said to be the case at the time of menstruation in women. It certainly is a sense which in the human race is retrogressing and differs widely in different races as well as individuals. It can become highly trained, as is evidenced by the performances of the blind and of all men living in a state of nature. Some individuals have a much more acute sense of certain odors than of others. Parosmia. — Parosmia is the sensation of odor appreciated by the individual when it does not exist. Singular to say, this perversion is never noticed as an agreeable odor. It is always the smell of unpleasant 234 NEUROSES OF THE NOSE or putrid matter, cooking meat, urine. The sensation is noted in the aura of epilepsy, in the fancies of the insane, and it has been noted as a symptom' of cerebral tumors. It is also observed after severe coryzse, especially in influenza. It is not susceptible of differentiation into essential and respiratory categories as mentioned of anosmia. It is always essential, that is, due to a nerve lesion whose existence we can otherwise demon- strate or surmise; or it is purely subjective, though perhaps it is well to qualify that also by saying, or due to a lesion we neither divine nor demonstrate. The sense of smell is intimately connected with the emotional life of man. Odors, even foul ones, have been known to stimulate the poetical fancy, as rotten apples with Schiller; or induce fond memories of joys long past, as the corridors of Versailles, stinking with the excrement of human beings, is said to have touched tender chords in the breast of an old lady revisiting, after the Restoration, the places she knew in her youth in the riotous days of Louis XV. Sexual excitement in animals, as we know, is aroused by the sense of smell, and the predilection for them by the human female is a biological reminder of an instinctive knowledge. Anesthesia of the mucous membrane of the nose as the result of a lesion of the fifth cranial nerve has been noted, but disturbances of sensation except those attributable to psychical neuroses are practically unknown. REFLEX NEUROSES OF THE NOSE. The most familiar, liberated by irritation of the nasal mucous mem- brane, is sneezing. Of the origin of this there can be no doubt. It seems exceedingly probable that mental states and other peripheral impressions can also give rise to sneezing. Sexual excitement is said to do so, and the presumption is that it is through the excitation of the muscle fibers in the erectile tissue whereby their relaxation induces engorgement of the capillaries and the cavernous sinuses. Looking suddenly at the sun or passing suddenly from deep shade into bright sunlight is often accom- panied by sneezing; but the evidence here, so far as we know, is lacking that there is any preliminary disturbance of the nasal circulation, though such a preliminary nasal excitation seems likely. The effect of cold drafts on the external surface of the body probably initiates a mechanism first of capillary contraction, and then as reaction ensues the dilatation of the peripheral vessels in the nose releases the nervous impulse in some way. The whole thing is based on purely empirical theory, and where the evidence is very insistent, as it is in sneezing, by thousands of in- stances in which we have observed a sequence of events which implicates the same channel of connection between them, we are obliged to accept it; but when we pass to the reports of instances in which sneezing, or nasal occlusion or nasal pain, is ascribed to hemorrhoids, or vice versa, when intestinal pain or frequent micturition is ascribed to a coexisting nasal spur; when we are asked to believe in the innumerable and varied nasal symptoms which can be referred to lesions in distant organs or the REFLEX NEUROSES OF THE NOSE 235 affection of distant organs ascribed as symptoms of nasal disturbance, we should pause to reflect that empirical neurological theory is not a basis on which to build a scientific superstructure. Under such limitations of our knowledge we have a right to demand a bulk of clinical evidence as to reflex neuroses which has not been forthcoming. Experimentation and observation have sufficiently established the fact that the irritation of the mucous membranes of the nasal septum and that of the turbinates will induce a cough. It seems that in certain individ- uals the contact of a probe with certain areas of the intranasal surface will elicit the cough response and in others will not; but the marking out of a specific cough, area, or an area of ear pain or of asthma in the nose for general application, is founded on insufficient evidence and will not stand the test of critical analysis. We do not wish to take the ground that gastric, intestinal, cystic, cardiac, pulmonary, nephritic, cerebral, mental symptoms are never developed from nasal lesions; but we do wish to insist that the evidence presented in the vast majority of cases of such connection is insufficient; that to present it as conclusive is often absurd and discreditable to our specialty. It should be discussed only with the most searching critical analysis, and conclusions in regard to its validity should be accepted only with the utmost caution and reserve. When reasonable ground exists to suppose tha,t a nasal lesion is responmble for .the distant neurosis, and of course when the nasal lesion is producing nasal syjmptoms demanding relief, the nasal condition is to be rectified; but before it is concluded that a nasal spur is responsible for dyspepsia, both gastric and psychical factors are to be satisfactorily eliminated from the possible etiology. Vasomotor Rhinitis. — Under the heading of intumescent rhinitis we have referred to a condition due probably to more or less stable re- laxation of the contractile elements in the nasal mucosa. Instead of responding readily and frequently to changes of the air temperature or of the air contents, instead of swelling and contracting with physio- logical demands, the tissues react sluggishly at best and there is a more or less constant feeling of obstruction to respiration. We have included intumescent rhinitis in the category of chronic rhinitis, because, while the vasomotor sluggishness seems the chief element in the obstruction, there is usually, as in all chronic congestions, more or less hyperplasia of the tissues. In these cases the completeness with which they react to adrenalin and the bulk of the tissue remaining after the blood is out of it will act as a gauge whereby to judge the amount of obstruction due to vasomotor dilatation and of that due to hyperplasia of the connective tissue. While these cases really belong in the category of vasomotor affections, they are usually discussed elsewhere because they not only occur in a different general type of patient, but other treatment is indicated for them than that pursued in the patients who, with their nasal vasomotor disturbances, are distinctly neurotic from a general point of view. The distinction is a practical one, and it is well to bear it in mind. Vasomotor .rhinitis, in the acceptation of the term con- ventional with rhinologists, is characterized by intermittent nasal obstruc- 236 NEUROSES OF THE NOSE tion, which is exaggerated in the subjective history beyond that men- tioned in the histories of patients suffering from hypertrophic rhinitis. One side is said to be entirely free at times and the other nasal fossa occluded. This condition alternates, but inasmuch as nasal deviations and nasal spurs are all but universal in the white race, cross-examination usually elicits the information that the occlusion is more complete and more frequent on one side than on the other. These complaints impli- cating the nose are very often accompanied by others implicating the eyes or ears, stomach or intestines. The patient has weak eyes or tinnitus aurium, or acid dyspepsia or constipation, or all of them. Headache and eyeache in the morning are commonly alluded to. Careful question- ing will frequently elicit the fact that these patients suffer more during some periods of time than others. There is a large class of these indi- viduals who complain that their sufferings are more or less constant, but the skilful observer will have no difficulty in getting from them the admission that they have suffered much more at one time than another. Overwork, frequent fatigue, and worry very often play an important role in the etiology of the nasal affections of these neurotic individuals; but neurotic individuals living in idleness, especially women, once started on the evil path to the doctor's office, become pests or victims. These are difficult people to treat. It is impossible to know how much benefit they will receive from surgical treatment of the nose, but it is usually necessary to correct nasal deformities by operations on the septum, the removal of postnasal or pharyngeal hypertrophies, frequently so small as not to call for removal in more phlegmatic individuals. The hyper- trophy of soft parts within the nose, if any exist, must be very judiciously dealt with. These patients who say they suffer most from a trifling amount of obstruction will be the first to suffer acutely from a dryness of the nose or throat which they may suppose to be due to an operation. General systemic treatment, including attention to the other ailing organs, is often necessary. It is a rare thing, though it occasionally happens, that a nasal operation has a favorable effect in a general way on these patients. Sometimes the nasal operator is hailed as a Special Providence, but usually he is forgotten in the interest excited by the specialist for another organ. HAY FEVER, ROSE COLD, ASTHMA. Etiology. — The experienced clinician recognizes that the type of temperament sketched in the preceding section on vasomotor rhinitis furnishes the vast majority of patients who suffer from hay fever and its allied affections. They are neurotic people, to be sharply distinguished from the hysterical. In this country there are among them a much higher proportion of native Americans than among the population in general. This seems to be primarily due to the fact that they are more or less well-to-do, and are able to seek relief from the results of the neurotic ele- ment in their make-up which supplies them at once with the hay fever and with the money with which to attend to it. A certain number of HAY FEVER, ROSE COLD, ASTHMA 237 persons seems always to have suffered from hay fever, and there is no satisfactory proof that its victims are more numerous now than they were a hundred years ago, when the affection was first differentiated and studied by Bostock. It seems probable, however, that, on the whole, the number of cases has increased even relatively to the growth of population. Sufficient has been said to indicate our belief that the underlying cause is an instability of the sympathetic nervous system, betrayed in the organic neuroses of those whose temperament we describe as neurotic. There can be no question that abnormalities of the bony and cartilaginous framework of the nose are local predisposing causes of the affection. Much has been written as to the third factor, some irritating ingredient of the respired air present at certain seasons and not at others. The pojlen of various plants seems to have met the quest for the nature of this exciting agent. That furnished by the ragweed used to account for the cases beginning in the autumn, the bloom of the roses for those be- ginning in the early summer. Dust, sunshine, the blossom of the cereals, and the grasses and other matter which floats in the air between the middle of May and the middle of October have all been incriminated as exciting agents by both the patients and their doctors. The one thing which seems settled is that there is some quality or constituent of the inspired air during this season which is the determining factor, but the simultaneity of the first appearance of the supposedly offending matter with the onset of the symptoms in any given case has never been scientifically established. Without exception such apparent coinci- dence rests upon the surmises of the patient. Especially significant is the very frequent statement of patients that their symptoms always begin upon a certain day of the same month. Nature does not deliver its pollen or any other dust in the air on such scheduled time. There are also not a few cases of hay fever in which the onset of the attack occurs at a time when we have no reason to suppose there is any effluvia of growing plants in the air. Further, patients, as a rule, are not relieved entirely from symptoms by removal to high altitudes or to the middle of the sea. They may be moderately free from symptoms in some special locality during bright, dry weather, but the drizzling rain which washes the floating matter of the air out of it drives the sufferers with greatly exaggerated symptoms within doors to the fire. The patients suffer more in the morning while the dew dampens the vegetation and prevents its giving off its impalpable bloom than they do in the afternoon, when the wind drives it from the dry surfaces of the flowers and leaves of plants. Frost definitely puts an end to the symptoms of the typical case if they have lasted until it has arrived; We are desirous of bringing those facts into prominence which demonstrate the uncertainties upon which rests the assumption that in any given case the identification of the exciting cause in the air has been satisfactorily established. We have remarked that deformities of the nasal septum and other intranasal lesions of an obstructive nature are predisposing local causes. We have elsewhere noted the coincidence of nasal polypi in cases of 238 NEUROSES OF THE NOSE hay fever. Inasmuch as it is frequently assumed that these are also among at least the predisposing causes of hay fever, it seems desirable to discuss the matter a little further. It not infrequently happens that the existence of polypi is discovered at the first visit of the hay fever patient to the rhinologist. It quite as often happens that the removal of the polypi greatly relieves the patient's symptoms, so that he considers himself cured. An actual permanent cessation of symptoms may ensue after the thorough eradication of nasal polypi, or the correction of septal deformities, but these are exceptional cases. As a rule the hay fever symptoms return whether the polypi do or not. Cross-examination will reveal in many cases — in practically all cases where the history is definite — that the hay-fever symptoms existed before permanent nasal occlusion was noted — usually years before it. Every indication, clinical, physiological and pathological, points to their relationship being de- pendent upon a common factor. What is asserted in this regard may also be said of bronchial asthma, when the latter is not associated with cardiac or nephritic lesions. Vasomotor excitation is at the bottom of the serous exudate which causes the coryza and the bronchial spasm alike. It is said that in bronchial asthma there is an exudate of serum under the epithelium of the bronchi similar to that seen in the connective tissue of the nasal mucosa. In the latter, for a longer or shorter space of time, dependent in its variation in each case on structural and dynamic causes, the contractile elements in the mucosa are able to expel the exudate — in other words, it is absorbed after each attack as long as the resiliency of the tissues remains effective; as this declines polypi form. With the vasomotor excitation of the nose and the bronchi we have a similar phenomenon of the conjunctivae. Watery secretion runs from the eyes as well as from the nose during the paroxysm of the symptoms. Polypi may arise from the vasomotor excitement incidental to simple rhinitis and exist without any classical signs of hay fever. Severe hay fever and bronchial asthma may exist for many years, repeated regularly every season without the formation of nasal polypi at any time. The nasal mucosa always retains its resiliency. When hay fever and nasal polypi coexist the mucous membrane of the nose has not retained its resiliency. Occurrence. Sex. — It is said to occur more frequently in men than women in a proportion of 3 to 2. Age. — Under ten years, 21 cases; ten to twenty years, 28 cases; twenty to thirty years, 38 cases; thirty to forty years, 19 cases; forty to fifty years, 10 cases; after fifty years, 3 cases (Giddings-Weyman). Region. — The temperate zones, especially in America. Certain locali- ties are said to be exempt from this disease — notably the White Mountains of New Hamphsire, but by no means do the majority of sufferers get anything like entire relief when dwelling there temporarily. Season. — May to October. In the earlier months the affection is called Rose Cold. Occupation. — There is a marked preponderance of the cases among brainworkers, physicians, manufacturers, merchants, clergymen, lawyers, making up much more than half the number of cases. HAY FEVER, ROSE COLD, ASTHMA 239 Race. — Chiefly Anglo-Saxons in America and England, but by no means exclusively confined to them. Symptoms. — ^With the advent of the latter part of May, attacks begin to develop, usually at more or less the same time of the month in the same individual. This continues through June. These cases are as a rule not the severe cases. After the first of July until the ■ middle of October, but especially during the latter part of August and early in September, a number of individuals have attacks varying in severity from year to year, many returning with every recurring season until old age, while in other individuals after a number of years the severity of the . attacks diminish and in the larger number cease entirely after fifty or sixty years of age. The onset is sudden, sneezing, lachrymation, nasal occlusion coming on within a few hours. All the symptoms of the acute stage of coryza are present, varying in intensity on different days and at different times in the day, varying much in severity in different individuals. The discharge from the nose is profuse, mucoserous rather than mucopurulent at any stage. There may be involvement of the accessory sinuses, although usually not as the direct sequel of the coryza of hay fever. The ear symptoms are usually con- fined to temporary deafness and tinnitus aurium, though a chronic discharge from the ear as from the nasal sinuses may be much exacerbated during the prevalence of the hay-fever symptoms. There are many cases which suffer mildly each year during the summer and fall who do not seek medical or surgical relief, because of the lack of severity in the symptoms. There are others who are so afflicted that they are forced to abandon their business during the existence of their more severe sufferings. The initial attack and perhaps several succeeding ones each season may be of a mild nature. Subsequently they may become more severe or always remain mild. In the severer cases the patients are apt to suffer from more or less asthma. Shortness of breath is experienced which is much aggravated by exercise, while attacks of it, as of the hay- fever symptoms, are excited by dust, high winds, and damp weather. Prognosis. — ^Prognosis is usually good as far as life is concerned. In a small percentage of the cases, edematous nasal polypi form. This condition may become serious through its liability to give rise to sinus suppuration. Given this combination of phenomena, — sinus suppura- tion, nasal polypi, bronchial asthma — it is possible that a patient's condition, at first only that of a mild hay-fever case, may subsequently become extremely grave. Yet these cases, when it is possible to put the nose in a good condition, are the ones which make the most striking recovery, even from their vasomotor symptoms. The shock of the operation seems to cure the neurosis at times. Indeed cases are on record where the breaking of a leg accomplished the same result. The case of Dr. J. N. Mackenzie has been famous for a generation. He was able to produce a paroxysm of Rose Cold in a female by allowing her to smell of an artificial rose. When the deception which had been practised was revealed to her, she was subsequently able to inhale the perfume of a -real flower without detriment. Our ignorance of the pathology of the 240 NEUROSES OF THE NOSE sympathetic nervous system leaves us entirely without explanation of these things. We only know that cases of spontaneous and often capricious cure are observed, and that the advent of old age exerts a favorable influence on the symptoms in the majority of the cases. Treatment. — This with some exception has been plainly indicated from the point of view exposed in what has preceded. During the interval between the attacks, the nose and throat should be put surgically in as good a condition as possible. The general health should be carefully inquired into and errors of diet and habit rectified. Drugs as a rule are to be avoided. Both opium and belladonna when administered, the former during the attack, and the latter for a week or ten days before it, at times are beneficial, but the objection to this use of opium is obvious, while belladonna produces a number of disagreeable sensations which are apt in the long run to be as uncomfortable as sneezing and lachryma- tion. We know of nothing but the personal experience of each individual which can be trusted to select a locality beneficial to him during the hay- fever season. Any change benefits some cases; no change does others any good. The White Mountains, Colorado, Lake Chatauqua in Western New York, Cresson in Pennsylvania, and many other localities give complete and instantaneous relief to a few cases and are beneficial to many more seeking it. How much relaxation from nervous strain and absence from the usual worries of life have to do with the success of this therapy it is impossible to say. A sea voyage often gives complete relief, while the patient is in midocean, but seasickness cures it too. Needless to say, not all care to be seasick; many cannot take up their residence in midocean nor on mountain tops for a month or six weeks each year or even more. There is little left to recommend to those individuals who have sought relief in vain from the surgeon and from change of scene. Stoic philosophy need not be suggested, for these people are not stoics. "Pollantin" and various sera, such as Dunbar's serum, have been said to cure certain cases, but so have Christian Science, the mind cure, and countless quack remedies. RHINORRHEA. By this term we mean a condition of serous discharge from the nose, which, whether somewhat intermittent or more or less constant, is in excess of that seen in acute or chronic infiammatory conditions and is unassociated with them except that they coexist to a comparatively insignificant extent. We have every reason to believe that a certain amount of serous exudation is constantly going on not only through the epithelium of the Bowman glands and the surface epithelium, but through the epithelium of the racemose glands. Aschenbrandt estimates the amount to be between the wide limits of 350 and 1400 sirams per day. Normally this is absorbed. Patients afflicted with true rhinorrhea are rare, but some reports^ exist ' See the collection made by St. Clair Thomson (The Cerebrospinal Fluid).. DISCHARGE OF CEREBROSPINAL FLUID FROM THE NOSE 241 in literature of typical cases entirely distinct from the other rare category of the discharge of cerebrospinal fluid from the nose. The condition may begin in adolescence and last for years. It may give great annoyance for two or three weeks and then there may be a shorter or longer remission, after which another attack supervenes. The attacks may become more frequent or they may be very frequent and annoying from the first and then gradually cease and disappear altogether. The flow is con- tinuous, but in some cases it ceases during sleep. In a few cases the watery discharge has apparently come from the maxillary antrum, and there are a number of cases on record by Noltenius in which the natural opening being closed, a condition of hydrops of the maxillary sinus existed. Scraping and cauterizing the walls of the cavity have been reported as resulting in a cure, but the one or two cases which we have seen we regarded as a pure neurosis. They occurred in patients of the type of those who suffer most frequently from hay fever. The discharge when of this type is reported as being accompanied by sneezing and as coming from both nostrils. The discharge is irregular in amount from time to time. It may be accompanied by the presence of polypus within the nasal chambers. The analysis of the fluid from one case as given in St. Clair Thomson's book by HalUburton shows for the nasal fluid: Water 98.792 per cent.\ ,„„ „„„ , rr, . 1 cs vj 1 ono if 100.000 per cent. Total Souds 1 . 208 per cent.J Proteids, including mucin . 260 per cent. Other organic substances ' . . . . . 163 per cent. Inorganic substances . 785 per cent. while for the cerebrospinal fluid the total solids are not so great, there is a substance which reduces the salts of copper in Fehling's or Benedict's solution for the detection of sugar. There are globulins and albumoses, but no mucin. Treatment. — ^Treatment has for the most part been of no avail in these cases, but, as a matter of routine, attention to the general health and nerve tonics are prescribed. After a longer or shorter time these cases seem to have recovered without any evidence that therapeutic measures had much to do with it, with the exception of those cases spoken of above in which the maxillary antrum was opened and curetted. THE DISCHARGE OF CEREBROSPINAL FLUID FROM THE NOSE. Cases are not infrequent in which, violence or disease having caused fracture or perforation of the base of the skull, there has resulted a discharge of cerebrospinal fluid from the nose. St. Clair Thomson (l. c.) was the first to demonstrate a case in which this leakage from the cranial cavity was spontaneous, that is, due to no ascertainable cause. He was able, in 1899, to select the reports of nine cases from literature in which the evidence seemed conclusive that the dripping of a sterile limpid secretion from the nose had its origin in a solution of continuity, at the 16 242 NEUROSES OF THE NOSE base of the skull which had been established without assignable cause. The occasional coexistence of a nasal polypus seems to have been the result rather than the cause of the nasal discharge. The duration of the discharge extended over a period of time varying from a few months to eight years. Headaches were usually complained of, increased at times in certain cases when there was a temporary diminution or cessation of the flow. This was uniform, drop by drop, night and day. Cerebral symptoms were present in some. One or two of them died with what was apparently meningitis. The general health was good in some; in one or two others there was hydrocephalus or dizziness and trembling. The quantity discharged was, in those in whom it was possible to calculate it, apparently at the rate of about 250 c.c. per day. Eye symptoms were noted in some cases. The composition of the cerebrospinal fluid, varying a little in density morning and night in Thomson's case, containing a little more solids in the morning than at night, showed on analysis: ^ate^ ''n-SQfi'"""°J') 100.000 per cent. Solids . 996 per cent.] Inorganic . 878 per cent. Organic 0. 118 per cent. Owing to the fact that the fluid in traversing the nose must, though probably usually to a very slight extent, have some of the nasal discharge incorporated with it, owing to the uncertainty of the composition of the watery nasal secretion in cases of essential rhinorrhea, absolute depend- ence upon the chemical analysis of the fluid cannot be entertained for the differential diagnosis, though the presence of mucin in the cases of essential rhinorrhea and the presence of a reducing substance in the case of its cerebrospinal origin should be given great weight. The steady drop-by-drop discharge of the cerebral fluid, its persistence during sleep, distinguishes it from the more or less intermittent and irregular flow of the rhinorrhea dependent upon vasomotor causes. Increase of cerebral pressure by straining, by abdominal compression, etc., increases the rate of flow of the cerebrospinal fluid, but this is probably also the case for essential rhinorrhea. The cases due to violence partake of the same character as those which we have just discussed in which the discharge of cerebrospinal fluid was idiopathic. Some cases have been reported as reaching a spontaneous cure, but most of them have died either as the direct result of the violence or as a consequence of the meningitis which has ensued as a result of subsequent infection. Treatment is of no avail, surgical interference tending to precipitate the advent of meningeal infection. CHAPTER IX. NASAL NEOPLASMS. Benign. — In treating of the pathological histology of the inflammations of the mucosa of the nasal chambers we have alluded to the hyperplasia of its various elements as producing forms of growth often indistinguish- able from what the histologists call true tumors. It is impossible here to enter into a discussion of the general question. It will suffice to repeat that the line of division between the two, if there is one, is a wide and wavering one. If we limit the nomenclature of true tumors to those growths showing no evidences of plastic inflammation in their structure, the true benign nasal tumor is an exceedingly rare occurrence, even though we may admit in certain instances that the products of inflammation are of secondary occurrence. Adenoma. — Of no form of benign growth is the above more strikingly illustrated than in the adenomata. Billroth went so far as to call prac- tically all nasal polypi adenomata. Pure benign adenoma, that is, a benign nasal growth in which the glandular type of epithelial hyperplasia is the dominant tissue change unassociated with marked evidences of its origin in the stages of chronic inflammation of the nasal mucosa is an exceedingly rare phenomenon. A benign adenoma of this description is a much less common neoplasm than a malignant adenoma. When they do occur it is as papillomatous masses in the nasal fossae frequently presenting evidence of the involvement of the mucous membrane of the accessory sinuses, especially of the ethmoid and sphenoid. The papillary projections on the surface are made up of a core of connective tissue covered by a single or double layer of non-ciliated columnar cells. Convolutions of these exist deep in the substance of the growth in the form of imperfect acini and ducts of the racemose glands. In Fig. 181 will be seen the illustration of the most striking example of a benign adenoma of the nose we have ever seen. It represents the histological structures of a growth in the case of a patient of Dr. F. W. Hinkel, of Buffalo. The patient, a woman, began to complain of symptoms in 1891 and several years later as much as possible of the growth was removed by Dr. Hinkel and sent to Dr. Wright for examina- tion. It was a number of years before the tumor ceased to recur after operation. From 1902 until 1913 there was no recurrence. It then again recurred, and again a fragment was removed and sent to Dr. Wright, twenty-two years after the first nasal symptom began. In the period of seventeen years which had elapsed since Dr. Wright first examined the growth and the more recent study, pra'ctically no change had occurred in its histological character. As represented in Fig. 181, 244 NASAL NEOPLASMS it appeared in 1896 and again showed itself in 1913 essentially a benign adenoma.^ On reference to Figs. 99, 100, and 101 the reader will note the evidence of change in the glandular and surface epithelium in papillary edematous nasal polypi. The gradation between the structure of a growth plainly having its origin in chronic inflammation and a benign true tumor, here an adenoma, is a continuous one. Fig. 181 Nasal adenoma. In benign cases, as a rule, while there is great lateral proliferation of the gland-like cells, forming long rows, one or two deep, these do not form solid masses of cells in the stroma. When this occurs in section of adenomatous growths it is a decided presumption, but not conclusive evidence of malignancy. Sometimes the stroma supporting this laby- rinth of epithelial tubul'es and acini is edematous — ^perhaps so much so that it seems quite evident there is a condition of adenomatous ' For remarks on this case and incidentally the more general discussion of nasal adenomata ■ see papers by Dr. Wright, Transactions American Laryngological Association, 1897, p: 61, and American Journal of the Medical Sciences, October, 1898. ADENOMA 245 hyperplasia engrafted on an ordinary edematous polyp. Only rarely indeed is it that no such origin is apparent. As in this class of growth elsewhere, hyaline degeneration of the granules of some of the connective-tissue cells causes the appearance in the stroma of various berry-like bodies. These may be surrounded by a cell membrane, in which case the separate berries are compressed into facet forms, or a cluster of them may lie loose in the stroma, showing spherical outlines. More common than this form, plainly derived from intracellular degeneration, are isolated globules of the same material. That the origin of these hyaloid bodies is the same seems extremely probable. Fig. 182 'Hyaline" bodies or "berries" taking eosin and fuchsin stain, but not hematoxylin. Camera luoida. Obj. i. Such growths may exist for many years and recur after repeated removals. Finally, after they are completely eradicated, together with the mucosa from which they spring and the bony walls which it covers, they may cease to grow again. It is too often the case that finally, either through a mistaken interpretation of the microscopist or through the 246 NASAL NEOPLASMS occurrence of an actual transformation of a benign into a malignant potentiality of growth, this favorable prognosis is belied and the case comes to present all the clinical and pathological features of an adeno- carcinoma. Fig. 183 Hyaline drops or separate globules taking eosin and fuchsin stains, but not hema- toxylin. Camera lucida. Obj. i. Angeioma (Bleeding Septal Polyp). — Unconnected with the septal growths and with the plainly hyperplastic angeiomatous conditions of the posterior ends of the inferior turbinated bodies, nasal angeioma is a rare form of tumor. As a septal growth springing by a broad base from the mucosa of the middle of the cartilaginous septum it partakes of the nature of a granuloma and is a comparatively frequent phenomenon (Fig. 184). It owes its origin to a thinning of the mucous membrane and its frequency on the septum to the vascular distribution of the area known as Kiesselbach's, where capillaries radiate from one or more arterioles. The change in the mucosa which initiates the proliferation of the bloodvessels and their dilatation is a disappearance of its contractile elements, chiefly the elastic fibers, or their change from an efficient agent of tonicity and support in the stroma to an inefficient granular state. That this state of the mucous membrane of the septum is a result of inflammatory action seems probable, but inasmuch as it is not regularly FIBROMA 247 accompanied by marked chronic inflammatory changes of other parts of the nasal mucosa, this must not be too hastily assumed. The numerous bloodvessels lined with a single-walled endothelium, or at least showing no muscular coat and but little adventitia proper, are small and he in a stroma of very lowly organized connective tissue containing large numbers of leukocytes, including many lymphocytes and plasma cells. Surgical eradication is almost always eiBcient in preventing recurrence, though in a woman we have seen it repeatedly return with each recurring period of pregnancy. The growth is more common in women. The microscopical appearances of a "bleeding polyp" of the septum, recurring twice at the seventh month of pregnancy (X 10) . Fibroma. — ^The fibrous elements which constitute the framework of every tumor may be so abundant in comparison to the other elements, the granulomatous and hyperplastic processes in the one case may be so highly organized or in the other so predominantly fibroid as to sanction the name of fibroma in the judgment of the observer of its minute struct- ure. The frequency with which this occurs depends upon the personal bias of the observer. Hence, with the reports of fibroma as of adenoma and of angeioma in rhinological literature one has to consider the personal equation in judging as to the frequency with which these growths occur in the nose. Personally, Dr. Wright has seen only two or three growths in twenty years' experience, largely devoted to histological work, which he has been disposed to call fibromata of the nasal chambers proper. ' When one deals with that region of the nose immediately contiguous to the nasopharynx, such neoplasms are occasionally met with, but there is always a question of anatomical boundaries. Such purely intranasal growths as show little or nothing but dense wavy fibers of connective tissue, with sparse nuclei or cellular elements and scanty bloodvessels, are exceedingly rare. Round, smooth, hard, their density is such as to 248 NASAL NEOPLASMS distinguish them from the usual nasal growth. Their base of attachment is usually a more or less constricted one. Their removal is usually not followed by recurrence. Osteoma. — Osteoma of the nose is usually situated in one of the sinuses, but in about a third of the cases they are said to spring from the walls of the nasal chambers themselves. They are nearly always of slow growth. They are broad based and probably spring from the bone itself; though in most cases there is no reason why they should not have their origin from a metaplasia of the fibroblasts of the periosteum or perichondrium. Bone occasionally, though rarely, is found in various tissues of fibroblastic origin entirely remote from normal bone. It is not probable that the hyaline cartilage cell itself ever gives rise to bone formation. When new formation of bone occurs in connection with cartilage it is probable that it springs from the perichondrium. It is uncertain if the osteoma of the nose springs from the bone itself or from the periosteum covering it. Its structure may be soft and cancellous, containing numerous Haversian canals; or it may be of a hard and dense character. It may grow to a very large size, filling the various nasal cavities and distorting the external configuration of the nose, absorbing the bony tissues on which it presses. It may be firmly incorporated with the underlying bone, or its connection with it may exist only by a small pedicle which, when fractured by manipulation or absorbed in the pro- cess of growth, leaves its origin in doubt. Such a condition is spoken of as a dead osteoma. Cases have been reported of bilateral and of multiple nasal osteomata. Its invasion of the base of the skull may give rise to meningeal and cerebral symptoms. Otherwise it is benign and does not tend to recurrence after complete removal. Papilloma. — We have referred to those cases of papillary hypertrophy and of papillary adenomata which, unmindful of the conventional nomen- clature of Virchow, have in the past been called papillomata with resultant confusion. If we exclude papillary hypertrophies and papillary adenomata and include only papillary fibromata in the term papilloma, as is the custom in standard works on histology, it is entirely accurate to say that nasal papillomata are excedingly rare, there being perhaps less than fifty well- authenticated cases reported in rhinological literature. We cannot find space to discuss further the question of nomenclature, but to make the objective description more distinct it is necessary to refer to the fact that, following the rule of Virchow, who chose to use the substantive to describe the predominant histological feature of any given growth, papillomata should, in consistency therewith, be called not papillary fibroma but papillary epithelioma, for the tissue element chiefly in process of proliferation is the epithelium; but the objections to calling a benign growth an epithelioma are obvious. Papilloma or fibroma papillare, therefore, in the nose as elsewhere, is made up of a proliferation of surface epithelium the character of which is determined to a large extent by the normal character of the epithelium of the surface from which the growth springs. Following the rule of all hyperplastic processes in the nose the surface cells of a papilloma, like the surface CHONDROMA 249 cells of an hypertrophy, may have undergone some metaplasia, but they often exhibit the typical columnar appearance in the surface layers. The epithelial hyperplasia may exhibit surface appearances of two kinds: the hard growth or papilloma durum has usually a fairly smooth, hard, and often asomewhat corneous scaly surface. The lower margin of the epithelium is thrown into long digitations which dip down into the stroma, sections often showing under the microscope detached islands which represent peninsular vagaries of the continental epithelium. The soft papilloma, or papilloma moUe, is usually described as con- sisting of projections of slender branching bunches of fibrils from the subjacent connective tissue, whose surface is clothed with numerous layers of proliferated epithelium and whose centre is occupied usually by a minute capillary bloodvessel. Further histological details and remarks upon the differential micro- scopical appearances distinguishing the benign from the malignant epithelioma will be spoken of in connection with the laryngeal growths, much more common and involving questions of much more import to the patient in the prognosis and treatment of the affection. The true papilloma is usually situated on the septum just behind the columna, when it is usually of the hard variety, or farther back on the septal niucosa, where its papillary excrescences are apt to be more marked. It is also seen on the floor or in the vestibule. True papilloma is rarely seen on the turbinated bones, and papillary hypertrophy or papillary adenoma is rarely seen on the nasal septum; hence given a papillary tumor of the nose, its situation is the chief moment in its gross differ- ential diagnosis; but the gross appearances of the three varieties of papillary growth are often identical, and the microscope is necessary in a final solution of the histogenesis of such an appearance. Myxoma. — We desire to mention this form of benign nasal growth in order to point out that it practically never occurs in the nose. Hajek and Polyak^ have reported a nasal growth as a myxoma lymphangiec- taticum, and admit that, as a benign growth, it should be considered as unique, but from the history we may well suspect it was a myxosarcoma. In modern rhinological histology edematous polypi are no longer reported as myxomata. A case of lymphangeioma of the nose has been reported by Hamm.^ Chondroma. — We are aware that some authors have described nasal chondromata, but so far as our own experience is concerned, and so far as we can judge from the nature of the reports in rhinological literature, aside from the local hyperplasias of the septal cartilages — ecchondromata — spoken of as septal spurs, aside from the chondrosarcomata or osteo- chondrosarcomata which should be classed among the malignant growths, it is doubtful if chondroma as a true benign tumor of heterologous origin ever occurs in the nasal tissues — or ever occurs as an endogenous growth ' Hajek and Polyak, Frankel's Archiv f. Laryngologie und Rhinologie, 1910, Band xxiii, p. 43. 2 Hamm, Munch, med. Woch., February 24, 1903, No. 8, p. 332. 250 NASAL NEOPLASMS — enchondroma, though a few cases have been reported in Hterature fairly free from the above criticism. Cysts arising from glandular ectasia, from the effusion of serum beneath the epithelium or in the stroma of a nasal polyp or hypertrophy, from the roots of the teeth and from the excentric growth of preexisting cavities in the bone of the ethmoid region, have all been incidentally referred to under other heads. While syphiloma, tuberculoma, and rhinoscleroma are frequently classi- fied as tumors and given that affix in nomenclature, it is more convenient to speak of their histology and etiology as granulomata and place them among the infections where they belong in a classification based on etiology. Fig. 185 Rhinosporidium kinealyi. Granulation tissue covered by hyperplastic epithelium with gland-like digitations and containing cysts : a, large cyst in the sporemorular stage, whose walls are being replaced by a fibrous connective tissue ; 6, a cyst in the granular stage, one nearby shows a nucleus ; c, sporules and sporemorulae escaping in the epithelium and on the surface. Rhinosporidium Kinealyi. — This is a protozoon which has been found in the granulomatous tissue of the septum, and of the anterior parts of the turbinated bones. The tumors in which it was found resembled small papillomatous masses, vascular and sometimes pedunculated, with attachment to the localities indicated. It was first described as having been found in India by Major Kinealy.* The microorganism was described by Minchin and Fantham^ in 1905, and later by Beattie' in 1906. Dr. Wright* later identified the organisms as occurring in a nasal growth, sections of which were sent him by Dr. Ellett, of Memphis, Tennessee. It is a sporozoon, with endogenous spore-forming cysts in the epithelium, and the various representations of the microscopic appearance, with the accompanying legends, may be ' Journal of Laryngology, 1903, p. 375. " Minchin and Fantham, Quarterly Journal of Microscopical Science, London, 1905, xlix, p. 521. ' Beattie, Journal of Pathology and Bacteriology, xi, p. 270, 1906. '' Wright, New York Medical Journal, December 21, 1907. RHINOSPORIDIUM KINEALYI 25] seen in Figs. 185, 186, and 187, the legends to which sufficiently elucidate the appearance. On operative eradication, as far as is known, the growth does not recur. Fig. 186 «^__ m ^^n J CV , C'"* Sporemorulae or pansporoblasts, with their sporules in the epithelium and free on the surface. Fig. 187 The granular stage of a cyst, with a thick external chitinous wall, the granules showing a chromatine granule at one pole. The Symptoms and Differential Diagnosis of Benign Nasal Neoplasms. — Properly to differentiate one form of intranasal tumor from the other the 252 NASAL NEOPLASMS microscope must be called into service to cooperate with the clinical symptoms. To a certain extent the microscopical appearances have been alluded to or may be found to some extent described in connection with the same type of growth occurring elsewhere. We shall also elsewhere have occasion to make some remarks on the use of the microscope as an aid in the differentiation of neoplasms of the upper air passages. Here we shall briefly discuss the character of the symptoms common to all forms and the special subjective phenomena and characteristic gross appearances which serve to differentiate them clinically. The character of nasal tumors is somewhat determined by the age of the patient, divided into three periods. (1) those cases under ten years of age; (2) those from ten to forty; (3) those from forty on. With the exception of an occasional polyp, one rarely finds nasal tumors in children under ten years, other than the lymphoid masses in the nasopharynx and an occasional hypertrophy of the posterior tips of the turbinated structure. The ordinary mucous polyp may be found, however, in all three periods, but is probably most frequent in those cases over forty. Fibromata and fibro-angeiomata nearly always occur in young adult life and therefore belong to the second classification as regards age. The same may be said of adenomata, osteomata, and chondromata, and likewise to this period belongs the malignant sarcomata with their variations in patho- logical structure. To the third period belong essentially the malignant tumors, particularly epitheliomata. By far the most numerous nasal tumors are the mucous polypi, which have been discussed under a separate head. The growths have a varying amount of fibrous tissue in their structure and assume such proportions at times that they project into the nasopharynx, occluding the postnasal orifices. Their attachment is usually by a pedicle to the ethmoidal structure or to the edge of or just within the hiatus semilunaris of the maxillary antrum. These tumors occasionally occur in children as well as in adults. When they do occur in children the symptoms simulate those of adenoids, and the operator is prone to attribute such nasal disturbances to adenoids rather than to the infrequently occurring edematous polypi. When the naso- pharynx can be examined with the mirror, errors in diagnosis are obviated, as the presence of the tumor can be definitely determined. The most marked symptoms are nasal stenosis associated with excessive discharge, often fetid, and unilateral as a rule; mouth-breathing, snoring, lack of nasal resonance, and occasionally nosebleed. When the tumor assumes sufficient proportions to create pressure there is headache and a dull sensation of soreness in the head which is continuous. The symptom common to all these growths is nasal obstruction. With the exception of bleeding polypi of the septum it is the difficulty in respiration which causes the patient to seek reUef. It is therefore largely from the basis of the appearance of the growth in situ that we will take up the differential diagnosis. We have already described the appearance of the edematous nasal polyp. The observer must remember that growths of this character modified somewhat in appearance according as they present a papillary, a lobulated or a smooth surface are the ones SYMPTOMS 253 he will see in a patient's nose nine times out of ten when he discovers by anterior rhinoscopy that the patient's nasal obstruction is due to some form of neoplasm. If a neoplasm is manifestly not an edema- tous polyp, the chances are in favor of it being a malignant rather than a benign tumor. An adenoma is usually associated with tissue which is edematous and often with typical edematous polypi. A papillary vegetating surface is apt to be seen in the region of the anterior or posterior ethmoid cells. They are apt to bleed more readily than the simple edematous polyp and pretty regularly infiltrate the ethmoidal cells, presenting histological evidences of an inflammatory origin or going on to rapid recurrence and the clinical manifestations of malignancy; glandular hyperplasia of the nasal mucous membrane is not very rare, but a true benign adenoma, as we have already said, is very rare indeed. The question of the con- version of a benign into a malignant adenoma is discussed elsewhere. The exact nature of this form of growth is often difficult to establish by any method of diagnosis. Without a microscopical examination it cannot be satisfactorily differentiated from other forms of nasal neoplasm. Indeed, clinically the diagnosis is pretty regularly one of edematous polyp until a microscopical examination is made. Angeioma, or bleeding septal polyp, is usually a smooth or possibly a lobulated growth situated in a position whose centre may be described as usually being a little anterior to and below the centre of the cartilagin- ous septum — ^the so-called Kiesselbach area. It may extend from this so that its periphery occupies a large part of the anterior portion of the septum. Its surface bleeds easily, and, distinguished as it is from other nasal neoplasms by its local appearance, its history is also marked by complaint of frequent and violent epistaxis. It is more frequently seen in women. Sometimes its appearance is that of fungous granulation tissue. Superficial ulcerations and abrasions covered by a clot occasion- ally account for the hemorrhage. While this growth is more frequently seen on the septimi of the nose, a similar condition is at times seen on- the outer wall at the anterior end of the middle and inferior turbinate bones. It is not infrequently, especially in the latter situations, associated with sarcoma as a malignant tumor— angiosarcoma. Fibroma. — A few of these tumors have been found in the nose attached either to the septum or the turbinated bodies, and they may assume considerable size, in which case their direction of growth is toward the nasopharynx rather than anteriorly. They appear as rounded, globular, bottle-shaped masses, which vary in color from pale white to that of bluish venous engorgement. The extremity of the tumor is usually hardened and thickened, and gives the appearance of shrunken leather, while the base is pedunculated. Upon palpation with the probe a hard, non- resisting mass is determinable, and the sensation experienced is quite at variance from that experienced from polypi or adenomata, unless the probing is directed to the attachment alone, where the tissue even of the edematous polypus is apt to be firm. A sense of pressure is experienced when the tumor has assumed sufficient 254 NASAL NEOPLASMS size to occupy the transverse space of the nasal fossa, and when this is so the pressure symptoms of headache, mental hebetude, and nasal occlusion exist. A distinct nasal quality is imparted to the voice, lessening its resonance. Pain is sometimes experienced, particularly if the pressure is great, and epistaxis is also a frequent symptom. If it reaches an unusual size there is widening of the nasal bones, the eyeballs project outward, and facial deformity follows, known as "frog face." Deafness may ensue, due to Eustachian tube obstruction. Such extreme development of the nasal fibroma denotes its affiliation with the nasopharyngeal growths. Indeed, the attachments of all intranasal fibromata are regu- larly to the back part of the nasal chambers. Papilloma. — True papilloma of the nose as distinguished from the papillary hypertrophies of the mucosa of the inferior turbinated body is very rare and is usually seen upon the septum. Occasional cases have been reported as having their base at the anterior end of the turbinate bodies, just back of the vestibule. The marked vegetating surface places it among the papillary tumors. It is to be distinguished both from the papillary adenomata and from the papillary hypertrophies of the mucous membrane. This it is difficult to do if the papilloma is the soft, vegetating variety. The hard wart situated just behind the columna of the septum is, as a rule, easily made out. Existing along the lower border of the turbinate bodies, especially the inferior, the microscope will usually show it to be a papillary hypertrophy. Indeed, the latter form of growth is not unknown upon the septum. High up on the septum and infiltrating the ethmoid cells it usually causes one to think of a papillary adenoma or adenocarcinoma. The rapid recurrence of all these forms of true benign tumor is very common in the nose, owing to the fact that it is difficult to eradicate all the tissue which is giving origin to the new growth. This applies pretty regularly to all the forms hitherto described in the symptomatology except fibroma. The latter has a constricted base of attachment and is easily completely removed. We have seen adenomata, angeiomata, and papillomata repeatedly recur after removal. We have already referred to a case of persistent recurrence of an adenoma over a period of twenty- two years. We have seen similar recurrence of a papilloma extending over a period of ten to fifteen years and others not so long. We have seen the bleeding polyp persistently return on the septum of a woman at each succeeding pregnancy for several years. Yet in all the cases referred to we have, by microscopical examination, proved that the benign structural type was just as much in evidence at the last recurrence as at its first appearance. While metastases do not form in the cases at least of adenoma and papilloma, widespread extension and persistent regrowth of tumor masses may invade not only the sinuses but the orbit and lachrymal canal and cause a serious if not a dangerous condition. Treatment. — This can only be of a surgical nature. With snare, curette, and actual cautery the growth must be not only fully removed, but the base of mucous membrane must be thoroughly destroyed. If the eth- TREATMENT 255 moidal or other sinuses are involved the disease should be vigorously attacked in them. In the case of the persistently recurring papilloma in our practice, in spite of the thorough and repeated destruction of all visible growth, subsequently, after leaving our hands, the growth spreads to the orbit and accessory sinuses. At last accounts this woman was being treated, successfully, according to her statement, by Christian Science. She certainly had been unsuccessfully treated for many years by the other kind of science. Removal by the cold-wire snare is the most effective and most fre- quently employed means of eradication, although some operators prefer the galvanocautery loop, as by its use recurrence is probably reduced in frequency. There is associated, however, with the galvanocautery loop certain dangers, particularly when used in this locality, for apparently in this danger zone the galvanocautery produces more constitutional disturbances than when employed elsewhere in the body. Whether this is due to the proximity of the brain structures and to the transmission of inflammation toward the brain through the veins and lymphatics one is unable to determine. As it is so easy to remove these growths by the snare it is unwise to resort to chemical escharotics, as more damage is likely to be done by their employment than by the use of the snare, and they have also in the majority of instances proved ineffective. More extended remarks on the technique of intranasal operation specially directed toward the extirpation of edematous polypi may be found in Chapter IV, p. 184. It may be applied to all those forms of intranasal benign growths, modified, of course, to meet the demands arising from the character of each. Osteoma. — ^This forms an exception among the benign tumors as to appearance, symptoms, and treatment, and requires separate mention. The symptoms of this essentially benign growth, like the former, are those of obstruction and pressure. They have been noted spring- ing from the walls of the sinuses as well as from those of the nasal chambers proper. Their tendency is to continue to grow until checked by eradication; they distort or absorb other bony structure, and are recognized on examination as smooth tumors extremely hard and resist- ant to the probe. They do not bleed nor, as a rule, cause much pain, though in the upper part of the nose they may give rise to headache and dizziness. As they progress in their growth, symptoms dependent upon the invasion of the orbit, lachrymal sac, and even the cranial cavity, add variety and danger to the clinical picture of what in itself is not a serious affection if recognized when its complete removal is possible. The site of the tumor must be thoroughly exposed by external incision over the nasal bones or the maxillary sinus, and with chisel and gouge the growth must be thoroughly eradicated. This usually does not prove so difficult a procedure as appears, provided the base of the growth is thoroughly exposed. A blow with the mallet and chisel frequently shells a more or less isolated mass of bone from its bed. With curette and rongeur forceps this should be thoroughly gone over to remove any remains of the new growths. Thus thoroughly extirpated, recurrence is not usual. 256 NASAL NEOPLASMS MALIGNANT NASAL NEOPLASMS. In dealing with the pathology of malignant nasal neoplasms no attempt will be made to go into the histological description of these tumors from the standpoint of the general pathologist except in so far as the differential histological diagnosis is correlated with clinical rhinological observation and the points in general pathology affecting the special problems met with in rhinology. In a general way the structure of nasal malignant neoplasms is the same as those of corresponding tumors found elsewhere. It must be understood in classifying nasal neoplasms as benign and malignant, that, so far as the histological structure goes, it is somewhat an arbitrary division, inasmuch as in nearly all forms of malignant growths instances are occasionally met with in the nose and pharynx where a structure, conventionally regarded as belonging to growths of malignant potentiality, is subsequently seen to have characterized growths of a benign clinical course, and vice versa. While this is true for the nose and the pharynx it still more frequently intrudes itself into the experience of the observer of laryngeal growths, clinical and histological. Occurrence. — ^The usual malignant tumor of the nose is a connective- tissue tumor. According to Gurlt^ out of 848 cases of sarcoma in all regions there were 15, or nearly 2 per cent., of them which occurred in the nose, while out of 9554 cases of carcinoma only 4, or less than 0.05 per cent., which occurred in the nose. There is a striking reversion of these figures for the larynx. In the nose malignant disease is more frequent in the male both for the epithelial growths and for the sarcomata. In the summary of cases given by Bosworth there were 40 males and 22 females. This ratio conforms with our own experience, and does not widely differ in the epitheliomata from that in the sarcomata. The age at which malignant disease of the nose is most frequent, whether epithe- lioma or sarcoma, is in the two decades between forty and sixty years. While this is true for sarcoma as well as for epithelioma, the occurrence of cases of sarcoma before forty forms a larger ratio to the occurrence of cases after forty than is the case with epithelioma. Both have been seen even in childhood but epithelioma is exceedingly rare even in adults. Etiology. — ^While there are some reasons to believe that injuries to the tissues either by blows or chronic inflammation are causes, these seem minor factors in the etiology of malignant nasal growths. It is not infrequently the case that the history of a blow on the external nose is included in the antecedents of such cases, but blows and falls on the nose are of frequent occurrence, though the clinical history of such events are usually lacking. Malignant growths are said to spring from the edge of old ulcers, and there is said to be good evidence of this in the stomach. In the nose such a sequence has not been noted. The discussion in regard to the transformation of a benign into a malignant growth has received some contribution from rhinological literature, but here as elsewhere the 1 Archiv f. klin Chirurgie, 1880, Band xxv, p. 421, MALIGNANT NASAL NEOPLASMS 257 evidence of its actual occurrence is lacking or so insecure as not to be able to withstand critical analysis. Here as elsewhere it seems safe to say that such a phenomenon must be very rare indeed, if it ever occurs. As remarked, the maUgnant nasal tumor is usually a sarcoma. All forms are noted. In our experience the most common form is the lymphosarcoma. The clinical history frequently suggests that such a growth has resulted from the transformation of an ordinary edematous nasal polypus. The gross appearance is not always suggestive. At the first removal microscopical examination is not made. Prompt recurrence and the altered appearance arousing suspicion, the growth is examined and found to be malignant in structure. It naturally happens that this Fig. 188 Lymphosarcoma of nasal cavities. course of events seems so conclusive to the clinical observer that the case is reported as one of transformation of a benign polyp into a sarcoma. Needless to say this sort of evidence does not carry convic- tion to the student of oncology. The structure may be so clearly indicative that the neoplasm is made up of the wandering cells of the body fluids, i. e., of small round lymphoid cells, as shown in Fig. 188, that one sees at once its affiliation with the leukemic hyperplasias of lymph glands. Such an appearance in a nasal growth portends a rapidly fatal course. Other cases present an appearance in which, mingled with the engorgement and dilatation of the lymph spaces, there is marked spindle-cell proliferation of the stroma. It may be laid down, as a general rule, to which there are occasional exceptions, that according as the 17 258 NASAL NEOPLASMS first form of atypical cell hyperplasia preponderates over the other, one may expect a rapid termination. Differentiation. — The affiliation of the purely lymphoid form of sarcoma with the malignant granulomata emphasizes the difficulty encountered in distinguishing the malignant neoplasm from the infectious granulomata, such as syphilis, tuberculosis, rhinoscleroma. Under other headings further remarks on the differential diagnosis will be found. Suffice it to say that while often the cell forms, as seen under high magnification, depart so widely from the lymphoid cells of inflammation that little difficulty is met with by the histologist in distinguishing one from the other, it will not infrequently happen that he must allow the symptoms and the clinical course of the case to act as a guide to structural differentia- tion. The stroma may be seen to be so scanty and so lowly organized that this in itself is sufficient to make the diagnosis. The vascularity of these growths, as seen under the microscope, does not seem to be great enough to account for the frequency and the copiousness of the hemorrhage, often spontaneous, noted in the clinical history. This is always a sus- picious circumstance in the latter alone, but when combined with the histological observation that the capillaries are small and not specially abundant added support is present for the diagnosis of malignancy. When the growth presents the appearance shown in Fig. 188 there can be no doubt as to the diagnosis, but often this characteristic structure is lacking. The islands coalesce into an unbroken continuity of granu- lomatous structure, and one has to eliminate syphilis and tuberculosis in an histological study as well as in a clinical diagnosis. Again, the round- cell proliferation may be seen to be that of cells markedly larger than that of normal leukocytes, and yet they do not present the cytoplasmic phenomena of plasma cells or other lymphocytes. Spindle-cell Sarcoma. — Recurring to the remark already made that the lymphoid cells may lie in a spindle-cell matrix, we find a natural transition to that form of malignant connective-tissue growth which borrows its designation from the preponderance of this characteristic. Differentiation. — It has its own difficulties of differentiation. They are, for the most part, those inherent in distinguishing it from angeioma and fibroma. Aside from the neoplasms of the septum, where one meets with this embarrassment, as I have said, a nasal fibroma, pure and simple, is a rare thing. On the septum nasi one occasionally meets with a fibrous growth of considerable vascularity, which shows so much spindle-cell hyperplasia that it is impossible to distinguish it by histological study alone from the so-called bleeding polypi. Again, the clinical course of the affection must act as a guide. In spite of much round-cell infiltration, in spite of the clinical history of much bleeding, in spite of the fact that the histological appearances are identical with that of malignant tumor elsewhere, these growths, unless of considerable proportions after a very short history, are apt to prove of a benign nature, if one is to be guided in such an opinion by the fact that after superficial removal they do not tend to recur or recur only slowly. Such a tumor of doubtful potentiality is shown in Fig. 184, MALIGNANT NASAL NEOPLASMS 259 We omit from our category those growths often designated as endothelial and usually ranged among the sarcomata, in view of the fact that the utmost confusion reigns in general histology as to the justification of setting them apart from the older classifications of the sarcomata. The assertion that the endothelium of the lymph spaces or of the nascent bloodvessels gives rise to these growths is difficult to prove or to dis- prove. It must suffice to say here that such growths of uncertain histo- genesis are seen in the nose as elsewhere. Giant-cell sarcoma are occasion- ally seen in the nose, though rarely. It seems likely they spring from the periosteal layers. Here as elsewhere they present the appearance of a fibrosarcoma, the mixed type referred to above in which at fairly regular distances may be seen, on microscopical section, very large protoplasmic masses without definite cell membrane, in whose centres a number of deeply staining nuclei, three to twelve or more in number, are imbedded. While some have gone so far as to say that these growths do not belong among the true tumors it is difficult to appreciate the reasons for the opinion, or otherwise, to classify them. They are not very malignant, and they form the basis of some reports in literature of triumphant surgery and radium and x-ray therapy. Osteosarcoma. — Among the slowly growing fibrosarcomata it not in- frequently happens that many foci of lowly organized bone formation are noted. This may go to such an extent that the loose cancellous struct- ure makes up the bulk of the tumor. The same link of affiliation is observed here as elsewhere between the benign cancellous osteoma and the malignant osteosarcoma. The type of connective-tissue cell which makes up the soft tissues acts as the distinctive element by which differentiation is to be made. Their clinical manifestations also again must enter into a consideration of the differential diagnosis. Osteochondrosarcoma. — ^It is doubtful if we are justified in making any line of distinction between a chondrosarcoma, an osteosarcoma, and an osteochondrosarcoma of the nose. They occur as rare growths, not, as a rule, forming metastases, but dangerous, owing to the fact that they infiltrate and absorb the bony structure of the ethmoid and its contiguous regions, rendering complete extirpation impracticable. Histologically areas of hyaline cartilage cells and of lowly organized bone structure are seen in a matrix of the usual structure of a fibro- or spindle-cell sarcoma. Either the bone or the cartilage may be lacking throughout much of the tumor, especially the areas of cartilage cells. Areas of myxomatous degeneration are seen in these sarcomata, and the extent of this may vary. It may be well to remark here that myxoma in an histological sense does not occur in the nose except in these rare complex tumors. This is a term which was formerly applied to the ordinary edematous polyp, but of late years these have been recognized as of the nature set forth in this work. In myxoma, branching embryonic connective-tissue cells are seen lying in a homogeneous matrix of gela- tinous material which takes the basic stains deeply in sections. The delicate processes running through it can be traced to the branching 260 NASAL NEOPLASMS cells, and are not to be mistaken for the fibrils of coagulated fibrin seen in a,n ordinary polyp. Epithelial Tumors. — Adenocarcinoma. — As in benign adenoma, this tumor is chiefly found springing from the ethmoid region of the mucosa and present in these sinuses primarily or invading them secondarily. By the time the diagnosis is made the growth has usually advanced too far for one to be able to form any opinion as to its exact point of origin. In dealing with the benign adenomata the affiliation of the true tumor with tissue hyperplasia was set forth and reference was made to the difficulty of knowing, from the structure alone, its clinical potentialities. That a pure adenoma of pronounced character and benign course in the nasal chambers is a rare phenomenon, we think will be admitted by all ob- servers who are acquainted with the clinical as well as the histological side of nasal pathology. It has so often happened that the histological diagnosis has been disqualified by the subsequent clinical course of the disease that support has been afForded to the claim that a benign neo- plasm has become malignant or, on the other hand, that the microscope is not a reliable agent of diagnosis. No other form of tumor of the nose and throat so often furnishes force to both the one and the other of these claims. In a general way the malignant adenoma presents a solid mass of epithelium to view in the sections. The tubules and convolutions, representing the ducts and acini in atypical fashion, are less in evidence than in the benign adenoma. In the latter one or two rows of columnar epithelium of the glandular variety, but more or less atypical, skirt the canals formed by longitudinal section or encircle the lumina traversed by transverse section. Connective tissue joins this formation with neighboring structures of the same description. It is the extent of this connective tissue and the degree to which it is infiltrated by epithelial cells derived from the atypical structures referred to which tells for malignancy. The atypical state of the infiltrating epithelium will have something to do also with the question of malignancy. While mitotic figures are abundant in the benign form as in the malignant, while hyaline degeneration of the cell granules is seen as often in one as in the other, the epithelial cells of the malignant growth are more compact, perhaps due to the greater pressure of growth and depart more from the glandular type of cell. The epithelial whorls of cancroid are absent. In the nose it is practically impossible, on account of the bony labyrinth, to remove contiguous tissue and judge of the infiltrating potentialities of growth, so that the microscopical diagnosis of adenocarcinoma rests largely on the few differential points above detailed. Needless to say, these are for the most part insufficient by themselves in many instances to determine the question of malignancy at a stage when radical operation holds out hopes of success. Often only when too late both the clinical and the microscopical indications point to malignancy. In removing pieces for microscopical examination one can never argue from the idea that the portions obtained represent the whole growth. Benign characters may preponderate or there may be an entire absence MALIGNANT NASAL NEOPLASMS 261 of any appreciable malignant landmark, yet in this sort of growth espe- cially one can never be sure until it is all out and under the glass that it all shows benign characters. Here, as so often with other evidence of the kind, a negative report does not form a satisfactory negation of malig- nancy. All grades in the latter are noted clinically. Repeated recurrences in situ after intranasal operative procedures may cause the case to drag on for years. Final recovery in such cases always raises the question of mistaken diagnosis, but it has been repeatedly noted, on the other hand, that the whole course of the disease may be run in less than eighteen months and the disease prove rapidly fatal after the most extensive operation. Metastatic involvement of the glands is, as a rule, made out only in the later stages of the disease. I have dwelt thus at length on the histological diagnosis of adenocar- cinoma because it is by far the most common form of malignant nasal epithelial tumor. Columnar-celled Epithelioma. — ^While the above is true enough as to the relative frequency of adenocarcinoma of the nose when compared to other malignant epithelial neoplasms, primary epithelioma of the nasal chambers is absent from the experience of many practitioners who have been observers of nasal disease for years. We have seen in our own practice and in that of others not to exceed a half-dozen cases. Unlike adenoma and adenocarcinoma, but resembling in this respect the benign epithelial hyperplasias, the columnar-cell- epithelioma starts from the mucosa covering the inferior turbinate, the lower border of the middle turbinate or the septum, oftener than it does from the ethmoid labyrinth or the sinuses. In at least half the cases we have seen it has been recognized at a comparatively early stage as a discrete tumor without the preponderating surface proliferation which characterizes the papillary adenomata. Its infiltration of the submucosa, however, goes far beyond surface indications. Its finer structure differs not at all from that seen elsewhere. The microscopical differential diagnosisfrom a simple papilloma or any other form of growth presents no special difficulty even at an early stage, and renders extensive description here superfluous. While in two instances the course of the disease was slow, and the patient passed from our observation in fairly good condition, it is in other cases rapidly fatal, and metastases are noted comparatively early in the deep cervical glands. The rarer forms of growths which have been reported as occurring in the nose are two cases of glioma^ of congenital origin, a case of rhab- domyoma^ and one of cylindroma.^ Accounts of these can best be studied in the reports of the observers. The same may be said of the attempt to identify among nasal malignant neoplasms the variety of carcinoma known as the basal-cell epithelioma^ of Krompecher, though some reference to this form of epithelial growth will be made in this work under the heading of Laryngeal Tumors. ■ Clark, American Journal of the Medical Sciences, 1905, cxxix, p. 769. 2 Vail, The Laryngoscope, December, 1908. » V. Dembowski, Deutsche Zeitschrift f. Chirurgie, 1891, No. 32. * Donogany and Lenart, Frankel's Arohiv f. Laryngologie, 1904, No. 15, p. 586. 262 NASAL NEOPLASMS Teratoma. — ^There are a certain number of tumors seen springing from the posterior portions of the nose and upper parts of the nasopharynx which probably have their origin from some of the vestigial tissues of embryonic life. That these may become malignant in their manifesta- tion is probably true. They contain various tissue constituents, such as fat, large areas of smooth muscle cells, epithelial structures resembling hair follicles, besides the elements which may have been derived from their point of origin which makes them hard to classify except as teratoid growths.! They may present many features of malignant epithelial or connective-tissue growths, so that they are reported as epithelioma, endothelioma, myxosarcoma, etc., but they are usually encapsulated and benign. Symptoms of Malignant Nasal Tumors. — Sarcoma. — The most frequent type of sarcoma in the nose and nasopharynx is the lymphosarcoma. It is frequently spoken of as being a rare tumor, but the experience of those associated with large clinics teaches that they are by no means infrequent. Their origin is ordinarily within some of the adjacent cavities of the nose, and ultimately they protrude into the nasal passage. They are rapid in growth. They may extend through the septum and involve the opposite side as well. The antrum is the most frequently invaded of the sinuses, with the ethmoid, - sphenoid, and frontal following in about this relative order of sequence. In the early stages little or no disturbance is experienced by the patient other than the one-sided stoppage of the nose associated with unilateral discharge. Epistaxis is likely to be the first evidence to the patient that there is some condition existing worthy of medical attention, and for this he usually consults a physician. On looking into the nasal fossa one will observe a soft, pulpy, bluish-white mass in one nostril, which may or may not be observable by postnasal examination. Probing easily causes bleeding, which it is often difficult to control. If the tumor is in the antrum its extension is toward the nose and also downward through the alveoli. This tendency will loosen one or more teeth or possibly will occasion pain in the teeth, which the patient through ignorance will often have extracted. In due course of time the cheek bulges on the side affected and the eye may be pushed upward and outward. Spontaneous hemorrhage occurs at intervals, but it is by no means as frequent nor as severe as that found in cases of angiofibroma. Sarcoma in its early stages is often mistaken for an edematous polypus, and in cases where considerable hemorrhage is attendant upon the removal of the growth resembling a polypus suspicion should be directed to the possibility of sarcoma, and if recurrence takes place shortly after the operative pro- cedure microscopical examination should be made to determine the exact character of the growth. Very often these polypoid degenerative pro- cesses and even polypi may proceed from a sarcomatous base, and exami- nation of the periphery will not reveal the true character of the underlying organism. ' Coffin, Annals of Otology, Rhinology, and Laryngology, December, 1909; Serapin, ref. Semon's Centralblatt f. Laryngologie und Rhinologie, 1904, No. 20, p. 339. MALIGNANT NASAL NEOPLASMS 263 In the majority of cases, by the time the growth has become visible within the nasal cavity it has extended so far that operative procedures are ordinarily unsuccessful. This of course does not obtain in those cases where the growth is in the antrum or on the external wall and the superior maxilla may be removed entirely. Price-Brown has reported a number of cases of sarcoma, of varying kinds, successfully treated by the galvano- cautery, in which recurrence has not taken place in a period of over twelve years.i Criticism of course may always be advanced, as the possibility of error in diagnosis is very great. However, Price-Brown has continued to employ the galvanocautery in the treatment of these cases, and has reported many successful results. In inoperable cases the injection of Coley's serum will in rare instances be followed by a cure. In the majority of instances, however, it is not only ineffective, but the constitutional disturbances incident to its injection are almost unbearable. In one of our cases of sarcoma involving both ethmoidal tracts this serum was employed under the direction of Coley, and for a while it appeared to retard the progress of the growth. It unquestionably created some change within the structure of the tumor, so that when a radical operation was of necessity performed for the relief of pain, there was comparatively little hemorrhage, in fact very much less than that which had followed the removal of a section for microscopical examination. Epithelioma. — ^It occurs in the majority of instances near the nasal floor or in the antrum. With the exception of spontaneous hemorrhage, which is less frequent, the symptoms vary but slightly from that of sarcoma. Pain from any malignant growth is due to one of two causes, either pressure within the closed bony cavity or periostitis. The only treatment that can be relied upon is surgical. Radium has been ad- vocated for the cure of epithelioma, and in one instance coming under our observation, a case of columnar-cell epithelioma of the antrum projecting into the nasal cavity, progress of the disease was arrested for a period of three years by the application of radium. After an interval of one year's time, however, without the application of radium the growth has increased materially in size, but has made no apparent inroads upon the constitutional condition of the patient. As many of these tumors are slow growing it is difiicult to conclude what part, if any, the radium played in restricting its progress. While dry, superficial epitheliomas have unquestionably been eradicated by the application of radium, those of a deep-seated character or occurring upon the moist surfaces, such as the mucous membranes, have been but little affected by its application. So far as the differentiation of malignant nasal growth from benign ones and of the different forms of malignancy from one another has not been brought out in what has already been said, the symptoma- tology of malignant nasal disease can best be considered as a, whole, since the detail of it as exhibited in all the different histological varieties would involve much repetition. 1 Transactions of American Laryngological Association, 1912. 264 NASAL NEOPLASMS Nasal obstruction and epistaxis are each in varying degrees fairly- constant symptoms of malignant nasal disease. Given a tumor occluding the nares, and frequently repeated spontaneous hemorrhage involving the loss of an appreciable amount of blood, the chances are decidedly in favor of the growth being of a malignant character. It is true certain vascular tumors of the septum of a benign nature, which we have already discussed, cannot be excluded. These do not reach a large size, and usually do not bleed spontaneously unless they are malignant. All malignant tumors do not bleed. Even all malignant connective-tissue tumors do not bleed to excess, but the angio- and lymphosarcomata, the most frequent of malignant nasal growths, are thus characterized at a very early period of their growth, while the later stages of all kinds of malignant nasal tumors are pretty sure to exhibit a marked tendency to free spontaneous hemorrhage. With the exception of the benign tumors of the septum just alluded ^.. and the rare cases of extensive papillomata involving the septum, nasal neoplasms which are not essentially malignant do not show marked tendencies to spontaneous hemorrhage. Fungous, red surfaces exhibited by a nasal growth are to be looked on as exceptional in simple edematous polypi. Syphilitic granulomata may exhibit them, but the benign nasal polyp is apt to be translucent. It is apt to be edematous even if it is a true tumor. Frequently edematous polypi cover a growth of more serious import behind them. The proportions and the progress of the growth are of great significance. The infiltrating malignant tumor is not at all halted by the pressure of parts. It infil- trates and incorporates them in the process, not only by infiltration but by displacement as well; the contour of the nose is altered as soon as the tumor has grown to a size to fill the nasal chambers and the accessory cavi- ties. Pain is not frequently a very marked symptom, and may be absent altogether, though when well advanced, neuralgic pain is apt to be experi- enced. Finder claims that of the sarcomata 50 per cent, occur in the region of the ethmoid. As we have noted, a larger proportion than this of the adenocarcinomata occur in the upper regions of the nose. The antrum of Highmore gives origin to a certain proportion of the cases. Many of the so-called sarcomata of the septum do not run a malignant course. Grow- ing, therefore, as the larger number of malignant growths do in the upper regions of the nose, eye symptoms are a frequent accompaniment of such growths. With a probe one ascertains the fact that the suspected growth is broad based and its extent is indefinite. It blee'ds easily when touched. Postnasal examination will reveal its extent in that direction. The widening of the nasal arch, the protrusion of the eyeballs, in other words, the typical "frog face," will indicate its extent upward. Its involvement of branches of the anterior cranial nerves, causing anosmia, blindness, neuralgia, and paralysis of the ocular muscles, indicate its widespread infiltration. Striking as is. this clinical picture of a nasal malignant growth in its later development, it is desirable to recognize it by a study of its earlier stages, for in the later ones cachexia, glandular involvement, and metastases have probably supervened. Involving the posterior ethmoidal cells and the sphenoidal sinus the optic nerve may be involved, MALIGNANT NASAL NEOPLASMS 265 causing disturbances of vision and marked changes in the fundus. These eye changes are often detected at an early stage by the careful measure- ment of the limitation of the field of vision. By pressure upon the os planum or by its growth back of the eye the tumor may cause its marked protrusion and its outward displacement, muscular anomalies being perhaps first noted by the patient himself, with pain referred to the back part of the eye. All these symptoms supervene very quickly in cases of lymphosarcoma, but in adenocarcinoma and in epithelioma the course is not so rapid. The epithelioma, a rare form of nasal malignancy, has been seen by us as a moderate-sized swelling diffused and ulcerated on the border of the inferior tixrbinate and plainly infiltrating the tissues. In one case it had not gone to a surface proliferation sufficient completely to occupy the space between the turbinate' bone and the septum when the mucous mem- brane was under the influence of cocain and adrenalin. Sooner or later in them all, the nasal fossae and their accessory sinuses are filled with the growth and their walls widely infiltrated. Occasionally perforation of the cheek or of the nasal bones may occur before the case is terminated by penetration of the base of the cranium and death from meningeal and cerebral involvement, but in many cases this is the course of the disease whatever its structural form. Involvement of the lymph nodes in situ- ations where their presence can be appreciated is usually late. They are first felt high up near the angle of the jaw in the cervical region. This being briefiy the general and some of the exceptional features of malignant disease of the nose, it must be remembered that a definite and differential diagnosis can only be made by microscopical examination of the structure. In its early stages this is all important because not only are the other methods of differentiation at this time inconclusive, but because at this time only does there exist a possibility of successful surgical treatment, which must be very different from that for a benign growth. Duration.^The period from the beginning of recognizable symptoms to the fatal issue varies greatly, chiefly with the form of growth. The so-called sarcomata of the septum may last for years and they often do not return after more or less superficial extirpation. The adenocarcinoma, while at times running a comparatively short course, may last for many years, recurring persistently after intranasal operation, but not going on to a fatal issue for five or six years. The more malignant growths are the lympho- and angeiosarcomata. The patients afflicted with these growths rarely live more than a year and a half. Such epitheliomata as have been reported are not more malignant in the nose than elsewhere. The course of the disease may last for two or three years and we have seen one case of columnar-celled epithehoma of the middle turbinate in which after removal with a snare the growth did not return for at least a year. In another case in which the inferior turbinate and the maxillary antrum were involved the patient was alive after two years, having been treated with radium; both these cases passed from our observation at the end of these periods in good general condition. 266 NASAL NEOPLASMS Prognosis. — ^This of course is of the worst. When the ethmoid cells are involved and the structure of the growth plainly intimates its malignant nature, we believe the condition to be inoperable. Radium has been used with some reported success in the milder cases, such as giant-cell sarcoma and columnar-cell epithelioma, and where there was any reasonable hope of an extirpation of the whole growth, life has been prolonged by operation. This is specially true of the adenocarcinomata. Treatment. — ^The same treatment may be applied to both sarcoma and carcinoma, with but slight variations in accordance with the nature of the tumor. Three methods of treatment may be employed, and they vary in accordance with the location, the extent of involvement, and the condition of the patient. They may be divided into internal operative, external operative, and palliative treatment. Internal Operation. — Pedunculated sarcomata may be snared and the place of attachment curetted and cauterized with the Paquelin cautery or galvanocautery. Preparations must be previously made for the control of severe hemorrhage, and it is unwise to attempt the operation except in a hospital or where adequate means are at hand to meet this emergency. After the cauterization the nose should be packed with strips of iodoform gauze thoroughly saturated with vaselin, so that irritation and hemor- rhage may be avoided upon its removal. If the growth is upon the turbinated bodies or in the ethmoidal region within easy reach, it may be snared or removed with biting forceps piecemeal, or torn away with ethmoidal forceps and the hemorrhage controlled by packing. In every instance hemorrhage is severe, and it is the greatest problem with which the operator has to contend. The location of the attachment of the tumor should be thoroughly cauterized in every instance. Price-Brown advo- cates the removal of the growths by the galvanocautery applied at numerous sittings at varying intervals, in accordance with the reaction following the cauterization. He cites a number of cases treated in this manner wherein recurrence has not taken place for several years. Sar- comata or carcinomata appearing upon the septum can be removed by curettement followed by cautery. All of the internal operations may be painlessly performed with the use of cocain and adrenalin. External Operation. — ^Where an external operation is necessary, general anesthesia must be employed. When any of the malignant tumors involve the antrum it is necessary to approach it by the Caldwell-Luc operation, and if the tumor is found to involve the bone it is necessary to remove a large part of the walls of the antrum and frequently the whole of the superior maxilla. Where such extensive surgical procedure is necessary it will often save time, lessen the shock to the patient and prevent extreme hemorrhage by first performing a tracheotomy, after which the whole of the pharynx and nasopharynx may be packed tightly with gauze and the attention of the surgeon and his assistants directed entirely to the control of the hemorrhage during the operation. When the posterior nasal structures or the sphenoid is involved it becomes quite a question as to the best method of approach. Three operations offer feasible means of reaching the tumor when so located, and when it is unapproach- MALIGNANT NASAL NEOPLASMS 267 able by any of these three the more serious surgical procedures will be of but little avail in eradicating the growth. The operations of Rouge, Moure, and Oilier combine the most effective measures for removing tumors remotely situated in the nasal chambers. Rouge's Operation. — ^An incision is made along the gingivolabial fold from the first molar tooth of one side to the corresponding position on the other. This incision is made down to the bone. The periosteum and the soft tissues over it are then elevated until the cartilaginous border of the septum is exposed. The cartilage of the septum may then be cut away until the growth on one side or the other is freely exposed, leaving only sufficient of the cartilage attached anteriorly to the skin to uphold the tip of the nose. Fig. 189 Rouge's operation for the removal of nasal and postnasal tumors. Moure's Operation. — This procedure offers one of the best opportunities to obtain a lateral view of the tumor, and consists in an incision extending from above the inner canthus of the eye downward, following the junction of the nose with the cheek, to the ala, then a curvilinear incision around the ala into the vestibule of the nose. At the beginning of the first incision a second incision is made, following the rim of the orbit outward for two- thirds its distance. The lower flap is then depressed, together with the periosteum, downward and backward, and the upper raised until a free exposure of the nasal bone of that side is obtained. The cartilaginous part of the nose is then separated from its junction with the bony and, beginning with the opening into the nose at this point, the bony structures are removed with bone forceps sufficiently to expose the tumor in its location. It is desirable to leave a part of the nasal bone on that side and also the rim of the orbit to support the tissues after their replacement. The tumor is removed as rapidly as possible and its base cauterized. The tissues are then replaced and sutured and the drainage and packing necessary to control hemorrhage are instituted through the nasal vestibule. 268 NASAL NEOPLASMS Ollier's Operation. — The operator is enabled by this method easily to approach tumors in the anterior part of the nares, and it is particularly adaptable to those cases where the tumor has penetrated the nasal septum and involved the opposite side. An incision is made to the bone from the extremity of the nasal bone at a point where the nose is outlined against the cheek and carried upward just above the inner canthus of the eye, where it traverses the root of the nose- and extends downward on the opposite side to a point corresponding to its beginning. With a small thin nasal saw the line of incision is followed by sawing through the nasal bones and septum, following the line of cutaneous incision. The bony parts, together with the attached soft parts, can be retracted forward and downward, exposing the anterior part of the nasal chambers- After the removal of the growth and cauterization of the attachment the tissues are replaced and sutured and drainage and packing instituted through the nose. Fig. 190 Ollier's operation for the removal of nasal and postnasal tumors. Palliative Treatment. — ^There have been certain measures employed for the retardation and sometimes even eradication of malignant tumors in which operative procedures have been inadvisable. Dawbarn has advocated the hgation of the external carotid arteries of both sides and the complete occlusion of the bloodvessels supplying the structures of the pharynx and nose by the injection of paraffin. This starvation process has in some instances retarded the advance of malignant growths of the nose, but there has in most istnances been sufficient nutrition derived from other sources or the restitution of circulation through anastomoses to furnish ample nourishment to the tumor to preserve its life and to promote its progress within a few weeks after the operation. Unquestion- ably the ligation of the external carotids previous to an operation on these tumors lessens hemorrhage at the time of the procedure, but in the authors' experience permanently good results have not been obtained. Goley's toxins of the erysipelas streptococcus and the bacillus prodigiosus has in the hands of Coley been of material benefit in retarding the progress of the growth, and has in some instances apparently brought about a cure. In one case of sarcoma in our own experience, springing MALIGNANT NASAL NEOPLASMS 269 from the ethmoidal region and extending through the septum and involv- ing the ethmoidal region of the opposite side, the growth was materially cheeked in its progress for a while by the employment of this treat- ment, and this induced the hope that another favorable case would be added to Coley's series. This hope was soon dispelled. The initial dose ordinarily begins with yV minim, which, if effective, will occasion a rise in temperature to 103° or 104°, associated with head- ache, intense pain in the limbs, and considerable depression. One day should elapse, when a second dose is given of the same quantity, which, if not followed by the same constitutional disturbances, is increased to J- minim at the third dose on the day following. An increase of ^ to J minim is given at each succeeding dose at intervals of one or two days until the same constitutional disturbances are obtained. If at about the end of three weeks there is no material change for the better in the general appearance of the growth,Ht is wise to discontinue its use. In this case there was almost daily spontaneous hemorrhage previous to the beginning of the use of Coley's serum, but after the first injection there was no further hemorrhage except upon instrumentation. In considera- tion of the cases of inoperable sarcoma which have been benefited by the employment of Coley's serum, it seems advisable to use it in all cases which are inoperable. Radium. — ^Beneficial results were first expected of radium, but even in the hands of the most ardent advocates it has proved of little or no avail in the cure of malignant tumors of the nose. The a;-ray has no effect whatever upon malignant diseases of the nose except superficial skin epithelioma externally. Pain. — This may be modified by insuflSations of orthoform or iodoform. It is sometimes necessary to cocainize the projecting part of the tumor, which will give temporary relief from the pain of ulceration. Hypodermic injections of morphin or some form of opium administered internally is the only means of overcoming pressure pain. Hemorrhage. — ^This may be treated by packing with adrenalin or iodo- form gauze well vasehned. It may sometimes be controlled by dusting a few granules of thrombokinase on the bleeding point. Pledgets of ' cotton soaked in peroxid of hydrogen and packed into the nasal cavity are also of benefit. Odor. — Irrigations with a 20 per cent, solution of permanganate of potash, 50 per cent, solution of peroxid of hydrogen, or douching with any of the antiseptic solutions will tend greatly to reduce the disagree- able odor. Pharyngeal Occlusion.— It often happens that the tumor will project into the nasopharynx and extend down toward the larynx,^ interfering with deglutition and respiration. If the tip becomes necrotic it can be broken off with the finger or snared off sufficiently to give some tempo- rary ventilation, and this is not attended with any serious consequences other than bleeding. This procedure is strongly advocated by Lambert Lack. CHAPTER X. THE ANATOMY, EMBRYOLOGY, AND HISTOLOGY OF THE PHARYNX. TOPOGRAPHICAL ANATOMY OF THE PHARYNX AND ITS STRUCTURES. The pharynx, as a whole, is a conical tube, like a funnel, which is the upper extension of the gastro-intestinal tract, and extends from the base of the skull to the level of the cricoid cartilage, thus existing not only as a cavity which communicates directly in its upper portion with the nose and in its middle portion with the mouth, but in its lower portion it lies behind the larynx as a flattened membranous tube. It is therefore roughly divided into the nasopharynx, the oropharynx, and the laryngeal pharynx. Into the description of its muscular and fibrous coats we will not enter, while the description of the more minute structure of the mucous membrane which lines it we will treat elsewhere. From the basilar process to the cricoid cartilage it occupies a space of four and a half inches. Its lateral diameter is greater than its anterior posterior, the greatest breadth existing at the level of the greater cornu of the hyoid bone, and its most constricted part being its communication with the esophagus. In the nasopharynx one descries in the postpharyngeal mirror the images of the choanse, in whose lumina the posterior ends of the three or four turbinated bones present themselves. The superior region of the nose occasionally even shows the existence of five scroll bones, but in the vast majority of the cases only three on each side can be made out. The observer must realize that posteriorly the inferior turbinate bone is not infrequently hidden by the veil of the soft palate, and that the two scroll bodies he sees are the middle and the superior turbinates. The oval openings of the choanse seen on each side of the septum in their vertical or long diameter measure about an inch, and in their trans- verse diameter below about half an inch each in the adult. Between the posterior border of the septum formed by the vertical edge of the vomer it varies much in the total thickness of bone and of the soft parts which cover it. The latter near the upper part on each side are thickened chiefly by the existence of a small amount of erectile tissue, more abundant in the bovine race than in man, capable of expansion and contraction through the action of the venous sinuses which it contains, and thus varying in its prominence from time to time in the same indi- vidual. While in certain individuals there may- rarely be noticed some deviation of the posterior border of the nasal septum from the median TOPOGRAPHICAL ANATOMY OF PHARYNX 271 line, the structures thus far mentioned are symmetrical, and extending from them in the form of a half-arch or demivault above are the walls of the pharynx proper. Above the mucous membrane presents its thicken- ing made up of lymphoid tissue and forming the pharyngeal tonsil, a structure with its bursa or median recess, to be described later. Spreading out and downward from the vault are the lateral and the broad posterior walls of the nasopharynx. On the lateral walls behind the choanee are the openings of the Eustachian tubes formed by cushions of fibrocartilage and mucous membrane, bounding a vertical slit or an oval or round opening. The periphery of the tubal projections is skirted by a shallow recess known as the fossa of Rosenmiiller, most accentuated behind and below them, representing the second branchial cleft of embryonic life. There is a fold of mucous membrane of the muscle connecting the two structures known as the salpingopalatal fold between the tube and the nasal fossa, while another fold, more posteriorly and lower down, known as the salpingopharyngeal, contains also muscle fibers. In the adult the lateral measurement between the Eustachian eminences on each side represents the transverse diameter of the pharynx. It is about an inch to an inch and a half. The lower border of the nasopharynx is reckoned as a plane extending from the articulation of the vomer with the posterior border of the palatal bones to the prominence of the axis vertebrae, and is partly filled in by the tendinomuscular veil of the soft palate and root of the uvula, showing a raphe in the median line of their nasopharyngeal surface. The oropharynx with this plane and the movable roof of the soft palate for its upper limit extends to the larynx at the level of the hyoid bone. The isthmus of the fauces is its communication with the mouth,and its lateral walls are formed by the anterior and posterior pillars, which hold between them whatever of tonsillar structure may be present in the fauces proper. This consists of a slight elevation of tissue dotted with the openings of seven to ten crypts, but, as we shall see, its volume varies widely even in conditions we may regard as normal. Into the oropharynx from its attachment to the thyroid cartilage juts the leaf-like process of the epiglottis, assuming the shape of a Phrygian cap through its covering by the soft parts. In front of it are seen the structures at the base of the tongue, the valeculse, the lingual tonsil, and the circumvallate papillae and glosso-epiglottic folds. Lower down begins the laryngeal pharynx, showing in the mirror only as a transverse fold behind the triangular opening of the larynx, bounded on each side by the aryteno-epiglottic folds, which limit the pyriform sinuses on each side. Its lower border behind the cricoid cartilage is at a level of the intervertebral disk between the fifth and sixth cervical vertebras. In the buccal cavity the laryngologist has frequently to note the condition of the teeth, the shape of the palatal arch above, which varies so widely between the sharp ogival peak and the low, flat vault of the wide-jawed individual, and he has often to seek out the openings of the ducts of the salivary glands, those from the sublingual on each side of the frenum linguae anteriorly and others from the submaxillary joining Wharton's duct, which opens there in a small papilla or elevation, while 272 ANATOMY, EMBBYOLOOY, AND HISTOLOGY OF PHARYNX Stenson's duct from the parotid opens on the inner surface of the cheek opposite the upper second molar tooth. There are marked developmental changes which take place in all these structures. The palatal vault of infancy — low and flat — changes to the high arch of adult life. The alveolar processes deepen to hold the teeth, and the general bony architecture gradually takes on the highly differ- entiated form bequeathed to the individual by his ancestry, a matter discussed in its bearings on certain etiological problems in disease of the nose and throat in other chapters. The lymphoid material of the pharynx undergoes certain hypertrophic changes accompained by regression, with a regularity which seems so universal as to be physiological rather than pathological. Indeed, the changes from infancy to old age induced by the environment are so inextricably related to those due to physiological and hereditary causes as usually to be indistinguishable. These, whether we are to regard them as physiologial or pathological, just as they bring about in the nasal mucosa a certain degree of atrophy in the pharynx, lead to the same result. In the nose it is largely the bony, vascular, and the glandular constituents of the mucosa which shrink; in the pharynx it is the lymphoid elements. EMBRYOLOGY OF THE PHARYNX.^ The pharynx belongs, not only from many of the clinical phenomena there exhibited and from its being in anatomical continuity with the gastro-intestinal tract, but from its embryological development, to the digestive tube, which extends from the base of the skull to the anus. The cranial end of the foregut in the third week of embryonal life is flattened out anteroposteriorly. It represents the pharyngeal cavity and part of the oral cavity. The side walls soon become furrowed and form the branchial furrows or pharyngeal pouches. In the beginning this part of the foregut is a tube with a blind end which lies between the oral opening of the amnion and the heart cavities in front and the chorda dorsalis and cerebral vesicles behind. These structures, developed from the ectoderm, are thus separated from one another by the intrusion of the digestive tube formed from and lined by the cells of the entoderm. The line where the two kinds of cell derivatives meet in extra-uterine life is at the anterior pillars and the edge of the soft palate. Five pharyngeal furrows or pouches separated by ridges or arches are formed on each side of the foregut early in embryonal life. These pharyngeal or branchial arches are sometimes called the mandibular, the hyoid and the thyroid for the first, second, and third. The fourth and fifth have no distinctive names. They are pushed outward in the growth of the mesenchyme until they reach the inner surface of the epidermal layer. In the lower verte- brates they perforate it and form the branchial clefts, but normally in mammals they dilate into pouches which do not communicate externally ' Authorities: Stohr, Retterer, KoUiker, Bonnet, Keibel, Schwabach, Ganghofner, Disse, Broman. EMBRYOLOGY OF THE PHARYNX 273 with the surface. From the arches separating the pouches and from the furrows themselves various structures are formed. At the level of the upper two pouches the pharynx rapidly grows broader. The others do not continue to grow. The first pouch takes part in the formation of the tympanic cavity of the middle ear. The faucial pillars arise in the arches which separate this from the second pouch. This expands into the pharynx, and in the dorsal corners there are formed from it the tonsillar sinuses which give rise to the faucial tonsils through the development of a protrusion, the tuberculum tonsillare. This becomes flattened and is bounded by a fold which represents the plica tonsillaris. The retro- tonsillar plica is of later formation. The supratonsillar fossa is formed out of the upper recess of the tonsillar sinus. Fig. 191 Embryogeny of the pharynx: Rabbit embryo, 6 mm. long. (After Mikulicz.) A, cerebral vesicle; B, amnion; C, oral opening; D, pharyngeal membrane; E, cardiac cavi- ties; F, rudimentary pharynx; G, chorda dorsalis. The crypts of the faucial tonsil are formed from the epithelium of the plica triangularis. Out of it epithelial branches form, solid at first, which burrow down into the mesenchyme. These solid epithelial processes become hollow by the degeneration of the central cells. Around the depressions thus formed appear the lymphoid cells, which press into the epithelial tissue itself. This epithelial formation takes place at a considerably earlier stage than the round-cell infiltration. The former occurs when the fetus is 70 mm., the latter when it is 110 mm. long. The lymphocytes appear when the embryo reaches 140 mm. The lymph nodes are not distinguishable until at a still later stage-^235 mm. — not until after birth, according to some recent observations. By this time the tonsils have received their essential characters. The origin of the lymphocytes and of the polynuclears was supposed by Stohr to be from the blood-stream, but later Hammar insisted they are derived from the fixed connective-tissue cells of the mesenchyme. To this view perhaps the majority of histologists are inclined. Retterer, however, has insisted for thirty years that not only the lymphoid cells but some of the fixed 18 274 ANATOMY, EMBRYOLOGY, AND HISTOLOGY OF PHARYNX connective-tissue cells of the mesenchyme are derived from the basal layers of the epithelium. His idea is that the epithelial ingrowths of cells become separated from their fellows and form the collection of lymphoid cells which make up the parenchyma of lymphoid organs. It has been suggested, as a sort of compromise between the views of Retterer and those of Stohr, that the presence of the ingrowing epithe- lium in embryonic development, acting as a foreign body, attracts the lymphocytes to their neighborhood in the stroma. These lymphocytes become the 'lymphoblasts from which the leukocytes of the lymph nodes are formed. The fact that the lymphoid cells appear at a much later date in embryonic life than the epithelium, and that they are first seen around the bloodvessels, according to Disse, would seem to militate against this view of Retterer. As to embryonic and normal material we are unable to furnish any opinion drawn from personal experience, but in the personal observation of pathological processes we have taken the view of Retterer. We infer from general experience that the patho- logical processes of inflammation revert to embryonic and physiological lines in their organized products. We have therefore considerable sympathy with this view of Retterer as to lymphoid embryogeny, sup- ported in laryngology as he is by Cordes and by Wood. While the leukocytes appear in the mesenchyme tissue at a date later than the formation of the epithelial branchings, preceding crypt formation, -the secondary deposits, the nodules or closed follicles are visible only at a still later period. KoUiker says : " In the fourth month the faucial tonsils appear as simple clefts or cleft-like dilatations of the mucous membrane of each side which lie in a line with the openings of the Eustachian tubes or a little behind them. In the fifth month each tonsil is a flat pouch with cleft-like openings and some small accessory pits whose medial wall appears almost like a valve. The lateral walls and floor of the pouch are already considerably thickened, and the microscopical examination shows that here in the connective tissue of the mucosa there has taken place a thick deposit of cellular elements which at this time are continuous and not grouped in follicles. Even in the sixth month one sees nothing characteristic of follicles, but they are perfectly plain at term and in the newborn." The manner in which the crypts are formed in the embryo, that is, by the degeneration and cornification of the central cells of the solid epithelial processes, a condition sometimes recognizable in the living infant at birth has a direct significance in the pathological changes noted in extra-uterine life. In certain activities of the tonsil, as we shall see, there is a resumption of this embryonic or physiological process. Keratosis of the tonsil must be regarded in this light as conforming to a general law of pathology, which presents many other exemphfications of it. Broman thus describes the development of the pharyngeal tonsil: " In the sixth embryonal month the posterior three-fourths of the pharyn- geal roof is diffusely infiltrated with leukocytes. This infiltration extends itself then to the upper parts of the posterior and lateral walls of the nasopharynx. Just before or just after birth, follicles are formed in the infiltrated parts and even in the neighborhood of the ducts of the mucous EMBRYOLOGY OF THE PHARYNX 275 glands which exist here. In the first years of infancy this pharyngeal wall part grows markedly and forms a usually prominent pharyngeal tonsil. After puberty this gradually retrogresses and, as a rule, is not plainly discernible in adults." Occasionally the faucial tonsils are want- ing or rudimentary. Sometimes the tonsillar sinus is prolonged into a diverticulum. Sometimes the tonsil is entirely or partly displaced on to the posterior pharyngeal pillar or imbedded in it — rarely is it pendulous. According to Stohr the lingual tonsil appears at the eighth fetal month, leukocytes gathering around the ducts of mucous glands, being derived from the veins and penetrating the reticular connective tissue, and they proliferate there by mitotic division. He leaves it uncertain as to when the secondary nodes appear — later than the fifth year of the child. Even in the eighth, month of fetal life he observed the leukocytes traversing the epithelium.! They continue to do so throughout infancy and adult life wherever there are closed follicles and germinal centres. It is said that the lymphoid tissue continues to increase in amount up to twelve or sixteen years of age. While this may be so absolutely it is probable that growth of lymphoid material in the child's pharynx begins to fall behind the general development after four or five years of age, so that relatively to the size of the pharynx at six or seven years of age a diminution is apparent. To resume the description of the gross development of pharyngeal structure, only the first two pharyngeal arches unite in front. The pharyngeal wall thus formed in front surrounds the oral cavity roofed over by the wall of the cerebral vesicles above. The olfactory pits from the ectoderm in front deepen from before backward until they reach the situation of the choanse at the nasopharynx. When this is perforated we have the meeting of the ectoderm and the entoderm, as in the formation of the oral cavity and oropharynx. As has just been said, the oral cavity by this time is beginning to be walled in by the maxillary process derived from the first pharyngeal arch, thus continuous embryologically with the structures of the nasopharynx. The oral cavity is further walled in anteriorly by the globular process of the wall of the olfactory pit, which becomes the intermaxillary process. The second pharyngeal arches approximate the median line and the furrows between them form the back part of the tongue, while the lingual surface in front of the cir- cumvallate papillae is formed by a prominence arising between the anterior ends of the first pharyngeal arch. At the meeting of the second and third arches with their opposites in the median line the root of the tongue is formed. The floor of the mouth is formed by the ventral wall of the foregut bounded laterally by the fourth pharyngeal arch. It gives rise to the tongue — the anterior part of it. The middle lobe of the thyroid is at first represented at this meeting of the second and third arches. The epiglottis is formed from the tissue at the meeting of the 1 Recently it has been denied that this takes place until after birth and inferentially we should conclude it is a pathological process, the result of toxin action and not a physio- logical action.. Anna Goslar, Beitrage zur pathologisohen Anatomie, etc., 1913, Band Iv, Heft 2,[p. 405. 276 ANATOMY, EMBRYOLOGY, AND HISTOLOGY OF PHARYNX fourth pharyngeal arches. Back of this, two processes form between them the rhomboid-shaped opening of the larynx. At the upper posterior part of the first pharyngeal pouch there occurs a depression just in front of the chorda dorsalis, known in German embryology as Rathke's pocket, which represents the anterior lobe of the hypophysis. Laterally at its posterior part the first pharyngeal pouch remains as the opening of the Eustachian tube, oval, at birth. The second pharyngeal furrow above forms the fossa of Rosenmiiller, and the second pharyngeal arch remains in front of the tonsil as the anterior pillar of the fauces. The pyriform fossa on each side of the larynx is formed from the fourth pharyngeal furrow. In the embryo the Eustachian openings are oval, closer to the choanse, and are at birth little raised above the surface. In the first five years they grow rapidly and the Rosenmiiller fossa is thus deepened around them. The descrip- tion of the formation of the pharyngeal tonsil given by Schwabach differs a little from that quoted by Kolliker. He says the furrows repre- senting the pharyngeal tonsil begin to form in fetal life after the third month. In 60 to 70 mm. embryos there is first noticed a shallow furrow in the posterior pharyngeal wall at its transition into the fornix in the median line. This represents the median embryonal recess, which he declares better expresses its nature than the term pharnygeal bursa. It sometimes happens, others state, that this part of the pharynx remains smooth until birth. Some embryologists state there is often a deep depression at the centre of the pharyngeal vault before the furrows can be perceived (Rathke's pouch). This lies behind the structures from which the pharyngeal tonsil is formed. The pharyngeal bursa is believed to be usually a pathological product formed out of the median recess of the pharyngeal tonsil by the superficial agglutination of the surfaces of the opposing median ridges through infiammatory action. This may go to the extent of closing off a cavity altogether, forming a cyst lined by the epithelium and walls of the median recess. Mayer in 1842, Luschka many years later, and other investigators since who base their observa- tions on postmortem examinations claim that in addition to this there exists in a small proportion of skulls a true recess leading back to the body of the sphenoid bone which may. open into the pathological for- mation above described. The pathological condition is not infrequently observed clinically, more or less imperfectly developed. The physiological cavity must be accepted as occasionally (though rarely) existing as an exaggeration of embryonic development. In the descriptions of the earlier histologists the lymphatic system was described as developed embryologically from the mesenchyme cells which form the boundaries of its peripheral distribution. Recently a number of observers, especially in America, describe it as arising from sacs in communication with the venous arches in the early weeks of embryonal life. Prolongations of closed tubes are pushed out, with intercalated lymph nodes, until they occupy all the peripheral spaces between the fibers of' mesenchyme origin, their walls consisting of a single layer of endothelial plates. While this central origin of the lym- ANATOMY OF THE MUCOUS MEMBRANE OF THE PHARYNX 277 phatic system and its method of evolution seem well established by the work of Huntington, McClure, and others, the acceptance of the reality of closed tubes for its peripheral distribution must be received with some reserve. By some histologists the denser reticulum which forms the framework of the closed follicles seems a grillwork of fibers in direct relation with that of the lymphatics. Others look upon it as a sort of syncytium with many nuclei. THE MINUTE ANATOMY OF THE MUCOUS MEMBRANE OF THE PHARYNX. This has been very largely taken up in the course of the preceding remarks upon the embryology of the pharynx, without a correct understanding of which many of the points in clinical and histological pathology cannot be intelligently discussed. It will be necessary to supplement what has already been said by some remarks concerned chiefly with postembryonic development and anatomy. Faucial Tonsil. — ^The faucial tonsil at birth and often in infancy pro- jects very little beyond the surface of the tonsillar sinus. It consists of rows of openings which indent the slightly thickened mucosa. These are so slight that in infancy they are with difficulty recognized by intra vitam inspection. They are easily discernible by postmortem examination, and on section they are seen to consist of infoldings of the surfaces with ramifications of branching crypts whose walls are studded with lymph nodes as described for the pharyngeal tonsil. These probably have a tendency to continued development aside from the excitation of cold catching in infancy, but what would happen if a child never had a cold we do not know. Every practitioner at once recognizes how inadequate is the description just given of the anatomy of the faucial tonsil as he sees it (Plate IV). Bosworth has, with a considerable degree of truth, insisted that the faucial tonsil is a pathological structure. When it obtrudes itself on the attention of the clinical observer there is reason to say that such a statement is entirely justifiable. It is necessary, however, to realize that an anatomical structure has been developed in the embryo, and apparently its reaction to the environment of postembryonic life is more or less a physiological one. When removed in infancy it tends to reciu" like a lobster's claw. When it ceases to be chiefly a physiological structure and becomes chiefly a pathological structure the child has reached four to six years of age. After this its removal is not often followed by recurrence, but the processes by which it has evolved in uterine life continue in early childhood under the stimulation of the environment, and in adolescence these become the processes of patho- logical hypertrophy. Retrogression usually does not begin until puberty is reached. Of the lingual tonsil the same may be said, but it is of later embryonic development, of later atrophy, and its pathological hypertrophy is rela- tively more apt to give rise to symptoms in adult life than that of the 278 ANATOMY, EMBRYOLOGY, AND HISTOLOGY OF PHARYNX faucial and pharyngeal tonsils. The method of retrogression has not been the subject of a careful histological study. In active growth degeneration of cells and phagocytosis are going on at the same time. Essentially it is probable that the germinal centres cease to shed off young lymphoid cells, so that the waste of these due to transmigration and cell death is no longer compensated for. This is a theme to which we shall recur later. Before proceeding farther it will be necessary to revert to other ana- tomical features of the pharyngeal structures. As to the faucial tonsils in the adult there is an arrangement of the circumjacent stroma of which, for clinical reasons, it is necessary to take account. Above and external to the tonsil, and extending toward the median line of the soft palate, is a loose areolar collection of connective tissue which is apt to be the site of the peritonsillar collections of pus in quinsy. Another region, also exceptionally well provided with this submucous stroma, is just below the tonsil, though here the pus does not so frequently form or at least does not so frequently give local evidence of its presence. Both these areas are the starting-points of a lymphatic peripheral network which is especially abundant. The epithelium of the faucial tonsils is flat and corneous on the surface. The thickness of the layers and the degree of cornification vary with the size of the tonsil, and relatively to the other elements it varies with the degree of regression which has taken place in the structure. It may be represented by only four or five rows of cells or it may be many times thicker than this. There is often seen a ragged condition at the lower border of the epithelium, and the stroma approaches very close to the surface. This has been interpreted as evidence of the phagocytosis of the epithelial layers by encroaching lymphocytes. What is said of the epithelium of the faucial tonsils may be affirmed of that of the lingual tonsils and of the epithelium covering the lymphoid tissue generally in the oropharynx. There is not much tendency to the formation of papillae, though strands of connective tissue shoot up into the epithelial layers. The basal cells of the epithelium approach the cuboidal and indeterminate type. Occasionally they exhibit fibrils or the appearance of them which seem to be lost in the connective tissue. The line between epithelium and stroma may be sharp and distinct, but more often it is not. Lymphocytoid cells are mingled with the lower layers in such a way that it is often impossible to distinguish them. This condition is found chiefly some years after birth, and may be due to pathological conditions. Mitoses in the lower layers are occasionally seen, and there is often evidence that the lymphocytes have their origin in the basal cells of the epithelium, which it is difficult to ignore. In the crypts the corneous layers are held longer in juxtaposition to the living cells than elsewhere, but the hyaline condition obtains in the superficial layers of the surface as well as in the crypts. Pharyngeal Tonsil. — ^Reckoning the soft palate where it joins the hard palate as forming the anterior part of the imaginary floor of the naso- pharynx, Luschka estimates its size at birth as 14 c.c. From the posterior ANATOMY OF THE MUCOUS MEMBRANE OF THE PHARYNX 279 border of the vomer to the pharyngeal tubercle is about 2 cm.; from this line to the top of the vault measures about 1.5 cm., and the width is about the same. As seen in the third or fourth year of infancy the nasopharyngeal structure has undergone some disturbance, which seems incidental to ordinary human environment, due to recurrent inflamma- tion of a greater or less intensity. This, as a rule, is expressed in the bulk of the development of the pharyngeal tonsil and to some extent to the distortion of its gross features. To a less degree do we note at this time the metaplasia and degeneration of its minute structure, which gradually after this time becomes more and more apparent. We may say in a way that the development of the pharyngeal tonsil has been stimulated perhaps to an exaggeration of its features, but not to any great relative disproportional development of epithelium, lymphoid cells, or supporting Fig. 192 The pharyngeal tonsil. stroma. It consists of two median ridges inclosing the median recess and two lateral ridges bounding the two lateral furrows externally, their internal walls being the external aspect of the median ridges. We must repeat the remark that this is seen in a large number, but possibly not in the majority of children under four years of age. Many, it is true, present a much more complex aspect, more irregular branches of con- glomerate papilliform or bulbous lymphoid hyperplasias. In, however, the large proportion referred to, sections show more or less regularity in the epithelial covering, while close beneath it are more or less regular rows of lymph nodes or germinal centres of lymphocytes and their derivatives, the nuclei split off from them, usually supplied with a scarcely discernible cell body in their nascent state. Beneath this layer the stroma bears not only a diffuse infiltration of lymphoid cells, but 280 ANATOMY, EMBRYOLOGY, AND HISTOLOGY OF PHARYNX often the ducts of racemose glands, while beneath this still is the firmer fibrous layer which shades off into the fascia of the pharynx. A more or less schematic representation of these features may be seen in Fig. 192. In the embryo and in the newborn the epithelium of the nasopharynx is of uniform character. Ciliated cylindrical columnar epithelium in layers of varying thickness cover the subjacent structures. The vertical diameter of this epithelium is given as 0.11 mm. This rapidly diminishes as metaplasia sets in, which soon occurs after birth. There are then found stretches of epithelium without cilia, these being preserved in the furrows but stripped off the ridges. The metaplasia may rapidly advance and convert the columnar epithelium into a type closely resembling the pavement epithelium covering the faucial tonsils and the oropharynx. This metaplasia of the epithelium may always be found developed to a greater or less degree at the period of life above referred to, and it sub- sequently becomes more marked. The basal cells of the epithelium thereafter and to some extent before lose their definition and shade off indefinitely into the subjacent connective-tissue cells. In places these areas of indeterminate cell type approach close to the surface. Numerous leukocytes may be seen in the basal layers, many of them plainly showing an amount of cell body around the nucleus to warrant their classification as small lymphocytes; others show scarcely any of it, and seem to be naked nuclei such as are seen at the periphery of the germ centres. On the surface and in the crypts these two types of cells are seen, and are said by histologists to vary with conditions of quiescence and of active inflammation of the lymphoid structure. The emigration of leukocytes, as Stohr long ago pointed out, seems to be a physiological process. Their origin, at least in postembryonal life, is a matter of considerable doubt; but that they emigrate from the subjacent stroma through the epithelium to the surface is a common observation. The process is described occasionally in such a way that we are to infer that there are stomata between the epithelial cells com- municating directly with endothelium-lined channels of the lymphatic system. This, however, has never been demonstrated. A membrana propria has been described as existing beneath the epithelium as a struc- tureless body of protoplasm through which the wandering cells penetrate from below. So far as this is shown in the prepared sections it is prob- ably an artefact. It is often absent even in these, and when present it probably represents a lipoproteid semipermeable membrane, to traverse which bodies entering from without or penetrating from within must possess a specific biophysical relationship of surface. It does not always appear in sections as homogeneous, but sometimes a finely fibrillar appearance is noted. This probably represents a condition of con- vection currents in the semifluid sheet of protoplasm present at the time the tissue was fixed. Fat cells are seen in the connective tissue, repre- senting probably the retrogression of the lymphoid structure which takes place in adolescence. Much which has been said applies not only to the minute structure of the pharyngeal tonsil, but to that of the faucial and lingual structures as well. The tonsils furnish to the pharyngeal ANATOMY OF THE MUCOUS MEMBRANE OF THE PHARYNX 281 secretion not only a large amount of the corpuscular elements found in it, owing to the transudation of the leukocytes manufactured in excess by the germinal centres in the tonsils, but desquamated epithelium and perhaps some serous exudate and mucus. Lingual Tonsil. — ^In some places in the tonsils there is but a layer or two of superficial cells between the surface and the lymphoid or lympho- cytoid collections of cells. The latter follow the fibrous bands deep down into subtonsillar fibrous planes. The lingual tonsil presents these appearances as well as the faucial. Mingled with the depots of lymphoid cells. which go to form it are the ducts of subjacent mucous racemose glands. These structures in this situation are in close apposition to or surrounded by the muscle bundles of the tongue, whose movements tend to express their contents. It occasionally happens that even in the faucial tonsils the duct of a racemose gland may open at the bottom of a tonsillar crypt, while in the nasopharynx this is frequently noted. Fig. 193 Section through soft palate. (After Levinstein.) Racemose Glands. — ^The distribution of the racemose glands is an irregular one in the pharynx. Many are found along the posterior surface of the anterior pillars of the fauces, and their ducts are said to open posteriorly for the most part. Around the ducts of these glands are apt to be found small collections of lymphoid cells, and these make up some of the "granules" of the chronic granular pharyngitis. It seems likely that such "lymph nodes" are for the most part of inflammatory origin. There are, however, many of these lymph nodes in the fauces and on the posterior pharyngeal wall, to which one can trace no glandular afiiliation. The glands of the pharynx have been described as lying with their acini against the muscle sheets or mingled with their fiber bundles. This is specially true for the musculature of the tongue and of the fauces. The racemose glands of the uvula bear the same relation to its musculature as do those of the fauces to their own. They also for the most part open on the posterior surface, while at the tip of the uvula glands are 282 ANATOMY, EMBRYOLOGY, AND HISTOLOGY OF PHARYNX absent for the most part. Nevertheless, both in the uvula and in the fauces there are many isolated and lobulated racemose glands whose acini bear no relation to the muscular layers and whose ducts are not specially thickly surrounded by lymphoid cells. In the soft palate the racemose glands form layers on each side of the musculature and the pharyngeal and oral surfaces respectively, but on the pharyngeal side the glands are closer to the epithelium, as are the muscular layers. On the oral side the glandular layer is thicker and is separated from the surface by a thicker area of connective areolar tissue (Fig. 193). The posterior faucial pillar and its continuation above to the Eustachian tube and downward along the pharynx is particularly rich in racemose glands, and this is so to a scarcely less degree for all the vertical folds of the pharynx which project toward the middle line in the act of degluti- tion — an indication of the lubrif acient function of the glandular structures of the pharynx. The mucous membrane of the oropharynx, which may be said to begin at a point opposite the termination of the hard palate or at the top of the superior constrictor of the pharynx, just above the odontoid process of the second cervical vertebra, is regularly covered with laminated pave- ment epithelium into which there is a moderate ingrowth of connective- tissue papillae. There are numerous glands laterally, but not many in the centre of the pharynx, where the mucosa is thin and firmly attached to the underlying tissues. The same structure obtains in the laryngeal pharynx, though the various muscles expand their terminal fibers in the submucosa. While, as a rule, there is some correlation between the abundance of lymphoid structure in the extratonsillar regions of the pharyngeal mucosa and its glandular supply, that is not always the case. This seems to apply especially to the soft palate. Levinstein has remarked the abundance of elastic fibers in the stroma seems not to favor the presence of lymph nodes. To this we can subscribe from our own observations. In the nose the glands seem to depend for their excretion largely on the pressure of the elastic fibers in the general stroma, in the pharynx largely on the musculature. Where neither surrounds the ducts of the glands one is apt to find collections of lymphoid cells, but these rules cannot be considered of any very close application. On the posterior pharyngeal wall the glands lie on or in the muscle layers beneath a con- siderable stretch of connective tissue which separates them from the epithelium. When lying in the muscle layers the ducts seek the surface between their fiber bundles. They are irregularly scattered. Lymphoid Tissue. — In addition to that of the various tonsils already described the lymphoid deposits are unevenly distributed. Over some areas, differing in extent and frequency in different individuals, collections of lymphoid cells gorge the connective-tissue spaces and the lymphocytes abound in the regions bordering on both the surface epithelium and the gland ducts. That in some situations these lymphoid cells are of vascular origin seems undeniable; that in other situations the lymphocytes are derived from the basal layers of the epithelium seems very probable. The so-called phagocytosis of the epithelial cells by the lymphocytes it ANATOMY OP THE MUCOUS MEMBRANE OF THE PHARYNX 283 is certainly justifiable to regard as a transmutation in certain inflamma- tory processes. That these lymphocytes take up much of the proteid and lipoid detritus of the crumbling cellular protoplasm cannot be denied, but that they destroy the epithelial cell is an unwarranted conclusion. In childhood the lateral pharyngeal lymphoid development is infre- quent. In adults it develops as the result of inflammation. On account of its proximity to the Eustachian tube it has been called the tubal tonsil, but the term is not in common use. " Waldeyer's ring," therefore, as applied to the distribution of the lymphoid tissue in the throats of adults, including the faucial, lingual, and pharyngeal tonsil, is connected by a line of lymphoid deposits obviously due to pathological activities in their inception. Indeed the so-called lingual tonsils, first apparent as we have seen only at a comparatively late period of embryonic life, is chiefly of a structure developed in late adolescence. Germinal Centres of the Lymjjhoid Tissue. — ^The lymphoid material in the pharynx, as elsewhere in the digestive tract, tends to gather in clumps, or rather a focus of round cells is set up by the local accumulation of daughter leukocytes around a proliferating lymphocyte lodged in the lymph channels of the stroma — or an area of round-cell infiltration gathers around a bloodvessel. In the pharynx, aside from these localized follicles or lymph nodes, the stroma which intervenes between them is free from any considerable round-cell infiltration when it is not the seat of an active infiammation. In these physiological and pathological lymph nodes the structure is practically the same. It can best be described as a type from which morphological deviations are not of importance. Histology of a Lymph Node. — The finer histology of the tonsils is ap- proximately that of the other lymph glands, but what gives the various tonsils of the pharynx a unique interest is that a lymph gland is there, as nowhere else in the body, exposed to an environment varied in extent and concerned, beyond all others, with the first impact of the food and air upon the animal organism. The sinus of the lymph gland — for instance, of the cervical region — is represented in the pharyngeal structures by the small area intervening between the germinal centres and the epithe- lium at the periphery and by the similar loose lymphoid structure which lies beneath them, analogous to the hilus of the lymph node. The con- nective tissue which acts as a framework to support this abundant cellular infiltration is continuous with that of the areolar tissue in which it lies. It is modified as it enters the lymphoid area, but it presents the same general features of fusiform and stellate or branching cells whose fibrils interlace and form larger and smaller spaces (Fig. 194). Around the base of the faucial tonsils are denser layers of fibrous tissue which send septa into the tonsillar structure. This is sometimes called the capsule of the tonsil. By the sinus of the typical lymph gland is meant the looser areolar spaces at the hilus and at the periphery. Between these lie the closed follicles, or nodes, or germinal centres whose support- ing framework is a denser reticulum. In the sinuses lymphoid cells are plentiful, but the leukocytes are less densely crowded together and the areolar meshes are larger. 284 ANATOMY, EMBRYOLOGY, AND HISTOLOGY OF PHARYNX At the germinal centres of the lymph nodes or closed follicles are the small lymphocytes with round nuclei which act as lymphoblasts, giving rise to the leukocytes which traverse the lymph channels. Most of these find their destination in the general circulation, but many of .them manu- factured by the germinal centres of the tonsils find their way through the epithelial cell layers to the surface and are lodged in the crypts, as has been noted. There is no doubt that in the meshes of the lymphoid tissue there exists normally a certain number of red-blood cells, but whether they are manufactured there, as some have ventured to assert, and enter the circulation, or whether they issue from the bloodvessels and are destroyed in the tonsil, as most believe, is not entirely clear. A large number of categories and varieties of leukocytes are noted. Large lymphocytes or macrophages, abundant in chronic inflammations of the tonsil, plasma cells, acidophils, and polynuclears are all seen, and different Fig. 194 Reticulum of cervical lymph node. (After Ferguson.) a, polynuclear lymph corpuscle; b, large mononuclear; c, small mononuclear; d, connective-tissue cells. authorities classify these and describe others in a way which is very confusing. It may be said that small lymphocytes at the centres of the closed follicles, while they present mitotic figures, seem to be perpetually giving origin to young leukocytes by an amitotic process. The destruction or, it is safer to say, the phagocytosis of degenerating cells is performed by the large lymphocytes. This may be the origin of many of the granules which, from tinctorial reactions, seem to be lipoid or fatty in character. They are seen in the cytoplasm of lymphocytes under certain conditions. That all such granules are of extraneous origin is probably not a correct statement. Lipoid Material. — ^The nature of the fatty material is often a question of considerable doubt, but in a general way it may be said that the neutral fats and the fatty acids, or rather their representatives, the soaps, are those more usually found in the lymphocytes. The neutral fats are predominant in the quiescent tonsil, while stains reveal an ANATOMY OF THE MUCOUS MEMBRANE OF THE PHARYNX 285 increase in the soap granules in inflamed tissue. Neutral fat granules may be very abundant and demonstrable in the lymph spaces in large amounts — coarse globules outside of the cells sometimes, but usually Fig. 195 -3 *e ,-0 .«^.^ v.« t. J c ivl;: «*%!' Showing distribution of fat droplets in an osmio acid section of the faucial tonsil. Oil immersion y.,. finely divided in the cytoplasm itself. Soap stains usually reveal a moderate number of large globules in a few of the lymphocytes or lying free in the lymph spaces in clumps indicative of their cell origin. In Fig 196 a, f''l # . Showing at 4 a binuclear stipple cell, such as is seen either with the process for staining neutral fat or lecithin with scharlach roth, and at B-C.what is said to be evidence of lecithin. Oil immersion yV- acute inflammations and in chronic inflammations of infectious nature the soap granules are enormously increased in numbers. Associated with the soap or perhaps existing independently of it in combination 286 ANATOMY, EMBRYOLOGY, AND HISTOLOGY OF PHARYNX with proteids, cholesterin may be demonstrated by tinctorial reactions said to be characteristic. It seems probable that in the connective-tissue planes the combination is a cholesteryl oleate. At the surface, however, both in the epithelial cells and in the contiguous subepithelial connective Fig. 197 -^■^ :~ '~~'~^-~ i ^£ '-' .- ~^ '^mJSStttt m - "- "^X r y \ ^ < ■'■' • S r- - M*--^-^ -'y •=*^? ■ ^y ■^'■. ', -^ -■ ''' - -. j~ '' - -^ - B-'6M ' .:..-■=' Showing the mononuclear stipple oell^ or granulocytes, as revealed by the stains for soap and for cholesterin. tissue, cholesterin is very abundant. The crypts are often black with it in sections stained for it, having its origin doubtless in the keratotic masses which are found there. In the superficial epithelial layers soap granules are occasionally demonstrable, but there does not seem to be Showing the round globules of cholesteryloleate free in the tissue as a cluster, evidently scattered from some "lipoid cell" in which they originated. the close combination of cholesterin with the soap in the epithelial cells and in the connective-tissue cells in close opposition to them, which is observed at greater distances from the epithelial line. On the other hand lecithin, as far as the tinctorial reactions thus far indicate, seems ANATOMY OF THE MUCOUS MEMBRANE OF THE PHARYNX 287 to exist in varying amount not only in the free lymphocytes of the con- nective tissue but in the epithelial cells. Much of the work on which these Fig. 199 -*-^^^^^4jjp- Showing the distribution of cholesterin in the epithelial layers, and its absence from the stroma just beneath the epithelial area, except for the deep stain of some of the com- pressed erythrocytes in a capillary. remarks are based needs confirmation, but there is little doubt that in the study of these lipoid bodies and in their relations to the proteid metabolism of the cells we are to find much enlightenment in the physi- FiG. 200 Showing with the soap stain a ring body free in the tissue of a tonsil which had been removed from the throat under ether. ology of the tonsils. The accompanying illustrations with their legends taken from the work' alluded to will give some idea of the appearances. » Wright, New York Medical Journal, February 11-25, April 8-22, May 13, 1911. 288 ANATOMY, EMBRYOLOGY, AND HISTOLOGY OF PHARYNX The Lymphatics. — The lymphatic spaces of the internal nose are directly continuous with those of the nasopharynx. On the posterior surface of the palate and on the lateral wall below the Eustachian tube the mesh- work of spaces is specially well marked. On the lateral wall of the pharynx they communicate not only with the internal nose but with the middle ear. The anterior wall of the laryngeal part of the pharynx, that is, the posterior surface of the cricoid cartilage, is also thickly supplied. These surface channels beginning close beneath the epithelium and around the lymph nodes are gathered into stems which leave the pharynx in the anterior part of the floor of the pyriform sinus, laterally at the situation of the faucial tonsils and posteriorly beneath the posterior pharyngeal wall. Those leaving in the sinus pyriformis join with the superior laryn- geal lymph vessels to pierce laterally the thyrohyoid membrane near the superior laryngeal artery and to reach the deep cervical lymphatics. They involve in their course the lymph glands lying at the carotid bifur- cation and the mouth of the facial vein where it empties into the jugular. There are other small glands on the thyrohyoid membrane which may be injected from as far down as the surface of the epiglottis but not from the inside of the larynx. The lymphatics from the tonsillar regions pass out more or less directly and reach the anterior superior glands lying beneath the lateral belly of the digastric muscle. Posteriorly some of the lymphatic trunks leave the pharynx on the posterior wall and some laterally reaching the jugular glands in each case. Beitzke a number of years ago and Lasaqua more recently have shown there is no communication, so far as can be shown by injection experiments on cadavers of children between cervical lymphatics and those of the thorax. The infection of the lungs so far as it depends upon infection of the nose and pharynx, either naturally or experimentally, is a blood- born infection. The cervical lymphatics pour their drainings into the vena cava, from which they are distributed to the lungs and other regions of the body by the blood current. The submental glands receive the superficial lymphatics of the skin of the cheeks, but they cannot be injected from the mucous lining (?). The lymph from the mucosa of the cheeks passes to the submaxillary gland and thence to the deep cervical lymphatics. The same may be said of the lymphatics of the mucous membrane of the alveolar processes. Bloodvessels of the Tonsils. — ^The arterioles of the tonsil structure proper are of small size, but sometimes, lying in the fibrous planes which shoot in from the capsule of the tonsil, in conditions of hypertrophy they have rigid walls, which condition often gives rise to serious hemorrhage in operations. The capillary supply is not abundant. It follows the smaller fibrous septa and capillaries of minute size skirting the closed follicles in places — in places making a superficial network beneath the epithelium (see Plate IV). Tonsillar Bacteria. — In the crypts which communicate with the surface, in those which are sometimes sealed at the surface by agglutinating inflammation upon the surface itself, varying in numbers and in species, varying in those respects not only in different individuals but at different THE "FUNCTION" OF THE TONSILS 289 seasons of the year, influenced by the existence of epidemics such as diph- theria and influenza, are found not only bacilli and cocci and spirilla not known ever to produce disease in the human subject, but with great regularity streptococci and staphylococci which are also constantly associated with sepsis, diphtheria bacilli, even virulent forms, pneumo- cocci, fusiform bacilli and spirilla, coli bacilli and the bacillus tetragenus, leptothrices and streptothrices. All these have been found associated not only with normal states but with forms of throat inflammation otherwise indistinguishable from one another. While they may exist indefinitely in quiescent throats, when these take on morbific conditions certain ones more or less constantly associated with these specific morbific conditions assume a malignancy apparently which makes them more apt to act as carriers of disease to other individuals. They increase enor- mously in amount, becoming the predominant organism in each case. THE "FUNCTION" OF THE TONSILS. It is desirable that the teleological significance inherent in the term should be eliminated from the discussions as to the biological processes which go on in the tonsils. It is quite true, as writers love to assert, in this sense the function of the tonsils is unknown. There are, however, certain biophysical and biochemical reactions recognized as part of the activities of the lymph glands on the surface of the pharynx which it is desirable to keep in mind. It will be necessary to do so if we are to solve the question as to whether the tonsils in their non-obstructive state subserve any purpose in the physiology of the organism. We know that, like all the lymph glands, they manufacture leukocytes at their germinal centres. We know that some of these leukocytes find their way to the cryptal surfaces. We know that foreign substances injected into distant parts of the animal body — as, for instance, carmin into the thigh muscles of the rabbit or guinea-pig — after a certain length of time are found on their way to the surface in the parenchyma not only . of the lungs but of the tonsils. Granules of it may be seen in the walls of the pulmonary vesicles and in the lymph channels of the tonsils as well as lying in the air vesicles and in the tonsillar crypts; so that we know there is an emigration not only of leukocytes but of foreign bodies to the cryptal surfaces of the tonsils. On the contrary, we know that though the crypts of the tonsils are regularly crowded with bacterial forms in conditions of good health, carmin and other powders, it is said even dead bacteria, dusted on the tonsils or at least placed in the crypts, penetrate the epithelial layers and are to be seen in the internodal connective tissue of the tonsils. We have followed a line of such granules stretching more or less continuously from the surface to and within the walls of the capillary bloodvessels. We have every clinical reason to believe that pathogenic bacteria find entrance to the general lymphatic system and bloodvessels through the tonsils as portals of entry. It has been shown that the external surface 19 290 ANATOMY, EMBRYOLOGY, AND HISTOLOGY OF PHARYNX of all cell membranes is covered by a labile lipoproteid coating which acts as a semipermeable membrane and which apparently regulates, by its physicochemical reaction toward its environment, the endosmosis and exosmosis of the cell. There are also reasons for believing that it is by virtue of this varying external lipoid coating of the cell and of the lymph- space walls that a physical reaction, probably of surface tension variation, is set up between the wandering cells and lymph-space wall. Thereby the cell creeps along the spaces to its destination, the surface or the blood- vessel, or wanders through the meshes of the lymph spaces. When by phagocytosis the foreign body is covered by the hull of its devouring cell it obeys, in its peregrinations, the law of the surface tension existing at the surface of its host. It seems likely that this surface tension may also be influenced in the case of a carmine granule not only by being engulfed in the protoplasm of the cell, but it may acquire a lipoproteid covering from the fluids of the lymph spaces independent of the cell. Evidently then its destiny, its destination, will depend on the relation its surface bears to the surface coating of the lymph spaces. The living bacterial cells of the tonsillar crypts have a surface tension of their own, so to speak. They may borrow another from their environ- ment. At any rate, in quiescent states one does not see them passing the outer line of the membrane of the cells walling the crypt, when that cell surface is firmly incorporated with the cell. When, however, that outer surface, corneous or hyaline in appearance, is scaled off and lies as keratotic detritus in the lumen of the crypt, the bacteria penetrate it and may be seen lying in it, sharply contrasted with their relationship to the living surface in their behavior. As has been shown the lipoid, recognizable by tinctorial reactions most abundant in the outer layers of the tonsil — especially in the epithelium, but to some extent in the subepithelial connective tissue contiguous to it, is cholesterin. It is cholesterin and its allies and derivatives which furnish many of the physical phenomena which can be identified in the biological activity of the cells. In the combinations of cholesterin and lecithin with the proteids at the surface of the tonsils we may well believe we will find an explanation of those biophysical activities whereby immu- ■ nity and infection are regulated, so far as they have to do with the impermeability and the receptivity of the surface to infection. In the fats and soaps and their metabolism as they enter into combination with the proteids and the other lipoids of the cell membranes we have reason to believe we shall find, as an explanation, a mechanism analogous to that described for the osmosis of the single cell in modern biochemistry.^ 1 For a fuller presentation of these questions see Wright, New York Medical Journal, February 11, 25, April 8, 22, May 13, 1911. CHAPTER XL THE INFLAMMATION OF THE PHARYNX. ACUTE INFLAMMATIONS OF THE THROAT. The Etiology of Acute Inflammations and the Mechanism of Cold-taking. — Knowing, as we do, that there may exist in one individual in a condition of perfect health, microorganisms which, introduced into another indi- vidual, produce disease; knowing that even in the tonsils of the same individual streptococci may assume toward their host at some period a maleficence which previously they, had not exhibited, we seem jus- tified in concluding that if the systemic human factor is a changeable one the extraneous bacterial factor is scarcely less so. What changes the systemic factor and to a large extent what changes the bacterial factor is unknown. In any given case of disease it is usually impossible to decide which factor preponderates in its maleficent influence in the production of the disease, the microorganism or the Organism of the host. It is a change of relationship. In the nose we have no assurance that bacteria enter the surface layer of epithelium in the initial stages of a coryza. It is quite possible that an ordinary coryza may run its usual course without such a thing happen- ing. It seems probable that such is not the case, but there is no clinical, his- tological or bacteriological evidence absolutely to prove that the bacterial life which is increased on the surface of the nasal mucosa enters its paren- chyma during acute catarrhal inflammation. This we have more reason to believe does occur in acute inflammations of the pharynx. While in the primary stages of an acute inflammation of the tonsillar structure the evidence is not satisfactory that bacteria regularly penetrate the surface layers, while it is still less evident that their entrance is coincident with that of the preliminary stage of erythema of the pharyngeal mucosa, we know that in the later stages they can sometimes be found in the subepithelial tissue. Practically always they can be identified by bacterial reagents in the severer inflammations of quinsy and diphtheria. At what stage in the process they break through the epithelial line from their habitat in the crypts is by no means certain. To say that bacterial infection is the antecedent, primary cause of cold-taking or perhaps of any acute throat infection is an entirely un- founded assertion. To deny that they take part in the pathological pro- cess at any stage is still more unwarranted. We do not wish to advance the following concept of the mechanism of cold-taking and infection as anything more than an attempt to furnish a working hypothesis more in accord with clinical facts and laboratory findings and not incompatible 292 THE INFLAMMATION OF THE PHARYNX with various biophysical and biochemical facts which recent research has revealed. The Relation of Cold-talcing and Bacterial Infection in the Upper Air Passages. — ^The facts, which have been indisputably established, in regard to the presence of pathogenic microorganisms for long periods of time on the healthy mucous membranes of healthy human beings have done much to accelerate the decay of belief in bacterial influence as sufficiently explanatory of the onset of disease. While there is incidentally much allusion to these facts in what has preceded and in that which will follow in this chapter, it seems desirable to present as clearly and as succinctly as possible the views of the authors not only as to the cause of inflammatory disease of the upper air passages, but as to those physico- chemical processes which form, it may be, the chief elements in the whole process of cold-taking or act as a prelude only to the graver states in which microorganisms play the chief role. It is probably true that there are some organisms so virulent that their mere contact with epithelial surfaces suffices to open a way to their entrance to the system of efferent blood and lymph channels, along which they find opportunities for a growth which is serious or fatal to the individual infected. It grows apparent, as we advance in knowledge, that such vicious power at the furthest must exist in very few indeed of the pathogenic microorganisms. Such a relationship is unthinkable for bacteria and mankind at large as a constant state. It is the condition approached in some severe epi- demics which have been recorded in the history of medicine; but were it absolute and were it continuous in its action; were there no such state as the resistance of mucous surfaces to invasion by pathogenic germs, the human race perhaps would not perish from the earth because it would still have internal systemic immunity to defend it; but upon the latter would be thrown a strain of necessity which would have developed internal immunity into a very much more efficient weapon of defence than experi- ment and observation show it to be. Clinical observation of sporadic, of endemic, and of epidemic infectious disease points irresistibly to the conclusion that individuals differ greatly as to their receptivity to disease; that resistance to it varies in the same individual from time to time; that some individuals seem absolutely immune to every disease associated with microorganisms. Certain individuals dwell in constant contact with cases of phthisis, typhoid fever, diphtheria, cholera, and do not contract these diseases. In each one of these affections, mentioned at random, it has been definitely proved, tubercle, typhoid, diphtheria, cholera bacilli dwell for indefinite periods of time on the mucous surfaces of certain individuals who have always been and who always remain healthy. In a much larger, number they seem to dwell for an indefinite time on the surface and then something happens which causes them either to set up disease on the surface like diphtheria or to penetrate by the blood and lymph channels to internal organs where they multiply and give rise to the clinical signs of disease. In the upper air passages it is a legitimate part of the functions of those who observe disease clinically there, to take account of such facts as ACUTE INFLAMMATIONS OF THE THROAT 293 serve to elucidate the mechanism whereby a streptococcus or a tubercle bacillus finds entrance to submucous tissues. As before hinted the scientific man has learned to fight shy of postulating antecedent events as causes and subsequent events as results from them. The bacteriologist no longer insists upon the bacterial factor as the only one in the mechanism of disease, and the therapeutist no longer directs his energies exclusively to annihilating it. The epidemiologist no longer regards the prevalence of certain species of bacteria or of the agents which carry them as the final cause, or at present the interesting factors, in contagious diseases. The scientific man has nothing to do with finalities; his functions are concerned with processes, not with causes. As students of disease of the upper air passages we are interested in knowing what happens in the short interval between the long period of time in which the streptococcus has dwelt as a saprophyte in the creases of the mucous membrane of the pharynx and the comparatively limited period in which it appears as so intimately associated with lacunar tonsillitis or endocarditis as to inti- mate that it plays an important role in the phenomena of each, a part of which is revealed to us as a sore throat or a valvular heart murmur. We want to know what biochemical changes take place which render the diphtheria bacillus, hitherto without maleficent qualities in a certain individual's throat, an active agent in the formation of a false membrane and in the exhibition on the part of the patient of dangerous systemic ' symptoms. Much of the mechanism whereby these results are brought about will long remain a mystery to us even though we totally abjure our pre- dilection for final causes; but if we, as laryngologists or as bacteriologists, for long periods of time, are to give ourselves up to the thought that the moon or the north wind or the tubercle bacillus is solely responsible for consumption, the complete understanding of the mechanism of disease will be removed to a period so remote as to discourage thought itself. One of these periods of time in which for most medical men progress had ceased has been occupied with the contemplation of the purely bacterial causation of disease. From physics, chemistry has borrowed those laws which have created a new science, the biochemistry of infection. The proper understanding of that electric state of matter which the physicist calls surface tension has resulted not only in the extension of our knowledge to many physio- logical acts of osmosis, but to the discovery of the almost universal presence of a relationship between the molecules of certain body fluids exactly analogous to that known to exist between the molecules of the inorganic colloids. We have long been familiar with fluids which creep along surfaces in defiance of the laws, of gravitation, and we are now becoming aware of the penetrability of cell boundaries by inert and by living matter in direct relationship to the state of surface tension existing between the surface of the cell membrane and the surface of the con- tiguous granule or organism. We know that just as the chemist can alter the surface tension of water by dissolving in it certain simple salts and thus bring about a different distribution of oil globules throughout 294 THE INFLAMMATION OF THE PHARYNX it, so the experimental biologist can modify the surface tension of cells in such a way that they will absorb what before the change they repelled. Many of the vasomotor disturbances we have studied in the pathology of the nose are evidenced by the transudation of fluid from the blood- vessels of the nasal mucosa and from its surface. This as we have seen causes certain structural changes, such as nasal polypi, and certain symptoms, such as profuse nasal discharge. The relaxation of cell wall, whereby the blood loses some of its water, is brought about through the influence of nerve currents. This influence we recognize as also active in the mechanism of vascular dilatation. One of the contractile elements, the muscle cell, has been shown to exercise its function by virtue of a shifting of electric polarization on its surface due to the convection to it through nerve tissue of certain electrolytic salts. Variation in the currents of a galvanic or chemical battery may be produced by a variation in the chemical composition of the solution of salts in the battery jars. The mechanism of the muscle cell is evidently analogous. All we have to do to alter the rate at which osmosis is taking place through an animal membrane is to alter the relative salt contents of the fluids on each side of it. The electrotherapeutist takes advantage of this to drive medicaments through skin surfaces. The nerves which govern the venous sinuses of the nasal mucosa and the mucous surfaces, which excrete and secrete, belong to the sympathetic system. There are certain phenomena in cold-taking which we recognize as dependent upon vascular contraction and dilatation and upon changes in the minute excretory and secretory channels with which the microscope and much biophysical research have made us familiar. The fat-like chemical constituents of the tissues have been somewhat loosely classified on the basis of certain physical characters and as a whole placed in a category expressed by the term lipoid. The lipoids, probably always combined with or influenced by the contiguity of other chemical bodies distinguished by different physical properties and called proteids, go to make up a colloid compound at the periphery of all cells, which is a state of matter extremely sensible in its physical manifestations to the influences of nerve currents. Experimentally we know this lipoproteid material forms semipermeable membranes which are traversed by currents of fluids according to the amount and the kind of electrolytic salts they hold in solution. In view of these facts and the relationship they bear to one another, and in view of the clinical phenomena of cold-taking, the attempt to correlate them seems justifiable. A simple coryza runs a course which in all but its terminal period is so similar to that of a vasomotor neurosis there seems no reason to suppose it is in reality due to microorganisms. There has never been any evidence worthy of atten- tion presented that a microorganism is associated in any regularity with a simple rhinitis. The same may be said for many attacks of pharyngitis. The latter disease, however, in the later stages of what may have been at first clinically nothing but an erythema of the mucous membrane, in those cases which rapidly give evidence of the deep involvement of the mucous membrane and in the cases of diphtheria, often presents the ACUTE INFLAMMATIONS Oh' THE TIIUOAT 295 typiciil clinical features of hactcrial acti\iti('s. Kvcii in theses latter, however, we have every reason to suppose that there is an antecedent ciiauge iu the state of the patient's mucous surface which renders possible the growth, the invasion, and the development of toxic material on the part of the bacterium which may have been for a longer or sliorter time a saprophyte in the relation it bore to its host. Whether the antecedent eliaage is always due to the influence of vasomotor disturbances perhaps will not be universally admitted, but there seems reason from what v\e know of the history of disease to suppose that such is the fact in a con- siderable proportion of cases. It may well be, as has been admitted, that certain bacteria are at once pathogenic when they reach the mucous membrane. Indeed this seems very probable when they reach the mucous membranes of certain individuals. It may well be that such individuals always present, owing to systemic states, conditions of the mucosa which offer an ever open avenue to infection; but granting all this, which indeed is in reality a part of our conception of the mechanism of the process, it seems extremely likely that local biochemical change, dependent upon molecular activities acting through the sympathetic nervous system, is the antecedent in the majority of cases of bacterial infection. This molecular disturbance of the normal activities of the sympathetic nerves may be set up by external or internal agencies, by the chilling of the body surfaces, or by (lerauficments in the activities of the internal organs. Owing to the fact that wet feet and the chilling of distant regions of the surface of the body ari', at least in clinical experience, quite as frequently followed by coryzas and sore throats as the direct impact of such external influences on the liead and neck, we have the right to infer that the shock at the surface must be transferred to internal nerve ganglia and there translated into impulses which are carried to the surfaces of the mucosa of the upper air passages. Thi-rc they give rise to the chain of biophysical and biochemical changes whicli may simply result in a mild coryza or a catarrhal pharyn- gitis, tlie resolution of which terminates the chain, or these conditions may be in themselves the starting-point of bacterial invasion. We do not con- sider it profitable to follow the chain of events farther. The science of serology has grown to proportions whic^h now transcend any limits possible in a text-book on the disease of the nose and throat. In the clianges set up in the body fluids by the presence of pathogenic bacteria, serology has found opportunity greatly to extend our knowledge of the biochemistry of disease. We naturally in this connection use the term biochemical as applicable to the processes demonstrated by serological science. We as naturally speak of biophysical agents in discussing the processes by which a bacterium traverses the surface and passes along the channel in tlie tissues, though it seems from ultimate analysis that they rest on the same fundamental hws. Without referring more definitely to the enormous literature setting forth the results attained than is absolutely necessary to indicate that there is good reason for the hypothesis, we may say tliat Jacques Loeb, who has been active in elucidating biochemical mechanisms, bad 296 THE INFLAMMATION OF THE PHARYNX previously shown that currents of electricity set up, not by contact, but by induction in an exposed nerve causes certain salts to be formed at the terminal filaments of the nerves in the muscle substance, whereby we know from the work of others that relaxation and contraction of the muscle fiber is accomplished. Lately he has published reports of more elaborate studies and investigations and the importance of the part played by electrolytic salts in modifying the surface tension of various kinds of cells in various vital reactions has become more apparent. It has long been known through experimental demonstration that arterioles and capillaries are first contracted, then dilated by irritation of the sympathetic nerves or their ganglia. It has been shown that surface tension conditions are altered in the process of muscle-cell contraction and relaxation. It has been shown in the endosmosis and exosmosis of cells in the act of nutrition and of fecundation. It has been shown that the fats and lipoids are active agents within and without the body in these chemicophysical reactions by the investigations of the lipoid contents of the tissues carried out by many workers with chemical and histological methods. Hence it seems very probable that these are the agents which with the proteids form surfaces which are altered as to their tension by the salts set free at the surface of the tonsillar epithehum by excitation of sympathetic nerve centres. This may arise through the chill of the surfaces of the body from the external influence of cold. It may arise from internal causes due to gastro-intestinal irritation. It may likewise be due to chemical influences brought about in the general circulation by chronic conditions of the system, rheumatism, gout, etc. Thus an altered relationship is brought about between the lipoproteid coating of the epithelial cell of the tonsillar crypt and the lipoproteid surface of the pathogenic bacteria they contain. Thus a surface hitererto impermeable to them becomes receptive of them. That such a change takes place when the external corneous layers of the epithelial cells become dead material in the tonsillar crypts, we have already intimated as the result of observation. Clinically, as has been stated, we know that the more serious forms or the later stages of tonsillar inflammation are associated with bacterial infection. We believe that some such mechanism as here shadowed, forth will ultimately be shown by direct experiment. So long as we have before our eyes the presence of pathogenic bacteria lying harmlessly in the tonsillar crypts of man, we must presuppose some changes in their relationship which renders them harmful in the processes of disease. That change must be looked upon as the initial step in etiology so far as they are concerned. In what has preceded, we have attempted to suggest the nature of that change, a belief in which is necessary for the compre- hension of the onset of inflammation of mucous surfaces. The initial stages are seen to be not those of infection in the strict sense of the term, but those of proteid metabolism in the nerves and the nerve endings. We understand then why rheumatic and gouty subjects are more sus- ceptible to cold; why coryza often is associated with gastro-intestinal and with depressed neural conditions; why the shocks of operations ACUTE INFLAMMATIONS OF THE THROAT 297 deepen the catastrophe of infectious processes in many cases; why the surgeons now hesitate to handle and bruise the abdominal contents in laparotomy. If we were disposed to continue the list of clinical phenomena, we might trace the same mechanism in the process of fatigue as illumi- nated in the admirable experiments of Crile and others. This is no place to fill in more fully the outlines of this conception of the infection of mucous surfaces in the process of taking cold, but some- thing of such an elaboration may be found in the publications of one of us already referred to. Histology. — If, as we have seen, there is uncertainty as to just at what stage of acute throat inflammations the bacterial factor becomes an important one; if, in the prefatory or earliest stages of an acute catarrhal inflammation we do not know the changes which take place in the relation of the bacteria to the surface, singular to say we know as little of the histology of this stage. In the fully developed stage of the ordinary un- classified inflammations of the pharynx, there is a marked desquamation of the lacunar and tonsillar epithelium, a marked swelhng of the lymph nodes, and an increased and wider spread infiltration of the stroma of the mucosa with leukocytes. In other words the epithelial and the wander- ing cells of the mucosa are enormously increased in number, due to the activity of the basal or germinal layer of the surface epithelium and of the germinal centres of the lymph nodes. The process is fundamentally then an activity of two forms of cells which Retterer and some others think are closely related in genesis. The exudation of serum and the coagulation of its fibrin, the mixture of abnormal quantities of mucus with it, the dilatation of the bloodvessels and the diapedesis of some of their corpuscular elements are the general phenomena of all inflamma- tions; but it would seem that the important features in the pathology which characterize the inflammations of the pharyngeal mucosa are those of the epithelium and of the lymph nodes. We can distinguish a period of congestion and an exudation of round cells from the superficial and deeper capillaries into the subepithelial tissue. This is accompanied by the engorgement of the lymph spaces with serum and in the later stages with some formation of new connective tissue in proportion to the severity and chronicity of the process. Prob- ably there remains indefinitely more or less of this around the prolonga- tions of the surface epithelium of the glands and crypts. The epithelium undergoes some destruction and the regeneration is rapid and exaggerated. Superficial loss of cells may be detected as the result of necrosis. The severity and the extent of these changes depend so much upon factors in the etiology that it can be more conveniently described under that head. Even in the mildest throat inflammations there is an increase in epithelial desquamation and in leukocytic transmigration. As to the latter it is said that while in quiescence the leukocytes which migrate partake more of the character of lymphocytes, having an appreciable cytoplasm and a round or oval nucleus, the leukocytes carried outward in tonsillar inflammation are young organisms, almost naked nuclei. These 298 THE INFLAMMATION OF THE PHARYNX and the free chromatin, which their disintegration furnishes, are mingled with the desquamated epithelial cells in the crypts of the tonsils to make up the familiar white spots on the tonsils, the follicular or lacunar tonsillitis of the clinician. Membranous Tonsillitis. — ^As the intensity of the inflammatory process grows these become more numerous and larger. The serous exudate at the surface coagulates into a fibrinous layer which causes the cryptal plugs apparently to coalesce with one another in forming a faucial mem- brane covering the tonsillar surface. Considerable liquefaction of the surface epithelium takes place and adds to the debris which makes up the false membrane. While usually this is thin over the intercryptal surfaces, sometimes the whole is united into the form of a thick, uniform, dead white or partly necrotic surface. In it streptococci and the other organisms mentioned are found in abundance, one form, a streptococcal, predominating. These are also found beneath the epithelial line at this stage in the living tissue. A blood culture very often, when properly made, will reveal the fact that the predominant organism is circulating in the vascular system of the heart. Membranous tonsillitis may be looked upon as an exaggeration of the exudate seen in the usual cases of lacunar tonsillitis, that is, the separate plugs in the crypts become confluent and cover the entire tonsil with a thick grayish or even black membrane which is indistin- guishable from that of diphtheria. Usually when such a well-pronounced membrane is sharply limited to the tonsil the only pathogenic organism found is the streptococcus. Nevertheless in a certain proportion of the cases, diphtheria or diphtheria-like bacilli are found. Some of these cases which present no evidence of systemic diphtheria and in the membranes of which the diphtheria bacillus cannot be found, yield promptly to injec- tions of antitoxin, that is, the membrane peels off promptly and the case goes on to recovery. As in the case of membranous rhinitis the rela- tionship of these exceptional cases to diphtheria has not been satisfactorily defined. Quinsy. — It is in order here to speak of the peritonsillar or subconnec- tive tissue inflammation. Theoretically it is not impossible that the focus of tissue disturbance in these cases may occasionally be primarily in the endothelial and connective-tissue cells of the stroma, but practically all clinical experience points to disturbance first in the more superficial layers. There seems no real reason to suppose that this deeper dis- turbance has any other origin than the growth in a lymph space of the connective tissue of a colony of bacteria, a streptococcus or staphylococcus more frequently than other forms, which has been caused by the migration thither of individuals to whom the road has been opened by the changes in the more superficial layers to which I have referred. Necrosis and liquefaction of the connective-tissue cells and of their fibrils is the immedi- ate result of the engorgement of all the channels with lymphocytes and polynuclears. That all of these are of extraneous origin is not probable. They serve not only to block the efferent channels of infection, but to furnish material in their dead bodies for the formation of pus at the ACUTE INFLAMMATIONS OF THE THROAT 299 centre of the infiltration. Around this we have the persistence of the initial changes in the mucosa itself referred to above. While distant tissue infection is occasionally manifested as the results of a quinsy or even of a lacunar tonsillitis, such as a nephritis or an appendicitis, while direct extension along the cellular planes of the neck is a still more frequent sequela, the wall of engorged lymph spaces usually limits the focus of sepsis. The burrowing of pus in the planes of the neck is in infants apt to produce a general bulging of the posterior pharyngeal wall as well as of the lateral wall behind the tonsil. This condition, known as retropharyngeal abscess, is frequently due not primarily to tonsillar disease but to the breaking down of a tuberculous gland or to the extension of suppuration from a tuberculous focus in the bone of the spinal column. Symptoms of Acute Naso- and Oropharyngeal Inflammation. — ^When we come to consider the clinical aspect of the subject we recognize that, no less than is the case with the pathological histology, one appearance merges so into another, the relation of subjective signs varies so widely that it is impracticable to consider them apart as separate disease entities. A catarrhal pharyngitis may quickly become a deep pharyngitis or quinsy, or it may pass off without even the appearance of mucous plugs in the lacunse. This being so it seems more rational to treat of the subject as one of interrelated phases or aspects rather than to divide it into septic pathological entities. The first symptoms of acute pharyngitis are discomfort and dryness in the throat, which are followed by irritation or pain and a desire to clear the throat of the presence of a foreign body by hawking or coughing. These symptoms may increase until swallowing, either in eating or in getting rid of the saliva that accumulates in the mouth, is associated with acute pain. Occasionally there may be a slight chill followed by a tem- perature of 100° to 102° F., which condition will be accompanied with malaise, headache, stiffness of the neck, and pain in the back and shoulders. The voice is thick and nasal, and when the catarrhal con- dition extends toward the larynx it may be lost entirely. The tongue is coated, the breath foul, and there is considerable thirst. Constipation is often present. There is little or no difficulty in examining the pharynx in these cases, such as may be experienced in the examination of cases of quinsy or tonsillitis. The pharyngeal wall is of a deep, congested red, more or less swollen, which condition may be exaggerated in certain localities. The lateral pharyngeal walls are frequently involved and are also thickened and red, and stand out distinctly from the general curve of the pharynx. The other structures of the pharynx, as the soft palate, uvula and tonsils, may be involved and the uvula in particular becomes congested and edema- tous and sags downward into the larynx, producing a gagging, choking sensation. It is frequently this swollen condition of the uvula which produces the sensation as of a foreign body in the throat, and of which the patient complains as much as of the discomfort of the pharynx proper. Mucus is secreted in great quantities and hangs in masses from the 300 THE INFLAMMATION OF THE PHARYNX palate and pharyngeal wall, but it is more easily detached than in chronic pharyngitis. In the acute catarrhal tonsillitis the initial chill followed by fever is frequently absent, and in the beginning the patient may not complain of local pain at all; in fact, the inflammatory conditions may exist for a day or so without any other symptom than malaise, unusual thirst, and a sense of depression. This simple inflammatory condition may be the result of digestive disturbances or a manifestation of an underlying rheumatic condition, and may pass without any of the exaggerated symptoms that characterize a follicular tonsillitis. In the follicular variety, however, a chill followed by a temperature ranging from 100° to 104° is often associated with backache, headache, pains in the shoulders and limbs, general malaise, sharp pain in the tonsillar region extending upward toward the ear, acute pain associated with difficulty in swallowing and great prostration. The secretions are markedly increased, the uvula and soft palate swollen and possibly edematous, the lateral pharyngeal pillars thickened, all of which conditions tend to make the voice thick and nasal. On lying down the patient has difficulty in breathing, and will frequently snore while sleeping. The glands of the neck are swollen and tender, the pulse is accelerated, reaching frequently to 120, and the blood-pressure is raised. The temperature may fall to normal or even subnormal in the morning, rising as night approaches. The bowels are constipated, digestion is poor, and the skin alternately cold and clammy, followed by increased surface heat. Examination. — It is often difficult to get a good view of the pharynx as the inspection is accompanied with gagging and retching, and the jaws are somewhat fixed. If the condition is observed in the early stages one tonsil only may be affected, but in the majority of instances the other tonsil becomes affected shortly afterward. The first inspection may reveal only a highly congested state, presenting a livid red hue, with no spots appearing, or on one tonsil there may be isolated areas of a yellowish- white deposit on the surface of the tonsil, which on the second day may have coalesced, forming a general membrane, or both tonsils may be covered with these isolated areas. Inflammation extends to the faucial pillars, soft palate, and pharynx, which present the appearance of a gen- eral pharyngitis. These little islands of broken-down tissue usually occur in the opening of the mouth of the crypt and are in the beginning below the surface and can be easily wiped away, but repeatedly recur. When these islands have coalesced they form a membrane over the sm-f ace of the tonsil quite similar to a diphtheritic membrane, but it may be more easily detached and the under surface looks raw. It does not bleed as easily as in diphtheritic cases. In follicular tonsillitis the membranes do not invade the mucous surfaces of the soft palate, while in diphtheria it extends up on the soft palate and uvula. A swollen tonsil frequently pushes the soft palate upward, and by pressure and the production of venous stasis produces an edematous condition of the palate and uvula. The tonsUs may reach such size that they come in contact in the middle line and offer great obstruction to both respiration and deglutition. ACUTE INFLAMMATIONS OF THE THROAT 301 The whole throat is filled with a thick, tenacious mucus, which the patient is inclined to let drip from the lips rather than to bear the pain which accompanies swallowing. The voice, owing to the infiltrated palate, becomes husky and almost unintelligible, and an attempt at swallowing liquids will frequently result in a regurgitation through the nostrils. The tongue is coated, the breath foul, and the general aspect of the patient if that of suffering. The face becomes pale and anxious, the patient is nervous and despondent, and the loss of sleep and the absence of food occasion rapid loss of weight and a general depression, which is more marked in this class of cases than in any other tonsillar involvement extending over the same length of time. The urine becomes cloudy and highly colored, but rarely shows the presence of albumin or casts, which is a distinguishing feature from diphtheritic involvement. The act of swallowing necessitates the patient extending the head forward, preceded by a pause in which to get the secretions or fluid down into the laryngo- pharynx before making the effort, and is quite characteristic of follicular tonsillitis and quinsy, while in diphtheria the effort is by no means accompanied with such pain. From diphtheria it may be differentiated by its sudden onset, greater constitutional manifestation, bilateral involvement, greater pain, higher temperature, greater diflBculty in the examination of the throat, a more circumscribed area of infection, i. e., not extending to the mucous mem- brane and soft palate and the uvula, less bleeding when the membrane is removed, the absence of albumin in the urine, less likelihood of tonsil- litis in young children, and finally the absence of the Klebs-Loffler bacillus. From the tonsillitis of scaralatina it is more difficult to make the diagnosis. In scarlet fever the age of the patient is often under that in which you would expect a follicular tonsillitis. Both tonsils are usually attacked at the same time and are equally involved. The redness of the tonsils and pharynx is more diffuse and more intense than in tonsilhtis, and the buccal mucous membrane is likewise involved. Associated with the involvement of the tonsils and pharynx is the characteristic straw- berry appearance of the tongue, upon which the papillae are markedly enlarged in the very early stages. Upon the second day of the involve- ment of scarlet fever the face becomes flushed, the skin is hot and dry and the pulse very rapid, and upon the neck and shoulders may be seen the first evidences of the typical scarlet-fever rash . The general symptoms of septicemia are more marked and the glands are involved at an earlier stage and may go on to suppuration. The Eustachian tube and middle ear are more frequently invaded than in tonsillitis, and the urine will show in all probability the presence of albumin. These being the symptoms and the characteristic appearances of the severer forms of pharyngeal inflammation it remains not only to remark that the physical appearances vary greatly, but to recognize that a slight erythema of the throat is often the extent of the surface mani- festation of some inflammations of its mucous membranes. Still more important is it to remember that even more serious clinical pictures 302 THE INFLAMMATION OF THE PHARYNX are seen in the conditions commonly referred to as quinsy, Ludwig's angina, and septic sore throat, yet all really belong in one category insofar as the exciting cause, the pathological processes, and the con- tinuity of the symptoms are concerned. It is probably the internal or systemic factors, it is the resistance which the patient offers to an inimical environment including bacterial invasion, which tells for the severity and the character of the symptoms. These, as has been said, vary greatly in different cases. Pain. — ^The complaint of a sore throat is common to them all. It is rare that this is so specifically located as to draw attention to the naso- pharynx, yet to a greater or less extent the nasopharynx and the larynx, as well, are, even in acute catarrhal pharyngitis, likewise the seat of inflammation of the mucous membrane. In a general way the severity of the dysphagia is a gauge to the extent of the inflammation, especially as regards the depth to which the subepithelial tissue is involved, so that with severe sore throat we will be pretty sure to find swelling due to the subepithelial infiltration with the products of inflammation. It is true there are numerous exceptions to this rule. One is dependent upon the temperament of the patient. One patient will make loud complaint of a passing erythema in the throat which in another patient does not elicit even incidental remark. In certain patients who have an atrophic condition of the pharynx, especially in anemic women, pain is often severe, even with a comparatively mild and superficial involve- ment of the mucous membrane. Other patients may exhibit to the examiner widespread and deepseated inflammatory disease accompanied by edema, lacunar tonsillitis, even quinsy, with only moderate com- plaint of discomfort from the pain. Rhinorrhea and hoarseness, indicating the existence of a rhinitis and laryngitis, is the rule, but this varies much in the attacks of acute pharyn- gitis. A much safer guide than pain, in the general clinical picture of subjective symptoms as an indication of the gravity of the attack, is the history of initial chill and the temperature range. In adults the former may be severe; in children the latter may be high in any given case without necessarily implying the existence of diphtheria or of septic complications. In such cases bacteremia is frequently present. Careful blood cultures with an adequate amount of blood (10 to 20 c.c.) will show very frequently a growth of streptococci, less frequently of staphy- lococci, which have been said to be of more serious prognostic import. Neither, however, should give rise to any undue apprehension when unaccompanied by evidences of distant septic lesion, since bacteremia in sore throat of moderate severity is of very much greater frequency than is commonly supposed. Duration depends essentially upon the depth of the inflammatory changes. A superficial catarrhal infiammation is often practically over in forty-eight hours so far as the subjective symptoms go, and the objective appearances last but little longer. Lacunar tonsillitis, or follicular tonsillitis, is regularly seen in all sore throats when the severity of the catarrhal pharyngitis has passed a ACUTE INFLAMMATIONS OF THE THROAT 303 moderate degree, and is seen very frequently in those in whom there exists some faucial and nasopharyngeal tonsillar hypertrophy even when the general congestion of the mucous membranes is of the slightest. More or less concrete white spots are seen upon the tonsils representing plugs of mucus, fibrin, and leukocytes in the crypts. The degree to which the tonsil protrudes will depend on its state of chronic hypertrophy. Sometimes there is no protrusion beyond the faucial pillars, but the latter are swollen and edematous, and partly hide the condition of the tonsillar crypts by their approximation. In such conditions the secre- tion of the crypts protected from attrition of food and drink is not washed away and the concrete spots coalesce into a continuous false membrane. In a certain proportion of these cases of faucial lacunar tonsillitis the use of postpharyngoscopy will reveal a like picture in the nasopharynx. The lymphoid hypertrophy arranged there in the form of ridges and slits shows an analogous deposit of secretion. Membranous tonsillitis is but an exaggeration of this lacunar exudate. Owing to the abundance and the coalescence of the cryptal exudates a false membrane forms. This may be slight and not very adherent to the surface, so that when wiped away with a pledget of absorbent cotton the lacunae alone are seen to persist in exhibiting a white exudate. On the other hand the false membrane may be excessively thick and tenacious, clinging firmly to the tonsillar surface. We have seen such a membrane apparently an eighth or a quarter of an inch thick, and black on the surface, yet not extended beyond the limits of the tonsillar surface. Diphtheria in the first forty-eight hours may have the same local appear- ances, but a membrane of this kind limited to the tonsillar structure on the third day after the onset of the cryptal exudate is usually not associated with the typical course of diphtheria. Peritonsillitis, or quinsy, belonging to the severer forms of sore throat, always shows not only its own characteristic local appearances but those of catarrhal and lacunar tonsillitis. The pain is sometimes very severe. Swallowing is performed with great difiiculty. The jaws are set. The saliva drips from the corners of the mouth. Prostration is extreme and the fever high. Examination shows a bulging anterior pillar with a swollen but not necessarily a voluminous tonsil behind. The venous stasis from pressure gives a dusky hue to the surface and the edges of the soft palate and the uvula are usually edematous, the latter sometimes excessively so. The whole affair is sometimes a picture of apparent peril, yet a fatal issue is very uncommon. Palpation with the finger will usually show by the third day a spot of softening due to the determina- tion of the pus beneath the mucosa. With this feeling of fluctuation there is usually considerable tension of the surface. The spot where these signs are most often and soonest appreciated is roughly defined as half-way on a line between the root of the uvula and the crown of the last upper molar tooth or a little below it. Pus, however, may be found anywhere around the tonsil, the next in frequency to the spot mentioned being the infratonsillar region. In children it is often behind or under the tonsil, amounting to a postpharyngeal abscess. The formation of 304 THE INFLAMMATION OF THE PHARYNX a nidus of pus, as a rule, does not reach a stage in which the abscess cavity can be located and opened by incision before the third day from the date when the peritonsillar process begins. This period may be lengthened several days, and not infrequently the abscess discharges spontaneously with a gush of pus through one of the lacunae, before its presence has been located and it has been evacuated surgically. Patients are liable to subsequent attacks. It is in this class of patient one notices the coincidence of a history of rheumatism and not infrequently the attack of quinsy precedes an attack of rheumatism in such a suggestive way as to justify the conclusion of some etiological connection between the two. This question we have already discussed. Quinsy may begin either as a primary infection or as secondary to a follicular tonsillitis. When secondary the symptoms associated with follicular tonsillitis will necessarily precede those of quinsy. In primary infections, without evidence of previous follicular tonsillitis, the first thing noticed by the patient is a sense of fulness of the side involved. Speech becomes thickened and salivation increased, which symptoms become more exaggerated as the quinsy ripens. Difficulty in swallow- ing and localized pain over the side involved occurs during the act of deglutition. On the second day all these conditions are more exaggerated and pain becomes intense and referred to the ear. A swelling over the tonsillar region externally, which is exquisitely tender to the touch, is recognized. The jaws become more or less fixed and the patient has great difficulty in opening them sufficiently, either for examination of the throat or the ingestion of food. The pain is so intense that the patient will frequently do without food rather than experience the discomfort incident to swallowing. The voice becomes peculiarly nasal and of such quality that it alone almost differentiates quinsy from other throat infections. Constitutional symptoms are frequently marked, there being often a chill followed by fever, general malaise, headache, and an anxious expression of the countenance, indicative of pain and quite characteristic of quinsy. The act of swallowing, which is necessitated frequently by the increased saliva, is associated with peculiar movements of the head and neck, with extension of the head forward and cringing down to the shoulder on one side, while the patient grasps that side of the throat with the hand. Examination of the throat will reveal a large, extremely reddened swelling of one side, involving the tonsillar and supratonsillar region, and extending up into the palate. The soft palate and uvula are ordinarily edematous, particularly if the quinsy has lasted for several days. It may be difficult to obtain a view of the entire mass, owing to the fixation of the jaws. The throat is filled with secretions and the outer surface of the tonsil may be covered with a membrane, which represents broken-down epithelium mixed with mucus and leukocytes. In some cases both sides are involved and the two swollen masses come together in the centre of the throat, which con- dition materially increases the gravity of the case. Epidemics of lacunar tonsillitis and membranous tonsillitis are met with, associated with septic symptoms of considerable gravity. Many ACUTE INFLAMMATIONS OF THE THROAT 305 such cases terminate fatally from exhaustion or from involvement of the internal organs, the heart or kidneys, in the process. They often, but not always, have been traced to foci of infection in connection with the milk supply. While this has been the tendency of sanitary authorities of late years, defective sewerage was once equally incriminated, but inasmuch as the majority of individuals are known to have partaken of the tainted milk with impunity, and in view of the fact that sewer laborers are not known to suffer from contagious sore throat, common-sense compels us to reject such etiological theories as unsatisfactory, though there is no reason to deny to them a belief that they may account for occasional factors in the chain of events. There are always plenty of streptococci both in sewage and in milk, and when there is a distinct coincidence of cases at the source of supply and along the routes of distribution of the milk there is a fair probability that the milk is an agent. Another coincidence may be remarked, however: The cessation of the reports of sewage epidemics with the spread of the knowledge that streptococci and diphtheria bacilli do not readily rise from damp surfaces. An appreciation of the lack of completeness in the chain of reasoning as to etiology based on a purely bacterial etiology of disease will do much to facilitate the discovery of other factors. In all these cases of the severer forms of simple acute pharyngitis, in acute lacunar tonsillitis as well as in quinsy and septic pharyngitis, there is submaxillary glandular involvement and an often apparent engorgement of the lymph spaces which causes quite visible external swelling. Even when it is not apparent to the eye it is sensible to the examining hand. In a manner, therefore, there is a gradation of areolar infiltration through all the more or less arbitrarily divided clincial varieties of sore throat. In, all the severer forms the pharynx and fauces are filled with a tenacious and abundant secretion difficult to void, fre- quently the cause of much discomfort, and always an indication for the use of detergent mouth washes and gargles. Septic Pharyngitis or Erysipelas of the Pharynx. — With this complex of the various forms of pharyngeal inflammation, more frequently with severe lacunar tonsillitis and with peritonsillitis, there is seen a form whose manifestation in the pharynx is that of rapidly extending blebs and blisters already alluded to. It may be associated with erysipelas of the skin, and it is apt to be accompanied by a septic temperature' and the evidences of systemic infection. This is a condition rarely accompanying more or less severe inflamma- tion of the tonsils which is marked by edematous infiltration of the submucosa of the pharynx to such an extent that festoons of membrane may be seen along the borders of the soft palate, and the uvula is enor- mously swollen and the whole mucosa streaked and spotted here and there with a thin, non-adherent false membrane . The edema often extends to the epiglottis and into the larynx, and may there give rise to the in- dications for prompt tracheotomy or intubation. Glandular swellings are present. This condition may accompany erysipelas or it may exist as a purely pharyngeal affection. Virulent streptoccoci are found, usually 20 • 306 THE INFLAMMATION OF THE PHARYNX in the form of long chains, abundant in the secretions. All degrees of systemic reaction are noted in these cases and the degree to which this goes is not always proportional to the amount of local involvement. Associated with the lesions mentioned, foci of pus may form around the tonsils, presenting the appearance of a peritonsillitis; but in these cases the collection of pus is apt to present itself in exceptional localities, either high up in the soft palate or deep beneath the tonsillar structures. Ludwig's Angina. — Closely associated in etiology at least with the cases of septic pharyngitis or erysipelas of the larynx are cases of deep infiltration of the sublingual and submaxillary connective tissue with the products of inflammation, so that great swelling is observable around the jaws, usually bilateral. This swelling, which extends across the front of the throat, is often of a board-like hardness, and it is to this quality that we owe the separation of the affection into a clinical category apart from the other inflammations of the throat. It seems probable that the ordinary local pharyngitis, the septic or erysipelatous pharyngitis, the Ludwig's angina, associated as they are usually with the presence of streptococci in the tissues and in the secre- tions, are the expressions of variations in the systemic and local resistance to the organisms with which they are associated, but inasmuch as these organisms are found in the healthy throat and seem to be in their patho- genicity mutation forms of the saprophytes, the systemic factor in all these inflammations would appear to be the most important. The board-like hardness of the infiltration of the tissues beneath the jaw we have already alluded to. The typical cases to which this nomen- clature has been attached are not common. They usually give this history of the attack immediately supervening upon a period of pro- tracted alcoholic debauch. The systemic depression is profound. The interference with respiration is sometimes of a dangerous nature. The prognosis is bad. It is seen, we believe, only in men. Even with the prompt external incisions recommended for it these patients not infrequently die with the complications of endocarditis and peri- carditis, and in a state of asthenia. It is true that the disease does not always present so sharp cut a picture as this, and cases are seen which may be considered as forming a connecting link with the forms of quinsy and septic pharyngitis of a less severe type. SequelcB. — ^Upon the etiological connections of some of these cases with rheumatism we have commented, and we have alluded to evidence of local and systemic suppurative lesions, endocarditis, nephritis, appendi- citis, etc., as representing foci of infection which has begun with a tonsillitis- While we feel that the coincidence of tonsillitis and of rheumatism is fundamentally due to their dependence on a common systemic factor rather than existing as cause and effect, while we believe the frequency of the coincidence of tonsillitis and suppurative lesions elsewhere has been grossly exaggerated, it cannot be denied that there is occasionally good grounds for the belief in an etiological connection between them. The local sequelae are chiefly those of the ear complications and the lymphoid hypertrophies or chronic tonsillitis and pharyngitis. ACUTE INFLAMMATIONS OF THE THROAT 307 Treatment. — Prophylactic. — The prevention of colds, so far as they are dependent upon habits which enervate the peripheral nerves, is a part of the duties of the medical attendant, easier of accomplishment than the cure of them; but it never receives that gratifying acknowledgment which is secured through the aid the patient has received from the regular course of Nature's cure and mistakenly ascribed to the physician. Were the prevention of colds only dependent upon the constant exercise of the peripheral circulation, their control would be an easy matter. Frequent excursions in the open air; sleeping with open windows; the cold plunge in the morning; muscular exercise and the friction of the skin; deep, rapid respirations ; frequent and more or less rapid exposures to cold and warm air, or the constant living in the open air would prevent them. In- deed the latter has been shown effectively to do so. But the matter is not so simple as this, nor are all the above recommendations susceptible of complete realization in the practical routine of civilized life, especially in the cities. Many of them would be perilous for the enervated system of the hot-house bred individual at once to adopt. If such an individual is earnestly bent upon putting himself in the best physical condition in the future to prevent colds (and such earnest vows are usually only taken to be violated) he must proceed judiciously. Vigorous exercise in the open air, but not too much or too rapid cooling off; the gradual lowering of the temperature of the morning bath never to pass the point when the body cannot be made to glow by vigorous friction afterward; exposure at night not at first to drafts of cold air, but to it in its stationary state, etc. — these are necessary cautions to give in the regimen prescribed above. Unfortunately, as we have set forth in the etiology of cold-taking, it is not only the epidermal and the muscular tissues which need the alter- nate expanding and contraction of their peripheral bloodvessels.- The internal organs must be in a correspondingly physiological condition. The nephritic, the cardiac, the gastric, the intestinal functions and struc- tures must be in order not only to allow the peripheral exercise to be taken with impunity, but their diseased states in themselves evidently place the sympathetic nervous system in a condition over-receptive to impres- sions which are badly translated in their peripheral manifestations; suffice it to say that the specialist must in this instance, as in many others, broaden his faculties of judgment to take all these matters into account in the process of hardening through which he wishes to put his patient. If a physiological state of the general system is the indispensable pre- liminary to the prevention of a cold, the physiological state of the upper air passages themselves is scarcely less so. The laryngologist should thoroughly appreciate the fact that desirable as symmetry is, a tortuous nasal passage is often quite capable of performing its functions, that a moderate excess of lymphoid tissue in the fauces and pharynx is not necessarily a thing of evil in its influence; often they are much less harm- ful than the void left by a nasal spur removal or the fibrous scar tissue left by a curettement of the pharynx. With this warning, which we believe has been too often ignored, it must be left to the judgment and the con- scientiousness of the physician to decide what he is to do to put the upper 308 THE INFLAMMATION OF THE PHARYNX air passages in proper order to diminish the frequency of cold-taking in his patient. Finally, with sound internal organs, with a body periphery properly groomed and exercised, with upper air passages capable of moistening, warming, and filtering a sufficient current of inspired air, the dangers of infection during the disturbances set up by cold-taking will be all but abolished. Yet it would be egregious folly not to admit that there are numerous facts as yet unknown to us, both as to the imme- diate and the predisposing causes of cold-taking and its consequences. These the revelations of the future can alone explain to us. Still more evident is the practical fact that people as a rule cannot be made to carry out a regime which their education does not permit them to understand, which their sloth does not allow them to adopt, and which the exigencies of practical life do not permit them to exercise. Direct. — Once initiated to the extent of the transudation of the cellular and watery contents of the bloodvessels of the pharyngeal or nasal mucosa into its stroma, no cold is "aborted." Until that stage is reached no one knows whether it would have been a cold or a congestion. Opiates may obtund the senses and quinin may divert the attention from the itching in the throat to the roaring in the ears, atropin may stop the exudation through the epithelial line, but none of these things will drive the products of inflammation back into the vessels. The protection of the surface of the body from cold, the breathing of a pure moist and warm air, attention to the functions of the digestive tract may be attained by remaining indoors, eating lightly, and taking a purge. The inhalation of a warmed and moistened air by means of some form of steam-producing apparatus is of advantage in the first stages of a sore throat as it is in coryza. The use of some form of gelatinous troche grateful to the taste and capable of diffusing a film over the pharynx, such as some of the many forms of licorice or tragacanth, will be pleasant and quite as efficacious as some of the atrociously tasting pellets recommended for their supposed but occult medicinal powers. As secretion becomes abundant and the patient passes into the second stage of a sore throat, detergent gargles or fine, gentle sprays of Dobell's solution or of listerine well diluted may some- times be employed, though unless the patient is impressed with their desirability they may be omitted. Later for these there may be sub- stituted some astringent gargle or spray. As recurrent attacks of pharyngitis are frequently due to improper ventilation of the nasal chambers it is advisable first to have established proper ventilation of the nose and nasopharynx, by correcting septal deviations and reducing existing hypertrophies of the turbinated struc- tures. Second to have corrected constitutional irregularities, as hyper- acidity of the stomach, gastro-intestinal fermentation, constipation, hepatic torpidity, and rheumatic diathesis. One of the best things to begin treatment with is the administration of 3 grains of calomel at night, followed by magnesium sulphate the next morning. This purgative should be followed by a daily admin- istration for a week of phosphate of soda each morning and bicarbonate of soda, I dram in a half-glass of water after each meal. To overcome ACVTE INFLAMMATIONS OF THE THROAT 309 the rheumatic diathesis, which underlies this condition in many instances, sodium salicylate, salol, salicylic acid, aspirin, bicarbonate of lithia, or colchi-sal may be administered until it is entirely over- come. In the later stages when the secretions become thick, irrigate the nasopharynx with hot water and Dobell's solution by means of the postnasal syringe, after which apply silver nitrate, 10 grains to the ounce, or argyrol, 10 per cent, solution. Pellets of ice frequently taken relieve the congested condition, and free libations of cold lemonade are very acceptable as well as helpful to the condition. The patient should be instructed to gargle frequently with a solution of bicarbonate of soda, I dram to half-tumbler of hot water, which is to be followed by a gargle or spray of alumnol, 20 grains to the ounce. Neglected acute pharyngitis frequently results in a chronic condition or in an extension to the larynx, which makes the voice husky and unreliable. Tobacco and alcohol must be absolutely forbidden during the attack of pharyngitis. A general tonic treatment should be given during convalescence and the patient instructed to regulate the diet and clothing and take systematic exercise. The old method of administering small repeated doses of tincture of aconite with an occasional dose of 3 to 5 grains of quinin is still adhered to by many practitioners. As there is an intimate relation between rheu- matism and tonsillitis the salicylates or aspirin, to which may be added antipyrin or phenacetin for the relief of pain, has often been most beneficial in shortening the attack. Guaiac internally and guaiacum lozenges sucked at intervals are productive of considerable comfort. Locally, frequent irri- gations of hot saline solution or hot alkaline solution administered by the foimtain syringe with the nozzle of the tube directed against the affected tonsil is very productive of comfort, and perhaps prevents the absorption of a great deal of toxic material which would otherwise accumulate upon the surface of the tonsil. The severity of the attack has been frequently lessened by employing a dental syringe and washing out each crypt sepa- rately with hot Dobell's solution, after which there is applied to the crypt of the tonsil equal parts of guaiacol and sweet almond oil. Instead of the guaiacol there may be used a 25 per cent, solution of argyrol, or Kyle's mixture of: 1} — 01. eucalyp., Ol. cassiae aa Ttlij Ext. pini canaden TTlx Tinct. benzoin q. s. ad giv The patient should be directed to employ at home first an irrigation of either hot saline solution, hot water and Dobell's solution, hot chlorate of potash solution or hot listerine solution, which will wash away the mucus and other detritus covering the infective area, after which a gargle of: IJ — Tinct. ferri chlor ..... 5 ij Glyc .... q. s. ad gij Sig. — Sj to S j of hot water. should be employed, the patient subsequently using a bicarbonate of soda mouth wash. 310 THE INFLAMMATION OF THE PHARYNX If the patient can be induced to swallow this mixture it makes the local application more thorough. The Leiter coil or an ice-bag externally will in the beginning of tonsillitis be of great comfort, but as the disease progresses hot applications are more grateful. Abundant nourishment is of considerable value and, as liquid food is harder to swallow than semi- solid, soups and broths should all be thickened with soihe substance to make them of a semisolid character. Lemonade taken in quantity through a straw is not only soothing but acts favorably upon the kidneys. As the convalescence proceeds in children, the syrup of iodid of iron is most beneficial. Fig. 201 Point of incision for peritonsillar abscess. This we believe is the best plan to pursue for all those forms of acute sore throat which have not gone on to excessive surface exudate in the form of a membranous tonsillitis or subepithelial infection in the form of a quinsy. The latter condition may be suspected from the bulging of the anterior pillars and from the previous history of the patient. Those who have had one or more attacks of quinsy are apt to have others every time they have a sore throat. The severity of the constitutional symptoms often lead these patients to keep to their beds or they should be told to do so. Difficulty of swallowing compels them to take a liquid diet. They should be given a saline purge; as many of them have a rheumatic history they should be put on free doses of the salicylates or salol and cardiac examination should be made to see that during the attack they have not gotten up an endocarditis or a pericarditis. The urine also should be watched for evidences of nephritis. In short, these patients should be treated as the sick people they are and counselled not to go about until the symptoms have abated. Inspection of the throat should be made at least twice daily, and as soon as the determination of pus can be made out an incision should be made to evacuate it. The best instrument for this is a triangular blade, the back of which is continuous with the long shank ACUTE INFLAMMATIONS OF THE THROAT 311 and handle and the point and edge very sharp. A dull point very much increases the pain of the incision. With the edge of the blade turned toward the middle line and its back to the cheek the spot of greatest bulging, in at least three-quarters of the cases situated half-way between the base of the uvula and the top of the tonsil opposite the last upper molar tooth, is pierced by the point of the blade in such a way that the line of puncture is away from rather than toward the vessels of the lateral pharyngeal wall. The line of incision should be directed downward and inward in such a manner that it makes a transverse section of the fibers of the faucial muscles rather than a slit between them. The former will remain patent until the abscess cavity heals from the bottom, the latter will quickly close and necessitate reopening. Properly made it is not necessary and we believe it undesirable to probe the cavity or do further violence to the tissues. The incision should not be more than | inch long and its depth regulated by the bulging. Before making the incision a small pledget of cotton saturated, but not dripping, with a 20 per cent, solution of cocain should be held on a probe or long forceps against the area of the proposed incision. After the latter, gargling with hot alkaline, solutions should be encouraged in order by the motion of the pharyngeal muscles to express the contents of the pus cavity. It is often necessary to do something to relieve the pain of the patient before the pus has formed. The tension is often great and sometimes an incision made at the locality indicated in order to cause local bleeding gives relief, but usually this is best attained by the application externally of large, hot, slippery-elm poultices. Opiates, as a rule, are inadvisable, though a Dover's powder at night renders such a patient much more comfortable. Hot alkaline gargles also tend to relieve the pain. Such patients on recovery should be advised to have the tonsils removed or the crypts thoroughly destroyed, and to carry out prophylactic measures already referred to. Quinsy is the most frequent resultant of a follicular tonsillitis, and it is often produced, according to some observers, by the use of peroxid of hydrogen injected directly into the follicles and driving the infection up- ward into the soft tissues. This may be true in theory, but in the expe- rience of many peroxid has proved a valuable remedy for cleansing the crypts. However, it may be wise first to use hot Dobell's solution to free the crypt of the greater part of the infective detritus. Quinsy follows in a great many instances in those patients subject to rheumatism and who have had recurrent attacks of tonsillitis. Otitis media is another frequent sequel, but may be prevented by keeping the nasopharynx cleansed by the use of the postnasal syringe with hot Dobell's and water, followed by a 1 per cent, solution of argyrol. The infection may occasion- ally travel downward in the soft tissues of the neck, producing phlegmon- ous conditions of the whole side of the pharynx and larynx and possibly result in death. Cardiac and kidney lesions are by no means infrequent results of follicular tonsillitis. In those cases of paralysis of the pharynx or soft palate which are seen later, it is always possible that the diagnosis has been incorrect and the physician has had to deal with a case of diphtheria 312 THE INFLAMMATION OF THE PHARYNX instead of simple follicular tonsillitis. A number of conditions such as orchitis, pleuropneumonia, osteomjelitis, pyemia, endocarditis, as we have said, have at least followed so closely upon the attack of tonsillitis that it may be reasonably associated with it. Occasionally in those cases subject to recurrent attacks of quinsy the first symptom will lead the patient to take measures that may prove abortive to the formation of pus, such as applying ice externally in an ice-bag. The physician will then instruct the patient to apply argyrol, 10 per cent., to the infected tonsil, applications of equal parts of guaiacol and sweet almond oil and the internal administration of antirheumatic remedies, as aspirin, salol, sodium salicylate, etc. If these measures do not prevent pus formation they may at least lessen the severity of the attack. A rare but very dangerous sequence to quinsy is hemorrhage. It is due to necrosis of a bloodvessel adjacent to the abscess cavity. These hemorrhages are occasionally fatal and a number of cases are on record where every attempt at controlling them has proved ineffective. Where the quinsy is of long standing the necrosis of the tissues may extend back- ward and outward into the region of the neck where the larger vessels are situated, but it is doubtful if the carotids have ever been involved in any of the instances cited. In those cases of long neglect sometimes seen in the clinics the patient should remain in the hospital overnight following the incision, for when the hemorrhage begins it is usually fast and furious. A second sequence is the extension of the quinsy down the lateral pharyngeal wall or even an extension of the pus down through the fascia of the neck into the thorax. In some instances there will occur a phlegmon of the larynx or epiglottis which presents grave symptoms. Edema of the larynx sometimes occurs, which is rapid in its progress and fatal in its termination. Membranous tonsillitis usually calls for no exceptional treatment after the diagnosis is thoroughly established. Until then, careful isolation is to be resorted to. Indeed, as this form of acute tonsillitis is apt to be seen in epidemics of septic tonsillitis, the quarantine should be maintained until the recovery of the patient. The patients are kept in bed on light diet and the antiseptic gargles and sprays referred to for lacunar tonsillitis used. The signs of sepsis, high temperature, chills, etc., are to be met with every attempt, by nutrition and stimulation, to sustain the patient's strength. In cases accompanied by extensive infiltration of the tissues of the neck the prognosis is very grave. As soon as evidence of its becoming general, spreading to the front of the neck from the region over the tonsils and the surface hardness indicating a state of lymphatic stasis, when the typical picture of Ludwig's angina is present, deep incisions should be made into the tissues externally and drains inserted to keep them open in the hope thus to lessen the absorption of infection or its biochemical derivatives by the general system. Internally the mucous membranes are to be carefully inspected and any bulging area incised. Scarifications of the general infiltration of the surfaces is often desirable. So far as ACUTE INFLAMMATIONS OF THE THROAT 313 possible the mouth and pharynx and nose should be irrigated with warm alkaline antiseptic solutions. Postpharyngeal Abscess. — Etiology.— It occasionally happens that after an attack of coryza and pharyngitis, a young child may be found to have this condition as a sequel to it. All the cases, however, cannot be traced in their origin to an acute inflammation of the pharynx or tonsils. An enlarged cervical gland, usually the site of a tuberculous lesion, breaks down into a purulent sac alongside the pharynx and the pus burrows up and down the fibrous planes at the back and the side of the larynx. The same extension may take place from a tuberculous process in the bodies of the cervical vertebrae. Symptoms. — ^The symptoms may be obscured in the beginning of the abscess by the infectious diseases which precede it, such as measles, scarlet fever, or diphtheria. Where the abscess arises from entrance of infection through the retropharyngeal area, temperature varying from 100° to 104° may precede the development of the abscess by several days, but in the majority of instances the abscess forms slowly and insidiously. The symptoms may not present themselves for several weeks. The first thing noticed is disturbance of respiration where the inspiratory effort seems to be more difficult than the expiratory. There is difficulty in swallowing, the child usually giving evidences of pain or it may refuse the breast or bottle entirely. The mouth is kept open and the child snores while sleeping, leading the observer to suspect adenoids. The head may be held fixed or may extend to one side or the other, which condition should direct one's attention to the retropharynx. The glands, particularly those of the postcervical region, are frequently enlarged and tender. There is often considerable dyspnea, dysphagia, restlessness, and a croupy cough. As the condition progresses the child may become cyanosed. Ordinarily the patient is emaciated and pale, the skin is cold and clammy, there is considerable drooling from the mouth, and in some instances the disease progresses until asphyxiation is imminent, before which time there may be delirium and convulsions. The respiration is increased, the pulse is rapid and weak, and the child gives every evidence of septic absorption. The tumor seldom occupies the central portion of the pharynx, but will occur either on one side or the other and may be directly behind the soft palate or deeper down in the laryngopharynx. Unless the patient's head is held directly forward there may be a muscular pro- tuberance in the pharynx, looking suspiciously like an abscess, and this often leads to an incorrect diagnosis. The swelling of the abscess varies from one the size of the ball of the thumb to that of a pigeon's egg, or, as happens in some instances, it may burrow out through the tissues of the neck and point externally. The surface over the swelling is usually pale or but slightly red, and the neighboring tissues are seldom, if ever, indurated. Palpation will reveal a soft, fluctuating mass, the limits of which in an infant it is hard to determine, as the surrounding tissues themselves give almost the same feeling. In infants, however, the finger can be relied upon more definitely than the examination with the tongue 314 THE INFLAMMATION OF THE PHARYNX depressor, as the child usually gags and struggles so that inspection is difficult. Occurring in an infant, as they usually do, this condition often decei\'es the unwary and not infrequently eludes the detection of the more ex- perienced. The patient snores at night and has some apparent difficulty in swallowing. The range of temperature is elevated, but often the child does not appear very ill, and yet an infant with a collection of pus behind its pharyngeal wall is in grave danger. It may present as a generally diffused fluid which shows no definite tumor or bulging, but the whole posterior pharyngeal wall, pushed forward, narrows the breath and food channels. In one case we mistook the condition for an enlargement of the tonsil on one side. It overhung the entrance of the larynx and obstructed breathing. Not until this was amputated and the lateral pharyngeal wall was seen still to bulge was the diagnosis made. The examining finger with difficulty appreciates fluctuation, but a loose, doughy feeling is imparted by the mucous membrane to the examining finger. Pressure exerted externally at the side of the neck will sometimes aid the examiner to appreciate the existence of pharyngeal wall infiltra- tion. When the collection of pus is localized by containing walls its detection is not difficult, but the diffused condition often makes trouble for the diagnostician. This state of affairs is often more serious than appears, for the purulent matter may apparently fill the connective- tissue planes from the base of the skull to the thorax. It is astounding in some of the cases to see the amount of dirty, offensive pus that is released by incision. Treatment. — Evacuation of the pus by surgical means is urgently indicated. Not only may compression of the larynx and trachea cause death, but septic troubles may ensue from such a focus in such a locality'. The question of operation hinges chiefly on the origin of the pus. If that is in reality a tuberculous lymph gland or a tuberculous vertebra, an external incision and external drainage is doubtless indicated, but if it is idiopathic or evidently the result of a previous inflammation of the pharyngeal mucosa, we believe it best to evacuate the matter through an incision of the mucous membrane of the pharynx. The patient is wrapped in a towel, preferably without resorting to general anesthesia, and held with head dependent and extended. A bistoury point guarded by the finger and kept from wounding the tongue is carried into the child's pharynx and a deep incision is made as near the middle line of the posterior pharyngeal wall as possible. The child is quickly turned over so the pus will drain from the mouth and nose. Under anesthesia some of the pus is apt to find its way into the trachea, which exposes the child not only to the danger of immediate suffocation but to the danger of a subsequent septic pneumonia. Owing to these reasons some operators prefer, in all cases under anesthesia, to dissect down along the anterior border of the sternocleidomastoid muscle to the pharyngeal musculature and, perforating this and the pharyngeal fibrous aponeurosis, give exit to the pus through a channel less open to the objections apparent in the description of the internal operation. It will happen occasionally that ACUTE INFLAMMATIONS OF THE THROAT 315 Fig. 202 Position for opening abscess — retropharyngeal. Fig. 203 Position for draining pus from abscess — retropharyngeal. 316 THE INFLAMMATION OF THE PHARYNX the internal incision does not reach the pus or does not satisfactorily evacuate it, when the external operation must be resorted to. On the other hand the production of a long scar, the opening up still further of connective-tissue planes to infection, the anesthesia and its after-effects, the subsequent dressings, all, we believe, are arguments against the external operation except when the pus cannot be reached by internal incision and when the origin is a tuberculous cervical focus in a gland or in the vertebral column. CHRONIC PHARYNGITIS. The various manifestations of the process covered by this term have received a number of different names. Atrophic pharyngitis and hyper- trophic pharyngitis are terms to indicate stages, while nasopharyngitis and lateral pharyngitis are designations to define localities. They are, however, more or less arbitrary categories, which while having perhaps some clinical justification, to which heed will be given, have little histo- logical significance. Histology. — ^The structural changes in chronic pharyngitis have been to some extent referred to in the discussion of the pathology of acute conditions, and will subsequently be taken up in that of chronic lymphoid hypertrophy. The epithelium in places is thickened, in others thinned by the increase or diminution of its layers. The surface cells are cornified to a greater extent than normal in those parts supplied naturally with squamous epithelium, while in those supplied with columnar cells there has been a metaplasia to a more or less squamous type. We have already referred to the new deposits of lymphoid- cells around the gland ducts, many of them showing germ centres. As red clusters they show in sharp contrast to the color of the surrounding atrophied membrane or serve to form a considerable part of the thickening of an hypertrophied mucosa. It is largely in the distribution and in the amount still remaining of this lymphoid hyperplasia that we are to seek a structural cause for the con- figuration and surface appearance of chronic pharyngitis. Its diffuse infil- trating state tells for the thickening of the mucous membrane, while its partial absorption tells for the granular appearance mingled with atrophy to which is sometimes given the name of granular pharyngitis. The absolute amount of fibrous tissue appears to be diminished in all cases, a state of affairs in contrast to the condition of it in chronic rhinitis. While here and there may be seen localized thickenings of the fibrous, deep layers, the new connective tissue is formed only as a support to the diffused lymphoid infiltration which is an expression of the chronic inflammatory condition. The glands are many of them altered in structure by the invasion of their territory by the products of inflammation. This goes on in the later stage of atrophic pharyngitis to a marked degree and seems to be responsible for some at least of the dryness of the pharynx. The bloodvessels are dilated and often form a red map tracery on the posterior pharyngeal wall which gives a striking picture of contrast in atrophic cases. This CHRONIC PHARYNGITIS 317 being the outline of the changes in the minute structure of the mucosa apart from those of the lymphoid structure described more at length, there are the local gross appearances and the stages in the process to which allusion must be made in the description of the pathology. Chronic Nasopharyngitis is a term which receives its appellation rather for clinical than anatomical reasons. Nevertheless there are certain gross features which must be signalized. In the process of regression of lym- phoid hypertrophy which, beginning in adolescence goes on in adult life, the lymphoid cells disappear or rather diminish into insignificance com- pared to the epithelial and fibrous elements. The median recess deepened by the existence of a pharyngeal bursa, if such there be, becomes in a certain proportion of cases a veritable sinus, though chiefly by the agglutination of the surfaces of the folds of the mucous membrane which limit it. It may be a burrow with a blind posterior end or, the anterior end also occluded, it may become a veritable cyst cavity lined by epithe- lium and filled with secretion. These are rather uncommon, but they have been reported. They present themselves in the examining mirror as salient rounded swellings with broad bases, the longer diameter lying anteroposteriorly in the fornix of the pharynx. When these remains of the former pharyngeal tonsil have not so widely departed from normal as to form a sinus or a cyst, the deep furrow which exists giving lodgement to retained secretion serves to prolong and accentuate a condition which gives rise to the symptoms of postnasal catarrh. This in its more com- pletely developed state was once known as Tornwaldfs disease. Accom- panying this pathological state of the pharyngeal tonsil there may be a degree of general hypertrophy or atrophy of the pharyngeal mucosa suSicient in itself to give rise to distressing symptoms. There will not infrequently be seen stretching across the fossa of Rosenmiiller fibrous bands forming synechias, which have beneath them pits and sinuses arising from this complication of the configuration of the part. The condition arises in the same way as do the structures which result from the chronic inflammation of the walls of the median recess. The lateral recesses also may exhibit like dehiscences and in some very rare cases a sort of veil of fibrous tissue seems to have resulted from the agglutination of surfaces from beneath which the lymphoid elements have shrunk away, leaving a sort of false roof to the nasopharynx. By postnasal mirror, by probe and finger, these conditions, some of them not very uncommon, some rarely seen, may be appreciated by the examiner. Histologically the degree to which from the subepithelial tissue the lymphoid cells have disappeared varies greatly. The cutting forceps will in certain cases bring away little but fibrous tissue, while in other cases the tissues wiU show under the microscope all the features of lym- phoid structure. While these are conditions of much interest, it must be realized that they are more or less exceptional. Nevertheless, they will be found in the nasopharynx with a frequency in exact proportion to the care with which posterior rhinoscopy is carried out, and to the diligence with which the surface is explored by probe and finger. Aside, however, from these somewhat exceptional features of nasopharyngeal 318 THE INFLAMMATION OF THE PHARYNX pathology, the products of inflammation first embarrass the functions of the bloodvessels and the glands. The lymphoid, and fibrous hyperplasia which take part in this are but the structural expressions of the process which is emphasized in the engorgement of the bloodvessels and the exaggerated activity of the glands. As the result of this, permanent dilatation of the smaller arterial stems occurs and the gland cells grow granular while the gland acini dilate, and finally both their number and their efliciency decline to such an extent that the normal mucus is no longer secreted to lubricate the pharyngeal wall, but a vitiated secretion which does not flow promptly but terids to evaporate and form semi- solid mucous masses or dried secretion. With thickened epithelium, with dilated bloodvessels, with a fibrosis which stiffens the pharyngeal coats and presses upon the gland ducts, with the isolated clumps of lymphoid structure we get the typical picture of an atrophy following an hypertrophy. It will be understood that thus far we have dealt with the process as a sequel of the acute inflammations in which the lymphoid structure in childhood is so often involved. Atrophic Pharyngitis. — The question as to whether we are able to recognize a process apart from this sequel of lymphoid hypertrophy and secondary to hypertrophic and atrophic rhinitis we believe may be answered in the affirmative. In the sense of the disturbance of function resulting from intranasal disease producing pharyngeal sequelse, we think there is distinct clinical evidence to warrant us in looking upon many pharyngeal and laryngeal catarrhs as essentially secondary in their etiology. The improper warming and filtering and moistening of the inspired air is doubtless more influential in bringing about a nasopharyn- gitis than is the irritation of nasal secretion. For the most part this latter drips along the side of the pharynx and doubtless has its influence in the production of a lateral pharyngitis, but chronic pharyngitis in general may be considered due to alteration of the inspired air rather than to an alteration in the normal nasal secretion. We think the idea of an extension of the inflammatory process by continuity of structure from the nose may be definitely dismissed. We do not believe it occurs. Naturally this implies that we are skeptical of the occurrence of an atrophic pharyngitis because the coexistent rhinitis is atrophic in form. We believe a chronic pharyngitis occurs as the result of nasal disease which may be atrophic. This chronic pharyngitis, just like the chronic pharyngitis from nasal occlusion may become atrophic, but there is no reason to suppose there is a specific etiological connection between atrophic pharyngitis and atrophic rhinitis. As a matter of fact the evidence points the other way. Atrophic nasopharyngitis is the disease of middle adult life in men. Atrophic rhinitis is the disease of adolescence and early adult life in women. Etiology. — The coexistence of the two affections, the coexistence of pharyngeal crusts with those of nasal ozena afford no argument against the tenability of these views. There is no climate in which individuals are exempt from nasopharyngeal catarrhal symptoms. Some cases owe their origin to the salt airs of the northern seaboards; some, to the dryness CHRONIC PHARYNGITIS 319 of the western plains, according to the views of the sufPerers themselves. Previous inflammation of the lymphoid tissue, existing intranasal abnor- mality and finally gastro-intestinal disturbances are the chief elements in the etiology. As to the latter, some caution, we feel, is necessary in accepting it. People with acid dyspepsia, either as a result or as a part of a general condition, are neurotic and irritable. Dropping nasopharyn- geal secretion and all the rest of it are noticed when they would not be in more phlegmatic people. Nevertheless, doubtless there is some ground for the belief in the unfavorable influence on the nasopharynx of gastric catarrh. What we have said in regard to the alteration in the functional capacities of- the nose covers not only the cases of abnormal roominess of the fossse due to atrophic disease, but those thus afilicted as the result of injudicious intranasal operation. Many patients, after the destruction of the turbinated bodies or after certain devastating operations on the ethmoidal, sinuses complain of pharyngeal dryness and irritation, which in itself gives us a clue of value in the etiology of naso- pharyngeal disease. We are not aware that the moisture of tropical countries is blamed for the symptoms of nasopharyngitis; so that it seems likely that the chill of the surfaces so often an incident in the experience of city dwellers on the moist northern seaboard and the lack of moisture, with the dust of the plains, are each of them the factors in climate inimical to the comfort of patients who have nasopharyngeal mucous membranes whose structure has been altered, so that its functional capacity is impaired yet able to work efficiently under those special conditions of warmth and moisture favorable to the systemic or the local exigencies of the patients. Lateral Pharyngitis. — It remains to speak of a lateral pharyngitis. Extending from the pyriform sinuses below on each side to the lower border of the fossa of Rosenmiiller, involving the lower pharyngeal insertion of the posterior pharyngeal pillar and its free edge, there is often observed, especially in men, a thickening and infiltration of the mucous membrane presenting a reddened, nodular, irregular surface. Sections made for microscopic examination show the unevenness of surface and thickness of subepithelial tissue to be due largely to deposits of lymphoid tissue richly supplied with germinal centres. Mingled with these are the ducts of numerous racemose glands around which the round cells seem to have clustered. The inference is that they have gathered there as the result of a chronic irritation set up in the racemose gland structure. This condition has sometimes been called the lateral pharyngeal tonsil. Its existence is frequent and when exaggerated it forms the lateral member of the "Ring of Waldeyer" constituted above by the adenoids, below by the faucial and lingual tonsils. Symptoms of Chronic Pharyngitis. — ^The objective appearances have been largely alluded to. They vary somewhat, chiefly in the amount and the tenacity of the secretion covering the surfaces of the pharynx, in the degree of congestion of the surfaces, and in the localization of the hyper- plasias to which we have alluded above. The subjective complaints are those of increased secretion, of the hawking and disagreeable noises 320 THE INFLAMMATION OF THE PHARYNX and strenuous pharyngeal efforts leading to retching and actual nausea in the morning. The patient is conscious of phlegm dropping from his soft palate and running down the posterior pharyngeal wall. In the atrophic state chiefly, but also in the stage of hypertrophy, crusts may cling so tenaciously to the surface that the patient seeks to remove them by gargling or douching or by the use of the index finger. Stinging or burning pains plague these people in the morning hours and frequently a dull headache. They are apt to feel better by afternoon, but sometimes on the approach of evening the dryness and irritation of the pharynx again render them uncomfortable. Most of them have more or less tinnitus aurium and catarrhal deafness. These symptoms may last for many years and finally abate with the approach of age or the correc- tion of the intranasal condition on which the pharyngeal condition depends. It may be greatly ameliorated by change of climate; indeed, from the way some of these patients seem to respond to climatic con- ditions one is led to suspect that there is more than one factor of climate in the etiology. Certain it is that some of these patients will declare that their " catarrh" is due to and coincident with their removal to a hot, dry climate — others that it is due to the northern sea air. The fate of these patients, their comfort and their discomfort, will depend largely on the ability of the attending physician accurately to ascertain the causes of the disease in each individual case, and upon the ability of the individual to procure for himself the requisite treatment. Most of the causes are preventable ones, and most of the symptoms are capable of amelioration by skilful treatment. Indeed, usually time eventually cures the case, but it may be a long time. We mean by this that old age here as in atrophic rhinitis is accompanied by certain circulatory changes which favor the disappearance of the symptoms of postnasal catarrh. Discomfort may be said to be the predominant symptom of this form of pharyngitis except, as happens at varying intervals, an acute con- dition is superimposed upon the chronic, at which time the patient will complain of the throat being sore, aching, or he may complain of the sensation of a foreign body, like the presence of a fishbone or of a pin pricking. The excessive mucus thrown out from the over stimulated muciparous glands produces a continuous dripping into the larynx, or if the liquid constituents of the secretion are evaporated, a thick, tenacious mucus will adhere to the inflamed surface. The endeavor to liberate the throat of the mucus is associated with hawking, gagging and coughing, although there is usuaUy little result from such efforts. There is a frequent desire to swallow and preceding each sentence uttered by the patient a close observer wiU notice that there is an effort to swallow several times before the sentence is begun. Pain is seldom present, except an aching sensation which becomes very annoying after use of the voice, or the act of swallowing may be occasionally painful. There may be some cough present which appears exaggerated for the conditions existing. The lateral piUars of the pharynx may be very much thickened and red throughout, with here and there a reddened papule standing CHRONIC PHARYNGITIS 321 out from the general surface of the pillar. When the pillars are involved there is greater constitutional disturbance and pain will be experienced in one or both ears. It is often difficult to convince the patient that there is nothing directly the matter with the ears to occasion the earache. The Eustachian tubes are occasionally involved, followed by stuffiness in the tube and sometimes by slight disturbance in hearing. Examination in most instances is accompanied by retching and discom- fort to the patient, who will generally draw back and wish to expectorate as soon as the spatula is placed on the tongue. Occasionally even the sight of a tongue depressor or the thought of opening the mouth will occasion gagging. The mucosa of the pharynx presents an uneven red appearance, congested and bluish looking in spots, the unevenness beins; due to swollen mucous glands. Interspersed among the glands may be seen congested veins which stand out prominently from the surrounding surface, and which are evidences of venous stasis due possibly to gastro- intestinal disturbance. The uvula is frequently enlarged and thickened, due in a measure to the constant tendency of the patient to draw and suck down from the nasopharynx to relieve this region of its attached mucus. In due course of time the uvula becomes chronically enlarged and will tend to irritate and tickle the pharynx, which produces a part of the cough attendant upon these conditions. The tonsils frequently share in this process and may be subacutely inflamed and hyperplastic. Examination of the larynx will likewise reveal a catarrhal thickening, principally in the interarytenoid space, but often of the cords proper. This thickening in the interarytenoid space prevents the proper coap- tation of the cords upon vocalization and produces hoarseness. The mucus is seldom increased except when an acute attack is superim- posed upon the chronic condition, as a great many mucous glands have been lessened in their activity by previous hypersecretion, and likewise by the fibrosis that forms incident to the inflammation. That mucus which is excreted dries quickly and adheres with great tenaciousness to the pharyngeal wall. Pharyngeal effort at its removal results occasion- ally in rupturing some of the smaller bloodvessels of the mucous membrane, and the mucus is then tinged with blood, and that which remains forms a bloody scab upon the surface, peculiarly irritating in character. Public speakers, particularly those who speak in the open air, are frequently subject to this kind of pharyngitis, and in course of time the length of their discourse is materially lessened by pain and the fatigue incident to voice use. Catarrhal conditions of the stomach are often attributed to a pharyngitis of this nature, but in all probability the stomach disturbance is the cause rather than the effect of the pharyngitis. The subjective symptoms of atrophic pharyngitis vary materially in the different cases. In some, the same symptoms as are experienced in follicular pharyngitis are merely exaggerated, such as hemming, hawking, frequent attempts at swallowing, and a constant desire to moisten the throat. In other instances the patient experiences but little discomfort, even though the pharyngeal walls and the nasopharynx are perfectly 21 322 THE INFLAMMATION OF THE PHARYNX dry and with apparent disappearance of all muciparous glands. When the patient does complain it is most frequently of dryness in the throat, with morning retching and vomiting, occasioned by futile efforts to dis- engage the dried mucus and scabs attached to the pharynx. Use of the voice ordinarily increases the discomfort and becomes so annoying that the patient frequently absents himself from association with his fellow- beings to avoid this annoyance. The atrophy frequently extends down- ward to the laryngopharynx or even to the trachea, which produces exag- gerated hoarseness or even loss of voice. The dried, scabby secretions will form in the larynx and trachea, frequently producing a complete cast of the trachea, which may be coughed up in a solid mass. Few local conditions are accompanied by so pathetic a clinical picture as when the entire mucosa appears atrophic from the nose down to the bronchi. The picture presented varies in appearance from the first stages of the disease to' the later stages. In the beginning the mucosa is pale, dry, and glistening, with here and there islands of dried mucus attached to the sur- face. During this period it is not so difficult to detach the mucus, and there is slight evidence of break in the continuity of the pharyngeal mucosa. Later the mucus becomes dried over the surface almost con- tinuously, and where it is detached there will occur ruptures of the small vessels or a break in the mucous membrane, and the extravasated blood mixes with the mucus which dries and forms a scab, this adding discomfort to the patient's suffering. When the mucus is cleared away raw spaces or eroded areas will frequently be noticed on the pharyngeal wall. The other structures of the pharynx, such as the pillars and uvula, are attenuated and the prominences of the vertebral bodies are distinctly discernible upon the postpharyngeal wall. These conditions are the result apparently of excessive smoking or particularly of excessive drinking. Treatment. — The first attention of local treatment of chronic naso- pharyngitis should be directed to removing the tissue, which affords a structure for the persistence of sinuses or cysts with their secreting sur- faces. Once carefully explored by probe and finger and the extent of these appreciated, the most practicable course is by means of a slender postnasal cutting forceps to remove the thickened mucous membrane which hides them. Sometimes this does not present projections which can be seized and torn away. In tolerant patients, with the guidance of the mirror, a bent galvanocautery electrode may be used to lay open and destroy such sinuses. It is always desirable and usually necessary to carry these procedures out under local anesthesia. Cocain applied by spray or applicator will usually suffice, though some difficulty is sometimes experienced through the circumstance that the action of the cocain tends rather to increase than to lessen the reflexes. Care and skill on the part of the physician and persistence on the part of the patient, as well as of his own, will almost always in the adult result in the operator gaining such control over the patient's throat that, with a probe or cautery in the right hand and as large a postnasal mirror as practicable in the left hand, he can explore and destroy the nasopharyngeal tissues, and the patient, who quickly learns to lend his aid by depressing the tongue with CHRONIC PHARYNGITIS 323 a Tiirck instrument, from it will suffer no great pain nor inconvenience. In adolescence these conditions do not often occur, and when they do they are associated with a redundancy of lymphoid tissue, the removal of which under general anesthesia accomplishes the purpose. The bands of tissue which stretch from the Eustachian cushion across the fossa of Rosenmiiller, in our experience, are not of frequent occurrence, nor do they seem to give rise usually to any aural or pharyngeal symptoms. When the latter exist as the result of nasopharyngeal structural change, of which the structures referred to are a part, their removal may be easily accom- plished, but when they exist alone or as the chief structural abnormality not much result will follow their ablation. These being the local gross anatomical lesions of postnasal catarrh to which operative treatment may be rationally applied, attention must be turned to those cases in which no such gross lesions are discoverable. These form by far the majority of the cases which come under observation. With the exception of vascular dilatation and some scattered lymph nodes beneath the epithelium, there seems no anatomical abnormality to which surgical attention can be directed. Manifestly there is some disturbance in the secretory functions of the mucous membrane or there is some over- flow from the nasal passages of a secretion too vitiated or too abundant to be properly disposed of in the pharynx. This latter class of patients complaining of nasopharyngeal disease is a large one. All intranasal structure — ^that of the accessory sinuses as well as that of the foss8& proper — must be carefully explored and endeavors made to remedy by surgical or other methods such intranasal trouble as exists. A lateral pharyngitis often exists as a sequence of the intranasal or of the postnasal lesions whose operative treatment has just been discussed. Little is to be attained by local treatment, operative or otherwise, in these cases. The nasopharynx and the intranasal structures having been put into good condition a very large porportion of the cases suffering from postnasal dropping and pharyn- geal irritation will be much improved or entirely relieved. A certain number of cases, however, prove that "postnasal catarrh" can exist with- out an appreciable amount of postnasal lesion or intranasal lesion. Some of the excess of secretion and the pharyngeal irritation may be due to gastro-intestinal irritation or to what we are pleased to call the rheumatic or gouty diathesis, whether anatomical lesions of the nose and pharynx coexist or not; but certainly with a pharynx or a nose fairly normal to the naked eye, this is not often the case. We confess treatment directed alone to these conditions which may coexist do not often ameliorate the pharyngeal irritation except in those cases in whom it ameliorates the general irritability. Finally many cases of nasopharyngitis and oropharyngitis derive a certain amount of relief from the use of the postnasal douche. They may be taught to use it themselves, and while its curative effect on the structural lesion is probably small, it is indicated in those cases in whom nasopharyngeal and intranasal operation has failed to relieve all the symptoms, and in those cases in which atrophic rhinitis is associated with atrophic lesions of the pharynx, or at least with the existence of 324 THE INFLAMMATION OF THE PHARYNX pharyngeal crusts. In certain cases of idiopathic origin the postnasal douche gives relief, and in some who accuse the climate, but in those asso- ciated with gastro-intestinal trouble, with rheumatism, with neurasthenia, etc., it accomplishes nothing. Various applications of an astringent nature, or of a supposedly specific virtue, such as nitrate of silver, iodin, tannin, iron in their various prescriptions, form part of the routine medication in the pharynx. We are not convinced they are of any value. The galvanocautery has been used to destroy the lymph nodules on the posterior and lateral walls, but it is questionable whether the scar tissue thus substituted is not as objectionable as the lymphoid. Occasionally obvious benefit has resulted from destruction of nodules in the movable folds of the mucosa or those of the general pharyngeal surface upon which the folds of the palate or of the faucial pillars rub. We have seen no result from destroying with cautery the little superficial capillaries which stand out in relief against the pale background. We believe that this and the cauterization of the lymph nodules, with the exceptions noted, are bad practice. The cauterization of the lymphoid tissue of the pharyngeal, faucial, and lingual tonsils proper is frequently advisable. From fear of hemorrhage, from the objections of the patient, from the small size or flat shape of the lymphoid tissue, one may often derive reasons for the use of the cautery in the surgery of the tonsils themselves, but elsewhere in the oro- or nasopharynx it should not be employed, and the cutting operations, when not contra-indicated, should be preferred, as the result- ing fibrosis is less and the operation itself more effective. The constitutional treatment is virtually the same as that for acute pharyngitis; especially tonics should be given, as iron, arsenic, and phos- phorus. The administration of phosphate and sulphate of soda, Carls- bad salts or Epsom salts to relieve the local venous stasis is advisable. Kyle has obtained favorable results by giving after each meal drugs which are eliminated by the mucous membranes and recommends the'following combination: 3— Phosphori gr. ^^^ lodini, Bromidi aa gr. | Vini xerici 5j In public speakers and singers vocal rest is most essential, during which time every care should be directed toward securing proper food, proper hygiene, and absolute abstinence from alcohol and tobacco. Frequent irrigations of the pharyngeal wall with hot alkaline solution, such as bicarbonate or biborate of soda, 10 to 20 grains to the ounce, followed by a very mild astringent gargle, such as a 5 per cent, solution of argyrol, will aid materially in bringing about a restoration of the voice and lessen- ing the fatigue which previously had followed use of the voice. Tincture of guaiac 10 minims to the ounce of hot. water is of material benefit in those cases where rheumatism is associated with the disease. Iodine prepara- tions may be used locally with benefit provided they are not too strong, and No. 1 Mandl's solution (see formula p. 226) is to be preferred to the CHRONIC PHARYNGITIS 325 stronger preparations, and should be applied only after the pharynx has been thoroughly liberated of all attached mucus. The follicle itself may be reduced by the local application to its centre of either fused nitrate of silver or chromic acid, or, as is recommended by Thomson, touched with a glass rod, the tip of which has been moistened with dilute hydrochloric acid, trichloracetic acid, or pure carbolic acid. Care should be exercised to prevent the spread of any of these applications to the adjacent mucosa, and to prevent this the pharynx should be made as dry as possible before the application is made. In atrophic pharyngitis first liberate the scabs and secretions by gargling or mopping the throat with equal parts of hot water and per- oxid of hydrogen, after which the pharynx and nasopharynx should be irrigated with equal parts of hot water and Dobell's solution or some other alkaline lotion. After the secretions have been thoroughly re- moved applications may be made of equal parts of ichthyol and lanolin or Mandl's solution No. 2, or 25 per cent, argyrol solution. Attention should be directed to the cause of the trouble, particularly to the con- dition in the nose, as being the primary source of the pharyngitis. Cleans- ing of the throat three or four times a day followed by these applications is essential to favorable results. All irritating stimulation should be avoided, as it only tends to overstimulate what remains of the mu- ciparous glands, and they in turn exhaust themselves by excessive activity. The internal administration of tonics, particularly the syrup of iodid of iron, seems to influence in a measure the local condition. Massage of the throat has its many advocates and relief can unquestion- ably be obtained in some instances through its proper use. Careful attention to diet and hygiene, together with overcoming any septic condition of the sinuses, which might by their discharges produce second- ary inflammatory conditions in the pharynx, will often materially lessen the discomfort incident to atrophy. The restoration of destroyed mucous glands can never take place, but if the diseased area can be kept clean and a reasonable amount of activity be established in those glands which remain the discomfort of the patient may be materially lessened. At best the conditions of chronic pharyngitis are susceptible of amelioration only. The correction of intranasal troubles may do much to relieve the patient's pharyngeal annoyances. If to this is added some change of climate to be selected purely on an empirical basis considerable relief, even comparative comfort, is possible. Climatic influences are poorly understood and so modified by the individual systemic, temperamental, and local idiosyncrasies of the patient that the attending physician must exercise his tact as well as his laryngological lore in giving advice. CHAPTER XII. CHRONIC HYPERTROPHY OF THE PHARYNGEAL, FAUCIAL, AND LINGUAL TONSILS, AND OF THE UVULA. Pathology. — Sufficient has been said (p. 277 et seq.) of the finer anatomy of the tonsils in general to permit the remark that it is but little changed in those pathological conditions kn6wn under the clinical name of hyper- trophied tonsils or the sunken tonsils. In the former the fibrous septa shooting in from the capsule are larger and more abundant. This varies greatly in relative amount of fibrous tissue present. Sometimes it may be so great that little of the lymphoid structure is apparent. This relative preponderance of the fibrous structure is often quite as marked in the sunken small tonsil as in the larger ones. The relative amount of epithelium also varies. These variations in the amount of the fibrous hyperplasia and of the epithelial keratosis are due doubtless quite as much to the retrogression of the lymphoid cells as to the hyperplasia of either the fibrous connective tissue or the epithelium. The greater the fibrosis the thicker, as a rule, are the fibrous coats of the arterioles. The small atrophied- tonsils present this characteristic, of considerable clinical import, quite as often as do larger growths. Fibrosis is apt to be very much less noticeable in the regression of the pharyngeal tonsil than in that of the faucial tonsil. This process of fibrosis frequently goes on in such a way that the lymphoid cells in certain convolutions of the branching crypts are cut off from the rest of the tonsil. Gradually the strand of fibrous tissue making the connection becomes a pedicle, so that a considerable mass or masses of the tonsils can be moved and are finally self -amputated. To this one of us has given the name of autoclasis. This peculiar process may in rare instances be multiple and reduce the tonsil to sessile sprouting masses which have been mistaken for papillomata of the tonsil. A tonsillotome blade in making a section across the base of such a tonsil may bring away a large number of surface projections connected so loosely by the fibrous tissue at the base that they fall into separate masses when removed from the blade of the instrument. Whatever the gross appearance, an enlarged tonsil shows practically the same lymphoid structure as has already been described at length in the remarks on the normal lymphoid tissue. The fibrous framework, as intimated, presents a broader process of fibrous connective tissue. The lacunar and surface epithelium is increased in the number of its layers and in the extent to which the surface layers have become corneous. Practically all tonsils which have undergone hypertrophy as the result of chronic inflammation show this increase in the hyaloid layers at the surface, consisting in the fusion of the cell bodies and in the loss of the nuclei. We shall have PATHOLOGY 327 something more to say of this when we come to deal with the exaggeration of this epithehal change, known cHnically as keratosis or wrongly as pharyngomycosis. We have already referred to degeneration of the solid epithelial prolongations into the connective tissue in the embryo, by means of which the crypts are formed. It is the pathological continua- tion of this physiological process by virtue of which in the tonsil as we know it clinically the lacunae are deepened and widened and contain a large amount of epithelial keratinoid detritus. This being the nature of the change in the superficial epithelial layers, the basal layers present an appearance which has been interpreted in two ways: 1. In chronic inflammation the mononuclear lymphocytes, acting as phagocytes in large numbers, congregate at the base of the epithelial line and either destroy or engulf, after their vitality is gone, the basal or germinal layer of the epithelium, so that at places there is little or none of it left but the hyaline layer. They are prolonged cl,own into the coarser lymph spaces along the fibrous planes, where they become fewer and indistinguishable from the typical connective-tissue lymphocytes. 2. The other view, chiefly that of Retterer, of Cordes, of Wood, of Wright, is that, owing to the disturbance of the germinal layers of the epithelium which forms part of the general process of chronic inflamma- tion, there occurs a proliferation and to some extent a mutation of a basal epithelial cell into what is essentially a connective-tissue cell, i. e., the form of a mononuclear lymphocyte. There is in this view no attack upon the epiblastic cell by a devouring mesoblastic cell, but follow- ing a well-recognized biological law a disturbance in cell nutrition is the origin of an alteration of cell growth and cell form. This change occur- ring in the less sharply differentiated cells of the germinal layer of the epithelium finds more easily an expression in the cell form which, ceasing to be a fixed cell of the epithelium, takes on either the form of a fixed connective-tissue cell or gives birth in proliferation to wandering cells of the lymJ)hocyte type. While we prefer to accept the latter interpretation it is not a question to be argued further here. Suffice it to say that in many places in chronic inflammation of the pharyngeal, lingual, and faucial tonsils the limiting membrane between stroma and epithelium disappears and a broad and irregular zone of the cells is seen which, morphologically, it is impossible to distinguish on the one hand from basal epithelial cells and on the other from connective-tissue cells. There can be no denial that they do take up into their bodies the various constituents which have become the debris of other cells, but this is an argument neither for or against their belonging to one or the other embryogenic form of cell. Numerous lymphocytes, whatever their origin, but more frequently naked nuclei, are constantly seen passing through the intercellular spaces. The latter may be arrested in their course and absorbed by the cell bodies of the basal or middle epithelial layers. It is said the latter are more commonly seen on the surface and in the lacunae in acute inflammation than in chronic inflammation, when those cells having a recognizable cell body preponderate. 328 HYPERTROPHY OF THE TONSILS AND UVULA We have already spoken of the influence of the fibrous tissue in causing autoclasis of the tonsil. The bands of fibrous tissue after a while them- selves degenerate and change into granular or hyaloid matter which fre- quently give rise to puzzling problems of histological diagnosis. Around certain areas of this kind cluster irregular collections of epithelioid and even atypical giant cells. With this morphological condition at hand in a section one is frequently at a loss to know if the appearance is due to a fibroid degeneration or to a tuberculous focus. It occasionally happens that further sections will show more characteristic tubercle, and recent work in morphology has made it appear at least plausible that some of these areas of fibrous degeneration are in reality the marks of a previous tuberculous process. In the consideration of the etiology and of the symptomatology of tonsils and adenoids we prefer, as in considering their histology, to study the subject as a whole. Neither the finer anatomy nor the etiology of the faucial tonsils is essentially different from that of the nasopharyngeal . and the lingual tonsils, while, owing to their coexistence as hypertrophied lymphoid structures, their symptomatology and, to a larger extent, their treatment are intimately interrelated. Etiology of Tonsils and Adenoids. — At one time the word "lympha- tism" was used to designate an important factor in the etiology of tonsils and adenoids. On analysis about all this seems to mean is that the lym- phoid hypertrophies of the nose and throat are more frequently observed in those subject to the overgrowth of lymphoid tissue generally, a tau- tology which has deprived the idea of much significance, though doubt- less it is not well to forget the germ of truth lying beneath it, which we realize in our acceptation of the tonsils as an integral part of the general lymphatic system. Leukemias and sarcomata associated with small round- cell proliferation find in the tonsils a site where the condition is manifested with considerable regularity, and laryngologists are familiar with a type of patient which furnislies a number of instances of cervical-gland swelling, a puffiness of the mucous membranes of the pharynx, and more or less associated with lymphoid proliferation there. The type is not well defined, and its justification from the basis of histological classifi- cation can hardly be defended beyond the hints already alluded to, yet every clinician of experience in nose and throat work will easily recall the type. The question of heredity is always a vexed one. If there is a certain strain of the human race which is more prone than others to lymphatic enlargements the fact has not been well established, so that the idea of an hereditary lymphatism rests naturally upon much more insecure founda- tion than does that of individual lymphatism just discussed. Upon a much more secure foundation rests the inheritance of cranial type in its infiuence upon the configuration of the air passages bounded by the bony walls of the superior maxilla. It has long been evident to students of human paleontology that the shape of the jaw has undergone very marked changes during the comparatively short geological period characterized by civilization. Since man used his jaws in the mastication of unprepared ETIOLOGY OF TONSILS AND ADENOIDS 329 food, and doubtless in self-defence, the strength of the alveolar processes and the width and firmness of the dental arch have much diminished. With this change in the osseous architecture, which is prominent in the minds of us all chiefly because we have a theory or two by which to explain it, has been correlated the change of broad nasal passages to narrow nasal passages. In certain races of men, in certain families of the same races of men, these departures from the cranial architecture of primitive men are strikingly more apparent than in others. These are matters of common scientific information, and indeed are universally observed by the intelligent. Unquestionably the narrow high palatal arch and the consequent narrow jaw and compressed nasal alse are associ- ated more frequently with tonsils and adenoids than the primitive type of jaw. It is true one phenomenon is occasionally seen without the other, but the frequency of their association is so striking that coincidence without any relation of cause and effect is not a tenable argument. We are driven to conclude that in a general way the one is the sequence of the other. No mechanism has ever been demonstrated which has satisfied the reason or escaped the experimental demonstration of its inaccuracy in defending the thesis that the adenoids are the antecedent and the narrow alveolar arch is the consequence in the chain of causation. We believe that all the evidence points the other way. Children have adenoids because their parents transmit to them the inheritance of narrow jaws. The parents do not have the narrow jaws as an acquired trait but as an evolutionary one. This we believe to be the chief heredi- tary factor in the etiology of the occurrence of adenoids and tonsils. We do not assert that it is the chief cause in the etiology, but we confi- dently believe it accounts for the hereditary factor which cannot be ignored. It is, however, rather to environment than to heredity we must look for the most important factor in the etiology. The chief points in the discussion of this we have already taken up in the consideration of the etiology of coryza. It is to the frequent repetition of congestions of the mucosa of the pharynx that we trace both clinically and pathologically the genesis of lymphoid hypertrophy. Aside from repeated inflammations the lymphoid tissue receives the stimulus to proliferation from the direct impact of imperfectly filtered and moistened air and of secretions of the nasal chambers and their annexed cavities. The latter are as plainly a sequence of a narrow and distorted nasal passage as are the attacks of inflammation of the nasal and pharyngeal mucosa. The continued high temperature of the modern house in winter enervates the muscles of the cavernous sinuses of the nasal mucosa just as physical inertness debilitates the biceps and triceps of the athlete. Lacking experience, lacking practice in the function which tells for the health of the nasal mucosa, the unstriped muscle fiber and the other contractile elements not only deal improperly with the inspired air when exposed to that of the external environment of the steam-heated dwelling, but the nasal mucosa itself becomes the seat of a coryza. Without going farther we think we have sufliciently developed the view that the chain of events traced backward from the 330 HYPERTROPHY OF THE TONSILS AND UVULA phenomena of tonsils and adenoids diverges into the hereditary and environmental factors of etiology, though among the latter mention may be made of the climate. The importance of this we see exemplified in the clinical experience which has observed a larger proportion of cases among the children of the northern seaboard cities. Occurrence. — ^In the consideration of the pathology we have sufBciently dwelt upon the question of age. As to sex it is said that boys are more subject to them than girls. Suffice it to say that lymphoid hypertrophy has been noted in rare instances in old men and women. Long before middle life, in the great majority of mankind, lymphoid proliferation has sunk into insignificance and the traces of its former exuberance have disappeared except for certain fibrous sequelae, such as a chronic pharyn- gitis or chronic middle-ear deafness, which have been left behind. Clinical Appearances. — The Faucial Tonsils. — These vary somewhat. It has been cogently said that the tonsil is a pathological formation when- ever it can be seen in the throat. Enough has been said to indicate how here as elsewhere the physiological state passes by insensible processes into the pathological condition. Thus far we are quite in accord with Bosworth, though the corollary we reject. There is a physiological struc- ture recognizable by close inspection and by microscopical study as a quite definite entity which we may call the tonsil as a matter of convention. The structure, however, to which the name was applied was something which was recognizable as a thing to be cut' and of the size and shape of the almond (Amygdala), and named after it by the ancients. When it is of ovoid or almond shape it is usually a sessile, unoffending, pitted body which does not markedly project beyond the plane of the internal edges of the faucial pillars. When projecting beyond this plane toward the middle line of the pharynx it assumes more and more a circular shape in the plane of its transverse diameter. Wide, gaping mouths of the lacunae are apt to be filled with buccal secretions or food if they are not occupied by the products of tonsillar inflammation. They may be so large as to meet in the centre line, and when this condition obtains in an especially capacious adult pharynx they are formidable looking structures. On the other hand they may be neither the large imposing bodies just referred to nor the quiescent almond-shaped organs we have described. They may be partly covered by hypertrophied faucial pillars which it is necessary to draw aside in order to disclose them. These are now spoken of as "submerged tonsils," an absurd name in a pathological sense, since the condition is quite manifestly due to a very moderate enlarge- ment hidden by the swollen and hypertrophied mucous membrane form- ing part of the faucial pillars. Their retracted state and the valve-like action of the mucous fold over them, preventing the occasional emptying of the lacunar pits, are responsible, doubtless, for the frequency with which patients bearing such tonsils give evidence, by the swollen state of their cervical lymphatics, of their acting as the reservoir for bacterial proliferation, and as the portals of systemic infection. In order to disclose 1 But the word is said by etymologists no< to be from the root of the latin word "to out." PLATE IV Hypertrophied Tonsils. THE PHARYNGEAL TONSIL OR THE "ADENOID" 331 the full extent of the lymphoid hypertrophy in such a patient it is neces- sary to pull aside the faucial pillars with a blunt tenaculum. The moderate-sized, almond-shaped tonsil frequently gives rise to no appreci- able symptom whatever. The Pharyngeal Tonsil or the "Adenoid." — It cannot be too often or too insistently repeated that the existence of a considerable degree of hyper- trophy of the lymphoid tissue in the oropharynx as well as in the naso- pharynx is quite consistent with a satisfactory state of the health. The sooner the practitioner gets over the idea that the tonsils are heaven- ordained structures created by a Special Providence for the repletion of the purse of the laryngologist the better it will be for the dignity of the medical profession. The appearance of the pharyngeal tonsil as seen in the postnasal mirror varies even more than that of the faucial tonsil. In children younger than twelve or thirteen years the postnasal exami- nation by mirror is usually too difficult, tedious, and unsatisfactory to warrant the use of that method of diagnosis. In older patients the lymphoid mass may present: 1. As a more or less smooth-looking tumor. 2. As a solid mass, furrowed by anteroposterior grooves, the typical gross structure of the pharyngeal tonsil with its median and lateral recesses. 3. As a grape-like bunch of tissue. 4. As blunt papillary bodies covering the whole of the visible vault. With a bent probe in many tolerant patients the skilful examiner Can explore the recesses and protuberances of the mass, thoroughly mapping out its crevices and ascertaining the limitation of the attach- ment of its lobules. Digital examination is usually preferable in children, and it is some-: times necessary in adults. In infancy it is the sole reliance. The per- formance of this really simple act on the part of the unskilled leads at times to scenes of widespread devastation of office equipment and the alarm of the neighborhood. A skilled nurse or assistant should take the little patient on his lap, fasten the legs and feet between his knees, and with the right arm thrown across the patient's body and grasping firmly the left forearm he fixes the patient's head against his shoulder by the pressure of his left hand on the forehead and over the eyes of the patient. Thus secured the physician, standing at the left of the assistant and behind him, inserting a bit of wood or other object between the patient's jaws on the left side, taking care not to bruise the cheek or gums, rapidly passing his index finger over the tongue and behind the patient's palate, a sweep of the finger is sufficient for the experienced examiner thoroughly to appreciate not only the existence but the extent and location of the soft, slightly bleeding masses, which have been graphically but not ele- gantly likened to a bunch of angle worms in the sensation imparted to the examining finger. In the absence of nurse or assistant, another maneuver is usually successful : The little patient is directed to hold his mother's or father's hands with both of his. These made secure by the cooperation of the parent, the examiner stands behind the patient, quickly 332 HYPERTROPHY OF THE TONSILS AND UVULA inserts first with his left hand the wood or other guard between the patient's jaws on the left side, and thrusts his right index finger into the pharyngeal vault as the patient throws his head back in alarm. When the patient is taken by surprise the practised movements of the examiner easily accomplish the purpose in view, and the little victim should then be given ample opportunity to express his indignation, his grief, jand his resentment at the unfair advantage taken of his trusting nature. Occa- sionally the latter is not in evidence and quick as a flash the little squirmer outwits the doctor and overawes the parent. However, the thing should be accomplished and a seemingly puny but experienced assistant will often astonish a stalwart young fellow by the ease with which he holds him powerless in his grasp while, by the first method already described, the doctor sweeps his index finger across the base of his skull. Disagree- able as all this is to the patient and his parent, no one should presume to make a definite diagnosis, much less advise operation, until by actual palpation or by perfectly clear vision the state of the lymphoid tissue in the nasopharynx is ascertained. It usually happens only once to a conscientious operator that, trusting to the assertion of another, he makes elaborate preparation, etherizes his patient, and finds nothing to remove from the nasopharynx but his finger at its first visit. This situation is one for the moralist, not the scientist, to deal with. In infants the pharynx is so small and the normal lymphoid structures occupy relatively such a large part of it that it is usually difficult or impossible properly to appreciate the anatomical landmarks and the pathological conditions. The examiner even of older children should remember that when the patient's head is thrown back the posterior part of the pharyngeal vault lies posteriorly to his finger as he places the index in the patient's pharynx. Half a turn of the finger must be made sometimes in order to ascertain or to locate the hypertrophy. Singular as it may seem the finger is more reliable than the postnasal mirror in exploration of the pharyngeal cavity, unless by pharyngoscopy the use of the probe is possible. Many a smooth-appearing pharyngeal vault is coated one- quarter or three-eighths of an inch deep with lymphoid cells which require removal. Symptoms. — ^It is by these that the conscientious operator should be guided in his attitude toward tonsillectomy and adenectomy rather than by the very simple though very unscientific consideration of the size of the tonsils and the adenoids. We have been impressed with the frequency with which the large tonsil is associated with a very good state of the general health. The patient may indeed suffer to some extent from local symptoms and from complications, but often in spite of an apparently considerable degree of obstruction to respiration the patient is well nourished and not anemic. This, of course, is not the case in a majority of patients. They are apt to be, to a certain extent, pale and flabby. This is specially marked in city , children, but those children living largely in the open air of the country, when well fed and not over- worked, often show very large tonsils and a robust general appearance. In a considerable proportion of these patients. Even in those not SYMPTOMS 333 suffering from actual deterioration of the health, there is apt to be mental hebetude usually of a slight degree. To the extent of being unable to study or to fix the attention upon their school tasks, this mental trait is rarely seen in these cases. Such cases there are without a doubt, but the extent of the mental defect has been exaggerated, since Guy many years ago described it and called it "aprosexia," and ascribed it to interference with the cerebral circulation and the lack of oxygenation of the blood. Such patients drop their jaws and do not hear well, and consequently appear stupid. They often do not sleep well. They suffer from more or less excess of nasopharyngeal secretion which interferes with digestion and appetite and thus often appear below par. There is, however, many a case of "adenoid facies" to be observed without the adenoids. The above remarks apply more particularly to. those children who exhibit, it may be, a considerable degree of faucial tonsillar hypertrophy with a moderate amount of postnasal lymphoid hypertrophy. Even with the faucial hypertrophy alone these patients are apt to suffer from catarrhal deafness and from attacks of otitis media suppurativa, but it is a mistaken idea that large tonsils are always in themselves either a menace to or accompanied by manifestations of general ill health. Many cases of eneuresis have been said to have been cured of the habit by the operation of the removal of adenoids, and we have heard other specialists say the same of circumcision. Both often fail. We do not pretend to do more than draw attention to the facts. So many children wet the bed and so many have adenoids that it is unthinkable there should not be frequent coincidence. In discussing the etiology we have spoken of the narrow jaws which go to make up the typical picture of the adenoid facies. The mouth is open, partly through habit. The patient can fre- quently breathe with ease through the nose when he closes the mouth vol- untarily, and the inference is that mouth-breathing is a habit acquired diu-ing the frequent intermittent attacks of intranasal and nasopharyngeal congestion. This is rendered extremely probable by the fact that in the majority of cases the removal of postnasal obstruction does not at once do away with the open mouth and vacant look. These children are often pigeon-breasted, and the lower lateral rib arches are sunken so one needs sometimes to lay a hand in the concavity to even up the surrounding surfaces. That some of this depends upon malnutrition and rickets and has no connection whatever with nasal obstruction we are well convinced, but it is impossible to exclude the influence of the obstruction in the upper air passages from the etiology of pigeon-breast in all cases. We only know the latter condition often obtains without the former. The symptoms directly referable to faucial and postnasal obstruction are snoring, the disagreeable snuffling indicative of improper nasal drainage, the muffled, thickened speech, the vowel sounds without resonance, and the ear symptoms already mentioned. These patients occasionally suffer from frequent nosebleed. The cervical glands are so frequently the site of a tuberculous lesion which runs an innocuous course, if the patients remain under good hygienic conditions, that the 334 HYPERTROPHY OF THE TONSILS AND UVULA conviction has grown that it is often to a latent tuberculosis rather than to a chronic hyperplasia as a sequel of simple chronic inflammation of the pharynx that we are to ascribe the coexistence of enlarged lymphatic glands and large tonsils. Notwithstanding the revelation of many facts recently which seem to justify this opinion, we think unquestionably that enlarged cervical glands are observed frequently in connection with pharyngeal and nasal inflammation to which no suspicion of tuberculosis attaches. Whether tuberculous or not they often disappear or diminish markedly in size when the source of pharyngeal irritation is removed. In civilized countries it is not often, of late years, that one has the opportunity to observe the existence and the persistence of a condition of lymphoid hypertrophy in the throat. In uncivilized coun- tries it does not for the most part prevail. Occasionally it happens that one sees an adolescent or an adult and, for other reasons than those of discovering adenoids, examines the nasopharynx. A very large proportion of such individuals will be found to have, and probably to have had since infancy, a considerable degree of lymphoid hypertrophj^ The same may be said of the faucial tonsils, with the reservation, how- ever, that being more accessible to view by the general practitioner or by the public school examiner they are more apt to be destroyed. The practical prognosis may be summed up with the remark that in people who live in the open air they are often harmless, in others living under the conditions of modern civilized life they are sure to be extirpated in the cities. That part of the question of operation which deals with its sub- division — when to operate — belongs to a consideration of the prognosis and the symptoms. That part of it concerned with how to operate will be taken up under treatment. In the absence of ear symptoms, in the absence of any marked deterioration of the general health ascribable to the existence of adenoids and tonsils, in the absence of repeated serious attacks of coryza and sore throat, tonsils and adenoids should not be removed before the child is four years old. ^After that age it is often advisable to remove them for less pressing symptoms than before it. The reasons for this are twofold: (1) it is more difficult completely ' to eradicate the trouble, and (2) the condition is more apt to be repeated by a re-growth of the tissue in the infant. The small size of the patient's oropharynx and nasopharynx often renders manipulation with instru- ments and exploration of the cavities with the finger a matter of great difficulty. From text and illustration the conception of lymphoid hypertrophy as essentially a surface or immediately subepithelial growth may have been formed. While this is largely justifiable it is not altogether an accurate view. The round-cell hyperplasia, especially in the nasopharynx, extends practically down to the periosteum. The strict interpretation of the remark that the growth has been "completely removed" is perfectly well appreciated by the histologist as inaccurate. It may in the future be considered as significant that we have clin- ically for years recognized the fact that lymphoid tissue in infancy SYMPTOMS 335 tends to be reproduced when removed. As long as the tadpole has use for a tail it is reproduced, and this is a fundamental biological law, and so it is with the infant's lymphoid tissue. However suggestive the phenomenon may be, or however much in accord with evolutionary doctrine, it has not the practical bearing which the clinical aspect of it has. A parent easily assumes a critical attitude toward an operator who has to repeat an operation. He is very likely to listen to the remark that the growth was not all removed the first time. Hence an eagerness to operate should be curbed in the case of a child under four, if for no other reason than that it is a part of worldly wisdom. For both reasons, therefore, the operation should be deferred until the patient is six or seven years old at least. Properly selected, properly operated, and properly nursed, tonsil and adenoid patients rarely die or suffer any unfavorable results from the operation. We are aware that this statement may be considered a conclusive argument in justification of the tendency to remove all tonsils. This, however, we believe is not the proper attitude to observe. Tonsils and adenoids should be removed for symptoms, not because they exist. It is quite self-evident that a little patient suffer- ing from otitis media, from repeated colds, and the inability to sleep at night, should be shorn at least of such part of his lymphoid hypertrophy as projects into his pharyngeal air passages; but it is upon these indi- cations rather than upon the mere presence of lymphoid tissue that the good sense and good principles of the medical adviser must depend to guide him in his advice to the parents of the child. Thus far we have had chiefly to consider the symptoms from the general standpoint of their bearing upon treatment and upon etiology. Closely connected as are the f aucial tonsils in their histology and etiology with the pharyngeal tonsil there are some points in the symptomatology which we have not fully detailed nor sufficiently emphasized. To these we must now recur after having discussed the prognosis and the question of when to operate in their bearing on the symptomatology. In infants the objective symptoms of adenoids are often present even shortly after birth. The child is unable to nurse for any prolonged period, releasing the nipple, crying, and making ineffectual attempts at proper nursing, snoring, snorting, and throwing the head from side to side. When sleeping the infant is restless and subject to startled awakenings, accompanied with gasps for air. Infants all endeavor to breathe through the nose, and any obstruction to this method materially disturbs their comfort, and only by long-continued effort do they ulti- mately learn to breathe through the mouth. After this obstruction has existed for some time the sternum and lower ribs will show retraction on inspiration, and from now on the chest becomes narrowed and poorly developed from the necessitated mouth-breathing. Owing to inability to properly nurse, together with the restless, disturbed sleep, the infant shortly becomes anemic, badly nourished, highly excitable, and altogether miserable. In children, if the adenoid develops after the first year or so of child life the symptoms come on more insidiously than in the infant. The 336 HYPERTROPHY OF THE TONSILS AND UVULA same disturbance of respiration exists proportionate to the amount of obstruction present. There is snoring during sleep with the mouth either open or closed. Respiration is shallow and more frequent, the chest is narrow, with retracted intercostal spaces, and the voice is flat and non-resonant. Owing to the lack of proper exercise of the nasal muscles the alee of the nose fall in, particularly on inspiration, and by a valve-like action they thus add still further obstruction to the nasal airway. In due course of time the nasal vestibule becomes a mere slit. Owing to disuse of the muscles between the upper lips and the eye, they become atrophied, resulting in a smooth, flat, expressionless condition. The fold of the upper eyelid at the inner canthus becomes enlarged and sags downward, which is very characteristic of the existence of adenoids. The child is subject to repeated colds, the nose is running most of the Fie. 204 "Adenoid faci'es." time, which produces excoriations on the upper lip, and there is frequent nosebleed. In other cases the child may have a perfectly dry nose and draw the secretions into the nasopharynx, which are then swallowed. Upon exertion the child breathes rapidly and is easily tired, and as the respiration is carried on entirely through the mouth the pharynx becomes dry and the patient complains of thirst. In eating the child bolts its food in order to obtain sufiicient air for the purposes of respiration, and it may be indigestion following this rapid ingestion of food that accounts for the temperature in children with adenoids. At any rate in these children there will often be an evening rise of temperature which cannot be accounted for, and it disappears after the removal of the adenoid. In adenoid children the lips are usually thicker than normal, particularly the upper one, which is shortened and somewhat upturned. The upper SYMPTOMS 337 teeth usually project over the under ones, the chin recedes, and the arch of the hard palate projects itself into the nasal chamber, thereby still further interfering with nasal respiration. In direct association with adenoids there is disturbance of hearing, which has been definitely established by examination of thousands of school children, in which the percentage of deafness, according to the investigator, varies from 27 to 60. Earache when associated with acute cold is one of the definite symptoms of the existence of the adenoid. Inflammation and infection of the adenoid tissue may be communicated to the neighboring Eusta- chian tube. The symptoms of acute otitis media may not be present in all cases, but even transient pains in the ear or occasional periods of deafness will be sufficient evidences of the existence of the adenoid. Enlarged cervical glands or a chain of small postcervical lymphatic glands are also indicative of adenoids. Remote secondary conditions have also been riientioned, bronchitis, anemia, gastro-intestinal dis- , turbance, and retarded chest expansion. Many reflex phenomena are attributable to adenoids, such as bad dreams, asthma, sleeplessness, nocturnal enuresis, stammering, stuttering, epilepsy, chorea, coughing and hawking, and even convulsions. The mental and physical ability of children with adenoids often is somewhat lowered. The child com- plains of headache, is indifferent to both study and play, is easily fatigued, is bad-tempered, excitable, and easily irritated. ' In adults the growth may escape notice except for the dropping of mucus into the pharynx and larynx, which at times may result in hoarse- ness and even acute laryngitis. Middle-ear deafness is not infrequent, and disturbances of hearing with unaccountable pains . in the ear, to- gether with defective vocal resonance, are the symptoms leading the observer to suspect the presence of adenoids. In examination the first inspection will reveal a collection of mucus hanging on the postpharyngeal wall, coated tongue, catarrhal breath, irregular, protruding upper teeth, spongy gums, and a high-arched palate. The muciparous glands on the posterior pharyngeal wall are enlarged and secreting mucus, with considerable venous conges- tion; the soft palate is relaxed, giving evidence of lack of muscular tone, and when the tongue is depressed and the soft palate retracted against the postpharyngeal space a clear viscid mucus will be expressed from the nasopharynx and drop into the pharynx. In some cases the soft palate may be gently lifted upon the tip of the tongue depressor and a view of the lower portion of the adenoid growth obtained. In these cases one is often able to obtain a view of the postnasa,l space by 'posterior rhinoscopy. When such is the case the observor -^ill notice a lobulated mass of soft lymphoid tissue with ridges running perpendicularly through it, and from which there will be exuding a stringy mucus, while in the crypts may be noticed deposits of cheesy matter. When the examiner is unable to obtain a view with the mirror it is necessary to make a digital examination, to the methods of which we have referred. The examiner is frequently surprised, however, to find the nasopharynx perfectly clean in cases giving the symptoms regularly ascribed to the 22 338 HYPERTROPHY OF THE TONSILS AND UVULA presence of adenoids. In these cases other nasal obstruction, such as hypertrophies, benign tumors, high-arched palate, or postnasal atresia must be sought as the cause of the general facial aspect and other signs suggesting adenoids. In nervous children, where the high-arched palate and nasal obstruction may be eliminated as the cause of the symptoms existing, and where there has been middle-ear trouble, -it is often unriecessary to examine for adenoids if the faucial tonsils are en- larged, as in nearly every instance these growths will be present. In children whose membrana tympani is retracted and dull in color, it is almost proof positive that adenoids exist. Other conditions of the middle ear, as perforations, chronic discharge, old scars, may be evidences of previous scarlatina, measles, or diphtheria. There is no operation for the relief of obstructive breathing which results in such beneficial and rapid improvement as the removal of adenoids. If these growths alone have been the cause of the disturbance noted by the patient and the physician, their removal will within a month or two produce a complete change for the better in the patient. Nourishment is taken with ease and relish, sleep is quiet and noiseless, the child becomes active mentally and physically, the apparent anemia disappears, and all of the other constitutional disturbances subside. If, however, the adenoid is not the only factor responsible for nasal obstruc- tion and a high-arched palate remains or a deflected septum or hyper- trophied turbinate, the effects of the adenectomy will be attended with only partially good results. Hypertrophy of the Faucial Tonsils. — Before we take up the subject of the removal of adenoids something must be said of the symptoms and treatment applicable to enlargement of the faucial tonsils aside from its coexistence with pharyngeal hypertrophy. Just how often they coexist is impossible to say, since no definition has been possible whereby we could draw a line between the normal and abnormal hypertrophy of either region. Suffice it to say that in children in a considerable majority of cases the existence of a hypertrophied faucial tonsil requir- ing removal is indicative of a considerable degree of hyperplasia in the lymphoid material of the nasopharynx. As a result of recurrent attacks of acute tonsillitis the structure of the tonsil becomes enmeshed with fibrous elements and there occurs a general fibrosis throughout the organ, which prevents shrinkage after the acute inflammation of the tonsil has subsided. The perma- nently enlarged tonsil offers obstruction to nasal respiration, and gives a distinctly nasal tone to the voice, and may interfere with correct speech. Tljese enlarged masses also produce venous stasis in and around the pharynx, particularly on the posterior and lateral pharyngeal walls. Deglutition is interfered with and, during the act of swallowing, food may occasionally regurgitate into the nasopharynx. The crypts of the tonsil harbor a foul secretion, which at times is expelled in the form of small pearls, which when crushed give forth a most disagreeable odor. It is probably due to these collections of detritus that enlarged tonsils often produce a foul breath as well as a bad taste in the mouth. Owing TREATMENT 339 to the diseased condition of the tonsil absorption results in enlarged cervical glands which during acute exacerbations of tonsillitis become painful. Hypertrophied tonsils induce considerable Eustachian catarrh, not only by direct pressure adjacent to the Eustachian opening, but by inducing venous stasis in that region they prevent proper pharyngeal ventilation and the drainage of the secretions. Enlarged tonsils occasion frequent attacks of indigestion, and the patients, particularly children, are often anemic, badly nourished, and nervous. The posterior pharyn- geal wall becomes irritated by these large masses passing up and down in the act of deglutition, which act is often associated with retching. When the examiner puts the spatula upon the tongue there is marked retching and gagging. Persistent cough in children has been frequently relieved by the removal of these tonsils and many nervous phenomena, to which children are prone, are likewise overcome by the same means. Upon the introduction of the tongue spatula the patient will gag, at which time both tonsils will tend to evaginate themselves and push forward, frequently coming in contact in the middle line. (Plate IV.) In children one may observe marked hypertrophy without cryptal openings, but in adult life the majority of cases will reveal the mouths of the crypts filled with a yellowish, cheesy material, which upon pressure will be evacuated. Occasionally pressure on the root of the tonsil will liberate a pus-like fluid which has apparently been held in a cystic formation within the tonsillar tissue, and it is perhaps the absorption of this material that often produces a high tem- perature in children which cannot be accounted for by the general prac- titioner. This cheesy matter and pus-like material is not always found within the crypt, but it may exist between the anterior fold and the tonsil, or in the supratonsillar fossa. A tortuous vein may frequently be seen extending from the pharyngeal wall up over the tonsil, but operations in these cases have not resulted in any more hemorrhage than those in patients in which there has been no evidence of a superficial venous plexus. The tonsils often present more than one lobular mass; in fact, they may be divided into two or three, extending down to the base of the tongue. In these cases it is very essential that each lobe should be removed, otherwise the beneficial effect from the tonsillectomy will be lessened. In some cases where the fibrous tissue has increased markedly from repeated attacks of inflammation or from quinsy, the tonsils will be small and submerged, so that evidence of their size is not obtainable by inspection from the use of the tongue depressor alone, but by making the patient gag or by pulling the tonsil from its bed with tenaculum or forceps, some idea of its size may be obtained. When these tonsils are enucleated their size is frequently a matter of surprise to the operator and it is this class of tonsil which often produces the greatest constitu- tional disturbance. Treatment. — ^In enlargement of the faucial tonsils benefit has been derived from liberating the adhesions of the tonsil to the anterior pillar of the fauces and by cleansing the crypts with a curette, after which there should be applied within the lumen of the crypt equal parts of 340 HYPERTROPHY OF THE TONSILS AND UVULA guaiacol and sweet almond oil. Although the hyperplasia is not reduced by this method, yet the tendency of the tonsil to acute exacerbation is markedly lessened and the inflammation and swollen tonsillar tissue is reduced in size. In addition to the guaiacol, tannic acid, and glycerin, tincture of iodin pure or with glycerin, 25 per cent, ichthyol solution or the tincture of ferric chlorid and glycerin may be used. The galvano- cautery has been employed by many with material benefit, but on the other hand it has been unsuccessful in the hands of other operators. Shambaugh and others claim that the cautery merely destroys the upper or external part of the crypt, shutting off the remote extremity and leaving it as a focus of infection deeply seated within the tonsillar structure. When a particular crypt within the tonsil constantly harbors cheesy material, its tendency to collect this matter may be overcome by slitting the crypt wide open with the galvanocautery point, so that the act of deglutition instead of forcing material into a nearly closed cavity tends rather to evacuate it. In the adult treatment of chronic tonsillitis, if persisted in, will materially benefit the patient and in many instances obviate the necessity of removal. In the removal of tonsils or of ade- noids or of both together, the question of method is largely concerned with the consideration of the advisability of administering a general anesthetic and with the selection of one if its use is determined upon. When from the combined clinical evidence and macroscopical appear- ance it has been decided that the tonsils should be removed, the question arises whether they should be removed entirely, leaving the bed free of lymphoid tissue or whether there should be left some part of the tonsillar structure. When it first became popular to remove tonsils it was the habit of the majority of operators to remove only the pro- jecting part of the tonsil, leaving its base in its fixed position. In many of these instances it was noted that the part remaining not only did not shrink upon the removal of its superstructure, but occasionally increased in-size. It is also thought that that part of the tonsil remaining seems to be more subject to the invasion of bacteria and becomes more frequently inflamed than before the operation. The crypts of tonsil, which are the culture tubes in which bacteria detrimental to the health are germinated, extend ordinarUy to the full depth of the tonsiUar mass, and unless the removal extends beneath these crypts the remaining pocket is often walled off by the formation of superficial scar tissue and leaves an in- fected focus behind, which in many instances occasions either quinsy, intratonsillar or peritonsiUar abscess. In those cases in which the mouth of the crypt is not contracted by fibrous tissue the remaining' portion of the crypt still offers the facilities for harboring bacteria which may penetrate through the tonsfl into the lymphatic chain of the neck. In consequence of these sequelse of partial removal of the tonsils, it has been almost universally agreed that when operative procedures are indi- cated at all complete enucleation of the tonsil is advisable. Having determined that enucleation is the proper procedure the next question to determine is the method by which it shall be accomplished. ANESTHESIA 341 Anesthesia. — Local. — In children local anesthesia is contra-indicated because cocain, eucain and novocain are badly tolerated. In adults anesthesia, more or less complete, can be obtained by rubbing into the tonsil and upon the folds a cocain paste, which represents pulverized cocain crystals with sufficient adrenalin solution to make the paste. Less constitutional effects result from the employment of this paste than when a weaker solution is used requiring more frequent application. In addition to the paste an injection of cocain, 0.5 per cent, in sterile water, introduced through the anterior tonsillar fold and directed toward the base of the tonsil, will aid in anesthetizing its under surface. An applicator wrapped with cotton and bent at an angle can be introduced into the supratonsillar fossa covered with the cocain paste and this ma- terially lessens the pain incident to liberating the anterior folds. Eucain and novocain produce less constitutional disturbance, but are less effective as anesthetics. Schleich's infiltration anesthesia does not work well in the tonsillar area, as the tonsil being porous prevents the pressure effects upon which this method of anesthesia largely depends. Quinin and urea have been tried by many, but have not proved entirely satisfactory owing to occasional postoperative sloughing. General. — An anesthetic which is quick in its results and yet will produce relaxation is the ideal one for tonsillar work. Nitrous oxide gas almost meets this requirement with the exception that it is too transient in the period of unconsciousness and does not produce the relaxation essential to a successful operation. However, nitrous oxide gas is used by a great many operators without the addition of ether or other anesthetizing agents, but it becomes necessary to re-administer it two or more times during the course of the operation. In young children gas is contra-indicated and in infants it often produces a spasm of an appalling character. For the removal of an adenoid gas is often all that is necessary, and in the removal of tonsils only, particularly in young adults, gas will frequently meet the operative requirements. Should there be difficulty in removing the tonsil and should unf6reseen delay occur, the gas must be administered again before the operation is com- pleted, and in some instances where hemorrhage follows the operation it is difficult to overcome it because of the consciousness of the patient and the gagging which accompanies efforts at its control. Ethyl chlorid has been employed by many, and those who favor its use are loud in its praise and wonder that it is not more universally employed. However, it has not been generally administered in large clinics principally because the period of unconsciousness is limited and it is somewhat uncertain in its effects. Somnoform produces longer anesthesia than the other two anesthetics mentioned, but several fatalities have followed its use which are sufficient themselves to condemn it in operations where less dangerous and equally efficient anesthetics may be employed. Nitrous Oxide Gas, Ether, and Essence of Orange. — The vapor arising from essence of orange has proved to be in itself an anesthetic and by its addition to other anesthetics it has lessened to a minimum the quantity 342 HYPERTROPHY OF THE TONSILS AND UVULA of them it is necessary to employ. There is no nausea following the use of essence of orange alone and when the amount of ether is reduced the nausea following its employment is proportionately lessened. Since the introduction of this combination by Gwathmey, it has been used by many operators, particularly by French/ who operates upon his patient in the upright position. The advantages of this combination are the rapidity with which the anesthetization can be accomplished, the unconscious period sufficiently long to meet the requirements of operation and to control hemorrhage, and the materially lessened ill effects incident to general anesthesia. Fig. 205 Recumbent position in operation for adenoids and tonsils. Gas and Oxygen. — The same objection may be brought against this combination as was brought against gas alone, since the time of anesthesia is limited and the relaxation is insufficient effectively to remove adenoids ' Transactions American Laryngological Association, 1913. ANESTHESIA 343 and tonsils. The advantages, however, are that even in cases of weak heart and kidney complications there are little or no deleterious effects. Gas and Ether. — ^This combination has been found to be the most expedient in the general run of cases in large clinics where fifteen to twenty. operations for the removal of adenoids and tonsils are performed in one afternoon. In all patients over six years of age this combination is perfectly safe and produces the quickest anesthesia with the greatest relaxation of any employed. The quantity of ether necessary is reduced to a minimum and, so far as the general observations are concerned, no great detriment results therefrom. In very young children ether, without the addition of gas, is preferable for the reason mentioned previously, that gas occasionally produces a dangerous laryngeal spasm. Fig. 206 Lateral position in operating for adenoids and tonsils. Chloroform. — While some operators still employ this .agent of anesthesia and report unqualified success extending over many years, it is the consensus of opinion among the majority of observers that chloroform is too dangerous in its effects to warrant its use, except in extraordinary cases where either the kidneys or lungs are involved. Position. — Under a general anesthetic the favorite position is the recumbent, although French and those who still employ the Mathieu tonsillotome prefer to have their patient in the upright position. The Fig. 207 French's chair for the operation on tonsils and adenoids. Fig. 208 Upright position in French's chair. METHODS OF REMOVING THE FAUCI AL TONSIL 345 question of position is one of personal preference and bears no relation to the effectiveness of operative procedure, excepting where chloroform is employed, when the upright position is absolutely contra-indicated. Under local anesthesia the upright position or the semirecumbent one is to be favored. Fig. 209 Recumbent position in French's chair. Fig. 210 Lcland tonsil knives. Methods of Removing the Faucial Tonsil. — Except where the Sluder method is employed the tonsil is liberated from its anterior fold and 346 HYPERTROPHY OF THE TONSILS AND UVULA in many instances from the posterior as well. This may be accom- plished by the use of the Leland tonsil knives, in which case the tonsil is not drawn out by a tenaculum, but is liberated by intro- ducing the knife into the supratonsillar fossa and with a sweep from above downward the knife, which is at right angles to the shank, is passed Fig. 211 Kurd's separator. between the anterior fold and the tonsillar mass. To insure this separa- tion without attachment of tonsillar tissue to the fold, the knife is drawn upward after its introduction into the supratonsillar fossa and held in close contact with the fold, when it is carried downward until a point is reached where the shank of the knife can be held fixed, and a sweep outward of the curved part of the knife on the handle as its axis will Fig. 212 Yankauer's blunt dissector. just disengage the lower attachment of the tonsil to its anterior fold. Care should be exercised not to carry the knife too far downward before this attempt is made to disengage the blade, otherwise the lower tonsillar plica will be severed. The knives are right and left with blunt tips, so that the extremity will not do injury to the underlying structures. The other methods of liberating the tonsil from its attachment depend Fig. 213 M'athieu's tonsillotome. largely upon drawing it out with tenaculum forceps and separating the anterior and posterior fold by either the curved sharp separator of Hurd or the blunt dissector of Yankauer. In the experience of most observers it is better to make a clean sharp dissection than one by means of blunt instruments; for although the hemorrhage at the time may be METHODS OF REMOVING THE FAUCI AL TONSIL 347 somewhat in excess, the subsequent results are less painful and less necrosis follows. _ Mathieu's Tonsillotome. — While perfect in its conception, this is but little eniployed in the removal of tonsils at the present time, although when reinforced it may be used in the same manner as the Sluder tonsil- lotome, and in the hands of the expert will enucleate a tonsil as well as Fig. 214 Mackenzie's tonsillotome. any of the others. Employment of this instrument is followed by a very clean wound and should not be discarded by those accustomed to its use. The recumbent position makes it difficult to use this instrument with effectiveness, but in the upright position it may be employed with advantage. FiQ. 215 Farlow's tonsil snare. When the Mackenzie tonsillotome is used it is necessary for the anes- thetist to exercise pressure externally over the area of the tonsil and shove it forward into the throat sufficiently for the blade to engage the tonsillar mass. When the anesthetist is well skilled in exercising continuous pressure with the middle and index finger beneath the lower jaw over the tonsillar area externally, the tonsils may be enucleated thus as thoroughly as by any other procedure. 348 HYPERTROPHY OF THE TONSILS AND UVULA There are many modifications of the tonsillar snare, the simplest of which is probably Farlow's. The objects of an effective tonsillar snare are (1) strength to withstand the obstruction offered by a fibrous tonsil; (2) the opportunity to apply a rapid tension by hand pressure. The snare should be loaded with a heavy No. 8 piano wire and the tonsil pulled out into the loop by means of a tenaculum forceps, of which there are a great variety. When the loop is drawn taut around the base of the tonsil by means of hand pressure, it may be continued until the tonsil is enucleated, unless the tonsil is particularly fibrous or unless there is an expectation of undue hemorrhage; but if from the recurrent attacks of tonsillitis there is considerable fibrous tissue, the wire may be made taut by means of hand pressure and the remainder of the enucleation performed by the aid of a screw-nut. Fig. 216 Liberation of tonsil from anterior fauoial pillar. Sluder's Tonsillotome is virtually of the same construction as the Mackenzie, except that its reinforcement is made to withstand pressure from the handle forward rather than that of pulling from the blade backward, as in the Mackenzie. The operation performed by Sluder has for its object the engagement of the tonsil in the fenestrum of the instru- METHODS OF REMOVING THE FAUCI AL TONSIL 349 ment by pressure exerted from the opposite angle of the mouth upward, forward, and outward against the alveolar tubercle of the lower jaw, Fig. 217 Enucleation of tonsil with snare. Fig. 218 Sluder's tonsillotome. 350 HYPERTROPHY OF THE TONSILS AND UVULA at the junction of the horizontal and perpendicular ramus. The blade of the tonsillotome is dull so that the process of enucleation may be slow, Fig. 219 Enucleation of tonsil by Siuder's method. and the small arterioles bruised to prevent hemorrhage. The tonsillar folds are not liberated prior to removal and the tonsillotome is introduced below and behind the tonsil and the mass elevated until opposite the Fig. 220 Showing relation of tonsillotome to tubercle of lower -jaw in Siuder's operation. tubercle of the jaw, when pressure is exercised from within outward and upward until the tonsil is dragged from its folds, and while the METHODS OF REMOVING THE FAUCI AL TONSIL 351 pressure is being exerted continuously the blade is shoved gradually home until the tonsil is enucleated by a slow cutting process. If the tonsil is not entirely engaged in the instrument the index finger is used to massage the gland into the fenestrum before the blade is shoved home. If the blade will not cut entirely through the base of the tonsil the index finger is again used to remove the tonsil by a slow process of Fig. 221 Anatomical outline of tubercle of lower jaw against which tonsil is pressed into guillotine. (Sluder.) massage between the tonsil and its anterior fold. In some instances the projection of the fold over the tonsil anteriorly is cut away, leaving a vast exposure of enucleated surface, but Sluder claims this to be no argument against the method as it prevents adhesions forming between the posterior and anterior fold, a condition equally undesirable in its after-effects. If the method is pursued in accordance with the instructions Fig. 222 Tonsils removed with capsule intact by Sluder's method. of the author there is little hemorrhage, little subsequent deformity, and the tonsils are almost invariably enucleated. This procedure is by no means as easy as the snare operation, and depends largely upon the skill of the operator for its success. Too many have condemned the opera- tion before they have had sufficient experience to perfect themselves in its technique. In addition to dexterity it requires some strength of 352 HYPERTROPHY OF THE TONSILS AND UVULA the wrist and hand and an ability to exercise a steady pressure against the inner angle of the jaw while shoving the blade into its sheath. Fig. 223 Sliidcr's operation, first step. Sluder's operation, second step. Fig. 225 Sluder's operation, third step. METHODS OF REMOVING THE FAUCI AL TONSIL 353 In the use of Beck's tonsillotome the operator is concerned with the same anatomical structures and employs the same technique as in Binder's operation. It consists of a strong hollow sheath on the extremity of a shank, in which sheath is concealed a snare loop which is pulled home Fig. 226 Beck's tonsillotome. after the tonsil is engaged, by means either of hand pressure or a screw- nut. It is claimed for this tonsillotome that it will remove the tonsil from the supratonsillar fossa in a greater number of cases than the Sluder tonsillotome, and that the hemorrhage incident to removal is very much lessened. Fig. 227 Sluder's tonsillotome with Ballenger's handles. To all of these instruments modifications have been added which may or may not facilitate the removal of the tonsils. Ballenger has added handles to Sluder's tonsillotome which add a mechanical power un- obtainable in the original instrument. 23 354 HYPERTROPHY OP THE TONSILS AND UVULA In the process of finger enucleation of the tonsils an initial incision is made in the anterior plica with knife or scissors, after which dissection is made with the index finger, beginning in the supratonsillar fossa and extending downward until the tonsil is separated from its bed and remains attached only by its lowest extremity, around which a snare is placed and the attachment severed. Hemorrhage is markedly reduced, but the trauma and pain incident to the operation are greater than where a cutting operation is employed. Fig. 228 Robertson's scissors. Robertson devised right- and left-hand scissors which cut in a curvi- linear manner at right angles to the handle of the scissors, and are very effective in removing the tonsil provided the folds first have been liberated and the tonsil is held forward with tenaculum forceps. Apparently they have no advantage over the other methods of removal, and in the hands of the inexperienced are capable of producing considerable damage. Ballenger, Freer, and others claim that with a good sharp scalpel the tonsils may be readily and effectively enucleated without any more hemorrhage than where the various tonsillotomes or scissors are employed. Here as in the case of scissors there appears to be little gained and un- questionably the unskilful operator endangers contiguous structures. Methods of Controlling Hemorrhage during and after Operation. — In anemic, badly nourished children as a prophylactic measure, it is advisable to give some form of iron tonic such as the combination of iron, arsenic and gentian, or in the very young some form of iron like the syrup of iodid of iron, which should be administered for two months prior to the operation. Controlling hemorrhage at the time of operation is based upon whether hemorrhage is from a spurting vessel or from a venous plexus. In the case of a "spurter" the vessel is clamped with long hemostatic forceps and tied off with catgut just as it would be in any other surgical procedure elsewhere in the body. Torsion does not always control the hemorrhage and ligation does. Another control employed by some is that obtained by deep suture inserted by means of a curved needle fixed on a shank and passed through the posterior to the anterior fold, and the two brought CONTROLLING HEMORRHAGE DURING AND AFTER OPERATION 355 together in the loop and tied off. This means of control may also be accomplished more quickly by the employment of the Michel metal sutures, which are introduced by means of a clamp attached to a snare handle, and the two folds of the tonsil brought firmly together by the bent metal clamp. These clamps are left on until the following morning, when they are removed by employing the instrument devised for the purpose, caution being taken to introduce the hollow blade beneath the suture so that the outer angular blade will force the Fig. 229 Michel's metal sutures. suture out from its basal attachment without drawing on the tissues. The bleeding from the small arterioles and veins incident to the removal of the tonsil may be taken care of by frequent sponging with small sponges attached to a long shank applicator. These may be occasionally moistened in an aqueous solution of equal parts of tannic and gallic acid, which is of sufficient astringent strength to control a part of the oozing. The blood may also be kept free from the operative area by employing some means of suction as the Bier suction pump attached to a large glass bottle, from which a separate rubber tube attached to a sterilized glass nozzle is run into the mouth and applied directly to the Fig. 230 Michel's metal suture extractor. bleeding area. While this is effective in keeping the parts clear for the operator it apparently induces by suction more hemorrhage than, would otherwise occur. The oozing that occurs sometimes after the operation may be controlled by the patient taking frequent sips of the aqueous solution of tannic and gallic acid and holding it in the mouth. Any attempt at gargling brings into play the pharyngeal muscles which break the clot away from where it has already formed, and may induce hemor- rhage. The oozing may also be controlled by holding a sponge on a 356 HYPERTROPHY OF THE TONSILS AND UVULA stick in place over the bleeding area for five or ten minutes and with- drawing it with care and gentleness, an attempt being made to disturb as little as possible the clot that has already formed. This procedure may in a measure be facilitated by soaking a sponge in the solution of tannic and gallic acid before making the application. Gelatin taken into the mouth in liquid form and held there will also tend to form a clot between the anterior and posterior folds of the tonsil which at times is effective. Peroxid of hydrogen will occasionally form a clot between the anterior and posterior folds that will of itself be sufficient pressure to control venous oozing. Adrenalin has but small effect in overcoming oozing from the large area made by the removal of the tonsil and has been ineffective in those instances where profuse hemorrhage occurs. Thrombokinase sprinkled over the bleeding area will often be effective provided the hemorrhage is not sufficiently large to wash away the granules when applied. Cautery, either Paquelin or galvano-, has no advantages over any of the other measures advocated for the control of hemorrhage, and it is difficult to get just the proper heat to sear and not to cut the bleeding vessel. In addition to the difficulty in its employ- ment the resulting inflammation materially retards the recovery of the patient and makes the throat very painful. Beck in his advocacy of the direct removal of adenoids employs a small rubber catheter intro- duced through the nostrils and extending out through the mouth, one end of which can be drawn taut against the side from which a tonsil is re- moved and, by exercising pressure sufficient to bring the posterior fold up against the anterior, controls the hemorrhage incident to the removal of the tonsil. He also advocates placing between the anterior and pos- terior folds a small wick of gauze and clamping the same with forceps. Fig. 231 Miokulicz-Stoerok hemostat. Tonsillar Hemostats. — ^There have been a variety of these presented at various times for the control of hemorrhage, all having as their object pressure over the tonsillar area. One of the first of these was one devised by Butts, which, extended within the mouth, created lateral pressure against both of the tonsillar areas without employing any ex- ternal counter pressure than that afforded by the outside tissues. The Mickulicz-Stoerck hemostat exercises internal pressure by a small hard- rubber piece which fits in between the anterior and posterior folds, and which should be covered with two thicknesses of gauze, and external pressure by a larger kidney-shaped piece which fits beneath the angle of the jaw over the tonsillar area externally, which piece can be moved PREPARATION OF THE PATIENT 357 backward and forward to meet the varying distances between the mouth and the tonsillar area in different individuals. This piece should be also covered with gauze to protect the tissues against undue pressure. The two blades of the instrument at this point are brought together gently by means of the handles of the instrument and are locked by a set-screw on the upper surface of the blades. The handles then may be detached and the blades left in place for a period not exceeding twelve hours. There is great security felt in the possession of this instrument when hemorrhage is active, as it can be absolutely controlled by it: the disadvantages are that it is more or less difficult to apply, it is ex- tremely uncomfortable to the patient, and great caution must be exer- cised to see that the pressure is not too strong and that the instrument is not left in place over too long a period, otherwise pressure necrosis will follow. In removing the instrument there is great difficulty experi- enced, as the patient is in a nervous state and the throat irritable, and excessive gagging accompanies the effort to withdraw it. This gagging is frequently attended with an awkard withdrawal of the blades. Hemor- rhage may be again started by taking away the inner blade with too great rapidity, thereby pulling away the clot that has already formed. Fig. 232 Kurd's tonsillar hemostat. Kurd's tonsillar hemostat is less cumbersome than the others and embodies the same principle. The inner blade of hard rubber should be wrapped with gauze and placed between the two tonsillar folds, while the other blade fits into the area of the tonsil externally below the angle of the jaw. The two blades are closed upon a clasp which is controlled by a ratchet. The instrument is light and effective in its purpose, being easy to apply and disengage. Vasomotor control of hemorrhage is induced by slapping the face with towels wet with ice-water. This apparently produces a sudden shock and controls oozing in some instances. It is employed universally in the hospitals devoted to this special work. Preparation of the Patient. — ^When it is decided that general anesthesia is to be given, the patient should have the bowels thoroughly evacuated, preferably by castor oil or by some saline cathartic, early on the morning of the operation. The cathartic that has been previously employed in 358 HYPERTROPHY OF THE TONSILS AND UVULA Fig. 233 the family for the purpose should now be used, as a change in cathartics may not result favorably. In children it is advisable to perform the operation in the early morning shortly after they awaken, as this obviates the hunger experienced and the irritation incident thereto if the operation is postponed until the afternoon; it also relieves the nervous tension of the family waiting for it to occur, and, lastly, if hemorrhage ensues it can be controlled before night and a night's rest may be insured. If the operation is not performed until the afternoon, the patient should have only a very light breakfast, just milk or possibly a soft-boiled egg, and nothing should be taken on the stomach after eleven o'clock in the day. By far the best opportunities afforded patient and operator are obtained in a hospital devoted to this special line of work, but as it is impossible to take all cases to the hospital the selection of the next best surroundings is of importance. The operation should take place upon the floor where the patient is to remain after the operation. The room should be selected where there is a minimum of curtains, hangings, and decorations, or if present they should be removed. If the operator employs daylight as a means of illu- mination, that end of the room which is nearest the window should be selected for the operation. A number of newspapers should be laid upon the floor, over which an old sheet may be spread, and on this an ordi- nary deal or kitchen table is placed, which is covered by several blankets and a sterile sheet. A second sterile sheet should be employed to cover the patient. The majority of port- able operating tables are cumber- some and too heavy for easy trans- portation, but one admirably adapted for operations upon children is that devised by Chappell, which is amply strong to hold a small adult, is collapsible and is carried in its case. This table permits of any of the positions desired, recumbent, upright, or with head over- hanging. It is just the right height for work of this special kind, is firm, not too broad and in all respects meets the requirements of a portable table. The family should be instructed to have at hand two large bath towels, six small towels, one porcelain basin in which bloody sponges and other material may be thrown, a second basin in which cracked ice and water may be kept. Two small extra tables, both covered with freshly laundered towels are also necessary, one of which is to be placed at the head of the table for the use of the anesthetist and the second on one side for the use of the operator's instruments. Children should be anesthetized in bed through the first stage and then brought to the operating table, for in this manner a great deal of the nervousness incident to the operation is overcome and the child retains no memory of the instruments and the preparation for the operation. Chappell's portable operating table. PREPARATION OF THE PATIENT 359 The child is placed upon the operating table in the dorsal position until the stage of anesthesia is reached, which will insure a successful termination of the procedure. If the patient is to be operated upon in the upright position, a sheet should be tightly pinned around the body, holding the arms and hands to the side, as in this manner the patient can be handled with greater ease. A rubber skull cap or a steril- ized towel should be pinned tightly around the head, the hair being entirely covered by it. A mouth gag, the tooth part of which is covered with rubber to protect the patient's gums and teeth, is introduced on the left side and carried well back toward the angle of the jaw so that when opened it will not interfere with the operative measures, yet it will keep the jaw distended at the greatest angle. If the Murdoch mouth gag is employed, which is of great advantage in young children without their incisor teeth or where the back teeth are in bad condition, it is introduced by opening the jaws with the tongue Fig. 234 Murdoch's mouth gag. depressor until the flanges can be engaged between the. upper and lower teeth, when it is opened to the required distance. The assistant then clears the pharynx and mouth of all collected saliva by means of a small gauze sponge, held in the extremity of a sponge holder. The patient is now placed in the position preferred by the operator, which may be the upright position, the recumbent position with the head slightly extended, or the recumbent position with the head well extended over the end of the table, or with the head turned to either the right or left side. These positions are entirely matters of choice with the operator. The tonsils are next separated by the methods already mentioned, or undisturbed if the Sluder or Mathieu tonsillotomes are used. They are then re- moved in accordance with the description for each of the tonsillotomes employed, the bleeding area being taken care of as described. After the tonsils are, successfully removed attention is then directed to the removal of the adenoid. 360 HYPERTROPHY OF THE TONSILS AND UVULA Adenectomy. — There is no diversity of opinion as regards the advis- ability of removing as much as possible of the adenoid tissue when it is deemed advisable to operate for it at all. This lymphoid mass in the nasopharynx, when hypertrophied, may consist of one large single mass, a two- or three-lobed mass, or a collection of small masses of lym- phoid tissue, the bases of which coalesce. A large mass in the middle of the epipharynx may produce very much less disturbance than a broad, thinner collection of lymphoid tissue extending out into the fossse of Rosenmiiller. In young children a partial removal of the adenoid will often result in the hypertrophy of that which remains and the effects of the operation will be lost. It is also the opinion of many observers that in very young children, even when the nasopharynx is perfectly freed, there will be a recurrence before puberty, necessitating a second operation. This recurrence, however, may be largely prevented by smoothing the whole operative field after removal of the larger piece, by massaging or rubbing that area with the index finger covered with a piece of sterile gauze. Fig. 235 Gradle's adenotome. Instruments for Removal. — For a number of years the forceps of Brandigee and Knight for the removal of adenoids were widely employed followed by the use of some of the adenoid curettes. These instruments seemed to meet the requirements of the case, especially when skilfully handled. Their use, however, was. not unattended with danger, as fre- quently in the hands of the beginner, and sometimes even in the hands of the skilful, the uvula would be pinched off in the handles of the forceps. Occasionally the Eustachian prominence on one side or the other would be engaged in the bite of the forceps and removed. Again, the mucous membrane would be picked up with the adenoid mass and stripped down on the postpharyngeal wall. In a few instances rupture of the soft ADENECTOMY 361 palate has occurred as the result of trauma caused by an unskilful opera- tor. These unfortunate accidents suggested to the minds of many experimenters the need of a solution to the problem which would obviate trauma even in the hands of the beginner. As a result an adenotome was devised by Gradle, in which a guillotine blade is concealed in the upper extremity of the instrument, and is pulled downward through the adenoid mass after it has been properly placed in the nasopharynx. In the act of pulling the knife home the pressvu-e against the nasopharynx is lessened so that it frequently cuts through the middle of the mass and not through its base. Again, this implement has no means by which the adenoid mass can be extracted and it is often either swallowed or lost in the course of the operation. LaForce designed an adenotome, which in its construction obviates all of the dangers enumerated for the adenoid forceps; likewise it has a blade, which, when the adenotome is properly pressed against the nasopharynx, is forced home and thereby exercises additional pressure against the postpharyngeal wall, where it is necessary to maintain a pressure to remove entirely the adenoid mass at its base. It, however, frequently removes only the middle portion of the mass and leaves some adenoid tissue in both fossae of Rosenmiiller Fig. 236 LaForce's adenotome. and little just behind the septum in the postnasal angle. These masses have to be removed with a curette and smoothed down with the finger wrapped with gauze. This adenotome comes in different sizes which are adaptable to the size of the nasopharynx, and in the opinion of those who have used it, it meets the requirements and less frequently produces bad results than any of the others in use. In addition it brings out the greater quantity of the adenoid "en masse," held in the box-like recep- tacle anterior to the blade. The preservation of the adenoid enables the operator to demonstrate to the parents the removed growth, which often satisfies them of the necessity for the operation which has been performed. There have been many modifications of the original form of adenoid curettes, all of which have for their principle the removal of the superim- posed lymphoid mass leaving the mucous membrane uninjured. Those most frequently employed are Gottstein's, Beckman's, and Thomson's. When using the curette it should be borne in mind that it must not be employed with too great force and that the proper way to hold it is the same as one holds a pen, lightly between the thumb and first and second fingers, with the handle of the curette resting in the space between the thumb and first finger. The curette should be intro- 362 HYPERTROPHY OP THE TONSILS AND UVULA duced well up behind the soft palate until its extremity touches the posterior part of the septum, when a downward sweep of the blade is made until the lower part of the mass is reached, then the handle of Fig. 237 Gottstein's adenoid curette. the curette is drawn upward against the front teeth of the patient and the blade end brought out with a quick, sharp jerk. Unless this is done the curette will tear down the mucous membrane below the adenoid Fig. 238 Chappell's adenoid curette. mass on the posterior pharyngeal wall, which denudation is often the cause of fever and other systemic disturbances. It also will leave a little tip of mucous membrane at the point of injury, which remains an evidence of unskilful work on the part of the operator. Those curettes, Fig. 239 Beckman's adenoid curette. as Chappell's and Beckman's, which have serrated edges cut more readily through the lymphoid mass, and are particularly efficient where there is any fibrous tissue in the adenoid from previous inflammations. They Fig. 240 St. C. Thomson's adenoid curette. will, however, cut deeper into the underlying tissues and should be used with less force than the smooth-bladed curette. The excessive force frequently employed in the removal of adenoids with the curette alone ADENECTOMY 363 is to be condemned, as the mucous membrane is often stripped down from the adenoid area and a dry, scabby, atrophic condition is left behind as evidence of surgical trauma. Just after using the curette, following the removal of the major part of the growth by the adenotome, the finger should be covered with sterile gauze and introduced into the nasopharynx, and the operative area smoothed down, particularly in the fossae of Rosenmiiller. The patient's head should then be turned to one side, to evacuate the mouth and pharynx of the blood collected there during the operation, after which if there appears unusual bleeding the finger may be again wrapped with gauze which is soaked in peroxid of hydrogen and , introduced into the nasopharynx. This will frequently produce sufficient pressure to prevent hemorrhage. If hemorrhage is severe following adenectomy, peroxid of hydrogen may be injected through the nares with more or less force, so that it comes in contact with the bleeding area of the epi- pharynx and will not. drip from the soft palate, which is apt to be the case if no force is employed, and this will form a clot between the palate and the bleeding surface. In cases of emergency lemon juice, vinegar, or alum solution may be injected through the nares in the same manner, but if possible to avoid it they should not be used. A solution made from equal parts of tannic and gallic acid may also be run through the nose so as to come in contact with the bleeding area, but solutions of iron should not be employed in the nasopharynx because of the very disagreeable clot that forms after it. If the hemorrhage is sufficiently severe to warrant it, a postnasal tampon may be introduced and left in for six or eight hours. The tampon may be introduced by employing a Bellocq sound to draw through the nostril one end of a string attached to the nasal tampon, the other end of which is brought out of the mouth and tied to the nasal end. The tampon is made of sterile gauze, should vary in size in accordance with the size of the nasopharynx, and should be well vaselined before being drawn up tightly into the naso- pharynx by means of tension on the nasal string. When it is necessary to withdraw the tampon the tongue is held down with a spatula and pressure is exerted gently on the string which extends through the mouth until the tampon is disengaged from its position behind the soft palate. It endangers the Eustachian tube to keep a postnasal tampon in position for over a few hours, as the clot forms in and around the tampon, ad- jacent to, if not within the beginning of the Eustachian tube, which is endangered thereby. After hemorrhage is properly overcome the patient is returned to bed and placed upon the side with the head turned to the right, and the right arm is drawn from under the patient and extended out above the head from the shoulder, while the face is slightly elevated by a towel so that the nose and mouth will not sink too far into the covers, which might otherwise impede respiration. The foot of the bed should be raised and no pillow or other support placed under the head. The blood and saliva will now run out through the nose and mouth rather than flow into the stomach or larynx. Careful watch on the part of the nurse or doctor should follow the anesthetic for the 364 HYPERTROPHY OF THE TONSILS AND UVULA space of several hours, until the patient is entirely recovered from the effects of the anesthesia and the danger of immediate hemorrhage follow- ing the operation is past. No drink or food should be given the patient until four hours after the operation, when, if there is no bleeding, small pieces of cracked ice or sips of cold water may be given to test the stomach to see if it will retain liquids. If the stomach does not throw off the ice- water, half a glass of cold milk or a small quantity of ice-cream may then be given. It is best not to encourage the patient to eat anything until the following day, as a glass of milk or a plate of ice-cream will be all that is necessary until the next morning. Suggestion to young patients will frequently make them fret for food, which would not occur except for, the intimation on the part of some member of the family that they should have it. The next morning a mild cathartic should be given, such as citrate of magnesia or castor oil given in sarsaparilla, which entirely overcomes the disagreeable taste, for the purpose of removing from the stomach and intestines blood thafhas been swallowed, which if it remains there may create gastro-intestinal disturbance. When the patient has been operated upon in the hospital he may be safely re- moved home the next day, provided it is not too far distant and within reasonable reach of the operator in case of an unexpected hemorrhage, - and provided there is no fever or other deleterious constitutional symp- toms arguing against the removal. On the third day after the operation the patient is permitted to sit up and play around the room for a while in the morning and afternoon, provided there is no temperature higher than 99|° F. Semisolid food may be given and the ordinary care exercised to prevent the patient taking cold. On the fourth day if there is no temperature and no contra- indications the patient may be permitted to go out for a short while and also to take solid food. One week after the operation the child should be brought to the operator for observation and at this time it should be placed upon some mUd iron tonic. Sequelae. — One of the immediate sequelse is hemorrhage, which has been known to occur in dangerous form even upon the fifth day after operation. The control of hemorrhage is brought about in the same manner as described for hemorrhage following immediately after the operation. In cases of partial exsanguination a hot saline enema must be given in addition to a small enema of hot black coffee, to which brandy- may be added if necessary. In those cases in which the partial exsan- guination has taken place the patient should be kept in bed for at least a week, and great care should be exercised in the diet and in the adminis- tration of those drugs necessary to aid in blood formation. Injury to the faucial pillars which produces cicatricial contraction on one side or both is frequently seen, particularly in those cases operated upon with the snare. The soft palate is sometimes torn as a result of too energetic operative work upon the adenoid, or to some mishap when adenoid forceps are employed. This may produce a partial paralysis of the palate or result in sufficient cicatricial adhesions to bring together the palate and the posterior pharyngeal wall, a condition which has been observed SEQUELS 365 by us in several instances. In singers the cicatrization following injury to the pillars is a grave condition in so far as it lessens the ease of vocaliza- tion and creates a retraction on one side or the other, reaching from the palate to the tongue. The less hemorrhage there is at the time of opera- tion the quicker is the recuperation of the patient, and where excessive hemorrhages occur the time of recovery is very much prolonged. Too little stress is frequently laid upon hemorrhage incident to this opera- tion, and the total disregard of the quantity lost is very frequently in evidence. The suction apparatus for keeping the operative field clear, while a great aid to the operator, nevertheless causes the patient to lose blood which seems unjustifiable, particularly so in young and anemic children. Aural Conditions Resulting from Nasal and Postnasal Obstruction.— Ventilation of the Eustachian tube is one of the essential requisites for the preservation of hearing. This may be prevented by hypertrophies, deflections of the nasal septum, nasal tumors, catarrhal conditions of the nose and nasopharynx, and by lymphoid masses in the nasopharynx. Chronic rhinitis or true hyperplasia when involving the turbinated structures, particularly the inferior, will often occasion an occlusion of the Eustachian tube on that side. Attempts at swallowing, when such conditions exist, force the catarrhal exudate into the lumen of the tube. Rarefaction of air in the tube, due either to catarrhal thickening or to hypertrophy of the posterior tip of the turbinate, will ultimately induce a retraction of the drum-head, disturbances of audition, and tinnitus aurium. Often a small spur will deflect a current of air directly into the Eu- stachian tube, which produces catarrhal inflammation of such gravity that all the symptoms of catarrhal otitis media will be experienced. To a greater extent septal deflection will occasion the same disturbance. It is noted, however, that otitic conditions are often on the opposite side to the deviation or spur, but this does not argue that the spur or deviation is not responsible for the condition, as the currents of air may be deflected around the posterior border of the septum and im- pinge against the tube of the opposite side, or the concavity of one side corresponding to the deflection of the other may produce on that side too strong a volume of air for the maintenance of proper conditions of the mucous membrane. Lymphoid structiu-es in the nasopharynx are not only productive frequently of catarrhal otitis media, but by harboring infective material adjacent to the Eustachian entrance they may cause otitis media suppurativa. The most frequent source of purulent otitis media in chil- dren is the adenoid tissue in the nasopharynx. It is conceded by all observers that the presence of hyperplastic lymphoid tissue in this region, irrespective of its amount, if associated with aural disturbances, should be removed immediately. In infants who are unable to breathe properly, owing to the existing adenoid, a part should be removed, if not all, so that adequate ventilation of the Eustachian tube may be established. Rarefaction of air in the pharyngeal end of the Eustachian 366 HYPERTROPHY OF THE TONSILS AND UVULA tube results in retraction of the drum membrane and is productive of evil results if permitted to continue. Scarlet Fever and Diphtheria. — These are two conditions which come directly under the observation of the specialist and produce a number of the suppurative conditions of the ear. Scarlet fever particularly often causes the most virulent infection and often results in the saddest con- sequences. To obviate infection of the middle ear during the course of these two diseases it is advisable to irrigate the nasopharynx from the beginning, first with equal parts of Dobell's solution and hot water, followed by a 5 per cent, solution of argyrol. These irrigations can best be carried on by means of the postnasal syringe and should be carried out once or possibly twice daily. Pure peroxid of hydrogen is now being employed in babies' hospitals, not only as a preventive measure, but as an antiseptic precaution against infection of the Eustachian tubes; and while formerly it was believed that peroxid was a dangerous solution to be employed in the nasopharynx, it has been demonstrated that otitic complications are materially lessened by its employment. The local infections of the pharynx have all often resulted in ear infection, as are used in scarlet fever or diphtheria. The physician, however. The same precautionary measures should be employed in these, instances should take particular pains to see that the pharynx is properly cleansed before the nasopharynx is washed out. Another precautionary measure is to see that the nasal fossae are sufficiently open so that the injected solutions will find free outlet through the passages. Postoperative Complications. — Following the removal of adenoids it is not unusual that some ear involvement ensues. This may be due to blood being forced into the Eustachian tube, or to the extension of infection that is already present. In cases of hemorrhage from the removal of the adenoid it is 'often necessary to insert a postnasal tampon for its control. In these cases otitis media has resulted even to the extent of suppuration necessitating a mastoid operation. In other cases ear- ache will follow operations upon adenoids, apparently due to a bubble of air gaining access to the tube and creating pressure against the drum. This results only in a little redness of the drum over Shrapnel's membrane and becomes quiescent within a day or so. Operations upon the nasal septum have often resulted not only in ear complications of a catarrhal and infectious character, but they are also frequently followed by acute follicular tonsillitis. Just what the association is has not been determined, but it is reasonable to suppose that lessened resistance has resulted from operation and that infective bacteria, both upon the tonsils and in the en- trance of the Eustachian tube, have become active owingto lessened surface resistance. Otitis media following operations upon the nose is due often to attempts at irrigation and to blowing the nose when it is obstructed. This efl^ort drives the infectious material in the direction of least resistance, which in these cases is the Eustachian tube. Not infrequently suppura- tive otitis media follows directly upon an effort on the part of the operator to force through the nose solutions for the purpose of freeing the nostrils from accumulated blood and mucus without having first shrunken INFLAMMATION OF THE LINGUAL TONSIL 367 down the swollen tissues by the application of cocain and adrenalin. Attempts at irrigation with a nasal douche such as the Douglass douche should never be undertaken until both nostrils are perfectly open to respiration, which condition is facilitated by the local application of an astringent. Injury to the Eustachian prominence has resulted from the attempt at adenoid removal, particularly with adenoid forceps and curette, and as a result of this otitis media of an acute character has been induced. Such operative trauma has also followed attempts at snaring postnasal tumors and ear complications have resulted. The extension to the ear of atrophic nasal conditions is frequent, but apparently this condition has resulted in much less harm to hearing than the hypertrophic. In cases of whooping cough and spasmodic laryngeal cough from other causes, catarrhal material has been driven into the Eustachian tubes as well as air bubbles, which have created considerable pain, lasting for . periods varying from a few hours to several days, Inflaimnation of the Lingual Tonsil. — ^We have no reason to suppose that acute inflammation ever occurs in any form except as the lingual structure participates in the inflammatory processes of the mucous membrane of the pharynx as a whole. Abscess has in rare instances been reported as observed in the connective tissue beneath the lingual tonsil. It is a very painful affection and in this situation more than elsewhere in the pharynx the liability to systemic septic infection is marked. A smooth painful swelling impedes deglutition and by pressure exerted on the upper part of the larynx there may be caused dyspnea, hoarseness, and cough. Prompt evacuation of the pus is indicated. There is little or no departure from the histological features of lingual lymphoid tissue hypertrophy in general which we have described, but in the chronic inflammations of the lingual tonsil there are certain etiological and symptomatic features which demand special notice and certain principles of treatment which are not prominent in the consideration of the therapy of the faucial and pharyngeal tonsils. Certain anatomical features common to the pathology of all the tonsils have a special bearing on that of the lingual trouble. This will be considered later. Etiology. — We presume there can be no doubt that the cold taking with its resultant general pharyngeal inflammation is an important factor in the etiology of lingual tonsillar enlargement. Yet this does not assume that clinical prominence in the history which is observed for the role played by cold-taking in the etiology of the hyperplasia of the other tonsils. This is emphasized in the age of the patients who seek relief from symptoms ascribable to the condition. Faucial and pharyngeal hyperplasia is seen chiefly in patients under twenty. Lingual hyperplasia is found chiefly in patients much older than that. It is true that some of this apparent difference in the age incidence is due to causes to be discussed immediately. There is doubtless a considerable percentage of young patients in whom the lingual tonsil is appreciably enlarged as an accompaniment of a general pharyngeal lymphoid hyper- trophy. The removal of the faucial and nasopharyngeal representation of this suffices to banish or so greatly to ameliorate the symptoms that 368 HYPERTROPHY OF THE TONSILS AND UVULA further study of the case is abandoned and thus the hyperplasia of the lingual tonsil in young patients escapes detection altogether or at least is ignored. The suppression of an abnormal state of affairs in the upper reaches of the pharynx may have a favorable effect on the lingual con- dition which subsides of its own accord or gives- no inconvenience in the future in the great majority of the cases. It is clinically to be observed that those patients who in adult life complain of symptoms of lingual hyperplasia present no higher percentage of records of tonsils and ade- noids in their youthful history than any other class of patient. It seems, therefore, that while one set of influences due to the patient's tender age may give rise to the hyperplasia of the tissue of the lingual tonsil, it is another set of influences due to the patient's more mature age which gives rise to the symptoms. If age presents these phenomena in the etiology, sex plays a scarcely less significant role. A considerable preponderance of females is observed among patients complaining of discomfort referable to the base of the tongue. The patients are for the most part not those who labor — especially they are not those who perform physical labor. As a class they are neurotic. There is aimong them a large number of idle people. Chronic dyspepsia of the nervous type is observed in a considerable number of these patients. Constipation is another condition which is apt to be associated with the lingual hypertrophy. Whether the close relation- ship in anatomy and function with the gastro-intestinal tract has any influence in the association of acid dyspepsia and constipation and lingual tonsil symptoms we do not presume to say, but we call attention to the suggestiveness of the coincidence. It is often said that gout and rheumatism are unusually prominent in the clinical histories of these patients, but that is not a feature which has impressed us. Reference may now be made to the marked increase in the proportional relationship of the epithelial to the lymphoid hyperplasia when compared with the histology of the other tonsils. We have spoken of the keratosis of the superficial layers as more noticeable in the epithelial covering of the faucial tonsils than in that of the nasopharyngeal structure. Still more marked proportionately is that of the lingual tonsil, a fact of some importance in consideration of the attrition of surfaces which takes place in the muscular movement of the lower pharynx in deglutition, respiration, articulation, and loud voice production. In middle-aged people the masses removed are regularly seen to be made up of a con- siderable amount of hyperplastic epithelium and a very sm^U amount of lymphoid tissue. Symptoms. — ^A tickling, a scratching, a feeling of a hair or other foreign body in the throat, an inclination to swallow, a lump in the throat, sensations of various kinds referred to the larynx, are the paresthesic signs of enlarged lymphoid material at the base of the tongue in neurotic patients. Actual pain is sometimes described; cough, laryngeal spasm, globus hystericus, fatigue of the voice, are often ascribable to sensations arising from congestion and hyperplasia at the base of the tongue. The severity of the symptoms bear no relation to the degree of abnormality, INFLAMMATION OF THE LINGUAL TONSIL 369 but correlation of the intensity of symptoms and the neurotic tempera- ment of the patient is very marked. The coexistence of gastric and intestinal symptoms has been mentioned. Prognosis.^ — The condition is annoying, but it is in no way a menace to the health of the sufferer, except in a very indirect way, such perhaps as serving to keep up an undesirable condition of high nervous tension in a neurotic person. The prognosis as to cure of the symptoms being obtained by local measures is very uncertain. Given a moderate amount of hyperplasia, considerable congestion, and a neurotic patient, it can be pretty safely predicted that the removal of the superficial layers or their cauterization will not serve by themselves to cause any ameliora- tion of the symptoms. Given a large amount of the tissue and a small amount of complaint, the result of operation is much more favorable. This class of patients is a troublesome one to the surgeon or the physician whose chief desire is to cure his patient. Hypertrophied lymphoid masses at the base of the tongue may occur either as two lobules on either side of the median raphe or as a collection of small lymphoid masses occupying the entire region across the base of the tongue above the lingual surface of the epiglottis. There is always associated with these masses a venous stasis; although at times the veins may not be clearly visible, at others the veins interlace in a plexus between the lymphoid masses. Fig.' 241 Myles' lingual adenotome. Treatment. — As the hypertrophy is frequently due to gastro-intestinal disturbances, the attention of the physician should be directed primarily to the correction of the underlying cause. Small doses of calomel should be administered twice or three times a week, followed by an efficient saline cathartic the next morning. After each meal two drams of rhubarb and soda mixture are to be given. This medication itself often relieves the symptoms. The patient is given also a spray of alumnol, twenty grains to the ounce, to be used twice or three times a day, preferably .after meals. If these measures fail the base of the tongue should be cocainized by the local application of cocain paste and cauterized with the lingual galvanocautery point. At each sitting two linear cauteriza- tions should be made through the mass on either side of the tongue, and in the course of a week a second similar application should be made. The masses should not be entirely burnt away so that a dry smooth surface is left instead, but should be only sufficiently reduced in size to control the constant laryngeal irritation, or reduced sufficiently to prevent contact with the epiglottis which occasions a hacking cough 24 370 HYPERTROPHY OF THE TONSILS AND UVULA and clearing the throat. The growths are frequently so large that it is necessary to remove them by means of a lingual adenotome. In order to do this thorough cocainization is necessary, but it is inad- visable to apply adrenalin, as in the first place it reduces the size of the tumor so that it is more difficult to remove, and secondly it is attended by postoperative hemorrhage to a greater extent than if not employed. Immediately after the removal of the growths local application of thrombokinase or chlorid of zinc should be made to control the hemor- rhage which is often severe following this procedure, and as there is no way by which satisfactory pressure can be applied, it assumes in some instances an alarming form. It is therefore advisable always to try cauterization first before attempts at cutting are made. Removal is easy and is accomplished under the guidance of the laryngeal mirror, the direction for pressure upon the extremity of the instrument being in the opposite direction from the apparent indications of the laryngeal image. Accessory thyroids have often been mistaken for a large lingual tonsil, and whenever an extremely large mass is to be removed from the base of the tongue it is advisable to have a microscopical examination made to determine its character. Keratosis of the Tonsils (Mycosis Tonsillaris). — ^In this place properly belongs a reference to a condition occasionally found in hypertrophied tonsils which is sometimes referred to as mycosis of the tonsils and some- times referred to as keratosis of the tonsils. The origin of this condition has been alluded to in the descriptions of the genesis of the tonsils. It is essentially an inflammation or activity of the germinal or basal layer of the epithelium which results in hyperplasia and an increase in the epithelial layers of the tonsillar crypts to such an extent that the ex- ternal cells undergo a keratohyaline degeneration and scale off as masses of dead epithelium in the tonsillar crypts. These layered masses present themselves at the mouths of the crypts as white spots and project to such an extent from the surface that they resemble tufts rather than plugs. On section they appear to be threads of tissue which lie close against the tonsillar surface and parallel with it. As a matter of fact they are simply sections of the layers of this desquamated keratohyaline material. In it the Leptothrix buccalis finds a favorable nidus for its development and at one time it was regarded not only as the character- istic but as the cause of the lesion. It is seen at all ages even in the new- born infant. It is frequent in the lingual tonsil. In this situation, as also in adults upon the posterior wall of the pharynx, the same process is set up at the mouth of the ducts of racemose glands so that plugs of keratotic material project in hair-like processes from them. The cause of this epithelial activity is unknown. It probably has some relation to climate inasmuch as the only therapeutic measure which seems to be efficient is the removal of the patient to some other locality. This alone is sometimes sufficient to cure the condition, though removing the re- dundant lymphoid and epithelial hyperplasias from the pharynx is also indicated. It is most frequently seen in young adults or in adoles- cence, but it occurs at both extremes of life. The condition, as has KERATOSIS OF THE TONSILS 371 been intimated, is frequently spoken of under its original designation, mycosis. It is still acknowledged that there exists some justification for that appellation, since the number of leptothrix threads and spores found in the material is often very large. The spores especially seem to be so numerous in some cases as to obscure the fields of microscopical sections. This is specially true of masses found in the tonsillar crypts. It is, however, doubtful if the leptothrix itself ever grows with sufficient exuberance independently of the keratotic material to be seen as the white plugs which give the striking appearance to the local condition clinically. Symptoms. — ^These may be insignificant or very distressing. White tufts are seen projecting from the surfaces of the faucial and lingual tonsil in cases of pharyngeal irritation or they may be discovered by accident in the routine examination of the throat. The symptoms which they themselves seem to give rise to are a tickling sensation and the feeling of a foreign body in the throat. In neurotic persons this is often very marked. Some pain is complained of and when the patient chances to discover the condition, by the inspection of his own throat, considerable alarm is often excited. Repeated attacks of sore throat, not very severe in character, are apt to be associated with the trouble. The persistence which, in spite of all local treatment, the condition exhibits, and frequently the extremely neurotic state of the patient, especially when it occurs in a female, are the salient features of the cases clinically. Attempts to dislodge the masses meet with no result. The attempts to scrape them or biu'n them out are of no avail, unless they are carried to the point of the destruction of the tissue from which they grow. They tend to disappear spontaneously, but a change of climate and of habits is some- times associated with that event. Differentiation of this condition from that of others with which it may be confounded will be taken up separately. Treatment. — Measures for the relief of keratosis of the tonsils or mycosis tonsillaris are usually without result unless they include some change of climate. It is said that smoking tobacco taken up as a new habit will sometimes cause the tufts to disappear. If tonsils and adenoids are large their removal will sometimes be followed by subsidence of the condition even on the lingual tonsil, but the condition is not infrequently observed in the pharynx and on the tongue of those having no note- worthy enlargement of pharyngeal or faucial lymphoid tissue. Change of locality and even entire change of climate do not always abolish the condition. We have seen cases in which it temporarily disappeared on a change of climate, in one case for many years and subsequently reappeared. The cure when it takes place, therefore, is usually a spon- taneous one, though the indications above detailed should be heeded. Some have pretended to be able to differentiate between a condition of keratosis and one of mycosis pharyngis, but though we confess to a feeling of doubt as to this, Brown Kelly, of Glasgow, has made a dis- tinction. Mj/com.— Differential diagnosis between these two diseases is summed up by Kelly in the following points: (1) keratosis appears in the prime 372 HYPERTROPHY OF THE TONSILS AND UVULA of life, mycosis may affect any age; (2) the cause of keratosis is unknown, mycosis is generally caused by some local abnormality of the buccal secretions or of the digestive tract, or possibly some diathesis, as rheuma- tism; (3) in keratosis the symptoms are slight or absent, in mycosis they are pronounced; (4) in keratosis the surrounding mucosa is normal, while in mycosis it is inflamed; (5) in keratosis the excrescences of the tufts are firmly adherent and assume characteristic shapes, in mycosis they are soft and easily removed; (6) keratosis is confined to some part of Waldeyer's ring, while mycosis may be at any point between the mouth and stomach. Mycosis shows a resemblance to thrush or sarcinia, while keratosis does not, if we leave the leptothrix out of account. Local application will cure mycosis while it does not affect keratosis. While these differential points are very clearly and distinctly drawn, they are not of so much value in the clinical consideration and treatment of the disease. Those cases which have yielded to local applica- tions of bichlorid of. mercury solution 1 to 1000, nitrate of silver, tincture of iodin, calomel insufflations, tannic acid, chlorid of potassium, and perchlorid of iron solution may have been all cases of mycosis rather than keratosis. Unquestionably the horny projections of keratosis can be only overcome by cauterization or, if circumscribed upon the tonsil, by the removal of that organ. A curette emploj^ed in scraping away the mycotic growth, followed by local applications of equal parts of guaiacol and sweet almond oil, results in the quickest cure, as a rule. Bone in the Tonsil. — Another condition due to chronic hyperplastic change which is often treated under a separate heading is the occurrence of bone and cartilage in the faucial tonsils. Various theories have been advanced to account for this condition, some claiming that they are teratomatous developments having their origin in the displacement of cartilage from the branchial arches in embryonic life; some claiming that it is due .to ossification of the prolongation of the styloglossal liga- ment. Without entering into this discussion it will suffice to say that we believe the condition arises from metaplasia following upon the increase in the fibrous connective tissue at the base of tonsils which are undergoing regressive changes. Here as elsewhere in the body fibroblasts are often changed into chondroblasts or into osteoblasts, and we have the formation of larger or smaller areas of cartilage and bone cells existing in the deeper layers of the tonsil. This rarely gives rise to any symptoms apart from those of the chronic tonsillar hypertrophy with which it is associated, and is usually only discovered at an operation for the removal of hypertrophied tonsils. Tonsilloliths. — In the crypts of the tonsils concretions are occasionally found of the salts of lime and magnesium deposited around some foreign body similar to the objects described as being more frequently found in the nose. They lie in cavities formed by dilatation of the crypts due to their mouths being sealed at the surface. They set up a certain amount of irritation and are detected by probing or occasionally only at a tonsillotomy when the instrument grates against them. TONSILLOLITHS 373 Acute and Chronic Inflammations and Elongation of the Uvula. — Acute inflammations of the uvula are seen, usually with acute affections of the pharynx, but occasionally without it. In the latter case they are apt to be due to burns or injury, especially operative. The loose areolar tissue which intervenes between the epithelium and the muscular layers, espe- cially at the tip of the uvula, is apt to become edematous, and some- times the bulk thus formed is considerable in the fauces and embarrasses deglutition and respiration. Serum is effused from the bloodvessels and the membrane becomes translucent, streaked with tiny capillaries or diffusely suffused with a dark-red color. Repeated attacks of pharyngitis and the existence of a chronic in- flammation result in the elongation of the uvula, due to proliferation of the areolar tissue and to the loss of the elastic fibers which are abundant in the normal mucosa of the uvula. While the muscular tissue in these cases may be relaxed, it usually does not take part in the forination of the elongated portion to any great extent. On the other hand the uvula may not be elongated, but the fibrous hyperplasia, supplementing the epithelial proliferation, may lead to a considerable increase in its trans- verse and anteroposterior diameters. This affection is the result of or a part of the general pharyngeal acute or chronic inflammation, and the results of the latter may progress to such an extent that the organ habitually lies on the base of the tongue and in this condition causes a very marked pharyngeal and laryngeal irritation. Tickling and increased secretion result. There is a feeling of a foreign body in the throat. Examination may reveal the condition, but sometimes simple inspection does not. A long, slender tip may be folded laterally or posteriorly in such a way that it escapes inspection, but the use of the probe usually reveals the condition. The uvula is subject to the same diseases, both infectious and other- wise, as the soft palate and pharynx. It will often become edematous under conditions where the soft palate escapes, and will occasion more discomfort than when the soft palate is alone involved. Edema fre- quently arises from excessive smoking or drinking, particularly from drink- ing carbonated wines. In chronic postnasal catarrhal conditions the uvula becomes elongated and the mucosa thickened, so that it occasions nausea, retching, coughing, snoring, and often all but strangling when the patient lies down, which may produce grave anxiety. The uvula is the site of syphilis, tuberculosis, and epithelioma, and it is often destroyed from these causes. Another occasional cause of its destruction is accident in the removal of adenoids, when it becomes engaged between the handles of the adenoid forceps or caught in the extremity of the curette and removed at the same time with this growth. Papilloma involves the uvula more frequently than any other neoplasm, and its presence is associated with prolonged fits of coughing, simulating phthisis. Illustrative of this is a case of a young man in robust health, coming under the observation of the writer, at a sanatorium for consumptives admitted with the diagnosis of phthisis. A coincidence influencing the diagnosis of the physician sending him there was that his mother was in 374 HYPERTROPHY OF THE TONSILS AND UVULA the same sanatorium with advanced tuberculosis of the lungs. His cough had extended over a long period and had not yielded to any of the various remedies administered for the control of the trouble. Physical examination was negative, as was also microscopical examination of the sputum. X-ray examination also failed to reveal any involvement of the lungs. Upon examination of the throat, however, a small papilloma the size of a pea was found attached by a long pedicle to the uvula, which upon inspiration would fall into the larynx, creating a continuous irri- tation until the violent fits of coughing would expel it, after which, for a limited period, the coughing would cease. Removal of this growth completely overcame the cough. The uvula due to hypernutrition in- creases frequently not only in length but in diameter, and especially is this found in cases of chronic pharyngitis in plethoric persons. In the thickened extremity there is to be found not only connective tissue but fibers of the relaxed and hypertrophied muscle, which necessitates removal before satisfactory conditions can be obtained. Treatment. — In edema due particularly to alcoholism, burns, or excessive smoking, several pricks with a sharp-pointed bistoury or scarification will in the majority of instances relieve the condition, after which an astringent gargle, such as alumnol, 20 grains to the ounce, must be administered for several days. The treatment of the acute condition is habitually merged into that of an acute pharyngitis, but the elongation of the uvula as the result of chronic inflammation frequently calls for uvulotomy after cocainization. By means of a long-handled forceps and long-handled scissors, curved on the flat, the organ is drawn forward and severed in oblique fashion, so that the raw bevelled surface looks posteriorly. If the part of the organ amputated contains muscular tissue, or if the latter seems to show in the stump, an attempt may be made to excise a little more of it, so that there wiU be a little redundancy of the mucosa to cover the raw surface. This will lessen the subsequent suffering from the operation which occasionally is very marked on deglutition for several days, and very hot or very highly spiced food is to be avoided. Topical applications or astringent gargles are useless in decreasing in any degree this redundancy of tissue. Those conditions producing nasopharyngitis, such as gastro-intestinal disturbances and rheumatism, or any nasal obstruction, as adenoids, hypertrophies, or septal deviations, should be overcome. Hypertrophied tonsils should be removed and smoking stopped. Astringent gargles, together with the local application of nitrate of silver, may in a few cases overcome the turgescence of the mucous membrane and reduce the vari- cosity that generally appears on the posterior surface. But as in the case of the turbinates, when true hypertrophy has been established, nothing short of surgical measures will overcome the disturbance. DEFORMITIES OF THE UVULA. There are many congenital deformities of the uvula, but few of them influence in any degree the act of swallowing or articulation. The one REMOVAL OF THE UVULA 375 found most frequently and one that influences articulation to the greatest extent is the bifid uvula. This may exist as only a slight cleft in the tip, or it may extend to a complete division through its extent, and even into the soft palate. Where the bifurcation extends only a short distance it is unnecessary to interfere surgically for its correction, but when it extends high up and the patient is unable to say k or g, it becomes expedient to pare the opposite sides and coapt the two parts with one or more sutures. Fig. 242 Casselberry's operation for elongated uvula. (Ballenger.) REMOVAL OF THE UVULA. Hypertrophy or elongation from long-continued suction necessitates removal. Many methods and numerous instruments have been devised for this procedure. The attenuated tip of mucosa tends to curl up over the denuded bundle of musfcular fibers, thereby reducing the irritation incident to the operation. However, the uvula remains sensitive in some cases over a period of several weeks. This condition has been overcome 376 HYPERTROPHY OF THE TONSILS AND UVULA by a method advocated by Casselberry, which consists in catching the tip of the uvula only by the mucous membrane and by gentle traction drawing it below the muscular tip, where it is excised with scissors. The mucous membrane then retracts, exposing the extruding bundle of mus- cular fibers. The muscular fibers are then caught with forceps and pulled out from the retracting mucosa ajid cut through. When these retract they pull up within the sheath of mucous membrane which closes around the tip in a cuff-like flap, protecting the sensitive tip of the uvula, and if a stitch of small-sized catgut is taken in this tip it will frequently result in primary union. Packard's Operation.— Packard's operation consists in seizing the tip of the uvula with tenaculum forceps and drawing it directly forward, when by means of scissors or scalpel a wedge-shaped piece is removed, consist- ing of mucous membrane and muscular tissue, after which two catgut sutures are introduced to hold the cut surfaces together. Primary union usually follows the excision. Hays has devised a uvulotome which makes this incision through the mucous membrane and muscular tissue at one bite. Fig. 243 ^U^m Hay's uvulotome. In the removal of the uvula, by whatever means, one should exercise particular care not to take off too much, as there will always follow cica- tricial contraction after the operation that will still further shorten it. In a general way it might be advised that only one-third of the elongated uvula should be removed, leaving two-thirds in place. Subse- quent treatment consists in soothing gargles such as Dobell's solution, a mild carbolic acid solution, or troches in which there is a slight amount of cocain for the relief of the pain. Pellets of ice taken frequently will also lessen the congestion and pain. Very hot and highly seasoned food or drink should not be taken for a few days after the operation. CHA'PTER XIII. THE INFLAMMATIONS OF THE BUCCAL CAVITY. Catarrhal Stomatitis. — In a study of the acute and chronic inflamma- tions of the buccal cavity it soon becomes apparent that bj' far the most characteristic is that form which affects the epithelial layers. Of this disturbance the most common clinical aspect is one of ulceration, usually superficial in character. The formation of the ulcers usually occurs as a sequel to bleb formation. From whatever cause it may arise it is characterized by a general swelling and softening of the gums and by redness of the other parts of the mucosa. The epithelium becomes swollen and proliferates rapidly to compensate for the loss of superficial layers which are desquamated. There is round-cell infiltration of the deeper layers. The papillae of the tongue are enlarged by the same process. In all forms of stomatitis, and there are very many, the above may be taken as the more or less common fundamental histological - change. Local necrosis of the epithelium is liable to occur in them all, either from the detachment of the epithelial layers by effusion of serum, forming blisters, or by a diffuse infiltration cutting off its nutrition with- out the formation of blebs, but it is possible for a mild, simple, catarrhal inflammation to occur without these manifestations, for the most part in association with digestive and other disorders which render the mild mouth lesions of secondary importance. Stomatitis Aphthosa. — Adults in poor health suffering from uremia, anemia, leukemia, mercurial and saturnine poisoning, scurvy, children suffering from digestive disorders, present these aphthous conditions in stomatitis. A much graver form than these common lesions is the deep necrosis of tissue known as noma or gangrenous stomatitis seen in some of the acute infectious diseases, typhoid fever, scarlet fever, but also in profound mercurial poisoning and leukemia. Deep destructive ulcers, extending to the cheeks and tonsil, covered by a foul and dirty mem- brane, rapidly lead to a fatal issue in most cases. Streptococci of a virulent type and other pathogenic organisms are found in the lesions. The abolition of systemic resistance from general causes lies at the bottom of these profound local adynamic processes. The distribution of the ulcers varies somewhat with the nature of the etiological factor, but the milder forms as well as the more severe are seen especially on the soft palate and fauces. They are also common elsewhere on the mucous sur- face of the lips, cheeks, tongue, gums, and posterior pharyngeal wall, on the tonsils and epiglottis. Bednar's aphthm is a term referring to the grouping of the aphthous ulcers together, which may subsequently coalesce with the one large, well-defined patch. 378 THE INFLAMMATIONS OF THE BUCCAL CAVITY In the brief mention of the various forms of stomatitis, reference has been made to the etiological factor of a general nature prominent in each. In none of them has there been proved to be any one determining cause. While no specific organism has been identified as the exciting cause a number of pathogenic forms are found in them, and some of the forms of stomatitis are occasionally noted as endemic in children's hospitals and in the army. Conjecturally this is due to some common factor in the food or in the hygiene. Mikulicz describes a chronic recurrent form noted in anemic chlorotic women, but this seems to belong among the herpetic throat lesions, though the clinical and pathological conditions are not clearly differentiated. Histology. — The epithelium becomes cloudy and necrotic over localized areas, there are fibrinous deposits in it; superficial desquamation occurs. There are mitotic figures in the epithelial cells around the shallow ulcers just formed, with leukocytic infiltration of the layers. The severer form of noma is often extremely destructive. It rapidly presents necrosis of the subepithelial layers, it perforates the cheeks or makes deep, foul, sloughing ulcers in the fauces and tonsils, and is rapidly fatal. In this also the organisms of Vincent's angina and other pathogenic organisms are found, but they are evidently secondary phenomena in the etiology. Treatment. — The treatment of these forms of stomatitis, symptomatic as they are of some general disorder or gastro-intestinal disturbance, must be directed to the underlying condition. The digestion must be regulated by a proper dietary, especially in infants, constipation or diarrhea overcome. Not infrequently change of climate, especially when it means a change of regimen as to diet, will benefit these cases. Boric acid mouth washes or alkaline antiseptic solutions, such as hsterine or Dobell's solution, may be used for local detergent effect. Sometimes argyrol in solution or fused nitrate of silver may be applied to the ulcera- tions with advantage. The severe forms which grow out of what was at first an aphthse or a catarrhal stomatitis, the malignant form of ulceration called noma, following the exanthemata at times, require as vigorous local antisepsis as it is possible to apply by bichlorid irrigation locally and a stimulating medication of alcohol internally in the form of champagne; but unless the systemic resistance rescues them a fatal issue may be expected in spite of systemic or local treatment. Deep, foul, sloughing ulcers occur in the fauces and tonsils, and the affection is rapidly fatal. In this also the organisms of Vincent's angina and other pathogenic forms are found, but they are evidently secondary factors in the etiology. Gonococcal Stomatitis. — A number of cases have been reported of a gonococcal infection of the buccal and pharyngeal mucosa. Superficial but widespread ulcers covered with yellow pus form a smooth surface level with the rest of the mucosa. It is attended by slight constitutional disturbances. It has been remarked chiefly though not exclusively in children. While the gonococcus can at times be satisfactorily demon- strated in smears its identification is not by any means an easy matter. From the meningococcus it is the opinion of the majority of bacteriolo- VINCENT'S ANGINA 379 gists that it can only be distinguished by means of the complement- fixation test. The meningococcus and the gonococcus can be distin- guished from the diplococcus catarrhalis by the slowness and difficulty with which they grow upon plain agar, the diplococcus catarrhalis growing freely upon it. As the micrococcus cannot be distinguished morphologically from a number of coccal forms which occur in acute catarrhal conditions nor from the gonococcus, all being frequently found inside of the cells, a diagnosis of gonococcal stomatitits or rhinitis must be made with great reserve when dependent on bacteriological examination alone. How many of the cases reported of gonococcal infection of the upper air passages would stand the criterion of present- day bacteriology it is difficult to say.^ The cases are probably very rare even in children. The question has been raised whether the disease ever occurs as a primary affection in the upper air passages. The claim that other bacteria initiate the lesion may be dismissed with the remark that the regular presence of numerous pathogenic forms in the mouth and pharynx of healthy people deprives them of little significance as primary factors, whatever the status of the gonococcus may be in acute inflam- mations. Vincent's Angina. — ^While in laryngological literature this affection has been erected into a separate clinical affection to be separated from the other forms of ulcerative stomatitis and pharyngitis, there are small grounds in the histological lesions and in the bacteriological findings to warrant such a classification. Nevertheless, its clinical features are suffi- ciently clear-cut, and its place in literature having been made more or less a specific thing by previous writers, it may be well to consider it apart from those affections with which its clinical and pathological features naturally classify it. Etiology. — ^All forms of aphthae, the milder as well as the more severe, including noma, often show abundant fusiform bacilli and spirilla in their secretions. The question of the specificity of these in the clinical form known as Vincent's angina must probably be answered in the negative. They are found in ordinary syphilitic ulceration as well as in other less specific forms of buccal and pharyngeal disease. As has been said, they are not infrequently found on the normal mucosa. As to the two forms which are always associated in the lesions known as Vincent's angina, that is, the spirocheta and the fusiform bacillus, although so closely associated as to be considered by earlier writers as involution forms of the same organism, considerable doubt has been thrown upon this idea of their unity. The matter, however, has not been fully settled, although cultures have been obtained showing both forms. Tunnicliff 's investigations rather tend to establish the unity of the two forms, while those of Dick would seem to leave the question still an open one. The former writer also brings forward evidence to show that these forms may be the determining etiological factor in septic processes.^ 1 For children, see Rosinski, Zeitschrift f. Geburtshulfe und Gynakologie, 1891, Band xxii, pp. 216-359. For adults, see Jiirgens, Berliner klinische Wochenschrift, 1904, No. 24, p. 629. 2 TunnioHEf, Journal of Infectious Diseases, 1906, No. 3, p. 148; ibid., 1911, No. 8, p. 316 ; ibid., No. 1, 1912, p. 1. Dick, Journal of Infectious Diseases, 1913, 2, p.^91. 380 THE INFLAMMATIONS OF THE BUCCAL CAVITY Histology. — More or less deep sluggish ulcers are seen in the tonsillar region, often lasting for weeks, covered by a grayish membrane. On the tonsils these ulcers may lead to considerable destruction of tissue. The minute structure, however, presents essentially the same features already noted in other forms of buccal ulcers and in other forms of acute and subacute inflammations of the mucosa. Symptoms. — Children are most frequently affected, particularly those in institutions, and it is rare that infection occurs in a patient over thirty. The disease is ushered in with a slight sore throat of one side, accompanied with headache, malaise, and slight temperature of from 99° to 102°. There is seldom a chill such as is experienced frequently in follicular tonsillitis or quinsy. There is some pain and dysphagia with increased salivation. The breath is foul and the digestion dis- turbed. In adults constitutional symptoms are more marked and the temperature has occasionally risen to 104°. A whitish-gray patch occurs on one tonsil, which represents the centre of an ulcer, from which there extends to the faucial pillar and soft palate a grayish membrane which indicates an extension of the infection from the ulcerative area. The tonsil is swollen and the neighboring tissues red and indurated. There may also appear on the gums and inside of the buccal cavity similar areas of exudate, which closely resemble stomatitis or aphtha. In some instances the infection may be seen on both tonsils, but it usually begins on one and extends to the other. ' In a few days the slough may come away from the tonsil, leaving a moderately deep ulcer, raw in appearance but not bleeding as in a diphtheritic slough. Following the slough the tonsil appears to have been clipped off with some instru- ment. The duration of the case is usually from one to two weeks, the length of time being determined somewhat by the general health of the patient and the condition of the mouth. In persistent cases of Rigg's disease, the characteristic organism may be found in the pus from the gums, which may extend over a period of several years. In children there appear to be two types of infection as regards location of the ulcera- tion, which may be called tonsillar and extratonsillar. The tonsillar type is the more frequent; the ulcer occurs in the crypt in the upper part of the tonsil just behind the anterior pillar. In the extratonsillar type the ulceration is confined to the mucous membrane of the tonsillar pillar or soft palate. In the latter type the ulceration is not so deep and there is an inflammatory areola around it with no infiltration of the surrounding tissues. In a series of twenty-four cases, reported by Mul- holland, the onset is described as sudden, associated with sharp pain on the affected side, while talking and swallowing are difficult. There was also profound depression without rise of temperature. These symp- toms persisted for several days or until the slough took place, which apparently established drainage, followed by quick recovery. The appearance of the membrane bears strong resemblance to* that of diphtheria, and it is frequently only by microscopical examination of a smear showing the presence of the fusiform bacillus and the spirillum of Vincent or the Klebs-Loffler bacillus in the culture that a positive VINCENT'S ANGINA 381 diagnosis is made. In cases of streptococcus mixed infection there is a higher temperature, and here the culture or smear will determine the difference. In some instances of syphilitic infection it is difficult to determine the difference, as was reported by Levy, where the spirillum and fusiform bacillus were found in a young boy who appeared to have Vincent's angina, but whose condition was determined subsequently to be chancre of the tonsil. The Wassermann reaction is a diagnostic resort where syphilis is suspected. The patients, as a rule, give a history of at least several days, often of several weeks, of gradually increasing malaise, but they are never, certainly at least never in the initial stage, prostrated or confined to their beds. There is moderate enlargement of the glands at the angle of the jaw. Examination shows a surface covered by a grayish membrane situated usually near the top of the tonsils and usually more or less extensively invading the adjacent faucial pillars. The diagnosis cannot be sufficiently established "without the microscopical examination which reveals very large numbers of spirochetse and fusiform bacilli. Its differentiation, therefore, is a matter of some diflSculty and is often of great importance. It will be taken up again in the chapter on the differentiation of acute membranous disease of the pharynx. Treatment. — Rest in bed; gargles should be used of equal parts of peroxid of hydrogen and water, followed by some alkaline solution, such as Dobell's and water. When the area is cleansed by this process nitrate of silver, 30 grains to the ounce, argyrol 25 per cent., Lugol's solution of iodin, or a 25 per cent, solution of ichthyol may be applied once or twice daily. Attention should also be given to constitutional disturbances and likewise to the hygiene of the mouth. The patient should be isolated, as it has been demonstrated that the disease is probably infectious. Ill-defined as it is, both clinically and in its bacteriology, it is impossible to be more specific in the discussion of the treatment of Vincent's angina. It is often advisable to give a 3 to 5000 unit dose of diphtheria antitoxin on the theory in any given case that the spirilla and bacilli have by their growth concealed the essential organism in the lesions. Otherwise the treatment is entirely symptomatic. The mouth wash or gargle of an alkaline antiseptic, the spray of 1 to 3000 bichlorid of mercury solution frequently repeated seem all that are indicated locally. The severer forms of noma and destructive ulcerative lesions with which the organism is associated are conventionally treated by systemic stimulation of alcohol. Vaccines of course have been given, but reports of the results must still be received with caution, and there are theoretical reasons to suppose they are more apt to do harm than good. Sequelse. — Several deaths have been reported as resulting from this disease, particularly by Bruce of London, in one of whose cases the larynx and trachea were involved. The cervical glands are frequently affected so that ultimately they come to suppuration. The kidneys have also been known to be affected. Painful swelling of the joints and other systematic complications of an infectious nature have been reported by different writers. 382 THE INFLAMMATIONS OF THE BUCCAL CAVITY INFLAMMATIONS OF THE PHARYNX WITH SYSTEMIC SYMPTOMS OR DERMATOSES. (There are various affections of the pharynx which, while some of them present in that situation their chief lesion, such as diphtheria, are never- theless essentially systemic. A line of distinction of this kind drawn between septic or erysipelatous pharyngitis and diphtheria is more or less an arbitrary one. The drawing of another line between some of the lesions of the skin with pharyngeal manifestations and syphilis is open to the same criticism, yet manifestly as a matter of clinical convenience the consideration of these lesions as a sequence to that of the more specific inflammations of the buccal and pharyngeal mucosa seems justi- fiable.) Diphtheria. — Etiology. — Of all the diseases which affect the upper air passages in man, there are none which have been so clearly proved to be due directly to the action of a microorganism as diphtheria. Its constant presence in the throats of patients showing the tj^pical mani- festations of the disease; the experimental demonstration of the influence of its toxins in producing the necrotic lesions of tissues which in the epithelium leads to the characteristic tissue reaction; the fact that the body produced by the action of toxin in horses and other animals, that is, the antitoxin, seems to be clearly shown to have a distinct therapeutic value, all go to point in the most unmistakable way to the Klebs-Loffler bacillus as chief factor in the etiology of diphtheria. If, however, we accept this evidence, overwhelming as it is, in the conventional uncritical spirit, all further progress in scientific investigation of the disease will cease. In admitting the fact that other organisms besides the Klebs- Loffler produce false membrane on the mucosa; in admitting that virulent diphtheria bacilli are found in healthy throats; in admitting that the virulence in given strains of diphtheria bacilli varies with the environment; in admitting that some bacilli apparently the same in other respects as the Klebs-Loffler do not produce toxin at all, we not only open up new fields for future investigation, but we realize very vividly that there are contributory factors to the etiology which cannot be ignored simply because they are not, like the bacillus, definitely demonstrable. These factors are summed up as a rule in the term sus- ceptibility, though this is a mere tautology. Some individuals are probably immune all their lives long. This lately has been indicated by Schick's skin test. A very much larger number certainly are immune during longer or shorter periods of life. The term bacterio- logical diphtheria' was applied to those cases which, with a sore throat, show no membrane in the clinical examination, yet yield to cultures typical diphtheria bacilli. Were it not for the evidence that such a sore throat is sometimes followed by pharyngeal or other paralysis, one would be warranted in concluding decisively that in such cases of sore throat the diphtheria bacillus is essentially saprophytic as it is in the throats of healthy people. Notwithstanding this argument, it seems DIPHTHERIA " 383 warranted to believe that the relationship of the bacillus to the sore throat in certain cases is of that character. There is no excuse to speak of streptodiphtheria, since in nearly all cases, at least when the disease is situated in the pharynx, there is more or less mixture of the strepto- coccus with the Klebs-Loffler. During the first six months diphtheria in the infant is not often seen, the larger proportion of cases occurring in children from three to ten years of age. Adults are very markedly less liable to contract the disease. According to Baginsky the incidence of the disease in 2711 cases was 0.55 per cent, at six months of age and, reaching the maximum of 13.05 . per cent, between four and five, declines to 2 per cent, between thirteen and fourteen. Sex, constitution seem to have little to do with it, but as in all contagious diseases the economic factor is of influence inasmuch as overcrowding and neglect raise the incidence and the mortality of the disease to a certain extent, though these are not at all prominent in the etiology. There are some reports^ which would indicate that the bacillus of diphtheria, of virulent nature, finds a more favorable nidus of develop- ment in the nasal and buccal secretions of sickly and poorly nourished children; but they may exist there indefinitely without setting up any of the clinical evidences of diphtheria, so that we may be justified in saying that though sickly children may offer a good soil for the growth of diphtheria and diphtheroid bacilli, they do not necessarily furnish excep- tionally good subjects for the development of diphtheria. The lower animals are either not at all or only with great rarity susceptible to the contagion of human diphtheria by other than experimental methods. Guinea-pigs, rabbits, and many other animals, however, are susceptible to and may be killed by its toxins. The membranous inflammations seen in lower animals are practically always due to other organisms not pathogenic for man. It is said that the disease has been contracted by cats and by colts from man. Intimately connected with the subject of the etiology is the question of quarantine and disinfection. It is the rule of some Boards of Health to require the isolation of the patient until throat cultures show a negative result as concerns the diphtheria bacillus. While usually this involves but a few days' detention after actual symptoms have disappeared, it occasionally is extended beyond the week or ten days usually associated with final convalescence. From what has preceded, it is clear that the period in which the diphtheria bacilli may persist may be indefinitely extended. The use of disinfectant gargles and nasal douches may tem- porarily at least cause a disappearance of the bacilli from the cultures in these cases. As found in the throat the diphtheria bacillus^ in stained smears is an organism 0.3 to 0.8 microns in diameter, 1 to 6 microns long. Varying in these proportions in the throat, the variations are still wider in those grown on the different artificial media. They may be in chains of three I Conradi, Miinoh. med. Woch., March 10, 1913, No. 10. ' Park and Williams, Pathogenic Bacteria and Protozoa, 1910. 384 THE INFLAMMATIONS OF THE BUCCAL CAVITY or four and they often exist side by side, and when these are small they may be mistaken for diplococci. There are granules in their bodies whose refraction to light and receptivity to stains varies from that of other parts of the protoplasm, but though these are said to originate new bacilli they are not what is usually understood by spores. LofHer's methylene blue and some other stains bring out a rather characteristic reaction. Some are deeply stained, some less so. The situation of the beads or granules or parts of the protoplasm staining more deeply varies in cultures. In the smears from the throat these granules are not as a rule seen at the extremities while in some of the cultural forms they are. The morpho- logical variation of the diphtheria bacillus itself is such a wide one and. its pathogenicity varies so much in virulence that great confusion has resulted. Bacteriologists of late years have been inclined to look upon these variations as due to the environment furnished by the host or the Fig. 244 Fig. 245 Extremely long form of diphtheria bacil- lus. This culture has grown on artificial media for fifteen years and produces great amounts of toxin. X 1100 diameters. (Park.) v)3 l.^^ X' Diphtheria bacilli, characteristic in shapes, but showing even staining. X 1000 diameters. Stain, methylene blue. (Park.) artificial culture media upon which they grow; yet there seems no doubt that while this may be true for some of the morphologically similar varieties, there are some which, while presenting otherwise closely corresponding characters, differ permanently from the pathogenic form in their lack of specific effect upon the human organism. The so-called Hoffmann bacillus is included in the first category of mutating forms by many, while the xerosis bacillus found on the conjunctiva in health and disease belongs to the latter or permanently saprophytic varieties. Into the discussion as to these points we cannot enter. Suffice it to say that the uncertainties arising from this source have seriously affected the differential diagnosis even by cultural methods, while by purely morphological examination usually nothing of value is to be gained, though perhaps it may strengthen the presumption of the diagnosis of the lesion from clinical data when in the smears they are present in more or less abundance. DIPHTHERIA 385 From the various illustrations with their legends taken from the work of Park & Williams, edition 1910, one may appreciate the possible sources of error in the diagnosis of various culture forms. Tinctorial reactions furnish some evidence of value when used as above indicated. Fig. 246 FiQ. 247 ' < 4«Vw H a* Non-virulent diphtheria bacilli, showing stain with Neisser's solutions. This ap- pearance was formerly supposed to be characteristic of virulent bacilli. Bodies of bacilli in smear, yellowish-brown; points, dark blue. (Park.) B. diphtherias agar culture. Bacilli small and uniform in shape. X 1000 diameters. (Park.) Colonies grow most characteristically on coagulated blood-serum when the plants are made directly from the throat upon moist media. Not- withstanding these uncertainties of the bacteriological evidence in any given case, it is safe to conclude that when a patient is feverish and has a sore throat, the presence of membranes and the demonstration of diph- FiG. 248 Fig. 249 B. diphtheriae. Forty-eight hours' agar culture. Thick, Indian-clubbed rods and moderate number of segments. One year on artificial culture media. X 1410. (Park.) B.. diphtheriae. Forty-eight hours' agar culture. Many segments; long Indian- clubbed ends. One year on artificial media. X 1410. (Park.) theria bacilli by modern bacteriological technique is satisfactory proof that we have to deal with a case of diphtheria, but unless the clinical symptoms fill out the picture, unless we have a patient whose throat shows a frank membrane, whose systemic symptoms are more grave than 25 386 THE INFLAMMATIONS OF THE BUCCAL CAVITY those recognized as not infrequently seen in the absence of the diphtheria bacillus, a practitioner accustomed to weigh scientific evidence in a scientific manner is fully justified in doubting the etiological connection between the presence of the diphtheria bacillus and the throat mani- festation. This, however, is an academic question. He is not justified in allowing such scientific skepticism to interfere in the slightest way with the application of the safeguards which minimize the danger of the infection being carried to others. The persistent absence of the bacillus of diphtheria, of a fairly characteristic identification, from the cultures when certified to by those thoroughly conversant with bacteriological differentiation, justifies one in ascribing the clinical condition to other causes, however much the clinical symptoms point to the diagnosis of diphtheria, for the organism is easily isolated. The bacilli are found on the membranes or in the necrotic tissue, but not in the living tissue. Mallory lays stress on this saying: that in the accessory sinuses of the nose and in [Fig. 250 the middle ear the bacilli when present seem to produce only a mucoid or '" "^ purulent secretion. He supposed that ^ ^ they multiply in the secretion on the \ mucous membranes and produce a «* toxin which causes the necrosis of I '^^"^'/^L^ ^^ surface epithelium; but inasmuch iL^ •'iSBB* ^^ diphtheria bacilli are found occa- 'jp jju JB'^^B' sionally in the blood and internal ^^ijfiSy^LjV- organs, we must believe that a cer- ^^^^^^P'*' tain number penetrate the epithelial line of the body, either on the dis- B. diphtheriiE. Twenty-four hours' gased or on the normal surfaces. agar culture. Oooeus forms. Segmented mi ... ,, , ,, ,.. , granular forms on Loffler's serum. Only inC Supposition that they multiply variety found in cases of diphtheria at first in the buCCal seCretionS preSUp- Chiidren's Home. X 1410. (Park.) p^ggg ^^ jj^j^ial change in them. The supposition that they penetrate the epithelial layers in health and then multiply in the tissues or in the blood presupposes some antecedent change in the epithelium and in the body fiuids. Elsewhere in this volume something has been said as to the probable nature of the change in the biochemistry of the surface whereby this takes place. All this becomes impressive when correlated with the fact that diphtheria bacilli are often found in the upper air passages of healthy persons who have never had diphtheria. Evidently then, as we said in the opening sentence, in spite of the evidence of the predominance of the diphtheria bacillus in the etiology of diphtheria, there is something of quite as much importance lacking in our knowledge of its causation. Practically the same confusing facts await solution in influenza and septic affections of the nose and throat, associated with the streptococcus, in Vincent's angina and indeed in nearly all diseases with which specific forms are identified. The diphtheria bacillus secretes a toxin on the mucous membranes of the ^ DIPHTHERIA 387 upper air passages as well as in cultures, the virulence of which varies greatly in both environments. There are some diphtheria-like bacilli which do not produce toxin at all, and it seems probable that those so-called viruleijt bacilli which exist in normal throats do not produce it in them, but they might in other individuals. This seems the more probable from the fact that the tissues of the lower animals are susceptible to the toxins but not as a rule to infection, on their mucous membranes, by the bacillus. A strong diphtheria toxin is used in immunizing horses, and the quantity of toxin sufficient to kill 5000 guinea-pigs of 250 grams weight (Park) is injected together with 10,000 units of antitoxin into a healthy young horse in doses graduated in various ways by different makers. The antitoxin derived from the blood of such horses or, in its present appli- cation, the globulin part of the serum is tested so that a definite amount represents a definite number of units. "A unit may be defined as the amount of antitoxin which will neutralize 100 minimal fatal doses of toxin for a 250-gram guinea-pig." The artificial immunity conferred on many by the prophylactic injection of antitoxin probably does not last beyond a few weeks, and the evidence in regard to its efficiency rests upon uncertain data, though there is good reason to suppose that it markedly, if temporarily, diminishes the liability to contract the disease by those in contact with an active case. In a family of children its use must be strongly urged when the disease breaks out among them. Pathology and Histology. — ^In addition to the false membrane which is found upon the mucous membranes, there are various systemic lesions due. to toxin carried in the circulation, especially in the graver cases. There are also secondary lesions due to the presence of the strepto- coccus which are nearly always associated with the Klebs-LofHer. The order of frequeitcy of the occurrence of false membrane upon the mucosae is on that of the pharynx, larynx, nares, lungs, and conjunctiva. Exten- sion from these is sometimes seen to the nasal accessory sinuses and to the middle ear, seen through perforations in the drum. Rarely a membrane is seen at autopsy in the stomach, and it is sometimes carried to the vulva or the penis by the fingers. Of the 148 cases out of the 251 studied by Mallory, the membrane was confined to the tonsils in 9 cases, to the larynx in 5, to the trachea in 3, to the pharynx in 2, the epiglottis in 2, to the soft palate in 1, the esophagus in 1, the nares in 1. The other lesions were multiple. It may be noticed in this connection that the location of the membrane exclusively on the tonsillar surfaces is a clinical manifestation which usually indicates that the exudate is due to other causes than the diphtheria bacillus. This, however, should not receive much weight in the differential diagnosis until after the second day of the sore throat. The location of the membrane exclusively in the nose, even when the diphtheria bacilli are reported as present, is usually accompanied by slight systemic disturbances. When, however, the nasal membrane coexists with a like condition in the pharynx the symptoms are apt to be grave. 388 THE INFLAMMATIONS OF THE BUCCAL CAVITY Bronchial pneumonia and affections of other organs are indicated in the symptoms of some of the cases which recover, but very frequently it " seems evident that they are only the terminal lesions of the fatal cases. In the lungs especially, according to Mallory, diphtheria bacilli are apt to be abundant in the lesions, but here as elsewhere they are usually associated with other organisms, though in 17 of 140 cases they were found there in pure cultures. The intensity of the inflammation is apparently visited upon the epithelial cells: They take on a rapid, and direct or amitotic division of the nuclei. This is a prelude to necrosis and they then make up part of the false membrane which forms on the surface, in color dirty white or brown or grayish brown or even black. Besides the nuclear proliferation there is vacuolization in the cytoplasm and as the cell dies there seems to be a hyaline transformation with an intact nucleus which then disappears. This seems to be the case chiefly upon the pavement epithelium. Some- times acid-staining hyaline bodies are seen in the nucleus. There are also fatty changes in the cytoplasm. In the pavement epithelium, foci of these changes may exist separately with fairly normal looking surface between them and then coalesce. The epithelium desquamates slowly where it is of the pavement variety and advances more or less irregiflarly, but in the larynx and trachea where there is columnar epithelium it spreads easily, desquamates quickly, is thrown off as complete tubes, casts of the air passages, leaving behind simply the basal layers of the epithelium. There is abundant leukocytic infiltration and migration into the layers of .the epithelium, but there is less necrosis to be observed in the columnar epithelium. The gland epithelium shows some of the same features, necrosis being, however, very prominent. It is said that the endothelial cells which have proliferated below also undergo necrosis. In this case there is entire disintegration of the glands. In the violence of the inflammation the exudation from the vessels in the subepithelial tissue infiltrates the epithelial layers and separates them from the basal cells. In this way small vesicles may occur, though these are not visible to the naked eye. The coagulation of the fibrin in this exudate not only forms the larger part of the false membrane, but it is present in the subepithelial layers filling and compressing the lymph spaces. Leukocytes, large and small, the polynuclears and the lymphocytes, some plasma cells, and a few eosinophiles make up the other cellular constituents of the exudate. The mononuclears act as phagocytes and are found in the deeper layers of the epithelium con- taining much foreign protoplasm. False Membrane. — At first this is made up of fine fibrinous threads which later become swollen and coarse. The interstices are filled with detritus, with leukocytes, red-blood cells, and epithelial cells. These finally become fused with the fibrinous structure and broad hyaloid bands are seen making a characteristic appearance. Some of these may shut off small spaces, round or angular. This appearance is specially prominent in the false membrane on squamous surfaces where the membrane stays longer and more presistently in situ. Here it is bound down by processes DIPHTHERIA 389 of fibrinous threads leading from the membrane down between the under- lying cells. When the membrane comes away some of the underlying epithelial cells owing to this arrangement may come away with it. This is more or less the character of the false membrane everywhere it occurs in the upper air passages. In the crypts- of the tonsils the hyaloid con- dition does not obtain, according to Mallory, except as detached masses, though a smooth fibrinous membrane extends over the whole surface and all the crypts are filled with the exudate. A similar hyaloid appear- ance is noted as caused by the fibrinous infiltration of the submucosa and in the walls of the bloodvessels. These latter are dilated as are the lymph spaces, the latter filled with lymphocytes and hyaloid material. The smooth muscle fibers are swollen and their outlines are lost or they undergo granular degeneration. Ulceration, except such as may form from intubation of the larynx, is unusual. It was seen only in 12 of the 251 cases examined postmortem by Mallory. While an inflammation similar to that seen in the lymph nodes of other infectious diseases is found, Mallory describes in diphtheria and scarlet fever foci similar to those of tubercle with proliferation of endothelial cells, giving rise to large cells which act as phagocytes toward the other leukocytes of the lymph nodes, but the other minute features of tubercle seem to be lacking. In the tonsils there is marked swelling and activity of the germinal centres, with resulting necrosis and phagocytosis, as has been noticed in other forms of acute tonsillitis. The intensity of this is more marked in diphtheria and minute interstitial hemorrhages occur. Repair takes place after the membrane is shed from the surface by the growth of epithelium from the sound edges, and however wide the ar€a affected may have been, this takes place with fair rapidity. Adhesions of surfaces rarely occur. The subepithelial regeneration ensues after the fatty degeneration, resulting in the death of the parenchyma cells, has been removed by absorption. Other pathological changes occur in other organs, but into this we cannot enter here and the reader is referred to the work of Mallory.^ Local Symptoms. — In view of the situation as set forth in the fore- going remarks as to etiology, we are practically forced to treat every case of sore throat showing diphtheria bacilli in the secretions as diphtheria whatever may be the other signs of it. On this basis of nomenclature we are compelled to include many cases which show but trifling local and constitutional symptoms. Yet it would be setting forth the situation in a false light not to recognize that in a very large majority of the cases of sore throat associated with the presence of the diphtheria bacillus there are pretty sharply marked features which we recognize as typical of the disease aside from the presence of the organism. Locally these are the situations of the false membrane and the tenacity with which it clings to the surface. It is unusual that it is confined to the tonsil after the second day of its appearance as a more or less confluent exudate. A filmy, grayish cloud is seen in its earliest manifestations, indicating that it has its origin from the ' Nuttall and Graham-Smith, The Bacteriology of Diphtheria, Cambridge Press, 1908. 390 THE INFLAMMATIONS OF THE BUCCAL CAVITY surface and not from the crypts; but this stage is pretty regularly missed when it occurs, as it usually does, primarily on the tonsillar surface. On the soft palate it may at first exist in small detached areas, but before it becomes confluent in these cases it grows in thickness. It cannot be entirely wiped away and it has a zone of redness around it easily distin- guished from the edge of an ulcer. The clinical appearances have already been sufficiently included in remarks on the pathology. Sometimes deep ulceration and gangrene accompanying the diphtheritic process give rise to the supposition that some other microorganism is the causative factor in the anomaly, but there is nothing assured as to this, and it is preferable to refer such an event to the avowedly indefinite term — the asthenic state of the patient. The membrane spreading to the larynx may give rise to dyspnea necessitating intubation or tracheotomy. Dys- phagia is severe, but alimentation is rarely impossible. The use of anti- toxin immediately the diagnosis is made usually strikingly changes this picture. The membrane may sometimes be hidden from view and the careless examiner may miss it. A fold of the pharynx, the sulcus behind the tonsil, or the posterior border of the uvula and palate may harbor it. It usually exists on both tonsils before the termination even when it is of a mild type and when it is limited for the first few days to one of them. The uvula is pretty sure to be the site of the membrane also even in mild cases. The cervical glands are swollen. The severe forms of the disease are represented by the membrane in the pharynx and its coexistence in the nasopharynx and nose and its extension to the larynx and trachea. In a general way the severity of the systemic symptoms are proportional to the extent of the membrane. The extension from the pharynx to the nose is apt to emphasize this severity in the constitutional disturbance, though when the membrane begins and remains confined to one or even two nasal chambers, the systemic symptoms are often so slight that for some time membranous rhinitis was supposed never to be truly diphtheritic, but in a large pro- portion (50 per cent.?) of these mild nasal cases the diphtheria bacillus has been found. In any situation the form of the disease may rapidly become a grave one. Its extension to the trachea and bronchi or even to the larynx is not so frequent now that the disease is promptly recognized and properly treated. The Systemic Symptoms.— The onset may be more or less of a distinct chill or a general feeling of malaise, which gradually increases, accompanies the sore throat with boneache and general depression. The fever remains tinder 103°, as a rule, and the pulse is rapid and weak. Considerable importance was placed on these phenomena before diagnosis by bacterio- logical examination was common. Comparatively low temperature and comparatively high pulse rate were considered more or less pathogno- monic, and are still recognized as the rule, though neither may be marked. Albumin and casts in the urine are noted in the majority of the cases, though nephritis as a serious complication is not observed with frequency. The severity of the onset may be exaggerated and the patient may die from cardiac failure in a few days, but cardiac failure is more common in hlPHTHBRlA 391 the later stages of disease. In moderately severe cases, the T-curve in the first week varies between 100 and 104, usually with slight tendency to afternoon exacerbation, there being thereafter a steady decline to normal if the patient recovers. It is occasionally subnormal in those suffering from profound toxemia. The pulse rate in general is a better guide. While cases of brachycardia, or slow pulse have been reported, the condition is transitory, and the pulse rate, especially in children, is apt to be high and the blood-pressure low. A pulse of 130 to 150 is not un- common. As a rule the higher the pulse rate the more unfavorable the prognosis. Stengel quotes figures to show that the mortality with a usual pulse rate of 110 is about 5 per cent., and for every increase of 10 beats the mortality rapidly rises, and those recorded at 180 show in uncompli- cated cases a mortality of over 70 per cent. The severe cases show a high percentage of paralyses. As Stengel divides them the total percentage of paralyses is 17 per cent. Severe cases he puts down as 28.6 per cent., moderate cases as 13.2 per cent., slight, none; but as intimated this is not always true, as paralysis of the palate is at times seen which can be accounted for only by the supposition that an antecedent sore throat of so mild a character as not to form an important incident of the patient'^s subjective history was in reality diphtheritic in character. It seems to be a peripheral neuritis due to the presence of toxins. Usually it affects only the palate, or at most only slightly affects the muscles of deglutition; but almost any group of muscles exceptionally may suffer in a greater or less degree from paresis or com- plete paralysis. Not only voluntary muscles like the peroneal and semi- voluntary muscles, like the ocular muscles, but diaphragmatic and cardiac muscle paralysis may cause sudden death. This may begin early in the disease, even the first day, or it may not be noticed at least until the membrane has all disappeared. As a rule, except in the rare cases of a fatal issue, recovery ensues within a few weeks after the inception of the paralysis. The regurgitation of food and drink through the nose is usually the first indication of the palatal paralysis; the nasal voice and difficulty in swallowing then attract attention. The laryngeal cases, formerly so fatal, are at present not so frequently seen. The child becomes hoarse and aphonic, it is restless, and suffers from a gradually increasing dyspnea, which in its turn is accompanied by cyanosis. The deeply toxic cases betray the systemic poisoning in the dusky hue to the skin and the sunken, anxious facies. A brassy cough is often present, and in one of the paroxysms the patient may cough out complete casts of the larynx and trachea, or at least fragments of mem- brane. This often markedly relieves the laryngeal symptoms, and the systemic depression, to some degree dependent on the obstruction of the air-ways. In a few hours the signs of the laryngeal obstruction again supervene. Death may result from heart-failure during this laryngeal obstruction unless it is relieved by intubation or tracheotomy. The prompt administration of antitoxin will frequently arrest the dangerous formation of laryngeal false membrane. There are a certain number of cases of primary laryngeal diphtheria 392 THE INFLAMMATIONS OF THE BUCCAL CAVITY or those in which the membrane has spread from the pharynx to the larynx before the case comes under the observation of the medical man, upon the incidence of which the modern treatment of diphtheria has had no effect. The crowing respiration and the picture of air hunger is a striking feature of the disease, not now so frequently seen, but only too familiar in the period before the use of serum-therapy. We have already referred to the mildness of the cases of membranous rhinitis even when associated with the diphtheria bacillus. When, however, in the course of diphtheria, there is extension of the membrane to the nasopharynx and the nasal cavities from the pharynx, or when the nasal membrane forms from the first only a part of a more extensive exudate, the gravity of the symptoms is often very great. Profound toxemia, evidenced by the weak and rapid heart's action, the albuminuria, the anxious and dusky facies, all tell of imminent danger. A few cases of deep ulcerations with destruction of the subepithelial tissue are reported from time to time, leaving behind them, in case the patient recovers, cicatricial deformities of the pharynx and larynx. Diagnosis. — Every case of sore throat should be carefully examined. Any appearance of a confluent membrane, however faint or wherever situated; any exceptional feature in the systemic symptoms of a sore throat; any history of exposure to infection by a person suffering from diphtheria, is ample cause for precautionary culture examination of the secretions from the suspected spot. A sterile cotton swab is used to make the transfer. It should be rubbed with some force on the membrane, or in the absence of the membrane on the surface of the tonsils. When pos- sible a bit of the membrane wiped off with the swab or the sterile forceps furnishes the bacteriologist with a fairer opportunity and lends much greater weight to a negative report. It will not infrequently happen that a second culture made from a throat previously reported negative will show growth of the Klebs-Loffler bacillus. The clinical symptoms should never be forgotten in diagnosis or prognosis, but the bacteriological report of the presence of the diphtheria bacillus should never be dis- regarded in the quarantine and the serum treatment of the disease. The time for the appearance of a growth recognizable by the experi- enced laboratory man is eighteen to twenty-four hours after the tube is placed in an incubator. A negative answer may be returned once or even twice, and a subsequent culture may show positive evidence. Prognosis. — ^This is so largely dependent upon the early recognition and the early administration of the specific serum that it is preferable to speak of it chiefly after a consideration of the treatment. Sufiice it to say here, the diagnosis once made, it will require an observation of a day or two at least before an idea can be gained of the probable result in any given case. The evidences of toxemia and of a weak and rapid heart occasionally noted before the observer has had an opportunity to admin- ister antitoxin are of evil import. Some cases terminate fatally within a space of a few days, owing apparently to the rapid overwhelming of the system with toxins. DIPHTHERIA 393 Treatment. — Prophylactic. — To prevent the spread of the disease either to the members of the household, or to those with whom the physician or attendants are associated outside, it is necessary that great care should be exercised. Those directly associated with the patient should receive an immunizing dose of antitoxin of not less than 500 units, as well as the children who have recently been with the patient up to the time of the appearance of the membrane. At present the skin reaction as inaugu- rated by Schick promises to be of great aid in determining the immunity or susceptibility of individuals exposed to the disease. Before leaving the house the mouth and throat should be cleansed with, first, equal parts of peroxid and water, followed by equal parts of listerine and water; the nose sprayed with Dobell's or Seller's solution, and the hands washed with tincture of green soap and water and then sterilized iii a 1 to 1000 bichlorid of mercury solution. The nurses and doctor should be the only ones in attendance, and the patient should be isolated as soon as there is any sus- picion that diphtheria exists. Both nurse and doctor are supplied with gowns and head coverings which can be put on and taken off at the entrance of the isolation chamber, and hung in a closet just within the chamber or nearby, outside. All linen,as tow els, sheets, etc., employed in the sick-room, should be immersed in a 1 to 60 carbolic acid solution and then boiled before being turned over to other hands for further care. Knives, forks, plates, etc., should be similarly treated. All unnecessary hangings, books, etc., should be removed from the isolation chamber before the patient is admitted, as in the process of disinfection subsequent to con- valescence some of these may be injured. When the patient is pronounced well and two consecutive cultures have been negative with regard to the presence of Klebs-Loffler bacilli, the hair and body should be thoroughly washed, after which alcohol should be freely applied to both, and the patient clothed in clean under and outer clothing that has not previously been exposed to infection. The room and its contents should then be submitted to the Board of Health for disinfection if in a city, or if not under the jurisdiction of such a board, several formaldehyde candles may be burned in the room after closing the windows and doors. Pillows, mattresses, etc., which cannot be thoroughly sterilized should be placed in the sunlight for several consecutive days. Hygienic. — Proper ventilation is of material importance in the care of diphtheritic cases. The room should be maintained at an even tempera- ture around 70° F., and the windows should be open, permitting of free ventilation but not draughts. The patient is given a sponge bath of tepid water daily, followed by an alcohol rub. Bed-linen is changed fre- quently unless the patient is in a state of prostration which would render such disturbance unwise. Dietetic. — ^Liquid or semisolid food is administered, and with sufficient frequency to maintain the strength of the patient. Solid food during the acute stage of the disease is contra-indicated. The kidneys must be kept free, and lemonade, limeade, or orangeade are particularly grati- fying under these conditions as well as healthful. Beef juices, jellies, chicken broth, malted milk, and some cereals, all of which should be made 394 THE INFLAMMATIONS OP THE BUCCAL CAVITY fresh, are nourishing as well as easily digested. Egg-nogs and niilk punch, containing a small quantity of brandy or whisky, tend to keep the patient sufficiently stimulated, which at times is very essential. Fruit juices should be given frequently, but fruit itself should only be given in cooked form. Constitutional. — ^The heart and kidneys are the two organs to be kept under constant supervision. The pulse varies in different conditions, sometimes being slow, more commonly fast, but in the majority of in- stances rather weak and thready. Strychnin or caffein in small doses should be given hypodermically when .there is apparent need for stimu- lation. The urine should be examined frequently for any appearance of albumin, casts, or blood, and if the urine is high colored with high specific gravity, small doses of liq. potassii acetat. or sweet spirits of nitre should be given. The bowels must be kept well open, and it is preferable to keep them so by proper foods or stewed prune juice rather than by the administration of cathartics. Restlessness and sleeplessness should be carefully noted, and the patient should not be permitted to go more than two nights in this condition without the administration of some saporific to insure a night's rest. When the patient is unable to swallow, both food and drugs may be administered by rectum. Serum. — It is of vital importance ^that this medication should be begun at the earliest possible time. As soon as a positive diagnosis has been made of diphtheria, or even in cases bearing sufficiently strong evidence to justify the belief that it is diphtheria, antitoxin should be immediately administered. If the case is seen within a few hours after the membrane has begun to form, as small a dose as 3000 units may be given. If not seen until six to twelve hours after the exudate has begun to form, and the exudate is limited to the tonsillar structure alone, 5000 units will suffice. When the exudate has extended from the tonsil to the soft palate or uvula and yet not into the nasopharynx or larynx, 10,000 units are desirable. When the membrane has advanced from the tonsils into the nasal fossa, postnasal space, laryngopharynx, and larynx, 20,000 to 30,000 units must be administered. In septic and hemorrhagic cases this dosage is increased even to 40,000 or 50,000 units. Frequently re- peated small doses by no means produce the satisfactory result that one large dose will bring about, and they are often productive of anaphylaxis and will in any event produce more adverse constitutional symptoms than one large dose. The dosage is largely decided by the condition of the patient, by the amount of local manifestation and the duration of the illness, and by the experience of those coming daily in contact with diphtheria ; errors are more frequently made in the administration of small doses than of larger ones. The injections should be given in the soft tissues of the back, just below the shoulder-blade or above the rim of the pelvis, aseptic methods being carefully observed. Antistreptococcic _serum may be administered in high temperatures in cases where mixed infection occurs, since the high temperature probably is due more to the streptococcic infection than to the diptheritic. Par- ticularly is this justifiable after the administration of the antitoxin has failed to produce the constitutional effects anticipated. DIPHTHERIA 395 Local. — There is no solution which will effectively remove or dissolve a diphtheritic membrane, and it is unwise to tear away the membrane when it is adherent. The throat should be irrigated every two or three hours with some alkaline solution, such as Dobell's or Seller's, mixed with equal parts of hot water. To carry this out properly and easily a fountain syringe should be filled with the solution and hung three or four feet above the head of the patient. In tractable children or in or in adults the tube may be fitted with a glass nozzle and the stream directed against the pharynx and tonsils, while the patient's head is flexed Fig. 251 Treatment of diphtheria by means of fountain syringe. Lateral position ■upon the chest or reclining on the side upon the bed or table. In infants and intractable children it is necessary to bind them in the "mummy" band&ge, have them held upon the table on their side or stomach, and the stream directed against the infected area by the end of the rubber tubing held in the mouth without the glass nozzle. At least a pint of this solution should be used at each Irrigation. Following this in patients understanding how to gargle, a 1 per cent, solution of argyrol should be freely employed, and if the patient is too young to gargle the throat should be swabbed with the same solution. The less the absorption of 396 THE INFLAMMATIONS OF THE BUCCAL CAVITY toxins which takes place from the infected area the less the constitutional depression incident to the disease in a given case. From the first a postnasal irrigation should be given of warm boric acid solution, followed by 1 per cent, argyrol solution, but the latter should not be given until after the throat has been properly irrigated. This treatment is of necessity administered by the physician in charge. If nasal diphtheria follows in the course of the disease the nurse must be instructed to give Fig. 252 Treatment of diphtheria by means of fountain syringe. Prone position. nasal irrigations at the same time that the throat is irrigated, and this may be accomplished with the child in the same position as for the throat irrigation, the turbinates having been first reduced in size by running through the nostril from a medicine dropper a 1 to 10,000 solution of adrenalin in aqua rosae. This opening of the nasal passage will materially lessen the dangers of middle-ear complications following the nasal irri- gation. To prevent injury to the nasal mucosa it is best to have a blunt- DIPHTHERIA. 397 pointed nasal tip to introduce into the rubber tube before beginning the nasal irrigation. After thorough cleansing of the nasal fossse a 1 per cent, solution of argyrol should be run through the nostrils with a medicine dropper followed by a few drops of albolene to prevent subsequent dis- comfort. Further than keeping the throat clean, local application has but little influence upon the progress of the disease. The local applications of iodin and iron preparations have been thought to produce beneficial results, but it is doubtful if they have any further influence than that of reducing some of the inflammation brought about by the infection and destruction of tonsillar tissue. Intubation of the Larynx. — Indications for its Employment. — ^These are : rapid pulse; evidences of laryngeal stenosis, such as dyspnea, cyanosis, difficult respiration; retraction of the clavicles, sternum, and intercostal spaces, and, in young infants, retraction of the entire portion of the chest involved in respiration, recession of the supraclavicular region, with con- tinued and persistent restlessness. In suspected laryngeal involvement it is unwise to await evidences of cyanosis before the introduction of the tube is carried out. Fig. 253 O'Dwyer's position for intubation. Position of the Patient.— O'Dwyer employed the upright position, a description of which is as follows: The patient's^ arms are secured to the side by a sheet passed around the body, and he is then placed in the lap of the nurse or assistant, who is seated upon a low, straight-backed 398 THE INFLAMMATIONS OF THE BUCCAL CAVITY chair. The head is held with the left hand against the left shoulder of the assistant and the extremities clasped with the knees. A mouth gag is then inserted well back in the left angle of the jaws and opened widely. Just before the introduction of the tube the assistant elevates the chin of the patient by pressing the head backward with the left hand and the right hand is employed to keep the body still. The operator stands or sits upon a high stool in front of the patient. In his right hand he has the introducer with the thumb resting behind the thumb-piece; which serves to detach the tube. The index finger of the left hand is passed into the Fig. 254 The intubation tube passing into the larynx with index finger holding the epiglottis against the base of the tongue and guiding the tube into place. (Ballenger.) laryngopharynx and is employed to raise and fix the epiglottis and to act as a director of the tube while it is being introduced into the larynx. The extremity of the tube is placed against the guiding index finger and held there throughout its course into the larynx. In the introduction of the tube care should be exercised to keep it in contact with the finger all the time, otherwise it might enter the esophagus or form a false pass- age in neighboring structures. When the operator is satisfied that the tube is inserted into the larynx and not into the esophagus, the introducer and obturator are withdrawn by pressing forward the thumb-piece on the upper surface, while counter-pressure is made with the index finger DIPHTHERIA 399 of the right hand on the trigger beneath the introducer. The index finger of the left hand is held in contact with the upper part bf the intubation tube to prevent its being withdrawn when the obturator is extracted. There is a string attached in the eyelet of the intubation tube so that ■ it may be easily removed without the necessity of reintroduction of the obturator in case the dyspnea is not promptly relieved. When the tube is felt to be in place, which is evidenced by relief of the strenuous efforts at respiration, the mouth gag is lowered, but not withdrawn until evidence is positive that there will be no necessity of removing ^the tube for reintroduction. Then the mouth gag is again opened, the string is cut, and the tube is held in place with the left index finger while the string is being withdrawn. There is a paroxysmal cough upon the introduction of the tube in the larynx just as there is from tracheotomy when the tube Fig. 255 Willard Parker Hospital position for intubation. is introduced, and this effort usually expels considerable mucopus. Care must always be exercised not to force the tube into any opening, for if the tube is properly selected, a-nd if it meets the requirements of the case, it will enter the larynx with ease, and will result in almost immediate cessation of the alarming symptoms which have necessitated its employ- ment. Eapidity and ease of intubation comes with experience; but if the operator will keep to the median line, be certain that his guiding finger is lifting up the epiglottis at the proper angle, and that the obturator is sufficiently elevated to get the exact angle of the larynx, and if the tube has been properly selected with regard to the age of the patient, slight difficulty will attend the efforts of the operator, particularly if he be at all skilled in laryngology. Numerous instances are on record where intubation has failed to produce the desired result; the most fre- 400 THE INFLAMMATIONS OF THE BUCCAL CAVITY quent of these is due to the fact that the membrane has been pushed downward into the trachea after the introduction of the tube, in which case it is advisable to invert the patient and administer brisk thumps on the back to expel the detached membrane, which if unsuccessful must be sucked out by means of a catheter attached to a Bier suction pump, . or, if necessity demands, by the mouth of the operator. After this has been removed the tube must be reintroduced. Fig. 256 Showing intubated child feeding from bottle. Another method of intubation now being employed at the Willard Parker Hospital (Fig. 255) is called the dorsal method; in this procedure the patient is wrapped in a sheet while one assistant holds the head so that the mouth is in a direct line with the trachea, while another holds the feet and body. The operator stands upon the patient's right side and introduces the left forefinger to elevate and fix the epiglottis as in the O'Dwyer method. The tube is introduced in the same manner and the string and mouth gag withdrawn just as in the upright position. Mosher employs this position for the introduction of the intubation through a laryngeal speculum (see Laryngsocopy) . The question of feeding the child with the intubation tube in place has been solved by Casselberry. The patient is held in the nurse's DIPHTHERIA 401 arm with the head well extended backward, the nursing bottle is held perpendicularly upward above the patient's mouth, and the child virtually swallows uphill, or the patient is placed on the back upon a table with the shoulders elevated and head extended. Another way is to have the patient take food through a rubber tube, lying prone upon the table, in which case the liquid food is sucked directly up- ward. Rectal feeding is not only attended with discomfort, but it Fig. 257 Intubated patient taking liquid food in prone position. is by no means as satisfactory as when food is given by the mouth. Semi- solid food, as custards, junket, jellies, broths, and ices, may frequently be ingested with less discomfort than liquid food, which has a tendency to get into the trachea and produce cough. Extubation.— About a week after intubation the tube may be safely removed, provided the patient has been breathing freely for the last two days of the seven. The preparation necessary for extubation is the same as that for intubation as regards position, restriction of limbs, and assistants. The guiding left index finger is again introduced after the jaws are opened with a mouth gag, until it comes in contact with the top 26 402 THE INFLAMMATIONS OF THE BUCCAL CAVITY of the tube. The extubator is then taken in the right hand and, guided by the left finger, the beak is introduced into the lumen of the tube. Pressure is then made with the thumb on the lever of the extubator and the tube is brought upward and outward with slow, firm manipulation until relieved from the restricting pressure of the larynx, when it is withdrawn from the throat. The patient must be observed carefully for several hours after the tube is withdrawn, as there is a probability of the cartilages of the larynx retracting under deep inspiration, owing to the loss of tonicity brought about by the pressure of the tube during the week it has been in place. If the child breathes badly after the withdrawal of the tube it must be again reintroduced and frequent removals must be performed until the laryngeal cartilages have regained their elasticity. Tracheotomy. — When intubation fails to relieve the obstruction to respiration and other methods for expulsion of the detached membrane have failed to produce the desired result it is reasonable to suppose that the membrane has extended downward into the trachea below the point to which the intubation tube reaches, and it then becomes imperative to do a tracheotomy. Schleich's infiltration or the injection of one-half of one per cent, of cocain solution is ordinarily sufficient in anesthetic results to permit of tracheotomy being performed. High tracheotomy is usually sufficiently low to permit of the cannula extending beyond the extent of the membrane. (For further guidance regarding the steps of this operation see Tracheotomy). Sequelae of Diphtheria and its Treatment. — Anaphylaxis. — It happens in very rare cases, said to be as infrequent as once in 50,000 cases, in the use of antitoxin that a patient suddenly dies with symptoms of collapse and heart-failure after the second or even after the first dose. Much more frequent are the minor accidents classed under the same category, ill understood, and apparently unforeseen. In such cases about ten days after injection of large doses of antitoxin certain symptoms present them- selves, which are classed under the head of "serum sickness," such as rashes of varying kinds, intense itching, pains in the joints, and fever. The pulse is usually quickened, but it is not necessarily weakened. The symptoms present resemble those of scarlatina or measles. The treat- ment for this condition is entirely symptomatic. Sponging with alcohol or water to reduce the temperature, local application of mentholated oil for the itching, and hot compresses to the joints for the pain may be employed. Another complication following an acute attack of diphtheria is one afi'ecting the heart, in which the pulse rate is materially accelerated, its action being classified as the "gallop rhythm." This condition must be treated with absolute rest in bed, with appropriate stimulation, the best of which, according to Jacobi, is alcohol, in properly graduated doses, or, as is most frequently used in the South Department, Boston, camphor, caffein, atropin, and strychnin. The kidneys are occasionally involved in the course of the diphtheritic attack, but by no means as frequently as in scarlatina. Occasional examination of the urine will indicate the proper treatment for this complication. INFLUENZA 403 The extension of the diphtheritic membrane to the Eustachian tube and middle ear is by no means infrequent, and examination of the membrana tympani should be performed regularly and the drum incised immediately upon any evidence of involvement. Other extensions of the process have been alluded to. Paralysis of the soft palate and larynx often occurs in diphtheria, which can best be treated by electrical stimulation and the hypodermic administration of strychnin. (The further treatment of paralyses and stenoses are taken up under their respective heads.) Influenza. — Traces of epidemics of influenza go back to the remotest antiquity. Repeated epidemics have appeared in the civilized world since 1889, and the affection may be almost said to be now endemic. The peculiarities of its onset, especially in its recrudescent form in the early nineties, renders it impossible to accept its communicability from person to person as the sole method of its occurrence as an epidemic. Within forty-eight hours it would appear throughout all sections of a city as large as New York. This was quite apparent at the time to all clinical observers. Since then the discovery of the influenza bacillus by Pfeiffer has not dispelled in any way this difficulty in accepting it as a purely communicable disease. Of late years the influenza bacillus has been found to exist in a very large proportion indeed of the throats and noses of individuals in New York during the winter. It is more abundant during the prevalence of colds which have certain of the features of influenza. It is found in pneumonia associated with the various organisms which are found in its lesions. It probably has some influence in determining the symptomatology and perhaps the prognosis of this and other affections. The bacillus is very small, being from 0.5 micron to 2 microns long and 0.2 to 0.3 of a micron wide. It stains with difficulty; it grows on blood-streaked agar or serum. It is not pathogenic in animals. There have been noted forms resembling it culturally and morphologic- ally which are sometimes called pseudobacilli. In order to get secretions less contaminated with the abundant micro- organisms of the mouth it is desirable to have the patient cough from the larynx or trachea upon a sterile swab or sterile mirror rather than to use the nasal or buccal secretions, although it can also be demonstrated in them without great difficulty. Upon the mucous membranes of the mouth and nose there appear in rare cases small superficial spots due to necrosis of the epithelium, which resemble the lesions of syphilis to a certain extent, but which last usually only a few days during the height of the disease and then disappear. While influenza is occasionally seen without any lesion of the upper air passages, acute rhinitis is said to occur in from 25 to 75 per cent., laryngitis in 5 to 15 per cent. The involvement of the accessory nasal sinuses is especially apt to occur in severe rhinitis accompanying in- fluenza, and while most of the cases of acute sinusitis both of this origin and of origin from sim,ple nasal inflammations are apt to get well spon- taneously, they not infpquently go on to the severest and most obstinate forms of chronic suppuration of the nasal sinuses. In this regard much 404 THE INFLAMMATIONS OF THE BUCCAL CAVITY depends upon the symmetry of intranasal structure and the patency of the mouth of the sinuses communicating with it. In these severe cases of influenzal infection, it occasionally happens that the meninges are involved and intracranial complications lead to a fatal issue. Symptoms. — Influenza, as it is known to this generation, has become endemic in all civilized countries since 1889-1890, when as an epidemic recrudescent after a period of forty years it again appeared with great suddenness in many lands. The discovery of the influenza bacillus has done something to render both diagnosis and etiology, but especially nosology more exact, but inasmuch as it is an organism found with fair regularity in the nose and throat of large nunabers of healthy people as well as in those suffering from the classical symptoms of the disease, it has in reality not a very well established standing among pathogenic microorganisms. The clinical picture shades off so imperceptibly into that of what is known as a common cold that classification of cases on this basis also is a matter of some difficulty. The classical symptoms, how- ever, are suddenness of onset, great lassitude and weakness and pain in the bones. A chill is sometimes a feature, but is not constant and the fever is seldom high. A A'ery great variety of exceptional symptoms are ascribed to the existence of influenzal infection — rapid and weak heart action, gastric and intestinal symptoms, excessive muscular weakness, loss of taste and smell without excessive inflammation of the mucosae, hysteria, neurasthenia, and "influenza psychoses," neural pareses and disturbances of hearing and vision. In addition, graver complications of meningitis, both cerebral and spinal, endo- and peri- carditis, nephritis, diabetes or glycosuria and the symptom-complexes of many other diseases have been supposed to be due to influenza. The local disturbances in the upper air passages, while often not well-defined, exhibit in general certain pretty well marked features. All local involve- ment may be of a very mild character — out of all proportion to the severity of the general symptoms. The rhinitis when severe and even when mild is much more apt to extend to involvement of the mucosae of the accessory sinuses, giving rise to intense pain, most frequently supraorbital, pointing to an affection of the frontal or anterior ethmoidal cells, which transillumination and roentgenology usually do not reveal. The sphenoid and maxillary sinuses and the Eustachian tube also fre- quently give evidence of invasion. All these things may occur in an ordinary coryza, but general experience teaches that they occur more frequently during plainly marked epidemics of influenza. A peculiar form of catarrhal ulcer is sometimes seen on the buccal and pharyngeal mucous membrane and in the larynx. Small ovoid, grayish patches exist for a few days in rare cases, giving rise to little or no pain and dis- appear as the symptoms subside. The catarrhal form of inflammation of the pharyngeal mucosa is usually present and in the larynx the pos- terior commissure usually presents marked evidence of epithelial thick- ening. Here as in the nose the inflammation is much more apt to spread than in cases not of influenzal nature. Tracheitis, bronchitis, and pneu- INFLUENZA 405 monia, of a grave type in old people and children, often supervene. The presence of the influenza bacillus in the secretions from a pneumonia or found in the blood of persons having the disease is thought to add to the gravity of the prognosis in all cases. At present it is difRcult to form an opinion as to that, since in its mild endemic form it is so often seen and since in all inflammation both of the upper and the lower respiratory tract the influenza bacillus is so frequently found. We know that, either as cause of its being then observed or as the effect of its real influence, the mortality from pneumonia is high when influenza is said to be prevalent. At present, however, the situation as to epidemiology is such that much which was formerly apparent in acute epidemics is of doubtful validity, from which we may infer that influenza as a separate entity is dying out as it loses its epidemiccharacter. In the twenty-five years which have elapsed since its recrudescence in 1890, each succeeding onset of the disease has been less severe in the gravity of the symptoms and less well defined in the differentiation of their features. Prognosis. — At present the mortality ascribed to influenza is small ; the complications, though occasionally grave, have lost much of their gravity as well as of their frequency of occurrence. Treatment. — ^The local treatment of the influenzal inflammations of the upper air passages differs in no way from that of the acute inflammations not apparently due to it. The systemic treatment is more important. A patient suffering from a severe cold associated with the presence of the influenza bacillus or signalized by recognizable symptoms of influenza, seeking relief, should be warned that the shortest road, as it is the safest road, to recovery, is to remain in bed at the onset of the symptoms for the first twenty-four or forty-eight hours at least and another day perhaps within doors. That a longer confinement to the house is advisable in many cases is to be understood, but while the above advice is not often sought and less frequently followed, it is the proper one for the physician to give. Usually the patient disregards such a regimen with immunity from serious consequences, but there is frequently an element of risk in doing so. Fatigue is easily induced in such patients and is particularly risky for them not only on account of the direct effect on the heart, but we have now every reason to believe that fatigue in many diseases and in this especially much lowers the resistance to dangerous infection. The local sequelce seen in the acute and chronic inflammations of the accessory sinuses and in the persistent laryngitis, tracheitis and bron- chitis need not detain us here. . In the prostration which frequently follows attacks of influenza there is not infrequently great mental depression and less often prolonged melancholia. Acute mania has been remarked as preceded by attacks of influenza. The treatment of these we will not discuss. Suffice it to say it is frequently desirable in the protracted convalescence of influenza that the patients should be treated by tonics and change of climate and environment advised, even if for only a short time. CHAPTER XIV. BUCCAL LESIONS IN DERMATOSES; BUCCAL DRUG LESIONS; THE KERATOSES AND MYCOSES, GLANDERS, ANTHRAX, ETC., DIFFER- ENTIAL DIAGNOSIS. MOUTH LESIONS IN DERMATOSES.^ Herpes. — Etiology. — It is often difficult in aflfections of the buccal cavity alwaj's to be sure that they have not begun with blebs formation. The tendency to this has already been alluded to and it is quite possible that it occasionally occurs in all even of the local affections of the buccal cavity associated with a false membrane. Herpes is a fairly well-defined lesion of the buccal and pharyngeal and laryngeal mucosse of a kind which, while the lesions may be seen as separate affections of the throat, they are often accompanied by similar lesions upon the skin. In the throat, herpes occurs as a recurrent and as a non-recurrent affection. It is not apparent, however, that the deep destructive herpetiform ulcerations sometimes seen with toxic symptoms in the throat belong to the same category with those of a less serious nature. The statement of Fournier, quoted by Trautmann, that recurrent herpes of the pharynx in 96 per cent, of the cases is seen in syphilitics is to be remembered, but to us it certainly seems that this is a much overdrawn statement. Not a few of these cases come under observation in persons who are suffering from syphilo- phobia, but very many of them fail to show any other indication of syphilis in their previous history or in their present condition. There is a form of herpetiform ulceration seen in influenza which much resembles certain cases of mucous patches in the throats of syphilitics. It is not clear, however, that these lesions always begin with the blebs formation. It is probable that the majority of the cases of herpes proper are caused by some form of neuritis or perineuritis which may be traumatic or may be due to the disturbances set up in such affections as pneumonia and tj-phoid fever and other general diseases. There is a recurrent form of herpes which Trautmann calls herpes iris et circinatus, a painful affection of the lips and cheeks and even of the pharynx and larynx, which some claim to belong to the classification of erythema exudativum multiforme. The French have given the name of hydroa to it and distinguish four stages : ' For many of the facts brought out in the pharyngeal complications of the dermatoses we are indebted to the excellent work of Trautmann, Die Krankheiten der Mundhohle, etc., bei Dermatosen, 1911. HERPES 407 1. The erythematous lasting but a few hours. 2. The phlyctenula or the formation of the blebs. 3. The ulcerative stage. 4. The healing stage. The lesions seen on the cheeks and tongue in measles known as "Kop- lik's spots" have also been classed among the herpetic eruptions. A certain number, in our experience a large number, of instances of idiopathic herpes occur on the buccal mucosa without accompanying skin lesions, but Trautmann says this is very rare and he subdivides what he declares to be by far the larger group into those which do not recur but exist as the accompaniment of some acute disease and those which recur at intervals depending upon some underlying general dys- crasia. Whether occurring in the course of pneumonia or other general disease or as a complication of an acute local state involving some nerve trauma, it seems likely that the nerve involvement is always present. The recurrent form seen most frequently in young men on the tongue has a doubtful etiology, though Trautmann is inclined to suppose that in most cases there is a systemic predisposition to it induced by syphilitic infection. This certainly cannot account for all the cases. We have seen the recurrent form on the soft palate in middle-aged men during periods of neurasthenia, but whether the latter was cause or effect is uncertain. Pathology and Histology. — Herpes is seen on the lips, tongue, and espe- cially the soft palate and the epiglottis, but it has also been noted in the nose, the esophagus, the larynx, and upon the pharyngeal tonsil. The Staphylococcus albus and aureus, streptococci, Vincent's bacilli, and spirilla have been noted in cases of supposed herpes. Like herpes of the skin, the formation of the blebs may be confined to the uppermost layers of the epithelium, but they quickly burst with the maceration to which they are subjected by the secretions of the mouth and throat. Sometimes the effusion takes place in the subepithelial tissue, pushes up into the papillary layers, and raises the whole epithelial covering. Whichever form the effusion takes, the superficial epithelial cells quickly undergo necrosis and the blister becomes a white patch . The bloodvessels in the neighborhood are dilated, there is some round-cell infiltration around the acini, but otherwise no change in the glands. Fibrinous coagulation is plentiful in the neighborhood of the blister in the tissues. These simple forms of herpes have nothing to do with herpes zoster. This occurs, though very rarely, on the buccal and pharyngeal mucosa in connection with the skin lesion, but it has been described as existing alone, as pseudoherpes, which, however, does not seem to deserve the name. It is occasionally spoken of as occurring as small abscesses in the areas of the racemose glands in acute angina. The herpes blebs may be multiple or single. In the latter case they have been held to account for the benign pharyngeal or laryngeal ulcer described by Heryng. Symptoms. — In its milder forms these are not severe. Pain is often very acute, and this is especially so for those lesions seen on the palate and epiglottis. This often seems out of proportion to the extent of the 408 MOUTH LESIONS IN DERMATOSES lesion. With it are usually associated various neurotic symptoms and a history of gastro-intestinal or gouty or rheumatic diathesis. The patient may have had only one attack or there may be the history of several such. Herpetic blisters of the lips may or may not be present. In the larynx where they are rarely seen the accompanying inflammation may cause hoarseness and cough. Prognosis. — Herpes, so far as we know, in its milder forms at least, has a good prognosis. In the recurrent forms it may frequently he the source of great annoyance. Its association with syphilis or with the graver forms of ulceration of the pharynx or with dermatoses, inci- dental as it is to these general affections, causes it to partake of their prognosis, but unassociated with them, such cases as we have seen ha^-e been annoying and sometimes painful affections, but not of grave import in themselves. Treatment. — Local treatment should be limited to touching the ulcera- tions with a mild escharotic like nitrate of silver in strong solution or in the fused stick. General treatment directed to the nutrition, the diges- tion, and the nervous system of the patient, the exhibition of iron, arsenic, strychnin, etc., in the form of tonics is usually indicated. As an expression of neurasthenia, either as cause or effect, it is to be treated from the standpoint of the phenomena in general. As an incident of graver conditions it scarcely calls for other than the local applications already mentioned, and perhaps some antiseptic mouth wash, like Dobell's solution or a saturated solution of boric acid. Impetigo Herpetiformis. — This is a rare affection. In its occurrence on the mucosa of the mouth it begins as yellow blebs on the cheeks near the corners of the mouth, on the tonsils, the pharynx and larynx, but the local appearances are so much like the lesions of syphilis that the differ- ential diagnosis must be made by other than clinical methods. The clinical course, like that of the general affection, to which reference must be made in the works of dermatology, is most grave. Pemphigus. — Etiology and Occurrence. — While pemphigus is said to attack persons in the best of health, such examples of it as we have seen have been chiefly in persons below par either from old age, anemia, neur- asthenia, or from general impairment of constitutional vigor. Trautmann refers to the extraction of teeth as having existed in a number of histories as the apparent determining factor in the etiology. It is a common enough observation of daily life among those who labor with their hands that some individuals are more liable to suffer from blisters than other in- dividuals whose epidermal surfaces have been subjected to the same experience. This tendency is expressed in a histological way by saying that such individuals possess a layer of stickle cells extremely disposed to react to moderate irritation by inflammatory exudate. This, as one would suppose, is apt to be an hereditary trait, and we may invoke such a predisposing factor in the etiology of all blebs forming lesions. It has been said that some of the blebs observed on the buccal and pharyngeal mucosa, which have been called examples of pemphigus, are seen in this class of persons. Such a predisposition, it may be said here, is probably PEMPHTOUFi 409 evidenced in those forms of lesions also which may be membranous or exist as erosions, blood cysts, or hemorrhagic effusions, white nodules or thickenings, and swellings around the teeth. Such affections of the skin are known as epidermidosis bullosa hereditaria, though it seems that the idiosyncrasy is not alone confined to the epithelial layers, but is sometimes expressed in swellings of the lymph glands. Pemphigus is a rare form of blebs formation seen on the mucosa and it may be divided into four categories as to its occurrence: 1. Those lesions appearing primarily on the skin and subsequently on the mucous membrane. 2. Those coexisting with the skin lesions. 3. Those primary on the mucosa and subsequently appearing on the skin. 4. Those confined to the mucous membranes. In the list of casei referred to by Trautmann, singular to say, numbers approximately the same have been placed by him in each one of these categories, 50 to 60 cases in each. Fully as many (55) as the average in these categories are found in the fourth, that is, in the one in which the lesion is confined to the mucosae alone. In this latter class of cases the disease has often been taken for the lesion of syphilis, and when it heals it often leaves scars which still further confuse the diagnosis. It leaves the smooth condition at the base of the tongue. In the majority of cases this condition at the base of the tongue is probably due to syphilis or tuberculosis, but that it may also be due in a considerable number to pemphigus seems undoubted from the statements of Trautmann. Very marked contractions and deformities result in the advanced cases of buccal and pharyngeal pemphigus so that deglutition and the voice are often interfered with. These scar formations are also seen on other mucosae when affected, notably on the conjunctiva. The nose and the larynx are much less frequently involved, especially in the lighter cases and in the earlier stages of the more severe cases, but it may even extend to the mucosa of the trachea and bronchi. It is rarely that the observer has a chance to see the disease in the blister stage unless the case in previous attacks has been under observation and has been requested to appear promptly when the blister forms. The membrane is often so widespread that it does not seem possible to ascribe it all to a previous stage of blebs formation, and it has been claimed by some that there are cases in which no stage of blebs exists, but that there is at once in these cases an effusion of fibrinous exudate or that this may be forming for weeks or months without producing blisters. Otherwise it closely resembles the membrane of diphtheria, but in making the differentiation it must be remembered, as just stated, that the stage of blebs formation does not always exist. The disease may for a longer or shorter period of time, even for years, entirely disappear and then constantly reappear and gradually become most severe. Pemphigus vulgaris is the form in which the blisters are susceptible of detection by observation or in the history of the patient, while the name foliaceus is given to those cases in which the mucous membrane epithelium, like the dermal epithelium, is so thin over the 410 MOUTH LESIONS IN DERMATOSES effusion that the fluid at once reaches the surface when effused and is not contained in epithehal bUsters. Thus the distinction will be seen to depend largely upon unimportant differentiation. In either case the necrotic epithelium' forms part of the false membrane. Histology. — The neighboring mucosa may be fairly normal, but in the immediate vicinity of the lesion there is apt to be marked congestion and redness, though rarely any swelling or thickening. Either the whole of the epithelial layer involved is raised by the effusion or only the basal cells are retained in contact with the submucosa. There is always moderate round-cell infiltration and dilated capillaries. Naturally in the pemphigus foliaceus, edema is more diffuse than in the pemphigus vulgaris, the capillaries are often dilated to such an extent beneath the lesion as to fill out the whole epithelial structure in which they lie in the basal line, and small hemorrhages are common. The marks of differ- entiation between the blebs of herpes and those of pemphigus of the mucosa are: 1. The blebs of pemphigus, are much less resistant than those of herpes, consequently they come less frequently under observation as blebs. The pemphigus blebs may only last a half-hour and it may extend, as we have said, without forming blisters at all. 2. In pemphigus the blebs vary in size from that of a pea to that of a penny or larger; herpes, from that of a pinhead to that of a small pea. 3. The loss of substance is greater in pemphigus. 4. The edges are apt to be less regular in contour in pemphigus. 5. Occasionally extravasation of blood is seen in the neighborhood of the pemphigus lesion. Further remarks on the differential diagnosis will be found elsewhere. Symptoms. — Patients with the lesions of pemphigus primary on the skin almost invariably come under the observation of the dermatologist or the general practitioner whether they have lesions on the mucosae of the upper air tract or not. As in lupus, so regular is this that many have insisted that a diagnosis of pemphigus of the mucous membranes without its coincidence on the skin is unwarranted. This position of late years has been virtually abandoned. Patients complain of the formation of blebs in the mouth, but when they present themselves for examination a thick false membrane is seen over a localized area which represents the former situation of the blister. Indeed, until the blister has collapsed and a little of the raw surface is exposed the patient's attention is not directed to the condition. We doubt if a case has ever been observed in which a blister in the nose or throat is seen during the first attack. One has to judge from the statements of the patient as to previous and recurrent attacks rather than from the blebs formation visible at the time of examination or inferable from the character of the history and of the false membrane. This area covered by the resultant false membrane may be small and single or it may be multiple or it may cover a considerable extent of the mucous lining of the cheeks, gums, soft palate, pharynx, and larynx. The pain is usually not severe, but it is always present to a greater or less degree. BnUG ERUPTIONS ON THE MUCOUS MEMBRANE 411 Many of the patients are much run down in general health, but some not appreciably so. Although for many succeeding attacks the lesion may be confined to the buccal or pharyngeal mucosa, ultimately it will usually appear on the skin, on the mucosa of the nose and especially of the conjunctiva. It usually does not produce serious cicatrices of the mouth and pharynx, but in the chronic cases the conjunctival mucosa, both ocular and palpebral, are disastrously affected. There may be only a few recurrent attacks or they may be repeated at frequent intervals for a period extending over years. All trace of the lesion may disappear from the surface during the intervals of the attacks or there may a chronic condition obtain in which on some portion of the mucous mem- branes the lesion may practically always be seen. Prognosis. — The prognosis is often grave, death from pneumonia finally supervening, but many of the cases cease after years to have any more attacks. Coexisting with a skin lesion the systemic condition is often serious and a fatal termination more or less rapid. In a general way the prognosis may be said to depend upon the extent and the number of surfaces involved rather than upon the persistence and frequency of recurrent attacks. Treatment. — Locally little can be done for these patients except to give them some form of alkaline and antiseptic gargle. In the milder cases treatment directed toward improved nutrition, rest, and tonics seems to be beneficial. In the cases dependent on syphilis the indications for treatment are clear enough, but in the severer forms of it neither medication nor any other form of therapy seems to have the slightest effect. What is said of herpes may likewise be said of pemphigus so far as the local applications are concerned. Herpetic ulcers should not be treated with strong astringents as more pain results than comfort. Mild antiseptic solutions should be employed for cleansing the surface, after which powdered iodoform or orthoform should be dusted thereon. Powdered calomel has frequently been of benefit. Chlorate of potash gargle or Dobell's solution, to which a suitable quantity of carbolic acid ha;s been added, is more soothing. In pemphigus the eruption is seldom seen in its blebs form, but usually after it has broken. The ulceration which results should be treated with the mildest antiseptic solution, followed by a gargle of chlorate of potash or plain bicarbonate of soda in water. Constitutional treatment is more effective than local. Drug Eruptions on the Mucous Membrane. — Those affections noted by Trautmann as lesions due to the administration or accidental poison- ing by various chemical substances are induced by antipyrin, anti- febrin, salipyrin, phenacetin, quinin, salicylic acid, turpentine, cubebs, bismuth subnitrate, chromic acid and chromates, aspirin and morphin, chloral hydrate, bromin, mercury, and iodin. This long list does not by any means include all the manifestations on the skin of disturbances set up in the digestive organs by the ingestion of various articles of drugs and of food which, owing to the idiosyncrasies of the patient, excite skin lesions, which phenomena are now said to belong among those of anaphjlaxis. 412 MOUTH LESIONS IN DERMATOSES The drugs mentioned are all or nearly all capable also of producing exan- themata, and are all more or less dependent upon individual idiosyncrasy. In fact anything capable of inducing gastro-intestinal disturbances may, in rare cases, be found to ha\'e recorded against it buccal and pharyngeal phenomena. We cannot refer specifically to the characteristics of all. The exanthemata of anti-pyrin are accompanied by or are represented on the mucosa occasionally by a diphtheria-like membrane on the soft palate and the tonsils. The mucous membrane is thickened and swollen. Small erosions may also be seen. As such appearances are often de- scribed as occurring in the administration of antipyrin to syphilitic patients, and as some of the lesions resemble those of lues, not only the question of differential diagnosis arises, but there is evidently reason to believe that at least syphilis is often a contributing factor in the etiology of such drug lesions. Mercury. — The mercurial manifestations are those with which we are more familiar and those which we are most frequently called upon to identify on the buccal and pharyngeal mucosa. Its poisonous action on these membranes has been known from the earliest times. On this account in every age, in spite of its therapeutic value, its use has been severely condemned by some physicians. It produces also lesions upon the skin and in other tissues, and poisoning from it administered even in graduated doses may go on to a fatal issue. Its lesions upon the mucosa resemble those of recurring herpes spoken of by some authorities as erythema exudativum multiforme when seen on the mucous membranes of the mouth. Mercurial anginas are described as affecting the soft palate and tonsils even in a chronic form. How much of this is due to the syphilis for which the drug is usually given, how much is due to the drug administered in a person subject to other herpetic eruptions, may not always be very clear, inasmuch as even after the withdrawal of the drug the lesions supposed to be caused by it may exist for months or even a year afterward, though appropriate treatment will hasten the elimination of the poison from the system and tend to heal the lesion in a shorter time. In the administration of mercury in syphilis these considerations have a considerable practical bearing. Pathology and Histology. — Mercurial stomatitis may occur in certain persons after the ingestion of a very small amount of the drug. The mucous membrane of the gums becomes swollen and spongy and no longer adheres to the teeth, secretion collecting in the sulcus between them. The inflammation may be confined only to one lateral half of the gums or it may spread over the whole buccal mucosa. When- it is seen on one side only it is said to be on that of the side on which the patient lies. It is not known whether the salivation which distinguishes mercurial stomatitis is of nerve origin or due to the irritation of the glands directly. This ordinary form of mercurial stomatitis may go on to deep ulceration, loss of teeth, necrosis of the bones, glandular swelling, and this again may resemble the similarly severe lesions of syphilis itself. The pathogenic mouth bacteria, including those of Vincent's, abound in dirty gray secretions of these ulcers. URTICARIA 413 In the pharynx the trouble beginning in the region of the circumvallate papillae extends laterally and downward on each side of the epiglottis. There is a slight blue tinge to the red and highly inflamed mucosa. It is said to be an erosion necrosis of the mucosa due to the irritation of the saliva. Treatment. — It is often difficult to be sure if some of the lesions seen in syphilis are due to the mercury given to cure it or to the disease. Accompanied by sahvation and gingivitis the picture is characteristic enough, but where there is reason to believe that the aphthous patches persist, not in spite of medication but on account of it, the mercurial part of the treatment should cease and iodid of potash in moderate doses well diluted in water should be given. Sometimes it will suffice to change the giving the drug by mouth to some other method of medica- tion. When mercury has been given medicinally in large doses or has been absorbed by accident in some way, it not infrequently happens that the stomatitis is at first increased rather than diminished on the initiation of the iodid medication. It often is rebellious to treatment and considerable time may elapse before the signs of mercurialization of the mucous membranes disappear. Usually, however, the adminis- tration of the iodid of potash will result in the elimination of the mercury in a short space of time. A detergent mouth wash, an alkaline antispetic or one containing the permanganate of potash, will do much to relieve the disagreeable local condition and the odor. Urticaria. — Occasionally in the manifestations of urticaria upon the skin there occur similar lesions upon the mucous membranes of the upper air passages. These seem to depend upon the same causes as do the skin lesions, usually gastro-intestinal irritation. There are certain individuals, however, who seem more disposed to this form of symptom arising from gastro-intestinal disturbance than others. We have seen a case of urticaria of the mouth and larynx in the person of a young man on whose skin excessive urticarial wheals arose with intolerable itching within fifteen minutes after eating large numbers of Tokay grapes. In a few minutes dyspnea came on and the patient coming into the Man- hattan Eye, Ear and Throat Hospital, the laryngoscopic examination revealed pale swellings of the fauces, epiglottis, and aryteno-epiglottic folds. There was difficulty in swallowing and the necessity for trache- otomy was imminent, but on being given a hypodermic of apomorphin the offending material was ejected from the patient's stomach. In a few minutes the dyspnea abated, as did the itching on the skin. The pharyngeal and dermal lesions quickly subsided and the man returned to a normal condition within less than two hours after the grapes were eaten. Various other articles of food have been known to produce these lesions of the mucosa, but the occurrence is a rare one, although the skin phenomena occur frequently enough. Histology. — Urticaria occurring on the buccal and pharyngeal mucosa is said to present the same histological features as do the skin lesions. There is a sudden infiltration of the mucosa with serum. The serous effusion may be so great as to evert the lips and produce serious obstruc- 414 MOUTH LESIONS IN DERMATOSES tion at the entrance of the larynx. It doubtless is closely allied in its neural affinities with asthma. The dyspnea attending some of the cases would suggest that the bronchi are involved in the process. Lichen Ruber Planus. — There are lesions occurring on the mucous membrane in this skin affection which present an histological structure analogous to those of the skin. There is a thickening of the squamous epithelial layers and an exaggeration of their papillary or basal layers. These are elongated and between them there is much round-cell infiltra- tion, especially around the capillaries, whose endothelial and adventitial cells are also proliferated. The vacuoles which occur in the epithelium with the accompanying serous exudation between the epithelium and stroma forming blisters is missed in the histological examination of the lesion when occurring upon the mucosa. Though there is a marked dilatation of the lymph spaces at the basal line of the epithelium, edema of the stickle cell areas and sometimes an elevation of the superficial cells in the form of a blister, the disease seems histologically to owe its genesis primarily to alterations in the functions and structure of the epithelial capillaries. The localization in the mouth is not a specific one. The lichen plaques for the most part retain their smooth surface without breaking down into ulcerations except perhaps from the attrition of food or from trauma, and they are not raised above the general surface nor can they be detached. Their edges are sharply defined; they may be oval or round or branching in shape. There is no infiltration of the submucosa or of the edges. The color is a glistening white, but often translucent. The lesion has sometimes been, reckoned a leukoplakia. In the initial stage the papules are separate, but later become confluent. Upon the tongue the appearance is somewhat different since the papillse there are first affected. Between them there is intervening normal appearing mucosa. This subsequently becomes infiltrated and the depressions between the papillse are filled up and the tongue surface loses its original papilliform appearance. Submucous Hemorrhages. — These occur with more or less regularity in patients suffering from leukemia, pernicious anemia, scurvy, and some other general disorders. They are frequently seen in persons suffer- ing from hemophilia; they are also seen in the larynx in cases of severe inflammation. In themselves they require no treatment, being merely incidental to the grave systemic conditions which they accompany or to the severe local inflammations. Erythema. — In various erythematous affections of the skin, redness of the mucous membranes of the fauces is observed, but aside from those which accompany the eruptive and contagious diseases such as scarlet fever, measles, etc., there seems to be nothing specific in these appear- ances. In some of these affections white plaques are noted and the differential diagnosis is often a matter of considerable difficulty. Lesions are described as occurring in connection with erythema exuda- tivum multiforme and erythema nodosum, which it is very difficult to differentiate from those of syphilis. LUPUS ERYTHEMATODES OR ERYTHEMATOSUS 415 Lupus Ersrthematodes or Erythematosus. — It was formerly supposed that this affection was allied to the forms of tubercular lupus which are now regularly included in that category. As a matter of fact they present no histological appearances of tubercle, and are not connected with it in any way. Trautmann has collected a large number of reports of cases: (1) those in which the lesion appeared first upon the skin and then upon the mucosa of the buccal pharyngeal and laryngeal cavities; (2) those in which lesions of the skin and mucosa coexisted; these are the majority; (3) those in which they appeared first upon the mucous membranes; (4) a few in which they were confined to the mucous membranes. These categories, however, from a statistical point of view are probably misleading because in a painless lesion like this the affection may exist unnoticed upon the mucous membranes until its appearance on the skin attracts attention. It appears on the skin as a localized smaller or larger red spot with slightly depressed centre covered by a scale. These areas are usually multiple and vary from the size of a pin's head to a larger extent. They coalesce often into the form of a scaly or crusty eruption. The same condition is noted on the mucosa of the lips, which seems to be the site most frequently noted in the reports. They are seen also on the inside of the cheeks between the rows of teeth. Less commonly it is seen elsewhere on the mucous membranes of the nose, mouth, pharynx, and larynx. The mucous membrane is red, swollen, bleeds easily, and is covered by crusts at some points of which the arrange- ment above alluded to can be remarked, fine scales in crescentic ragged patches indicating the coalescence of the original separate spots. They have more or less red and infiltrated edges which gradually slope to the level of the mucous membranes. The color may be somewhat purple or violet, but the character of the lesion is indicated in the term erythema. Superficial erosions and shallow ulcers sometimes occupy the places of the crusts. There is a very little resemblance in these appearances to those of tubercular lupus. Histology. — Epithelial proliferation of the lower or papillary border of the mucosa is seen, so that tapering streaks of epithelium run down into the connective tissue to a point, the type of the basal cells being much altered in the process. In the acute condition the epithelium is edematous and thus the outlines of the cells are not very sharply defined and there is abundant infiltration of leukocytes and vacuolization of the epithelial cells. In the recent lesions enlarged capillaries are seen at the edge, but in older lesions the edges are paler, due to epithelial thick- ening and subepithelial fibrosis, though the healing takes place from the centre accompanied by more or less atrophy whereby the depression of the centre of the lesion is still more accentuated. The papillary layer of the connective tissue is not much infiltrated with cells, but some edema of the fibrillee is observed. There is great abundance and great dilatation of capillaries; lymphocytes and mast cells are seen and leuko- cytes migrate into the epithelial layers. The clinical differentiation is supported microscopically by the absence of the structure of tubercle and the absence of the tubercle 416 MOUTH LESIONS IN DERMATOSES bacillus in animal inoculations and the difference in the skin reaction to tuberculin. Scleroderma.' — Scleroderma is occasionally accompanied by lesions of like character on the tongue. The course is more rapid than that of the skin and leaves an atrophied condition behind. The initial stage is that of edema and infiltration. Sometimes the mucosa of the cheeks shows plate or ring-like deposits, with atrophy in the centre. It is also seen on- the uvula and atrophic areas are seen there as well as upon the soft palate and the tonsils. The most marked changes are those of the tongue and the lips. The tongue surface is smooth and pale and the atrophy is marked enough to interfere with the movements and function of the organ. Something of the same con- ditions are said to have been seen in the larynx. Keratoses of the Mouth and Pharynx. — Among the keratoses of the mucous membranes the pachydermia of the larjnx and keratosis of the lymphoid tissue of the pharynx we have taken up in other connections, but there are similar lesions seen upon the mucous membranes which are commonly placed in other clinical categories. Psoriasis, leukoplakia, ichthyosis, black tongue, are all of them essentially due to epithelial hyper- plasia. Psoriasis of the lips and the soft palate is the name given to the rare lesions of the mucous membranes of this nature which have been noted as accompanying psoriasis of the skin. That the lesion known as leukoplakia of the mouth has anything in common with psoriasis of the skin is not now generally held, although the combination of the two lesions in the same individual is occasionally reported. A moderate amount of leukoplakia in the mouth is a fairly common phenomenon and is seen even in those who are not smokers. It is seen in syphilis and from the appearance of the lesion itself it is often quite impossible to tell it from that seen in those who have not had the systemic affection. Occurring in the latter it is chiefly seen in those who smoke, but the number of those who indulge in this practice so outweighs those who expose their buccal mucosa to other irritants it is quite easy to com- prehend the preponderance of this sort of an irritant factor in the etiology. Exclusive of syphilis and tobacco smoking and psoriasis, the occurrence of buccal leukoplakia has been ascribed, we know not how justifiably, to systemic disease and to intestinal disturbances. Icthyosis or hyperkeratosis of the skin has been seen^ associated with the general keratoses of the mucosa of the lips, gums, hard and soft palate, tonsils, and tongue. What the relationship is between this con- dition and psoriasis does not plainly appear. Even the cutaneous horn has been held by some to be matched by some pachydermatous thick- enings of the epithelium of the larynx. Trautmann draws attention to the similarity in the classification of epithelial growths on a structural basis in the air passages and on the skin. In remarks upon pachydermia of the larynx and keratosis of the tonsils will be found descriptions of the minute structure of these lesions, and these descriptions can be applied to 'This affection must not be confused with that of scleroma of the nose and larynx. '' Siebenmann, Arohiv f, Laryngologie und Rhinologie, 1907, Band xx, Heft 1. KERATOSES OF THE MOUTH AND PHARYNX 417 those of the affections under consideration here. It is true that warts on the skin and papillomata of the fauces and larynx are each of them com- mon enough, but a correlation of causes of the two rests on such a slender basis of coincidence, except in syphilitic condylomata, that the attempt to find a common etiological factor does not seem very hopeful. While . there doubtless is a keratosis of the sebaceous glands of the skin which resembles a keratosis of the tonsillar epithelium, we are not aware that the two have any evidence of coincidence to support the claim of a common etiological factor. In leukoplakia a hard, white spot will appear upon the tongue, most frequently in smokers, and upon that side of the tongue where either the cigar or pipe is from habit generally held. This location, however, is not fixed as there are many cases of leukoplakia where not only the tongue, but the cheeks and lips are similarly involved. The dorsum of the tongue and tip to one side or the other are the most frequent loca- tions. The involvement is usually after the age of twenty, although there is one case on record in a girl, aged eleven years. It begins as a reddened patch with raised papillae surrounding it, so that the patch appears depressed. The patch is covered with a whitish incrustation which peels away and the patient experiences a slight pain or soreness when taking alcohol, highly seasoned foods, vinegar, etc. The growth is slow and insidious and ultimately the reddened patch becomes white or several of these patches may coalesce forming one large patch. Acute . recurrent attacks produce a raw appearance on the surface of the pre- viously white area, in which will occur cracks and fissures, and this is frequently followed by thickening. Some patches remain stationary to all outward appearance for a number of years and never go on to ulcera- tion, and this area is free from pain as a rule, unless some irritant is applied. Recurrent ulceration finally results in a papillomatous growth which in many instances goes on to epitheliomatous formation, and for this reason all spots of leukoplakia should be watched with care and treated with due consideration. Palliative Treatment. — The use of tobacco, both smoking and chew- ing, should be forbidden, as well as all forms of alcoholic liquors. Highly seasoned foods and sauces should be omitted from the diet. Careful attention must be paid to the gastro-intestinal tract and all underlying diatheses. Each night the spot should be first cleansed and then have applied to it either boroglycerid or a mixture of vaselin, lanolin, and borax. Caustics, such as nitrate of silver, chromic acid, nitric acid, etc., should not be used; as their continued use only tends to a more rapid growth. Balsam of Peru has been used with beneficial effects, particularly by Broeckhardt. Surgical Treatment. — Butlin, from a large experience, has concluded that it is inadvisable to remove the patch in the early stages of leuko- plakia, as the resulting scar often proves as troublesome as the patch, and the borders of the wound develops leukoplakial conditions; but in cases where the patch has existed for a long while and is circumscribed, incision is indicated. When an ulcer persists and there are e\'idences 27 418 MOUTH LESIONS IN DERMATOSES of papillomatous formation it is reasonable to conclude that this con- dition is merging into an epitheliomatous form and immediate operation, the same as for epithelioma, should be performed. Erythema Migrans {Geographical Tongue). — This condition is unusual and appears more frequently in children than adults. It has been said to be congenital in some cases. It involves the dorsum of the tongue and extends over the lateral margins. It begins as a small patch or several small patches irregularly oval in outline, which are red, tender and smooth looking, with grayish borders. The redness is probably due to the fact that the filiform papillae have been thrown off. As the margin of the involvement is reached the redness is more intense, while the margin itself is a yellowish-gray and slightly raised. Occasionally the circles will merge one into the other and form a double crescentic formation, while their rings may contract and disappear. The condition is chronic and' may last for years and the areas involved vary from time to time in size and extent. There are no subjective symptoms, and the condition is usually discovered by examination of the fauces for other conditions. Treatment. — Apparently nothing is indicated, and it frequently occurs in the healthiest of children without digestive disturbance. It has been recommended that tonics and cod-li\'er oil be administered. "Black tongue, or melanoglossia, is histologically an hypertrophy of the filiform papillae, not of mycotic nature, which is associated with marked cornification and blackening of the tongue." (Trautmann.) This is due to the deposit of pigment in the epithelial cells. There is some diffusion observed in the intercellular spaces and in the connective tissue. It has been noted in syphilitic patients under mercurial treatment in such a considerable number of cases that the origin of the pigment has been supposed to be in compounds of this metal, but whether this is so or whether syphilis itself is a constitutional factor, the determining cause of the affection, is not clear. Eczema. — Moritz Schmidt has described a case of eczema of the palatal mucosa in which a very large number of tiny blisters appeared, but the pathology of it is not known and it is uncertain if the affection belonged in reality in this category. Pityriasis Lichenoides. — One case has been reported^ in connection with the skin lesion which it resembled in morphology. Thrush is a parasitic affection of the mucous membrane of the fauces showing white, stringy flakes against the red, inflamed mucosa. False membrane when removed and examined is found to consist almost exclusively of a growth of a mycelial organism known as oidium albicans. It is seen chiefly in nursing infants. Ulcers. — Traumatic ulcers are almost entirely due to irritation from jagged teeth, ill-fitting plates, or artificial teeth. Their location is usually along the edge of the tongue where it comes in contact with the object of irritation. The ulcer is solitarj^, irregular in outline, with marked 1 Rifckc, Archiv f. Dermatologie unci Syphilis, 1902, Band lix, Heft 2, p. 267. ACTINOMYCOSIS 419 precipitous edges. The breath is foul, the tongue coated, and the sub- maxillary glands are usually enlarged and tender. There may be an abundance of scar tissue in the edges of the wound, particularly if the ulceration has existed for a long time. The appearance may simulate a syphilitic condition, but that can be definitely determined by the Wassermann reaction. Certain idiopathic ulcers may occur upon the sides, dorsum, or under surface of the tongue. They are indurated, usually painful, irregular in outline, with borders thick but not hard, and the raw, exposed surfaces are without granulations. The pain is increasied on taking into the mouth acids, or highly seasoned foods. When an acute ulcer becomes chronic the edges become thickened and indurated and the raw surfaces dry and glazed, while the contracting scar tissue at the base pulls the healthj- tissue surrounding the ulcer inward, thus corrugating the edges. Treatment. — Correct errors of diet and omit smoking, drinking, and ingestion of highly seasoned food. Attention to the teeth, removal of carious teeth, and the smoothing down of sharp edges must be insisted upon. A mouth wash of chlorate of potash, peroxid of hydrogen, or listerine should be constantly employed. Frequent application of caustics or silver salts will result in an increased inflammatory condition and therefore they should not be employed. Chromic acid solution, 5 grains to the ounce, has been recommended, and this substance applied even in the fused form to an old chronic ulcer results favorably. It is necessary often to remove a chronic ulcer by excision, the line of incision being carried well wide of the edges of the ulcer as well as beneath its floor. The incision is made in an elliptical form and the edges brought together with sutures, when it heals very satisfactorily. Actinomycosis. — While the infection with the ray bacillus not infre- quently takes place through the mucosa of the mouth, especially the gingival mucosa, and the pharynx, a surface lesion of the upper air passages due to it is a great rarity. It forms abscesses beneath the epithelial layer about the jaws occasionally in man, and it has been found in the internal organs, especially the lungs. It is chiefly a disease of cattle and the lesions it produces around the head are known as "lumpy jaw." The organism grows outside of the body, on various vegetable matter, usually on the inside of straw or grass stems. This introduced into the human mouth, piercing the mucosa, provides entrance for the bacillus or its spores into the submucous tissue. A very large number of \'arieties, morphological and cultural, diflScult to distinguish, have been described for this organism. A con- siderable number of them are not pathogenic, yet they show the same morphological appearance as do those which are pathogenic for man and cattle. Their growth and culture are matters of considerable difficulty, and the diagnosis has to be made upon the strength of the morpho- logical appearance of the bacillus plus the appearance of the lesions they set up in the tissues. In a considerable proportion of tonsils, clumps characteristic of this organism are seen in the sections lying in the crypts. These, as a rule, exist as saprophytes. Of late attention has 420 MOUTH LESIONS IN DERMATOSES been drawn to the association of the tubercle bacillus in cases in man when suffering from actinomycosis. Inasmuch as these organisms in some of their forms and in some of their culture characteristics belong in the same family, the coincidence of their occurrence in the same patient is worthy of note.' The localization of the lesion of actinomycosis in the faucial tonsils of the pig is said to be not uncommon. In man it is rarely seen to have penetrated the cryptal epithelium against which it is so frequently found lying, in the sections of the tonsils. Fig. 258 Camera-lucida drawing of a section ot a tonsil, showing under low power an abscess cavity containing masses of actinomyccs. At a is seen the beginning of the growth of a colony in one of the lymph nodes. There is a larger number of lymph nodes than usual in tonsillar hypertrophy. Histology. — However, in the accompanying illustrations taken from the history of a case which applied for treatment to the Manhattan Eye, Ear and Throat Hospital for hypertrophied tonsils, it may be seen that such lesion occasionally happens and is more or less characteristic of the lesion as found elsewhere in the animal body. Fig. 258 shows a low-power drawing by camera-lucida of the abscess cavity in the tonsil which evidently had been created by the enlargement of the crypt in which the clumps lay. In Fig. 258 and in Fig. 259 the effect of the growth upon the configuration of the epithelium is plainly ' The Streptochoses and Tuberculosis, Milroy Lectures, 1910, by Alexander G. R. Foulerton. ACTINOMYCOSIS 421 seen. The form of the hyperplasia of the epithelium resembles somewhat that seen around tubercles or syphilitic ulcers. Under a high power, Fig. 259 rfT^-^ ifv-- iiirr^ Proliferation of the epithelium of the crypt. The degeneration and the granular condi- tion of the cells render the epithelium atypical and indistinct, a, actinomyces clumps; e, epithelium; I, lymphoid tissue. however, such as that of the appearance shown in Fig. 260 it will be seen that the fragmentation of nuclei in the surface epithelium is ex- FiG. 260 Camera-lucida drawing under high power, showing the hyperplasia of the epithelium of crypt and the "granulation" due to the influence of the adjacent clump of actinomyces. tremely well marked. The actinomyces threads seem to be intimately incorporated with the epithelium. At one point in the unstained sections 422 MOUTH LESIONS IN DERMATOSES is shown a yellow focus. Cellular changes in the round cells of the lymjih node of a peculiar nature are shown in Fig. 261. Numerous Fig. 201 Camera-lucida drawing, under high power, of the colony seen at a in the low-power drawing of Fig. 258. The fragmentation and breaking-down of the lymph cells around the bundle of mycelial threads is very evident, h, branching of the filaments; c, edge of the lymph node. Fig. 262 ^^ia^^'^'^ \ Camera-lucida drawing under high power of the edge of one of the masses of aotino- myccs lying in the abscess cavity. The drawing does not give very accurately the "granu- lation" of the mass.. minute spores were scattered throughout this and large numbers of leukocytes were entangled in the terminal filaments. The patient, who BLASTOMYCOSIS 423 was a boy nine years old, suffered no further inconvenience after the removal of the tonsils, and from the summary of the evidence thus produced it will be seen that the organism is capable even in this apparently saprophytic form of setting up changes in the tissue.^ A few other cases have been reported of much more serious lesions resulting from infection with the actinomyces which had entrance probably through the tonsils.^ Whether entering through the tonsils or elsewhere the lesion presents itself as an abscess containing the clumps mentioned above and numerous leukocytes and with the organisms peculiar to the lesion may be associated other bacterial forms. The abscess sometimes presents itself on the posterior wall of the oropharynx or the nasopharynx as an extension of the lesion of the vertebral column. One case of its occurrence in the nose is referred to by Trautmann. Dr. Arrowsmith, of Brooklyn, reported a unique case of actinomycosis of the larynx in 1910^ which we have had the privilege of seeing and from which we examined sections of the growth. A dirty white surface growth, extending from the epiglottis through the larynx into the trachea, pre- sented a perfectly unique appearance of cauliflower growth and some hyperplasia of the arytenoid cartilages. Pieces removed from the glottis showed the actinomycosis clumps under the low power. Under the high power the typical structure of actinomycosis was revealed. The case subsequently showed tubercle bacilli in the sputum and died of that disease. The coincidence of this singular actinomycotic lesion with that of tuberculosis has received many exemplifications as recorded in the Milroy Lectures referred to. Into the general treatment of actinomycosis we will not go further than to say that the evacuation of the fluid contents of the abscess and the administration of iodide of potash are successful in a majority of the cases. As for the bodies seen in the tonsillar crypts which closely resemble it and very probably are saprophytic varieties of the ray fungus, they have no clinical significance, are discovered by accident, and require no treatment. Blastomycosis. — This is one of the rare forms of infectious disease of the tissues. It may extend from the skin of the face to the internal nose as a secondary affection, rarely as primary in the nose. It has been described there as a deep ulcer of the septum the size of a bean, covered with dark crusts. This may lead to perforation and breaking down of the cartilages and bony septum. It seems to begin as a small yellow pustule. Cases of blastomycosis in this country have been reported chiefly on the Pacific Coast or in the far Western States. The diagnosis, both clinical and microscopical, presents some difficulty of differentiation from 1 For further remarks on the subject of actinomycosis of the tonsils see Wright, Am'er. Jour. Med. Sci., July, 1904. 2 For further literature on the subject see Heinrich's Archiv f. Laryngologie, 1904, xvi, Heft 2, p. 350; Henrici, ibid., 1903, xiv, Heft 3, p. 519; Miodowski, ibid., 1907, xix, Heft 2, p. 277; Gappisch, Verhandlungen der deutsohen Gesellschaft, 1906, p. 130; Natzler, Disser- tation, Leipzig, 1908. 3 Arrowsmith, Laryngoscope, October, 1910. 424 MOUTH LESIONS IN DERMATOSES syphilis and tuberculosis. The ordinary blastomycosis lesion is a gran- uloma presenting giant cells and necrosis but no typical tubercle. Inoc- ulations of the tissue of guinea-pigs will serve usually to reveal the nature of the disease; careful search of the sections will show the budding yeast- like organisms. It occurs in two forms, the budding branching organism of the type of the ordinary yeast and in a form with endogenous spores called blastomyces coccidoides.' It is said that forms of blastomyces have been found in the crypts of the tonsils leading an apparently sapro- phytic existence. It seems probable that some of the reports in literature of the occurrence of blastomyces in tumors are mistaken interpretations of appearances due to cellular degenerations.^ Sporotrichosis, resembling in some of its manifestations syphilis and in some tuberculosis, presents itself as small infiltrations of the skin or as verrucous erythematous projections of the surface due to the presence of the Sporothrix schenckii or Sporotrichon beurrmann, a disease first noted by Schenck. Upon the mucous membrane of the fauces it has been noted as an ulceration in which the organism was found. In another case it was found in a wart-like lesion of the larynx (Trautmann). All these fungus diseases yield to the administration of the iodid of potash. Trichophyton, herpes tonsurans, or ringworm has been noted as a primary affection of the mucous membrane of the cheek and lower lip. A dirty yellow, scaly eruption is seen with some yellowish-white paints in the neighborhood. Secondary to the skin eruption it has been seen on the tongue.^ Mycosis fungoides, for the most part a fatal skin lesion running a chronic course, has been noted by Paltauf as presenting lesions on the tonsil, soft palate, and larynx. Leptothrix Buccalis. — In order to complete the catalogue of appear- ances due to the presence of bacterial growth in the nose and throat, reference is again made to this fungus organism regularly found in the lesions of tonsillar keratoses already alluded to elsewhere as white tufts projecting from the mouths of tonsillar crypts or racemose glands, it is seen mingled with the more numerous desquamated epithelial cells not only on the tonsils in the fauces, but upon the lingual tonsil, posterior pharyngeal wall, in the larynx, and we have seen a tuft in the nose apparently protruding from the mouth of a racemose gland just back of the vestibule. Glanders — Malleus. — Usually acquired from the horse when it occurs, glanders is a rare disease in man, though probably not so rare as is com- monly supposed. Even those exposed freely to the disease do not often contract it. The entrance for the bacillus is usually through the wounded • For further referent-p tu this affection which so rarely occurs in the mucous membranes of the upper air passages, see Wolbach, Journal of Medical Research, December, 1904, vol. xiii, No. 1, pp. 53-60; Bowen and Wolbach, ibid., July, 1906, vol. xv, No. 1, pp. 167- 177; MacNeal and Taylor, Journal of Medical Research, 1914, xxx, 261. 2 01i\'iero Barrago-Ciarella, Archiv f. Laryngologie, Band x. Heft 3; Ludwig Polyak, Band xi. Heft 2, p. 346. 'Plant, Kolle and Wassermann, Handbuch der Pathogen. Mikrobrganismen, 2 Aufl., 1912, Band v, p. 112. GLANDERS 425 skin, but it may enter by the nasal mucosa and the conjunctiva. It may assume an acute and chronic form in man as in horses. The acute form after an incubation of three or four days is more severe in men than in horses, but the chronic form is about the same, the mortality being 50 per cent. While cattle seem to be immune to the disease, besides horses, asses, guinea-pigs, cats, dogs, ferrets, moles, field mice, according to Park, are susceptible to it, as to a less degree are also sheep, goats, swine, rabbits, white mice, and house mice. The bacillus is an aerobic, non-motile microorganism about 0.25 to 0.5 microns broad and 1.5 to 5 microns long; it stains with difficulty. It grows well in the incubator on glycerin agar. The cultural and the morphological differentiation is a matter of considerable difficulty. Various .agglutination and complement fixation tests in addition to the behavior of the bacillus in guinea-pigs serve to identify it. The favorite site of the lesion is on the mucous membrane of the nose, where the ulcerations exist as red excoriations with hemorrhages, but it is occasionally seen elsewhere, as in the larynx, trachea, lungs, and upon the skin. The first nodules form, then break down, and in the nose the cartilaginous and the bony septums are destroyed, as well as the other nasal bones. Suppuration of the submaxillary glands and deep-seated abscesses in the bones of the head have been noted. It is said that cases of chronic glanders have been known to exist in man which have lasted for years, and various diagnoses of the lesion have been erroneously made until bacterial cultures disclosed the malleus bacillus. Their morphological and tinctorial reactions are not sufficient to differentiate them from other forms of bacterial life frequently seen in the nose. Symptoms. — There is pain in the limbs and joints, increasing fever with- out exacerbation, malaise, nasal stoppage, purulent secretions from the nose, often fetid and blood-stained. The external nose is swollen as well as the lips and cheek, all of which assume an erysipelatous look. The chain of cervical glands is enlarged, sometimes breaking down and sup- purating. Single nodules appear upon the mucous membrane of the nose, which finally coalesce and become ulcers. This nodular formation fre- quently, extends to the soft palate, then to the pharynx, and possibly to the larynx. The disease is divided into two forms, acute and chronic. In the acute form the patient dies within one or two weeks; in the chronic, death ordinarily follows in due course of time, but the condition may extend over a period of five or ten years, and the end comes as a result of an acute exacerbation of the chronic condition. In the acute form the symptoms resemble those of acute rheumatism, grip, typhoid fever, septic poisoning, and pneumonia in their method of invasion. The eruption may be taken for that of impetigo, scarlet fever, smallpox, and several other of the skin lesions, but the acute nasal symp- toms associated with the disease, together with the fact tbat the individ- ual has been in close contact with horses, should aid materially in directing the attention to the possibility of glanders. In the chronic cases it is often mistaken for syphilis, but as the Wassermann reaction will readily 426 MOUTH LESIONS IN DERMATOSES determine the character of syphilis it is easy to determine the nature of the lesion. If the discharge is examined the bacillus mallei may be found and injections of maUcla, from 10 to 15 minims, will often aid in making the diagnosis, just as tuberculin will in tuberculosis. Anthrax. — For the sake of completeness, it is necessary to note that lesions of malignant pustule have been seen' on the mucous membranes of the larynx, the pharynx and the tonsils. Differential Diagnosis of Lesions Showing False Membrane in the Throat. — It is a frequent occurrence that the observer is called upon to make a differential diagnosis in cases of this nature at the first visit the patient makes. The lesions which are to be thought of are syphilis, diph- theria, membranous tonsillitis, leukoplakia, herpes, pemphigus, influenza, tuberculosis, about in the order of frequency named. We may dismiss tuberculosis in view of the fulness with which the condition has been treated elsewhere. As the problems of diphtheria and syphilis involve pos- sibilities of the patients being the carriers of infection of serious nature to others these cases frequently impose upon the medical attendant responsi- bilities which, if he is conscientious, will often result in considerable embarrassment. The important thing, in the practical sense implied in this consideration, is that the diagnostician excludes or identifies the two conditions mentioned at as early a time as possible. The signs of lesions on the skin, the scar of the primary lesion and the secondaries on the genitals, large lymph nodes in the groin and at the elbow should be looked for. The local appearance is often far from characteristic. The situation may be anywhere upon the buccal or pharyngeal mucosa. There is usually more or less general erythema of the throat with it. This condition must at times be distinguished from diphtheria. In the latter there is more fever and systemic disturbance and the membrane is apt to be thicker. The question as to whether the false membrane is diphtheritic or due to the streptococcus or other germ occasionally is a pressing one. Both may have at the first examination systemic disturbances. If the mem- brane is confined to the tonsils in a case in which there is a history of sore throat for three days or more, it is usually not diphtheria. As between these two diagnoses, reliance should not be unhesitatingly placed on this local phenomenon nor upon any other. The patient should be isolated until a bacteriological culture can be reported on. Unless the differential diagnosis can confidently exclude syphilis, precaution should be taken at the first interview to avoid the infection of the patient's intimates. Within a few days the report as to the Wassermann reaction, or the development of further signs of syphilis or the recession of the condition which excites suspicion will probably have cleared the diagnosis, but in the interval due precaution should be advised. No reliance should be placed on a negative history of infection. In females it is exceptional to secure a positive history. Herpes shows discrete spots of small area, depressed and exceedingly 1 Glas, Milnchener medizinische Wochenschrift, 1891, No. 11, p. 1906; Wiggins, New York Medical Journal, Zia Noury Basha and Haidar Bey, Deutsche medizinische Wochenschrift, 1908, No. 33. ABSCESSES 427 painful, which serve to distinguish it from sj'philis. An afebrile tempera- ture is added to distinguish it from diphtheria. From pemphigus certain differential characteristics are mentioned under the description devoted to the two lesions. The appearance of a false membrane in influenza is a rare occurrence. A number of small discrete areas may put one on the right track, but it is often at the first interview indistinguishable from syphilitic lesions. It is much more ephemeral in its duration and it will at the worst onl}' serve to mislead the observer for a short time. With leukoplakia the suspicion of syphilis at first sight is often entertained. Its favorite location is the tongue. Its edges are less discrete, the syphilitic erythema is absent, as are the concomitants of the secondary stage of the venereal disease. There may be a history of the patient having observed the condition as existing for months, which pretty clearly indicates its nature. Pemphigus is rarely confounded with syphilis and the occasions which give rise to that uncer- tainty are exceptional, though there is considerable reason for believing that some of the more severe forms of skin pemphigus are seen more frequently in syphilitics than in other persons, especially in the congenital syphilis of children. The elicitation of a history of the blebs stage or the existence of the blebs is sufficient to distinguish both herpes and pem- phigus from the ordinary lesions of syphilis. Abscesses. — Abscesses of the tongue are very rare. They usually occur at the base of the tongue near its central part, and may exist for years without further symptoms than the sensation of the presence of a foreign body which occasions cough and slight discomfort on swallowing. Such a case, which may originally have been a cyst, was reported by Richardson which remained quiescent for a number of years and finally became acute, necessitating free incision and evacuation of a very thin, offensive and watery pus. Pain in these instances is referred to the ear, there being no localized pain except on pressure. There are other varieties of abscesses that result from injury to the tongue, as from a fishbone, etc., which are accompained by intense pain, swelling, tension, increased salivation and very frequently edema of the epiglottis and larynx. This edema comes on suddenly and is attended with severe symptoms of dyspnea and sometimes syncope. In the acute cases the patient should be under constant observation and if possible placed in a hospital where in an emergency an immediate tracheotomy can be performed. Free incision of the abscess should be made, and this is best accomplished by a long curved bistoury or by a knife such as is employed in the larynx for laryngeal scarification. After the first evacuation of pus it is necessary to reopen the abscess on the following day; or if the abscess is of sufficient size to warrant it, wash out the cavity and pack it with a small strip of iodoform gauze, to which is attached a string fastened on the outside of the cheek with a piece of adhesive plaster to obviate the possibility of its falling into the larynx during sleep. As edema of the larynx may occur at any time, necessi- tating tracheotomy, the patient must be carefully watched while the symptoms are acute. 428 MOUTH LESIONS IN DERMATOSES Macroglossia. — The disease affects usually the anterior half or three- fourths of the tongue and may consist of one or more nsevi, each of which may represent one or a collection of vesicles containing lymph and blood, the outlines of which are rendered distinct by the bloodvessels lined between them. The condition is usually observed soon after birth, but may remain until puberty, when it gradually begins to disappear. The tongue may grow until it protrudes from the mouth and the saliva dribble continously and persistently from the lower lip and chin. The child cannot speak and is only able to mumble a few words. As the tongue protrudes between the teeth it is often bitten and the constant pressure may form ulcers or furrows upon both its under and upper surface. That part which projects from the mouth becomes dry and cracked and the jaws being kept widely apart, become more or less fixed, and force the incisors forward producing great deformity. Treatment. — ^The growth should be removed as early as possible before the child begins to try to talk, and before the jaws become deformed. It may also be necessary to operate to permit the ingestion of food and to relieve the embarrassed respiration. The operation consists in removing a A^-shaped piece from the tongue with the angle of the V extending posteriorly, after which the flaps are drawn together with sutures of silver wire or iron-dyed silk. CHAPTER XV. TUMORS OF THE TONGUE, OROPHARYNX, AND NASOPHARYNX. TUMORS OF THE TONGUE. Ranula. — When cystic tumors occur under the tongue they are spoken of as ranula, a term which was originally given to cystic tumors which were supposed to spring always from the duct of the sublingual gland, but in practice it has been applied to the cysts of the origin referred to above which may be summarized as : Dilatation of the sublingual duct. Dilatation of the submaxillary duct. Dilatation of the racemose glands. Dilatation of the thyroglossal duct. Dermoid cysts. It is very frequently impossible to decide to which of these origins we are to ascribe the formation of the cysts about the floor of the mouth. Often they are not bigger than a small nut, but they may reach enormous dimensions. We have seen one which extended across the whole front of the pharynx so that when the finger was introduced in an opening made in the floor of the mouth it could be swept from the cornu of the thyroid cartilage on one side to that of the other. The cyst must be removed together with its sack completely to eradi- cate the tumor. Incision with evacuation of the cystic contents will result in reformation. The majority of these cysts can be removed by operation within the mouth, but in isolated cases of submaxillary ranula with bulging externally it is necessary to perform an external operation beneath the jaw. Benign Tumors. — Lipoma, fibroma, angioma, and adenoma have all been found, though in rare or isolated instances, upon the tongue, par ticularly on the side and tip. Excision is the easiest and most efl'ective method of removal, although in cases of angioma it is well to remove them by cauterization or the galvanocautery loop. Malignant Tiunors. — Epithelioma. — It is not our purpose to enter at length into a discussion of malignant disease of the tongue, since lingual cancer is so largely concerned with the problems of general surgical tech- nique that the subject is better studied, at least from its operative and statistical point of view, in the text-books of general surgery or in special treatises. The diagnostic side of the question is the one which more often confronts the practitioner of laryngology than any other. Various new growths besides cancer are seen on the tongue. Syphiloma and tuber- 430 TUMORS OF TONGUE, OROPHARYNX, AND NASOPHARYNX culoma are discrete rare forms of systemic affections of which the local Ungual ulcerative appearances are far more common. The points in the differential diagnosis of these lesions we ha^'e taken up elsewhere, as is also the case of the various dermatoses in their manifestations on the mucous membranes of the upper air passages. The aid of the Wassermann and of the von Pirquet reaction and that of the microscope we have also fully discussed on other pages. Excessive pain is not always observed in cancer of the tongue, though it is apt to be an early persistent and in the later stages the most prominent symptom. The situation of the lesion along the border of the tongue, beginning at a point roughly estimated at an inch from the tip and extending to the root may be fairly stated as the situation involved in the process in the ^'ast majority of the cases. We have seen it, however, as a symmetrical deep tumor on both sides of the middle line of the base of the tongue, running well up so as to involve the posterior third — not ulcerated and not very painful before the diagnosis was made and operation was per- formed.^ While metastases in the glands and infiltrations of the floor of the mouth occur early, the diagnosis is also apt to be made while the case is still an operable one. Butlin and others have spoken of the "pre- cancerous" stage of carcinoma of the tongue, and their statistics based on a diagnosis of malignant disease before conclusive proof of malignancy can be accepted, have tended doubtless to save a considerable number of patients from an unfortunate sequel. In this sense, the vital one we admit, such a classification is fully justifiable, but scientifically it has served, so far as such cases have been included in the general statistics of cancer, to befog any attempt to arrive at a sane judgment as to just how much the operations are to be credited with favorable results and how far the latter are dependent upon the fact that malignancy would never have developed. While leukoplakia and local thickenings of the epithelium are often a prelude to the development of lingual cancer, they are states of the tongue which may exist for many years, from middle life to death from old age, without showing clinically malignant potentialities if left undisturbed. That some of these present minute structure strongly indicative of cancer is well known. We quite agree with the followers of Butlin that they should be excised when exhibiting any evidence of a nodule forming beneath the epithelial surface, but to rank such cases with carcinoma of the tongue in surgical reports or even to speak of them as in the precancerous stage is unscientific and subversive of accurate information to be obtained from the clinical study of cancer. We realize in this aspect of the question the existence of fundamental difficulties, not only of a theoretical, but of a practical nature, into the discussion of which in this publication it is not proper to go. The disease occurs much more fre- quently in men, in a proportion of 6 to 1, according to Butlin. The rule as to age in the occurrence of lingual cancer conforms to its incidence elsewhere. While cases as young as twenty-six are known, and after thirty it is not infrequent, forty to sixty covers the period of the incidence > Wright, New York Medical Journal, November 12, 1892. BENIGN TUMORS OF THE OROPHARYNX 431 of the vast majority of the cases. It is usually of the pavement-cell type. Symptoms. — Of these we have space to speak in only the briefest way. Pain is the first thing noticed by the patient, which is not only felt at the point of involvement but in the ears. The movements of the tongue are restricted and the organ becomes stiff and painful. The ingestion of hot liquids or highly seasoned food results in acute pain. Later there is considerable hypersecretion of mucus and saliva which dribbles from the mouth, and as time goes on this secretion becomes peculiarly offen- sive. Swallowing, owing to the immobile condition of the tongue, is attended with difficulty and considerable pain. The submaxillary glands are enlarged and frequently go on to softening and breaking down. When slough occurs it is followed by hemorrhage which may become serious. Gastro-intestinal disturbances are prevalent not only due to the inroads of the disease producing anemia and cachexia, but to the swallowed secretions which create a gastritis. Treatment. — Operative measures in the beginning of the disease offer favorable prognosis, provided that the glandular structures have not been materially involved and the patient is in fit physical condition to withstand the shock of the operation. Ligation of the external carotids has seemed to retard the progress of the disease and the application of the ,i-rays, liquid air, fulguration, and radium, have all had their advocates and favorable results from their application have been reported by many. When the tip or the anterior third is involved and the extension is not too great, an operation through the mouth can be satisfactorily per- formed, but if the extension is backward or into the neighboring glandular structures to any extent, the external operation is demanded. The operative technique and more extended consideration are best given in the text-books on surgery. Sarcoma. — Sarcoma of the tongue is a very rare affection, only a few cases being on record in the literature of the subject. There have been cases of sarcoma of the tongue reported by Foote, Shambaugh, and others in this country, but as a primary lesion it may be considered as one of the rarest of malignant lesions. The symptoms do not vary materially from those of epithelioma. It is often difficult, however, to differentiate it from syphilis, tuberculosis or macroglossia. The same disturbance in swallowing, local pain, salivation, foul odor to the breath, and con- stitutional manifestations are present here as in carcinoma. The treat- ment is operative in the early stages and if beyond the possibility of operative aid Coley's serum may be employed, though with slight hope of alleviation. BENIGN TUMORS OF THE OROPHARYNX. Papilloma. — The most common of all the true tumors of the oro- pharynx and of the mouth is the papilloma or fibroma papillare. It springs usually from the edge of the pillars of the fauces and from the soft palate and from the uvula. The so-called papillomata of the 432 TUMORS OF TONGUE, OROPHARYNX, AND NASOPHARYNX tonsil reported in literature are many, if not most of them, instances of the process of tonsillar regression which has been called by one of us "autoclasis of the tonsil," and to which reference has been made. We have never seen a case in which a true fibroma papillare sprang from the epithelial surface of the tonsil itself. This condition, however, may simulate it as also sometimes the fimbriated extremity of the uvula. In the latter situation true papillomata, however, often occur. They may last for years without attracting attention and if they produce no symptoms there is no reason why they should not remain without interference. Histology. — Here as elsewhere, whether in the nose or in the pharynx, the structure of a true papilloma is the same. It consists of strands of connective tissue holding small capillaries and covered by numerous layers of stratified epithelium which at the surface usually have character- istics of the pavement type, inasmuch as these tumors usually spring from a mucous surface covered with that type of epithelium. The papillae of the surface from which they spring may extend deeply into the submucous connective tissue, and as their shape is sometimes dis- torted, sections may fall in such a manner as to cause representation of islands of epithelium existing in the connective tissue independent of the surface from which they spring, thus giving rise to the surmise of malignancy. This is still more emphasized in cases where, as often happens, the boundary line between the epithelial hyperplasia and the subjacent stroma is not well marked. It also must be remem- bered that in some layers ' of a simple papilloma, especially near the surface, hyaline plaques and whorls may exist resembling somewhat the whorls of cancer. This question will be discussed more at length in speaking of the epithelial growths of the larynx. Adenoma. — Occurrence. — In the oropharynx these are rare tumors, but they occur in rather a striking way between the layers of the velum palati laterally and not in the median line. They present a smooth surface, as a rule, though there are sometimes ulcerations. These growths are apt to be a part of the mixed tumors to which we have referred as characteristic of the nasopharynx, and contain epithelial and endothelial vagaries from the lymph spaces which sometimes go under the name of peritheliomata, resembling the tumors of the parotid.^ These growths are sometimes capsulated and can easily be shelled out. They contain glutinous colloid material. They vary in size from that of a pea to that of an orange. They may be spheroidal or ellipsoid in contour or lobulated. In addition to the glandular epithelium and the other structures already mentioned, they may contain cartilage, bone, and lymphoid material. Fibroma. — Fibromata in the oropharynx are very rare. They may spring as pedunculated tumors the size of a nut from the gums or from the middle of the tongue. More frequently they are sessile, painless neoplasms along the line of the teeth, giving rise to the supposition that they are of inflammatory origin due to injuries in mastication. 1 Verhoeff, Journal of Medical Research, February, 1905. BENIGN TUMORS OF THE OROPHARYNX 433 Fibromyoma and myxochondroma occur as separate organisms or in combination with the mixed tumors referred to under the heading of Adenomata. Myxochondroma^ here as elsewhere, presents the same afEHation with malignant neoplasms. Epulis. — ^This is a name given to tumors occurring around the teeth- They may be epithelial or fibrous, and often present puzzling problems due to the fact that they occur confined between bony or dental walls under pressure and the epithelium is apt to assume fantastic and lawless shapes giving rise to the suggestion of malignant disease. So close is this histological resemblance that it is frequently wise to counsel a wider extirpation than is usual for benign growths. Teratoma. — ^Teratoma about the fauces are, relative to their general rarity, frequent in the back part of the oral cavity where the ectoderm meets the entoderm in embryonic development. They present the manifold combinations of epithelial and mesoderm structure which make them objects of such microscopical and pathogenic interest elsewhere. Their structures may show abortive hair follicles bordering on extensive areas of fat cells or smooth muscle cells. They are apt to show also certain areas of embryonic branching cells such as are noted in the myxomata; they may contain cartilage and bone. One or all of these heterologous elements may be present in a tumor otherwise predomi- nantly epithelial or fibrous. They seem especially adapted to confuse the histologists. Dermoid cysts have also been reported in this region as yellowish, smooth tumors whose appearance is due to the atheromatous material they contain. Elements of the skin, hairs, etc., are found in them. They may form obstruction in the pharynx interfering with the nourishment of the newborn infant. Branchial Cysts. — Cysts of branchiogenetic origin lined with cylindrical or cuboidal epithelium and showing cartilage or other remains of embry- onic life, may exist almost in any place around the jaws and out of them may spring malignant tumors which may be thus said to be of embryonal origin. In addition to the cysts of the character already referred to others are sometimes met with along the walls of the oropharynx due to broken- down lymphoid material or to dilated lymph spaces or to .agglutination of the folds of the pharynx. Other cysts seen at the base of the tongue and on the oral aspect of the epiglottis may be due to some faulty development of the embryonic thyroglossal duct, but more frequently to glandular ectasia. They have a translucent appearance and are often of a bluish color, due to the large plexus of veins amidst which in these situations they may arise. The complete eradication of the gland cysts is often very difficult, as it is necessary to follow the cystic duct to its source and completely to remove the walls either by surgical procedure or cauterization before permanent cure can be effected. When these tumors occur on the pos- terior pharyngeal wall it involves delicate and extensive surgery properly to overcome the condition, and it may be necessary to do a preliminary tracheotomy so that the laryngopharynx can be completely walled off 28 434 TUMORS OF TONGUE, OROPHARYNX, AND NASOPHARYNX with gauze packing during the process of operation. General anesthesia is necessary. Hemangioma at the base of the tongue and tonsil is not infrequently observed. These growths arise from the venous plexus around the lingual and faucial tonsils. They are apt to be rather diffuse in their boundaries; they are constituted by loops of dilated veins growing together rather than what we understand as true tumor formation. They may exist for many years without inconvenience or danger to the host. They sometimes reach such a size as to make it necessary, on account of symp- toms of obstruction, or possibly bleeding, to remove them. Lymphangiomata are also mentioned as showing white masses occasion- ally seen in the oropharynx and in the tongue, where they may exist as cystic tumors. They consist of dilated lymph spaces either singly or more or less diffuse like the hemangiomata. They are very rare. Fibrolipoma. — ^It probably is a fact that fibroma of the oropharynx is never a pure fibroma. More frequently here than elsewhere the tissue which is mingled with the fibrous hyperplasia is fat cells. These tumors known as fibrolipomata have been described as springing from the cheeks, the gums, from the tongue, from the epiglottis and the top of the larynx. They are peculiar finger-like projections of tissue M'hich are quite characteristic in thier configuration. Structurally they vary a great deal in the relative amounts of fibrous and fat tissue which they contain. In a case reported by Dr. Hinkel,^ we were able to examine repeated recurrences of the growth extending over a number of years, in which at one time the bulk of the mass would be made up of fat cells; at another recurrence the tumor would be made up principally of fibrous connective tissue. From this behavior it seems very clear that we have an indication of a biochemical disturbance in the cells as the origin of a tumor. Fibromyxoma, fibrochondroma, and fibrolymphadenoma have all been reported as occurring in the pharynx in various situations. The fibro- chondroma and the fibrolymphadenoma partake somewhat of the char- acter of malignancy. The fibromyxoma, though a rare growth, is essen- tially benign, though all these growths tend to recur unless they are very thoroughly extirpated. Chondroma and Osteoma of the Tonsils. — We have elsewhere re- ferred to the occurrence of cartilage and bone in the faucial tonsils, and although these conditions, we believe, cannot consistently be placed under the category of true tumors, we mention them here for the convenience of reference. Symptoms of Non-malignant Tumors of the Oropharynx. — The symptoms set up by tumors of the oropharynx of a subjective nature are insig- nificant before the patient himself by inspection becomes aware of their presence. The mobile tumors of the soft palate — papillomata — the obstructing tumors of the fauces, the lipomata, the tumors of the gums causing discomfort in mastication, all attract the attention of the adult . 1 Transactions ot the American Laryngological Association, 1898, p. 75. MALIGNANT TUMORS OF THE OROPHARYNX 435 patient and the use of the mirror reveals their presence. The gross appearances, peculiar to each so far as they are characteristic, have been , referred to. The methods of removal present no difficulty and the technique needs no special mention in a work where the full description of the general technique and armamentarium of the laryngologist is de- scribed. The pedunculated tumors are easily removed with snare or scissors; the vascular tumors are removed or destroyed by galvano- cautery snare or point. Treatment. — These tumors may be frequently overcome by the local application of fulguration at intervals of seven to ten days. The galvano- cautery, either employed in the way of frequent puncture or the galvano- cautery loop, has been successful for many years in their complete and effectual removal. The cold-wire snare, scissors, evulsion forceps and the knife have all had their advocates and it may be safely stated that any method by which the tumor can be completely removed is indicated, and the only consideration is that of hemorrhage, which must be controlled either by ligation of the bleeding vessel or by cauterization after removal with the Paquelin or galvanocautery. It is inadvisable to employ escha- rotics or chemical cauterization for the reduction of these tumors, as when the slough takes place there may be hemorrhage, which, owing to the possibility of the patient being out of reach at the time, may prove serious. MALIGNANT TUMORS OF THE OROPHARYNX. Sarcoma. — ^In the pharynx all forms of malignant growths are seen, and here as elsewhere they fall under two headings, the sarcomata and the epitheliomata. The former may consist largely of spindle cells or of endothelial cells. These may be arranged in such fashion as to give rise to the term alveolar sarcoma, in which areas of endothelial cells are separated by strands of connective tissue, which on section are more or less ovoid or polygonal in shape. A case of rhabdoviyosarcoma has been reported as occurring in the soft palate by Mikulicz. The most frequent form of sarcoma, however, is the lymphosarcoma or small round-cell sarcoma, having its origin in the tonsils or in the lymphoid tissue around the throat. We have seen a case which began as apparently a recurrence of tonsils which had been removed for hypertrophy. Sections showed nothing to distinguish the recurrence from the ordinary tonsillar struc- ture, lymph nodes being well marked. With each recurrence the growth rapidly took upon itself the typical form of a malignant lymphosarcoma, the histology of which has been described elsewhere in this work. Less frequently the sarcomatous cells are spindle-shape and many combinations may occur in which fibrous and lymphoid elements predominate in the structure of the growth. More than half the cases reported of sarcoma of the tonsils have occurred in persons over fifty years of age. It has been noted as early as six and as late as eighty-nine years of age. Out of 32 cases analyzed by us, all but 5 were of the round-cell variety. Sometimes in the course 436 TUMORS OF TONGUE, OROPHARYNX, AND NASOPHARYNX of the development of these sarcomata they break down and form ab- scesses with subsequent scar formation, and this, when it occurs, is apt to confuse the diagnosis. Bosworth, in enumerating from literature the reported cases, speaks of 45 cases of sarcoma being seen in the tonsil and 20 in the fauces and soft palate. Carcinoma. — In a total number of 30,000 cases of carcinoma referred to in the statistics of Lebert, Sibley, Walsh, Gurlt, and Winewater, but 20 cases of carcinoma of the tonsil are reported. This seems a ratio entirely too low from laryngological experience. A larger proportion of the cases of carcinoma of the tonsil occur in persons over forty years of age than of sarcoma, although sarcoma is more frequent after forty as well as carcinoma. Carcinoma has been observed as young as seven- teen and as old as eighty-two. The forms of carcinomata of the tonsil and pharynx are usually epitheliomata which may be classified as of the pavement-cell variety or cancroids and as the basal-cell epitheliomata of Krompecher, and as adenocarcinomata. The gradations between the tumors classified as epithelioma and as adenocarcinoma are sometimes referred to as tubular epithelioviata. The histological structure of the epitheliomata is described in other sections of this work. Symptoms. — ^Malignant disease of the oropharynx, like a benign tumor, is apt to attract the attention of the patient before it has given rise to any marked subjective symptoms. When they do supervene they are chiefly pain varying in intensity with the patient and with the ulcerated or non-ulcerated state of the growth. In the later stages the discharge and the peculiar odor is especially marked in cancer of the oropharynx and larynx. In many cases, n;iingled with that of the usual fetid quality of the odor of ulceration, cancer of the mouth gives off an odor which reminds us of that of the iron compounds when used as a styptic gargle. Metastases occur early in the cervical glands. The appearances of an ulceration with an indurated, uneven, or lobulated base, with anemic or pale-blue edges are sufficiently characteristic to those familiar with them. Without ulceration the growth enters that uncertain category of doubt which calls for the exercise of the acumen of the clinical observer in a difl'erential diagnosis upon which often hang matters of great importance to the patient's chance of escaping 'a painful and lingering death. To fail to avail one's self of the aid which the examination of its minute structure with the microscope affords would be to fail in the serious duty the practitioner owes to his patient, even where the clinical evidence for benignancy or for malignancy is most clear. Prognosis. — This is bad but b>' no means hopeless in the early stages. While early metastases are the rule and extensive operations usually necessary in a region prone to give rise to septic infection, a number of sarcomata and epitheliomata have been removed from the palate and elsewhere in which the patients survived for a number of years without recurrence. More accessible than the nasopharynx, the opportunities for complete eradication, while not of the best, are far greater. The choice of operation is a matter that varies with every case. The use of the .x'-rays on mucous surfaces has led to no result. The therapeutic MALIGNANT TUMORS OP THE OROPHARYNX 437 employment of radium and thie radio-active group in inoperable cases is justifiable, but thus far there is no acceptable evidence that this method of treatment can hold out any greater hopes of relief than have the count- less cancer cures in times past which have sunk into oblivion. The early- use of the knife and the early establishment of diagnosis here, as in other regions of the body, discounting all the criticism and all the faulty statistics, have unquestionably increased the number of those who have survived the eradication of pharyngeal cancer a reasonable number of years. We say this, fully aware of the exaggerations so natural to dis- cussion on the subject by overenthusiastic and optimistic writers. Sarcoma of the Tonsil and Oropharynx. — The tonsil frequently is the site of involvement by sarcoma in its many varieties, the most common of which is probably the lymphosarcoma. In its incipiency it may be mistaken for abscess of the tonsil or chronic hyperplastic conditions following frequent attacks of tonsillitis. It is also difficult at times to differentiate it from syphilitic involvement, but in the light of modern methods it is easier to deterinine the character of the lesion than formerly. The growth may exist for a long period without giving evidence of the serious character of the lesion and only produce in the patient symptoms of discomfort, increased salivation and difcculty in swallowing. Pain, which is often absent in the early stages, will frequently be referred to the side of the neck and ear on the involved side. Before ulceration takes place the tonsil will appear swollen, bluish red, with extension to neighboring parts, as the palate and the lateral wall. These may be edematous adjacent to the tonsil, owing to infiltration and venous stasis. The glands, both anterior and postcervical, are ordinarily involved. As the disease progresses ulceration takes place, after which there may be repeated hemorrhages, a constant flow of saliva which is blood-tinged, a disagreeable odor to the breath, pronounced difficulty in swallowing, cachexia, and general constitutional symptoms of malignancy. Definite diagnosis can be obtained by examination of a microscopical section. Treatment. — Sarcoma may be entirely enucleated provided the growth itself is confined to the tonsillar structure alone. As this is seldom the case it is often necessary to remove a part of the soft palate as well as a part of the lateral pharyngeal wall. When extensive removal has been accomplished, together with the removal of adjacent lym- phatic glands, the prognosis is by no means hopeless, as a number of such cases are on record where the growth has not recurred after a period of six or eight years. The galvanocautery, electrolysis, galvano- cautery snare, and the Paquelin cautery have all been employed for the removal of these tumors. Favorable results have followed the employ- ment of each of these, though the experience of Price-Brown in the use of the galvanocautery has been exceptional. In the experience of the majority of operators radical surgical procedure followed by the applica- tion of either fulguration or radium to any persistent granulating tissue, remaining for any length of time after the operation, has given the best results. A preliminary tracheotomy is necessary before the operation, so that the laryngopharynx may be packed with gauze and the surgeon 438 TUMORS OF TONGUE, OROPHARYNX, AND NASOPHARYNX enabled to devote his entire attention tb the hemorrhage which occurs during the operation. It is well to let the tube remain in the trachea for several days, so that the mouth can be packed with sterile gauze and the wound kept as dry as possible. The small round-cell, spindle- cell, and melanosarcoma are particularly difficult to eradicate in this locality, as the involvement of the lymphatic system is often extensive and the soft tissues of the neck are infiltrated early in the process. In a great many instances the patient presents himself for operative measures after the disease has gained such headway that it is impossible to give a favorable prognosis. In these instances it is advisable to use the x-ray, radium, and Coley's serum. Palliative measures consist in keeping the parts clean by gargles of peroxid of hydrogen and water and a weak solution of permanganate of potash. When there is great pain in swallowing, a powder of equal parts of boric acid ajid orthoform applied directly to the tumor will enable the patient to take food with more or less comfort. Epithelioma of the Oropharynx. — The uvula and soft palate are more frequently attacked than any of the other structures of the pharynx, and when seen sufficiently early offer the most favorable results from the surgical stand-point. Local irritation with frequent desire to swallow, associated with a thick nasal voice due to the induration of the soft palate, are the first evidences of involvement. Upon inspection there will be seen a hard, warty tumor, either on the tip of the uvula or at its junction with the soft palate, with a red indurated area extending up into the soft parts above. There is increased salivation and later difficulty in swallowing associated with pain transmitted to the ears. Treatment. — Chemical caustics and escharotics are extremely uncertain agents in the removal of these growths, and their efficiency in isolated cases impeaches the diagnosis. In well-defined epithelioma their application tends rather to irritate than to eradicate. Radium and fulguration have both been employed in the treatment of these cases and favorable results have been reported from their use; also the galvanocautery knife, electrolysis, and ignipuncture. However, when seen sufficiently early no time should be lost in the complete surgical removal of the growth together with the greater part of the soft palate, which owing to its structure offers a most favorable opportunity successfully to circumscribe the area of involvement. A case of epithelioma of the uvula and palate coming directly under our observation was operated upon three different times with recurrence after each procedure, and at the last operation it was necessary to remove the remaining portion of the soft palate and a part of the lateral pharyngeal wall, but for a period of five years following this, while the patient was under observation, there was no recurrence. Epithelioma of the tonsils was previously considered rare, but in later years there have been a number of cases reported both in this country and abroad. Symptoms. — Difficulty in swallowing is one of the first symptoms noted by the patient. Pain begins shortly after invoh^ement, but often it is PLATE V Fia. 1 Postrhinoseopie Image of Nasopharyngeal Polyp Attached to Hiatus Semilunaris. Postnasal Fibroma. NASOPHARYNGEAL TUMORS 439 present only during muscular involvement in the beginning. It soon becomes constant, and is referred to the side of the neck and ear of the affected side. The Ij^mphatics are early involved and may become painful on palpation as they increase in size. There is a profuse flow of saliva, which is not so frequent nor so profuse as in sarcoma. The early appear- ance is that of a hard, warty mass, with an area of induration in the centre of the tonsil, and a red, infiltrated area surrounding it. The soft tissues shortly become involved and are red and indurated, but are not quite so edematous as in sarcoma, neither does it so often have the dark red, congested appearance characteristic of sarcoma. The patient becomes anemic, emaciated, and later cachectic. The general symptoms of malignant involvement appear early in the case. A definite diagnosis can only be made by the examination of a microscopical section. Treatment. — ^All forms of cautery, electrolysis, caustics, and escharotics have been employed, but to no purpose. The progress of the disease has been retarded by ligation of both external carotids and the injection of paraffin into the distal branches of the artery as recommended by Daw- barn. Trypsin, colloidal copper, and mercury have been employed with- out success. Injections of an emulsion made from a part of the growth itself has been strongly recommended by Beebe and others, but 00 definite statement can be made now relative to the permanent benefit from it. Fulguration has been used as well as the x-ray, and pain, discharge, and hemorrhage have been materially lessened by their use; but the per- manent eradication of the tumor has not been thus accomplished. Radium at present is much in vogue, but there is no case on record in which it has been favorably applied to the tonsil. There are some cases on record in which radical surgery has been effective, but nothing short of external operation, together with removal of the lymphatic chain adjacent to the tonsil, offers any hope of permanent relief. Palliative measures consist in the administration of narcotics and local applications of orthoform for the control of pain and frequent irrigations with alkaline solution, followed by a gargle of permanganate of potash solution to overcome the foul discharge. NASOPHARYNGEAL TUMORS. Benign. — Occurrence. — Those most commonly known and those which we involuntarily think of in speaking of benign nasopharyngeal neoplasms are the fibromata. These occur in a rather exceptional manner, that is, they are seen chiefly in males and chiefly in adolescence or, more compre- hensively, from ten to, twenty-five years of age. While the age limit does not often fall outside of these boundaries, a few cases of fibroma of the nasopharynx have been seen in females. Occurring at this age, it evidently has something to do with the development of the bones of the cranium, but why it should show the specific sex incidence it is impos- sible to conjecture. It may be of some significance, however, that the tumor when it occurs in females has been noted before and after the age limit mentioned above. 440 TUMORS OF TONGUE, OROPHARYNX, AND NASOPHARYNX It springs from the fibrous tissue and the periosteum over the basilar process of the occipital and sphenoid bones. It consists of dense, fibrous connective tissue in which there are areas of spindle cells and round cells and occasionally a giant cell. Just insofar as the cellular richness is marked, the question of the differential histological diagnosis of sarcoma arises. The bloodvessels, as a rule, are not large, but being imbedded in fibrous tissue they are probably kept open by its dense character and do not collapse readily when cut. Sometimes, however, they are very abundant and very large and the same may be said of the lymph spaces. In these tumors, it is true, there is more or less edema present, but if it exceeds a very moderate amount, investigation will nearly always show that the tumor has its origin pretty fairly within the choana of the nose. Those tumors springing from the A'ault or the poste- rior wall nearly always consist of densely arranged fibers. The pedun- culated fibromata which one sees in the nasopharynx, we have consid- ered under the heading of Edematous Polypi, inasmuch as their origin is nearly always intranasal and occasionally within the openings of the acces- sory sinuses, especially the maxillary. The tumors of the nasopharynx which are seen in childhood are usually more or less distorted adenoids. Sometimes strips of mucosa have been left behind after adenoid operations, and these become pendent as fibrolymphoid tumors of the pharynx. Sometimes in the adenoid tissue of the pharynx cysts develop, probably through the breaking down of the stroma of the lymphoid parenchyma, when they are not frankly due to the coaptation of the surface walling off a space as the result of inflammatory action. This formation may arise from the median recess or the so-called pharyngeal bursa, but it is also seen in other situations in the pharynx. One or two cases of papilloma of the nasopharynx have been described, but these are great rarities, and so rare are they that the question arises whether a mistake has not been made as to the diagnosis of their histo- genesis. This is illustrated in the report by Schmidt.^ Besides the forms of benign tumors of the pharynx already mentioned, we meet in this region with comparative frequency the teratoma. We have described at considerable length the embryology of the pharynx, and from its complexity the student may readily understand why there should be a greater liability to detachment from the embryonic layers. A number of mixed tumors have been reported in this region which it is difficult to explain on any other basis than that of their fetal origin.^ Inasmuch as others occur in which this is evidently the explanation,' since they have been described as containing hair and other dermal structures, we may believe that when a tumor starting from the naso- pharynx is found to contain racemose glands and smooth muscle fibers, embryonic connective-tissue cells combined together in an unusual manner, it is because of the reason assigned. ' Archiv f. Laryngologie und Rhinologie, 1906, p. 556. 2 See Coffin, Annals of Otology, Rhinology, and Laryngology, December, 1909. ^ Conitzer, Deutsche medizinische Wochenschrift, 1892, No. 51; Lennox Browne, Bur- nett's System of Diseases of the Ear, Nose, and Throat, vol. ii, p. 926. NASOPHARYNGEAL TUMORS 441 Symptoms. — There is a similarity of signs of the existence of benign and malignant tumors of the nasopharynx which renders their differ- entiation by purely subjective symptoms all but impossible, especially in the earlier stages. The thick speech and obstructed respiration are symptoms common to them all. Even epistaxis may be a symptom not only of nasopharyngeal true tumors, whether benign or malignant, in their early stages, but even of lymphoid hypertrophy. Severe pain is frequently complained of chiefly in the later stages of the benign fibromata and more frequently in the earlier stages of malignant growths. As time goes on the hemorrhages and pain become more severe, and long before the cachexia and enlarged cervical glands force themselves on the observer's attention in malignant disease, postrhinoscopic examination and palpation have, with the microscope, settled the diag- nosis. For the ten years following the advent of puberty in the male, the chances of the growth being a fibroma are large if the existence of lymphoid hypertrophy does not account for the condition. The appearances of the foreign fibroma as seen in the postnasal mirror are thosfe of a smooth tumor or one divided into a few lobules when it is of the connective-tissue variety. The surface is reddened and there may be superficial ulceration even in benign fibromata. These latter give a hard, resistant sensation to the examining finger which is fairly characteristic. It is to be remembered, however, that the fibro- sarcoma also presents all of these signs and that while more common between thirty-five and fifty-five it is by no means unknown from fifteen to thirty-five. We know of no method of further elucidating the diagnosis of a nasopharyngeal tumor during this period than by a resort to the microscope. It must be confessed that even this too often leaves the question in doubt. Just how much infiltration of cells there may be, how far they may depart from typical connective-tissue cells, it is frequently impossible to say. While in the first two years of the history of a connective-tissue growth of the pharynx observers, even with the help of the microscope, may be left in doubt as to its nature, one may conclude with a fair degree of prob- ability that it is benign if the outlines and limitations of the growth are still fairly defined and it has not infiltrated the soft parts, even though it may have displaced both soft parts and hard parts and caused marked symptoms of pressure. This is especially the case existing in a male of the age period which falls between fifteen and twenty-five. The growth soon penetrates the nasal cavities, the nasal fossae proper, and the acces- sory sinuses, and may cause marked exophthalmos by pressure at the back part of the orbit, and as it advances there is a development of the frog-face when, with the protrusion of the eyeballs, the superior maxillse are separated and the face widened. These symptoms of continued growth and advancing involvement of the ijeighboring structures, which may include ocular symptoms, limitation of the field of vision, and atrophy of the optic nerve, may, after nineteen or twenty, reach a stationary period in which the patient is no worse and regression subsequently may set in and even entire absorption ensue. This spontaneous cure, how- 442 TUMORS OF TONGUE, OROPHARYNX, AND NASOPHARYNX ever, is often protracted into the third decade of life. It may be incom- plete and some of the damage to structure consequent upon pressure, such as atrophy of the optic nerve, can never be repaired. Thus it is often unwise and impracticable to await the time for recession of the growth. Epithelial tumors are exceedingly rare in the nasopharynx. The papillomata and the teratoviata do not necessarily spring from a broad base in the vault, though we have seen a case which did so and which invaded the sphenoid cells. They are apt to have their base of attach- ment, large or constricted, at the side of the pharynx or lower down on its posterior wall. Neither the epithelial nor the mixed and teratomatous growths give that sensation of firm resistance to probe or finger to be noted in the fibromata proper. They are movable or softer neoplasms which are not manifestly infiltrating the mucous membrane at their base. In this class of growth the microscopist meets not only with difficulties of differentiation between malignant and benign potentialities, but with difficulties of classification all his own. Prognosis. — Naturally this depends essentially on the nature of the neoplasm. Although the nasopharyngeal fibroma is essentially a benign form of connective-tissue growth, the ramifications which it has sent into various regions, such as the sphenoidal and orbital and even cranial cavities, the uncontrollable hemorrhage which often attends operative interference with it, renders the prognosis a grave one. It is dependent upon the surgical possibilities of eradication and these are difficult of estimation. The approach of the period when we can have a reasonable hope of the arrest of growth in a nasopharyngeal fibroma will also have much to do with the prognosis. On the whole it may be said that there are few essentially benign growths (by this we mean those with a type of structure not usually associated with malignancy) which defy the art and the technique of modern surgery. In spite of the frightful hemorrhage and the great extent of the operation wound, the mortality from opera- tion is low. Left to itself the pressure of a growing fibroma upon the structures of the base of the skull may bring about a fatal issue or the patient may bleed to death. Nevertheless, the peculiarity about this form of growth is not so much its situation and the tendency to bleed, but the limitations of growth and the atrophy which in many cases sets in after the patients have emerged from adolescence, though this cannot always be depended upon. The question of operation is often a serious one. Nasopharyngeal fibromata, when not too large or with too extended and flat a base, present no extraordinary difficulties of technique and offer a prospect of prompt relief from symptoms without great risk, which fully justifies surgical procedure even when the time of natural regression is approaching. On the other hand, the most intrepid operator may well falter before the dan- gers and difficulties of operation which attend the eradication of some of the tumors which, though having their origin from the fibrous aponeurosis of the pharynx, are widespread in their involvement of structures at the base of the skull. The urgency of the symptoms and the exigencies presented by each case must decide. NASOPHARYNGEAL TUMORS 443 Treatment. — The removal of soft edematous polypi projecting, into the nasopharynx or the simple procedures for removal of the other rarer forms of growths need not detain us. The classical operation of excision of the jaw and other procedures familiar to former generations of surgeons and not unknown to this, for removal of the nasopharyngeal fibroma or sarcoma is often attended by such appalling hemorrhage and always followed by such disfigurement that many devices have been resorted to in order to eradicate the disease or to hold it in check until, in the case of fibroma, the advent of a more advanced age will cause the tumor to recede spontaneously. Many pro- cedures have derived a reputation for efficiency from persistence in them until nature brings the relief otherwise not obtainable. However, it is often impossible, from a practical point of view, to refrain from adopting some measure of relief. The injection of monochloracetic acid directly into the tumor at intervals of one or two weeks, beginning with three minims and increasing the injection one minim each time until ten have been reached may, if persisted in, culminate in the disappearance of the Fig. 263 Harmon Smith's postnasal monochloracetic acid injection syringe. tumor. To render this injection easy of accomplishment a syringe with a protected needle, so that it will not engage in the palate or other soft parts when being introduced into the nasopharynx, has been devised by one of us. This syringe is so constructed that the needle is cov- ered by a flexible steel protector until it is carried into the nasopharynx and against the tumor, when by digital pressure on the thumb-piece at one extremity of the syringe, the needle is exposed and held in place by a ratchet on the side of the syringe, until it has been introduced into the tumor and the injection made. Additional pressure on the thumb- piece will carry the ratchet one more space and thereby liberate the pro- tecting sheath, which will again cover the needle and also receive the excess of acid that may exude from the injection in the cup-like extremity of the sheath, after which the instrument can be removed from the naso- pharynx. By this method drops of acid exuding from the tumor are kept out of the larynx and no injury is inflicted upon the palate by an unprotected needle. The slough from the injection of the monochloracetic acid seems to be held within the fibrous capsule of the tumor, and no 444 TUMORS OF TONGUE, OROPHARYNX, AND NASOPHARYNX Eustachian disturbance or other unfavorable results have been noted from its employment. Electrolysis and Galvanocautery . — ^Voltolini was the first to advocate the reduction of the vascularity of this growth by means of electrolysis applied near its base, to be followed subsequently by the removal of the growth with the galvanocaustic ecraseur. By this means he was enabled to remove the tumor through the nasal passages, likewise to reduce the hemorrhage incident to its removal to a minimum. The cautery not only removed the larger part of the tumor itself, but the base of the tumor was likewise affected so that what remnants remained of the diseased tissue were sufficiently destroyed to make the procedure radical and complete. Lincoln followed Voltolini and successfully employed similar measures in a number of cases. These procedures fell into disuse for a number of years, but attention has been called to them in recent articles by Delavan, which have awakened new interest in their employment.' This method of removal obviates the serious preliminary measures necessary to the surgical removal of these growths, and as compared to the measures recommended by Doyen, Bond and Tilley, it materially lessens surgical shock, profound hemorrhage, and other dangers insepa- rable from major surgery. The success attendant upon the use of the galvanocaustic ecraseur, as reported by Woods and others, of necessity forces upon us the importance of employing first electrolysis and then the galvanocautery before any major surgical operation. Other Operative Procedures. — One is sometimes able to introduce a cold wire snare through the nose and engage the base of the tumor by digital manipulation, so that a satisfactory removal is accomplished, but in the majority of instances the base is sessile and the outline of the tumor so globular that the wire will slip off rather than engage in the mass of the growth. This has been obviated by a method suggested by Ingals, by which he introduces the loop over the tumor and then grasps the latter next to the loop with very strong, serrated tooth forceps which, when the loop is pulled home, prevents the wire from slipping over the tumor and causes it to engage at the point where the forceps have been attached. When the wire tends to pull out of the tumor another hold is taken at that point with the forceps and this is repeated until the larger part of the growth has been removed. It sometimes becomes necessary, or at least has been deemed necessary, to split the soft palate, strip the growth of its superficial covering, and with a volsellum forceps tear the growth away from its attachment. The quicker the tumor is removed, after it has been uncovered, the less hemorrhage will ensue; but, as has frequently happened a mass of bone from the anterior face of the sphenoid may be pulled away with the tumor and alarming hemorrhage may follow. Where the growth has completely filled the posterior part of the nasal fossa as well as the nasopharynx. Rouge's operation has often been employed to facili- tate its removal. This procedure, however, unless the nasal septum is removed, offers but little advantage to the operator, as the attachment ' Transactions American Laryngological Association, 1911. NASOPHARYNGEAL TUMORS 445 is so far posterior that little or no advantage is gained by elevating the anterior nasal structures. Freer access is obtained by splitting the soft palate and if necessary the hard palate, which can be drawn together with sutures after the operation without great detriment to the patient. It has been recommended that the external carotid arteries nourishing the tumor may be ligated with possible disappearance of the growth, but as the region of attachment receives considerable blood-supply from other sources, this measure has not resulted favorably except in a limited num- ber of cases. If the growth appears in a very young adult and its size does not materially affect the individual either by pressure, hemorrhage, or constitutional disturbance, it may be left alone until the fibrosis increases to such an extent that it will cut off its own blood-supply and cause it to disappear spontaneously. This has been known to happen in some instances, but is so unreliable that neither operator nor patient is willing to abide by the slow processes of nature for its disappearance. All radical operative procedures on this class of tumors are attended with severe, if not dangerous hemorrhage, and properly to control it, it is best to perform a preliminary tracheotomy, so that the attention of the operator may be directed entirely to the hemorrhage and its control when it occurs. Unless the tumor is thoroughly removed there is great proba- bility of its recurrence, but when thoroughly enucleated they very seldom recur. In a recent experience with fibro-angioma (Plate V, Fig. 2), we were enabled to remove the tumor by passing the snare loop up behind the soft palate and engaging it easily in the soft angiomatous mass that projected from the sphenoidal region forward into the posterior choana of one side, and with the tip of the ecraseur held firmly in place at the base of the tumor, which appeared just below the soft palate, the major part of the growth was removed with more or less ease. Severe hemorrhage followed, which was controlled by repeated packing of the nasopharynx with gauze soaked in a solution of tannic and gallic acid, and by intro- ducing a postnasal tampon and leaving it in place twelve hours. A pre- liminary tracheotomy had been performed which greatly facilitated the control of the hemorrhage; the tracheotomy tube was remoyed on the following day. Within three weeks' time, however, there was marked evidence of the return of the growth, since which time injections of mono- chloracetic acid have been administered with a perceptible reduction of the size of the tumor. In addition to the postnasal growth there was in the left nasal fossa a large tumor of like character, apparently attached to the side wall of the nose, just above and anterior to the Eustachian prominence. When operative measures fail or if there is recurrence after partial removal of the tumor, injections of monochloracetic acid should be immediately instituted. Malignant. — Sarcoma. — Some of the characteristics which are attached to the benign fibromata of the nasopharynx are seen in those which are manifestly malignant. Sarcoma, like fibroma, is most common in males. In the tables given by Bosworth, for instance, the proportion is fourteen males and five females, but following the rule of sarcoma elsewhere the 446 TUMORS OF TONGUE, OROPHARYNX, AND NASOPHARYNX greatest frequency is between forty and fifty years of age. It is usually in the form of a spindle cell or fibrosarcoma and the differential diagnosis, microscopically, is often one of great uncertainty. The clinical history, unfortunately, is likewise uncertain because the nasopharyngeal fibroma, though histologically essentially of a benign character, involves important structures in its extension and by pressure produces absorption to such an extent that the symptoms may assume a malignant character. The variation also of the amount of cellular infiltration of the fibromata to which we have referred introduces an element of doubt in the differential histological diagnosis. The sarcomata soon begin to ulcerate and to slough. Hemorrhages are more frequent and uncontrollable. While these are seen to some degree in some of the cases of fibroma, they are not seen so early in the history of the case. By this time the microscope and other signs usually combine to render the diagnosis of malignancy manifest. Epithelioma. — Squamous-cell and columnar-cell epitheliomata and papillomata are all exceedingly rare. Rapidly succeeding the stage of obstruction alone, common to all nasopharyngeal neoplasms, there begins a period of pain, hemorrhage, and ulceration. The rhinoscopic mirror reveals a less well-defined growth. The surface is not smooth or largely lobulated, but is papillary, sessile, widespread, ill-defined. Such an appearance is sure to invite a microscopical examination which in this class of growth is usually fairly conclusive in its. evidence. Carcinoma is recorded in literature more frequently of late years. It seems relatively more frequent in women than is sarcoma. It may be of the pavement-cell or the columnar-cell type, and occasionally adeno- carcinoma of the nasopharynx has been reported. In one case of round- cell sarcoma a nest of epithelial cells with cancroid structure has been reported as warranting the diagnosis of carcinoma sarcomatodes.^ In malignant disease in this region, by the time a satisfactory diagnosis has been made, many cases are beyond the hope of successful surgical interference. Metastases are prompt to occur and infiltrations are far- reaching. Occasionally a case of sarcoma -will present features which justify its extirpation from the hope of lengthening the patient's life, but less infrequently it can only be considered from the view-point of ameliorating the patient's suffering. Epitheliomata are so rare that no rules of general application can be formulated for operation, but it will depend here as elsewhere chiefly on the early period at which the differential diagnosis is made. Treatment. — The operations for the removal of malignant growths of the nasopharynx belong among the most fatal and desperate known to surgery. Seen sufficiently early a radical operation is often considered justifiable. The reader is directed to modern works on general surgery for the elaborate details of procedures for the eradication not only of these malignant growths, but for the scarcely less formidable surgical tech- nique of the operations for the removal of nasopharyngeal fibromata. Modern surgery now includes such a wealth of detailed technique, 1 Klein, Wurzbiirger Dissertation, referred to by Herxheimer, Beitrage zur pathologische Anatoniie, 1908, p. 165. PHARYNGEAL NEUROSES 447 both as regards asepsis in the preparation of the patient, as well as in the course of operation, and as regards the successive steps of manipu- lation, not to mention the after-care of these patients, that it is impossible here to further encroach on the domains of general surgery. PHARYNGEAL NEUROSES. Paralyses. — These are peripheral or central or due to some involvement of the nerve trunks. The peripheral form, the most familiar, is that fol- lowing attacks of diphtheria, when the palate is immovable and relaxed and drink is regurgitated through the nose. They not only follow diph- theria, but in rare instances other severe forms of acute inflammation of the pharynx, especially those set up by burns caused by caustic fluids swallowed by mistake. They are also seen in cases of typhoid fever and influenza and Rethi^ claims that he has seen it due to pressure of large tonsils, though this may be doubted. It is not often that we see cases of pharyngeal paralysis due to involve- ment of the nerve trunks, except those caused by disease of, or operation upon, the middle ear, when the facial nerve being affected, we have an involvement of the palate through its innervation by the tympanic branch. Bulbar lesions which cause the paralysis of other and contigu- ous regions, such as the tongue and larynx, are not infrequently seen. Progressive bulbar paralysis beginning at the lips and extending to the pharynx and larynx and muscles of deglutition thus ushers in a fatal lesion. This is also seen in syringomyelia. We are not familiar with any cortical cerebral lesions affecting the pharynx, or at least no cerebral cortical location representing movements of the pharynx is known, al- though in the medulla at the origin of the vagus and the glossopharyngeal nerves such areas have been identified. Other interferences with the motility of the pharynx have been seen in tabes, giving the impression of ataxia and lack of coordination. Spasms of the pharynx which occur in tetanus, hydrophobia, etc., are also occasion- ally seen in hysteria. The latter condition may account also for some of the cases of apparent peripheral paralysis and the globus hystericus, or complaint of a ball or obstruction in the throat is familiar to laryngolo- gists. It is frequently associated with lingual tonsil hypertrophy. Hyperesthesia, anesthesia, paresthesia, are all seen; anesthesia either accompanying essential paralysis or less frequently the paralysis seen in hysteria or other functional disturbances. Feelings of a foreign body may sometimes be placed under this category. The sensation in these cases is frequently referred to the larynx, but it may be due to some defect of peripheral innervation of the pharynx. The pharynx also is occasionally the seat of origin of various reflexes of a purely nervous character giving rise to asthmatic attacks and per- sistent cough. The subject of neuroses of the pharynx is more easily studied in connection with that of laryngeal neuroses with which the pharyngeal manifestations are frequently associated. 1 Motilitat's Neurosen des weichen Gaumons, eine klinische Studie, 1893. CHAPTER XVI. ANATOMY OF THE LARYNX, HISTOLOGY OF THE LARYN- GEAL MUCOUS MEMBRANE. ANATOMICAL AND SURGICAL CONSIDERATION OF THE LARYNX. Cartilages. — The larynx is a triangular-shaped cartilaginous box, flat- tened behind and at its sides, but bounded in front by a prominent vertical ridge. It becomes more cylindrical as it approaches the trachea. The cartilages of which the larynx is composed are held by ligaments and are suspended by muscles which move them in accordance with the necessities of phonation or deglutition. Mucous membrane covers the entire inside of the structure and is continuous above with the pharyngeal and below with the tracheal mucosa. Its type is similar throughout except over the true vocal cords. The single cartilages of the larynx are the thyroid, cricoid, and epiglottis. Those associated in pairs are the arytenoids, the cartilages of Santorini, and the cartilages of Wrisberg. Thyroid. — This is the largest of the number and forms the greatest protection to the inner vocal mechanism. It consists of two large plates coming together at an acute angle in front, which from its prominence has been called Adam's apple. At the superior angle of attachment of these cartilaginous plates is a V-shaped notch, while their upper margin continues in a sinuous curve to end in two extensions called the superior cornua. At the junction of the two cartilages internally and anteriorly are attached superiorly, the epiglottis, intermediate, the two false cords, and inferiorly, the two true cords. The continuation of the posterior border above terminates in the superior cornu to which are attached the lateral thyrohyoid ligaments. The lower extension of the posterior border terminates in the inferior cornu, which articulates with the side of the cricoid cartilage. The inferior margin anteriorly is connected with the cricoid cartilage by the middle portion of the cricothyroid membrane. This cartilage becomes harder and calcification occurs in a greater or less degree after middle age. Cricoid. — It is situated below the thyroid and next to the trachea. Its shape is that of a signet ring, with the smaller portion anteriorly, from which resemblance it derives its name. Its posterior portion is broad and deep, with a groove in the centre for the attachment of longi-. tudinal esophageal fibers. The upper border posteriorly presents a median groove on each side of which is a smooth, oval surface or facet for the articulation of an arytenoid cartilage. The Epiglottis.— This is a leaf-shaped piece of fibrocartilage, thin and flexible, attached to the receding angle between the alse of the thyroid just below the median notch. The projecting extremity is broad and ANATOMICAL AND SURGICAL CONSIDERATION OF LARYNX 449 Fig. 264 rounded and is permitted to swing up and down by two ligamentous attachments, the upper one the thyro-epiglottic attached to the thyroid cartilage, and the lower, or under one, attached to the hyoid cartilage, called the hyo-epiglottic ligament. The ante- rior, lingual, or upper surface of the epi- glottis is covered with mucous mem- brane which is reflected to the sides and base of the structure, forming a median and two lateral folds called the glosso-epiglottic folds. The posterior, laryngeal, or under surface is concave from side to side, concavo-convex from above downward, with its lower part projecting backward as an elevation called the tubercle or cushion of the epiglottis. Indentations are found within the substance of the cartilages for the lodgement of mucous glands. On either side are two folds attached to the arytenoid cartilages, known as the aryteno-epiglottic folds. The Arytenoid Cartilages. — ^These are two in number and of pyramidal shape. The base is situated upon the smooth, rounded facets of the superior posterior border of the cricoid cartilage. Their apices are somewhat curved toward one another. The anterior or external surface has a transverse ridge about one-third the distance from base to apex, to the inner end of which the false cord is attached and to the outer part the thyro-arytenoideus muscle. The other surfaces are unimportant to the laryngologist. There are two prominent angles, the "external" to which the posterior muscles are attached, and the "anterior" which is the more pointed and forms a horizontal projection forward, to which the true vocal cord is attached. The apex curves backward and ap- proaches its fellow of the opposite side, and is surmounted by the carti- lages of Santorini, which serve to prolong the arytenoids backward and inward in the act of articulation. The cartilages of Wrisberg are small yellow bodies on each side of the arytenoids and lodged in the fold of the mucous membrane extending from the summit of the arytenoid to the epiglottis. Ligaments and Membranes. — They are classified according to position, as "extrinsic," those connecting the thyroid cartilage and epiglottis with the hyoid bone, and the cricoid cartilage with the trachea; and "intrinsic" those which connect the several cartilages of the larynx to each other. (Gray.) Muscles. — (The description of these muscles and their action is taken from Gray's Anatomy.) 29 Side view of the thyroid and cricoid cartilages. (Gray.) 450 ANATOMY OF THE LARYNX These are divided into extrinsic and intrinsic also. Under the extrinsic are those which depress or elevate the larynx and are attached to the cartilages of the larynx externally, and the contiguous osseous structures. Fig. 265 Epiglotti Citneifonn carl Arytenoid. Insertion of CRICO-ARYTENOIDEUS POSTICUS ET LATERALIS Cornicula Jaryiuih. /\ ' TJCNOI C Arytenoid cartilages, base. Posterior surface. Cricoid. Articular facet for arytenoid cartilage. Articular facet for inferior coma of thyroid cartilage. The cartilages ot the larynx. Posterior view. (Gray.) as the clavicle and hyoid bone, together with the muscles of the supra- hyoid region, the middle and inferior constrictors of the pharynx, and the stylopharyngeus, and palatopharyngeus, all of which act somewhat upon the larynx. The intrinsic muscles are the cricothyroideus, crico- ANATOMICAL AND SURGICAL CONSIDERATION OF LARYNX 451 Fig. 266 Cornicida laryngis. arytenoideus posticus and lateralis, arytenoideus and thyro-arytenoideus. The action of these muscles is as follows: The Cricothyroid. — The cricothyroid muscles produce tension and elongation of the vocal cords. This is effected as follows: the thyroid cartilage is fixed by its extrinsic muscles; then the cricothyroid muscles, when they act, draw upward the front of the cricoid cartilage, and so depress the posterior portion, which carries with it the ary- tenoid cartilages, and thus elongates the vocal cords. The Posterior Crico-arsrtenoid Muscle. — ^The posterior crico- arytenoids separate the chordae vocales, and consequently open the glottis, by rotating the arytenoid cartilages outward around a vertical axis passing through the crico-arytenoid joints so that their vocal pro- cesses and the vocal cords attached to them become widely separated. The Lateral Crico-arytenoid Muscle. — The lateral crico- arytenoids close the glottis by rotating the arytenoid carti- lages inward so as to ap- proximate their vocal pro- cesses. The Arytenoideus Muscle. — ^The arytenoideus muscle approximates the arytenoid cartilages, and thus closes the opening of the glottis, especially at its back part. The Thyro-arytenoid Muscle. — The thyro-arytenoid muscles, consisting of two parts having different attachments and different directions, are rather complicated as regards their action. Their main use is to draw the arytenoid cartilages forward toward the thyroid, and thus shorten and relax the vocal cords. But, owing to the connection of the inner portion with the vocal cord, this part, if acting separately, is supposed to modify its elasticity and tension, and the outer portion, being inserted into the outer part of the anterior surface of the arytenoid cartilage, may rotate it inward, and thus narrow the rima glottidis by bringing the two cords together. Blood-supply. — The Superior Laryngeal Artery. — The superior laryngeal artery which arises from the superior thyroid accompanies the internal branch of the superior laryngeal nerve; and the inferior laryngeal artery Articular facet for ' inferior cornu of^ thyroid cartilage. Muscles of larynx. Side view. Right ala of thyroid cartilage removed. (Gray.) 452 ANATOMY OF THE LARYNX from the inferior thyroid courses along with the recurrent laryngeal nerve. The veins accompany the arteries. The superior laryngeal Fig. 267 Interior of the larynx, seen from above. Enlarged. (Gray.) Fig, 268 Superior thyroid Superior laryngeal artery. The origin and distribution of the arteries of the larynx. (Lusohka.) THE MINUTE ANATOMY OF THE LARYNGEAL MUCOSA 453 artery passes between the greater cornu of the hyoid bone on the upper border of the thyroid cartilage and enters the larynx through the thyro- hyoid membrane after passing beneath the thyrohyoid muscle; its distribution is to the epiglottis, and the mucous membrane, the muscles, and the glands of the upper and interior portion of the larynx. The Inferior Laryngeal Artery. — This artery arises from the inferior thyroid opposite the lower border of the thyroid cartilage and passes directly inward to the cricothyroid membrane, where it divides into two branches; the lower anastomoses with a branch from its fellow of the opposite side, enters the larynx, and is distributed to the mucous mem- brane below the vocal cords. The upper branch, which passes beneath the border of the thyroid cartilage, anastomoses with branches from the superior laryngeal artery, which fact necessitates the ligation of both thyroid arteries to shut off the blood-supply to a tumor within the larynx. There is a posterior laryngeal artery which is a branch of the inferior thyroid. One of its branches is distributed to the posterior crico-ary- tenoid muscle, while the other anastomoses with the branches of the superior laryngeal artery. THE MINUTE ANATOMY OF THE LARYNGEAL MUCOSA. Here as elsewhere will be followed the rule of looking at the minute anatomy of the parts from the stand-point of the clinical observer of disease. Instead of treating the pathology as dependent upon the his- tology, those salient points of the latter will be emphasized, which the experience of the pathologist has taught him receive a rational explana- tion in the study of morbid changes. Mucous Membrane. — ^The thickness of the soft parts covering the fibrous and cartilaginous framework of the larynx varies greatly, but to give accurate figures of the thickness of the mucous membrane is impossible, for no one has ever defined where mucosa leaves off and submucosa and stroma begin. It cannot be reckoned by the depth of the acini of the mucus-producing elements inasmuch as the glands, some of them, end in the muscular substance. Heymann^ quotes conventional authorities as estimating the thickness from 10 microns to a half-millimeter, a rela- tive variation of 1 to 50. Epithelium. — ^The forepart of the anterior surface and the upper half of the posterior surface of the epiglottis, the upper part of the aryteno- epiglottic folds and the true vocal cords are covered by stratified squam- ous epithelium ; all the rest of the laryngeal mucous membrane is covered by columnar ciliated cells (Gray) . The thickness of the layers and the number of them can be seen to vary from a mere row, a layer or two thick in the fundus of the ventricle, to a large number of layers on the posterior wall of the larynx, varying with the use to which the larynx has been put in life; naturally much ' Heymann's Handbuch der Laryngologie and Rhinologie, Band i, Abt. i. 454 ANATOMY OF THE LARYNX thinner in childhood than in middle life. To draw the line between thickening from the normal use of the larynx and its abnormal use has inherent in it all the difficulties of defining what is normal and what is disease. What is normal for the individual should be the guide were it possible to establish it by any arbitrary statement. Fig. 269 Scftion through the laryngeal mucosa of the false vocal cord, showing columnar ciliated epithelium and beaker cells. (After Heymann.) There are places where a single columnar epithelial cell seems to stretch from the surface inward to the connective tissue and by the side of it may be a columnar cell with its broadest diameter at the base tapering upward to the surface and terminating in a single cilium in the sections. Much of this appearance in sections is due to the plane of the cell through which the section falls. As a rule in the columnar epithelium the shortest cells are on the limiting line of the stroma and are cuboidal in appearance. The height of the cilia varies from short bristles, just overtopping the cell in the more exposed surfaces, where they tend to disappear altogether, to long, waving masses elsewhere. It is best not to attach much significance to the conventional terms, columnar cells and pavement cells. They are useful as significant of type, but actually they shade off into one another in a manner entirely conformable to the function of the part, whether that function be one of the normal larynx or one induced by some pathological change. The laryngeal epithelium, like all the other tissues of the bodj', responds to THE MINUTE ANATOMY OF THE LARYNGEAL MUCOSA 455 the demands of its environment. At the vocal cords, where attrition of opposing surfaces takes place, a smooth, firm, hard surface is induced which is adapted to the clear-cut tones of articulate speech in man and to the less complicated vocal sounds of the lower animals. This smooth, horny surface varies with the configuration of the normal larynx and in the abnormal larynx it varies with the attrition of surfaces adjacent to the normal areas, a metamorphosis in conformity with the abnormal demand brought forward by the lesion. We refer not to disease primarily of the epithelium, as in the benign and malignant true tumors of the Fig. 270 Section through the mucosa of the upper surface of the true vocal cord, showing pavement epithehum. (After Heymann.) cords, nor to inflammations involving the epithelium of the cords, but to tumors or other affections causing deformity and attrition in places other than the normal. Either the columnar or the squamous areas may be extended or diminished by functional demands. Squamous cells, even of the skin, when turned into the columnar areas of the larynx by flaps, are rapidly metamorphosed into columnar cells at the demand of their new environment. We can confirm the statements of Heymann that in the adult larynx isolated areas of flat cells may be seen in the midst of columnar cells. 456 ANATOMY OF THE LARYNX At the top of the larynx the flat epithelium of the pharynx passes over into the columnar type; that is, the vertical diameter of the cell from being the shortest, as in the squamous type, or being equal to the trans- verse diameter, as in the so-called cuboidal cells, becomes frankly much longer. This conforms to the parts it has to play in the physiology of the larynx. At the introitus the passing air current is not perfectly warmed and moistened or freed from foreign matter. The mucous membrane receiving from above the fluids of the mouth and nose is more or less exposed to the passage of drink and food, rubbing against other surfaces, the tongue and pharynx, in the act of deglutition. The columnar or cuboidal cells of the newborn infant are thus rapidly transformed into flattened epithelium. At the same time there is a brushing away of those cilia of the surface which are in the road. Between this pavement epithelium above and that below there is in adults an area of columnar cells under the lee of the false or superior cords, which extends downward into the ventricles of the larynx and to the beginning of the surface of the true cords. This columnar epithelium, by virtue of its internal granular and molecular constitution, is adapted to the elaboration and exudation of secretions and, by virtue of its waving cilia, to their trans- portation. The dendritic papillae which fringe the under surface of the pavement epithelium in vertical microscopical sections are usually de- scribed or spoken of in such a manner that the reader infers they are cone-like projections into the stroma. Of course they are, as Frankel long ago asserted, really interlocking ridges of stroma and epithelium which, when cut vertically, show in profile as peaks and pits of varying height and depth. By maceration in acetic acid this is very perfectly demonstrated (Heymann). The dendritic papillae vary much both in their vertical and in their transverse diameter as well as in the distances between them. Both their number and their depth are increased in chronic inflammation. Normally the squamous cells of the cord begin at a more or less well-defined line which varies in its distance from the free edges of the cord to such an extent that the most careful writers content themselves with saying rather vaguely that it covers its upper and lower surfaces. A short distance from the edge of the cord on its lower surface the epithelium changes gradually again to the columnar ciliated cells of the trachea. The metamorphosis, when it occurs in answer to physiological or to pathological demands, is almost entirely to that of the surface layers. The basal cells of the squamous areas con- form very closely to the basal cells of the columnar areas in many places. There is a fairly well defined hyaloid fibrous layer which separates the epithelium from the stroma, but this also varies greatly in health, as well as in disease. In the latter especially, but even in the absence of any marked chronic inflammatory changes, areas are frequently met where this is entirely absent or represented only by a very thin fibril, a micron or two in diameter. As has been said, in thickness the epithelial layers both of the columnar and of the squamous kind vary greatly, the latter over the vocal processes being very thin with very little stroma but firmly binding it to the cartilage. Here occurs a slight depression THE MINUTE ANATOMY OF THE LARYNGEAL MUCOSA 457 of the surface due to the thinness of the mucous layer. In moderate swellings of the mucosa the depth of this depression seems considerable and it is not infrequently mistaken for an ulcer. Scattered in varying numbers through the rows of columnar ciliated cells, beaker or goblet cells are seen distended with coarse granules. These discharge at the surface and their secretion is doubtless an adjuvant to that of the glands. There is a certain amount of transmigration of the leukocytes into the layers of epithelium, especially in congested areas of the mucosa. Some- thing resembling the taste-buds of the tongue has been described in the epithelium of the epiglottis and upper parts of the larynx. Racemose Glands. — ^The glands of the larynx Luschka divided into an anterior group, a lateral group, and a posterior group. The anterior group at the base of the epiglottis is sometimes seen in laryngoscopy in a normal larynx. There is also a posterior group between the arytenoid cartilages. There is a lateral group in the folds of the ventricular bands. These are, however, only general statements as to the places most rich in glandu- lar supply, for they are found everywhere, even near the edge of the vocal cords and near the edge of the epiglottis above. They are abundant around the sessile cartilages of Wrisburg in the aryteno-epiglottic folds, and there is a row of them along the pyramidal base of the true vocal cords above and below the glottis with long ducts obliquely directed toward this edge. The finer anatomy of mucous glands has been sufficiently described in the chapter on the Nose. It only remains to say that the laryngeal glands are on the whole not only less numerous, but less voluminous and less complex in their acinal evolution than those in the nose. They are for the most part acinous glands, but as in the upper part of the nose some of them consist of a straight tube, which may be slightly dilated at the fundus, indicating a transition to the acinous type. Some of them, as intimated above, lie with their fundal extremities imbedded in the deep muscle fibers. For the most part duct openings are not found in the squamous epithelium with the exception of observations referred to by Frankel, but they are rather more abundant at the anterior portion of the glottis than elsewhere along the cords. Along the free vibrating edge of the true cords no gland ducts or acini are to be noted. Frankel asserts that he has observed a gland duct opening within 1.1 mm. of the edge of the cord, but at a considerably greater distance than this there is a strip of surface only scantily supplied with glands, so that the lubrif action of the surface is due almost entirely to the flow of secretion from the surface of the mucosa external to and above the true cords. In the trachea the glands form a more or less regular layer of structure situated well beneath the epithelial line. Connective Tissue. — ^The subepithelial connective tissue, sometimes called the membrana propria, is made up of a fibro-elastic areolar network. In places it is all but indistinguishable from the perichondrium, as over the vocal processes. Elsewhere it is thick and holds many gland acini, but always a very moderate number of bloodvessels. Nodes of lymphoid tissue are only rarely seen. Along the lip of the glottis forming the true 458 ANATOMY OF THE LARYNX vocal cords, the fibro-elastic tissue is close and white with very minute lymph channels between its parallel fibers. It is the gorging of these minute lymph canals with the products of inflammation which causes the edge of the vocal cords to lose its sharp-cut outline and become rounded and incapable of normal tone production in inflammation. In the pyramidal base of the vocal cords are arranged the muscle fibers, so inserted toward the median line and so anchored to the cartilaginous external framework that they form an ideal instrument of sound to the perfection of which man has never been able to approach in any of his mechanical devices. It is one of the most marvelously adapted muscular mechanisms in the whole body. Any interference with it by disease or accident immediately betrays itself and demonstrates the delicacy of its adaptations. Lymphatics. — ^The peripheral channels of the lymphatics cannot be considered aside from the fibro-areolar stroma, made up of the con- nective-tissue fibrils. Recent investigations go to show that the space between those communicate everywhere with efferent and afferent lymph channels. So numerous are the observations which describe these spaces as lined by endothelial cells coterminous with those of well-defined trunks that we are justified in looking upon the submucous stroma as a lymph sponge. Along the cords, where the fibrous bands are dense, and in the basal line between the stroma and epithelium these channels are of excessively fine caliber, while in the ventricular bands in the thick stroma they are wide-meshed. Below the vocal cords the narrow meshes again widen out and from the more or less parallel channels of the cords they become again sponge-like. De Santi describes^ the trunks draining the supraglottic space as running toward the lateral parts of the epiglottis and aryepiglottic folds. They then pierce the hyothyroid membrane at the point of entry of the superior laryngeal artery. They then divide into an ascending group, one or two in number, which cross the hypoglossal nerve and end in a gland situated just below the posterior belly of the digastric muscle. There is a horizontal group which empties into a gland lying on the internal jugular vein at the level of the bifurcation of the common carotid. Another or inferior part of the lymphatics ends in glands of the same group a little lower down near the middle of the lateral lobes of the thyroid gland. The infraglottic trunk piercing the cricothyroid mem- brane near the middle line empties in lymph nodes along the interior border of the sternomastoid muscle, in front of the larynx and trachea, and communicates with deeper glands lying farther beneath that muscle. It has been demonstrated that the lymphatics of the upper cervical region do not communicate with the lymphatics from the pulmonary or bronchial tissue, but that at about the lower level of the larynx the lymphatics which drain the pharynx become channels which unite and empty their contents directly into the truncus lymphaticus. Beitzke^ says that the deep upper cervical lymphatics in children, when injected, ■ The Lancet, June, 18, 1904. 2 Virohows Archiv, 184, Heft 1. THE MINUTE ANATOMY OF THE LARYNGEAL MUCOSA 459 are seen to terminate at the lower border of the thyroid, the lymph current then entering the lymphatic trunk which empties directly into the superior vena cava. The bronchial and pulmonary lymphatics, coming up from below, are seen to terminate at the same place, but even when the common lymph trunk is ligated material injected from above or from below does not pass this boundary. These observations were made postmortem on newborn children. This has an important bearing on the now widely accepted view that infection from the pharynx first enters the blood channels and the general circulation before it reaches the lungs. In the mucosa of the laryngeal ventricles and in that of the trachea are often found aggregates of lymphoid cells which in the former situation are sometimes dignified with the name of "laryngeal tonsil." These aggregates are merely ill-defined areas of loose lymphatic spaces gorged with young lymphoid cells, showing occasionally germinal centres. The lymph vessels in the older books are described as consisting of two layers in the thicker portions of the mucosa and of one layer in the thin. Intralaryngeal Bloodvessels. — ^The capillary bloodvessels as a rule are more abundant just beneath the epithelium and among the glands, and consequently form a more superficial network than the lymphatics. Nerve Endings. — The terminal nerve endings do not enter into practical considerations sufficiently to warrant an extended description of them here. The nerve trunks and the central nerve supply of the larynx receive notice in the chapters on Laryngeal Neuroses. Ossification of the larynx^ is a normal process of metabolism in elderly people, but it not infrequently begins at a comparatively early age. It is said to begin in the thyroid cartilage near its lower cornu and the areas of ossification advance toward the median line. It is more marked in men and occurs in them at an earlier age than in women. It is more often far advanced in larynges which are the site of morbid processes, as cancer and tuberculosis, than in the normal larynx. Occasionally its extent is insignificant or even absent at an advanced age, especially in women. The mucous membrane thus constituted adapts itself to the cartilagi- nous muscular and fibrous structures which underly it. The configuration of the larynx is represented as divided into parts by the projection of the true cords forming the rima glottidis, the supraglottic and the infraglottic space. At the top of the former is the aperture of the larynx more or less heart-shaped, while at the lower end of the latter is the lower border of the cricoid cartilage. The supraglottic space conforms more or less to the shape of the thyroid cartilage, that is, it is triangular in form, and it again may be considered divided, at least as to its walls, by the folds of the false cords and the mucosa covering them which limit the cavity known as the ventricle of the larynx and its appendix on each side. Posteriorly is the broad surface presented, when the glottis is dilated, by » Scheier, Beitrage zur Anat. Physiol, und Therap. des Ohres, der Nase, und des Halses, Band iii, p. 279. 460 ANATOMY OF THE LARYNX the interarytenoid space. The folds of mucous membrane forming the superior or false vocal cords turn around the slender fibrous bundle known as "the superior thyro-arytenoid ligaments," which is attached in front to the angle of the thyroid cartilage immediately below the attachment of the epiglottis and behind to the anterior surface of the arytenoid cartilage (Gray). This constitutes the upper boundary of the laryngeal ventricle where it communicates with the visible part of the air tube as seen in the laryngoscope. It is crescentic in shape. The inferior or true vocal cords limit it below. The ventricle, itself an oblong fossa, is thus bounded internally, while its outer wall is the mucous membrane covering the thyro-arytenoideus muscle. The appendix or laryngeal poiich is a prolongation of the ventricle upward and backward to a variable extent beneath the crescentic upper boundary. As remarked these surfaces are especially rich in racemose glands. The lower boundary is the essential organ of the voice, the true vocal cords, a little less than an inch long on the average, whose cross-sections represent triangles with the bases outward. When abducted they form a triangle with the base posteriorly. They are made up of the lower thyro-arytenoid liga- ments into which are inserted the various muscles which adapt them to their function. The breadth of their upper surface varies greatly inas- much as the fibrous elements are revealed as shining white material showing through the epithelium in proportion to the varying trans- lucency of the latter and the extent of the fibrous tissue covered by the darker-hued muscle insertions. The width of the rima glottidis in abduction at its widest portion, just in front of the vocal processes, being somewhat elliptical, is given at a third of its length (2.5 x 0.8 cm.), but in extreme abduction it seems likely the glottis is more widely opened than indicated by these figures given by Frankel. The median position of the cords is the glottis firmly closed by extreme adduction. The phonatory position shows a narrow slit between the cords, which are more or less tense. The respiratory position is one in which the glottis assumes a plainly relaxedstate of the edge of the cords while the vocal processes are not in apposition. Extreme abduction is one in which the glottis is wide open and the posterior wall somewhat bowed by the space between the vocal processes not representing its widest part. The vocal cords are elliptically adapted against the lateral laryngeal wall. The cadaveric position is rather ill-defined anatomically. In current laryngological phrase, it means a wider separation of the vocal processes and a greater relaxation of the edge of the cords than is seen in the act of inspiration or expiration, but not one of extreme abduction. It is quite certain that the position actually assumed by the cords in the cadaver is not seen as a fixed condition in the living larynx, however complete the paralysis. It is desirable to keep these four positions well in mind, as they have an important physiological and pathological significance, and the terms to indicate them should be used with precision in laryngological literature, which at present is not always the case. The inspiratory movement of the glottis is one of abduction at first and then a slight adduction, while the THE MINUTE ANATOMY OF THE LARYNGEAL MUCOSA 461 free relaxed edge of the cords can be seen to move slightly. Expiration is accompanied by a wider abduction. The trachea is flattened posteriorly by the gap between the ends of the 16 to 20 cartilaginous arches, which is filled in by a membrane in apposition to the esophagus. Some of the cartilages are bifurcated and some are joined one to the other. It is thus an imperfect cylinder which extends from the cricoid cartilage to its bifurcation, a distance of about 4J inches. This represents the vertical space lying between the sixth cervical vertebra and the fourth or fifth dorsal vertebra. Slightly narrower than the larynx at the level of the cricoid cartilage, its diameter is given at three-quarters to one inch (Gray). Both the larynx and the trachea are regularly larger in the male than in the female. The mucous membrane is lined with long, ciliated, columnar epithelium and the sub- mucosa richly supplied with mucous glands. It is bound much more firmly to the cartilaginous rings than is the laryngeal mucosa to its cartilages, and consequently the subepithelial areolar tissue is more scanty, though sometimes supplied with lymphoid cell foci. In the laryngoscope, the division of the bronchi can be plainly seen in a considerable proportion of people when it is used with strong illumi- nation. It is seen that the edge of the division is placed to the left of the middle line so that while the lumen into the left bronchus is in a straighter line, the right bronchus going off more at a right angle would seem more likely to receive from above a foreign body, which in reality is said not to be the case. CHAPTER XVII. ACUTE AND CHRONIC LARYNGEAL INFLAMMATIONS. Etiology. — Acute inflammations of the larynx have practically the same factors in their etiology as do those of the nose and pharynx. Chronic inflammations of the larynx are nearly always due to some concomitant nasal or pharyngeal lesion. It is the epithelium which presents the most profound changes. Obstructive lesions of the nose cause a defective warming, cleansing, and moistening of the inspired air. Dripping of an altered and an increased amount of the pharyngeal secretions night and day into the larynx comes from a pathological state of the mucosa in the nose and pharynx and induces a pathological state of the laryngeal mucosa in some, but not in all individuals. While, there- fore, we may say that practically all chronic inflammations of the larynx are accompanied by lesions in the air passages above, the reverse is not true. There are certain exceptions to this statement. Certain occupa- tions involve overstrain of the voice, but, with a normal nose and pharynx, laryngeal lesions which persist after the larynx is put at rest are very rare. Moreover, in such cases it is rather the muscular strain than the epithelial or fibrous hyperplasia which is the cause of the symptoms. There is a form of laryngitis seen in dispensaries frequently but not limited to this class of patient, known as alcoholic laryngitis, where the subacute and chronic congestion of the larynx bears a very direct relationship to the imbibition of alcoholic drinks. This condition also promptly clears up when the patient becomes for a time a teetotaler, provided the lesion has not resulted in a pachydermia, when the recovery is of slow duration. Histology. — The minute changes in the acute inflammations of the laryngeal mucosa lack, as a rule, the increase in volume which the mucosa in the pharynx exhibits where there is much subjacent lymphoid tissue, but the laryngeal mucosa otherwise exhibits the same phenomena except such as are due to the configuration of the surface of the tonsils. The subepithelial connective tissue, while crowded with leukocytes, is apt to become edematous more frequently than that of the pharynx. This in severe septic conditions, of which we wifl speak more at length, may easily give rise to alarming symptoms of laryngeal stenosis. The glands pour forth an abundant secretion in the later stages of an acute inflammation and the surface epithelium from the flrst is swollen and probably pro- liferates to some extent in order to make good the losses of superficial cells which it supplies to the increased secretions. In chronic and sub- mucous inflammations this is especially well marked. Epithelial meta- plasia and the thickening of the epithelial layers are everywhere seen. In the posterior commissure especially the epithelial proliferation is ACUTE INFLAMMATIONS OF THE LARYNX 463 well marked. When very abundant the surface assumes a white appear- ance and the condition becomes known as a pachydermia. The fibrous elements in the vocal cords and elsewhere do not, as a rule, present such decided hyperplastic changes as does the epithelium. ' Both the fibrous tissue and epithelial hyperplasia take part in the formation of the singer's nodules. While both these and the pachydermia or epithelial hyper- plasia are of distinctly inflammatory origin, on account of the structural, clinical, and genetic affinities they have with benign neoplasms, they will be considered under that heading in this work. Acute catarrhal tracheitis is an affection observed clinically usually in connection with a similar affection in the larynx. We have no reason to believe that its histology differs essentially from what little we know of that of acute catarrhal inflammations of the upper air passages already alluded to. ACUTE INFLAMMATIONS OF THE LARYNX. Appearance. — The entire mucous membrane may be hyperemic, and covered with a tenacious, thin exudate, which dries upon the surface in spots and is difficult to expel. The true cords may appear red, or they may not appear involved at all, and only the false cords are pufl^y, hyper- emic, and edematous, proper phonation being prevented by general con- gestion of the mucous membrane. Occasionally one observes a few streaks of red running parallel with the long axis of the true cords, which is of such insignificance from the observer's stand-point as to render the conclusion doubtful if this can be the cause of the hoarseness and laryngeal discomfort. However, these apparently limited involvements often seem sufficient to cause the most pronounced symptoms. Occasionally only the tips of the arytenoids and the interarytenoid space will be red and dry in appearance, resembling the congestion of the nasal mucosa in the beginning of a coryza before the exudative stage, arid in these cases pain is experienced. The inflamiiiation incident to voice-strain will often produce a diffuse redness of the entire laryngeal mucosa, with a marked pink, edematous puffiness of the true cords. In tenor and high soprano singers the cords are normally slightly pink after vocalization, so that this must be borne in mind when their larynges are examined. In patients abusing alcohol an edematous appearance with abundant secretion is noted in addition to the redness, while in the excessive smoker the membranes look dry and red, with a drawn or puckered appearance, as though they were in very close contact with the underlying cartilage. Occasionally minute ruptures of the arterioles or venules will occur into the submucosa, giving it a spotted or a mottled red appearance. During a violent fit of cough- ing, vomiting or excessive use of the voice these may rupture, and pro- duce slight hemorrhage which streaks the expectoration with blood. In subjects suspicious of underlying tuberculous involvement, this may produce unjustifiable alarm. This variety is often known as "hemor- 464 ACUTE AND CHRONIC LARYNGEAL INFLAMMATIONS rhagic laryngitis." In looking at the larynx after use, during the course of a laryngitis, the cords will have lost their ribbon-like appearance and will have become rounded on the edges and sometimes bowed. Course. — The term of the disease is, in the majority of instances, of short duration, this being influenced by the willingness of the patient to abstain from alcohol, tobacco and excessive use of the voice. If rheu- matism or other constitutional conditions underlie the laryngitis a longer time is necessary to effect a cure. The majority of acute conditions pro- ceed much in the same way as an acute coryza and pass into the exudative stage at the end of forty-eight hours, from which it gradually passes away. It is only in the first stage of involvement that pain or discomfort is felt, although the hacking and clearing of the throat in the latter stage is very annoying both to patient and friends. Symptoms. — Sudden hoarseness, together with pain in speaking, are usually the first evidences of a beginning laryngitis. The voice may assume a deep bass, with now and then a falsetto note, and in the course of a few hours it may be entirely lost. There is a frequent desire to swallow and a slight hacking cough with inability to remove the offending irritant. There may be slight pain upon inspiration or an aching sensation in the larynx, particularly in rheumatic cases. In the alcoholic variety there is considerable mucus even in the early stages. The inflammation may extend to the trachea or up into the nose. In most instances the voice is worse in the morning, but in those who use their voice during the day the laryngitis may become worse as evening approaches, owing to the strain upon the cords. There may be a rise of from one to two degrees of temperature with a rapid pulse, together with constitutional symptoms of a beginning coryza, such as pain in the limbs, malaise, headache, etc. Treatment. — This may be divided into local and constitutional. The local application of strong astringents should be condemned, as it only tends to increase and prolong the acute inflammatory condition. In laryngitis occasioned by the use of alcohol or tobacco, the removal of the cause will often occasion the disappearance of the inflammation. In laryngitis due to ^oice-strain, absolute rest of the voice as well as of the body should be insisted upon. If practicable the patient should be put to bed and kept in a warm, well-ventilated room. The larynx may be sprayed twice daily with a mild alkaline solution such as Dobell's and water, or some other similar preparation, well diluted. Probably little of the spray enters the larynx, but sufficient trickles down on the epiglottis and over the laryngopharynx to relieve some of the congestion present. The local application of a 5 per cent, argyrol solution by means of the laryngeal applicator is advisable, after which an oily spray of albolene, with five grains to the ounce of menthol should be employed. Too much instrumentation in the larynx only tends to increase the inflammation. Inhalations from a steam kettle, to which a teaspoonful of J^ — 01. pini pum gj Menthol gra. ij Milk magnesia ■Si SIMPLE CHRONIC LARYNGITIS 465 should be added to the pint of boiling water. This inhalation can be given every three hours. Cold compresses or the Leiter coil should be applied to the larynx, one hour on and one hour off, but not left in situ while the patient is sleeping. Equal parts of chloral, menthol, and cam- phor rubbed over the larynx twice daily will frequently relieve the pain. If it is absolutely essential for the patient to meet some engagement for speaking or singing, one or two drops of diluted nitric acid on the tongue every half-hour will frequently clear the voice sufficiently to meet the requirements, or a tablet of ^ — Ac. nitrici dil TT^iij Tr. opii deodorati Tlliij Cocain pheuate sr. iV every hour for three or four hours will materially lessen the temporary inconvenience (Kyle). There should alsp be intrusted into the hands of the patient a mild adrenalin mixture for spraying purposes, as Q— Adrenalin (1-1000) 5j Aq. rosffi Sj the astringent effect of which is sufficient to tighten up a flaccid cord. and squeeze out some of the extravasated serum. If it becomes necessary to consult a laryngoldgist, frequent treatment in the beginning of the trouble will tend materially to hasten the disappearance of the difficulty. Patients should be put upon a strict diet and thorough evacuation of the bowels should be procured. The intratracheal injection of albolene or viridol is recommended, following the application of any astringents that may be employed. SIMPLE CHRONIC LARYNGITIS. Appearance. — The mucous membrane is thickened, hyperemic, and often nodular, especially on the cords or in the interarytenoid space or in folds. The cords are red and upon the surface mucus is firmly attached and upon deep inspiration cobwebby strings will form across the inter- vening space. The reddened condition may not always involve the entire cord, but may occupy either extremity or the border, or the vessels may show as enlarged on the surface only. The ventricular bands are also red, thickened, and bathed in mucus. The hyperplasia may become so exten- sive as to hide the true cords or render their outlines uncertain and prevent phonation. In all such cases the subglottic space is involved in a similar manner and the trachea is of the same dull-red appearance as far down as can be seen. One chtiracteristic of simple inflammation is the bilateral involvement, which enables the observer to differentiate it from other laryngeal conditions of a more serious nature. Owing to partial paresis of the internal tensors the cords are prevented from approximation upon phonation, or the same condition may obtain from a thickening of the 30 466 ACUTE AND CHRONIC LARYNGEAL INFLAMMATIONS mucous membrane in the interarytenoid space. The epiglottis, par- ticularly on its laryngeal surface and the aryepiglottic folds, are often similarly involved. Small superficial abrasions may be noted when the laryngitis is of long standing and the efforts to liberate the tenacious mucus have been of undue severity. Symptoms. — The voice is always altered and varies in intensity from a slight huskiness to almost complete aphonia. Hawking is almost con- stant, particularly in the morning or after a long vocal rest, due to an accumulation of mucus which adheres tightly to the mucosa. After the larynx has been moderately exercised the hawking and huskiness lessen. Pain is seldom complained of except in acute exacerbations or from fatigue, but a soreness and a tired feeling are frequently present. More mucus is excreted and coughed up when the trachea and bronchi are involved in the same process. The expectorated material may be yellowish and purulent or white and frothy. Both may be tinged with blood owing to capillary ruptures from coughing or constant hawking. Treatment. — Occupational laryngitis can only be overcome by a ces- sation of activity in that particular way. Hucksters, motormen, coal- heavers, quarrymen, firemen, and those exposed to irritating chemical fumes alike are included in this class. Clergymen, public speakers, and professional singers with chronic laryngitis must have rest and special instruction in the proper use of the voice. Many singers can sing cor- rectly but they use their voices improperly in singing and in talking, which produces a chronic inflammation of the cords, unyielding to medi- cinal or local treatment but disappearing under the intelligent instruction of the elocution teacher. In patients subject to repeated colds which ulti- mately affect the larynx, attention must be directed to systemic disturb- ances, ventilation and clothing, and if they are not prevented by these measures a sojourn in a different climate will often effect a cure. Gout, rheumatism, kidney involvement, gastro-intestinal disturbance, will be found to underlie many cases of laryngitis which will not yield to local treatment until these have been corrected. Rest is the cardinal principle in the treatment of any condition of the larynx. The voice should be employed only to obtain the essentials of existence and should by no means be used in the open air or in crowded, badly ventilated rooms. Abstinence from alcohol, tobacco, and highly seasoned foods should be insisted upon. Exercise, properly regulated, with free evacuation of the bowels and the administration of antiacids, prove of benefit in all these cases. The physician believing that chronic laryngitis can always be cured by local applications alone is limited in experience or erroneous in his deductions. The essential object is to remove the cause together with the contributing factors, as catarrhal conditions of the nose and nasopharynx. Cleansing sprays of Dobell's solution, or other alkaline solutions, will remove the overlying mucus and permit the astringent solution to come in contact with the diseased mucosa. Nitrate of silver in solution (grs. x to xx to the ounce) may be rationally employed, provided care is exercised to note that the application is not increasing rather than diminish- ing the hyperemia. Argyrol is quite eflicient in solutions of 10 per ATROPHIC LARYNGITIS 467 cent, to 20 per cent. Ichthyol in 10 per cent, solution and No. 1 Mandl's solution of iodin are of equal merit. Zinc chlorid may be tried, provided these other measures fail, and should be used in the milder solution first of grs. v to 1 ounce, and increased to grs. x or xv to 1 ounce. Following the astringent solutions some hydrocarbon oil with menthol or eucalyptus in mild form should be injected into the larynx with the laryn- geal syringe, as albolene 1 ounce, menthol grs. v. It is not only soothing but efficacious to have the patient inhale, twice daily, steam laden with the medication of oil of pine, menthol and milk of magnesia (see formula, p. 464). A 2 per cent, solution of lactic acid applied locally with the laryngeal applicator has been recommended by Massei. Pilocarpin and strychnin internally may promote secretions or even potassium iodid in small doses will often induce secretion of a watery character and reduce the hyperemia. ATROPHIC LARYNGITIS. Appearance. — The laryngeal mucosa looks dry and leathery and is covered entirely or in- part with yellowish, greenish, or blackish crusts. The interarytenoid space and posterior ends of the cords are the locations where the crusts gather most frequently. In advanced cases a complete cast of the larynx and often of the trachea is formed by the dried muco- purulent secretion, and great difficulty is experienced in removing them. The underlying surface of the cords and adjacent mucosa is abraded in certain areas and presents the appearance of an ulceration from which a scab has been removed. Symptoms. — Voice. — Hoarseness is the predominant symptom, being more marked in the morning before the crusts have been coughed up. A dry, hacking cough or continued hawking is always associated with this form of laryngitis. The expectorated material consists of dry, scabby secretions which are partly the product of local formation and partly of nasal and postnasal secretions which have dropped into the larynx. Atrophic laryngitis is always associated with a similar conditipn in the regions above and appears to be an extension of the pharyngitis sicca. The crusts may often be blood-tinged owing to the abrasion of the mucosa incident to liberating the crust, and this fact may cause un- necessary alarm to the patient. Odor is present in some instances, but it is not a constant factor and ordinarily the laryngeal crusts have not the odor the nasal crusts have. The quantity of secretion expelled seems to play little part in the odor, as the foulest odor is often noticed in cases with little secretion. Treatment. — If the cause can be determined attention should be directed to this rather than to local treatment. If occupational, removal from the source of disturbance is essential in the treatment. Hygiene and proper food and clothing are of great importance in conjunction with any local treatment. Syphilis either directly acquired or inherited must receive due consideration, and the administration of a saturated solution 468 ACUTE AND CHRONIC LARYNGEAL INFLAMMATIONS of potassium iodid, beginning with five minims, three times daily, and increasing the dose until symptoms of iodism appear, will aid materially in overcoming crust formation, whether there be any syphilitic taint or not. Equal parts of peroxid and water injected into the larynx with a laryngeal syringe will loosen the crusts and aid in their expulsion. A second irriga- tion of Dobell's and water will clean the surface, after which a stimulating application can be made which will come in direct contact with the dis- eased mucosa. For this purpose many formulae have been advocated. Ichthyol in 10 per cent, to 20 per cent, aqueous solution has been found of benefit. Mandl's solution of iodin, argyrol, 20 per cent, solution, is of unquestionable value. Lactic acid bacilli held in suspension and dis- pensed in tubes under the name of lactobacillin has in many instances been more beneficial than the other stimulating solutions. Steam inhalations with oil of pine or tincture of benzoin added are of value in dislodging the crusts. Intratracheal injections of some of the hydro- carbon oils after the other treatment is not only soothing but of great benefit. The liquid oleostearate of zinc to which iodin has been added in the proportion of one minim of iodin to the ounce is one of the best preparations for injection into the trachea of atrophic cases. TRACHEITIS. Involvement of the trachea either from inflammation or infection is usually secondary to a similar involvement of the respiratory apparatus above; but it is stubborn in character and yields slowly to treatment. The mucosa is red and puffy, with here and there punctate elevations secreting mucus. There are areas of mucosa covered with mucus which become detached on coughing, leaving a raw-looking surface beneath. Upon successful illumination a view may be occasionally obtained as low down as the bifurcation. A tracheitis occasions more discomfort than a laryngitis in certain ways, especially from frequent hacking and painful respiration. It also pro- duces more constitutional disturbances resulting in mental depression and a temperature. The majority of the symptoms are the same as in acute or chronic laryngitis. Steam inhalations with formula (p. 4(34) often soothes the mucosa more than anything else. A few drops of warm Dobell's solution injected into the trachea with a laryngeal syringe will remove the tenacious mucus, after which a few drops of 10 per cent, argyrol may be similarly injected. All injections of an astringent character should be mild and followed by a few drops of liquid albolene. Sweet spirits of nitre, potassium citrate, and some of the milder expec- torants aid the local treatment very greatly. Change of climate is often necessary and the patient is not unwilling, in most instances, to carry out any directions that will lessen his discomfort. It is an exceedingly rare thing to see a case of chronic laryngitis, or tracheitis, not dependent upon a specific cause such as syphilis or TRACHEITIS 469 tuberculosis or alcoholism, which is not associated with some obstruction or disease of the nose or nasopharynx. Those cases whose chief etiological factor is a constitutional dyscrasia are very rare. From these considerations of an etiological nature it follows not only theo- retically but it is practically demonstrated in experience that unless the upper air passages can be put in a more normal condition by operation or other treatment, chronic laryngitis, though the symptoms may be temporarily relieved, will not get well. It will improve permanently only insofar as the upper respiratory passages are put in a state properly to perform their functions. CHAPTER XVIII. BENIGN LARYNGEAL NEOPLASMS. Occurrence. — Moritz Schmidt,' in his most valuable text-book, classi- fied 460 benign tumors of the larynx in a manner that no longer is in accord with a more critical pathological differentiation. Rearranged in the way the subject would now be treated histologically, they would be as follows : TRUE tumors: benign. Epithelial : *Papilloma 46 (31 males; 15 females) Connective tissue: *Fibroma 256 (178 males; 78 females) Myxoma 3 (males) Fibromyxoma 1 (male) Lipoma 1 (male) Inflammatory: Singers' nodules 109 (56 males; 53 females) Tubercular tumors 36 (14 males; 22 females) Cysts 8(2 males; 6 females) Those marked with an asterisk we shall have reason to suppose include many growths which are of an inflammatory nature as to their origin, yet in both of these classes it will be seen how much more frequent benign neoplasms of the larynx are in men than in women. In those growths which we are very sure are of inflammatory origin it will be seen that more than half were in females. Now if we note the malignant growths as reported by Schmidt we find : Carcinoma . 75 (61 males; 14 females) Sarcoma 3 (males) These of course were true tumors in the modern acceptation and we find them more than five times as frequent in males. We do this by way of illustration rather than in the belief that it is possible to draw any hard- and-fast line, as the histologists attempt to do, between true tumors and those of an inflammatory origin. It illustrates very sharply at least that, for those growths which surely have some other factor in their etiology than that of hypertrophy of elements previously existing in situ, females possess larynges less disposed to their development than men. Of the fibromata it may. be said that the fist includes in all probability chiefly tumors which in the nose we have referred to as edematous polypi. In these there is often such a trifling increase of fibrous tissue that we may well regard the chief pathological change as one of local transu- dation of the serous elements of the blood, rich also in mucin from the ' Die Krankheiten der oberen Luftwege, 1894. OCCURRENCE ill neighboring glands and containing little or no protein coagulable by heat and the mineral acids. If then we are to exclude this class in which it is impossible to know just how much new connective fibrous tissue has warranted the observer in placing his case among the fibromata in each instance; if we also remember that many of the so-called papil- lomata really spring from an inflammatory, syphilitic or tuberculous base and from a malignant base, as will hereafter appear, it seems very probable that we would find that malignant tumors of the larynx are more fre- quent than true benign tumors, in the histologist's acceptation of the term. It may be said that the number of women with malignant laryn- geal growths observed by Schmidt far exceeds the proportion noted by most other observers. It has been said that men are from ten to fifteen times more frequently affected with laryngeal cancer than women. This is more in accord with our own experience. Two or three women at the most are all that we have seen with malignant disease of the larynx. Of intrinsic laryngeal cancer Semon^ reported (1908) that he had seen 124 in men and 12 in women, that is, about 10 to 1. Of extrinsic cancer, on the other hand, he had seen 53 in men and 23 in women, less than 3 to 1. It is plain that such a discrepancy as this is not explicable on the basis of the greater strain put on the larynx in men and its greater exposure to dust, either for benign or for malignant growths. It may be observed that in the singers' nodules, which we all know have those factors in their eti- ology, the proportion is about equal. In those categories, fibroma and papilloma, which often are really growths improperly classified among the true tumors, the discrepancy is less marked (together, 209 men and 93 women). Aside from the relative frequency of the incidence of laryn- geal tumors in men and women, the relative frequency of malignant tumors and benign tumors of the larynx will depend on the extent of the observer's consulting practice. No reliance, therefore, can be placed on individual statistics when laryngeal malignant disease is compared with the total number of laryngeal patients seen. Still less for another reason, can reliance be placed upon collective statistics, for a patient with laryngeal cancer almost invariably comes under the observation of many more laryngologists and surgeons than a patient with a benign growth. There is another remark which is to be made as to the frequency of laryngeal neo- plasms in general, but particularly applicable to tumors of inflammatory origin. In the early days of laryngology and consequently in the early reports, fibromata and papillomata, observed by individual laryngologists, bore a much larger proportion to the total number of cases of laryngeal disease seen; in many instances the numbers of papillomata and fibromata alone, reported by early observers (Fauvel, Mackenzie) far transcended the total number of all cases of laryngeal neoplasms seen today by the busiest practitioner of the specialty. This can be safely considered as being due chiefly to two causes: First, the number of trifling laryngeal complaints which come under the observation of the laryngologist today is enormously increased. Second, today treatment in these cases, but ' System of Medicine, AUbutt and RoUeston, vol. iv, part 2. 472 BENIGN LARYNGEAL NEOPLASMS especially early and judicial treatment of nasal and pharyngeal disease, has greatly cut down the liability to inflammatory benign laryngeal neo- plasms. Statistical information, therefore, is a bad basis for knowledge without critical analysis and the appreciation of the changes modern science is continually bringing about in the aspect of affairs. BENIGN EPITHELIAL NEOPLASMS. In dividing tumors into benign and malignant we do so, not because we believe it is devoid of objections, which have been pointed out already and which will form the subject of remark in what is to follow, but be- cause it is desirable to follow, when possible, conventional lines when they do not lead us into confusion and because, while not devoid of objec- tions, this plan presents fewer objections than any other in a subject where some orderly arrangement is necessary. Histology and Etiology. — ^We do not pretend to say when a hj'perplasia of the epithelium assumes the character of a tumor, for from the pachy- dermia of the larynx seen in simple chronic inflammation, from the flat epithelial vegetations over a tuberculous or a syphiltic or a cancerous substratum, up to the voluminous papillomata filling the whole larynx, all gradations exist. The proliferation is in all cases chiefly that of the epithelium. We will only deal at length here with those proliferations without specific tuberculous or cancerous factors in their etiology. Pachydermia Laryngis. — Pachydermia laryngis is a term applied by Virchow to thickenings of the posterior laryngeal wall and the posterior half of the vocal cords seen in subjects whose habits of spirit drinking or whose occupations as street hawkers have exposed their vocal appara- tus to raspings and strains unusual in other walks of life. It is not very clear just how 60 per cent, alcohol passing down the pharynx and esopha- gus starts the epithelium between the vocal processes to proliferat- ing, unless we are permitted to imagine that some small film of the fiery liquid actually passes over onto the posterior laryngeal wall as the an- cients believed. Certain it is, however, that chronic topers often have chronic thickenings of the epithelium in the interarytenoid space. Vir- chow remarked that the psychic stimulus of the Hquor leads to "song- like"exercises in the raw night air in some of these sufferers, but, the pleasantry aside, this is not a very attractive explanation of why hard drinkers are often troubled with hoarseness. Newsboys and street peddlers furnish occasional examples of etiological factors that are more satisfactorily comprehended; but why they should have thickenings on their posterior laryngeal waUs and tenors and sopranos of the opera should have thickenings of the vocal cords at a certain spot anteriorly can only be explained upon the assumption that it is the mechanical nature of the muscle-strain and the location of the attrition which makes the distinction. There is another class of patients in which is seen in- flammatory thickenings of the posterior laryngeal wall, and these are those who suffer from chronic rhinitis, especially from chronic atrophic rhinitis and ozena. Here we may possibly find a clue to a common etiolog- BENIGN EPITHELIAL NEOPLASMS 473 ical factor in the topers. We see the dried secretions which have dripped down overnight in ozenatous cases. We cannot but believe that the irri- tation thus set up is to some extent due, not to secretions of the larynx, but to secretions of the pharynx. If the secretions, why has not the 60 per cent, alcohol of the toper, after the establishment of a certain amount of toleration, finally tanned the surface of the mucosa? This may not be entirely convincing, but the sequence is at least suggestive. The grayish-white surface has a darker tinge than some of the smooth, glistening, white epithelial hyperplasias, probably because in the papillary surface there is lodged a certain amount of secretion holding dust particles. Small rugae and pointed projections from a thickened base are all due to the proliferation of the superficial layers of the epithelium, but the basal layers are thickened also and present the same dendritic digitations into the stroma to be more fully described in remarks on the histology of papilloma. Indeed except for the proliferation of the surface into pro- jecting masses of tumor, pachydermia differs in no way from it in minute structure. When it extends beyond the vocal processes, as it usually does, there are crater-like depressions over them which are due, doubtless, to the firm cartilaginous impact of one process against the other, keeping down the vegetations, in attempts at phonation. The symmetrical ap- pearance, the location and the nature of the overgrowth, will distinguish these depressions seen in the laryngoscopic mirror from ulcers, a point upon which Virchow dwelt at length. Papilloma, Fibroma Papillare, Benign Epithelioma. — ^Virchow placed papillomata among the fibromata, that in his view being in conformity to the rules he formulated for the nomenclature of neoplasms. He believed that the fibrous elements were the essential and initiatory site of the pathological process. Others, with whom we agree, believe on the con- trary that the epithelial hyperplasia is the initiatory, as it certainly is the preponderating feature of papillomata. Inasmuch, however, as strict conformity in nomenclature to this view would compel us to adopt the term benign epithelioma, to which the objections are obvious, it seems best to adhere to the conventional term papilloma, which has small claim to any histological grounds for its selection, since it refers to a gross and minute structure seen in many kinds of tumors. Papilloma is a name given to epithelial projections on the surface of the laryngeal mucosa growing from a base of epithelial proliferation which has resulted also in dendritic prolongations into the subepithelial connective tissue of the basal cells of a hyperplastic epithelium. There are localized forms of epithelial proliferation which have no papillary surface which are some- times reckoned as papillomata, sometimes as pachydermia of the cords. They may have a smooth surface or one presenting irregularities. They may be of the color of the cords, or darker gray in color or red or rose colored. They are often mistaken in the laryngoscope for fibromata or singers' nodules, being more often seen in the anterior portion of the cords at the edge. The characteristic papillary form is one of conglomerate excrescences, of a pearly white color with darker shades in the sulci. They may be 474 BENIGN LARYNGEAL NEOPLASMS broad based, extending over the whole larynx as round or acuminate pro- jections. They may be single or multiple pedunculated growths, with slender base, small and moving in the respiratory current, or crowding one another in a mass filling the whole larynx. Cores of fibrous tissue strands, often including a small capillary, shoot up into the surface papillae and these latter may be simple or complex. The simple, flat acuminate projections give off a few or no branching cores of stroma and epithelium, but present a broad base, usually very white and accompanied by much cornification and desquamation of surface layers, while the dendritic papillae of the basal layers are exaggerated and distorted in the underljang connective tissue. Such cases in elderly men are to be looked on with great suspicion even when the microscope reveals no indication of malignancy in small bits removed from the surface. This category of cases will be more fully discussed in its diagnostic relationship under the heading of Epithelioma. Differentiation is to be made from papillary adenoma on the same grounds as described for the nose, but adenoma of the larynx, occurring chiefly in the ventricles, does not present a clinical picture which is so apt to confuse the diagnosis as in the nose. It will be further spoken of in connection with malignant adenomatous disease of the larriyx. While the type of cell is usually that of the pavement variety, at least on the surface, this is not invariably so, as in exceptional instances, especially when springing from a portion of the mucosa normally covered with columnar cells, those at least below the superficial layers assume more or less the character of the epithelium from which they spring. Inas- much, however, as this surface is usually exposed to attrition of various kinds and intensities, the superficial layers partake somewhat of the metamorphosis due to the general laws to which we have referred in remarks on the histology of the mucosa of the normal larynx. In the sulci between the papillae in such cases the cells are seen to have preserved more of the columnar configuration. Of whatever type the bulk of the growth may be, where there is corni- fication of the superficial layers, a certain number of concentric hyaline masses may occasionally be seen, the so-called whorls, usually so charac- teristic of malignant epithelioma. A practised eye often has no diflSculty in noting differential appearances, but it is well to bear in mind that these often escape confident detection. Sections may sometimes include the branching cores of stroma in such a way as to give rise to the same appearance. In the basal layers there is frequently seen a certain number of leukocytes, chiefly lymphocytes. These may contain some nuclear material of foreign origin. On the contrary atypical epithelial cells con- taining other nuclear detritus than their own are of more doubtful signi- ficance. While the sections often fall in such a way as to separate the basal dendritic prolongations from the other epithelium of the growth, benign papillomata usually (not always) exhibit a sharp line of demarca- tion, often arnounting to a basal membrane, from the underlying stroma. Capillary bloodvessels .of minute caliber are often to be noted running along the borderline between stroma and epithelium. BENIGN EPITHELIAL NEOPLASMS 475 The thickness of the epithelial layers covering the papillee and the thickness of the general epithelial base vary greatly. In benign papil- lomata the nuclei are, as a rule, in the same relative position in all the cells of the same layer. At the base next to the stroma they are nearer the stroma border of the cell; at the surface they are in the centre flattened with the cell or when the cell is swollen they are usually near the centre. Any marked irregularity as to this gives a confused and disordered ap- pearance in the sections and should be looked on with suspicion. Papillomata are said (Semon) to constitute 39 per cent, of all the cases of benign growths; others put them as high as 50 per cent., but for reasons already alluded to these figures can be considered in no way as resting on a secure diagnostic basis. When isolated they are much more common on the vocal cords than elsewhere, and in this state are seen more frequently in the anterior half than posteriorly. Situated elsewhere in a limited area they are to be looked on with suspicion in patients beyond forty. In children papil- loma of the larynx is the most common of all laryngeal growths; con- genital cases have been reported. It is in children that the treatment is especially difiicult. Histologically they present usually the complex form of branching and budding on the surface. They usually spring from the whole extent of the laryngeal mucosa and almost invariably recur persistently until at least the time of puberty. The change in the nutrition of the larynx which takes place at that time seems to tend to bring about a cessation of their persistent recurrence. The use of the laryngoscopic mirror in young children is occasionally practicable, but usually the examination must be made by direct laryngoscopy, when it may be possible to remove some at least of the masses which obstruct the glottis. The rule is for all forms of papillomata, in children or in adults, to recur repeatedly after removal. One of us has seen a case in which papillomata had been removed from time to time over a term of seventeen years. Another is reported by Packard^ extending over thirty years, during which time thyrotomy had been performed twice. Adenoma. — It is questionable how many cases of this tumor have been observed. We have never seen any. All those presenting glandular structure have turned out to be malignant adenocarcinomata. Jurasz refers^ to a case reported by v. Bruns and another by Schmiegelow. Zenker^ has recently reported a case. They almost always spring from the ventricles of the larynx. They are thus only partially accessible to inspection and usually entirely inaccessible to endolaryngeal removal of pieces for microscopical diagnosis. They are to be looked upon with much suspicion, for even when apparently entirely benign, according, to conventional histological rules, or in the clinical history, they often go on to a malignant course subsequently. (For the liistology of adenoma refer to the chapter on Nasal Neoplasms.) 1 Transactions of American Laryngological Association, 1910 2 Heymann's Handbuch der Laryngologie und Rhinologie, Band i, Abt. ii. 3 Frankel's Arch., Band xxii. Heft 1. 476 BENIGN LARYNGEAL NEOPLASMS Symptoms. — ^Adults: Hoarseness or some disturbance of phonation is always present in pachydermia, papilloma, or fibroma of the larynx. The degree varies without apparent reason or reference to the location of the tumor. Greater hoarseness is present in marked pachydermia than in the smaller papillomata or fibromata, the reason for which may be a,ttributed to a greater muscular involvement beneath a more exten- sive superficial epithelial cornification. Respiration is interfered with but slightly, except in the larger fibromatous growths. Inspiration is more difiicult when the tumor is above the cords and expiration when the growth is beneath the cords. Dyspnea and cyanosis are hardly ever present in adults, except when the patient exercises violently or is unduly excited. The growths in adults, being single in the majority of instances, interfere less with respiration than in children, where they are most frequently multiple. The subjective symptoms are cough, tickling sensation in the larynx, as from a foreign body, a constant tendency to clear the throat, and a hesitancy in speech, due possibly to the fear of making a false note. Pain is rarely present. Children. — Hoarseness, if the child can talk, or a hoarse, croupy cry in infancy will call attention to papilloma of the larynx. Respiration is much more difiicult in children owing to their multiple character. Dyspnea followed by cyanosis is frequently manifest upon excitement. As there are many conditions in the child which might occasion similar symptoms, such as diphtheria, false croup, foreign bodies, retropharyngeal abscess, laryngeal stenosis, abscess at the base of the tongue, and laryn- gismus stridulus, one must not rely upon subjective symptoms as proof of the presence of papillomata. A sharp, "pinched" face of a child without fever, suprasternal retraction upon inspiration, slight cyanosis with dyspnea upon excitement, together with a history of hoarseness extending over a period of several weeks or months, favors the diagnosis of papilloma and warrants the examination of the larynx with the Killian or Jackson tubes. Indirect laryngoscopic examination may be attempted first, but ordinarily it results in failure. Treatment. — Adults: Endolaryngeal. — In pachydermia removal of the cause will result in improvement of phonation, if not in restoration of the voice. Stimulation by local applications of argyrol (25 per cent, solution), silver nitrate solution, gra. x to Bj, or tannic acid in glycerin followed by an intralaryngeal injection of pure albolene will hasten the recovery. In papilloma or fibroma the immediate removal by snare, forceps, or cautery is preferred to any attempt by topical application. Skin and vesical warts are successfully removed by fulguration, and it is reasonable to conclude that laryngeal papilloma will respond to this treatment also. It has been used with some success in children. The snare best adapted for the removal of these growths is one having a tip that will form a loop parallel with the lumen of the larynx, as the tumor most frequently projects into the lumen from the cord. Technique, Indirect Method. — The patient should be well cocainized first, and to accomplish this most satisfactorily it is necessary to apply a 4 BENIGN EPITHELIAL NEOPLASMS 477 per cent, solution of cocain to the pharynx, the epiglottis, and the larynx; and then drop one or two drops of a 20 per cent, solution of cocain directly into the larynx with a laryngeal syringe. In the experience of many operators this is far more satisfactory than frequent local applications with the cotton-wound apphcator, and produces fewer symptoms of cocainism. The second step is to place the laryngeal mirror firmly against the oropharynx with the soft palate held upon the top of the Fig. 271 Sajous' laryngeal snare. mirror. The patiient holds his tongue forward with his right hand, which procedure is aided by a piece of gauze to prevent its slipping backwards. The third step is to introduce the forceps into the larynx, avoiding the epiglottis in the descent, and when the growth is approached the blades should be opened sufficiently to grasp it. The patient should then say "a," (not "ah"), which brings the growth nearer the median line if on the border of the cord. If below the cord, a full expiration will force it into view; if along the margin of the cord a deep inspiration Fig. 272 Mackenzie's laryngeal forceps. facilitates removal. Then with pressure sufficient to remove the entire mass, the forceps are closed over the tumor before traction is made. The Mackenzie forceps necessitate a backward and forward movement together with traction to remove the growth, and for this reason fre- quently the operation results in unnecessary trauma. The Krause-Heryng forceps are sharp-edged and cut the growth smoothly, and in the hands of the experienced operator do not endanger the normal structures adjacent. 478 BENIGN LARYNGEAL NEOPLASMS Should the growth be multiple or too large to enable its removal with one effort, repeated attempts should be made until it is removed. If bleeding is sufficiently profuse to obscure the parts, a solution of adrenalin FiQ. 273 a ^^MF KStemmwf^ ' Krause's laryngeal forceps. (1 to 1000) should be applied locally. Unless bleeding occurs it is un- necessary to apply adrenalin, as it shrinks the tumor and renders it more difficult to grasp. Fig. 274 Dundas-Grant laryngeal forceps. When the growth is sessile and projects between the cords or is sub- glottic, the Dundas-Grant laryngeal forceps is of great aid, as the blades have a long vertical axis and will grasp any object upon the border of the cords or below it. In looking down into a deep larynx the perspective BENIGN EPITHELIAL NEOPLASMS 479 is confusing, and an instrument of this kind greatly facilitates the act of removal. The thermocautery is frequently used with advantage, and is of particular value in removing growths situated upon the cord, and not easily grasped by any instrument. Great care is necessary not to cauterize adjacent normal structures, and this may be obviated by placing the end of the cautery on the tumor before turning on the current. Very little reaction results from any of these procedures, but the patient should never be permitted to go far from reach for at least twenty-four hours after the operation, and local treatment should follow at intervals for several months afterward. To the inexperienced the operation is difficult, but he must bear in mind that the image in the mirror is reversed and that he must move his instrument in an opposite direction from that which the image indicates. Practice upon a phantom is a convenient method of acquir- ing dexterity. Local applications of alcohol as advocated by Delavan has proved efficient in certain cases of papilloma; but unless contra-indicated operative measures are surest. Fused chromic acid will remove some papillomata if applied directly to the growth, but the normal tissues of the larynx are endangered by the tendency of the acid to spread. Castor oil, salicylic acid, nitrate of silver, chlorid of zinc, lactic acid and other topical applications have been disappointing in thier results. Thuja occidentalis has been recommended by Shurly, but has not gained favor. Direct Method. — Many operators now prefer the use of the Killian or Jackson tubes, through which these growths may be more easily removed. (See Laryngoscopy.) Should the practice of the operator be more extensive in this than in the indirect method of approach it is well to follow it, but the experienced laryngologist can remove these growths with less fright to the patient and less disturbance to himself by the indirect method. The future laryngologist will apparently have less opportunity for perfecting his sense of touch and dexterity of laryn- geal manipulation than the older ones, as these neoplasms appear to be diminishing in frequency, owing possibly to more careful consideration of the nose and nasopharynx, or to the attention given to the minor affections of the larynx in the early inflammatory stages. Extralaryngeal Operation. — In adults it is rarely necessary to approach these growths from without, but if so, thyrotomy is the only procedure to be considered (see Thyrotomy). Children. — Papillomata in children are more frequently multiple than single, and are often a menace to life. Internally. — ^Arsenic seems to influence favorably the disappearance of these growths; but those cases responding to its use may have reached that physiological change which results in their disappearance anyway. It is the belief of Clark and other observers that they will disappear at the time of puberty, or possibly before, if the physiological change favors it. 480 BENIGN LARYNGEAL NEOPLASMS Potassium iodid is frequently of benejfit particularly if they are due to inherited syphilis. Thuja occidentalis is also recommended. Operative Treatment in Children. — Removal of multiple papillomata from the larynx of a child only results in their return with additional growths upon the mucosa wherever it has been abraded in the immediate neighborhood. This has been demonstrated in a number of instances. However, it is necessary, at times, to remove at once a sufficient number to relieve embarrassment of breathing. When a child is cyanotic, or dyspneic with the characteristic "facies" denoting insufficient respiration, and the diagnosis is positive, nothing can be more satisfactory than low tracheotomy, after which nothing further should be done, .as the lowered vitality of the patient centra-indicates at this time any further operative measures. Tracheotomy enables the larynx to rest, and if the tube is left in for a long period, varying from one to two or even three years, the growths will disappear in the majority of instances. This method of treatment is almost universally advised by those having had exceptional experience in the care of such cases. Hunter Mackenzie advocates tracheotomy as the only measure for the cure of papilloma in children (see Tracheotomy). Thyrotomy. — ^The few successful cases recorded as a result of this operation are insufficient to counterbalance the many failures reported or the permanent injury to the voice which follows. With the other successful measures at hand it is to be condemned. Abbe^ reports a case in which thyrotomy was performed four times, followed in each instance by recurrence, although the bases of the growths were cauterized. Tracheotomy was finally done, and the tube remained in place six years, when the papilloma disappeared. The voice was never recovered, owing to the destruction of tissue, due to the thyrotomies. Walker Downie reports another case in which thyrotomy was per- formed six times in one year in a child two years old. Lindon^ gives the history of another unfavorable case in which thyrotomy was performed seventeen times in two years, resulting finally in laryngeal stenosis and the necessity of a permanent tracheal tube. The following recorded cases of unsuccessful thyrotomies argue strongly against the procedure: Massei,' 1; Garel,* 2; Oertel,^ 2; Railton,* 2; Eliasburg,' 1; White,^ 1; Cowgill,^ 1. Professor B. v. Bruns,i''of Tubingen, collected statistics of 127 children with laryngeal papilloma; 48 were not operated upon, and of these 32 died, 28 by suffocation; 3 were cured spontaneously; 26 were trache- otomized, 7 dying after the operation; 21 were subjected to laryngotomy, 1 Medical Record, April 28, 1900. 2 The Treatment of Laryngeal Growths in Children, G. Hunter Mackenzie, British Medical Journal, September 28, 1901. 2 Internationales Centralblatt f. Laryngologie, Jahrgang x, p. 362. ' Annales des maladies de I'oreiUe et du larynx, Juni, 1891. ' Sammlung klinischer Vortrage, No. 315, p. 2807. 5 British Medical Journal, February 19, 1908. ' Journal of Laryngology, v, p. 245. 8 Ibid., vi, p. 486. » Medical News, October 4, 1890. '° Handbuch der praktischen Chirurgie, 1902. BENIGN EPITHELIAL NEOPLASMS 481 8 of these were permanently cured; 40 were treated by intralaryngeal methods, of whom 13 were permanently cured. Dundas Grant^ reports one case, however, where a tracheotomy tube was worn for twenty-two years without the growths disappearing. While the tracheal tube is a safeguard against suffocation and enables surgeons to employ any of the other methods for removal with impunity, its long-continued use may result in stenosis of the trachea or reduce the elasticity of the rings so that it will collapse when the tube is with- drawn. This unfortunate condition may be obviated by the frequent removal of the tube or the substitution of a rubber tube of much smaller dimensions than the trachea. Indirect. — ^In rare instances a child is perfectly tractable and affords an opportunity to remove the growths indirectly by means of cutting forceps. If this can be accomplished in a satisfactory manner the larynx may be kept free until the proper physiological time arises for them to disappear entirely. Direct. — ^By this means the larynx can be almost completely relieved of the presence of papilloma; but their return is almost as certain (see Laryngoscopy). Postoperative Care. — ^The patient should be kept under a tent for twenty-four hours and the air moistened with the steam from a croup kettle to which is added, at three-hour intervals, one dram of a non- irritating solution such as: 'Sf — 01. pini pumilionis 3ij Menthol gra. x- Milk of magnesia gij Upon the reappearance of these growths the same proceedings must be employed until they finally disappear. Fulguration. — ^This method has been employed in a number of cases, but these are yet too few and observation is of too short duration to warrant a positive statement as to its efficiency (see Fulguration). X-ray. — A. L. Gray,^ of Richmond, cites two instances of papilloma of the larynx in children treated in this manner where good results were finally obtained; but as both children had had tracheotomy performed and had worn the tube for some time a definite conclusion as to the value of the a;-ray cannot be drawn. Complications. — Measles is more to be feared than any other of the diseases of childhood, and death very frequently ensues. The presump- tive evidence is that the mucous membrane being naturally inflamed from the presence of a tracheal tube, the additional inflammation from measles entirely closes the lumen of the trachea; at any rate, death is due to strangulation. Pneumonia is likewise particularly fatal. Loss of voice, .disturbance of phonation, partial stenosis, collapsed trachea, and incomplete closing of the tracheal wound are all apt to ' International Medical Annual, 1904. 2 Annals of Otology, Rhinology, and Laryngology, June, 1910. 31 482 BENIGN LARYNGEAL NEOPLASMS occur. These unfortunate conditions can be partially avoided by fre- quent removal of the tracheal tube, and insertion of a soft-rubber catheter. If the child can breathe at all, a daily removal of the tube for a few minutes gives the tracheal rings relief sufficient to preserve their elasticity. Too extensive and too frequent operative measures within the larynx should be avoided, likewise too extensive fulguration or cauterization. The tracheal wound had best heal by granulations; but should this not occur, aplastic operation becomes necessary, in which all the old scar tissue is removed and freshly denuded tissues brought into apposition. Histories Illustrating Nature and Progress of Papilloma of the Larynx in Children. — Seven cases have been under our immediate care in the past five years. One of these had a single papilloma projecting from the junction of the vocal cords anteriorly. Another had multiple inherited syphilitic papillomata, which disappeared in a few weeks after a single injection of salvarsan, and the other five had multiple papillomata of unknown origin and of typical form. Fig. 275 Case I, F. L., male, aged seven years. Drawing made after beginning operations for removal of the growth. The white area surrounding the base of the neoplasm is the fibrosis resulting probably from the frequent removal. Case I. — F. L., aged seven years when first seen in 1903. There was a single papilloma springing from the anterior commissure of the cords, which was mulberry in shape and sessile. The child was tractable and permitted the removal of the growth by the indirect method under cocain anesthesia. The growth was removed with the Mackenzie forceps at irregular intervals over a period of three years, the longest period between removals being two months. At the end of three years a fibrosis had occurred which projected along the margin of the cords, uniting them with the growth for about one-third their length. At this time it was the expressed opinion of Dr. Wright that the tumor and the fibrosis would disappear when the usual physiological change at adolescence occurred. PLATE VI FIG. 1 FIG. 2 FIG. S Fig. 1. Fibroid Tumor. Figs. 2, 3, 4. Different Forms of Papilloma of Larynx. BENIGN EPITHELIAL NEOPLASMS 483 In December, 1909, the fibrosis had reached its maximum and the child was requested to return monthly for observation. On January 11, 1910, when thirteen or fourteen years old, he reported for examinatiori and not a vestige of the growth nor of the fibrosis was observable, and the voice was strong and resonant. The change had occurred in one month's time. Case II.— A. Le R., Italian girl, aged ten years, was admitted to the climc July 11, 1907. She was brought to the hospital especially for the removal of tonsils and adenoids, although she had been hoarse for five months previously. Owing to her struggles it was absolutely impossible to examine her larynx in the clinic. No family history bearing upon the case was obtainable. There were five other children in the family, all of whom were healthy and without hoarseness. No warts were found upon the body. The patient had had none of the diseases of childhood, but had lost about fifteen pounds in the previous five months. Case II, A. Le R., female, aged ten years. The drawing presents the condition following the first operations for removal of the neoplasm. At the time of examination there was a slight cyanosis, and that anxious "facies" denoting difficult respiration. The voice was a hoarse whisper. She was immediately admitted to the hospital, where adrenalin sprays and steam inhalations temporarily relieved her distress. On July 18 she was anesthetized for the removal of the tonsils and adenoids, at which time a view of the larynx was obtained, and some papilloma removed for examination. The larynx had three rather large growths in it, two upon the cords anteriorly, and one in the subglottic region. Dr. Wright, in reporting upon the specimen, said that the growth was a papilloma springing from a base of granulation tissue, probably tuber- culous. Examination of the lungs, however, revealed no evidence of tuberculosis, nor the sputa any bacilli. The patient was immediately put on cod-liver oil and arsenic, and seemed to respond to the treatment by gaining four pounds in two weeks. On August 1 tracheotomy was performed, as it was deemed the best thing 'for the patient, for three reasons: (1) her breathing was difficult 484 BENIGN LARYNGEAL NEOPLASMS and she became quite cyanotic at times; (2) she was absolutely intract- able for operative measures per "vias naturales;" (3) the presence of a tracheal tube would permit the better use of the Jackson speculum for the frequent removal of the growths if necessary. High tracheotomy was performed under cholorform anesthesia and the immediate results were good; but the next day, and for many subse- quent days, severe hemorrhages would occur from the trachea and from the wound itself. The child would work at the tube until it was out of place, and owing to many attempts of the nurse and house-surgeon to replace it, a false passage was made along the side of the trachea. This condition continued for about ten days, until finally the inflammation subsided and the tube became less irritating. Exuberant granulations sprang up around the tracheal wound, which were removed with scissors, and the bases were cauterized with fused silver nitrate. On October 15, under choloroform anesthesia, a small quantity of papillomata was removed from the larnyx through the Killian tubes. On November 2 more were removed. On February 13 she was again operated upon, and this time the Jackson self-illuminating speculum was used, and also his forceps. A large number of papillomata were removed, and they were also noted in many places where they had not been seen pre- viously. The Jackson speculum was much more satisfactory than the Killian. On March 27 the operation was repeated, and as many growths as had been previously taken out altogether were removed. Following this operation more space was obtained in the larynx, and the child could speak in much clearer tones than before. The tube remained in situ until October, 1908, about fourteen months, when practically all the growths had disappeared, and the child was fat, healthy, and better tendpered. At this time the tube was removed and the patient was permitted to go home to return for weekly observations. She was seen last in July, 1909, at which time her voice was good and she could sing fairly well. The growths had disappeared, with the exception of a small granulation on one cord, which appeared bleached and of low vitality. The tracheal wound had knitted firmly and there was perfect movement of the vocal apparatus. Case III. — J. M., of German parentage, male, aged five years; was admitted to the throat clinic of the Manhattan Eye, Ear and Throat Hospital October 26, 1907. The mother gave a history for the child of snoring and mouth-breathing, and at the time of admission attention was directed only to the presence of adenoids and tonsils. Nothing was said at this time to indicate the presence of laryngeal growths. Upon subse- quent investigation the following facts were obtained from the father: When the child was two years old he had sore throat with fever, and after three day's sickness had a sudden attack of dyspnea and became slightly cyanotic. After several months' hoarseness he was taken to a hospital, where some growths were removed from the throat, which resulted in no apparent relief, although the child remained in the hospital for one week. He was then taken home, where for about six months he remained BENIGN EPITHELIAL NEOPLASMS 485 with no discomfort other than hoarseness. However, about one year subsequently the child began to breathe badly and would choke at night. The father said that frequently the boy would rise in bed, stretch out his hands, and apparently plead for air. He then took him to another Fig. 277 Case III, J. M., male, aged five years. The drawing shows the appearance of the larynx before any radical interference had taken place. Only a few papillomata had been removed when this drawing was made. hospital, where the doctor removed some growths from the larynx, and after two weeks repeated the operation. These two operations overcame the choking condition, and he was brought to the Manhattan Eye, Ear and Throat Hospital for the relief of snoring and sore throat. No family history had any bearing upon the case. There were three other children in the family with normal voices and good health. Case III as it appeared May 1, 1908. Upon admission the child was fairly well nourished and the breathing was not bad except upon excitement. His tonsils and adenoids were re- moved on October 29, after admission to the hospital, and not until he protested rather vigorously against the anesthetic was anything unusual 486 BENIGN LARYNGEAL NEOPLASMS noticed with liis voice. He took the anesthetic badly, but before remov- ing his tonsils and adenoids his larynx was examined and found to be almost completely blocked with papillomata. Some of these growths were removed at this time, to give him better breathing space, and after the operation he was placed under a tent. The breathing and hoarse- ness became worse after the operation, and the symptoms continued to increase until November 16, when tracheotomy was performed. This overcame the difficult respiration. The patient made a good recovery from the tracheotomy, and on January 25 a large quantity of papillomata were removed from the larynx with the Jackson speculum and forceps. Chloroform anesthesia was employed. Temporary relief only was ob- tained, for new growths had sprung up in different areas, completely filling the larynx and even encroaching upon the epiglottis. On Feb- ruary 18, pursuing the same methods as before, at least half a dram of these warts was removed. On March 3, the same operation was done, and more growths than ever before taken out. The larynx filled up again with a greater number and larger growths than ever, one being about the size of a raspberry. Alcohol, zinc chlorid, and silver nitrate were applied locally, and pure castor oil was injected into the larynx once a day in the hope that the same results would be obtained in the larynx as upon the skin. Fulguration was now tried after the manner described under this head- ing (see Fulguration), and from this time the growths rapidly disappeared, and he was sent home to return for occasional observation. In July, 1908, he was readmitted to the hospital and his tracheal tube removed. This occasioned him no inconvenience and his breathing was excellent, as nearly all the growths had disappeared. The tracheal wound did not close satisfactorily so that a plastic operation was performed October 20, 1910, which completely closed it. At this time a small papilloma still remained on the left cord. January 12, 1910, the patient was again seen, and both cords were clean and the wound perfectly closed. The voice was strong and loud, but low- pitched. Case IV. — Italian boy, age four years, had multiple papilloma of the larynx with loss of phonation and had difficulty in breathing at times. A syphilitic history was obtained from the father. A Wassermann test was not made, but salvarsan was administered upon presumptive evidence. Within a month all growths had disappeared, but the cords remained thickened and phonation was imperfect. He returned home, where he remained several months, apparently gaining daily in health and strength. At the end of this time he developed a severe jaundice, upon which therapeutics had no effect, and from which he died about three weeks after reentering the hospital. Case V. — J. S., boy, aged three and a half years, of Hebrew parentage, was admitted to the hospital June 27, 1912. He had been hoarse for several months, and could not speak above a whisper when admitted. He had had frequent attacks of dyspnea. His general health was good. Examination of the larynx by the direct method revealed masses of papil- BENIGN EPITHELIAL NEOPLASMS 487 lomata on both cords, which occupied nearly the entire lumen of the glottis. At this time sufficient growths were removed with the Jackson forceps to render breathing less difficult. July 11 fulguration was first applied, followed by the disappearance of some of the growths. The symptoms, however, quickly returned, and it was again applied July 18, August 1, August 15, September 5, and September 12. After each application the growths diminished in size but would grow again. After an application of undue severity there was labored breathing, cyanosis, and slight temperature. This continued for five days, and on September 17 tracheotomy was performed. After this the patient was more comfortable and in better physical condition. October 24. Took anesthetic badly and no examination made. A number of fulgurations were given at varying intervals, and there seemed to be improvement as regards recurrence; but on the night of January 20, about 4 a.m., he pulled out the tracheotomy tube and died from asphyxia before the house siu-geon could reach the ward. The nurse made an unsuccessful attempt to reinsert the tube. Case VI. — E. T., a girl, aged three years, of Hebrew parentage. Was admitted to the hospital July 11, 1912. There was no previous his- tory of tuberculosis, diphtheria, syphilis, or other chronic disease. There were many papillomata in the larynx. She had only a whispering voice, and her breathing was difficult. On July 12 it was decided to apply fulguration without removing any of the growths. The Jackson speculum was used and the manner of application was as is described under this heading. Improvement of the voice and breathing immediately ensued. A second application was given July 18, with slight improvement. On August 1 and 15 the same procedure was gone through. After each application the larynx appeared to be free from papillomata. On August 18 the child was permitted to go home upon condition that she return at intervals for examination. September 1 she was brought to the hospital with a diffuse bronchitis. A few days later she had a^ choking spell, at which time an intubation tube was inserted. After this the child was very comfortable. On Oc- tober 9 she developed a suspicious membrane on the right tonsil. October 10 diphtheria was diagnosed from culture and patient removed to hospital for infectious diseases, where twenty thousand units of antitoxin were given. On October 11 the patient died of pneumonia. Case VII. — A. V., boy aged thirteen years, of Hebraic parentage, admitted to clinic September 19, 1911. Previous History. — He was hoarse from infancy and the history given by his parents would indicate it to have been a case of congenital papilloma. Seven years previously he had had thyrotomy performed, and there was no recurrence of trouble sufficient to warrant operative measures, until July, 1911, although hoarseness, difficult breathing, and cyanosis had been present at times during this interval. At this time respiration became so difficult that a tracheotomy was performed, and the tube was still in place when he was first examined at the clinic. The examination proved it to be a case of multiple papilloma of the larynx. 488 BENIGN LARYNGEAL NEOPLASMS October 19. Examination was made with Jackson's laryngeal speculum and a few papillomata pinched off. Treatment was instituted in the clinic subsequent to this operation, but the growths reappeared. April 23, 1912. Fulguration was applied with apparently satisfactory results, and for a time it was thought that the one application was going to be sufficient. However, there was a recurrence, and on July 18, September 11, and October 10 it was again applied. After each of these applications the larynx looked better and the growth lost its granular character. T here remains a small, smooth, fibrous-looking mass at the anterior commissure. The patient has gained in weight and general health. BENIGN CONNECTIVE-TISSUE NEOPLASMS. Fibroid : Singers' nodules. Edematous polypi. Cysts. Lymphangeioma. Tophi. Fibromata: Fibromyxoma. Fibroangeioma and angeioma. Lymphoma. Lipoma. Amyloid tumors. Chondroma. Osteoma. Myxochondroosteoma. Laryngeal struma. Fibroid Neoplasms. — Inasmuch as fibrous connective tissue prac- tically forms a part of every tumor whatever its designation; inasmuch as the proportion this bears to other tissue constituents of the tumor varies a great deal; inasmuch as the fibrous tissue in itself has very httle pathogenic importance, it would be much better to exclude from the designation of fibroma those tumors containing lymphoid, glandular, vascular, and epithelial hyperplasias in any considerable amount, and to exclude also those very numerous polypi sometimes spoken of as soft fibromata, and which it has been our custom to speak of as edematous polypi. We classify the fibroid tumors in a group together, because it is impossible to draw histologically or clinically any very sharp line between them. While manifestly chronic inflammation and local irritation do not play an important part in all of them, this factor cannot be satis- factorily excluded from the etiology of any of them. Doubtless, the prod- ucts of chronic iriflammation which are found in practically all of them may be reasonably looked upon as secondary to the proliferation of fibrous tissue in some of them, but it is impracticable to define the limits of the BENIGN CONNECTIVE-TISSUE NEOPLASMS 489 one or the other. It must also be noted here that the gradation between them and those tumors called fibromata in many of the text-books is continuous. Singers' Nodules. — ^These are seen chiefly in those who use their voices for many hours each day in singing. It is said to be due to a wrong method of voice production. As a matter of fact, this is an opinion founded on the assertions of the trainers of the human voice, who each have their own ideas which vary with each teacher. It is a convenient commercial device to criticise the methods of the former instructor in favor of the new teacher. Every larynx is more or less a law unto itself. Some cannot sing without final injury to the larynx by any method. Ac- cording as the more difficult notes are habitually practised, according to the intensity of effort and its prolongation, the numbers of singers' nodules increase. We may with these remarks join in the consensus of opinion that they are due to the overstrain of the voice, since, as is to be inferred from the above, what is overstrain for one singer is not for the other. They are most common in sopranos and tenors. They are usually noted at the edge of the true cords where the anterior third joins the pos- terior two-thirds. They may be chiefly made up of thickened epithelium, but they almost always show beneath the epithelium some increase in the fibrous connective tissue, and there is always more or less infiltration of the lymph spaces with serous exudate. There is always considerable infiltration of the stroma and of the basal epithelium with leukocytes. They may be as large as a full-grown pea, 1 cm. or more in diameter, but they often are smaller than a grain of wheat; they are situated, however, in such a locality that they interfere markedly with vocal-cord vibration. Pieces removed for microscopical examination are usually very small and are often found to be made up almost exclusively of the thick- ened epithelium. Removal of larger pieces, however, discloses a disturb- ance in the stroma beneath in accord with the above description. A certain amount of catarrhal inflammation may exist throughout the whole larynx or may be confined to the one vocal cord. Sometimes they are bilateral, but in this case they are rarely symmetrical. When unilateral there is often an indentation of one cord opposite the protuberance on the other. Symptoms. — Subjective. — Hoarseness. — This varies with the position and size of the nodes and likewise with the fatigue of the patient and voice. If the nodes are on both cords and in apposition less disturbance is experienced than if a single node is present. The fatigue of the voice experienced is incommensurate with the amount of vocal exercise. False notes are frequent and there is an inability to place the voice at the desired "pitch" or to "strike" the tone the note calls for. The middle register is more productive of false notes than either the lower or the high register, for in the low register the cords are sufficiently apart for the nodes not to come in apposition, while in the high register the tone is produced by the vibration of the anterior third of the cord and the nodes act as fulcra upon which the posterior part of the cords are held in apposition. Thus it is seen that in the middle register the whole length of the cord is 490 BENIGN LARYNGEAL NEOPLASMS in vibration and that they approximate sufficiently to make the nodes interfere with tone production. There is also a tendency to clear the throat, the sensation being that of a foreign body. Objective. — Laryngoscopic examination reveals a small whitish-gray nodule either upon the surface of the cord or, as is more frequently the case, upon the border. The most frequent location is at the junction of the middle and anterior third of the cord. There may be one, two, or more of these nodes, and they may be opposite or at irregular intervals. There is a period preceding the formation of the node when a varicosity or a thickening appears at the location where the nodule will subsequently form. Nodes appear more frequently in mezzo-sopranos trying to be- come sopranos and in baritones endeavoring to become tenors. They are directly the result of voice strain and misuse of the vocal apparatus. There is frequently a hyperemia along the margin of the cord, but the growth itself is not always red. Treatment. — Prophylactic. — Proper teaching and direction as to how to place the voice, particularly in assuming high notes, is the easiest and most effective treatment. Humming and exercises on "mo," "ma," "ma," and "mi" will frequently cause the immediate disappearance of the nodes. Rest of the voice will almost invariably cause their disappear- ance, but if the singer or speaker again resumes its improper use they will reappear. Singing when indisposed or when fatigued, from whatever cause, will frequently occasion the formation of nodes. Head tones should be practised and vicious methods of forcing the voice should be abandoned. Flatau^ says, "Small symmetrical nodules may be present in singers, especially sopranos, without functional disturbances; in fact these nod- ules probably serve a useful purpose. If a nodule causes functional dis- turbance it is usually unilateral, and such should be treated surgically." Surgical — Koenig^ favors the galvanocautery. He uses a specially devised cautery point protected with ivory, so as not to endanger the adjacent healthy tissue. Peters^ likewise recommends the galvanocautery and reports three successful cases. Botey and Lermoyez are both advocates of the galvanocautery. While this method is unquestionably of surgical value, particularly in the hands of skilled laryngologists, yet the danger to neighboring structures is greater than when the Mackenzie or Krause forceps (Figs. 272, 273) are used in their excision. In the use of the direct method with these growths our own experience is unfavorable, as they are so small that either the secretions excited by manipulation or the tension from the laryngeal speculum is so great that they become invisible. In one experience we had finally to resort to the laryngoscopic mirror and the indirect method for the removal of a vocal nodule. Caustics should not be employed, for if strong enough to remove the tumor they will spread to the normal tissue and do harm, and if not strong ' Zeitsoh. f. Laryngol., Rhinol., etc., Band iii, Heft 4. 2 New York Medical Journal, February 11, 1911. ' London Journal of Laryngol., Rhinol., and Otol., January, 1911. BENION CONNECTIVE-TISSUE NEOPLASMS 491 enough they will only irritate the larynx and not remove the growths. Attention must be directed also to the upper air tract, for in many in- stances the singer is forcing his voice through an obstructed nasal pas- sage, or the larynx is constantly becoming the receptacle for irritating nasal secretions which collect there during sleep. Extreme care must be exercised, in the removal of these growths, not to endanger the underlying healthy cord, and before operation of any kind is instituted the methods of Curtis^ should be tried. These consist in exercises which are meant to relieve the tension of the muscles employed in reaching certain notes and to bring into use certain other muscles which have previously remained quiescent. We have seen very favorable results follow from this pro- cedure. Edematous Laryngeal Polypi. — Chiari and many others have repeatedly drawn attention to the fact that most of the so-called laryngeal fibromata are really little more than serous infiltrations of the stroma. On this matter in regard to nasal polypi we have dwelt sufficiently, and it only remains to add that the same criticism holds for the laryngeal polypi. Yet for the latter it must be acknowledged that the serous infiltration is not as a rule so marked as in nasal polypi. The strands of fibrous processes are more abundant and the fibrinous threads, while in very much larger numbers than the former, do not make up so exclusively the web of laryngeal polypi as that of the nasal polypus. They spring from or are sessile on the cords, as a rule, but in rare instances they have their origin from other parts of the larynx, as, for instance, from the posterior wall in the interarytenoid space. It is possible sometimes to judge even from the laryngoscopic appearances as to the probable amount of serous infiltration. Degrees of translucency exist, and the color varies from a pale pink to a deep red. It varies at different times in the same case, as does the congestion of the larynx itself. They all have a smooth surface varying in this way from the exuberant papillomata. Cysts. — ^They are seen on the anterior surface of the epiglottis, within the larynx on the true cords, or on the lateral wall, in this order of fre- quency. They may be very small as on the cords, or of considerable size as on the epiglottis. They are of two essentially different categories. Glandular Cysts. — These are very rare in the larynx. They are more common, naturally, in those regions of the larynx in which we noted the glands as abundant. They consist of walls lined with altered glandular epithelium and are due to dilatation of the gland acini and ducts. Some- times the original epithelium is so flattened and altered it is difficult to make out the nature of the growth. In this event there is usually a thickened, low-grade, fibrous lining to the cyst cavity. Connective-tissue Cysts. — ^These may be due: (a) To a localized effusion of serum under the epithelium between it and the stroma, making a smooth, shining, white protuberance which collapses when punctured and may or may not reform. This is frequently the character ' Voice Building and Tone Placing. 492 BENIGN LARYNGEAL NEOPLASMS of the growths on the vocal cords, (b) To the effusion of serum into the stroma. They are traversed by fibrous threads and sometimes fibrous bands. The method of formation of these two varieties of cysts has been more extensively considered in the description of nasal neoplasms. Lymphangeiomata. — Under this heading are occasionally reported neoplasms whose pathogenesis is closely - related to the growths just mentioned. Localized dilatation of the lymph spaces of the ventricular band presenting itself clinically as a soft ill-defined tumor was reported by MenzeU in 1904 as a lymphangioma. An earlier case was reported by Koschier^ in 1895. The large size of the lymph spaces and the thinness of the septa may give them the semblance of a cyst. They contain a milky, viscid fluid. Many benign tumors contain enlarged lymph spaces, so that the condition may be associated with the fibromata and other tumors. Tophi. — In a certain proportion (2 out of 29 — Gerhardt) of cases of systemic gout, small collections of uric acid salts have been seen in the mucosa of the epiglottis and the arytenoid cartilages. Fibroma. — It is unnecessary to dwell at length upon the histology of this growth, since it has been fully discussed in the chapter on nasal neoplasms and in what has preceded in speaking of fibroid laryngeal growths. Dense wavy lines of fibro-elastic tissue containing few bloodvessels and only an insignificant number of the other elements of the laryngeal mucosa and submucosa, without marked serous infiltration, constitute the classical picture we should expect in a nomenclature strictly consonant with the classification of Virchow. Such an histological structure of a tumor of the larynx we have never seen, and since different histologists differ as to the relative amount of fibrous tissue a fibroma ought to contain, statistics are useless as to the frequency of the occurrence of fibroma. For instance, not one of the nine tumors Zenker^ collates from his own microscopical examinations can be accepted as filling the above demands of nomenclature. Under this heading are described both sessile and pedunculated growths, and their appearance is sufficiently well illustrated in Fig. 1 of Plate VI with the legend of fibroid tumors. Fibromyxoma. — Myxoma. — It very rarely happens that all the tissue of. a tumor of the larynx is made up exclusively of the striking and char- acteristic structure of a pure myxoma. In Plate VII will be seen the appearances of one in which there were seen no fields in the sections under the microscope in which at least the preponderating characteristic was not that of a myxoma. It usually occurs associated with fibromata, chondromata, sarcomata, or with tumors of more complex structure. In the chapter on nasal polypi will be found the contrasting picture of edematous growths formerly so often confounded with true myxoma. Myxoma occurs in the larynx but not in the nose. In many of the so- called fibromata there are areas of stellate branching embryonic connec- tive-tissue cells growing in a matrix of homogeneous substance taking ' Archiv f. Laryngologie, Band xv, p. 178. 2 Wiener med. Blatter, 1895. » Loc. oit. PLATE VII Myxon^a of Larynx. Fat globules, miAcin and branching cells are shown. (Dr. Jonathan Wright's specimen.) BENIGN CONNECTIVE-TISSUE NEOPLASMS 493 the basic hematoxylin stain, giving a quite characteristic appearance to eosin-hematoxylin stained sections as seen in the figure alluded to. The processes of these embryonic stellate cells form an interlacing network, and probably they are, some of them at least, coterminous with one another, though it is difficult to be sure of this. There may be a very limited amount of this myxomatous degeneration in fibromatous or other tumors of the larynx, and the growth containing it may be sessile or pedunculated: but where it is abundant the tumor is usuaUy broad- based, more or less translucent and of a dusky hue. If otherwise of a benign nature the growth shows no tendency to recur even after endo- laryngeal removal if thoroughly done. Fibroangeioma. — Angeioma. — ^This differs in no way histologically from its appearance elsewhere. There are all gradations in vascular richness between the condition in which the growth is made up almost exclusively of larger and smaller bloodvessels bound to one another by scanty stroma and that of an angiofibroma where the mass of the tumor is chiefly made up of fibrous tissue more or less richly supplied with bloodvessels. They vary in size between that of a pin's head and that of a voluminous tumor seriously obstructing the glottis. They are usually seen on a vocal cord sharply defined as an intensely red mass against the white of the vocal cord. They may exist for years without symptoms, occasionally streaking the sputum with blood, but not often giving rise to any serious hemorrhage. They are covered by a moderately thin layer of the epithelium of the cord. These small angeiomata, as well as those very vascular fibromata to which the name is sometimes given, are in om- experience not uncommon. The more extensive and diffuse growths are very unusual. Lipoma. — This growth is occasionally reported in the larynx. It is not very common. When the attachment is reported it is almost always noted that the growth springs from the epiglottis or the aryteno-epiglot- tidean folds. A few cases have been reported as growing from the lateral and some from the posterior wall of the larynx above the vocal cords. They are practically always associated with fibrous hyperplasia. In the case of Dr. Hinkel,^ which one of us had the privilege of examining micro- scopically, it repeatedly recurred, and on sectioning these various growths they were found sometimes to present a preponderating amount of fibrous tissue, while the next recurrence would show the fat cells as the chief feature. Further consideration has been given to the nature, minute anatomy, and physical appearance of lipomata occurring in the pharynx and mouth. Professor Max Goldstein^ has given an exhaustive de- scription of the growth and a resume of eleven cases. It is seen in infants and in old people, and shows no marked preponderance as to sex. It presents the same physical characters as described in the remarks on pharyngeal lipomata. , Lymphoma. — By lymphoma we mean structure which is predominantly lyrnphoid in character, consisting of young round cells and stroma 1 Transactions American Laryngological Association, 1898. 2 Laryngoscope, September, 1909. 494 BENIGN LARYNGEAL NEOPLASMS similar to the tonsil. ' In order to avoid confusion it must be distinguished in the larynx, as elsewhere, from those malignant cases of general lympho- ma or lymphosarcoma which are so difficult to classify and include some cases which are called Hodgkin's disease. There is nothing in their structure to distinguish them from the lymphoid structure of the pharynx and nasopharynx. Dr. John N. Mackenzie' reported in 1889 a case of lymphoid tumor of the larynx extending from the left side to the right side of the pyriform sinus and the lateral wall of the pharynx. It con- sisted of a large amount of areolar tissue in which there was lymphoid structure, according to Councilman, indistinguishable from that of the hypertrophies of the pharynx. Wolfenden and Martin^ reported a case and give a drawing of the histological structure similar to one of our own. The latter was in a girl, aged nineteen years, otherwise perfectly healthy. It extended from the under surface of the cords to two and one-half inches below them, occupying in its greatest extent three-quarters of Fig. 279 Papillary lymphoma in the larynx. the anterior part of the circumference of the cricoid cartilage and the neighboring tracheal rings. It resembled in its gross appearance a papilloma, but its structure consisted (Fig. 279) of papillary masses of K-mphoid tissue covered by two or three layers of pavement epithelium. While the stroma of the growth was rather more abundant than that usually seen in the lymphoid hypertrophies of the nasopharynx, and while the germinal centres were a little faint in the stained sections, there is no reason why this should not be considered an hypertrophy of the lymphoid tissue of the larynx. We have, however, called it a lymphoma for reasons it is not necessary here to dwell upon, but it might well be called an hyper- trophy' of the laryngeal tonsil, bearing in mind the reference we have made to small aggregates of lymphoid tissue in the normal mucosa of the larynx. ' Jour. Amer. Med. Assoc, 1889, xiii. ^ Studies in Pathological Anatomy, 2d brochure, 1888. BENIGN CONNECTIVE-TISSUE NEOPLASMS 495 Unless they are part of a general lymphomatosis, as in the cases of Beale' and of Gottstein,^ and perhaps of Clark/ their removal is not followed by recurrence, and they are of as benign a nature as hypertrophied tonsils. Chondroma. — This growth is reported from time to time in literature, but its occurence is very rare.^ It is usually combined with myxomatous degeneration. More or less extensive areas of hyaline cartilage cell are seen with a few stretches of the typical embryonic branching cells of myxoma in a homogeneous matrix. Very frequently such tumors are combined with osteomatous areas and are then sometimes reported as myxochondroosteomata. They have a semimalignant character widely infiltrating the tissues, but not readily forming metastases. The mixed growths often in places warrant the description of them as fibro- sarcomatous. They sometimes present as a protuberance of the thyroid or cricoid externally, hard and incorporated with the cartilages. In- ternally they are usually smooth, hard growths covered by the normal mucosa, but they may be ulcerated. Here as elsewhere the ecchondroses or local cartilaginous hyperplasias shade off into so-called tumors, but when of a size sufficient to interfere with laryngeal function they should be widely excised by external operation because of their probable semi- malignant nature, and because such operations when practicable have a fair prognosis, metastases at a distance from the original growth being unusual. The cricoid cartilage was involved in over half the cases in which the site was mentioned, but the thyroid, the epiglottis, and the arytenoid are occasionally the only ones reported as affected. The malig- nant or mixed growths always involved the cricoid and thyroid cartilages. It is reported twenty-nine times in men and four times in women in the lists of Alexander and Mansfeld. The ages of the patients ranged from twenty to seventy years, but 19 out of 30 cases were between forty and sixty years of age. The tumor may be of any size from one hardly discernible to one involving the whole larynx and very evident externally. The mucosa is usually smooth and pale; the consistency is character- istically hard and resistant; the growth is firmly attached to the under- lying cartilage; cervical glandular involvement is usually not present even in extensive growths with external swelling; the dome-like or spur- like form of the growth is characteristic. Sometimes the bony and carti- laginous shell of a cyst can be made to crackle under the finger externally. The usual symptoms of hoarseness and obstruction to respiration, common to all laryngeal growths, are of course present. Absence of pain will 1 Lancet, London, October 15, 1889. ^ Die Krankheiten des Kehlkopfes, 1888. ' Medical Times and Gasette, December 13, 1893, Transactions of London Pathological Society. ■■ In English reports are to be found by Ryland, A Treatise on Diseases and Injuries of the Larynx, London, 1837, p. 231; Porter, Amer. Jour. Med. Sci., 1879, p. 391; Mackenzie, Diseases of the Throat and Nose, 1880, vol i; Musser, Philadelphia Medical Times, 1882, No. 337; Asch, Transactions American Laryngological Association, 1884; Ingals, ibid., 1888; Bond, British Med. Jour., May 6, 1893. In German, Alexander (Frankel's Archiv, 1900, Band x) made a complete and exhaustive study of the subject. In 1909 Mansfeld (ibid.. Band xxii, p, 508) brought the literature of the subject down to a recent date, fur- nishing a total of thirty-nine cases reported since 1831, which apparently does not cover quite all that have been noted in literature. 496 BENIGN LARYNGEAL NEOPLASMS often be of service in the diagnosis. External swellings of a hard nature are frequently found over the cricoid and thyroid cartilages. The growth may remain for j'ears unchanged in size. Recurrences after incomplete operations are the rule, but the statistics give few indications as to the ultimate result of radical operation. One patient reported as operated on at sixty-two years of age was alive at seventy-five; another, five years after operation. Amyloid Tumors and Amyloid Degenerations of the Laryngeal Mucosa. — These conditions have been reported twenty-six times according to Seckel (1912). ^ It is described as presenting a glossy or mottled, smooth surface, and the growth is seen not only as a degeneration of fibrous and other tumors, but as a diffused thickening and degeneration of the surface of the mucosa, sometimes existing thus as thickened areas isolated from one another, or the areas may be interspersed with projecting or peduncu- lated masses. It has been reported as a slowly advancing disease of the pharynx, uvula, and upper part of the larynx, lasting from six months to ten years. The amyloid material reacting to Gram and other stains extends throughout the submucous tissue in ovoid masses. It involves the walls of the bloodvessels and the glandular epithelium. It has been noted as ovoid flakes in the lumina of the capillaries. It is uncertain whether this material is formed from the cells in situ, especially those of a preexisting tumor, or whether it is deposited in them or in the hitherto unaltered cells from elsewhere. Occurring in connection with tumors would lead one to suppose that it is usually due to the infiltration of the tissue with adventitious material. The presence of plasma cells, of leukocytes, and of giant cells among the amyloid flakes is hardly conclusive of the existence of neoplastic tissue to begin with. There seems to be no marked growth of new connective tissue in the diffuse form of it, and the glands and bloodvessles stand out, with methyl violet and other stains, in a characteristic way in the sections. Fine drops of the material are seen in the epithelial and endothelial cells of the glands and bloodvessels not entirely transformed by it, suggesting that it is an intracellular metabolism of the granules of the cells. Neither the surface epithelium nor the muscular tissue is involved, the material being sharply defined at the border of each. While it seems usually to be formed in connection with an existing or a preexisting tumor it is occasionally reported as being a diffuse infiltration of the subepithelial stroma. Various systemic affections, tuberculosis, syphilis, and chronic lesions of the internal organs, the lungs, kidneys, liver, especially suppurative lesions, are found usually as the chief affections, causing a fatal issue in cases of amyloid affections of the larynx. Willimann,^ who has added another case to Seckel's list and gives thirty-four as the number of cases in which it has been noted in the "upper air passages," reports it as occurring in a patient otherwise apparently healthy, and in whom, after removal of a piece for micro- scopical examination, the condition disappeared. It occurs chiefly in men. '■ Frankel's Arohiv f. Laryngologie, Band xxiv, Heft 1, full literature. No report In the English language so far as we know. 2 Ibid., 1912, Band xxvi, Heft 2. BENIGN CONNECTIVE-TISSUE NEOPLASMS 497 One of the cases in Seekel's list was twenty years old, but 18 of the 26 cases were over fifty years of age. Thyroid Tumors in the Larynx.— Intralaryngeal struma had been reported^ three times before 1898 according to Jurasz. More recently others have been reported by Zenker,^ Hoffmann,' Meerwein.* Some- times it was the hypertrophy of an embryogenetically misplaced organ, sometimes penetration of the thyroid or tracheal cartilages and connection with an external struma. Tracheotomy is usually necessary, but the operative treatment will depend largely on the circumstances in each case. The removal of the growth by thyrotomy has been successfully performed. Schaeffer^ collected reports of 16 cases in the trachea and subglottic space. Prolapse of the Laryngeal Ventricles. — ^This is a term applied to a rare condition first mentioned by Moxon and subsequently more par- ticularly described by Frankel.^ Usually arising in some chronic inflam- mation of the larynx, such as tuberculosis, the lining of the laryngeal ventricles becomes hyperplastic and presents itself above the vocal cords as a smooth surface which may be easily mistaken for a tumor. Indeed, such a condition may be complicated with neoplastic growth. Usually, however, the tissue exhibits evidence of inflammation, being edematous and containing glandular elements normally found in the mucosa of the laryngeal ventricles. It presents many difliculties in diagnosis, being usually associated with other laryngeal lesions. We have seen it in a patient presenting no other local lesion of moment, but who was suffering from some obscure nervous affection and again in an otherwise apparently healthy woman. The degree to which it presents itself to view in the laryngeal mirror varies nearly always from time to time, arid it is rarely so extreme that it may not, during some of the time, entirely disappear from view. It, however, is occasionally so pronounced that the necessity for prompt surgical interference is evident; this motility of the mucosa causing a smooth tumor to appear and disappear, to vary in size and somewhat in shape, and in situation affords the chief clues to its nature when observed clinically. We have seen it several times in tuberculous subjects with a moderate amountof tuberculous laryngeal lesions. We have seen it associated also with inflammation due to overstrain of the voice. Symptoms of Benign Laryngeal Neoplasms. — {Connective-tissue Type). Edematous polypi. Lipoma. Cysts. Lymphoma. Lymphangioma. Chondroma. Tophi. Osteoma. Fibromas. Myxochondroosteoma. Fibromyxoma. Amyloid tumors. Fibroangioma. Laryngeal struma. Angioma. 1 Kehlkopfgeschwillste, Nothnagel's Special Pathology, 1896. 2 Archiv f. Laryngologie, 1909, Band xxii, Heft 1. . ' Centralblatt f. Laryngologie, 1910, p. 160. ' Deutsch. Zeits. f. Chirurgie, 1907, Band xoi. » Dissertation, KonigsBerg, 1907, Ref. Ceutralbl. f. Laryngologie, 1910, p. 574. « Archiv f. Laryngologie und Rhinologie, 1893, Band i, p. 369. 32 498 BEN ION LARYNGEAL NEOPLASMS The symptoms of these tumors bear such striking similarity, one to the other, that they may be considered as a whole. The method of treatment for their removal also differs only in minor particulars. The differential diagnosis is determined largely by the location, the macro- scopical appearance, and by a few subjective peculiarities, which will be enumerated under separate headings. They are most of them rare, and are of interest more as pathological curiosities than as clinical entities. Subjective Symptoms. — ^There is always present some disorder of the vocal apparatus, either slight hoarseness, whispering voice, aphonia, or diplophonia. Difficulty of respiration is experienced only when the tumor is of considerable size or when it projects directly into the air current from some of the laryngeal structures. When of sufficient size, dyspnea and cyanosis may be present. Under extreme muscular exertion or nervous excitement a very small tumor may either impede or embarrass respira- tion, particularly when situated upon the vocal cords. If attached below the cord they will not ifnpair the voice until they have attained such size as to come in contact with the cord during phonation. When located upon the epiglottis or within the cartilaginous part of the thyroid car- tilage, and not in contact with the vocal cords, they may exist for a long while without any subjective symptoms. The first thing noticed by the patient is a tickling sensation in the larynx, like that of a foreign body, followed by cough and hoarseness. Expectoration is increased, owing to the irritation of the mucous glands in that locality, and it is sometimes stained with blood, particularly if the tumor is of an angiomatous nature. The sputum will also frequently show the presence of epithelial cells, due to the surface exfoliation of the growth, though this is more significant of papillomata. Deglutition may be interfered with if the growth is situated on the epiglottis, the aryepiglottic folds, or in the pyriform sinus. Pain is not a constant factor and is rarely experienced. Objective Symptoms. — Edematous Polypi. — They are smooth, reddish white in appearance, and surrounded with an encapsulating membrane, and are most frequently attached in the anterior commissure or to the anterior third of the vocal cords. They very rarely assume magnitude, and their specific determination can only be obtained after removal from microscopical examination. Cysts. — Situation. — In 117 cases of laryngeal cysts collected by Moure arid reported by Greene' the following order of frequency was observed : Epiglottis 50 Vocal cords 45 Ventricles g Arytenoids • 4 Aryepiglottic folds 3 Ventricular bands 2 / Cartilages of Santorini ^ Sites not given 4 117 1 Laryngoscope, October, 1907. BENION CONNECTIVE-TISSUE NEOPLASMS 499 Their greatest size is usually attained when attached to the epiglottis. When so placed they produce nausea in addition to the symptoms common to these tumors. Disturbances of deglutition^ are also experienced when located in the pyriform fossa. They are translucent, with a smooth, rounded surface, and upon probing will show an indentation characteristic of the semi- liquid contents. They sometimes show a vascularity at their attachment or, as in Mackenzie's case, a bright-red surface. They may be either sessile or pedunculated. They have been known to assume quite a large size when attached to the epiglottis, but in the other locations they are uniformly small. Hamilton,^ of Montreal, reports one the size of a small hen's egg. Lymphangioma. — ^These tumors of the neighboring lymphatics of the larynx are rare in character and may come and go with the existence or disappearance of infective conditions of the larynx and upper air tract. They are seen on the lateral walls of the larynx and upon the vocal bands, but rarely appear upon the cords themselves. Tophi. — ^A small, white, chalky deposit may sometimes be found on the true cords and also upon the arytenoid cartilages, which are character- istic. Their presence is usually associated with a gouty diathesis. It is reasonable to suppose that such deposits are to be found in the aryteno- cricoid joint in certain gouty subjects complaining of intense pain on phonation. Fibromata, Fibromyxoma, Fihroangioma. — Symptoms of these tumors have been considered in connection with papillomata and in the frequency of their appearance in the larynx they come next to them. When of small size they give rise to the same subjective symptoms as papilloma or any of the benign neoplasms of the larynx. They sometimes assume rather large size, in which case the symptoms are very much exag- gerated. One such case came under our observation in 1906, which was subsequently reported by Dr. W. F. Chappell.' It was pedunculated and attached to the aryepiglottic fold and occupied almost the entire laryngopharynx. The patient was a woman, aged fifty-one years, and had suffered from difficult breathing since she was thirty-six. Previous to admission to the hospital she had been treated for asthma for several years. At the time of admission she was suffering from dyspnea and cyanosis of such grave character that it was deemed advisable to perform a trache- otomy. After recovery from this operation a subhyoid pharyngotomy was performed and the tumor was removed from its attachment and found to weigh twenty grams. Its circumference measured four and one-half inches. Microscopical examination showed it to consist of fibrous tissue, very moderately supplied with nuclei and round cells. Although the external surface of the tumor gave evidence of considerable vascularity there was little or no bleeding at the time of operation. The patient 1 John N. Mackenzie, Journal Amer. Med. Assoc, December 7, 1889. 2 Laryngoscope, October, 1907. 3 Transactions American Laryngological Association, 1907. 500 BENIGN LARYNGEAL NEOPLASMS made a complete recovery. In reporting this case at the time, Dr. Chappell was able to find in the literature histories of only eleven similar tumors. The location of six of these was given as follows: Epiglottis Aryepiglottic fold Anterior commissure Subglottic space, anteriorly . Anterior commissure and anterior third of right vocal cord Hemilarynx Fig. 280 3-<~^-,S.E Fibroma of larynx. (Chappell.) The most frequent location of the fibroangiomata is the anterior third of the cords and the anterior commissure. They are reddish brown, smooth-surfaced, pedunculated tumors of comparatively rare occurrence when of large size. Glasgow* reports a case in which a lobulated growth the size of a large pea was attached to the anterior part of the vocal cord. One of the lobules was attached by a pedicle and upon inspiration 1 Transactions American Laryngologioal Association, 1888. BENIGN CONNECTIVE-TISSUE NEOPLASMS 501 would fall below the cord out of observation, but upon forced expiration or coughing it would be brought into view. It had a glistening, edema- tous surface. Wolfenden^ reports a case of angioma occupying the posterior two-thirds of the ventricular band. In this article he cites eleven other cases, his making, twelve. The attachments of these cases were as follows: Vocal cords 6 Ventricular bands 3 Epiglottis 1 Right hyoid fossa 1 Pyriform sinus 1 Fia. 281 Angioma of the left vocal cord. (Casselberry.) Hemorrhage had occurred in only one of these cases. However, the sputum is said to be streaked with blood more in this class of cases than in any other. Semon^ reports a case of angioma of the larynx springing from the pyriform sinus. It was of a bluish and bluish-red color, slightly lobulated, with a smooth surface. There was a previous history of spontaneous hemorrhage. Lipoma. — ^An exhaustive investigation of this subject by Professor Goldstein^ shows their attachments to be in the following order: 1 London Journal of Laryngology, 1888, vol. ii, p. 291. 2 British Medical Journal, May 23, 1891, p. 1127. ' Loc. cit. 502 BENIGN LARYNGEAL NEOPLASMS Epiglottis 3 Aryepiglottidean area 3 Middle of tongue and anterior epiglottis 1 Lateral wall of ventricular fossa 1 Pyriform sinus 1 Of this number four were attached by a pedicle, three were sessile, and two were attached by a thin, flat band of tissue. They offer no subjective symptoms until they have attained considerable size and exercise pressure upon the epiglottis and obstruction to breathing and deglutition. They are ordinarily of a pale, yellowish-pink color, and are frequently mistaken for cysts. They are apt to be long, finger-like projections of rather peculiar configuration. Their rarity is shown by the fact that only twelve cases could be collected in the literatm-e up to the time of Goldstein's investigation. Chondroma. — ^The cricoid cartilage appears to be the seat of these tumors more frequently than any other part of the larynx. They are also situated upon the back of the thyroid cartilage and upon the arytenoids. It was formerly considered to be impossible to remove these tumors by the endolaryngeal methods, owing to their thickness and hardness; but since Asch successfully removed one by means of a guillo- tine, springing from the inner surface of the thyroid cartilage and at the base of the superior cornu of the right side, there has been no hesitancy on the part of laryngologists to attempt their removal per vias naturales. Asch^ cites eight cases besides his own, two of which only were diagnosed and treated during the patient's lifetime, and one of these had been treated by endolaryngeal methods. Ingals^ reports a case in the sub- glottic region just below the anterior commissure. It was conical in shape and of a yellowish color. It had a smooth, slightly nodular surface, with its base occupying partly the inner surface of the thyroid and the cricothyroid membrane. Chondromyxoosteoma. — ^This combination of cartilage and mucous tissue may arise from any portion of the larynx. Bond^ reports a case in which the tumor was situated upon the posterior portion of the left cord and also below it. The voice was hoarse and the breathing ster- torous. There was abductor paresis of the right cord. As time pro- gresses these tumors frequently become osteomatous in. character. Lymphoma, amyloid tumors, laryngeal struma, ventricular prolapse have all been sufiiciently described. Treatment. — Topical. — Ingals* reports the successful removal of a subglottic laryngeal enchondroma by the application of chromic acid. The use of this acid has been more successful than any other escharotic in the removal of tumors of the larynx. When fused on the tip of a wire or a laryngeal applicator and very carefully applied directly to the tumor, comparatively little harm follows; but in the case of singers' nodules, ' Transactions of American Laryngologioal Association, 1884. 2 Ibid., 1888. ' British Medical Journal, May 6, 1893. ' Transactions American Laryngological Association, 1888. BENIGN CONNECTIVE-TISSUE NEOPLASMS 503 where the disturbance of the larynx may result in serious affection of the voice, it is unwise to use a substance which may disseminate itself upon the entire vocal cord and which may, in irritable larynges, produce con- siderable disturbance. Glacial acetic acid has been successfully used for the removal of mucous polypi, fibromata, and angiomata. Such sub- stances as silver nitrate, sulphate, and chlorid of zinc have but little effect upon these tumors. Cautery. — Thermocautery, galvanocautery, and the cautery snare have been used with success in removing all these tumors. When hemorrhage is anticipated from the appearance of the growth, it may be wise to employ some form of cautery, as it unmistakably lessens it. The operator should exercise judgment in the selection of cases for the use of the cautery in the larynx of singers or public speakers, as they possess a peculiar susceptibility to irritation. Snares. — ^The cold-wire snare of an ecraseur is frequently used for the removal of these laryngeal growths, particularly when they assume any size. Evulsion. — ^This surgical method, while effective, is complicated by the possibility of subsequent hemorrhage or laryngeal spasm. While a number of cases have been reported Without these unfortunate conditions obtaining, it is still unwise to employ such methods when they can be avoided. External Operation. — Semon and von Bruns report two cases which were removed by subhyoid pharyngotomy, without entering the lumen of the larynx, but Semon's^ case was one of soft fibroma, projecting into the lumen of the larynx, just above the thyroid cartilage. That of von Bruns was a fibromyxolipoma and occupied the left ventricular band and ventricle. A number of cases of subhyoid pharyngotomy and laryngotomy have been reported in which the issue was extremely satisfactory, particularly in the removal of fibroid growths. In the removal of cysts it is sometimes necessary first to puncture the tumor and evacuate its contents, and then to snare or cut away its attachment to the laryngeal structure. Unless this is radically accomplished a recurrence of the cyst may be expected. Thyrotomy has also been employed for the removal of all laryngeal neoplasms, the method of procedure being discussed under that heading. The majority of operators have reported the removal of these growths by the indirect endolaryngeal method, but in view of the proficiency of modern operators with the direct method it is reasonable to conclude that it will be employed more frequently in the future than the indirect. 1 British Medical Journal, January 7, 1905. CHAPTER XIX. MALIGNANT LARYNGEAL NEOPLASMS. We have already stated that malignancy is a term of clinical and prognostic significance and it is therefore admissible as a designation for those growths whose histological structure, as seen in the microscope, is prognostic of a course ending in the death of the patient. It is not, however, a term of objective description, it is a term of prognosis and inherent in the term, as in every other prognpstic indication, there is a modicum of uncertainty. There can be no doubt of the fact that certain cases afflicted with cancer of the larynx which have up to a certain point run a typical clinical course, recover. Growths have been declared to exhibit the typical structure of epithelial cancer in its various forms, especially adenomatous, by the most compe- tent of microscopists, which nevertheless, without operation or without any radical extirpation, have permanently recovered their health and the growth has disappeared. It is calculated about 1 per cent, of all cases of sarcoma recover spontaneously. It will be seen, therefore, that while we look upon the microscope as the most valuable means of establishing the diagnosis, while we emphatically assert that no diagnosis should be made nor operation performed without recourse to the microscope, where it is possible to use it, as the most trustworthy of any of the various methods of arriving at a diagnosis, we do not regard it as the court of last resort superseding all other methods. We will return to this point in the consideration of the diagnosis and histology of the separate forms of laryngeal cancers as specifically illustrated in each. TRANSFORMATION OF BENIGN INTO MALIGNANT GROWTHS. Something must be said here about the so-called transformation of benign tumors into malignant tumors by endolaryngeal operation. The extensive and entirely conclusive investigations of Semon^ in 1889 should have settled the matter for the larynx twenty-five years ago. If transformation of a benign growth into a malignant one ever occurs it must be as an exception whose rarity entirely removes it from the practical consideration of laryngologists. Yet there is the practical consideration that a dwindling minority of medical men still believe in it, and that the public upon whom the laryngologist depends for a living is apt to hold him responsible for a possible appearance of transforma- ' Centralblatt f. Laryngologie, 1889. INTERNAL AND EXTERNAL LARYNGEAL CANCERS 505 tion after endolaryngeal and incomplete operation. This might seriously imperil his future success in practice. Personally we have never seen a case in which the evidence was in any way conclusive of such trans- formation. We have seen only one case in which what we originally regarded as a benign growth, with the concurrence of a recognized authority in pathology, finally after seven or eight years turned out to be malignant. Even in this case there was a difference of opinion by other competent men as to the significance of the structure of the original growth. - The endolaryngeal cautery or forceps may stimulate a quiescent malignancy by setting up an inflammation, but even here we believe the harm is more apparent than real. The inflammation causes swelling and increased laryngeal obstruction, it may be, but as to hastening the cancerous infiltration, that is a different thing, and we doubt very much whether it ever is the result. We have known many laryngeal cancers picked at with the forceps or burned by the cautery for months, even years in one or two cases, without causing more than a passing irritation, and however much such a course of treatment is to be deprecated for other reasons, there is no satisfactory evidence that it does more at the worst than hasten the advent of the necessity of tracheotomy. However, the exigencies of the practical effects on the laryngologist's reputation are to be seriously considered. It is best to get the consent of the patients to a radical extirpation of the growth in any suspected case of laryngeal cancer before it is touched by endolaryngeal procedure. In this eminently practical aspect the old professional adage in regard to cancer, Nolli me tangere, holds good today as it did in the Middle Ages, when the unlucky operator faced the possibility of having his eyes plucked out. Latency of carcinoma in and around the larynx is not uncommon and doubtless accounts in some cases for the long periods of immunity after endo- and extralafyngeal operations. It probably accounts also for some of the apparent transformations of a benign into a malignant growth. The surface presenting a papillomatous appearance and a corresponding histological structure is really growing as the result of a deeper-seated malignancy. After complete or partial removal, a period, varying from a few months to many years of apparent freedom from disease, supervenes before the malignancy declares itself. Such operations in our belief have little or no effect in determining the ultimate result. INTERNAL AND EXTERNAL LARYNGEAL CANCERS. Laryngeal cancers are frequently spoken of as internal and external. The internal cancers are naturally those which are confined to the inside of the larynx, but the external may originate internally and penetrate the cartilages or they may involve not only the upper part of the larynx, the epiglottis, or arytenoepiglottic folds, but the coritiguous pharyngeal tissues. The division is one of some practical importance. An epithelioma of the vocal cords is pretty sure to be seen at an early date, and when a 506 MALIGNANT LARYNGEAL NEOPLASMS growth is confined to the box of the larynx the chances of recovery after total or partial laryngeal extirpation are greatly increased. This is ascribed to the fact that the communication of the intra- with the extra- laryngeal lymphatics is limited to the avenues described in the section on the minute anatomy of the mucosa. While we doubt the entire validity of this statement and while we are inclined to attribute the better prognosis largely to the early recognition of cancer of the cords, there can be no doubt that intralaryngeal cancer presents a less hopeless outlook than that of the upper part of the larynx involving the tissues contiguous to the pharynx. In the latter situation considerable subepithelial pro- liferation is liable to have taken place before ulceration of the surface occurs, and pain instead of hoarseness induces the patient to seek relief. Whether in the larynx or out of it the growth is pretty sure to have advanced farther beneath the surface along the lymph spaces than the vegetation or smooth swelling or superficial ulceration on the surface would lead the observer to suppose. It is of course quite certain that the cervical gland involvement is more often present in the extralaryngeal cancers when they are first seen, but it does not follow that this is entirely due to the peculiarity of the lymphatic supply of the larynx. The greater frequency also of internal cancer would seem to be partly due to its earlier recognition. They are seen before they have had time to become external. The proportion as given by Sendziak is 188 of internal cancers to 86 of external cancers; other statistics show the same order of frequency. There is another phenomenon in the statistics which is much less sus- ceptible of explanation. External laryngeal cancer is relatively more frequent in women. One of the statistical accounts of extralaryngeal cancer shows it in women fifteen times while in men it occurred twenty- one times. Internal cancer occurs ten times as frequently in men as in women. Etiology and Occurrence. — It can truthfully be said of cancer of the larynx as of cancer elsewhere, that nothing is known of the chief factors in the etiology. Heredity plays a part; there is a preponderance of about 8 per cent, of the general incidence of cancer. We have seen a case in a young man, aged twenty years, who was born by a woman far advanced in cancer of the breast, and there are a number of analogous but isolated instances to be found in literature.^ There is some preponderance of phthisical history in the incidence of cancer. Age, as is well known, is a predisposing cause, three-fourths of the cases occurring from forty to sixty years, but it has been seen in infancy. Sex is a special factor of the predisposition, it being at least six times more frequent in males. Curiously this seems to vary greatly in individual experiences. We have seen it less frequently in women even than Jurasz, who gives the proportion of 20 to 1 . A very large number of other factors are mentioned by writers. We have simply mentioned those which have been in accord with our experience. The essential factors of cancer etiology in spite of the greatest efforts put forth > Jurasz, Heymann's Handbuch der Laryngologie und Rhinologie, 1898, Band i. INTERNAL AND EXTERNAL LARYNGEAL CANCERS 507 to discover them in the last few years have eluded detection, and this is as true for the larynx as for other regions of the body. Out of a total of 372 cases of cancer seen at autopsy it was seen three times in the larynx as a secondary growth — none primary. It is markedly less frequent than cancer of the esophagus, less even than cancer of the thyroid gland and of the tongue (Sendziak) . Its frequency relative to the total number of cancers is variously estimated at 0.11 per cent, to 0.65 per Cent. The relative frequency of carcinoma and sarcoma of the larynx and the ages at which they occur may be conveniently seen in the compact table of Jurasz :^ Age. Carcinoma. Sarcoma. Totals. to 10 years \ k q q 10 to 20 years / ° "^ ° 20 to 30 years 22 6 28 30 to 40 years 41 11 52 40 to 50 years 121 13 134 50 to 60 years 188 17 205 60 to 70 years 80 3 83 70 to 80 years 17 2 19 80 to 90 years 5 1 6 479 56 535 Epithelioma. — Pathology. — In remarks upon the forms of cancerous growths seen in a special and limited field of the body it would be beside the mark to give a complete description of all the histological observations which go to make up a differential picture of each variety. We can only dwell at length on those points of significance which have a special bearing upon our limited theme. The form of cancroid or flat-celled epithelioma of the larynx is the most common when the growth has its origin, as most of the intralaryngeal cancers do, from the true vocal cords, and consequently it preponderates in frequency, for to the total flat-celled epitheliomata of the cords are also to be added a not inconsider- able number which spring from other situations in the larynx. Its histology differs in no way from that of the flat-celled epitheliomata seen elsewhere on the mucosae. The same may be said of the columnar- celled epitheliomata. These springing from elsewhere within the larynx than from the true cords are often combined with forms of growth usually associated with the adenocarcinomata. The tubules and acini, into which shapes proliferations of the epithelium fall, are imperfect and bear, at most, only indistinct resemblances to the ducts and acini of racemose glands, yet in this form of epithelioma and to some extent even in certain cases of the flat-cell variety, a tendency to this arrange- ment may be noted. Of whatever variety it may be the epithelium is seen to be undergoing a proliferation in such a way that its component cells and internal cell structures seem to be obeying no common law of arrangement among themselves, many of them being atypical and the cells invading the subjacent stroma as vagrant prolongations or as isolated masses in the lymph spaces, with a tendency to the formation of 1 Heymann's Handbuch der Laryngologie und Rhinologie, 1898, Band i. 508 MALIGNANT LARYNGEAL NEOPLASMS metastases in the neighboring lymph glands and in distant regions of the body. In the larynx flat-celled epithelioma is the rule. Columnar-celled epithelioma is the exception, but scirrhous cancer and encephaloid are also reported, especially among the earlier statistics. How these would be classified in recent histological series it is impossible to say. The tendency is to call more and more of the malignant epithelial growths epitheliomata, and fewer of them encephaloid or scirrhous. We have never seen a case we were disposed to put histologically in the latter categories. The most common form is the pavement of flat-celled variety. In the in- cipiency it may exist as a shallow ulcer with but little projection from the flat surface of the mucosa, or it may be a small excrescence. In either case the subjacent stroma is encroached upon by a tendency of the epithelium to invade the lymph spaces and to obliterate the line of demarcation between stroma and epithelium. The cells of the growth are seen to be atypical in their external form and internal structure and in their relationship to the underlying stroma. Intracellular Changes. — ^The nuclei do not bear any constant relation- ship as to position in the cell body. They may be at the periphery or at the centre of a swollen cytoplasm. Their size may be relatively smaller or relatively larger than normal, but the important point is that the ratio of nuclear size to cell size is inconstant. The cell may be mono- nuclear or multinuclear, but in the latter case il is sometimes impossible to say whether this is the result of a fairly normal nuclear division or a fragmentation of the nucleus unassociated with any attempt at cell division. When there is any approach to spindle formation or equa- torial division it is often seen to be irregular and unsymmetrical. There may be such a large amount of chromatin fragments in the cell and so distributed that the foreign origin of some of them seems obvious. This becomes certain when one observes a certain amount of cytoplasm around some of the chromatin of such a shape and definition as to indi- cate that the phagocytosis of a leukocyte has taken place. In addition to the nuclear material a considerable amount of hyaline material of irregular shape and of varying amount is seen in the cell. This when fused with that of the neighboring cells gives the nest-like appearance characteristic of the so-called cancer "whorls," being arranged in a concentric manner. That in benign papilloma or pachydermia any of these intracellular features may be seen, that many of them may be present at the same time, even including whorls of hyaline masses, is true, but that they should all be present and in many localities renders a diagnosis of epithelioma all but unavoidable. Extracellular Relations. — ^The dendritic papillae at the basal line are not only hypertrophied and distorted as occurs in benign epithelial growths, but isolated masses of epithelial cells are seen growing in the distended lymph spaces either as clumps of cells or arranged in single or double rows, simulating gland ducts. The resemblance these islands of epithelium bear to imperfect gland acini and ducts varies, but it is seen often where the type of epithelioma is that of the surface cancroid. This is an interest- ing example of the tendency to variation when the equilibrium of cell life INTERNAL AND EXTERNAL LARYNGEAL CANCERS 509 is disturbed. Out of disturbances in the normal cell evolution set up by the environment we may imagine the first embryonic invagination of undifferentiated cells resulting in normal gland evolution takes place. This embryogenetic tendency we recognize when the mutating cells of a cancer form the imperfect tubes and ampullae which on section remind us of' gland ducts and acini, imperfect miniature stomachs and gall- bladders. In the periphery of these islands there may be seen no limiting membrane or, especially in the false tubules and acini, the walls of the lymph spaces may seem to supply it. The intracellular changes and the changes in topography are both prominent in those tumors chiefly made up of modifications and altera- tions of the surface layers. Almost invariably in this variety the basal cell layers, even when the topography is not excessively distorted, exhibit frequent intracellular and' intercellular infiltration of polynuclear leuko- cytes and mononuclear lymphocytes and of their disintegrated cyto- and karyoplasms. Fig. 282 Basal-celled epithelioma showing among the basal cells flat surface epithelial cells with whorl formation. (After Krompecher.) Basalrcelled Epithelioma. — ^There are certain clinical reasons, chiefly of prognostic and operative import, why some stress should be laid upon this variety of epithelioma, given special attention by Krompecher. It is true that its features are none of them distinctive, that even where the type of neoplasm is predominantly that of the normal basal cells there is always (in our experience) some atypical metamorphosis of the surface cells as described above; but even where this is considerable we are convinced that in the basal-celled epithelioma there can usually 510 MALIGNANT LARYNGEAL NEOPLASMS be recognized less of a tendency to malignancy, to isolated invasions of the lymph spaces, to distant metastases, and a tendency to a slower growth of the tumor and a consequent longer duration of the disease. In marked examples of this histological variety, rare, it is true, yet occasionally seen, we believe tendency to recurrence after operation is distinctly less. Experience, however, in the careful histological differ- entiation of this form of growth is as yet too limited to form a final judgment in the matter. As is to be inferred from these remarks, made chiefly with the purpose to elicit future efforts at histological differentiation, the prevailing type of epithelial cell is that which approaches more closely to that of the connect- ive tissue and less closely either to that of the pavement cell or of the columnar ciliated cell. The vertical diameter of the cell is greater than the transverse, the intracellular structure is less disturbed, the relation of cell and of nucleus is more constant in size than in other forms of epithelioma, and throughout a whole field of the microscope little change may be noted from normal except in the enormous proliferation. It is less easy, often impossible without prolonged study, to declare that this prolifera- tion is epithelial or endothelial. Where sections do not include the atypical cancroid surface layers it is therefore difficult to tell whether we are dealing with an epithehoma or an endothelial sarcoma. This is especially so in those tumors in which there is an absence of the atypical tubules and acini forming islands in the stroma.^ Often these are present. Often also, amid the preponderating mass of indifferent cells, there are sharply differentiated islands of atypical pavement cells showing at their centres hyaline whorls characteristic of cancroid. Such growths are not infrequently spoken of as mixed tumors or cancrosarcomata. We are inclined to think that the future progress of the disease may to some degree be judged by the predominance of the one or the other form of cell type. The degree to which this basal-celled proliferation, with slight alterations from the normal type, predominates over the can- croid whorls and fiat-cell displacements into the stroma or into the mass of basal cells themselves, seems to gauge in malignancy the departure of this form of epithelioma from the virulence of the other. The unknown and the apparently unknowable factor is the index of individual resist- ance to the invasion of the healthy parts by either form. It must not be forgotten that these remarks apply only to very pronounced forms of this predominance of basal-cell proliferation. The stroma fibers of an epithelioma of the larynx are scanty except in the deeper layers between the papillse and the islands of detached epithelium. It is claimed by some (Retterer) that the epithelial cells furnish fibrils to the fibrous framework, but this at least in pavement-celled laryngeal epithelioma we have not been able to discern, though in growths in other regions ' For further description of these points of differentiation between epithelium and stroma in mahgnant growths see Krompecher, Beitrage zur pathologisoheu Anatomie und zur allgemeine Pathologie (Ziegler), Band xliv, pp. 51 and 88; Retterer, Journal de Tanatomie et de la physiologie, November and December, 1908, xliv. No. 6. Also as to the nose and throat see Cordes, Frankel's Archiv f. Laiyngologie und Rhinologie, 1902, Band xii, and Wright, Laryngoscope, July, 1909. INTERNAL AND EXTERNAL LARYNGEAL CANCERS 511 this seems possible. In the neoplasms of Krompecher especially this seems highly probable. DifEerential Microscopical Diagnosis. — ^From what has preceded we may review the points that enter into the practical aspect of this question. There is hardly another region of the body where the microscopist so often meets with such demands upon his diagnostic acumen. It is useless to enter upon it from the standpoint of general histology. He usually has a tiny bit chipped off the surface of a laryngeal growth by the cutting forceps. Frequently it is not from the growth itself; hardly ever is it more than a small bit of the superficial portion. The assertion of the operator that it came from the growth must be carefully supported by inspection of the larynx after bleeding has ceased. There is a dis- position in some practitioners to believe that they will obtain more reliable information from the pathologists if they fail to give him clinical information or the opinion of other observers with the microscope. The microscopist has a right to expect a full and frank exposition of the clinical and pathological indications in all the knowledge the practitioner , has of the case. This is obvious, nowhere so pressing as in the problems presented by small pieces removed from the larynx for microscopical diagnosis. A small stretch of tissue may have one meaning in an elderly person, another meaning in a young one, one significance in a syphilitic patient, another in a tuberculous patient. It may mean one thing if a neighboring bit of tissue has presented to the examination of a former observer detached islands of epithelium and another thing if no such phenomenon has been observed. It would seem superfluous to dwell with such emphasis on this question of simple fair dealing, inasmuch as nothing but crass ignorance in scientific matters can account for any other view, but as a matter of fact the experience of every pathologist will bear us out in the assertion that evidences of this tricky habit of mind are only too frequent. This is of course a matter of very much less importance in postmortem or postoperative specimens where the examiner has the whole tumor before him, but it is of prime importance where there are only small bits of tissue to be examined. The operator should go as deeply as possible into a suspected growth with his forceps, as it has repeatedly happened in our experience that one or two fragments removed at first have revealed no evidences of malignancy, while pieces subsequently removed have absolutely established it. The marks of the endolaryngeal forceps have been seen subsequently in a postoperative specimen to have been limited to benign tissue over a nidus of tissue of a plainly malignant significance. When one sees epithelial whorls in a minute fragment taken from a sessile growth not in the posterior commissure, in an elderly person, "there can be no question but that this characteristic alone is of grave import. In the larynx as elsewhere this is never conclusive because benign papillomata and the flat excrescences of pachydermia not infre- quently present them. It is true that they are apt to present a little different appearances in malignant cases. In benign growths the cyto- plasm as well as the karyoplasm of the cells forming them is usually 512 MALIGNANT LARYNGEAL NEOPLASMS well defined and the presence of chromatin free from the nucleus is not a prominent feature. The hyaloid matter is not so prominently brought out by the acid stains and is confined more to the centre of the whorl. This may be occupied by the lumen of a small capillary or a mere proto- plasmic thread of connective tissue. In other words the source of its nourishment and the reason of its degenerated condition are more or less apparent. The structure exhibits some symmetry. The morbid spot is obeying some law of structure still, even in its degeneration. This regularity may be disturbed by artefacts in the rapid hardening methods and especially in the freezing process common in recent technique. This has been the cause of a mistaken diagnosis in more than one case, and the mistake has at least once in our experience led to regrettable operative procedure. A reference to pathological histology will supply the reader with further information on the intracellular and topographic features of malignant epitheliomata. In regard to the latter it seems well to repeat that the mere obliteration of the limiting membrane between the hyperplastic epithelium and the stroma is not of great significance, but in detached islands of squamous cells, especially when showing whorls and existing frankly at a lower level than the basal line of the epithelium, we often find fairly con- clusive evidences of malignancy, but one must be on one's guard that one is not looking at a section passing through some crooked fold or prolonged digitation from the continuous epithelium, especially when the cells are not frankly of a squamous character and the transition from this latter type to the connective tissue is not an abrupt one. The largely increased number of karyokinetic figures and of nuclear fragments is of considerable import in favor of malignancy, and the same may be said of the invasion of leukocytes, especially into the epithelial cytoplasm, but these are far from possessing a conclusive significance. Adenocarcinoma. — Owing to the lack of trustworthy critical analysis of the histological forms of cancer of the larynx it is impossible to say what percentage the cancers springing from or presenting tj-pes resembling the glandular elements bear to the whole number of cases — certainly very small. We have seen two -or three cases only out of a very large total (150 ?). Those we have seen have been of the ventricular bands, usually attaining considerable dimensions before they emerge from their under or ventricular surface. Covered by the smooth mucosa at first, their papillary surface often does not come into view until the disease is wide- spread. The greatest difficulty is often met also in their microscopical differentiation from benign adenomata, but this is not so often the case as in the nose, where they are much more frequent. In the chapter devoted to nasal neoplasms will be found an account of their histology. In the larynx the greatest interest attaches to their clinical differentiation, as it often happens that fragments for microscopical examination cannot be obtained at a period where diagnosis is so important. Malignant Connective-tissue Tumors. — Endothelioma of the larynx rightfully belongs among the sarcomata, but the question of endothelioma and of epithelioma is in much uncertainty because of the demonstration INTERNAL AND EXTERNAL LARYNGEAL CANCERS 513 of Krompecher that many of the so-called endotheliomata are in reality basal-celled epitheliomata. Endothelioma of the larynx is mentioned here for conventional reasons and for convenience of reference. Further remarks on the subject will be found elsewhere. Sarcoma. — Occurrence. — In the larynx the malignant connective-tissue growths considered under the head of sarcoma are markedly less frequent than the epitheliomata in the larynx, and this is still further emphasized if we rule out the sarcomata of the larynx in the subglottic space involving the mucosa over the cricoid cartilage. Out of 535 cases of malignant disease of the larynx referred to by Sendziak 56 only were sarcomata. It occurs most frequently in the same two decades, forty to sixty, in which epithelioma is most frequent, but the relative frequency for sarcoma during this period is not quite so great. Thus while epithelioma occurring between forty and sixty represents nearly three-fourths (f ff ) of all the cases of laryngeal epithelioma reported, sarcoma of the larynx occurring between forty and sixty represents nearly three-fifths (f |-) of all the cases of sarcoma of the larynx reported. Attention is drawn to these statistical facts because it is sometimes stated that sarcoma is more frequent in early adult life than in late, or that it is more frequent in early adult life than carcinoma. It is neither the one nor the other so far as malignant disease of the larynx is concerned. We have referred to the confusion which has arisen in regard to the question of endothelial sarcomata, so called, which seem to be in reality often deriva- tives of the basal cells of the epithelium. All forms of sarcoma are seen, the spindle cell being the nlore common form. The shape of these spindle cells conform to the name in some cases; in others the prevailing type approaches more that of the embryonal connective tissue. In these there is especially apt to be areas of typical myxomatous degeneration, warranting the appellation of myxosarcoma. In this category also belong those malignant cases of chondroosteoma, referred to under benign tumors. In such cases as has been pointed out for the nose, an appellation designat- ing fully the character of the growth is sometimes given as myxochondro- osteosarcoma. They probably do not so often present malignant clinical features in the larynx because of their earlier recognition. Their histology and general pathological features are the same as in the nose. The giant-celled sarcomata are also relatively less frequent in the larynx. All forms of sarcoma both in the larynx and in the trachea are less common than in the nose. Sarcoma is 'par excellence the malignant growth of the nose, epithelioma that of the larynx. Metastatic Growths. — ^The larynx is very rarely the site of metastases in malignant disease, hardly half a dozen cases being on record^ of carcinomata and sarcomata together. MenzeP has reported a case of malignant hypernephroma of the larynx which he supposes to have been a metastasis, though the primary growth was not satisfactorily located. It was a smooth pedunculated tumor springing from the right ventricular band anteriorly. ' Moritz Schmidt's Krankheiten der oberen Luftwege, revised by Edward Mayer, 1909. 2 Frankel's Archiv, 1912, Band xxvi, Heft 1. 33 514 MALIGNANT LARYNGEAL NEOPLASMS Coexistence of Cancer with other Disease of the Larynx. — Laryngeal cancer is reported as having coexisted with laryngeal syphilis and with laryngeal tuberculosis, but their coincidence in the larynx is so rare, while systemic tuberculosis and systemic syphilis by themselves are so common, that neither of the latter affections can be considered to play any part, when presenting lesions in the larynx, as a predisposing cause of the incidence of laryngeal cancer. Owing to the multiform appearance which they all present, mistakes in the diagnosis of each are common. The proof of their coincidence as lesions of the larynx can only be accepted on perfectly irrefragible evidence. Symptomatic or therapeutic evidence can hardly be above criticism. Microscopical demonstration of the tubercle bacillus or of the Treponema pallidum, or the typical structure of tubercle in the case of tuberculosis, seems the only evidence of the association of either with the typical structure of epithelioma in the larynx which could be accepted. The coexistence of systemic syphilis or systemic tuberculosis with laryngeal carcinoma has little bearing on the question of local symbiosis. The rare condition of prolapse of the laryngeal ventricles may be associated with cancer of the ventricles of the larynx as it more frequently is with tuberculosis and syphilis of the larynx. It is extremely infrequent that prolapse of the ventricle ever occurs without association with one of these conditions, but that it does so without the appreciable compli- cation of these affections we have at least once had the opportunity to observe. In tumors of the ventricles or in tumors hidden by the false cords and covered by a smooth mucosa this is one of the possible errors in diagnosis one must have in mind. Hyperplasia of the thyroid gland, especially malignant disease, some- times causes internal swelling and laryngeal obstruction. Carcinoma of the thyroid may infiltrate the thyroid cartilage, absorb it and present itself as a tumor of the laryngeal ventricle, without very marked external swelling, though so far as our observations go palpation will always reveal an abnormal state of the thyroid. Symptoms of Malignant Diseases of the Larynx. — For convenience in the further study of laryngeal cancer from a clinical as well as from an operative standpoint, the cases are divided into those which begin as intrinsic disease localized within the cartilaginous box of the larynx and those which, beginning at the upper aperture, are from the first extrinsic or soon become so. Ultimately all intrinsic laryngeal cancers, if allowed to run their course, by involving or absorbing the cartilage become extrinsic if the patients live long enough. Subjective. — Hoarseness. — Either hoarseness or some disturbance of phonation is invariably present. Continued hoarseness over a period of one or two months, particularly in a man over forty- years of age, warrants the careful examination of the larynx for the existence of a malignant neoplasm. This symptom is regarded with too little serious- ness by the general practitioner, and numbers of cases have gone without examination beyond the period of safe operative procedure through lack of attention to the importance of this symptom and the failure to refer INTERNAL AND EXTERNAL LARYNGEAL CANCERS 515 the case to a competent laryngologist for more extended examina- tion. Pain. — Although persistent hoarseness and interference with phonation are early and very important signs of possible laryngeal cancer, this is not true of pain. It usually appears after the time most propitious for successful treatment. This is almost invariably the case when the disease has begun upon the vocal cords below the entrance of the larynx. The pain is not always referred to the region of the larynx. The patient may complain of it in the ear or as "shooting" to the ear, the tongue, or to the side of the neck in general, but this is only after the disease has made some progress, and the same may be said, only with less truth, of the sensations of constriction and discomfort which do not amount to pain. The degree to which patients suffer from pain in the larynx is not so great when the upper part is unaffected by the first onset of disease. If this, however, is the case, the sufferings are often apparently atrocious. On the other hand we have heard a medical man, who met his sufferings with the stoicism of a well-calculated " fore-knowledge, declare that the pain of a cancer well within the larynx was in itself by no means unbearable. Dyspnea does not, as a rule, supervene until the disease is widespread and, in these days, not until the nature of the disease has long since been apparent. It may, however, occur in disease of the ventricles, and in some of the exceptional forms of adenocarcinoma and sarcoma, that the disease has progressed to a point where tracheotomy is necessary before the diagnosis is made. Cough. — ^This is present in both early and late stages, but when early has no special characteristic. The mucus that is coughed up is of a frothy character. In the late stages where destruction has taken place the expectoration may be streaked with blood and may be of a muco- purulent character. The cough is more persistent when the infiltration or destruction has overcome the protective influence that the sensory nerves give to the larynx, and food, saliva, or exudates may fall into the trachea, which brings on an irritating cough. Hemorrhage is sometimes abundant and alarming. Objective. — Cachexia and loss of weight are seen in the last stages of the disease, but many perish from complications peculiar to the site of the lesion or from perilous operations designed to eradicate it before this stage is attained. Location. — ^The lesion is said to have its origin more frequently in and on the ventricular bands than elsewhere in the larynx. When the vocal cords are the point of origin it is seen more frequently in the middle third. Any part of the larynx, including the subglottic space, may give rise to the disease. At times the whole interior of the larynx seems to be involved with the disease. We have seen one case where it took the form of an ulceration covered by mucopurulent discharge without much tumefaction in which the whole laryngeal surface was involved when first seen, but the symptoms had persisted for some time, and the patient, a doctor, with incredible folly, had disregarded them. Three 516 MALIGNANT LARYNGEAL NEOPLASMS cases of similar disregard of symptoms in medical men have been seen by us at an apparently late stage of the disease. The cause of the delay was probably in each a deep-seated conviction of the nature of the disease and a reluctance to have the suspicion confirmed. Usually at the first intimation given by persistent hoarseness the patient seeks relief. Con- sequently, interference with the vocal cords giving rise to this symptom at a very early date, it is in this situation that we see the incipiency of cancer at its earliest period except it be that of the growths of the fundus of the eye. Even cancers of the face are likely to have existed longer when they first come under observation than cancers of the vocal cord. Movevients of the Vocal Cords. — ^Whatever the form which the cancer may take, at an early stage we are very apt indeed to detect an interference with the movement of the affected cord — adduction or abduction is not complete — the cord moves a little slower toward the middle line than its fellow or there may be complete immobility. The thought occurs to the experienced observer the amount of lesion visible is out of proportion to the degree of limitation of movement of the cord. Without, however, some lesion of the structures of the cord or neighboring parts which betrays itself in the laryngoscope, the probability of cancer is remote, though not to be entirely excluded. The explanation of this phenomenon is doubtless the tendency of even incipient cancer to propa- gate along the lymph channels of the subepithelial tissues and thus to involve the muscle fibers which regulate the movements and the adjust- ments of the fibrous bands or, in other words, of the vocal cords. It is not likely at this stage that the cricoarytenoid joint is involved, at least in those cases in which the lesion is visible first near the centre of the cords or elsewhere than at the posterior commissure. Appearances of Incipient Laryngeal Cancers. — They are multiform, and as this is the all-important stage, so far as the interests of the patient are concerned, the consideration of them must be taken up seriatim, remembering that the later stages of all epitheliomata of the larynx have more or less the same local appearances. On the weal cords a sessile papillary growth scarcely larger than a pin's head or one even with something of a pedicle may be the first impression of the appearances. Careful observation may, however, show a slight elevation around its base of attachment marked by a slight congestion. A shallow ulceration of no larger size may be seen with a clean base and only very slightly retracted and thickened edges. A smooth tume- faction of a part of or of the whole cord with intense congestion may be the condition first seen. Slight tumefaction of the superior surface of the cord may be present and a papillary growth of minute dimensions may be seen appearing from underneath the edges of the cords. There is a peculiar form of growth of the cords characterized by a pearly white surface with hairy or acuminate papillary projections, often without much swelling, as illustrated in Fig. A, Plate IX, which is claimed by some observers to present appearances characteristic of cancer. There is hardly any one appearance in itself characteristic of cancer of the PLATE VIIl Lupus of Epiglottis. Epithelioma of Larynx. (Chappell.) PLATE IX Three Stages of Laryngeal Cancer Lasting More than Fourteen Years. A. Aeuminate papillary surface. (Gleitsmann.) B. Seen again after thirteen years. C. Larynx after total extirpation. INTERNAL AND EXTERNAL LARYNGEAL CANCERS 517 larynx, unfortunately, but this is one of them which indicates a con- dition of growth very likely to turn out to be of a malignant character. iNe have seen practically the same appearance in tuberculosis and in syphilis. So confident have some observers been of the pathognomonic value to be attached to this appearance that we know of a radical opera- tion, performed on a young girl suffering from laryngeal tuberculosis, for the extirpation of cancer in spite of a clinical diagnosis having been made of the condition by other laryngologists. On the other hand, as illustrating the diflBculties of differential diagnosis. Sir Felix Semon^ mentions a case in which the microscopical diagnosis of epithelioma of the vocal cord was disregarded because of the age and sex. It occurred in a girl of eighteen who died from the disease, it having been finally recognized at too late a date. On the ventricular bands we have never seen what we could regard as the initial stages of cancer of the larynx. All malignant growths in this situation, when they come under observation, are, as a rule, marked by considerable infiltration and swelling of the surface. This may be marked by a vegetative growth over a limited portion of the surface or an ulcera- tion, but the swelling, as a rule, involves not only the lateral surfaces of the larynx, but the ventricular bands and the aryteno-epiglottic folds. Sometimes this surface is a smooth swelling and beneath it one sees, just above the cords, a papillary growth emerging from the under or ventricular surface. With this location as with the former, but not so frequently, there is apt to be limitation of the movements of the vocal cords. At the posterior commissure malignant growths confined in the begin- ning of their invasion of the larynx to this situation are apt to have extended Jrom the pharyngolaryngeal wall, the growth being primary at the pharyngo-esophageal junction. Extrinsic Laryngeal Cancer. — On the epiglottis and thyro-epiglottic folds and in the pyriform sinuses pain is the first symptom. When existing on the laryngeal surface of the epiglottis this is not always the case. Here it may present itself in the papillary form described for the vocal cords. Usually when first seen in these situations there is considerable infiltra- tion of the subepithelial tissue and the top of the larynx is recognized as distorted. Ulceration may or may not be a prominent feature m any of these situations. The conditions which arise as the later stages of any ot these forms ot incipient malignant growths of the larynx everywhere exhibit some degree, usually a very great degree, of infiltration. The surface pro- liferation may fill the larynx with cauliflower growth whose primary base of origin may have been limited at first but is now widespread. Ulceration may also be widespread and deep and attended by necrosis of cartilage, however small the initial involvement of the surface may have been. ' The smooth, rounded surface, though it may have remained intact for several weeks or months, eventually breaks down into ulceration 1 New York Medical Record, November 5, 1905. 518 MALIGNANT LARYNGEAL NEOPLASMS and is covered by granulation tissue. Sooner or later in all forms the lumen of the larynx is narrowed and tracheotomy becomes necessary to avoid impending suffocation. However localized the iilfiltration may- have appeared at first in the laryngoscopic image, the observer may be sure if the disease is cancer, that it has spread far beyond the limits apparent from inspection alone. Eventually the intrinsic cancer becomes an external one from the growth penetrating the thyroid or cricoid cartilage or, extending upward and appearing in the pyriform sinuses, it involves the pharyngeal structures. Before this stage has been reached the anterior and lateral laryngeal lymph glands along the anterior border of the sternocleidomastoid muscle or more frequently near the upper lateral border the thyroid cartilage may be felt to be enlarged. These, as a rule, to which there is only an occasional exception in intrinsic cancer, cannot be felt to be involved until the disease has penetrated the" boundaries indicated. So far as the symptoms, course, and prognosis of oropharyngeal cancer are concerned they may be included in the consideration of extrinsic laryngeal cancer occurring at the upper limit of the larynx. We have referred to those cancers existing at the lower limits of the pharynx and the top of the esophagus. It occasionally happens that these cases first complain of some laryngeal symptom before they notice interference with deglutition. Usually, however, some annoy- ance with the latter is experienced when the patient is examined laryngoscopically. The prominence of the posterior wall then be- comes apparent and some interference with the mobility of one or both cricoarytenoid joints may be observed. Such cases are not very common. At the front and the sides of the larynx, malignant growths starting in one or other of the lobes of the thyroid gland may involve the laryngeal cartilages. A hard swelling is felt in the gland and pressure over the laryngeal cartilages, with which it seems, in these cases, more firmly bound than usual, elicits pain. The growth may penetrate between the interstices of the cartilage or absorb them and appear as an intra- laryngeal or intratracheal growth, giving rise to dangerous dyspnea. Indeed this may occur from the external pressure alone. At the upper border of the larynx, growths of the pyriform sinuses or extensions of growths from the tonsil may involve the larynx. These, unlike the intra- laryngeal growth, rapidly infiltrate the areolar planes and the lymph spaces and glands. Ulceration begins early and the symptoms are dis- tressing. The diagnosis is usually not made at an early date because of the rapid extension of the gro-vii;h in the subepithelial tissues. On oral examination, a broad-based tumor with angry, cauliflower granulations protrudes as one depresses the tongue. This gives the patient great pain. Often he cannot open his jaws widely or refuses to do so on account of the pain it causes. At the angle of the jaw and in the anterior triangles of the cervical region, and sometimes behind the posterior border of the sternocleidomastoid muscle enlarged lymph glands may be felt. Late Symptoms of Laryngeal Cancer. — Fetor of a peculiar character taints the breath. It has a quality one sometimes notes in patients who INTERNAL AND EXTERNAL LARYNGEAL CANCERS 519 have used a gargle composed of iron salts. Pain is incessant but of varying intensity. Deglutition is difficult or impossible. Secretions flow into the larynx and tend to suffocate the patient, who rids himself of the tenacious material only with great difficulty. Hemorrhage of threatening character is a frequent incident. It is often difficult even by a low tracheotomy to keep the breath-way to the lungs open. Gastrostomy or esophagostomy may be desirable in order to nourish the patient. Pneumonia usually terminates the scene. Prognosis. — Under this heading a number of considerations may be discussed in addition to the statement that the natural course of laryngeal cancer is toward a fatal termination. So regularly is this the course of events for a growth presenting the histological pictures and the clinical aspects which we have attempted to set forth that in a way the termina- tion in death has become a part of the definition of cancer. If it were conventional to so classify disease there would be no criticism to make. It is against the interests of the proper study of disease to classify it into those cases which are malignant ending in death and those cases which are benign ending in recovery. We recognize the folly of so classi- fying disease as soon as we attempt to apply it to almost any other cate- gory than cancer and an extremely limited number of other affections. Yet when the pathologist makes a diagnosis of epithelioma or of sarcoma of the larynx from the structural appearances as revealed by the micro- scope he is held to have made a mistake if the case spontaneously recovers or gets well after an operation manifestly incompletely eradicating the disease. More frequently the same error is supposed to have been committed by the clinician when the same result ensues. But while structural phenomena alone, and still more while clinical phenomena alone are not entirely safe guides in prognosis, when the two coincide in the diagnosis, the ultimate prognosis of laryngeal cancer, as of cancer elsewhere, is so regularly a fatal one that the exceedingly rare instances in which a fatal issue does not occur may be dismissed from practical consideration in forming the prognosis of any given case. Nothing further then need be said as to the prognosis of cases in which operative interference is impracticable or refused by the patient. Both in the intrinsic and in the extrinsic cases of laryngeal cancer the prognosis will depend upon the period in the progress of the disease at which the patient places his fate unreservedly in the hands of a competent adviser. It will depend on many other considerations, it is true, and the outlook is a gloomy one at best; but time lost in vacillation of decision, in resort- ing to radimn, x-rays, serums, or to whatever may be the fad by the time this statement is put in print will only serve to diminish the few chances the patient has of securing freedom from the disease by means of the surgeon's knife. Prognosis in extrinsic laryngeal cancer is distinctly as bad as it is possible for cancer to be anywhere in the body at any stage. It is true that in early cases prompt surgical eradication wards off a local recurrence for a considerable time in a considerable number of instances. In the meanwhile the patient may die with less suffering from a metastasis in a 520 MALIGNANT LARYNGEAL NEOPLASMS locality where the progress of the disease will entail less physical suffering. This is a triumph too lightly esteemed, because of the eclat of the appar- ently complete victory secured in those cases which die of some disease not cancer. In either event operation is distinctly indicated in a con- siderable number of cases of extrinsic cancer because thereby the prog- nosis is improved, both as to length of life and as to the amelioration of subsequent suffering. Further than this the question of operation in extrinsic laryngeal disease cannot be profitably discussed under the heading of prognosis. A very different outlook is presented by cases of intrinsic cancer, especially of those situated on the vocal cords. Here the disease, as a rule, is seen early; here it progresses slowly; here operative procedure, thanks to the advance in surgical technique, is simpler, safer, and more sure. The experienced laryngologist is not apt to be led away by the apparently small intralaryngeal area involved in the disease, but in expressing an opinion as to prognosis those of less experi- ence are sometimes led astray from its insignificant size. A thyrotomy and an examination of the tissue under the microscope almost always shows that cancerous infiltration has gone a long way beyond the limits of surface indication, and the operation to be rational must be more extensive than otherwise would seem justifiable. This thoroughly appreciated by patient and surgeon the prognosis of operation for laryngeal cancer by thyrotomy or hemilaryngectomy is good compared to that of cancer in general. Every laryngologist of extensive experience knows now of cases which have lived without recurrence long beyond the three years' limit which was once arbitrarily set up to decide whether a case of laryngeal cancer was cured or not. The Question of Operation. — Until recently under the leadership of Semon and Butlin it was pretty generally accepted in this country and Great Britain that every case of intrinsic laryngeal cancer should be operated on in which by thyrotomy or by hemilaryngectomy a reasonable hope could be entertained of entirely eradicating the local disease and removing any enlarged glands which could be detected. Of late years, under the impetus given to laryngeal surgery by Gliick and the con- tinental surgeons, the category of operable cases has been pretty generally extended to certain ones which could be freed from the disease only by total laryngectomy, an operation practised successfully by Cohen and by only a few other surgeons in this country many years ago. When the disease has progressed so far as to make this mutilation necessary, when in addition portions of the tongue, the hyoid bone, the pharynx, and of the esophagus have to be cut away, one may well pause to consider if life prolonged a few years in this state is desirable. Some patients have answered the question by suicide after recovering from the immediate effects of the operation. The position which the adviser assumes to the patient under the alternative of choosing to allow the laryngeal disease to run its course or to submit to the complete loss of his larynx is a delicate one. He must be guided in his advice largely by the temperament of the patient and leave it as much as possible for him and his friends to decide. The question of the immediate danger to life encountered INTERNAL AND EXTERNAL LARYNGEAL CANCERS 521 by the patient is not a matter to be seriously considered, since a mortality from operation on the larynx must needs be much higher than any surgical procedure actually is to counterbalance the results of allowing laryngeal canjcer to run its course without interference. The only question is, Can the cancer be completely removed and would the patient be in a condition afterward in which life would be endurable? Duration of Laryngeal Cancer Without Operation. — Scarcely any laryngeal cancer ever has gone to its fatal issue without some sort of treatment applied with the hope of avoiding it or of delaying it. In civilized countries we may say then we know nothing of laryngeal cancer left to itself. While anything but the radical extirpation of the growth, or operation necessary to keep the patient's breath-way and food-way open, we believe to be hopeless in prolonging life, it is very doubtful indeed if any sort of other treatment, futile though it may be, actually shortens the patient's existence. On the other hand there can be no doubt that many a case of laryngeal cancer has lived a shorter and more miserable life because of operation. To judge from experience with cases of cancer of the larynx which have received only futile or at best palliative treatment the average existence from the beginning of symptoms to the end of life does not greatly exceed two years, while it is rarely much short of a year except from accidental sudden suffocation. Life in a few cases has been prolonged a number of years without radical surgical interference which could be reasonably supposed to have any effect on the prolongation of life except only tracheotomy and gastrostomy. To our personal knowledge, several times five or six years and once more than twelve years have elapsed before death or the performance of attempts at the radical extirpation of the growth has taken place. Statistics have never been studied in a way scientifically to demonstrate if in any given case operation really has lengthened life. Probably no such study is possible, for every case is to be judged on its merits, irrespective of the lust for operation and the fear of assuming responsibility for any course to be pursued. Elsewhere we have considered the value of the microscope in aid of the clinical indications of cancer of the upper air passages and the methods of securing a specimen by means of which the maximum extent of that aid may be attained. Needless to say we do not regard any diagnosis unconfirmed by the use of the microscope a satisfactory one, and while it occasionally happens that operation must be undertaken without it, such operation should be so devised if possible that it may be halted long enough, before irreparable damage is done, to take advantage of the information to be derived from the examination of a frozen section. In epithelial growths this, while at times misleading even in a disastrous way, is often of the greatest value. Where it is possible to secure a specimen of sufficient size before the larynx or the trachea is opened, this is emphatically the method to be recommended. Further consideration of differential diagnosis in which the question of cancer enters will be found in a separate section. 522 MALIGNANT LARYNGEAL NEOPLASMS Treatment Other than Surgical. — In the cure of cancer of the larynx, treatment other than surgical has been of no avail even at the hands of the most skilled laryngologist. Galvanocautery, a;-rays, radium, fulguration, caustics, and escharoties have all been tried in ^^ain. Trypsin, arsenic, and other medication have all been tried, both by injection and by mouth, but in the course of time they have proved unavailing against this disease. In the hands of quacks, optimists, and certain kinds of cancer specialists all of the aforementioned remedies have been claimed to cure cancer, but when tried by men of ability and experience, unbiased by extraneous circumstances, they have proved absolutely devoid of merit. Many of the symptoms of cancer, however, have been ameliorated, and the progress of the disease somewhat retarded by the use of the x-ray, radium, starvation, cautery, and fulguration. As the progress of the disease depends so much upon the pathological character of the tumor it is reasonable to suppose that those cases apparently most benefited by treatment have been of a very low order of malignancy or on the border- line thereof. Palliative and Symptomatic. — The three most distressing symptoms of inoperable cancer are pain, odor, and dyspnea. Pain. — Anodynes, either local, by mouth or by injection, are necessary for the relief of pain. If there is ulceration or a break in the epithelial covering, topical application will suffice, but if the continuity is intact the medicament must be given by mouth or hypodermically. Previous to any topical application the surface must be properly cleansed with an antiseptic solution, such as Dobell's or any of the numerous solutions employed for cleansing the nose and throat. After cleansing a 5 to 10 per cent, solution of cocain may be applied at infrequent intervals, or orthoform by insufflation. Kyle recommends cocainized iodol, which contains 1 per cent, of cocain, also the insufflation of morphin powder. Ingals suggests the following mixture : IJ — Mqjrphin gr. iv Ac. carbol., Tannin aa gr. xxx Glyc, Aquse aa gss Odor. — Cleanse frequently with an alkaline solution, follow it immedi- ately with equal parts of water and hydrogen peroxid, and then apply a 2 per cent, solution of potassium permanganate. The inhalation of steam laden with any of the balsams, as benzoin or oil of pine, will lessen the odor. Dyspnea. — After thorough cleansing the local application of: li— Adrenalin (1-1000) 5j Menthol gr. v Aq. rosae gj will frequently afford temporary relief. This solution may be placed in the hands of the patient, who is instructed to spray the throat INTERNAL AND EXTERNAL LARYNGEAL CANCERS 523 frequently. Tracheotomy is ultimately necessary, as the lumen of the larynx narrows and the adrenalin ceases to shrink sufficiently. It is surprising how small a space is absolutely necessary to supply sufficient air to the lungs to maintain life. By means of Dawbarn's operation a temporary retardation of the growth may be obtained, but it is necessary to ligate the superior and inferior thyroid arteries of both sides, and even then the circulation will, in a few weeks, be established sufficiently to nourish the tumor. Coley's serum made from the toxins of erysipelas and prodigiosus has been successfully employed in some cases of inoperable carcinoma and sarcoma, but in the majority of instances it has proved unavailing. It has the disadvantage of rendering the patient exceedingly uncomfortable after its administration. Scheppegrell reports a cure of a malignant growth of the larynx by means of the a;-ray, but this growth was not examined histologically, consequently the conclusions are not without possible error. ^ Trypsin has been advocated by many, and Rice^ reports a case of "supposed" cancer cured by this agency, but trypsin has proved unavailing in the hands of many other experimenters. Tracheotomy. — There is an apparent retardation in the progress of the tumor after tracheotomy, due probably to the fact that the larynx is put at rest and less nourishment reaches the growth. A fatal result is postponed for about a year, and instead of the patient expiring in from eighteen months to two years frequently he lives for three years. Extirpation by Operative Treatment. — Endolaryngeal. — ^This method was employed by B. Frankel for the removal of epithelioma of the larynx in 9 cases, out of which 5 were successful (Knight). Upholding this argument were Jurasz, Bresgen, and Krieg, all claiming it to be the least dangerous interference with regard to life and voice in suitable cases of small cancers situated in accessible positions. Endeavors on the part of other operators have not proved so successful, and have demonstrated that the good results of Frankel were due to his manual dexterity, the early diagnosis, and the characteristics of the tumors upon which he operated. As opposed to these views von Bruns, von Schrotter, Chiari, Moure, and Semon have also adduced facts demonstrating beyond question that the method should not be universally employed. In very old patients who would not stand long operative procedures or general anesthesia, having an intrinsic growth within easy operative reach, there would be some justification in a skilled operator undertaking its removal by the endolaryngeal method. But in all other conditions the universal experience of many skilled laryngologists warrants a strenu- ous objection to such procedure. Ballenger reports one case operated upon in this manner in which recurrence took place ten months later, at which time a second operation was performed, followed by the death of the patient two months afterward. 1 New York Medical Journal, December 6, 1904 2 New York Medical Record, November 24, 1906. 524 MALIGNANT LARYNGEAL NEOPLASMS Frankel and Ballenger have both reported cases of pedunculated carcinoma of the larynx, which are extremely rare in occurrence. • In Ballenger's case, with a snare he removed the tumor, which was swallowed by the patient, but it was later recovered by emesis. The patient died eighteen months afterward; postmortem findings showed carcinomata in the liver, spleen, and stomach (Ballenger). The snare is inadequate for the removal of any form of cancer of the larynx other than the kind just mentioned. The large-sized Krause or Heryng forceps are the best for the indirect methods, while Jackson's or von Schrotter's are best for the direct removal. Cautery.- — ^The galvanocautery loop and points have been largely employed in the removal of malignant growths, but only moderate sat- isfaction has resulted therefrom. J. Price Brown has favored the use of the galvanocautery in the treatment of sarcoma, particularly in the nose and tonsils, but unqualified reports of cures of laryngeal cancer by this method seem rare. Pharyngotomy. — Suprahyoid and Subhyoid. — These two methods are practical for the removal of carcinomata of the epiglottis, but offer little advantage for removal of cancer of the larynx. If external operative procedures are going to be performed, it is far better to do a thyrot- omy. Thyrotomy. — Exploratory thyrotomy is justifiable if there exists the suspicion of malignancy based upon some of the most important symptoms, as age, hoarseness, immobility, etc. Before the operation is begun, consent should be obtained from the patient to perform a laryngectomy if conditions are found which would warrant it. If the tumor is limited to the interior of the larynx, if not too extensive, if not too near the posterior wall, if not yet infiltrating the laryngeal cartilages, with no glandular involvement, and if there exist no constitu- tional conditions such as Bright's or diabetes, which would contra-indicate operative procedures, there is nothing which offers as favorable prognosis as thyrotomy. But for the persistent efforts of Butlin and Semon, thy- rotomy might have remained as unpopular as it was rendered by the condemnation of Paul Bruns, which was based upon facts deduced from operations upon improperly selected cases. Extrinsic cancer does not often present the conditions which would justify thyrotomy. Hemi- and Partial Laryngectomy. — If the cartilage of one side is found to be involved in addition to the soft parts it is necessary to remove as much of the cartilage as will insure inclusion of the outer limits of the growth. This may require either a partial or total removal of the thyroid cartilage of that side. Total Laryngectomy. — ^It has been clearly demonstrated that total laryn- gectomy is surgically a justifiable procedure, and that the operation is warrantable under certain conditions. It has also been shown that a reasonably favorable prognosis may be given, provided certain conditions obtain, and provided the surgeon selected is thoroughly acquainted with the technique. A recovery from total laryngectomy is no more reported as a siu-gical miracle. Statistics relative to this operation are INTERNAL AND EXTERNAL LARYNGEAL CANCERS 525 misleading except those coming from competent operators having had sufficient experience to know how to select proper subjects for operation. Here, more than in the minor surgical procedures, the patient's tem- perament, will-power, resistance, physical condition, and surroundings play a most important part in determining the advisability of the operation. Arguments in Favor of Operation. — " Possibly a cure, based upon the extension of the involvement and the condition of the patient. Freedom, for a longer period than if left alone, from pain, cough, pyrexia, toxemia, and emaciation. If recurrence takes place at the site of the original lesion the conditions may all recur, but in less exaggerated form, and the intermediate period of rest justifies the attempt" (Jackson). Should metastasis occur death is robbed of many of the discomforts that would otherwise accompany it if from the laryngeal involvement. Arguments Agaiy^t Total Laryngectomy. — Delavan has claimed that the total number of years gained by laryngectomy in a number of patients was less than if all had been permitted to die by the natural progress of the disease; hence the possibility of death from surgical shock, pneumonia, lack of vitality, and lowered resistance must be seriously considered. Secondly, a man without a larynx is a deplorable object and is robbed of innumerable opportunities for enjoyment on his part, and he also con- tributes largely to the sorrow and suffering of those intimately asso- ciated with him. His efforts at talking are more or less futile and the mechanisms employed to aid articulation are far from perfect. The buccal whisper becomes intelligible to those constantly hearing it, but to others it is nothing more than inarticulate sound. While a few cases are on record where the patient has pursued his vocation apparently unhindered, the large majority are forced to abandon any calling neces- sitating articulate speech. The possibility of recurrence and the pos- sibility of cancer in other locations must be emphasized if the operator would deal justly with the patient. Immediate Dangers. — ^They are shock, anesthesia, iodoform poisoning, pneumonia, sepsis, syncope, intestinal hemorrhage, embolism, infarct,, hemiplegia, coma, and death. In thyroid extirpation we have myxedema. In vagus resection we may have respiratory failure, etc. (Jackson). Indications for Total Laryngectomy. — Extrinsic laryngeal cancer, either by origin or extension, if operable at all; intrinsic when of such extensive involvement that the surrounding healthy tissue cannot be reached without total removal call for its consideration. Where there is not too extensive glandular involvement, and in a patient who is deter- mined to get well and is of an optimistic disposition, the operation may be justified. A pessimistic view on the part of the patient has always resulted in failure in the experience of most operators. The growth must not have extended so far as to necessitate removal of neighboring parts, although Gliick removes nearly everything anterior to the spinal column. Complications such as Bright's, diabetes, tuberculosis, etc., would, of course, render the operation unjustifiable. Old age would argue against it unless the patient were particularly robust. Alcoholism, arteriosclerosis, and cardiac diseases render the prognosis grave. 526 MALIGNANT LARYNGEAL NEOPLASMS Prothesis. — A number of ingenious appliances have been constructed and invented to meet tiie requirements of articulation after laryngectomy and in the minds of the originators all have aided in rendering speech articulate. The facts in the case, however, demonstrate that the buccal whisper becomes equally intelligible to those frequently hearing the speaker as the sounds produced with the artificial apparatus. Fig. 283 Glilck's phonation apparatus in position, a, cap with valve; 6, voice, (von Bergmann, von Bruns, and von Mikulicz.) Gliick's Phonation Apparatus. — Gliick- has constructed an apparatus ' which has some merit, but the conspicuousness of the mechanism renders its use more embarrassing than the absence of vocal tone; hence few of the unfortunates are willing to make use of it. To the tracheal cannula a metal cap is attached, which has a valve permitting air to be inspired, but closes on expiration. To the upper portion of the cap a rubber tube is attached in which there is a small reed, and from this tube a second smaller rubber tube passes through the nose into the nasopharynx. When the patient expires the reed vibrates and the vibrating sound is carried to the pharyngeal cavity, from which the muscles of this region and the tongue transform it into articulate speech. NEOPLASMS OF THE TRACHEA. Occurrence. — Krieg^ collected a list of 201 cases of primary tracheal tumors, among them 42 cases of papilloma; v. Bruns states that only ' Beitrage zur klin. Chirurgie, 1908. NEOPLASMS OF THE TRACHEA 527 one-third of the 33 cases in his list of 147 were confined to the trachea. Doderlein^ has recently reported a case of carcinoma occurring in the trachea as a metastasis, the primary growth having occurred in the uterus. A very few cases of metastases in the trachea had been previously reported, but Doderlein claims his own as the only case observed in which the primary growth was in a distant organ. The tumors observed in the trachea are fibroma, papilloma, osteoma, chondroma, lipoma, adenoma, and thyroid neoplasms among the benign growths and epithe- lioma and sarcoma. The remarks as to the classification and the histology of these growths in the larynx may be held to apply to those of the trachea, but the order of relative frequency is a little different. As a whole they occur much less frequently than laryngeal tumors. In the collection of 86 tracheal growths made from literature by Vogler^ enchon- droma and osteoma together make up almost 13 per cent, of the total number. Sarcoma occurs one-third as frequently as carcinoma, the two together constituting over 37 per cent, of the total number. It will be seen that sarcoma is relatively more frequent in the trachea than in the larynx. Some confusion exists in the statistics of the larynx and trachea inasmuch as a subglottic tumor frequently extends from the under surface of the cords to the tracheal rings, as, for instance, in our case of lymphoma which we have placed among the laryngeal tumors, while Vogler's case of lymphoma is placed among the tracheal tumors, though both involved the cricoid and tracheal regions. (The marked examples of lymphoma then are subglottic.) All neoplasms of the trachea are more frequently seen in the upper portions of the trachea than in the deeper parts. Cancer of the esophagus occasionally extends to the trachea, while primary malignant disease occasionally, though rarely, is seen as low as the bifurcation. Theisen^ collected 135 cases of tumors of the trachea, of which 89 were benign and 46 malignant. They will be taken up in the order of their frequency as follows : Papillomata. — They are the commonest form, and are ordinarily found in connection with laryngeal papilloma, and, as in the larynx, are most frequently found in children. They are often single and appear in the upper part of the trachea attached to the anterior wall. Several, however, have been found close to the bifurcation of the trachea as reported by Siegert and Stork. There are 25 recorded cases up to the investigation of the subject by Theisen, in 1906. Fibromata.— Theisen gives the bibliography of 24 cases of this variety, from which it is deduced that the location is most frequently in the upper part of the trachea, although Rokitansky found one at the bifurcation. They appear to be equally attached to the anterior and posterior wall and the majority are pedunculated, although out of the 24 reported 9 were found to be sessile. Middle life seems to be the period in which 1 Archiv f. Laryngologie und Rhinologie, 1912, Band xxvi, Heft 2. ^ Ueber das Vorkommen, die Symptomatologie, Diagnose und Therapie der primareri tracheal Tumoren, Inaugural Dissertation, Zurich, 1896. 3 Annals of Otol., Rhinol., and Laryngol., 1906, xv. 528 MALIGNANT LARYNGEAL NEOPLASMS- they occur most frequently; only 3 were found in children whose ages were from five to fourteen years. Ecchondromata and Chondroosteomata. — ^There were 17 of these cases out of the 89 benign growths, and only one purely cartilaginous tumor, reported by Berg. The rest were multiple, both bony and cartilaginous in type. All have occurred in adults between the ages of twenty-five and sixty. Strumas. — These were attached to the lateral and posterior walls of the trachea in each instance, and were located ordinarily in the upper part of the trachea and lower part of the larynx. Only one case of attach- ment to the anterior tracheal wall was reported by von Bruns. They occurred in early life, usually from the fifteenth to the thirty-third year, and were of greater frequency in females than in males, the relative proportion being seven to three. Adenomata. — These are nothing more than round, hypertrophied mucous glands, slightly movable and attached on the posterior wall where the mucoUs follicles are most numerous. There were seven of these tumors recorded. Lipomata. — These are ordinarily mixed with adenomatous tissue, and only 1 case was reported by Rokitansky in which the tumor consisted of the genuine lipomatous material. There are only 3 cases on record. Lymphomata. — Only two cases have been reported, one by Clark and another by Vogler, and only 1 case is on record of an amyloid tumor. Carcinoma. — It appears most frequently in the male. Tweny-eight cases have been found by Theisen, including his own, and since that time at least one additional case has been reported by Berens. Location. — For primary carcinoma the upper and lower parts of the trachea seem to be favored, and the posterior rather than the anterior wall. In secondary carcinoma involvement of the anterior wall is found, particularly where the thyroid gland is the primary focus. Sarcoma. — Theisen collected 18 cases of primary involvement of the trachea which occurred with equal frequency in the male and female, and found particularly in young people. They are occasionally pedun- culated, but in the majority of instances are sessile and appear as a smooth oval tumor with a broad basal attachment to the tracheal wall. Symptoms. — The same symptoms are met with in both benign and malignant involvement of the trachea, particularly in the early stages. Interference with respiration is proportionate to the size of the growth and is a constantly increasing symptom. Cough is usually present with the inability on the part of the patient to remove the oft'ending irritation, and where ulceration has taken place the expectoration will be tinged with blood. Pain associated with dyspnea occurs in the later stages, particularly in malignant involvement. Diagnosis. — ^The ordinary laryngoscopic examination is frequently all that is necessary to determine the presence and location of the tumor, but in exceptional instances tracheobronchoscopy will aid materially in the location and determination of its character. Location, size, color, contour, and attachment, together with the age of the patient and the OPERATIONS ON THE LARYNX 529 length of time of its apparent existence, are points to guide the examiner in his diagnosis. Removal of a part of the tumor for microscopical examination is indicated. Treatment. — Palliative treatment has been of no avail. Tracheotomy will relieve the distress of the moment, provided the tumor is situated sufHciently high up in the trachea to allow the tube to enter below its site, or if it is of such small size as to permit the tube to pass the point of greatest pressure. In the malignant tumors which have gone beyond operative aid, tracheotomy often prolongs life and^ renders the patient more comfortable during the later stages. Removal of benign growths through the bronchoscope is perfectly feasible, but in papillomata, espe- cially in children, it will be necessary to do this a number of times, as they recur after operation just as in the larynx. A few growths have been successfully removed by the indirect method. The most feasible and complete method of removal is by laryngotracheal fissure or tracheal fissure if the tumor is low in the trachea. Resection of the trachea in malignant involvement has been accomplished with success by Paul Bruns, after which the patient lived six years. Prognosis. — For benign tumors operative measures are upon the whole favorable. In the malignant it is very unfavorable, as the involvement is usually situated posteriorly where the lymphatics are most numerous, and the patient has either a rapid recurrence or metastasis as the final outcome. The operative technique for tumors of the trachea is practically that for those of the larynx, whether internal or external, though owing to the greater depth at which they are situated, removal by indirect laryngoscopy often presents insurmountable difficulties. OPERATIONS ON THE LARYNX. . Endolaryngeal Operations. — Operations may be performed upon the larynx per vias naturales by either the indirect or direct method, the choice of which is to be determined by the object of the operative procedure, the skill of the operator with the respective methods, the idiosyncrasy of the patient, and the location of the operative field. Endolaryngeal operations are performed for three purposes: (1) the removal of specimens for microscopical diagnosis; (2) the removal of growths mostly benign, possibly malignant; (3) the evacuation of cysts, abscesses, extravasations of blood or serum. In the removal of specimens for microscopical examination, cocainization is as essential as if the entire growth were to be removed. This is ac- complished best by the drop method, which permits one or two drops of a 20 per cent, solution of cocain to fall directly into the larynx after the epiglottis and pharynx have been previously anesthetized by the topical application of a 4 per cent, solution of cocain. As the patient coughs up the two drops of cocain it disseminates itself to contiguous portions of the laryngeal mucosa and in about ten minutes produces a 34 530 MALIGNANT LARYNGEAL NEOPLASMS most satisfactory anesthesia. Adrenalin is never employed until after the removal of the specimen and only then when hemorrhage occurs. Pfau, of Berlin, has constructed a handle to which can be attached various sized tips made after the models of Frankel, Krause, Heryng and others, which enable the operator to select one best adapted to the size, location, and character of the growth from which the specimen is to be removed. If the patient is nervous and unaccustomed to instrumentation, it is better to have a few sittings at which the instrument is only passed under slight cocainization until the confidence of the patient is assured and the difficulty of the removal is determined. Several unsuccessful efforts at removal contribute to the nervousness alike of the patient and operator. When the time arrives for the removal of the specimen the patient should be instructed to breathe easily with rather prolonged inspiration and expiration until the instrument nears the growth,when, if it is situated upon the cords, the patient is instructed to say a (not Sh) ; if well anterior or at the anterior commissure, say e; if upon the border of the cords, inspire long and deeply; if below the cords and attached by a pedicle, expire forcibly. To the experienced laryngologist these instructions are super- fluous, but to the beginner they may be of some value. When these directions have been satisfactorily carried out and the growth rendered as immobile as possible, the instrument is firmly introduced either upon, around, or into the growth so that it removes a piece the full size of the cutting forceps, otherwise the specimen may be valueless to the micro- scopist. The specimen should not include all of the ulcerating surface, if malignancy is suspicioned, but a part of the infiltrated mass adjacent to the ulceration. The soft necrotic material of the ulcerative area will not afford sufficient stroma evidences to aid in diagnosis. Nor will the superficial epithelial covering of some tumors indicate the nature of the substructure. When the direct method of removal is employed the same technique is necessary as is given under laryngoscopy, and the same rules apply regarding local or general anesthesia. The instruments for the removal of the specimen are the same, except they are attached to a longer, straight projecting rod, instead of the curved one employed in the indirect procedure. To those having had limited experience in laryn- . gology the direct method will probably prove easier of accomplishment. There are few who advocate the attempt to remove malignant growths by endolaryngeal methods, and B. Frankel is the only operator who seems to have met with success. The galvanocautery "has been advocated by some, without sufficient justification for its use, when thyrotomy is available. The uniformly unsuccessful results demonstrate that endo- laryngeal methods for the removal of malignant growths of the larynx should not be employed, and that a continuance of the practice should be condemned. In benign growths it is seldom necessary to employ any other measure than either the indirect or direct method of endolaryngeal operation for their removal. The anesthesia is produced in the same way as for the removal of specimens, and the same technique is employed. Growths situated upon the epiglottis, except upon its laryngeal surface and near OPERATIONS ON THE LARYNX 531 are its attachment, are the easiest to remove. Those upon the folds of the epiglottis are also easily approached. Those situated upon the posterior part of the larynx and upon the cords up to the junction of the anterior and middle third are more difficult, while those upon the anterior third of the cords and the anterior commissure, or in the subglottic area, the most difficult to remove. Cysts, pedunculated growths and those pro- Fig. 284 jecting from the border of the vocal cords are sometimes more easily re- moved with the snare than with for- ceps. It is frequently necessary to remove the growth piecemeal if it is too large for one bite of the forceps. In these cases judgment should be exercised as to the degree of trauma and the amount of laryngeal spasm and irritation permissible to be pro- duced. It is often wiser to have several sittings, removing a part each time, than always to undertake com- plete eradication at the one opera- tion. The Mackenzie forceps are particularly serviceable in evulsions, but the Krause, Heryng, Dundas Grant and Frankel forceps cut easily and smoothly and produce less trauma. (See pp. 477, 478.) Cysts, Abscesses, Extravasations of Blood or Serum. — Cysts may some- times be snared, but if sessile their contents should be evacuated and the sac removed with the snare. When the cyst is incised the patient should be instructed to take in a deep inspi- ration and hold it, just previous to the incision, after which forced ex- piration will bring up the contents. This applies equally to pus collections. The Tobold concealed scarifier may be employed for either scarification in extravasations of blood or serum Toboid's scarifier. or for incisions of cysts and abscesses. The curved laryngeal bistoury is also of value, in abscesses particu- larly, but has the disadvantage of having its blade uncovered, thereby endangering neighboring structures. Local anesthesia is the only justi- fiable measure in the evacuation of cysts or abscesses of the larynx, owing to the possibility of getting the fluid contents in the lungs and producing pneumonia. 532 MALIGNANT LARYNGEAL NEOPLASMS Tracheotomy. — The operation is performed either above the isthmus of the thyroid gland and is known as high tracheotomy, or below the isthmus, when it is called low tracheotomy. Anesthesia for Operation. — None where the conditions are of such grave nature that even delay necessary for its administration is a menace to life. Marked cyanosis or even exaggerated dyspnea should be " danger signals" that should warn against waiting for anesthesia. Under such conditions a stab into the trachea with a pocket-knife, scissors, or any sharp instrument at hand may be a life-saving procedure. A tracheal tube can be improvised by a piece of rubber tubing, a quill or any hollow tube or retractor which will hold the rings of the trachea aside and permit air to enter the lungs. The nearer this incision can be made to the thy- roid cartilage the better, and the nearer the median line the more favor- able the outcome. Local Anesthesia. — ^This is entirely practicable in adults and it may be accomplished by the intradermatic (not subcutaneous) injection of a half of 1 per cent, solution of cocain; or the solution advocated by Jack- son consisting of 1 grain cocain hydrochlorate, and 1 drop of carbolic acid to 1 ounce of sterile water, or by the infiltration method of Schleich. Little pain is experienced except upon cutting through the tracheal rings, into the mucous membrane lining the trachea, which still retains its sensitiveness. Children are of course less amenable to this form of anesthesia. The hypodermic injection of y^ grain scopolamin and J grain of morphin half an hour before the operation materially lessens the pain, but it also lessens the cough reflex which guards the bronchi and lungs against invasion by blood and pus. Except when the tracheotomy is an immediate preliminary step to an additional operation upon the larynx or structures above, local anesthesia is preferable to general. All sedatives are advised against by Jackson. General Anesthesia. — Chloroform. — In young children and infants chloroform, when administered by an efficient anesthetist, is preferable; but if given by anyone unaccustomed to its administration it possesses the same dangers as it does when employed for operation elsewhere, and should not be given. Advantages. — Secretions are materially lessened. The struggles of the child are sooner overcome. The trachea is more at rest which facili- tates opening. The anesthetization is quicker, thereby rendering the operation more expeditious. Dangers. — Those resulting from chloroform under other surgical conditions, as shock, cerebral anemia, heart-failure, etc., together with the abolition of the cough reflex. Ether. — It takes longer, there is greater secretion, the trachea is less at ease, and apparently infection of the lungs results more frequently. Position.-^The patient should be in the dorsal position with the shoulders raised upon a sand-bag and the head extended sufficiently to put the tissues of the front of the neck on the stretch, but not so as to interfere with respiration; the patient should be in the Trendelen- burg position, assumed to favor drainage away from the trachea and lungs. OPERATIONS ON THE LARYNX 533 Instruments. — A sharp-pointed scalpel; two sharpi-pointed hooks for separating the edges of the wound; a tracheal dilator; thumb forceps; curved and straight scissors; an aneurysm needle; several artery clamps; needle holder with curved needles, and silk and catgut ligatures. Operation. — ^Time permitting, the external surface should be surgically cleansed, and in tracheotomy preliminary to laryngectomy or laryn- gotomy, the dressings should have been on at least twenty-four hours prior to the operation. High Tracheotomy. — A median incision is made through the skin and subcutaneous tissue from the lower extremity of the thyroid for a dis- tance downward commensurate with the requirements of the case. The sternohyoid and sternothyroid muscles are separated and held aside while the fascia covering the isthmus of the thyroid gland is divided. There are several veins of considerable size encountered in this locality which should be divided between ligatures. The isthmus of the thyroid is retracted downward so that a freer exposure of the rings of the trachea may be obtained. All bleeding vessels are ligated before further steps, unless the operation requires speedy entrance into the trachea. The trachea is now steadied by either the fingers or one or both tenacula, and the incision made directly in the median line and of sufficient length to admit the cannula. After incision the tracheal dilator is introduced and the cannula inserted. As the reflexes are not abolished within the trachea a violent fit of coughing usually follows the introduction of the cannula, by which blood and exudates are thrown out. The cannula is tied in place with tape strings. The upper and lower angles of the wound are sutured and a layer of gauze is placed between the wound and the flange of the cannula, over the mouth of which a few layers of gauze should be placed to act as a filter to the inspired air. The Cannula. — ^The size is determined by the age of the patient. The length of all cannulse in the market not specially constructed are too short. The tumefaction following operation frequently lifts the short cannula from the trachea, which accident should be specially guarded against by a long-tube cannula. The cannulse should be of silver. After-care. — The patient should be placed in a bed with the foot elevated. A croup tent erected around the bed and the tent supplied with steam from a croup kettle to which lime water or the mixture of oil of white pine and milk of magnesia has been added. A nurse specially trained in tracheal work should be in constant attendance to guard against the closure of the tube with blood or exudates, to guard against hemorrhage, to prevent the patient displacing the tube, and to properly change the dressings every half-hour if necessary. Should the tube be dis- placed the nurse had better hold the lips of the tracheal wound apart with dilators until the surgeon arrives, rather than attempt reintroduction of the tube, as by this effort false passages are often made. Instruments for dilating the trachea and a longer, smaller tube or rubber catheter should always be at the bedside of a tracheotomized patient to meet emergencies. Sometimes blood oozes into the trachea and, by clotting, impedes respiration below the point of the cannula, in which case it 534 MALIONANT LARYNGEAL NEOPLASMS may be removed by suction through a soft-rubber catheter, introduced through the outer tube. The dangers attendant upon tracheotomy are pneumonia, hemorrhage, shock and sepsis, together with those incident to anesthesia. Low Tracheotomy. — ^The incision is made in the median hne from about the fourth tracheal ring to the beginning of the episternal notch. The isthmus of the thyroid is retracted upward, or if too large to permit of free access to the trachea, a portion or all of it must be divided. The hemorrhage from incising the thyroid gland is controlled by mass ligatures introduced before division. Low tracheotomy is more diffi- cult, as the trachea lies deeper in the neck and is more inaccessible. Thyrotomy, Median Laryngotomy, Laryngo-tracheotomy, or Laryngo- fissure. — These terms designate an operation having for its object entrance into the larynx by means of a median incision through the tissues and thyroid cartilage of the larynx, for the removal of neoplasms, foreign bodies, cicatricial stenoses, or exploration. The position of the patient, the preparation of the operative field, and the question of anes- thesia are the same as for tracheotomy. Many operators prefer chloro- ' form, but local anesthesia is equally effective. In the majority of instances it is necessary to perform low tracheotomy previous to doing laryngotomy and the Hahn sponge-covered cannula is introduced into the trachea to prevent the blood and secretions from the laryngotomy gaining entrance into the lower part of the trachea and lungs. Additional safety may also be obtained by operating upon the patient in the Trendelenburg position. Butlin employs the lower end of his incision, which is carried from the hyoid bone above to about one inch from the sternum below, for inserting the Hahn tracheotomy tube. Through the upper part of his incision he performs his laryngotomy. After the first incision through the integument and subcutaneous structures all hemorrhage should be controlled. The sternohyoid and sternothyroid muscles are separated and held apart by retractors. The thyroid cartilage is then divided exactly in the median line, care being exercised to preserve the integrity of the vocal cords, which is favored by cutting from below up- ward, and following as closely as is possible the median line. The thyroid cartilage hardens as age advances, and in subjects over fifty there is always more or less calcification which renders it harder to cut. It becomes necessary in calcified cartilages to use extraordinarily heavy shears, a chisel or even a saw to separate the thyroid cartilage. After the larynx is open the wings of the thyroid are held aside by traction strings of strong silk carried through each section of the divided cartilage. An application of cocain and adrenalin materially lessens the reflex irritation if applied ■ to the lining mucosa of the larynx. The character and extent of the lesion isnow considered and an incision entending at least one-fifth of an inch from its free border should circumscribe the tumor. This incision is carried through the mucous membrane and down to the perichondrium, and the growth and the surrounding soft parts are then carefully dissected away from the cartilage. All bleeding should be controlled by torsion or liga- tion. In cases of benign tumors or cicatricial bands, the scissors and OPERATIONS ON THE LARYNX 535 curette may be employed in addition to the knife for their extermination. In malignant tumors it is wise to curette the underlying cartilage and cauterize the adjacent area with nitric acid or the galvanocautery. After all bleeding and oozing have been controlled the free borders of the car- tilage are coapted and united by catgut sutures. If the perichondrium is intact over the thyroid, one or two fine catgut coaptation sutures aid materially in keeping the cartilage together. After the larynx is closed the Hahn cannula is removed and in its place is substituted a very small tracheal cannula, or a section from a soft-rubber catheter. In the experience of a great many operators it is best to close up both . Fig. 285 I'osition of incisions for opening the laryngotracheal tract. (Bickham.) A, supra- thyroid laryngotomy (subhyoid pharyngotomy) ; B, thyrotomy; C, laryngotomy; D, high tracheotomy; E, low tracheotomy. The corresponding skin incisions are longer than the incisions into the laryngotracheal tract. tracheal and thyroid wounds and depend upon gravity for drainage, which is accomplished by keeping the head very much lower than the rest of the body by elevating the foot of the bed. After the wound is closed and dressed the patient is transferred to a room or tent which is filled with steam from a croup kettle, just as after tracheotomy. Should conditions exist making it desirable to perform thyrotomy without a previous tracheotomy the operation should be done with the head of the patient hanging downward over the edge of the operating table in the Rose position. If the tracheal cannula or rubber tube is left in the wound, it may be removed in from twenty-four to forty-eight hours if no edema of the larynx follows the operation. 536 MALIGNANT LARYNGEAL NEOPLASMS Subhyoid Pharyngotomy. — ^This operation is employed for the removal of large fibrous growths of the epiglottis and its folds, for the removal of the epiglottis itself, and large benign or malignant tumors around the upper aperture of the larynx. A preliminary tracheotomy is ordinarily performed, though this operation may be accomplished satisfactorily if the patient is in the Rose or Trendelenburg position. A transverse incision is made parallel with and just below the hyoid bone, dividing Fig. 286 Position of incisions for opening the laryngotracheal tract. (Biokham-Chappell.) the skin, superficial fascia, and platysma muscle. The sternohyoid and thyrohyoid muscles are also divided transversely. Superficial vessels are clamped before exposing the thyrohyoid membrane. The pharyngeal cavity is next exposed by an incision through this membrane, hugging the hyoid bone closely to avoid wounding the superior laryngeal vessels and nerves which pierce this membrane on either side. The epiglottis is drawn forward to the opening, which gives a good exposure of the OPERATIONS ON THE LARYNX 537 structures of the entrance of the larynx and of the adjacent pharyngeal wall. After the necessary operative procedures the pharyngeal wound is closed with catgut sutures, the muscles coapted and united, and the skin united entirely with the exception of a space for a cigarette drain extending down to the thyrohyoid membrane. The same treatment follows as that used after thyrotomy and tracheotomy. Suprahyoid Pharyngotomy. — ^This operation is adapted to the removal of growths situated in the lower pharynx, the pyriform sinuses, and the upper portion of the larynx. While this operation may be performed in either the Rose or Trendelenburg position without tracheotomy, in the majority of instances it is advisable to do a preliminary tracheotomy. A transverse incision is made above the hyoid bone extending from the sternomastoid muscles of one side to that of the other. This incision divides the skin, platysma, mylohyoid, geniohyoid, and some fibers of the digastric and hyoglossus muscles. Hemorrhage should be controlled by ligatures, after which the pharynx is entered by dividing the mucous membrane transversely in the line of the skin incision. This operation presents a view of the upper structure of the larynx and the lower part of the pharynx and enables one to remove neoplasms from this region with great facility without endangering the epiglottis or the superior laryngeal nerves. The wound should be closed by a layer of sutures accurately approximating the mucous membrane and ends of the muscles. It was first observed by Jeremitsch that suicidal cut throats healed more kindly when the incision was above rather than below the hyoid bone, and from this observation this operation was devised. Partial or Hemilaryngectomy.— This operation is indicated where it is found that the malignant tumor has involved the thyroid cartilage, and that without partial or complete removal of the cartilage recurrence at that point is imminent. The earlier steps of the operation are the same as in thyrotomy, with the additional necessity of doing a preliminary tracheotomy. Sometimes the rim of the thyroid cartilage may be left and only a window resection be necessary to remove all of the diseased cartilage, in which case there is better support to the superimposed tissues. When the entire thyroid cartilage has to be removed it is neces- sary to remove the thyrohyoid muscle, which leaves only the skin and subcutaneous tissue covering the larynx. If the wound is perfectly dry and there has not been too much destruction of tissue it is safe to remove the tracheal cannula and close up the wound immediately after the hemilaryngectomy. In this case it is very necessary to see that the patient's head and neck are much lower than the rest of the body, so that proper drainage will take place into the retropharynx, which it is necessary to keep clean by frequent sponging. The after-treatment is the same as for thyrotomy. Total Laryngectomy. — This operation is performed for extrinsic malignant conditions of the larynx, bilateral intrinsic involvement, and recurrent malignancy after thyrotomy or hemilaryngectomy. Preliminary Tracheotomy — This question seems an unsettled one, both as regards the advisability of performing it and the time it should 538 MALIGNANT LARYNGEAL NEOPLASMS be performed prior to the laryngectomy. Gliick performs both at the time of operation; Sohs-Cohen two to four days before; Brewer ten days preceding; and Chiari several weeks prior to the laryngectomy. The phenominal success of Gliick's work entitles him to marked con- sideration of each and every detail, but comparisons of each step of the operation cannot account for the favorable outcome of any work where the surgical skill of a number of operators is on an equal footing. Those cases resulting most favorably in the experience of the authors have all had preliminary tracheotomies ten days to two weeks prior to the laryn- gectomy. Fig. 287 Gliick's laryngectomy. Second step.' (Keen.) Gliick's Operation. — No preliminary tracheotomy. Chloroform is employed for anesthesia, and the patient placed in the Trendelenburg position with the head well extended. A flap, rectangular in outline, consisting of subcutaneous fat and platysma, is lifted, exposing the larynx and overlying muscles from the hyoid bone to the first ring of the trachea. The sternohyoid and sternothyroid muscles are divided and retracted to either side and the superior thyroid arteries exposed and ligated. The remaining muscle attachments are then removed and the larynx denuded and partly separated from the esophagus by blunt dissection. A transverse division of the thyrohyoid membrane is next ' The first step in the Gliick operation is now practically the same as that illustrated in the Brewer operation (Fig. 289) , but we have here described the incision as first practised by Gliick. OPERATIONS ON THE LARYNX 539 made just below the hyoid bone and the larynx drawn well forward and its interior examined. A 10 per cent, solution of cocain is applied to the lining mucosa and a tracheal cannula introduced in the superior aperture of the larynx and sutured in place. The anesthetic is now administered through the cannula. The larynx is next separated from the esophagus, care being taken to leave as much of the pharyngeal wall as possible, and drawn downward, gradually separating the neighboring tissues from it and the upper three or four rings of the trachea. A median longitudinal incision is then made over the trachea to the episternal notch, the thyroid Fig. 288 Gliiok's laryngectomy. Third step. (Keen.) isthmus divided between ligatures, the larynx severed from the trachea, and the tracheal stump attached to the skin at the lower angle of the median incision. A rubber feeding tube is then introduced through the nose and pharynx into the esophagus and the pharyngeal wound united with a double row of catgut sutures and reinforced by suturing the re- tracted sternohyoid and sternothyroid muscles over it. The rectangular flap is then replaced, its upper and lower margins sutured, and a generous gauze packing introduced through the unsutured lateral margin of the wound. A tracheal cannula is placed in the tracheal opening and the 540 MALIGNANT LARYNGEAL NEOPLASMS entire neck enveloped in a sterile gauze dressing. The patient is fed through the tube as soon as the stomach will bear fluids and an effort is made to have him sit up for a part of the time after the second day. Brewer's Method. — Under general anesthesia a low tracheotomy is per- formed through a median incision extending from the cricoid cartilage to the sternal notch after the introduction of the cannula. The upper part of the incision is united with silkworm-gut sutures, and the peri- tracheal space packed generously with iodoform gauze, both above and below the cannula. The after-care of a tracheotomy case is then carried out. About ten days after preliminary tracheotomy, if the patient has a normal temperature and is not suffering from cough and excessive secretion, the secondary tracheal operation is undertaken. Fig. 289 Preliminary traciieotomy with peritracheal tamponade. (Brewer.) Chloroform is administered through the tube until the patient is anesthetized, after which its administration is continued in the same manner, or colonic etherization is employed by means of the Sutton apparatus. The use of scopolamin y^^ grain and of morphin j grain one-half hour before operation is a decided advantage in these cases, as it not only diminishes to a considerable extent the amount of anesthetic required, but lessens the postoperative vomiting, and insures a period of from one to four hours of freedom from restlessness after the operation. OPERATIONS ON THE LARYNX 541 a period when most laryngeal cases are coughing and vomiting, and increasing thereby the always present tracheal irritation. The patient is placed on a flat table with the head well extended. An incision is made from the body of the hyoid bone downward to the upper limit of the former cut. From the upper extremity of this incision two lateral incisions are made in an upward and outward direction extending to the anterior border on the sternomastoid muscles. The two triangular flaps are turned outward, the sternohyoid muscles divided just below their attachment, and the sternothyroids detached from the cartilage. Fig. 290 Exposure of the larynx and thyrohyoid membrane. (Brewer.) The two superior thyroid arteries are next located and ligated. The superior laryngeal nerves are cut and all lymph nodes and neighboring lymph-bearing areolar tissues are removed. The attachments of the inferior constrictors are next divided and posterior surface of the cricoid partly separated from the esophagus by blunt dissection. When the larynx is thoroughly denuded the trachea is severed just below the cricoid, and its distal extremity immediately packed tightly with gauze, completely preventing the entrance of blood or pharyngeal mucus. The forefinger of the left hand is next introduced into the upper or laryngeal segment of the tube, and the larynx gently raised from the esophagus, any remaining attachments being separated by gauze sponges. 542 MALIGNANT LARYNGEAL NEOPLASMS When the larynx is thus completely separated from the esophagus, the thyrohyoid membrane is incised and the larynx removed. The pharyngeal wound is then packed with gauze to prevent excessive contamination of the wound, and the parts carefully inspected for evidence of remaining disease. The oval pharyngeal wound is next tightly closed by two layers of suture, the first of plain catgut, the second of chromic catgut. After closure of the pharyngeal opening, the entire upper wound is temporarily packed with wet formalin gauze, while the tracheal stump Fig. 291 Division of the trachea and separation of the larynx from the esophagus. (Brewer.) is prepared for closure. This is accomplished by removing redundant tissue above the cannula opening, dissecting out or destroying with cautery the mucous membrane, and packing firmly with iodoform gauze above the tube. A No. 30 f. rubber feeding tube is then introduced through the left nostril into the esophagus, and secured by a safety-pin and plaster straps tojthe face. The wounds are next united above, with generous gauze packing about the tube. The after-treatment is the same as that following the preliminary tracheotomy. Water is given through the tube as early as the morning Fig. 292 Suture of the pharyngeal wound, and packing the upper segment of trachea. (Brewer.) Fig. 293 Wound closed with generous gauze packing about tracheal stump. (Brewer.) 544 MALIGNANT LARYNGEAL NEOPLASMS following the operation, if there is no nausea. Milk, coffee, egg-nog, meat juice and soups follow as soon as possible. No atttempt at swal- lowing should be made for at least seven days, after which the tube may be removed. The wound should be dressed at least once every day, and two or three times if there is infection or pharyngeal leakage. The tracheal stump is quickly covered with granulations, and gives no trouble. The patients continue with the silver cannula. f CHAPTER XX. THE THROAT IN GENERAL DISEASES. SYPHILIS, TUBERCULOSIS. SYPHILIS. Occurrence. — ^The various stages of syphilis are seen in the nose and throat as elsewhere. Extragenital chancres of the mouth, lips, the nose, and the tonsil have all been repeatedly reported, while the occurrence of the secondary and tertiary lesions of the mucous membrane of the upper air passages is a part of the symptomatology of the disease. As with tuberculosis, the pathological histology of all the stages of syphilis are practically the same upon the mucous membranes of the upper air passages as elsewhere. In a general way all of them consist of an infil- tration of round cells, lymphoid cells, and lymphocytes, and the growth of new connective tissue which is apt to break down and form more or less widespread areas of necrosis. Epithelial proliferation is also seen, although this is confined more or less characteristically to the secondary stage. The lesions of the bloodvessels are also seen in all stages so that, notwithstanding the varying clinical picture of the disease, the histo- logical picture does not present the same extent of variation. Clinically, syphilitic lesions of the nose and throat may resemble a great many other lesions, but histologically the resemblance to tuberculosis and the rarer forms of granulomata, such as leprosy and rhinoscleroma, may be said to exhaust those processes in which there is close resemblance. Primary Chancre of the Mucous Membranes of the Upper Air Passages. — At the point of inoculation, the first appearance is said to be a slight vesicle which is apparently the reaction of the epithelium, but this is so rapidly followed by round-cell infiltration and the production of new connective tissue, the sclerosis typical of the initial lesion of syphilis, that accounts of the antecedent condition of the vesicle are very meager so far as their histological characteristics are concerned. With the round- cell infiltration there is more or less edema and swelling of the parts; there is endarteritis or swelling of the lining of the capillaries and necrosis is seen in the connective tissue before the infiltration has advanced very far. The infection spreading to the lymph nodes beneath the angle of the jaw produces the characteristic lesions there as well as upon the mucous membranes. This primary stage disappears as a rule without leaving behind it anything but an insignificant scar. The Spirocheta pallida has been demonstrated in the primary lesions lying between the strands of new connective tissue. 35 546 THE THROAT IN GENERAL DISEASES Secondary Lesions, the Mucous Patch. — In the course of a few weeks, as is well known, white patches occur upon the mucous membrane of the upper air passages whether the initial lesion has been there or upon the genitalia. However, the secondary syphilitic manifestations upon the mucous membranes of the upper air passages, following the extra- genital primary lesion located there, are apt to be very severe, very extensive, and even at this early stage of the general infection they may produce extensive destruction of tissue even leading to periostitis and destruction of bone. The characteristic of the mucous patch is due to an affection of the epithelium, which is swollen and the papillae are en- lairged. Mucous patches have been seen in the nose and in the larynx as well as upon those surfaces which are normally supplied with papillary layers. Upon those areas normally covered with columnar epithelium which does not have a papillary layer, they are very rare. We are not aware that it has been proved that in these rare cases of mucous patches, occurring within the nasal chambers and within the larynx, they are due to involvement of epithelium which has become metaplastic through a previously existing process of chronic inflammation or irritation, but it seems probable. The round-cell infiltration especially around the blood- vessels and the areas of coagulation necrosis are seen in the submucosa in the secondary lesion as well as in the other stages. The ulceration seen in the secondary stage may be superficial, apparently with loss only of the epithelial covering or it may be deep and destructive, differing in no way from that of the succeeding or tertiary stage, and in this way the secondary lesion may be said to merge with the tertiary, presenting the same characteristics. Tertiary Stage, the Gumma. — ^The tertiary lesion of the upper air passages commences in the form of a gumma which consists of a small nodule of syphilitic inflammation, especially distinguished by necrosis and fragmentation of nuclei in an area which rapidly becomes necrotic and breaks down, eventually involving the surface of the mucous mem- brane and showing very ragged, sharp-cut edges, indolent in character without much localized infiltration around them that could be recog- nized by the naked eye, though there is in reality a good deal of round- cell infiltration and production of new connective tissue at the periphery of these ulcerations. In addition to the nuclear fragmentation, there are small spheroidal and epithelial cells in great abundance, as there are in tuberculosis, and there may be also large numbers of giant cells, more or less of the Langhans type, though this may be regarded as excep- tional. The size of the gumma may vary from that hardly visible to the naked eye to the size of a nut or even larger, before it breaks down into ulceration. After this occurs the area may rapidly spread so that the whole pharynx is involved in the destructive process. It may be deep, involving cartilage and bone, as well as widespread. The hard and soft palates, especially at their junction, and the posterior wall of the pharynx form favorite sites of location for these gummata. In the former situa- tion the destructive process rapidly results in perforation into the nasal cavities, with more or less extensive destruction of the bony framework. SYPHILIS 547 It is this especially which characterizes the tertiary lesion of syphilis and the readiness with which the bone and cartilages are involved serves to distinguish it from forms of tuberculosis and other affections in which the bone is rarely involved or at a much later stage of the process. This is a very important consideration in the differential diagnosis because, while other processes involve bone and cartilage, such as tuberculosis, leprosy, rhinoscleroma, it is nearly always at a stage when there are so many other diagnostic signs of the affection that there is little trouble in classifying the lesion. In syphilis, however, there may exist widespread destruction of the bone and cartilage and the deeper tissues without any other very marked lesion of the nose and throat or of other regions. When under treatment healing takes place in these tertiary lesions with the formation of dense fibrous scar tissue of a low grade, it produces contractions and adhesions, causing stenosis and other serious sequelae. DifEerentiation in the Microscopical Appearances of Syphilis from that of Other Lesions. — ^Forming one of the large divisions of specific granulomata, syphilis, microscopically as well as clinically, can often be confounded with the others, and great care is necessary upon the part of the histologist to avoid doing so. There can hardly be any one feature seized upon as being characteristic. In a general way it may be said that the tissue necrosis and the nuclear fragmentation are more widespread in syphilis than in tuberculosis. Giant cells, when they do occur in syphilitic lesions, in our experience seem to be more abundant than is usual in tuberculous lesions. The fibrosis is as common in one as in the other, but its distribution is a little different. In tuberculosis it serves to wall off a necrotic area as though nature was continually and spontaneously endeavoring to bring about a healing of the lesion. In syphilis, however, it is distributed throughout the lesion and throughout the neighborhood, and especially in the walls of the bloodvessels in an irregular fashion, that is, it seems to be an essential part of the syphilitic process, while in the tuberculous lesion it seems to be a process of repair. The endar- teritis and occlusion of bloodvessels is very much more frequent and more marked in syphilis than it is in tuberculosis, but it occurs in both. The demonstration of the tubercle bacillus or of the Spirocheta pallida, both of them difficult histological performances in practice, the employ- ment of the Wassermann and the von Pirquet and the luetin reactions, and the clinical course of the disease, often are of the greatest advantage to the histologist in deciding as to the significance of otherwise baffling objective appearances. While tuberculosis is a thing most prominently thought of in connection with the microscopical differentiation in syphilis, it must be remembered that the vagaries of the epithelium, especially at the borders of syphilitic ulcers, may frequently give rise to appear- ances which resemble cancer. Epithelial whorls, atypical mitotic figures, are occasionally seen, and the nuclear fragmentation of syphilis may re- semble that of carcinoma where it infiltrates the epithelial layers; but, as a rule, if the tissue is extensive enough, the histologist has little diffi- culty in distinguishing syphilis from epithelioma. The differentiation from leprosy and rhinoscleroma will be referred to later. 548 THE THROAT IN GENERAL DISEASES Diagnostic Value and Demonstration of the Spirocheta Pallida in Lesions and Secretions. — It was hoped that when this organism was identified as the causative agent of syphilis it would serve as a valuable diag- nostic method in the difFerentiation of syphilitic lesions in the upper air passages; but as a matter of fact it has proved of very little practical value because in the secretions of the mouth and especially in ulcerative lesions of the mucous membranes of the mouth, a number of spirochetse are seen which so closely resemble the organism which Schaudinn de- scribed as the organism of syphilis, that little diagnostic value can be placed upon it either with the India-ink method, with tinctorial reactions, or with dark field illumination. These spirilla forms may be seen asso- ciated with syphilitic lesions of the mouth, but without the confirmatory evidence of other diagnostic signs it is of little value, while its demon- stration in pieces of tissue excised from the lesion is a matter of some difficulty and uncertainty and at best extending over considerable time. Its greatest value as a sign pathognomonic of the existence of syphilis is found in the demonstration of it in lymph removed by hypodermic needle from an enlarged lymph gland. Chancroid of the buccal and pharyngeal mucous membrane, both from auto-inoculation and from extraneous infections, has been noted. It possesses the same differential characters as regards the true chancre as the lesions on the genitalia, but without the history of infection and without the presence of a chancroid elsewhere it may be easily mistaken for other ulcerative lesions. A circular ulcer with sharp, ragged edges, not indurated, covered by secretion in which are found streptobacilli, has been identified as chancroid on the tongue and in the phaynx. There are submental and submaxillary glandular involvements. Symptoms. — The initial lesion as seen on the lips partakes of the characters of the initial sore on the genitals. A sluggish ulcer, with in- durated base and edges, often of elUptical or circular shape, it rarely comes under observation unless by accident until it has receded some- what and the secondary plaques and patches have appeared or there is glandular enlargement. Before these secondary phenomena appear it is usually o^'erlooked by patient and medical attendant alike. This of course is not always the case, but diagnosis is often a difficult matter. It can only be arrived at by exclusion, even though facts are revealed in the subjective history which suggest the diagnosis. The rapidity of its development will suggest a differentiation from epithelioma with which, on the lip in men, it may be confounded. It is to these characters that one must trust for the differential diagnosis when the lesion exists on the mucosa of the cheeks, gums, and tonsils. In the latter situation the lymphatic glands are rapidly involved. While these lesions are much more common than is usually supposed, they are rarely identified. While a large number of them are doubtless acquired from infection carried on pipestems and other articles innocently used, the proportion which are acquired by unnatural sexual practices is probably large. A number are seen in young women innocently acquired by kissing their relatives or their betrothed. In prostitutes they are seen in situations in the SYPHILIS 549 mouth which suggest other modes of infection. The subjective history in cases innocently infected is absent from ignorance; in the other cate- gory it is absent from shame. Early secondary stages of syphilis are seen everywhere in the upper air tract, with rarity, however, on the nasal and laryngeal mucosa. The broad, smooth mucous patch, said to occur only upon surfaces covered by squamous epithelium, is certainly rarely seen, if it ever occurs, else- where. These lesions very often give rise to no subjective symptoms and may pass entirely unobserved unless carefully looked for to confirm the diagnosis of syphilis entertained from concomitant lesions. In a considerable number of cases the secondary lesions of syphilis are much more marked than this in the mouth and pharynx. The patches are more pronounced, due to a deeper necrosis of the superficial epithelium. Around the edges intense congestion may exist and a true flat but more or less shallow ulcer with loss of substance may obtain. In all forms much erythema may exist at the back of the pharynx. The appearance of this has been described as more or less characteristic, but in the absence of other indications of syphilis it is insufiicient to warrant any such con- clusion but it may serve to excite suspicion. Perhaps its most suggest- ive feature is that the amount of congestion is out of proportion to the subjective symptoms. In the more severe ulcerations considerable pain may be complained of, but, as a rule, in these cases also the observer notes an amount of epithelial destruction and vascular engorgement out of proportion to the discomfort caused by them. In a simple non-specific catarrhal pharyngitis the pain is greater than when the process is acute and less when it is subacute or chronic; so that with what looks like a severe acute inflammation of the throat, the examiner gets a history of subacute duration. The patient will say he has had discomfort for two or three weeks, when one would expect from the looks of the throat, if it were not specific, he would complain of considerable pain, but with the history of only a few days' duration. The student will expect from' the local appearances some fever and chilly sensations, but in syphilis these as a rule are not complained of. A half-degree or a degree of tem- perature and slight malaise are common enough in these cases, but with a simple inflammation of a like local severity one would expect much more of each. The constitutional or systemic evidences of syphilis, the bone pains, the skin eruption, must all be sought for. The laryngologist comes to depend very much upon the presence of enlargement of the post- cervical glands in these secondary lesions of throat syphilis. "While as a rule they are somewhat late in appearing they are as pathognomonic as any one sign of the existence of syphilis. This enlargement is apt to be rather unique. The glands, not always, but usually are found as small, ovoid, movable bodies, the size of a pea or bean, in the posterior midcervical region along the posterior border of the sternocleidomastoid muscle. Suppurative aural disease and some non-specific laryngeal affections may cause the enlargement of this chain of glands, but these are not so constantly of the size and in the situation above described. It happens at times that the bites of the Pediculus capitis will give rise 550 THE THROAT IN GENERAL DISEASES to a condition quite typical of secondary syphilis of the throat so far as the postcervical glands are concerned. Given a case of sore throat lasting two or three weeks, even without perfectly convincing and typical mucous patches, if the observer can find these little ovoid bodies and can exclude suppurative ear disease and the presence of head lice, he is justified in entertaining the provisional belief that his patient is sufPereing from syphilis, even in the absence of all other objective symptoms and despite the denial of exposure to infection. That this opinion will occasionally have to be revised later is a reason for not giving it expression, but no reason for abandoning it. It will occasionally happen that these secondary lesions of the fauces and mouth are of such a nature and have persisted sufficiently long to give rise to the conjecture of tuberculosis. The comparative freedom from pain in the syphilitic lesion can usually but not always be depended upon to distinguish it from the tubercular lesion, and the same may be said of its shorter duration. Symptoms of Tertiary Lesions. — The one thing that stands out as a striking phenomenon in the symptomatology of the tertiary lesions of syphilis in the nose and throat is the appalling extent to which the dis- ease may have advanced before the patient's attention has been attracted to them, or at least before his suffering has become sufficient to induce him to seek relief. The syphilophobe is thrown into convulsions of fear by a fever blister and the syphilitic often does not find it worth while to seek a doctor until drink comes through his nose and he impregnates the atmosphere with the stench of dead bone. Almost painless, tertiary syphilis of the nose not infrequently furnishes the observer with exempli- fication of this statement. Before a gumma breaks down it will some- times exist on the septum or in the ethmoidal labyrinth in such a swelling as to cause nasal obstruction for which the patient seeks relief, but usually the tissues in the nose melt down without sufficient reaction even to cause this. Nasal obstruction, when it occurs in the course of nasal syphilis, is usually due to the descication of the discharges. Pain is prac- tically never a prominent symptom. The first thing to attract the atten- tion of the patient may be the extrusion of pieces of bone in his nasal discharges or the sinking in of the natural contour of the external nose. A persistent, thin foul-smelling, discharge, the odor appreciable very often by the patient himself, is perhaps a more frequent initial symptom. Examination may shbw a large perforation of the cartilaginous septum, but usually involving the bony plates. These are hidden from view by discharges covering the surfaces and blackened by necrosed bone detri- tus. A probe may detect the dead bone, but its presence is very fre- quently manifest in the odor when the bare surfaces cannot be felt by a probe. Nothing which, when existing alone, is so pathognomonic of any disease of the nose and throat as the odor of dead bone in the nose of a patient suffering from tertiary syphilis. Ozena and the presence of foul secretions around a foreign body may deceive the novice in the odor they emit, but he who has seen and treated a few cases of nasal bone syphilis cannot be deceived. SYPHILIS 551 No other nasal affection involves the bony structures with sufficient frequency to give rise to much hesitation in the diagnosis. Lupus, tuberculosis, phosphorus poisoning, rhinoscleroma, ozenatous atrophic rhinitis, sarcoma in rare instances or to a slight degree, may involve the nasal bones, but when it is once clear that the intranasal bony structure has been destroyed by disease, not otherwise perfectly apparent as to its nature, the observer can be fairly sure he has to do with syphilis. No part of the nose and none of the nasal tissues are immune to its ravages. The alse nasi, the septal cartilages, the bony septum, the bones of the nasal arch, the roof and the floor and the lateral walls, the epithelium and the connective tissue, especially the bone and the cartilage, are alike susceptible. The deformities arising in the course of the disease, when unchecked or resulting from its therapeutic or spontaneous cure, are of all kinds and of all degrees of severity. It is commonly supposed that the sunken nasal arch which so frequently and so greatly disfigures the victim of syphilis owes its origin to the withdrawal of support owing to de- struction of the septum nasi. As a matter of fact it probably never occurs unless the nasal bones proper and the nasal processes of the maxillary bones which act as buttresses are destroyed or involved. The 'whole nasal septum, bony and qartilaginous, may be removed with the excep- tion of a thin rim of the periphery of the cartilaginous portion without causing external deformity. The external contour of the nose, when altered by atrophy or erosion, owes its loss of symmetry to the removal of the firmer structure in immediate contact with the subcutaneous covering, and not to the loss of the wall which divides the two chambers. While no part of the nose is immune from the invasion of syphilitic dis- ease in its tertiary stage, the most frequent point of involvement in the gummatous degeneration resulting from syphilitic inflammation is the junction of the cartilaginous with the bony septum, the floor of the nose where the hard and soft palates are coterminous and the ethmoidal labyrinth. The defects and deformities produced in the first two locali- ties mentioned, the sunken and distorted external nose, the frequently wide communication made between the nasal and oral cavities, have called for the exercise of much surgical and mechanical skill. Oral and Pharyngeal Tertiary Syphilis. — ^We have alluded to the gummata of the palatal arch which on breaking down leave perforations into the nasal cavities. These may be exceedingly small, no larger in lumen than a knitting needle, or they may consist of the loss of practi- cally the whole bony roof of the oral cavity. Gumma and destructive necrosis of the alveolar borders are not common. The soft parts, espe- cially the soft palate and the faucial pillars, are frequently the site of gummatous infiltration. This breaks down into more or less characteristic ulceration. Neither in the bony tissue nor in the soft tissue is the stage of gunamatous infiltration without ulceration apt to come under observa- tion. A small, painless depot of syphilitic inflammation, even though it occurs in the form of a nodular tumor, is not apt to attract the patient's attention until it breaks down at the centre into an ulceration which 552 THE THROAT IN GENERAL DISEASES may rapidly extend in depth and in periphery. The pain and discomfort, even though slight, then bring the case under observation. Ragged ulceration, with sharp-cut, perpendicular sides, or a funnel-shaped deep ulcer, is seen covered with slough and bleeding slightly when touched. It is not very painful The ulcerations may be papillary and clean-looking. Bone or cartilage may be felt by a probe at the bottom or at the sides. Such a condition may have destroyed a large part of the soft palate. Occasionally it may occupy only the central portion without impinging on the lateral pharyngeal walls. If the destructive process can be halted at that stage a simple perforation and considerable fibrous degeneration of the soft palate may result. Through these perforations food and drink enter the nose and on account of them the voice is markedly nasal in character. When, however, the soft palate is involved it too often hap- pens that the lateral pharyngeal walls also break down in ulceration. Even when this is slight, if it occurs in the palatopharyngeal fold, the healing process involves not only quickly extending adhesion of the soft palate to the posterior pharyngeal wall, but such a shortening and stiffening of it in the fibrosis as to occlude the way to the nasopharynx. It often happens under these conditions that a small opening is left just behind the uvula, by means of which the nose and nasopharynx drain into the oropharynx. It is remarkable how small an opening, left after shrinking and adhesions have formed in these cases, will sufiice for the functions of the parts and for the comfort of the patient. An opening an eighth of an inch in diameter is ample to provide for this, both as to respiration and the preservation of a conventional voice. While in the palate and fauces the gummatous infiltration almost always rapidly breaks down into deep ulceration, in the much rarer tertiary syphilitic affection of the tongue this is not relatively so frequent. Syphilitic infiltrations with or without ulceration are seen in the tongue and frequently cause embarrassment to the diagnostician, who may easily confound them with the more frequent forms of ulcerative carcinoma. The Wassermann reaction will often be of great service in the diagnosis of these conditions, but the observer of nose and throat disease must learn to depend not on the subjective history nor upon any one factor in the diagnostic problem, but upon the local appearances and the weight of the evidence as a whole. The differential diagnosis of conditions, including syphilis, which embarrass even the most experienced clinician is considered in another chapter. Laryngeal Syphilis. — ^Tertiary syphilis may involve any part of the air tube from the epiglottis to the bifurcation of the trachea, the epi- glottis most frequently. This becoming the site of syphilitic inflammation it is infiltrated with its products causing swelling and distortion. This may rapidly break down into ulceration and destruction of the whole cartilage, or, in contrast to the syphilitic lesions of the fauces and pharynx, a chronic sluggish process may exist for years rebellious to treatment but not breaking down with destruction of tissue. In proportion to the amount of the infiltration and in proportion to its transformation into ulceration will be the subsequent deformity and constriction of the SYPHILIS 553 larynx. ^ In a general way these remarks apply not only to the tertiary syphilitic affections of the epiglottis, but to those involving the whole larynx. The appearances of infiltration are more apt to be combined with those of ulceration than to exist alone. The character of the ulcera- tion is the same for the larynx as has been described for the pharynx. Necrosis of the underlying cartilage may almost always be expected. The formation of sphacelus at the bottom of sinuses or under granulation tissue is frequently the cause of the persistence of swelling and infiltration in spite of otherwise most successful treatment in checking the progress of the disease. The supervention of interference with the voice and with respiration quickly brings these persons under observation, and this possibly may be the reason we more frequently see tertiary disease of the larynx in the stages of infiltration than we do like lesions of the nasal, oral, and pharyngeal cavities. These patients may be aphonic or simply hoarse. The latter condition used to be considered pathognomonic and the " raucedo-vocis" in prelaryngoscopic days was a valuable aid in the diagnosis of laryngeal syphilis. There can be no doubt that present- day experience testifies to its value. Hoarseness and a rough tone of the Voice is certainly a much more frequent phenomenon in syphilis than in tuberculosis or cancer, but more accurate methods of diagnosis have displaced, perhaps too completely, a sign to which the exceptions are not infrequent. Dyspnea of a very treacherous and dangerous kind is apt to accompany tertiary syphilitic conditions of the larynx. The patient gradually accus- tomed to the narrowing lumen of the larynx comes to breathe with com- fort through an. opening no larger than a slate pencil. So far as the breathing is concerned he declares he only suffers a little on increased exertion. Almost invariably, in spite of the warning of the laryngoscopist, he disregards or delays the operation of tracheotomy. A slight cold or the supervention of the slight congestion caused by the administra- tion of potassium iodid, or even a spontaneous increase in the inflamma- tory infiltration, within a few minutes puts the patient in extreme peril, and he not infrequently dies from suffocation before surgical help can be afforded. Naturally this is not always the case, but until all inflam- matory infiltration has disappeared, the patient, unsupplied with a tracheotomy tube in situ, must be narrowly watched and always con- sidered in imminent danger. The subsequent narrowing of the tube from cicatricial contraction does not as a rule present this liability to a sudden closure of the remaining breath-way. Instead of these deep ulcerations and massive infiltrations of the larynx which carry so much of immediate danger and so much promise of remote discomfort for the patient in the way of treatment necessary to overcome the cicatrices and contractions, there may be seen in the laryngoscopic mirror a condition of sluggish ulceration of a shallow char- acter which may simulate similar conditions of tuberculosis and cancer. In fact the varying appearances under which laryngeal syphilis may present itself in the laryngoscopic image; the varieties of course and dura- tion as noted in the history; the reluctance with which men admit and 554 THE THROAT IN GENERAL DISEASES the regularity with which women deny having been infected with syphilis, frequently baffle the diagnostic acumen of the most experienced and sur- prise the trained wariness of the most veteran observer. These shallow ulcers, like the deep ones, unless the latter, as frequently happens, have a base of necrotic cartilage, rapidly heal under the administration of ■ antisyphilitic treatment. The situation of the lesion in the cases of tertiary syphilis of the larynx in a general way is a lateral one. Except as it applies to the epiglottis, this is a rule which is fairly constant. Neither the posterior laryngeal wall nor the anterior commissure is apt to be the seat of any kind of a syphilitic lesion, though of course the rule is not an absolute one, since not only does lateral infiltration and ulceration of the cords and ventricles occasionally extend on to the posterior wall, but it occasionally though rarely happens that such conditions have their chief site there. The infiltration may hide the vocal cords from view or the ulcerations may have destroyed them. Sometimes, however, they may be seen. Their movement is not apt to be interfered with. Subglottic infiltrations are frequently seen, as are tracheal ulcerations. Indeed they are more common in syphilis than in tuberculosis of the air tubes so far as laryn- goscopic experience goes. Occasionally a view by direct or by indirect laryngoscopy may reveal ulcerations or localized infiltrations or nodules beyond the bifurcation. Externally there may be swelling and moderate tenderness to pressure over the thyroid cartilage. The cervical lymph nodes are not, as a rule, markedly enlarged. Pain is not a feature that is prominent in tertiary syphilis of the larynx, but there may be an amount of difficulty in deglutition which makes it necessary to feed the patient artificially, and even in less severe obstruction the pain on swallowing may be considerable. Much difference exists in the temperament of the patients, which has an important bearing upon the question of the amount of pain they suffer, so that the statement that syphilitic ulcera- tion of the fauces and upper part of the larynx is unaccompanied by marked pain is to be taken as a general one and is not always true for individual cases. Sequelae. — Rapidly to enumerate the sequelae which may be left behind when the active ulcerative and the destructive processes have been halted by medication we mention: External deformity of the nose, consisting of sinking in of the bridge of the nose which may be slight or extreme, — which may be accompanied by perforation through the external soft parts. The alae nasi may be partially destroyed; finally the whole external nose may be entirely destroyed, leaving an appalling disfigurement by which the whole nasal cavity and even the pharyngeal walls are exposed to view. Internally, any degree of perforation of the cartilaginous and bony septum; dehiscences and stenosis between the lateral walls of the nasal cavity; destruction of the external walls and those of the upper row of accessory sinuses; smaller or larger perforations of the hard palate, making wide communication with the buccal cavity. SYPHILIS 555 Pharyngeal, perforation of the soft palate or its entire destruction, usually replaced by a fibrous membrane, completely or partially cutting off the oropharynx from the nasophraynx; cicatricial adhesion of the f aucial pillars to_ the^ lateral or pharyngeal walls, or rather their conver- sion into cicatricial tissue and fusion with surrounding parts. Laryngeal. — ^Partial or complete destruction of the cartilage of the epiglottis; cicatrices and deformities from this and from the necrosis and expulsion of portions of the cricoid and thyroid cartilages or the whole of one or both of the arytenoids; stenosis, resulting from these fibroid cicatrices and contractions — necessitating tracheotomy. Treatment. — ^A glance at the sequelse as enumerated above should impress the student with the necessity not only for prompt diagnosis but for the institution of efficient treatment. In the primary and sec- ondary stages this calls for the special consideration of the syphilographer rather than for that of a text-book on the diseases of the nose and throat. The intravenous administration of salvarsan, supplemented by the older methods of mercurial medication, may be expected to be efficient locally as well as constitutionally in annihilation of the syphilitic lesions. Locally this treatment may be supplemented in the case of mucous patches in the mouth by the prescription of a bichlorid mouth wash, 1 to 5000, not so much for the healing of the lesion as for the prevention of infec- tion to others and impressing on the patient the fact that he has a com- municable mouth disease. When, however, the diagnosis of the tertiary stage of syphilis is made or suspected from the appearances of ulceration and infiltration no time must be lost. Until the diagnosis is confirmed by the Wassermann reaction or is assured in other ways, small doses of mercury and rapidly increasing doses of iodid of potash must be administered while, when the salvarsan is given, it is usually not neces- sary now to run up the dosage of the iodid of potash, which we have been accustomed to push to the extent of half an ounce a day — excep- tionally to an ounce and even more. Medication should be vigorously used to check the destruction consequent upon the infiltration of the tissues with the products of syphilitic inflammation. Forty-eight hours' delay may be responsible for a nasal deformity or a destruction of the palate which surgery will find great difficulty in remedying. In laryn- geal cases and at times in those in whom an idiosyncrasy has been detected or suspected it is safer that the administration of the iodid medication should be carried out under the constant surveillance of a medical attendant ready to perform tracheotomy at a moment's notice. We have known of more than one death, the direct result of the neglect of this precaution. An inflamed and infiltrated larynx already narrowed in its lumen suddenly becomes more congested or infiltrated with serum and the patient perishes by suffocation before the surgeon can reach him. It is rare indeed that at least a temporary recession of the syphilitic process cannot now be attained by the means at our disposal. Time only will show how much the new methods of medication will prevent recurrences of syphilitic lesions or the supervention of later and slower degenerative processes. The treatment, chiefly surgical, for the correc- 556 THE THROAT IN GENERAL DISEASES tion of the deformities, disturbances, and destruction of tissue has been taken up in a separate chapter. There is no more important rule in the treatment of syphiUtic disease of the nose and throat than that which is directed against any surgical interference with the lesions of the dis- ease until medication has entirely arrested the progress of it. Dead bone should be allowed ample time to separate spontaneously in the nose or hard palate. No attempt should be made to extract cartilage from the larynx until the full force of medication has been felt. Invariably more deformity will be produced by prematurely extracting from the face or nose dead bone, while curettage or incision of a gummatous infil- tration will usually result in the further extension of the inflammatory condition thus stimulated. Nevertheless, it will exceptionally be neces- sary to remove from the larynx dead cartilage and to attempt to separate necrosed bone in the nose from its base. This should never be attempted in the upper regions of the nose when it is possible to avoid it, as the sequestrum may be part of the cribriform plate of the ethmoid beneath which a reparative process has not entirely substituted a new tissue of separation from the cranial- cavity. When by probe and vision it is evident that the dead bone or cartilage no longer forms a part of the structure but is detached from it, steps may be taken to remove it. Sometimes, in the case of the nasal walls a comminution of the seques- trum will be necessary before it can be removed per vias naturales. In the involvement of the external integument, as of the face about the nose, a sinus will frequently lead to dead bone, but many months should elapse before an attempt is made to hasten natm-e's work by the use of an incision and the chisel. We have no reason to regret waiting an even longer period of time than this; after medication has done its duty the dead bone or dead cartilage should oftener than not be con- sidered as a prothesis to preserve the symmetry of structure while nature is making a substitution. In this place it is well also to warn the inexperienced that any history of constitutional syphilis is always a contra-indication against nasal operations, especially on the septum. It has not infrequently happened that an operation upon the nasal septum has resulted disastrously owing to the fact that the patient has been suffering from a latent unsuspected syphilis. Under these circumstances we have seen the whole septum rapidly take on syphilitic inflammatory action and great deformity result. Treatment of Laryngeal Syphilis. — ^The treatment of syphilis has been greatly simplified since the discovery and proper administration of salvarsan, or "606." After the diagnosis has been definitely established, and not before, antisyphilitic treatment is guided by the stage to which the lesion belongs. Chancre of the larynx proper is of such rare occur- rence that it may be dismissed with few remarks, other than that the five cases on record have all been lesions of the epiglottis. In chancre of the epiglottis, the local application of calomel or gray powder after cleansing with peroxid and Dobell's solution is all that is necessary in addition to the internal mercurial treatment, which will be taken up SYPHILIS 557 later. The mucous patch may be similarly treated, and alternating with the calomel powder a 10 per cent, solution of nitrate of silver may be applied upon a cotton-wound applicator. It is seldom necessary to employ fused nitrate of silver in these early manifestations. Constitutional— Alcohol and tobacco are to be forbidden in all instances, while good wholesome food and plenty of air are very essen- tial to prompt recovery. Mercury is the indispensable drug for the systenaic control of syphilis, both in its beginning and ending, although potassium iodid becomes an essential factor in the later stages. The internal administration of mercury is more conveniently and more easily administered without betraying to outsiders the nature of the malady; but it occasions indigestion, intestinal irritation, and possibly salivation. The inunction is quicker in its results and is non-irritating to the gastro- intestinal tract, but it is an uncleanly procedure necessitating the expen- diture of much time and the frequent change of undergarments. By Mouth. — Gray powder, 1 grain or a combination of 1 grain of Dover's powder and 1 grain of gray powder, three times a day after meals for one year, is the ordinary method employed. If the gray powder is given alone, then a month's interval every three months is advisable. If it is given with Dover's powder and it produces no diarrhea, the pills may be increased to six a day. Massa hydrarg. in 1- to 3-grain pills may also be used or liq. hydrarg. perchloridi in |- to 2-dram doses after meals.' Inunction. — R — Ung. hydrarg gra. xl. Adipia lanee gra. xx. may be rubbed in once daily after either a warm bath or proper cleansing of , the area selected for administration with soap and hot water. It is well to begin under the right arm and then under the left; the right groin, then left; and the inner surface of the right thigh, then the left. After utilizing these six localities a day of rest is permitted, when the same procedure is resumed. It is necessary to rub in the mercury for a period of at least twenty to thirty minutes. The quantity of mercury is increased after one month to 60 grains. Calomel Fumigation. — ^Twenty or thirty grains of calomel are sublimed in a saucer or saucepan, placed over an alcohol lamp, and the patient is seated over it iipon a chair surrounded by a sheet and some impervious garment such as a rain coat or a rubber sheet. It is necessary to remain about half an hour in the bath. A bath is given every other day until twelve are taken. A calomel fumigation may be given also by placing in an apparatus designed for the purpose three grains of calomel which is sublimated by an alcohol lamp and the fumes inhaled through the mouth or nose. Treatment of the Tertiary Form. — Pain. — ^When there is perichondritis or necrosis of some of the cartilages of the larynx or epiglottis, and the 1 Pollock, British Medical Journal, April 14, 1906. 558 THE THROAT IN GENERAL DISEASES products of necrosis cannot obtain an outlet, pain is experienced of a lancinating character. The physician cannot wait for the effect of con- stitutional treatment to overcome this pain, but must rely upon some immediate local treatment for temporary relief. If there is a focus of ulceration tending to show that one of the arytenoid cartilages is involved and is.in the process of extrusion, some surgical aid will materially hasten the expulsion of the diseased cartilage. An incision beginning at this point down to the cartilage will frequently relieve the distressing symp- toms. Orthoform blown into the larynx with a powder blower, iodoform or anesthesin used in the same manner, or a 10 per cent, solution of cocain locally applied, will in many instances give the patient consider- able relief. Morphin is also advocated to be used locally. Hot irrigations of Dobell's solution, to which an additional minim to the ounce of car- bolic acid is added, is of great relief to the patient, particularly if injected with the laryngeal syringe and not sprayed. Poultices or external appli- cations of hot lead and opium wash will occasionally give relief. In addition to the pain on swallowing there is likewise difficulty in getting food into the esophagus, which is often due to mechanical obstruction incident to the tumefaction in the posterior part of the larynx. Food is to be taken in a semiliquid state just as in tubercular laryngitis. Hoarseness and Aphonia. — In all cases of laryngeal syphilis hoarseness is present, which extends from a huskiness to the entire loss of voice, depending upon the amount of involvement and the destruction of tissue. Destruction of laryngeal tissue following syphilitic lesions permanently affects the voice and there is no surgical or medical treatment that will restore it. Dyspnea. — ^This distressing condition frequently comes on in the course of laryngeal syphilis, sometimes gradually and often rapidly. In view of this fact a patient appearing with perichondritis or perios- titis due to syphilis should be held under immediate observation either at the hospital or at his home. Absolute rest in bed is essential. Local applications of adrenalin and steam inhalations often ameliorate the symptoms and at least postpone the necessity for tracheotomy. Occasionally deep puncture into the tumefied area will lessen the dysp- nea by permitting the extravasated fluid to escape. There should be at hand measures for an immediate tracheotomy, as the larynx at these times may close up on very short notice. Patients after attending clinics have frequently been taken with dyspnea to the extent of suf- focation before they were able to reach home, and these occurrences are of such frequency that the majority of observers insist upon the patient's remaining in the hospital when he appears in this condition. If dyspnea continues associated with cyanosis it is inadvisable to delay tracheotomy. A low tracheotomy is preferable, as thereby the incision will probably be below the area of obstruction. Ulcers. — Peroxid of hydrogen in half-strength shoiJd be applied locally to the ulceration and the superficial detritus removed in this way. To the ulcer itself a saturated solution of iodin in creosote will frequently bring away a good part of the slough. If this fails after one or two SYPHILIS 559 applications, to accomplish the object, fused nitrate of silver on a probe will be of benefit. If the vilcer is deep with a lot of necrotic tissue within its cavity one is justified in curetting the necrotic tissue away and burn- ing the borders and the floor with the galvanocautery. Constitutional Treatment of the Tertiary Stage. — Intramuscular Injec- tions. — The soluble salts of mercury may be injected into the muscular tissues. Particularly is this advisable when there is intolerance of the skin or digestive tract to the administration of mercury. It is necessary to see the patient at least once a week when this method of treatment is employed. In cases suffering from Bright's disease or chronic liver trouble or in those advanced in life and cachectic, the intramuscular injection of mercury is contra-indicated. Lambkin's preparation known as "gray oil" is obtainable in ampoules^ ready for injection. Ten minims of this preparation should be injected once a week, and this should be continued for at least six weeks. Then an interval of six to eight weeks is allowed, followed by an eight months' treatment of one injection every two weeks. The third course consists in making an injection every two weeks extending over a period of two months, after which a period of six months' interval is permitted, when a monthly injection is made for four months. Some of the soluble preparations are the salicylate of mercury, benzoate of mercury, and perchlorid of mercury. Method of Injection. — ^A glass syringe with a platino-iridium needle somewhat longer than the ordinary hypodermic needle is employed for the injection. The customary aseptic precautions are used here as elsewhere. The buttock is usually selected as the most suitable site for the injection. It is made by deep puncture into the muscular tissue, after which the entrance is closed by either collodion or adhesive plaster. Potassium lodid. — ^This drug is given not as an antidote to syphilitic poisoning, but for promotion of absorption of the inflammatory products and infiltration, and in the later stages of syphilis it is almost indispen- sable. It is well to begin on 20 minims of the saturated solution of potas- sium iodid in a glass of water three times a day after meals. This dosage can be increased 1 minim a dose each day until symptoms of iodism occur, but if there is gastro-intestinal disturbance and immediate symp- toms of iodism, it is well to increase the dose to 40 minims three times a day, and in a number of instances there is greater tolerance from this increased dose than to a graduated one. If potassium iodid is given before meals it will act considerably quicker than if given on a full stomach, and if digestive disturbances follow they may be, in a measure, corrected by essence of pepsin taken at the same time with the drug, and both given in milk instead of water. Aromatic spirits of ammonia will frequently increase the efficacy of potassium iodid, while iron, quinin, and other tonics will aid in its absorption. Where there is intolerance to potassium iodid the sodium iodid may be given with great benefit. The dose may be extended even up to 180 grains, three times a day, and it is often necessary to administer what would appear > Each ampoule contains IJ grains of mercury and the 10 minims recommended for injections contain 1 grain of mercury. 560 THE THROAT IN GENERAL DISEASES an enormous quantity of the iodid to affect the extreme cases. Syrup of hydriodic acid is given in those cases intolerant to K.I., while iron, arsenic and phosphorus, in pill form, materially aid in its absorption. In those cases in which mercury and iodid fail to take effect it is well to put the patient on a pill containing these three drugs. The patient should be watched carefully to see that the iodid rash does not become prominent, and when it appears a combination of potassium iodid and sodium bromid may be substituted. To each patient should be given a mouth wash of chlorate of potash during the administration of mercury, and if diarrhea is associated with the administration of the mercury, opium in crude form should be likewise administered. Saharsan. — Salvarsan may be given by intravenous or by intramus- cular injection. The better results are sometimes probably obtained by intramuscular administration, but the danger of encystment, also the severe pain incident thereto, render this method objectionable, and it has been largely given up in favor of the intravenous method. For intravenous administration salvarsan is prepared in alkaline solution so that 50 c.c. of the solution represents 0.1 gm. of the drug, while the newer neosalvarsan is prepared in a neutral solution of such strength that 25 c.c. equal 0.15 gm. (0.15 gm. neosalvarsan is equivalent to 0.1 gm. salvarsan.) The drug comes in sealed glass ampuls, one of which contains the average adult dose. These should be carefully inspected before breaking to make sure that no change has occurred in the contents, such as change of color or alteration in the powdered form. To prepare the salvarsan solution, carefully empty the contents of the ampul on top of 300 c.c. of freshly redistilled, sterile boiling water and allow it to stand a few minutes until solution occurs. Then slowly add sodium hydroxid to neutralize the acid present. When this is first added a heavy precipitate is thrown down, but the addition should continue until it is all in solution. Usually 1.4 c.c. of a 15 per cent, solution of sodium hydroxid meets this requirement. With neosalvarsan it is only neces- sary to add the contents of an ampul to 150 c.c. of cold, redistilled, sterile water and solution will quickly occur. This should not be done, however, until just before using, as oxidation occurs rapidly at the tem- perature of the room. The use of redistilled water is important, as much of the toxic action of the salvarsan may be obviated by using water that has been redistilled until it has lost all traces of solid matter, either mineral or organic. The plan of administering salvarsan at the Manhattan Eye, Ear, and Throat Hospital, devised and carried out by Dr. Callisen, is to place the prepared drug in a graduated container, with the salt solution in another graduated container. These two con- tainers are connected with a Y-two-way valve by means of an arsenic- free rubber tubing, while a single tube leads away from the valve. When everything is ready, a tourniquet is placed around the arm and the patient is instructed to clench the fist. The operator, after locating a vein by touch, grasps the arm at the elbow with the left hand and draws the skin taut over the vein. With the right hand the needle is thrust into the vein until it bleeds freely. A sharp needle with a long, tapering SYPHILIS 561 bevel should be selected. The needle is placed, bevel side down, over the vein at such an angle that the face of the bevel is about parallel with the long axis of the vein. As soon as the point of the needle has pene- trated the first wall of the vein, the point should be lifted up to prevent its passing through both walls. With the blood running freely from the needle and the salt solution from the rubber tubing, the connection is now made between the two and the tourniquet removed from the arm. As soon as it is determined that the salt solution is passing into the vein, turn the valve and allow the medication to pass into the vein. After the desired amount of drug has been administered, allow the salt solu- tion to run through the needle again to wash away all traces of the salvarsan before withdrawal, as small amounts of the salvarsan injected in the vein wall and subcutaneous tissues may cause a cellulitis. The treatment of syphilis by the administration of single doses of salvarsan at long intervals is to be condemned. Such single doses cause the destruction of the free, active spirochetes, but release less of the protective substances which the tissues have elaborated. With this loss comes a rapid proliferation of the spirochetes remaining and the appearance of recidives. These recurrences seem more prone to affect the central nervous system. The patient is then in a worse condition than before treatment. The better plan is to use salvarsan for its effect in destroying the active, free parasites, and likewise administer both potassium iodid and mercury. The iodids hasten the absorption of the exudates and inflammatory new formations, setting free the encysted spirochetes. Mercury, through its spirillicide and inhibitory action, will prevent the rapid proliferation which gives rise to these " neurorecidives." The plan of treatment and the number of injections of salvarsan to be given will depend on the status of the individual case. A reliable plan to follow, as recommended by Swift and Ellis, is to administer four or five intravenous injections of 0.3 to 0.5 gm. of salvarsan at intervals of from five to seven days, combined with or followed by a course of soluble mercury by intramuscular injection. After the mercurial treat- ment salvarsan should again be repeated. If these two specifics are alternated, a most intensive treatment can be given with but little danger of an accumulative action from either drug. In the primary stage before the appearance of a positive Wassermann reaction, one course of each drug should be given. With a well-established Wassermann reaction two courses of salvarsan and one of mercury should be given, and after the outbreak of secondaries, at least two of salvarsan and three of mercury. The tertiary stages of syphilis are vastly more resistant to treatment, and so the use of these two drugs must be more persistent and longer continued. Repeated courses of mercury and salvarsan must be given to obtain results, and in many cases the best to be hoped for is to hold the disease in check while the patient remains free from clinical manifes- tations. In a certain number of these cases the Wassermann reaction remains positive in spite of all treatment. The unpleasant constitutional disturbances incident to the injection of salvarsan, such as nausea, vomiting, fever, etc., are largely avoided by 36 562 THE THROAT IN GENERAL DISEASES putting the patient to bed for twelve hours at least after the injection, and the administration of some aperient water on the following morning. A free evacuation of the bowels the night before the injection is also ad- visable. There are a number of contra-indications to the administration of salvarsan, such as marked chorioidoretinitis, acute syphilitic iritis, advanced Bright's disease, advanced myocarditis, and marked involve- ment of the nervous system. Some of these contra-indications are being daily eliminated by further experiment with the administration of sal- varsan where the doses are graduated and additional administration of other drugs which have eliminated the dangers incident to its injection. (For the treatment of the results of cicatricial contractions in the larynx and of loss of tissue elsewhere by syphilitic and other processes, see p. 647.) TUBERCULOSIS OF THE NOSE AND THROAT. Etiology. — So much has been said in regard to the etiology of tuber- culosis and it has so thoroughly entered into the knowledge of all medical practitioners that in a special work of this kind it is not necessary to treat of it except in the most cursory manner. Before the discovery of the tubercle bacillus, a number of pathological lesions were called tubercle which are now recognized as having no etiological connection with the bacillus of Koch. All such lesions have been crossed out of our nomen- clature as tubercle which do not give either direct or indirect evidence of the existence in them of the tubercle bacillus. Intimately connected with the lesion as is the tubercle bacillus, we have been compelled within the last decade to recognize the fact that both the tubercle bacillus and anatomical tubercle can be demonstrated postmortem upon the mucous membranes or in the internal organs of man in a very large majority of adults. As a corollary to this, it naturally follows that the decision as to whether a man is to die from tuberculosis depends upon other etiological factors in the disease than the presence of the tubercle bacillus in his body. A fresh invasion of a malignant form of the tubercle bacilli possibly may rapidly lead to an efHorescent tuberculosis and to an early death, but as a rule the tubercle bacillus excites lesions in the human organism which are not fatal in the majority of cases, and they usually pass unnoticed in the ordinary routine of clinical diagnosis and are only revealed as existing, either by careful examination at autopsy or by means of the delicate serological reactions now employed in clinical work. The term tuberculous diathesis or dyscrasia has passed out of scien- tific usage "and for these terms we have substituted those of latent tuber- culosis or of tuberculous heredity, and under careful analysis it will be found that they are quite as vague in their significance as the terms they have displaced. Latent tuberculosis, if we are to define it as a tuber- culosis which exists without symptoms, is open to the criticism that the symptomatology may be stretched to include its reaction to the von TUBERCULOSIS OF THE NOSE AND THROAT 563 Pirquet test or to the injection of tuberculin subcutaneously. By this means an affection which might be latent for the practitioner who did not use it becomes patent to him who takes advantage of modern methods of diagnosis. Until the age of six months children almost all react negatively to the von Pirquet skin test for tuberculosis. Gradually the percentage of positive reactions rises with the age, and at 15 years over one-half of all children give a positive reaction. This percentage goes on increasing in adult life, at 40 the vast majority of persons usually giving a positive reaction. As for the latent lesions of the upper passages which have been iden- tified in other ways than by the von Pirquet test, tuberculosis of the tonsil, in the sense of the presence of anatomical tubercle discernible by the microscope, is present not only in a very large proportion of cases of phthisis, but in an appreciable percentage of those children with enlarged tonsils not presenting clinically any other evidences of tuber- culosis, say from 1 to 5 per cent, of unselected cases. Children with adenitis, ill-nourished but with no definite clinical signs of tubercu- losis aside from that of the von Pirquet test, will be found microscopic- ally to have tubercle in the tonsil in a much larger proportion of the cases than this. It is probable that in a considerable proportion the microscopical lesions thus produced and revealed only by the use of the microscope, that is, the so-called larval or latent tuberculosis of tonsils in children, the lesion is due to infection with the bovine bacillus, but this is a statement which rests as yet upon insufficient work of differen- tiation in these cases. It is a significant fact that the faucial tonsil is much more frequently the site of larval tuberculosis than the pharyn- geal tonsil. We may suspect that this preponderance is due to the fact that the bacillus finds entrance into the faucial tonsil from the contSct of the food to which the pharyngeal tonsil is not exposed; but adenoids existing as dependent masses in the nasopharynx and constantly washed by the drip of secretions would naturally not afford a resting place for the bacillus derived from the air current as often as would the deep crypts in the fauces which act as pits to which the nasal secretion drains. At any rate, clinical facts all go to indicate that a considerable amount of tuberculous infection gains entrance to the system through the lym- phoid material of the throat. Contrary, however, to what was supposed when this first became probable, pulmonary infection does not take place directly through the lymph channels. Beitzke, who a number of years ago drew attention to the fact that the cervical lymphatics in children do not communicate with the thoracic lymphatics but are gathered into a common trunk at the level of the lower cornu of the thyroid cartilage and thus enter the vena cava separate from the pulmonary lymphatics, came to this conclusion. Lately in support of his former observation he has published^ an account of the examination of the general lymphatic-gland system of 27 apparently non-tuberculous children so far as the naked-eye inspection at post- 1 Beitzke, Verhandlungen der Deutaohe Pathologiache Gesellschaft, 1912, p. 100. 564 THE THROAT IN GENERAL DISEASES mortem could determine it. He found tubercle or the tubercle bacillus in the glands of nine of these cases, that is, 33 per cent., by means of microscopical examination. The point of entrance of the tubercle bacillus into the system of man has been the subject of the liveliest discussion and the most elaborate experiment. By the demonstration of the almost universal tuberculi- zation of the human race, the question of late has assumed a new phase and a new importance. As we cannot here go into the subject of the entrance of the bacillus by other ways than the air passages, it must suffice to state that there can be no reasonable doubt that it finds its way into the blood current from the gastro-intestinal tract in a certain number of cases, but if this is so it will have to be admitted that the bacillus in these cases does not leave traces of primary lesion of the mucosa or of the peritoneal surfaces contiguous to it. There is a question, how- ever, quite germain to our special subject, and that is as to whether the tubercle bacillus finds an entrance into the lungs directly by the air current or whether it is secondarily deposited there by blood channels. We have seen that a certain amount of evidence goes to show that those bacilli which lodge on the mucous membranes of the upper air passages do not traverse the lymph channels below the larynx. It is very evident, from what has already been said of infection of the cervical lymph nodes, that a considerable amount of tuberculous infection does occur directly through the upper air passages, but this does not exclude in itself the possibility of a certain number of tubercle bacilli being carried in the air current below the chink of the glottis; indeed, it is probable that under certain conditions this occurs. We believe, however, that it is exceptional and is not the usual method by which in nature man is infected with the tubercle bacillus. ■ Owing to the capacity of the air passages, the nose especially, as a filter for the inspired air; owing to the high point in the pulmonary tract at which the air becomes stationary; owing to the vigor of action of the tracheal and bronchial cilia, the a priori argument against the pulmonary tract as the region of admission for the bacillus in its first inroads is very strong. We have already drawn attention to the fact, in the discussion of the physiology of the nose, that it has been experimentally demon- strated that a very large proportion of the bacterial contents of the inspired air is deposited upon the mucous surfaces of the nose. It seems very likely that a considerably larger proportion is deposited in natural inspiration than the experiments demonstrate. After the passage of the soft palate there are broad surfaces of damp mucosa over which inspired air is distributed, and those bacteria remaining in it after passing the nose must to a large extent be filtered from the air by the time it passes to the trachea. The tremendous energy of the tracheal cilia and of those of the other surfaces of the air passages supplied with columnar ciliated epithelium rapidly extrudes foreign matter from the lower tubes. There is, however, a very large amount of direct experi- mental evidence which has been brought forward to demonstrate that, in spite of the apparent safeguards of nasal filtration and of damp mucous surfaces in the pharynx, and of the function of the cilia, the TUBERCULOSIS OF THE NOSE AND THROAT 565 tubercle bacillus does find entrance to the ultimate bronchi before it lodges on the mucosa. This evidence, we believe, however, will not stand a critical analysis. In the first place experiments have been carried out with an amount of microorganisms in the inspired air or an amount of dust to represent them, which practically never obtains in the environ- ment of man. The demonstration of the bacilli upon the surface or in the epithelium of the pulmonary vesicles is by no means satisfactory evidence that they got there in the air current. Carmine granules injected at distant sites in the body will, after a comparatively short time, find their way to the pulmonary epithelium and be excreted in the pulmonary secretion. After the inhalation experiments which have been so frequently ad- duced as evidence of air-borne infection, the demonstration of bacilli or dust in the lungs must be invalidated by the consideration that it may have been brought from the mucous surfaces above, where it has entered and may have been carried by the circulation to the pulmonary locality most commonly noted as the site of an initial tuberculous lesion of the lungs. This is undoubtedly at the apices. There is considerable evidence to indicate that under certain local conditions the action of the cilia on some mucous surfaces is reversed and that infection is carried up the genito-urinary and intestinal tracts; but while this might explain peripheral infection of the lung by bacteria deposited on the surfaces of the nasal and pharyngeal mucosa were the initial lesion equal in its proportional local incidence, it does not explain the preponderance of initial apical lesions. This must be sought in the supposition of a local predisposition or in some supposition involving the mechanism of the pulmonary circulation. The assertion that the lesion can always be demonstrated at the point of entrance through the mucosa has long since been abandoned in favor of the assertion that it can always be demonstrated in the neighboring lymph nodes. Clinical observation renders it likely that this assertion will also eventually have to be given up, in spite of the strong experi- mental evidence in favor of it. To assert that every live bacillus that passes into a lymph node cannot escape until it has produced tubercle, or only get through a lymph node after proliferating there, has not been proved, and clinical observation furnishes evidence which tends to refute the assertion. It seems probable that the invasion of the mucous membranes of the upper air passages is due to some extent to a direct surface infection, but doubtless in the majority of the cases such surface lesion is an auto- infection. So far as the clinical evidence goes, it points to the lungs as the site of the primary development of tubercle. While there are excep- tions to this rule, it is probably applicable to the majority of the cases. Nevertheless in the lymph nodes of the abdominal cavity, but especially in the tonsils and in the lymph nodes between them and the larynx, lesions are found which are discovered only from'microscopical examina- tion of the tissues. It is true that in one or twocases at'postmortem tuber- culous lesions have been seen in the larynx and in the trachea and none 566 THE THROAT IN GENERAL DISEASES found elsewhere in the body. As the great majority of patients with tuberculosis are those who are suffering manifestly from pulmonary lesions, the occurrence of these examples of primary tubercle in the larynx is entirely too rare to account for them acting as foci of dissemi- nation to the lungs. We must believe then that the lungs are affected either by direct inoculation or that the bacillus has been carried in the circulating fluids of the body from the point where it has passed the epithelial line in the mucosa of the upper air passages. As has been intimated, it seems entirely impossible that lesions of the ultimate bronchioles, especially at the apex of the lung, could be due to direct air-borne infection. The a priori argument for blood-borne infection to account for such lesions seems very strong. The method of infection of Fig. 294 Transverse section of larynx of stillborn infant just below vocal cords. the larynx secondarily seems to be through the surface epithelium. As will be noted the great majority of the tuberculous lesions of the upper air passages are at the glottis, where there is epithelium of a pavement type unsupplied by cilia and exposed to the air current, in coughing, from below, and more or less to inhalation and to aspiration from above. Not only have we here epithelium of the pavement type from which secre- tions can only be removed by the air current or by movement of the larynx, but here the mucosa is more firmly bound to the submucosa and to the cartilages. Fig. 294 represents a section across the larynx of a stillborn infant just below the vocal cords. It will be seen that the epithelial and sub- epithelial layers are connected by very loose areolar tissue with the TUBERCULOSIS OF THE NOSE AND THROAT 567 underlying firmer fibro-elastic connective tissue and perichondrium of the air tubes. When a child screams, when a stentorian-voiced street hawker shouts his wares, when a consumptive has a paroxysm of cough- ing, the air tube is put on a stretch and over that part of the area in which the epithelium is not so firmly bound to the subepithelial struc- tures as it is over the vocal process and posterior wall, it presents fewer tuberculous lesions. In the child especially we have such a loose-fit, accordion-plaited arrangement of the epithelial wall that a breach is not easily made in the epithelial line. The relative frequency of laryn- geal tuberculosis is very much less in children than in adults. Some of this difference may be due to the anatomical configuration referred to, but it is probable that the fact of the lesser frequency of tuberculous laryngitis in children is associated with the fact that a smaller proportion of them have pulmonary disease and a larger proportion have tuber- culous involvement elsewhere. The tuberculous lesions of the larynx have been seen, it is true, under one year of age, but it has seldom been remarked before the age of fifteen. It is most common between twenty and forty. During these two decades of life, 70 per cent, of the lesions of tuberculous laryngitis occur. Authors differ very much as to the frequency with which tuberculous laryngitis is associated with pulmonary disease. The estimations of percentage runs from 13 (Willigk) to 97 per cent. (Schaeffer). This association of the pulmonary and laryngeal lesion depends largely upon the stage to which the pulmonary tuberculous disease has advanced. Tuberculous disease is very much more common in men (71 per cent.) than in women (29 per cent.).i In adults the laryngeal epithelium, as we have seen, has not only lost its cilia and become more or less the seat of a metaplasia, but the subconnective network binds it more closely to the larynx. We can readily understand why it appears to be more vulnerable to the bacilli in the secretions from below in a tuberculous lung. These are cast by coughing more upon the posterior wall of the larynx, where we see the most frequent site not only of the metaplasia but the place of the firmer attachment to subjacent tissue than elsewhere in the glottis. As an illustration of the method of infection of the larynx even through hyperplastic epithelium, we may mention the appearances seen in a microscopic section passing through the mucosa of a tuber- culous larynx at the glottis in a patient who was in the last stages of pulmonary disease. The specimen was removed during life, and it could be easily seen that the bacilli were most abundant in the super- ficial layers and were passing readily through them toward the deeper tissues. While it seems certain that the vast majority of tuberculous lesions of the larynx are brought about in this way as secondary to pulmonary involvement, it has been definitely proved by postmortem examination that primary tuberculosis of the larynx and trachea can exist, it having been found as the sole evidence of tuberculous infection at postmortem examination. ' These statistics are chiefly derived from the text-books of Morris Schmidt and Bosworth. 568 THE THROAT IN GENERAL DISEASES Location of the Lesion. — If, however, this were the usual course of events, the frequency with which tuberculous lesions present themselves should be the nose, the mouth, the pharynx, the larynx, the trachea, and the lungs. On the contrary, the reverse is the rule as borne out in clinical experience and in pathological investigation. Tuberculosis of the larynx, however, presents itself not only as a lesion of the glottis, but it is seen in the edematous swellings of the epiglottis and the arytenoid tips and, indeed, as involving the whole of the laryngeal structure. While the larynx is the most frequent site of the involvement of the upper air pas- sages in a tuberculous process, it should be remembered that the subglottic spaces and the trachea compete with it in frequency below, while above the tuberculosis of the pharynx, tuberculosis of the tongue and of the nose are found with rapidly diminishing frequency. In the nose it has been seen as shallow, ragged ulceration nearly always in advanced stages of tuberculosis elsewhere, but it has also been observed in the form of a smooth, round swelling, the so-called tuberculoma. Upon the tongue and the lips, small white patches are seen in tuberculous patients, which resemble herpetic lesions (Plate X), but which are found upon examina- tion to be due to infection with the tubercle bacillus. Deeper more destructive lesions of the tongue are occasionally seen as the result of tuberculosis, and these have resembled carcinoma so much that the tongue has been removed under that misapprehension. In the pharynx it usually occurs as a more or less widespread and superficial but extremely painful ulceration with ragged edges, usually secondary to lesions else- where in the advanced stages. Miliary tuberculosis of the pharynx is observed in the acute infections of tuberculosis. They appear first as dusky granules scattered over the anterior surface of the soft palate and soon break down into confluent, ragged, and painful ulceration. Pathology. — ^The histology of tubercle is said to be the same every- where it occurs, and there is a constancy for the most part in tuberculous lesions which is rather the exception in other processes of inflammation. As to the typical tuberculous inflammation, this is not the proper place to dwell upon it at length. Here, as elsewhere, it occurs as a focus for the deposit of inflammatory products consisting of round cells supported by trabeculae which contain more or less fibrous tissue growing at the edge of the process. In the centre of this mass of round cells is apt to be seen more or less necrosis, while scattered through it and in this neigh- borhood are patches of the so-called epithelioid cells and the peculiar unipolar Langhans giant cell typical of tubercle. Bacilli can be demon- strated especially in the periphery of the areas of coagulation necrosis and in the giant cells, but this demonstration is often attended with con- siderable difficulty. This being the typical structure of tubercle in the larynx, it remains to speak more particularly of some of the exceptional forms more or less peculiar to the situation in the larynx. The initial lesion is first seen in the laryngoscope as a white thickening of the epithelium, especially upon the posterior wall. This may be so exaggerated as to form true papillomatous masses occluding the glottis more or less completely. At TUBERCULOSIS OF THE NOSE AND THROAT 569 their base will be found, on microscopical section, the true tubercle, but there is little to distinguish them from the papillomata ordinarily seen in the larynx without tuberculous complicatioris, unless one removes for examination more than the superficial parts. There may be very little infiltration discernible to the naked eye, but in these cases there is always a considerable amount of round-cell infiltration in the papillo- matous form of tuberculous laryngitis. This may be accompanied by an amount of edema which betrays to the practised eye of the clinician the fact that he has to do with something more than a simple neoplasm. This edema and infiltration may exist over the whole of the larynx, penetrate the cartilage, and be accompanied by necrosis of the framework of the larynx, so that pieces of necrosed cartilage may be, though rarely, present in the expectoration of patients with tuberculous laryngitis. It is the involvement of the deeper structures of the larynx in the lesion, inter- fering as it does with the normal blood-supply, that is the cause of the edema. The infiltration impinging as it does on the bloodvessels which lie close to the unyielding cartilage, the venous return is interfered with and we have the resultant edema peculiar to laryngeal tuberculosis. There may be, however, little or no epithelial proliferation, not enough to be seen in the laryngoscope, but the lesion presents itself as a more or less deep and widespread ulceration and infiltration of the surface. The minute ulcers referred to as existing on the tongue differ histo- logically in no way from the tuberculous ulcerations seen elsewhere, and the same may be said of the pharyngeal infiltration and the ulcerative lesions of the nose. Tuberculoma. — ^The form of tuberculoma, however, is rather peculiar. It is accompanied by a large amount of coagulation necrosis, so that both in its gross appearance and in its finer structure it may give the impres- sion of a gumma. Even the presence of numerous giant cells cannot always serve as differentiating evidence, since in the nose and throat such phenomena are not unusual in syphilitic lesions. However, the attempts at repair which are always more or less present in tuberculous lesions, evidenced by fibrous proliferation around small necrotic areas, will serve to distinguish it from syphilis, while the existence of very wide- spread areas of necrosis which one usually sees in gumma of the nose and throat would cause the histologist to think of syphilis. No con- clusive opinion, however, can be given as to the nature of the lesion without the demonstration of the tubercle bacillus or the infection of guinea-pigs with tubercle bacilli derived from bits of tissue removed from the lesion. Jjwpus Vulgaris. — Another of the exceptional forms of tuberculosis of the mucous membranes of the upper air passages is lupus vulgaris. Because the clinical appearance of this lesion is so strikingly different from the recognized lesions of tuberculosis upon the skin, earlier derma- tologists declared it had nothing to do with tuberculosis. It is now thoroughly recognized that all cases except those which are sometimes still called lupus erythematosus present microscopically more or less 570 THE THROAT IN GENERAL DISEASES typical lesions of tubercle, and in them the tubercle bacillus is probably always present, though it cannot always be demonstrated. The necrosis of tissue is not so widespread and the fibrosis is apt to be more marked, but essentially the description which has been given of the minute struc- ture of typical tuberculosis can be applied to the lesions of lupus. Lupus as a primary lesion of the upper air passages is a rare occurrence. It is seen with greatest frequency at the entrance of the nostrils in com- bination with lupus of the skin. It has been confidently asserted that in these cases the process more frequently begins upon the mucous mem- brane of the internal nose and spreads outward to the skin than the re- verse. This nasal lesion may exist upon the septum or upon the alar wall of the nasal vestibule. Its coexistence oh the mucosa and skin has been remarked in from 20 to 65 per cent, of the cases. In a painless affection of the internal nose not producing obstruction, this is strongly indicative of a considerable number of cases having been primary there. That the bacillus has been carried there by the finger-nail is probable but entirely conjectural. Lupus has been observed far within the nasal cavity and it is occasionally, though rarely, seen in the larynx and pharynx as a primary affection. We have seen it on the uvula as well as in the larynx, but elsewhere than at the introitus narium it is a rare affection. It must, however, be remarked that the rarity or frequency of its laryngeal manifestation depends somewhat upon the classification the clinical observer makes of the forms of tuberculosis, since there are all gradations in these from the lupoid form to the frank typical tuberculosis. Hasland has gone so far as to recognize laryngeal lupus occurring in 9 per cent, of the cases of skin lupus and Mygind has given about the same figures. The gross appearance of what is com- monly called lupus of the mucous membranes consists in small, dusky- white tubercles clustered together over a limited area of the surface, or they may be seen on the swollen mucosa as pearl-like white masses beneath the epithelium, the whole having sometimes a dusty look. These low excrescences may be exaggerated to the form of papillary masses similar to those seen often around a tuberculous ulcer. There is not, as a rule, any true ulceration in typical lupus, but the tissue seems to melt away and to be gradually replaced by scar tissue. The color of these patches may be dark and congested looking or paler than the surrounding mucous membrane. This appearance may take the place of the small tubercles referred to and they may advance to neighboring areas of the mucous membrane. These gross appearances are often strildngly similar to certain forms of syphilis. The question of the combination of a syphilitic lesion with a tuber- culous lesion has never been satisfactorily settled. We are unaware that the coexistence of the tubercle bacillus and the Treponema pallidum has ever been noted in any lesion. That syphilis occurs in tuberculous persons is of course admitted, but the mutual effect of one condition upon the other has not been sufficiently defined to warrant any attempt to describe the clinical result. That a tuberculous lesion may have been engrafted on a syphilitic lesion in a given case seems a very possible TUBERCULOSIS OF THE NOSE AND THROAT 571 thing, but we are not familiar with a report of any such instance in which the proof of its occurrence was conclusive. Differential Microscopical Appearances. — Upon these we have dealt to some extent in discussing the finer anatomy of tubercle. The epithelial proliferation to which we have referred as occurring in other conditions of the larynx and which occurs upon tuberculous ulcers may give rise at times to doubt in the mind of the histologist as to whether he has to do with epithelioma or tubercle, but as a rule this rarely enters into the microscopical differentiation of a tuberculous lesion. The differentia- tion from syphilis is a matter of much more difficulty. It sometimes, though rarely, arises with tuberculous involvement of the cartilage and the bone, but when it does so the process has advanced so far that the clinical diagnosis is quite apparent and the pathologist does not have the question of differentiation referred to him. It must be remembered, however, that frequently the histologist will have to depend upon other evidences for differentiation, than those presented by minute structural appearances. If the tubercle bacillus can be demonstrated either l^y tinctorial reaction in the tissues or by animal inoculation, the question is definitely settled. The nearer the lesion resembles the typical tubercle which has been described above, the more unlikely is the lesion to be of a syphilitic nature, but the absence of the demonstration of the tubercle bacillus morphologically should weigh but little in the exclusion of tuber- culosis. Attempts may be made to demonstrate the Treponema pallidum to establish the existence of a syphilitic lesion, but this is attended by even more difficulties than the demonstration of the tubercle bacillus in the tissue. The von Pirquet reaction and the Wassermann reaction may be of some value as a help to the histologist, but the other clinical mani- festations such as behavior toward treatment and the course of the temperature will be of greater value to him as well as to the clinician. The diagnosis of the latent tuberculosis of the tonsils is attended by considerable difficulty because children often present no other evidence of tuberculosis. Such cases occur in about 5 per cent, of hypertrophied tonsils. Absolutely to exclude by microscopical examination the presence of tubercles in a tonsil removed at operation, especially if the child has marked cervical adenitis, is a laborious process for the histologist, but he cannot be sure until he has sectioned the last fragment of each tonsil that he will not finally meet with typical tubercle in these cases. A more satisfactory way to establish the existence of latent tuberculosis is to chop up the removed tonsil to very fine fragments, digest them with antif ormin ^to kill the other bacteria, and the semifluid mass is then injected into guinea-pigs. Upon the result of this inoculation one may frequently have to depend for a satisfactory exclusion of the possibility of there being tubercle bacilli in the tonsil of these children. Under the name of lupus pernio Siebenmann^ has described a unique case of a concomitant lesion of the face known to dermatologists under that name and a nodular lesion of the lips, fauces, pharynx and larynx. 1 Archiv f. Laryogologie und Rhiuologie, 1907, xix, S. 177. 572 THE THROAT IN GENERAL DISEASES He seemed to think others had been described as belonging to the lesion of pseudoleukemia. Upon the mucous membranes it shows the con- gested blue appearance remarked on the skin. Histologically the char- acter of tubercle structure is fairly characteristic and the appearance on the mucosa, according to the illustrations, approximates other vari- ations in the gross appearances of lupus. Symptoms. — Those of General Tuberculosis. — It is convenient to dis- cuss them in this way because otherwise the observer will too often lose sight of the value of a consideration of the whole problem of diagnosis, prognosis, and advice in cases of tuberculous lesions of the upper air pas- sages. When the laryngologist is confronted with a lesion of the upper air passages which he supposes to be of a tuberculous character, he natu- rally seeks evidence of tuberculosis in the lungs or elsewhere. He will not be so vitally concerned to know if the patient harbors anywhere in his body a latent tubercle or a stray tubercle bacillus as to know whether or not the body tissues of the patient have elsewhere given evidence mani- fest enough to clinical experience for it to be easily detected. He desires to know this in order to gauge the natural resistance or the natural pro- clivity of the tissues of the upper air passages to lesions initiated by the more or less ubiquitous tubercle bacillus. Especially is his attention directed to the lungs. An extent of pulmonary tissue involved in a tuberculous lesion of sufficient area to betray itself by cough, hemoptysis, temperature, emaciation, night-sweats, etc., has great influence in deter- mining his opinion as to the significance of an epithelial erosion or hyper- plasia in the pharynx or larynx. We do not wish to go into the matter of the general symptoms of tuberculosis further than to emphasize the importance which an afternoon temperature curve should assume in clinical considerations, and to remark upon the proper weight to give to the demonstrations of the presence or absence of the tubercle bacillus and to the von Pirquet reaction. Often the pulmonary signs may be so equivocal that the daily afternoon temperature record taken by the physi- cian will be of great value. The uncertainty in the demonstration of the tubercle bacillus in the sputum depends upon the examiner and upon the individual patient. Repeated examinations may be necessary to eliminate the errors of the one and the pathological idiosyncrasies of the other. Caution must be observed in accepting the report of positive findings in the light of recent revelations of the liability to error in the matter of technique of demonstrating the tubercle bacillus. Acid-fast bacilli are found in the water and containers of the laboratory with suffi- cient frequency to make it of slight though of sufiicient importance for remark. The recently introduced technique of " enriching the field" with tubercle bacilli, as the phrase runs, has resulted in the revelation that certain granules supposed to be derived from tubercle bacilli and called Much's granules are often in reality acid-fast particles of fats or lipoids left behind in the dissolving process of liquefaction of the protein in the sputum by the use of antiformin. The protein of the mucopus and of other microorganisms than the acid-fast varieties is liquefied it is true, but the composition of protein, varying as it does both for cell and cellular TUBERCULOSIS OF THE NOSE AND THROAT 573 secretion, often has for some of its components fat and the lipoids. These resisting the action of the antif ormin or Hgroin are left behind and stripped of their protein' hulls, become acid-fast particles and serve, in rare in- stances, it is true, to confuse the observer with the microscope. While these sources of error are not of sufficient importance greatly to invali- date a positive report of tubercle bacilli in the sputum, they have been sufficient to cause some laboratories to issue positive reports under the head of "acid-fast bacilli" and are sufficient to deprive a positive re- port of its absolute confirmation of the diagnosis of tuberculosis of the air passages, it having been long recognized that a negative report is of value only in proportion to the care exercised and to the repetition of its negative character. As to the von Pirquet reaction the reverse is true. Recent experience with it has shown that in adults its positive reading is of little practical value, while its negative character is of great weight. While the majority of individuals at the age of the greatest incidence of tuberculosis of the upper air passages react positively to the skin test with tuberculin, they do not all do so. A negative reaction then in a person between twenty and forty years of age is fairly confirmative of the correctness of a negative diagnosis of tuberculosis based on the lack of other evidence, inasmuch as it is apparently only very rarely that even a latent tuberculous lesion exists in a patient not giving a fairly definite positive reaction. The degree of the reaction is held to be of some sig- nificance as to the extent or virulence of the existing systemic lesion, but this cannot be held to be true sufficiently often to make it of great value. Symptoms of the Local Lesions. — Nasal. — In the nose a tuberculous lesion may exist for an unknown length of time without giving rise to subjective symptoms, and when they are complained of they are usually only those of obstruction ascribable also to many other intranasal states. It is due to this fact probably that a tuberculous nasal lesion is supposed to so rarely occur in persons not in advanced stages of tuberculosis in other organs. The patient therefore only rarely draws the physician's attention to an occlusion or bleeding of the nostril due to a tuberculous lesion, and the laryngologist rarely thinks it is worth while to make careful intranasal examination in a case of tuberculous laryngitis as a matter of routine. Under the caption of histology and pathology something has already been said of the gross appearance, and in the consideration of lesions in localities immediately to be taken up more will be said as to the charac- ters of tuberculous tumors and ulcerations as revealed by examination. Pharyngeal and Laryngeal. — In the later stages of laryngeal tubercu- losis and in the initial conditions of pharyngeal ulceration pain is the prominent and distressing feature. Excruciating in character, it makes the patient's existence a torture. He has to choose between the torture of hunger and that of deglutition in well-developed conditions. Pain radiates to the ear and the side of the face. Swallowing of water or semi- fluids often causes more pain than solids. It is owing more to the element of pain than to the progress of deeper lesions that these patients so rapidly deteriorate. Hunger and physical suffering from the pain are added to 574 THE THROAT IN GENERAL DISEASES the pyrexia to cause this rapid decline. While this is the typical picture of tuberculosis of the throat many exceptions are noted peculiar to individuals and to the stage of the disease and to a large extent to the character of the lesion. In hipus, so classified from the gross appearance of the lesion, pain is so regularly absent that on this exceptional feature alone some observers are incUned to place painless cases of tuberculous laryngitis and pharyn- gitis in the category of lupus. In tuberculoma the same remark holds true. In the last stages of tuberculosis deep ulcerations and extensive infiltra- tions of tuberculous lesions in the pharynx and larynx sometimes exist without seeming to distress the patients much. This applies not only to those in articulo mortis, in whom the senses are obtunded, but such pa- tients, though far beyond all hope of recovery, may live for many months without suffering or at least without complaining greatly. As to individ- ual cases, complaint of pain varies largely with the temperament. Some, it is true, bear their sufferings with fortitude and stoicism, while others do not. Whether this is all due to moral stamina or neural obtuseness is not always clear. Pain is not only at times absent at the terminal stages of the disease, but more or less regularly absent in the initial stages of the lesion, especialh- in the glottis of the larynx. Ulceration at the top of the larynx on the epiglottis and the thyro-epiglottic folds, even when minimal in amount, is almost sure to give rise to great pain on degluti- tion. This is only slightly less true of edematous infiltrations in those situations unaccompanied by visible ulceration. The papillary form of tuberculous lesion of the glottis may go on to serious obstruction without giving rise to great pain. The enlargement of cervical glands is not a dis- tinctive feature in the symptomatology of tuberculous lesions of the upper air passages, though it may exist to an appreciable degree. Hoarseness and dyspnea and cough are symptoms depending upon laryngeal lesions, though the latter probably to a minor degree. The cough seen with tuberculous laryngitis depends almost entirely upon pulmonary involve- ment. The hoarseness may go on to complete aphonia. This is a com- mon occurrence, but it is very rare indeed that occlusion of the glottis and the air tubes reaches such a degree that tracheotomy is indicated for the dyspnea in itself, though minor degrees of it are not uncommon. The duration of 'symptoms of tuberculous lesions in unfavorable con- ditions may be said to be from three months to a year and a half before a fatal issue, but these limits are more or less arbitrarily given. Tuber- culous lesions of the larynx in themselves do not tend to a fatal termina- tion. The duration of lesions and symptoms depends upon the advance of the lesions coexisting in other organs, chiefly of course the lungs. While, therefore, the extent of the lesion in the upper air passages is some index of the generally lowered condition of systemic resistance, while the dis- tress arising from the local lesions usually has a marked influence in lowering the systemic resistance, the prognosis depends upon the general systemic condition. Under the great advances made in the treatment of that, under the wiser methods of treatment of the local lesion, chiefly manifested in leaving it alone, laryngeal tuberculosis is no longer looked TUBERCULOSIS OF THE NOSE AND THROAT 575 upon, as it formerly was, as essentially an incurable disease. Aside from its serving as an index of the gravity of the general situation, even under favorable economic conditions and skilled advice, in unfavorable cases of tuberculosis the laryngeal lesion may appear only a few weeks before death and rapidly progress to the involvement and destruction of all intralaryngeal structure. In those less severely affected by the general infection, many cases of laryngitis may, even the cases finally fatal, survive for years. In those who recover, at best it is a question of months and more frequently a year or more before all signs of tuberculous dis- ease disappears from the larynx. Local Appearances. — These have been to a large extent considered in what has already been said of the pathology of the lesion itself. Tlie lesion in the nose may present simply the appearance of granulation tissue with the history of its persistence in spite of treatment. It may present itself as a shallow, sluggish ulcer of the septum or as a smooth, round, broad-based tumor or tuberculoma. The appearances of the lupoid form of nasal tuberculosis have been sufficiently described. On the tongue and lips of persons suffering from ad^^anced pulmonary lesions shallow ulcers, in themselves often indis- tinguishable from aphthous or catarrhal ulcers, are not infrequent. They may be multiple or they may assume a serpiginous form, and may also become enlarged so as to involve in a continuous manner a considerable area of the tongue, cheeks, tonsil, faucial pillars, or posterior pharyngeal wall. They are painful in the latter situations and are so in proportion to their extent. Miliary tuberculosis finds its expression as an acute process of the pharynx in disseminated tiny granules beneath the epithe- lium with a little zone of inflammation around them. These rapidly coalesce as they break down in a superficial ulcer, the pain of which is ex- cessive. , The form of tuberculoma also occurs in the tongue and pharynx, and although it is very rarely seen, the possibility of its existence must not be forgotten in forming a diagnosis. In any case of a smooth rounded tumor the question of tuberculoma or syphiloma will often have to be considered, though the patient may exhibit no other sign of one or the other of the two affections. In tuberculoma this is one of its peculiar characters. These rare cases have given rise to many reports of mixed infection of tuberculosis and syphilis. Lupus exhibits in the pharynx and on the uvula appearances already described. The dusky granular surface becomes infiltrated and thicken- ings of considerable volume occur, which break down and form irregular surfaces which have been described as a "moth-eaten" appearance. This may be seen at the edge of the soft palate and upon the uvula. Turning from these less frequently affected localities and from the exceptional forms of tuberculosis to the average case of tuberculous laryngitis, one notes, on inspection of the palate and pharynx, a marked anemia of the mucous membranes, especially on the anterior surface of the soft palate. The laryngoscopical image reveals many widely separated physical appearances which it is impossible to classify with any exacti- tude, as they shade off into one another with varying pictures each pecu- 576 THE THROAT IN GENERAL DISEASES liar to a given case and itself changing with the progress of the disease. The simple, flat, sluggish ulcer is seen in the larynx as it is in the pharynx and perhaps with equal infrequency. In the larynx it is usually on the cords, and with the pallor which is seen so commonly in all cases, of tuber- culosis of the upper air passages it forms a rather striking picture, when, as occasionally happens, there seems to be no other abnormality in ap- pearances. It is painless as a rule when on the true cords, but above these it is apt to give rise to distress. Infiltration and epithelial hyperplasia are soon added to these appearances unless the case is successfully treated. This is a condition which was formerly regarded as a non-tuberculous catarrhal ulcer occurring in a tuberculous patient. Suffice it to say that this opinion was based on evidence no longer considered sufiicient to establish a diagnosis. The experience of twenty-five years since this matter was last actively discussed by Heryng and others has taught us that the appearances of tuberculous lesions are protean and that careful microscopical examination supported by negative animal inoculation is necessary to exclude from the diagnosis the possibility of these so-called catarrhal ulcers being in reality due to the influence of the tubercle bacil- lus. Nevertheless, on the other hand the possibility of such a condition cannot be denied even for a person with a pulmonary tuberculous lesion. Whether such a condition has ever been observed in a patient reacting in a negative manner to the von Pirquet test we do not know, but the absence of any pulmonary lesion manifested by less thorough methods of observation has occasionally been asserted by competent laryngolo- gists, but such reports have not of late years fallen under our notice. It is .fairly safe to conclude then that the so-called "catarrhal ulcer" of the larynx is due to some specific lesion — tuberculosis, cancer, syphilis, in- fluenza (?), etc., and not to simple inflammation or to the irritation of discharges from the lungs in coughing, when it is seen in a patient not sufl^ering from some acute febrile exhausting disease hke typhoid fever or pneumonia. ' Instead of a superficial ulcer, a condition of epithelial thickening may be seen at the posterior commissure associated with laryngeal pallor. This may assume the form of corrugations of the surface of a dusky-white color. These may be exaggerated into acuminate and papilliform pro- jections indistinguishable from papilloma, though their tendency to be confined to the posterior commissure and to the region around the ^'ocal processes ought to give rise to doubts in the mind of the observer. The proliferation may be so' great as nearly to fill the glottis and to cause not only aphonia but dyspnea. What may be mistaken for ulcerations among this mass of surface proliferation are the depressions over the vocal pro- cesses. Whether this condition is always due to a tuberculous infiltra- tion of the subepithelial tissue is open to even more doubt than in the case of the catarrhal ulcer just considered. It seems probable that in the initial stages such a proliferation is often due to mechanical rather than to specific causes, inasmuch as it is seen in other than tuberculous patients and is known then as pachydermia of the larynx. Later it is probable that the submucosa always presents a tuberculous lesion which TUBERCULOSIS OF THE NOSE AND THROAT 577 acts as an adjuvant to the external factors of stimulation to cell growth. Less equivocal signs of tuberculosis are seen in the characteristic form of extremely edematous infiltration of the epiglottis and aryepiglottic folds. The turban-shaped epiglottis and the rounded outline of the upper lateral contour of the larynx hiding from view more or less completely the true cords is an ominous picture familiar to all laryngologists. It usually betokens deep-seated involvement of the submucous tissues of the periosteum and perhaps of the cartilages themselves, though tuber- culosis does not tend to involve these. It occasionally happens, however, that this takes place even in patients from whose antecedents syphilis can reasonably be excluded. This massive infiltration may extend down to the true cords, but it usually halts there. It may break down into ex- tended areas of ulceration covered by abundant mucopurulent sanious discharge. To account for the extreme pain, it may be said that the ter- minal filaments of the nerves have been found involved in an inflammatory process, but it seems hkely that this is not extensive, for their function of conveying sensation to the nerve centres on the impact of food or the disturbance of structure in deglutition is mercilessly preserved, a contrast to the rule of syphilitic inflammation which involves osseous, cartilaginous, and neural structure with avidity. In the later stages of tuberculosis of the larynx perichondritis, frequently present in the earlier stages, results in extensive necrosis of the cartilages underlying these areas of edematous infiltration. Another form of infiltration is occasionally seen in the larynx not so markedly edematous. Instead of the pearly translucent swell- ings which are so frequently seen at the upper limits of the larynx the lower levels may present more solid appearances of congestion and infil- tration. This may involve the lateral or ventricular surface of the larynx or it is sometimes seen at the level of the glottis. The smooth infiltration of one or both true cords is sometimes seen as a thickened ridge of tissue taking the place of the normal structures, which, red and congested in appearance, have lost their normal characteristics entirely. This may be associated with shallow ulceration or the intense congestion and redness of the cord may exist with ulceration yet without much thickening of the rest of the cord. Lupus of the larynx presents the same "moth-eaten" appearances of the surfaces due to the peculiar melting away of the tissue without true ulceration, as described for the pharynx. The supervention of scar tissue is marked, and from the replacing of the infiltrated tuber- culous tissue by this some distortion of the larynx may result, to be dif- ferentiated from syphilitic sequelae. While tuberculous lesions are seen very frequently in the subglottic space and in the trachea at postmortem examinations, they are not as a rule recognized as existing independently of laryngeal lesions on laryngoscopical examination. Why this is so we do not clearly understand. Prognosis. — Until within a comparatively short period of years, well- developed tuberculosis of the larynx was considered by the majority of laryngologists as a condition beyond the hope of cure. It is true that cases were reported from time to time which had recovered under various forms of treatment or indeed with no treatment, but even in the wide 37 578 THE THROAT IN GENERAL DISEASES experience of the busiest practitioner such cases were exceptional. Since the institution of the rigorous attention to the general hygienic regimen of phthisis patients which is a phenomenon of comparatively recent de- velopment, many of the laryngeal cases have had the advantage of it and the cure of laryngeal phthisis is no longer exceptional. Inasmuch as this has occurred in many cases which, while rigidly subjected to the regimen of rest and a nutritious diet, have had all manner of local treat- ment, and also in a certain number who have had no local treatment but rest of the larynx, we seem warranted in the conclusion that active local treatment for the most part is of little value. Those cases presenting the milder forms of epithelial thickening and slight submucous infiltration, provided their general condition improves, may be assured a very decided hope of recovery from the laryngeal condition. In the deep-seated and wide-spread ulcerations of the mucous membrane of the larynx, the prognosis is of course more grave. Insofar, however, as this is not an index of the lack of general systemic resistance, but of local irritation, the prognosis is no longer entirely hopeless in these cases. A certain number with swollen and edematous mucous membranes over the epiglottis and ventricles and ulceration of the cords recover under the proper general regimen and rest for the larynx. The nasal lesions present no features as to the prognosis apart from those just stated for the larynx. The lesions of the pharynx and buccal cavity, in our experience, seem to indicate a more serious depression of the general vital resistance, upon which the result essentially depends, than do the lesions of the nose and larynx; It is in the fulminating cases of acute miliary tuberculosis that we find the pharynx and buccal cavity most often primarily and most seriously involved. ' Even the less exten- sive ulcerations of the tongue, lips, cheeks and faucial pillars are more apt to be seen in persons whose vitality is very seriously impaired. However, the healing of these lesions is not impossible. Finally, then, the question of prognosis in tuberculosis of the throat and nose is a question now of general vital resistance, just as that of the lungs. Like that of the lungs it is not only a question of general vital resistance, it is a question of finance. Those exceptional individuals who have tuberculosis and an income sufficient for their support during many years of idleness have, on the whole, usually a fairly favorable prognosis, whether they have a laryngeal lesion or not. This, in these fortunate cases, is largely influenced by the docility of their temperament which makes them subservient to the advice of competent and experienced practitioners, or in lieu of this, by their own intelligence. Those unable to procure money for an indefinite invalidism sooner or later, in a very large proportion of the cases of laryngeal phthisis, die. Its etiology rests largely on- economic factors and so does its prognosis. Treatment of Tuberculous Laryngitis. — Largely in what has preceded we have outlined our convictions in the matter of treatment. Rest, food, open air; the careful supervision of the daily routine of the patient; the observation and record of pulse, temperature, and weight;. the absolute submission on his part to the admonitions of his medical adviser can be TUBERCULOSIS OF THE NOSE AND THROAT 579 adequately obtained, we believe, only by sanitarium treatment. The interference of the family, the temptations of social life, the exigencies of business engagements, are the serious drawbacks of home treatment. The daily and hourly supervision by nurse and doctor, the appliances and the adjustment of routine necessary in order to give these patients the best chance of recovery, especially when suffering from a tuberculous laryngeal lesion, cannot be obtained at home, even by the expenditure of large sums of money. We, of course, as all others, realize that there are drawbacks to the sanitarium treatment. We do not believe that any particular locality has peculiar advantages as to climate or peculiar quality of the air. We believe that the essential thing is the discipline and the care possible of attainment in special institutions, and not any mystic quality of air or primarily any special form of drug or physico- or hydrotherapy which is of advantage. Homesickness, pecularities of temperament, lack of congenial company, and the depressing environment of other patients are serious objections, but most of them are serious because of the lack of fortitude of the patient which causes him to falter in his submission to advice. This is the serious thing, and it is more serious at home than at the sanitarium. Local Treatment. — Provided the larynx is put at rest we believe the less the patient gets of local applications the better. To put the larynx at rest it is not always sufficient to enjoin the abstinence from speech. If possible, this latter should be entirely interdicted and the patient made to use a pad and pencil to make his wants known. A cough is another disturber of laryngeal rest which should be treated with a view to its deleterious effects on the larynx. It is probable that some of the volatile balsamic drugs, such as benzoin, eucalyptol, extractum pini canadensis, vaporized by boiling water, when inhaled diminish the laryngeal irritation. For the most part laryngeal sprays for this purpose do more harm than good. The internal administration of opiates and other sedatives is so conditional upon the state of the digestive functions that it belongs to the general therapy of tuberculosis, but where permissible from this point of view they may be given to diminish the cough. The larynx, which is the seat of excessive pain on swallowing, requires that something should be done to place it at rest in this respect. For pain, therefore, the removal of the edematous tissue of the epiglottis and ventricles may be justified, but we do not believe that as a therapeu- tic agent in the cure of tuberculosis of the larynx operative interference is ever advisable. For the relief of pain, for the relief of stenosis it doubt- less has its place, and various cutting forceps may be used for the removal of swollen tissue. Thorough cocainization in the manner described for the removal of tumors of the larynx, sometimes usefully supplemented by the submucous injection, through a long-curved, hollow cannula, of co- cain in weak solution, is necessary. The whole epiglottis may thus be removed. The pain in swallowing often necessitates alleviation by means of cocain. The spray is often objectionable, causing retching and de- stroying the at best capricious appetite. Sometimes, however, it suffices to give the desired relief. The injection of alcohol, 95 per cent., into the superior laryngeal nerve trunk where its internal branch entersthethyro- 580 THE THROAT IN GENERAL DISEASES hyoid membrane, just in front of the greater cornu of the thyroid carti- lage, avoiding the wounding of the superior laryngeal artery, has been successfully resorted to to give relief to the pain in deglutition. Naturally this cannot be indefinitely repeated. The rest of the larynx from conver- sation and from forced respiration incidental to exercise often suffices to ameliorate the atrocious pain so often accompanying tuberculous infiltration of the larynx. Tracheotomy is sometimes, though rarely, necessary owing to obstruc- tion of the glottis with tuberculous sweUings. It has been used with re- peated success to place the larynx at rest both in respiration and in speech. Where other measures fail to relieve the laryngeal irritation it has its place. We have in several instances practised thyrotomy for the removal of tuberculous tissue from the larynx and the results have been far from gratifying. Any operative procedure, including the use of the galvano- cautery, whether internal or external; anything causing irritation and inflammation of the larynx; any stress thrown upon the patient's nervous energy by these measures, we strongly deprecate, unless the objects to be attained are very pressing and the hope of attainiiig them very real. Meddlesome surgery, even meddlesome spraying and pencilling of the larynx in these cases; the injection or the rubbing in of various drugs, lactic acid, iodoform, ichthyol, menthol, we believe is to be refrained from. They certainly can have absolutely no effect upon the activities of the tubercle bacillus in the tissue, either directly or indirectly, and they serve simply to add to the often already full cup of physical misery which these patients have so constantly at their lips, and they cannot but tend to deplete their powers of systemic resistance. The same principles apply in dealing with the ulcerations of the pharynx. It should be entirely symtomatic. The necessity that these patients labor under of taking sufficient food is often an embarrassing one. A swallow or two elicits such pain that appetite if not hunger disappears. Sometimes deglutition of fluids or semifluids may be accomplished with the head hanging off the edge of the couch so that the buccal cavity is a little lower than the fauces and the top of the larynx. Through a tube considerable quantities of milk or other nutritious fluid or semifluid may be swallowed without pain. While we believe that much of the meddlesome therapy advocated more in the past than at. present was distinctly prejudicial to the patient's chances of recovery, that against which nothing actively injurious to the local lesion or a disturbance to the general comfort of the patient can be urged may often be beneficial, inasmuch as man is always impressed much more readily by the interference of his fellow-man, of which from analogy he is able to augur good, than by the healing influences of mental and bodily rest and of food, which he usually is in no way able fully to comprehend. This mental effect thus derived is a valuable therapeutic asset. The committee appointed by the National Association for the Study and Prevention of Tuberculosis in 1905 recommended the following con- ditions as best suited climatically for the care of laryngeal tuberculosis : TUBERCULOSIS OF THE NOSE AND THROAT 581 Abuodance and bacteriological purity of the air; sunshine; coolness, or in a certain number of cases warmth; dryness, or in a few cases a mod- erate degree oi humidity; altitude; wind; equability of soil. But be- cause of inability of the patient to take advantage of a location embody- ing all these factors his laryngeal affection should not be neglected nor should aii attempt be abandoned to take advantage of such climatic conditions as his locality affords. A moderate amount of sunshine and a quantity of air in whatever locality the patient may be living will aid materially the efforts of the laryngologist to retard the progress if not to cure the laryngeal affection. Diet. — Owing to the pain incident to swallowing the bulk of the food must be reduced to a minimum and at the same time contain the maximum of nutritive value. Consistency must also be considered, as liquids often produce more pain than solids, while a semisolid is the ideal condition of food for the tuberculous patient. It is desirable to force a quantity of food at one time rather than to take small quantities at numerous intervals. Upon the whole tobacco and alcohol should be excluded, although Lockard has stated that in those addicted to smoking a moderate amount of such luxury is not to be entirely denied the patient, provided the mouth, fauces, and nasal cavities are irrigated with soothing alkaline solutions afterward. Nasal and Pharyngeal Hygiene. — In the experience of those best quali- fied to express an opinion concerning the matter, it is universally accepted that correction of nasal stenoses, such as spurs and deviations, is by no means contra-indicated in tuberculous cases, provided the general con- dition is good and the nasal distress considerable; neither is the removal of tonsils, and particularly lingual tonsils, entirely to be condemned. The better the breathing space afforded through the natural channels, the more favorable is the outcome of the tuberculous lesion. Lingual tonsils, in the experience of Lockard and Levy, are a great source of irri- tation to a tuberculous throat, and should be removed in each instance. There seems to be some peculiar idiosyncrasy of the tuberculous patient toward this condition, and in many cases of laryngeal tuberculosis lingual tonsils are present. Medicinal Treatment. — Constitutional. — ^As the diseased condition is to be overcome by the systemic resistance of the patient it is necessary to treat constitutional disorders in order to bring about local changes. An unlimited number of drugs has been advocated as positive cures for tuberculosis, but in due course of time they have all proved of but little avail. Cinnamic acid, ichthyol, creosote, and a nmnber of others, ad infinitiun, have been advocated by various physicians having tuberculous patients in charge. An injection of an aqueous solution of tuberculin directly into the infected area of the larynx was at first thought to be a specific for the disease, but a more extended experi- ence by careful observers has shown it to be inefficient as a curative agent, and only helpful in those cases where climatic and hygienic conditions are alike favorable to the process. It is now occasionally employed, not so much for its local as for its general effect, which by some is claimed to be 582 THE THROAT IN GENERAL DISEASES beneficial. For cough, heroin and codein still offer the most efficient means for its correction. Lozenges of menthol and orthoform will also frequently relieve cough and control pain. Creosote and guaiacol, given in the form of creosotal and dotal, are of great benefit in the control of expectoration. Local. — Inhalations. — Steam laden with oil of pine after the formula given on p. 464 is very soothing. The following prescription may also be inhaled for ten minutes, which will insure partial anesthesia of the larynx, ranging from one to three hours: IJ — Anesthesini 3v Mentholi 5iij 01. olivse 5iv Sprays. — ^Any of the alkaline solutions, such as Dobell's, alkalol, gly- cothymolin, etc., are at times helpful in removing the mucus and detritus collected upon the ulcerated area of a tubercular laryngitis. All of these sprays should be followed by an oily spray of camphor and menthol (formula, p. 583). Pain. — Cocain solution in 1 to 5 per cent, strength, or alipin in 1 to 10 per cent, solution, has proved more efficacious than any of the other solutions. Insufflations. — Powders blown into the larynx frequently alleviate suf- fering and temporarily enable the patient to swallow with ease. Those who have no particular dislike to the odor may have iodoform applied in this manner with considerable benefit. Just prior to a meal orthoform is probably one of the best powders for the control of pain incident to swallowing, while anesthesin is likewise satisfactory. To those desiring to pursue active treatment the following may be recommended : Pigments. — Lactic acid is by far the most universally employed agent of all the pigments. It is applied by means of an applicator directly to the ulcer, after the superficial coating has been removed with Dobell's solution or a weak peroxid solution. The acid is used in from a 20 per cent, solution to full strength, and should be applied twice weekly. It should be rubbed in. Formalin in a 3 to 10 per cent, solution every other day has been advocated by Lockard and Thomson as being more desirable than lactic acid. Ichthyol and resorcin in a 20 per cent, solution are stimulating and are less painful, upon the whole, than either of the others. Guaiacol in 1 per cent, solution has had a number of favorable results attributed to it, and is of value in some instances. Argyrol, be- cause of its less irritating effects, is to be preferred to any of the silver salts, and as it is very penetrating it will overcome the extension of a small ulcer to contiguous parts. Intratracheal Injections. — Many combinations of drugs having as their object the abolition of pain and as their basis some bland oil can be em- ployed, it is said, with benefit in laryngeal tuberculosis. The anesthe- tizing effect of menthol is to be favorably considered in some cases and a mixture of — TUBERCULOSIS OF THE NOSE AND THROAT 583 I^— Menthol, Camphor aa gra. x-lx Olive oil gj often produces a very agreeable sensation in the larynx, particularly after a coughing spell. Another combination, R— 01. thymi, Ol. eucalyp., 01. cinnami . aa lUlxxx lodoformi gra. xv 01. olivse giij forms a good mixture to be employed after any of the astringent prepara- tions. It is questionable if any of these injections are in any way curative, but the distress of pain is of such moment that anything tending to re- lieve it is greatly appreciated by the patient and the mental impression produced by using drugs is usually a comfort. The Freudenthal mixture, M — Menthol 1 part Almond oil 30 parts Yolk egg 25 parts Orthoform 12 parts "Water to make 100 parts is in many instances quite beneficial, but in a few cases produces intense pain. Why it should not be effective in certain isolated cases we are unable to determine. All the intratracheal injections should be warmed before using. Submucous Injections. — Chappell devised a syringe by which a solution advocated by him could be easily injected into the sub- mucous tissues: H — Creosoti, 01. gaultheriae aa lUxx Ol. ricini q. s. ad gj This solution should be injected in doses of one to three drops once a week with the submucous syringe. Light. — Nearly every conceivable form of light has been used for the eradication of laryngeal tuberculosis, as the Finsen light, radium, a;-rays, sunlight, and the arc light, but if any permanent good ensued it was not lasting in effect. Fresh air, rest, diet, and freedom from mental worry are the most essential elements in the treatment of laryngeal tuberculosis. Surgery in the majority of instances is impracticable, inasmuch as the lesion is not isolated and the location is difficult of approach; but if an incipient lesion is on the tip of the epiglottis it seems as unreasonable to avoid surgical intervention as it would to let a tuberculous gland of the neck remain unremoved. The indiscriminate curettage of tuberculous ulcers seems unjustifiable and the original advocates of ■ such surgery have had their enthusiasm diminished by the unsuccessful results of equally skilled laryngologists, but in certain instances surgery has been 584 THE THROAT IN GENERAL DISEASES of unquestioned value when the lesion has been circumscribed, accessible, and incipient. Tracheotomy has often given relief, but in few cases has a cure been claimed for it. In one case coming under our observation a marked retrogression of the most prominent symptoms took place ex- tending over a period of three months, after which the patient disappeared from view. The tracheotomy was necessitated by a sudden edema of the larynx, and so much comfort ensued that the patient refused to have the tube removed. Galvanocautery and electrolysis are of doubtful value. Occasionally when the epiglottis is thickened with tuberculous deposit and with edema, and when from this condition the patient suffers distress or marked discomfort, its removal by cutting forceps or by snare or by a specially devised instrument may be carried out with benefit. FiQ. 295 Chappell's submucous laryngeal syringe. Nasal Lupus and Tuberculosis. — ^Tuberculosis either in- a mihary form or as a single tubercle rarely attacks the nasal mucosa, but lupus does frequently, appearing upon the nasal septum anteriorly, the floor of the nose, or the anterior part of the inferior turbinate, from which local- ities it often extends to the alse and tip of the nose. The eruption in its incipiency is often overlooked because of the similarity of the nodules to the surrounding mucous membrane, but it may be clearly defined by blanching the mucous membrane with adrenalin chlorid, when the nodule will appear clearly and distinctly outlined as a pinkish spot against the white mucosa. If the nodular eruption is of the skin it may be brought out by compressing the skin with a cover-glass or microscopical slide, when the nodules are made more pronounced by contrast with the surrounding white skin. Occasionally lupus begins as a sessile tum6r of considerable size, varying from that of a pea to a lima bean. This may break down slowly and lead to ultimate perforation. Perforation may also result from the coalescence of a number of single lupetic nodules. The destruction of tissue is progressively slow and the resultant perforation is irregular in outline and covered with a tenacious secretion surrounded by pale infiltration. The secretion has a definite odor of an objectionable nature, but not to be compared to that of ozena or syphilis. Occasionally secretions will dry upon the perimeter of the opening and form a scab which when detached will result in slight epistaxis. The destruction may go on until the whole cartilaginous but not the bony septum is TUBERCULOSIS OF THE NOSE AND THROAT 585 destroyed and if the lupus has extended to the alae and tip a great portion of the lower part of the nose, both internal and external, may become involved in the destruction. The resulting deformity, however, differs somewhat from that of syphilis in that the tip of the nose and the alse are drawn downward and inward, giving to the vestibule a puckered appearance. This condition is emphasized in contrast to the typical saddle-back nose resulting from syphilitic destruction where both the bony and cartilaginous septum have been destroyed and the buttresses of the nasal bones have been weakened, occasioning a definite sinking in of the dorsum of the nose. In lupus the destruction confines itself entirely to cartilage and never invades the bone. The progress of lupus is insidious, unaccompanied by pain, as a rule, and gives few subjective symptoms until the destructive process has advanced to that stage where the multiple individual nodules have coalesced. The patient experiences a sense of obstruction, followed by a thin, watery secretion which later becomes viscid and foul in odor. Remarks upon the differential diagnosis of syphilis and tuberculosis will be found in the following chapter. Treatment. — In the early stages before the nodules have coalesced each focus of infection should be cauterized with the galvanocautery, after which the nostril should be kept well greased with vaselin nose cream (formula, p. 196). If a large ulcer is present it should be thoroughly curetted under cocain anesthesia and the borders and bottom of the ulcer touched with either the galvanocautery or fused chromic acid. Arsenic paste, lactic acid, carbolic acid, fused silver nitrate, and other chemical escharotjcs have been employed for the destruction of the lesion, all of which have proved of benefit In Individual Instances. Serum therapy, although limited, has been successful in a few cases. Radiotherapy, con- sisting of the ultraviolet rays, a;-rays, also radium and the Finsen light, have been used with more or less success. Spontaneous recovery, while rare, has nevertheless been recorded, owing possibly to a change of climate and the increased resistance of the system. Mercurial ointment, pyrogallic ointment, 10 to 20 per cent, balsam of Peru, Mandl's solution, bichlorid of mercury 1 to 1000, permanganate of potash 1 to 700, have all been employed by various experimenters with varying successes propor- tionate to the enthusiasm of the individual using them. Lupus in about 50 per cent, of the cases precedes tuberculosis of the lungs and other parts of the body, and Is infrequently secondary to phthisis. Consequently every endeavor should be made to overcome this local focus of infection, to prevent its spreading to parts where the danger becomes more immi- nent, and in view of this fact each of the therapeutic measures which have been recommended, although in the experience of the individual trying them they have been at times disappointing, should be persisted In until every resource has been exhausted In an attempt to overcome the primary lesion. CHAPTER XXI. THE NOSE AND THROAT IN GENERAL DISEASES. RHINO- SCLEROMA. DIFFERENTIAL DIAGNOSIS OF SYPHILIS, TUBERCULOSIS, SCLEROMA, AND CANCER OF THE NOSE AND THROAT. RHINOSCLEROMA. Occurrence. — ^This is a disease which was recognized first by Hebra in 1870. It occurs in the inhabitants chiefly of Germany, Russia, and Aus- tria, in a territory fairly well-defined, which may be described as border- ing upon or not far removed from the Baltic and Black Seas, but as the population, especially of the Russian and Austrian countries in this area, emigrate in large numbers to this continent the disease is often seen in New York City, though exclusively, so far as is known, among the inhabitants of foreign birth. The disease has also been reported in a few instances as existing in Switzerland and southern Italy. The extremely few cases which have been reported as originating in South America are rightly regarded with some doubt as to the correctness of the diagnosis or as to the statement of their nativity. The diSiculty of differential diagnosis and the obscurity and insidiousness of its early manifestations justify this reserve. In New York City many instances of it probably exist unrecognized. Indeed it is only of late years that laryngologists have reported it. It is usually seen after adolescence, though there are now undoubted instances of its having been studied in childhood. It occurs more frequently in males, though it is by no means uncommon in the other sex.^ Etiology. — ^The geographical distribution of the places of birth of these patients stands out as the most prominent indication in the etiology, which, with that exception, may be said to be unknown. With the lesion is alwaiys associated a bacillus called the Bacillus of Frisch, who described it a number of years ago, and which resembles in all respects the so-called Friedlander bacillus seen in lesions of pneumonia. There is also a bacil- lus indistinguishable from it frequently found in cases of ozena called sometimes the Bacillus mucosus or Abel's bacillus. This microorganism is also found not infrequently in the nasal and buccal secretions of com- paratively healthy people. All attempts to inoculate animals and even the few attempts to inoculate human beings, not only with the Frisch bacillus but with bits of tissue from the lesion itself, have entirely failed. '■ For a thorough discussion of the subject see Scleroma of the Upper Respiratory Tract, etc., by J. H. Gunlzer, New York Medical Record, July 24, 1909. RHINOSCLEROMA 587 The geographical distribution of the lesion in its incipiency, confined as It is more or less distinctly to well-defined localities, rather adds to than elucidates the mystery of its origin. Pathology and Histology.— The site of the lesion is more frequent in the nose at its posterior portions and extends to the pharynx, larynx, trachea, and bronchi. Not infrequently cases are seen in which the lesion is limited to the larynx. These cases are usually spoken of as scleroma of the larynx. It has also been noted on the external skin, in the auditory meatus, and on the skin of the shoulders. It has involved the tear sac and the tongue. It affects almost exclusively the soft parts of the nose, though the infil- tration of these is apt to produce nasal deformity and sometimes a small amount of necrosis and atrophy of the bone. The epithelium is not markedly altered, although it usually partakes of the character of the epithelium usually seen over granulomata, to which this lesion may be said to belong. The stroma is infiltrated with leuko- cytes and lymphocytes. In addition to the usual structure of a granuloma there are certain features more or less characteristic of it which allow an histologist who has previously studied such tissue to make a diagnosis with a fair amount of assurance. Like syphilis and tuberculosis, there is a large amount of nuclear fragmentation, but, as a rule, the necrosis of the cytoplasm of the cells is of a peculiar kind. These cells are usually lymphocytes and epithelioid cells, among which numerous eosinophils and plasma cells are seen. The changes in the cytoplasm referred to above, peculiar to the lesion of rhinoscleroma, are the preservation of the nucleus and apparently of the linen or thread-like processes of proto- plasm in the cell body, while the granular matter between them has dropped out, giving a peculiar lace-like or foam-like appearance to these areas. Hyaline bodies are much more frequently met with in this form of granulomata than in others. They possess the usual characteristics of the so-called Russell bodies, staining deeply with fuchsin and not at all with stains for fats. The lace-like cells are sometimes called Mikulicz cells, after the observer who first exhaustively described the lesions of rhinoscleroma. In the lace or foam cells it is possible often to demon- strate the rhinoscleroma bacillus with various stains, but occasionally it can only be done with great difficulty. They are also seen in the inter- cellular structure. A large amount of work has been done in attempting to differentiate the rhinoscleroma bacillus from the pneumobacillus and the Bacillus mucosus, but thus far morphologically and culturally they have been found indistinguishable, and in spite of a large number of at- tempts to differentiate them by means of the agglutinin and complement fixation reactions,' no definite conclusion has been arrived at, though some authors claim specificity for the Friedlander and the rhinoscle- roma bacillus respectively. While the hyaline or Russell bodies show no specific reactions to distinguish them from the bodies found elsewhere in granulomata, they are more mmierous. In the use of fat stains and stains for the lipoids, nothing specific or unusual has been noted except in the ' Streit, Frankel's Archiv f. Laryngologie und Rhinologie, 1904, 16, p. 440 et aliden; Wright and Strong, New York Medical Journal, March 18, 1911. 588 THE NOSE AND THROAT IN GENERAL DISEASES stain for the demonstration of fatty acids or soaps. These have been shown to be in great abundance, both intracellular and extracellular, in lesions of rhinoscleroma. It is probable, however, that this is a reaction which subsequent investigation will show to be universal in all of the infective granulomata. The histological change which gives to the lesions the designation of scleroma is the gradual supervention of low-grade fibrous tissue, the shrinking and atrophy of which contracts the former infiltration into a hyperplastic leathery mucosa, causing not only great deformity of the internal nasal structures, but altering the contour of the nose itself. In the larynx and trachea and even bronchi this induces frequently a nar- rowing of the air tubes which may in itself lead to a fatal issue. In the pharynx marked cicatricial bands and ridges stiffen the soft palate and even cause ankylosis of the jaw. Differential Microscopical Diagnosis. — Under this head, we desire to speak of the ease with which the bacillus can be demonstrated in the blood of the lesion. While upon the surface it does not seem to occur constantly or in any abundance, yet an incision made into the lesion caus- ing it to bleed results in carrying out with the blood an abundance of the bacillus of Frisch, so called after the investigator who discovered it in the lesion many years ago. A swab made from this blood upon slants of agar and placed in a thermostat will show inside of twenty-four hours such a profuse growth of this form of bacillus that it furnishes, with other evidence, the most satisfactory and easily applied laboratory test in the differentiation. The number of hyaline or Russell bodies, and especially the foam cells, and lastly the eosinophiles, are the other distinguishing histological marks of this peculiar lesion, to which we may add the demonstrMion of the bacilli in the tissue, although this is frequently impossible or accomplished with great difiBculty. These bacteriological and histological indications of course must be correlated with the points in the history as to the place of the patient's birth, and as to other clinical facts. While the gross appearance of the lesion is frequently mistaken for syphilis and tuberculosis, to the practised eye the resemblance is fairly characteristic, though it must always be remembered that exceptional cases of syphilis or tuberculosis may be mistaken for rhinoscleroma, and on the contrary the plainest, most characteristic cases of rhinoscleroma may escape detection when the observer has not been accustomed to study the lesion. It has also been mistaken for ozena and for leprosy, but this difficulty does not so frequently occur in the differentiation of these affections as in that of syphilis and of tuberculosis. Symptoms. — Beginning deep in the nose, deformity of its external con- tour is, as a rule, not observed until the lesion has existed perhaps for many years. Indeed it seems likely this is true of all the symptoms of rhinoscleroma, and accounts for the fact that the patients in whom it occurs in this country may have lived in a foreign land for many years in robust health before the disease manifests itself to the observer or its symptoms are noted by the patient. These are at first those of chronic catarrh, and this stage of the nasal disease may have been so insidious in RHINOSCLEBOMA 589 its beginnings and so slight, even on the patient's seeking relief, that it would not have attracted his attention but for the supervention of more serious inconvenience. A peculiar odor, described as "mouse-like," has been noted, but the first serious inconvenience arises usually from the formation and retention of intranasal crusts. Where, as occasionally happens, the lesion is limited chiefly or entirely to the larynx, hoarseness and a slight cough may be the first sjonptoms complained of. Except in some of the severe lesions of the pharynx accompanied by ulceration, pain is not a prominent feature, and in any event does not appear in the earlier stages. Entire nasal obstruction may not impede respiration, but set up affections of the Eustachian tubes. These may be directly invaded as the disease extends to the pharynx. Taste and smell are also inter- fered with. As ulcerations are not deep, hemorrhage is never severe. There is difiiculty in swallowing owing to cicatricial contractions of the jaws and pharyngeal structures. To this are soon added the discomforts and dangers of impeded respiration. In the larynx, the seat of the lesion is apt to begin in the subglottic space as a rather peculiar, dirty-white hyperplasia of the epithelium covering more or less marked swelling of the deeper tissues, and this condition is sometimes spoken of as chronic hypertrophic inflammation of the cords and subglottic tissues. The name of Stoerk's blennorrhea is another designation of a subglottic and tracheal condition dependent on the same lesion. With the dyspnea and stringy discharge of these distressing cases goes a metallic cough, owing to the contraction of the lower air passages. Death from inter- current affection, especially pnemnonia, is more often the termination of the case than that from suffocation which at many times may seem imminent. The nose in the later stages becomes hypertrophied in its external outlines rather than distorted by the destruction of its bony framework. The skin at the introitus narium becomes involved in the extension of the lesion from within. There is in places a superficial loss of epithelium on the mucosae which may simulate ulcerative lesions of a different character, but neither the cartilage nor the bone is affected except it may be from interference with their nutrition. On the external skin of the nostrils the same condition may be noted. The infiltration is deep and widespread, the ulceration shallow and limited in area. Duration and Prognosis. — The disease may extend over many years. As has been said it often ends fatally, but unless this is from intercurrent disease or from suffocation, these cases, after reaching a certain point which may be considered as the acme of their sufferings, probably tend to spontaneous recovery, which is as slow in taking place as the onset and the increase of the initial symptoms. When death occurs it is usually due to an intercurrent pneumonia. Treatment. — ^No encouraging plan of treatment has been put in prac- tice or proposed. Extensive operations were at one time performed in Austria for the excision of the sclerosed tissue from pharynx, larynx, and bronchi. The mortality was high and the results in the eradication of the trouble were disappointing. Nevertheless, tracheotomy and the use of V. Schrotter's tubes to keep the trachea and larynx open by dilatation 590 THE NOSE AND THROAT IN GENERAL DISEASES have to be resorted to. Various medicaments, mercury, arsenic, iron, were given internally, and others, carbolic acid, salicylates, toxins, vac- cines, have been given subcutaneously. A certain percentage of favor- able reports have been published as to the success of some of them, but as no cures have been claimed for any and as the favorable results as re- ported are not above criticism, .it is entirely safe to conclude that nothing has been found to cure the condition or materially to arrest its course. The latter varies from time to time in itself. There are remissions and regressions; there are spontaneous recoveries not only after certain in- fectious diseases, but some cases have survived to old age in whom the disease had declined. Needless to say the .T-rays and radium have been used with the usual euphemistic reports and with the usual silence following, and with the familiar sinking into oblivion which forms the regular role of ephemeral therapeutic optimism. In Giintzer's cases, which we had the privilege of observing, the use of autogenous vaccines of the Frisch bacillus was resorted to. One case had a prolonged period of improvement in the more distressing symptoms. There was practically no change in the others or they grew worse. In this disease, as in many others, while nihilism is not the attitude to assume toward the patient, optimism toward specific lines of treatment which nothing but an abnegation of the powers of observation and reason- ing justifies in the face of facts, personally experienced or gleaned from a thorough acquaintance with the literature, is not the attitude of intelligent discussion. Differential Diagnosis of Syphilis, Tuberculosis, Scleroma, and Cancer of the Nose and Throat. — In adding something to this work on the differ- ential diagnosis of these lesions of the upper air passages, we do so from the conviction of its great importance to the general practitioner and to the consultant specialist. The parallel columns usual in attempts to set forth the points involved in such problems have always appeared to us unsatisfactory, and we resort to a method of discussing those iiivolved either in cases actually observed by us or in hypothetical cases such as in reality present themselves constantly in practice. By this method we hope to set out in a more striking and impressive way information which it is almost impossible to impa-rt by other methods. We are quite aware that it is impossible thus to supply that clinical sense which appears to amount to intuition, but we also realize that it is an unsatisfactory state- ment for the student when he is told that he is to acquire this wholly by his own future experience. While this doubtless is to a large extent true, something we hope may be done in imparting some of it in a text-book. There is no question which arises in the practice of laryngology which calls for the exercise of so much experience, mental alertness, sound judg- ment, and familiarity with the literature of the specialty as the differen- tiation which it is often necessary to make between appearances which may indicate the presence of one of the three great processes, as some one has called them — syphilis, tuberculosis and cancer. It is only because of the rarity of the affection in most parts of the world that one is not so frequently called upon to include in the category of these confusing PLATE X \ A. Syphilitic Destruction of Palate (Congenital Syphilis). B, Tubereulous Fissure of Tongue. (Chappell.) C! Basal Cell Epithelioma of Tonsil and Oropharynx. DIFFERENTIAL DIAGNOSIS 591 appearances the affection known as rhinoscleroma. New York City, with its lafge population of foreign birth, especially of those born around the Baltic a^d Black Seas, furnishes instances enough in the experience of the busy practitioner where this disease intrudes itself among the others to be considered. A male of thirty presents himself with an irregular ulceration of the nasal septum which has been noticed by the patient for at least a month. Not pausing to exclude the simpler possibilities we are forced to conclude that it is an example of one of the diseases referred to. We might exclude rhinoscleroma but for the fact that this patient comes from regions where the disease is endemic. Exclusion almost positive could have been made in this way because elsewhere than in the regions alluded to in the sec- tion on rhinoscleroma in this work people are not born who subsequently in their lives develop rhinoscleroma, so far as is known. This patient has only noticed the trouble for a month, but individuals from the regions in- dicated often first complain of symptoms due to the affection only after years of absence from their birthplace. We have seen cases said to have left Russia four years before they noted any trouble in their upper air passages. This lesion, however, is confined to the anterior portion of the nose, but no evidence of it is seen elsewhere. This is exceptional in rhinoscleroma. It may be one of the other three. Epithelioma may be ruled out; the patient is young for it; it is a very unusual situation for it. It may be sarcoma; ulceration rarely occurs in sarcoma and it is a question if the sarcoma-like tumors which are sometimes seen there are really malignant growths; ulcerating sarcoma of the septum does not occur, though the bleeding polypus is seen in this situation, but that without any true ulceration gives a history of repeated attacks of more or less severe hemorrhage. We next consider syphilis. On examination with a probe we find there is no perforation of the cartilage and no involvement of the bony septum. An ulceration in a gummatous swelling of the cartilage would hardly exist for a month without lead- ing to one or the other. The history throws no light on the subject. Syphilis is denied by the patient, but this we have learned to disregard. It may be another form of syphilis — rare but not unknown in this situa- tion. It may be the initial lesion; no true induration around the edges or on the bottom of the ulcer can be detected — no submaxillary glands or mouth or skin lesions, though for the latter at least it may be too early. Yet on account of the characteristics, more or less distinct of the hard chancre, this may be ruled out. We may also rule out the soft chancre, because while there is no induration there is a certain tumor-like quality to it which is not noted in chancroid. We arrive then at tuberculosis. There is no lupoid lesion of the skin or we should have at once thought of primary nasal lupus, and this is not necessarily excluded because the skin lesion is lacking. Clinically then, the case seems to be some form of tuber- culosis. Primary tuberculosis of the nasal mucosa without demonstrable lesion elsewhere is a very rare affection. On pulmonary examination this patient is found to have signs of moderate amount of consolidation at the right apex and gross examination elicits the history of a slight cough. 592 THE NOSE AND THROAT IN GENERAL DISEASES A series of observations on the afternoon temperature is made and we find that it is more frequently over 100° F. than we should expect in a person in good health. We now have recourse to other than clinical methods of diagnosis. The sputum to be obtained is scanty in amount and negative results are reported of the examination. Repeated trials may be necessary before we can give such testimony due weight. If the report is positive for acid- fast bacilli by means of the antiformin method and by use of the centri- fuge, we are compelled to reihember that it occasionally, though rarely happens, that acid-fast bacilli of foreign origin, or that granules simulating bacilli and acid-fast, may mislead us into accepting the fact of demonstra- tion of the presence of the tubercle bacillus. This with a careful micro- scopist is unlikely. We turn therefore to the von Pirquet skin reaction. This we note is distinctly positive. We are aware, however, that in adults this is so in a very large proportion of cases who give no other manifestation of tuberculosis. The degree of reaction is occasionally severe in those who have other than the so-called closed or gland lesions. The Wassermann reaction is negative, and this is of some value in the ex- clusion of syphilis, which is not too recent and in a patient who has not been taking active antisyphilitic treatment for six weeks or more. We now turn to the resort of excising a piece of tissue for microscopical exami- nation. Under such conditions as are postulated by the case history thus far it is advisable, instead of limiting the incision to a portion of the lesion, to excise as cleanly as possible all of the diseased tissue. The technical difficulties are not great and the reaction is not more severe which we expect from a small incision than that from a large one. Whether large or small it should include enough of the lesion itself and especially of the bordering tissue to note not only the nature of the cell growth of the lesion, but the way the neighboring tissues react to its presence. In syphilitic and in tuberculous ulcers there is always an amount of epithe- lium which spreads in irregular and distorted areas around the edges in such a manner that the microscopist is at times uncertain whether this is not in itself the essential lesion. The same may be said in regard to the surface epithelium of rhinoscleroma. As a rule, however, there is not much difficulty in recognizing that the epithelial cells are not sufficiently sepa- rated in type and in location from those of the environment to warrant a diagnosis of epithelioma. The morphological features which distinguish the latter have been sufficiently considered, and it must also suffice here to allude to this tendency of the epithelium bordering the ulcers of the chronic granulomata to assume bizarre patterns and to be stimulated to wide incursion into the connective tissue bordering the loss of tissue. The abundance of leukocytes and the fragmentation of their nuclei along the border of the epithelium are sometimes very marked, especially in syphilis, and a certain amount of loose chromatin is taken up by the epi- thelial cells and lies between them, but not to the extent, as a rule, that is observed in epitheliomata. In this particular case we are considering it is hardly necessary to think of sarcoma. The extent of the infiltration in proportion to the ulceration is so small as to exclude the latter without DIFFERENTIAL DIAGNOSIS 593 entering further into the microscopical differentiation, under other clinical conditions, often so embarrassing. The absence of considerable areas of the lace cells, or Mikulicz cells; the absence of any considerable number of hyaline bodies; the considerable extent of the ulceration and the minor extent of the infiltration; in other words, the large amount of coagulation necrosis which one observes as present or as having given rise to the loss of substance is sufficient to exclude the serious consideration of rhino- scleroma. If, however, there is any doubt on the subject, a culture of the blood of the lesion, in the manner described in the section on Rhinoscle- roma, should be made. A word of caution as to the search for the charac- teristic lace-like cells of the connective tissue is important. A large number of areas must be examined with the oil-immersion objective. Under low powers this fine intracellular lacework is apt to escape detec- tion or to seem insignificant. With high powers in typical rhinoscle- romatous tissue it is very striking, as are also the small bits of hyaline ma- terial in the cell bodies. Those of larger dimensions and extracellular are easily recognized. In this connection it must be remembered that a cer- tain amount of this peculiar intracellular degeneration is seen in nearly all of the specific granulomata. The extent to which it exists in rhino- scleroma is pathognomonic to the experienced observer. In the case of the nasal lesion we have in mind, both the clinical and the microscopical evidence preponderates in favor of one of the granulomata, and we think we have excluded rhinoscleroma. We must again insist on the necessity of placing all the clinical facts obtainable fully before the microscopist. Any other course justifies the severest condemnation meted out to the folly which neglects or to the moral obliquity which conceals them. Syphilis and tuberculosis remain. It is true that often the morpho- logical evidence of tuberculosis is so striking to the pathological histologist that he is justified, with other supporting clinical and therapeutic evi- dence, to accept it as conclusive. Infrequently, however, the absence of the picture of typical tubercle gives rise to great uncertainty. The pres- ence of giant cells of the Langhans type is not conclusive. They are occasionally seen in great abundance in syphilis. Indeed, their abundance in a lesion not showing the other features of tubercle is an argument against rather than for its existence. The prominence of endarteritis, and especially of the thickening of the adventitia into a low-grade fibrous layer around what would otherwise be considered capillaries, strongly points to syphilis. The presence of areas of coagulation necrosis of con- siderable extent without the zone of new connective tissue around them also tells for it. We assume that these points of differentiation are suffi- ciently pronounced to warrant the positive or at least the presumptive diagnosis of tuberculosis from the standpoint of the microscopist. In view of the fact that at the end of his morphological study he may still be in some doubt, he cannot consider that be has exhausted all the means at the command of the laboratory in aiding the clinician in reaching a diagnosis if he has failed to inoculate two guinea-pigs with small bits of the fresh lesion when he has received it. Not infrequently the conclusive- ness of his testimony will be justified only on being able to report after 38 594 THE NOSE AND THROAT IN GENERAL DISEASES six or eight weeks that these guinea-pigs show satisfactorily the presence of the activities of the tubercle bacillus. This testimony, taken together with the points brought out above and in the chapters devoted to the objective descriptions of the various lesions in this work, may be consid- ered to have fairly exhausted the possibilities of differential diagnosis in the categories selected for illustration of it. However similar a case of cancer or of one of the granulomata may be to another case of the same disease, so far as the histological lesion is con- cerned, the question of differential diagnosis between them always pre- sents itself from points of view essentially divergent, so far as the location is concerned. Indeed, the features of the laboratory diagnosis them- selves have to be viewed at a little different angle in the pharynx from those studied in the nose and larynx. We will attempt to study the problem in the pharynx by the aid again of a suppositious concrete case: A woman of thirty seeks relief from an ulceration of the pharynx. It has caused some loss of substance and considerable tumefaction of one of the faucial pillars, and there exist redness and swelling of the tonsil on that side. Her general health is fair; the trouble has been noticed for three weeks. The first thought of the experienced laryngologist is of syphilis. She is unmarried and denies absolutely infection with syphilis, if the observer is maladroit enough to ask for a direct confirmation of his suspicions. If he is not inexperienced he will not have asked the direct question until all other possible avenues of approach to the diagnosis have been explored. He will give absolutely no weight to a negative answer if he is wise, even then. In such instances practically all women are inno- cent or ignorant or incapable of the truth. By the indirect method he may learn little. The history of the primary lesion is practically never obtained whether the woman is married or not. The history of secondary symptoms, except insofar as the present trouble may furnish them, is vague and unsatisfactory. In the large cities the specialist is so accustomed to find his first impressions ("his snap diagnosis") confirmed that he is apt to err on the side of syphilis. We assume in this case, as in the consideration of the nasal lesion, that investigations as to systemic infection or as to the existence of the confirm- atory lesions of tuberculosis, syphilis, scleroma are absent or eminently unsatisfactory. The existence of the characteristic lesion of syphilis in the nose, such as a perforation of the bony septum, or the absence of any nasal lesion in the consideration of rhinoscleroma may each in its way be a very strong factor in forming an opinion of the nature of the pharyngeal lesion, but we will suppose in this case that we must study the lesion from its local appearances alone and from the symptoms which may be ascribed to its existence. Essentially the study must again proceed by the method of elimination, and to avoid repetition as much as possible the points brought into prominence in studying the nasal lesion will be abridged or suppressed. Naturally this will greatly abbreviate the didactic study of the case as it is set forth here, but this is not to indicate that the observer of the actual instance is at liberty thus to abbre\'iate his attention to the DIFFERENTIAL DIAGNOSIS 595 problem. Epithelioma is infrequent at thirty and relatively infrequent in women. The glands in the cervical region in this case are not notice- ably enlarged or else have the diffused feeling common to simple inflam- matory states. One must not forget that some individuals suffering fre- quently from simple coryzas and anginas often have one or more submen- tal or submaxillary glands which are betrayed to examination by palpa- tion during the attack or may remain appreciably enlarged at other times. The duration of a history of epithelioma, which has gone on to ulceration, limited to three weeks is almost unknown. As between tuberculosis and syphilis of the pharynx, tuberculosis is rendered highly improbable be- cause of its rarity when existing without appreciable tuberculous lesions elsewhere. Pain, however, is the distinguishing feature. A pharyngeal lesion of a tuberculous nature of the ulcerative type is always extremely painful. The absence of distinct rise of temperature in the afternoon is to be more emphasized in excluding tuberculosis of the pharynx than that of the nose. Clinically then, we soon arrive at a conclusion in confirmation of the first impression of the local appearances. The question of it being a late or an early manifestation of pharyngeal syphilis occasionally re- quires some attention. The prominence of the cervical glands, especially of the postcervical referred to, are to be considered. Their absence here tells for the assumption that it is a case of tertiary ulceration. The local appearances noted at the first examination may now be described a little more in detail so far as they bear upon the differentiation. The ragged, sharp-cut edges, not indurated; the deep, broad, or even crateriform loss of substance, distinguish this typical tertiary lesion of syphilis from that of tubercle or of cancer or of secondary syphilis. There are some forms in the local appearances of the latter which are indistinguishable from tuberculosis; there are some forms of deep syphilitic ulcerations of the tongue indistinguishable from cancer; there are some white, elevated patches of syphilis indistinguishable from certain forms of cancer. One must recognize these facts and never lose sight of them when he meets these forms of local appearances. It is of less consequence to bear in mind that the more or less superficial lesions of secondary syphilis of the oropharynx are yet deep enough to allow the supposition that the patient is suffering from an old rather than a recent syphilitic infection. In the questions as to the nature of the lesion rather than as to the stage of the syphilitic process, resort must be had to other methods of differentiation. We have already dwelt upon these methods in what has preceded with sufficient fulness so far as concerns the laboratory methods of histology, bacteriology, and serology, with the exception of necessary remarks on the demonstration of the Spirochseta pallida. In the secretions of the mouth and pharynx its differentiation morphologically from the sapro- phytes which are regularly found in them is impossible and culturally it is impracticable from a clinical standpoint. We have also purposely omitted to say anything as to the method of differentiation offered by therapeutic methods. Both here and in the nose the experienced observer is fully alive to the fact that often he has no time to lose, from a thera- peutic point of view, in making a diagnosis assured in consideration of the 596 THE NOSE AND THROAT IN GENERAL DISEASES fact that he may have to deal with a gumma. A few days often is vital in deciding whether the patient is to have a greater or a lesser nasal deformity, a larger or smaller perforation or palatal adhesion. By the vigorous administration of mercury and potassium iodid instituted at once, precious time may be saved. In addition the result of the therapy will serve to clinch the diagnosis even before he gets a report as to the Wassermann reaction or the von Pirquet test or the finding of the spiro- chseta. The point which we wish to make is that while the diagnosis may safely be delayed a few days the treatment cannot. Luckily, the thera- peutic test in the differential diagnosis fulfils both indications. Blood should be drawn immediately for the Wassermann reaction and anti- syphilitic treatment also instituted at once. The period which may be supposed to intervene between the time of the administration of the first dose of mercury and iodid or of salvarsan and the time they affect the blood in such a manner as to vitiate the serological test may be safely placed at seven days. Thus the diagnostician, by keeping this point clearly in view, may do justice to his patient and yet preserve to his diag- nostic interest the advantage which an intelligent application of the Was- sermann reaction may give him. There are some precautions, which must be kept in mind when the patient has also a laryngeal lesion and iodid of potash is to be administered, which have been touched upon in the consideration of the treatment, but where the lesion is confined to the nose and pharynx this point, while not to be lost sight of, is not neces- sarily so prominent. It must be repeated that the observer should not forget the fact, quite aside from the unsettled question of "mixed infec- tion," that a phthisical patient may have a syphilitic lesion in his upper air passage in any of its stages and, per contra, a patient giving evidence of a previous syphilitic infection may, when he comes under observation, have a tuberculous lesion of his nose or throat. Neither one of these eventualities is at all uncommon. The differential diagnosis of lupus of the pharynx from a syphilitic lesion is often extremely difficult even if the observer is alive to the possi- bility of the presence of the former in any given case. The presence of primary lupus of the pharynx is an event of extreme rarity. When a skin lesion coexists, as is more frequently the case, the aspect of it may serve to remind the observer of its possibility in the pharynx. As a practical view of the problem it may be said that it is not desirable to await the confirmation of the suspicion of lupus of the pharynx, whether it is neces- sarily primary or whether the suspicion is strengthened by the coexistence of a skin lesion. Antisyphilitic medication should be begun at once. Suffice it to say the alert diagnostician will more often find his suspicion unconfirmed by the therapeutic test. Lupus in the pharynx never pre- sents the frank ulceration of the tertiary syphilitic lesion in its typical efflorescence, but syphilis in its innumerable forms may simulate any- thing. The sluggish infiltration with the dusky granular surface and the melting nature of destruction of tissue typical of lupus may well be syphi- litic rather than tuberculous. Whatever the form of pharyngeal lesion it is important that the diagnostician should never lose sight of the possi- DIFFERENTIAL DIAGNOSIS 597 bility of the existence of syphilis as the active etiological factor. In enter- taining the view that the disease may be a rare form of tuberculosis, therefore, the first test to be applied is the one of antisyphilitic treat- ment. A week's trial of this may well intervene in a lesion of the pharynx before a portion of it is removed for histological examination. In view of the fact that it may be an operable cancerous lesion too long a time must not be allowed to elapse in the interest of the patient before the micro- scope is called in as an aid in the diagnosis. Often there is no reason why a piece should not be removed at once. Thus three or even four diagnos- tic methods may be instituted at once when the patient comes under ob- servation. Tuberculin in the von Pirquet test, blood for the Wassermann reaction, a piece*of tissue from the lesion, and finally the therapeutic test may all be resorted to at once, without great inconvenience to the patient. The great desideratum, a diagnosis in which all possible advantage is de- rived from modern scientific methods, may thus be secured without loss of time, a consideration of very great importance when one has to do with the possible existence of destructive syphilitic ulceration, or of rapidly extending cancerous infiltration. A man of fifty presents himself with the history of some difiiculty in deglutition accompanied by a short, hacking cough beginning six months ago. He gives no direct or indirect history of syphilis. There is no pain even on swallowing. Four months ago his voice became hoarse and now he can only whisper, and there is some difiiculty in breathing. He has had antisyphilitic treatment with no result. He has lost twenty pounds in weight. His temperature varies from 100° to 102°, without distinct after- noon exacerbation. Examination of the larynx shows very marked swel- ling of both ventricular bands and of the interarytenoid space, the swelling being much more marked on the right side and, while most of the swelling is above the cords, the lumen of the larynx is so narrowed as to account fully for the dyspnea and aphonia. To the outer side of the right ventricular band is a large area of necrotic tissue which yields to the probe, which can be inserted more than an inch. We are more explicit in stating the conditions here, since we are giving what is practically an epitome of a case observed by us. (Figs. 295 and 297.) Notwithstanding the suspicion of malignancy entertained by others, who had previously seen the case, and the absence of any indications of syphilis in the history, we were inclined to regard the case as one of gumma of the larynx. In con- sideration of the condition of the larynx and in view of the fact that in any laryngeal lesion it is wise to be ready for a tracheotomy in an emergency when iodid of potash is given, the patient was put to bed and the drug administered in rapidly increasing doses in accordance with the principles already referred to as concerns the destruction of tissue. Improvement did not begin until the patient was taking a half-ounce of potassium iodid a day and the necrotic material had been expelled. The swelling diminished and the glottis hitherto hidden to view could be seen in the laryngeal mir- ror. While the infiltration did not entirely subside, the diagnosis of ter- tiary syphilis was considered as assured. We had excluded tuberculosis. The patient answered apparently fairly well to the therapeutic test. We 598 THE NOSE AND THROAT IN GENERAL DISEASES supposed the answer to the antisyphihtic treatment, which also included the hypodermic administration of mercury, was not so prompt as it usu- FiG. 296 Laryngeal cancer simulating syphilis. Fig. 297 ^ •^ '"*■■■' M ^Tk ^^H ^fe<$i 2 , jr^ |^kS> ^1 W'M wmf Mrn^ ■ ^^^ .'' -^ft ^ .-■•' jr^ J^mf Li . :. ^'-^^^^^ ^B' 4 1^ tii ^^^M Same case one year later. ally is because of the existence of a sphacelus in the thyroid or arytenoid cartilage. Doubts, nevertheless, were entertained and as soon as possible DIFFERENTIAL DIAGNOSIS 599 a portion of tissue at the edge of the depression, left by the expulsion of the necrosed material, was removed for microscopical examination. The report was unequivocal. It was a typical adenocarcinoma. While this particular case was under our observation, before the practice of the Was- sermann reaction became a matter of routine, we had no hesitation, on account of the necrosis and the partial reaction to the therapeutic test, in at least provisionally accepting the diagnosis of syphilis. It is possible that the Wassermann reaction, if it had been negative, might have made us more skeptical, but the question is still undecided whether the patient had not also had syphilis. We have seen similar cases of necrosis and sloughing and thereafter even partial healing in a case of round-celled sarcoma. In both cases the course of the disease was practically a typi- cal one, both ending fatally, the adenocarcinoma within three years and the sarcoma within a year and a half. There is no class of laryngeal neoplasm which will give rise to so much embarrassment for the diagnostician as malignant growths of the larjn- geal ventricles. The one, the history of which has just been narrated, doubtless began at the upper and back part of the laryngeal ventricles. Without surface vegetation, in fact very often covered by healthy epithe- lial surfaces, it frequently does not offer an opportunity for the removal of a piece for microscopical examination. The aid of the microscope in es- tablishing a diagnosis in this case was very striking. It often, without adequate control from the clinical facts, is misleading. A man of fifty was seen by one of us in consultation with Dr. Lee M. Hurd. A piece as large as a small pea had been removed from the growth and submitted to Dr. Wright for report as to the microscopical appear- ances. The histological findings furnished no support for a diagnosis of malignancy. It showed only a hyperplastic epithelium over a markedly inflamed submucosa. The man was robust and for six months complained only of hoarseness which did not amount to aphonia. Coming from a dis- tance to consult Dr. Hurd the picture presented by the local appearances was so striking that diagnosis of malignancy was at once made and the piece removed from the lesion for the microscope. When seen by Dr. Wright with Dr. Hurd, it was observed that there existed marked swelling of the left vocal cord, some impairment of movement on that side, an un- even, but not ulcerated surface showing at the point of greatest protuber- ance, which was a little anterior to the middle of the cord, the loss of tissue caiised by the laryngeal forceps. The surface gave the impression of sub- epithelial induration. So striking was the appearance and the history, so free from suspicion of tuberculosis and syphilis were both the history and the local appearance, that both observers considered a thyrotomy and a wide excision of the growth indicated. This was promptly done. The cord and some of the cartilage were excised. Microscopical examination of a section made through the centre of the growth showed that the intra- laryngeal forceps first used had removed a considerable depth of epithe- lium and subepithelial tissue, but had failed to include the closely sub- jacent structure of a typical epithelioma. The extent of this was small and apparently the limits of it had everywhere been exceeded by the 600 THE NOSE AND THROAT IN GENERAL DISEASES incision of the subsequent operation. The man made good recovery and was alive and well without recurrence four years after operation. We have illustrated by the citation of cases incidents where, in the dif- ferential diagnosis of the laryngeal lesions, the therapeutic test by its ap- parently positive nature misled us, where the microscope aided us, where it failed us. We have now to cite an instance where the therapeutic test by its apparently negative nature embarrassed us. We have seen how the necrosis of tissue led us wrongly to believe that a piece of dead cartilage at the bottom of a sinus prevented the entire healing of a supposed ter- tiary syphilitic infiltration. In the following case, persistence in the be- lief of such a condition finally resulted in the demonstration of the fact and in the cure of the lesion before great damage had been done. A man aged thirty-three years gave a history of an initial syphilitic lesion occurring seven years previously, but there were no subsequent symp- toms noted, he having had antisyphilitic (Hg. — K.I.) treatment for three years. We saw him in May and his attending physician stated that in February he had had an ulceration around a tooth apparently syphil- itic in character. In years past he had been able to sing, but for several months he had been hoarse. His voice in the high notes became falsetto in tone. He had had no pain. There had been slight loss of weight the past six months, but his general appearance was fairly good. Repeated and persistent examination showed no definite pulmonary signs and no tubercle bacilli could be found in the sputum. The temperature taken three times daily for several weeks sometimes, though rarely, went above 101°. Usually the afternoon temperature was 99° to 100°. There was no cough. On examination a papillary swelling was seen involving the posterior part of the right vocal cord and ventricular surface. There was only moderate impairment of the movement of the cord of that side. Can- cer is not usual at this age. With the amount and the situation of the swelling and the duration of the symptoms, we should have noted con- siderable interference with the movement of the cord were the case one of cancer. It was impossible to remove a piece for microscopical examina- tion. We were convinced that the case was one of tertiary syphilis. Large doses of the mercury and potassium iodid were given — the latter as high as a half-ounce a day. No material diminution in the growth was observed, in spite of the fact that the medication was varied in form of administration. For six months this course was persisted in, the patient coming at least once a week for observation. By this time it became evi- dent the patient did not have cancer, but so resistant was the laryngeal lesion to treatment that we were driven to consider the diagnosis of tuber- culosis. We were, however, so convinced of its syphilitic nature that the proposition was entertained of making an incision over the wing of the thyroid cartilage and raising a cartilaginous flap. We proposed thus to seek a piece of dead cartilage which might be keeping up the inflammatory infiltration. As this course of action might have resulted disastrously for the patient if the lesion were tuberculous and another consultant tend- ing to that belief, the patient went to the Adirondacks for several months. Returning in practically the same state, he shortly after appeared for DIFFERENTIAL DIAGNOSIS 601 examination with the statement that he had spat up one or two mouth- fuls of blood within the last day or two. We had been looking for some- thing of the kind in spite of the suggestion of tuberculosis which the incident usually excites, and we were not surprised to see a little blood in the larynx. In a few days the swelling had disappeared and in a short time very little departure from the normal could be seen in the larynx ex- cept that over the site of the previous swelling there was a depression. Evidently a small bit of cartilage or other necrotic tissue had come away with a little bleeding and the case cleared up in our minds. We have now to cite the history of a case which in some ways resembled the last described in which we were able by exclusion to arrive at a dif- ferentiation of a rare affection, essentially of a simple inflammatory na- ture, from tuberculosis, syphilis, and cancer. A minister of the gospel from a distant state was accustomed to strenuous use of the voice and abuse of his laryngeal structures by preaching in the open air when he had colds, and when his general health was run down by overwork. He was thirty-five years of age, without syphilitic or tuberculous antece- dents, with a negative Wassermann reaction, without physical signs in his lungs or tubercle bacilli in his sputum. A distressing cough, hoarse- ness and weakness of the voice had annoyed him more at some times than at others for a year or two, and he was finally compelled to give up his occupation of preacher and exhorter and seek relief. Pressure over the larynx on the left side gave pain, especially when exerted on the cricoary- tenoid joint. An angry red-looking swelling was seen in the larynx, over- lapping the left cord. There was a diffused sense of tumor behind the larynx which induced one observer to suppose -there was pressure exter- nally, perhaps on the nerve trunks. There was marked limitation in the movement of the left crico-arytenoid joint. There was not much pain in swallowing. Owing to the short time the patient was under observation and the number of conflicting diagnoses which were ventured, neither cancer, syphilis, or tuberculosis could be conclusively excluded. Suffice it to say that absolute rest of the larynx resulted in the entire subsidence of the symptoms both objective and subjective. This in itself established the correctness of the view that the patient had local chronic inflammation of the larynx brought on by voice-strain. Persisting in the use of the organ under these conditions, there had arisen a redundancy of the mucous membrane lining the ventricles and lateral wall of one side of larynx. The only clue which we had to this possible explanation from the objec- tive appearances was the variation in the bulk of the swelling. At times it had all the appearances of a true tumor. At the next examination, with the larynx still inflamed and red, the size of the growth had very evidently diminished. In the very few cases of prolapse of the ventricles whicla we have seen, this has been the striking differential feature. We only mention this case here in consideration of the differentiation of the three great processes of syphilis, tuberculosis, and cancer, because it sometimes, especially in tuberculosis, is seen as a complication. CHAPTER XXII. THE NOSE AND THROAT IN GENERAL DISEASES. Leprosy. — On the external nose, tuberculous leprosy is an early lesion in the history of the disease which usually manifests itself first as a skin lesion upon the brow. This extends down the nose, which loses its sharp outline; there is thickening of the skin and irregular tumors. When this condition spreads to the mucous membrane, the inside of the nose rapidly brealis down and forms an ulcer which in olden times is mentioned as pathognomonic of the disease. Internally it is the anterior part of the nose almost exclusi^•ely which is affected. In at least 80 per cent, of the cases of leprosy it has been asserted that the lesion is present in the nose usually in the form of ulceration on the cartilaginous part of the nasal septum. Etiology. — Nothing is known of the cause of leprosy beyond the fact that in its lesions are regularly found large numbers of acid-fast bacilli resembling those of tuberculosis, but they are non-pathogenic in animals and their inoculation into criminals has been uniformly followed by nega- tive results. • Histology and Pathology. — In the anesthetic form of leprosy, the nasal lesion is as regularly found as in the nodular and tubercular form. The initial lesion seems to be a sclerosis and the ulcer which soon forms is covered by a secretion which contains large numbers of lepra bacilli. The nasal lesion may take the form of a chronic hypertrophic rhinitis and perforation of the septum and distortion of the external nose as a result occurs. As the nasal lesion subsides, atrophy of the affected parts ensues. Besides the nose, the fauces, the pharynx, and the larynx are often in- volved. In the anesthetic form of the disease, the reflexes are abolished and the parts are easily examined with the laryngoscope. In the process of cicatrization, the soft palate and the pillars become agglutinated to the pharyngeal wall as in syphilis. So great is the resemblance of leprous lesions to those of syphilis and tuberculosis that diagnosis is often diffi- cult and the difficulty is often enhanced owing to the fact that in leprous patients both the Wassermann and the tubercular reactions are positive. Sections of the tissue show histologically round-celled infiltration which is abundant around the glands, the nerves, and the bloodvessels. It is due to the exertion of pressure upon these that certain clinical phenomena are noted; the pressure upon the nerve is doubtless responsible for the anesthesia which is present in certain forms of the disease ; the pressure upon the bloodvessels causes the ulceration and the involvement of the glands causes vitiation of the secretion so that thick crusts form upon the mucosa. The lepra bacillus which is present in all lesions is especially TYPHOID FEVER 603 abundant, according to Bergengriin, in those of the larynx, the bacilli often forming thrombi in the vessels. Here especially the epithelium is enormously thickened in places, though elsewhere it may be thin, and in the ulcers, of course, destroyed. In the course of the lesion there comes a stage in which there ensues healing of the ulcers, shrinking of the parts into a skin-like surface with extensive scar formation, and nasal synechia is present as well as pharyngeal and laryngeal adhesions and distortions. In the pharynx there are occasionally noted herpetiform or pemphigus-like blebs due to atrophic neurosis. The bacilli are found in the ulcers, in the blood of the lesions, and some in the buccal secretion, but they are very abundant in the nasal secretions.^ Fig. 298 Laryngeal leprosy. (John Horn.) Epistaxis is, one of the characteristic manifestations of leprosy just as hemoptysis is in phthisis. There is a chronic coryza associated with excessive nasal secretion in which the bacilli of leprosy may be abundantly manifest. There is invasion of the mucosa by nodules which coalesce and break down, which is associated with mucopurulent discharge, fol- lowed by crusts just as in atrophic rhinitis and later by cicatricial adhe- sions. The destructive process takes in the turbinates and the septum, just as lupus and syphilis, and retracts the external nose in the same man- ner as lupus. The nodular condition extends to the palate, pharynx, and larynx. The uvula and part of the soft palate may slough away entirely, leaving a star-shaped cicatrix blocking off the postnasal space. The epi- glottis is prone to invasion together with the aryepiglottic folds and ven- tricular bands, which in the beginning give the characteristic swelling of tuberculosis, but shortly the epiglottis becomes curved on itself and retracted into a mere knob so that the inside of the larynx becomes invisible. Typhoid Fever. — Hemorrhages in the submucosa of the nose and throat and epistaxis are among the pathognomonic signs of typhoid fever. In addition to these, in the later stages deep ulcerations have been seen, necrosis of the cartilage and perichondrium and noma are occasionally observed as the terminal lesions in fatal cases of typhoid. . Occasionally the ulceration may be seated on the septal cartilage and perforation may 1 For an exhaustive account of leprosy of the upper air passages, see Gerber, Archiv f . Laryngologie und Rhinologie, 1901, xii, 98. 604 THE NOSE AND THROAT IN GENERAL DISEASES result. Such ulcere are seen in the larynx and the involvement may be so deep as to involve the crico-arytenoid joint with resulting ankylosis. In these ulcers the typhoid bacillus has been occasionally found. In addition to the lesions already referred to, paralyses of the larynx of all kinds have been observed, of single muscles or total paralysis probably of peripheral character, involving adductors as well as abductors. They usually recover from these paretic symptoms; among the sequelae of typhoid fever are permanent deformities due to adhesions and loss of substance, such as perforation of the nasal septum and ankylosis of the crico-arytenoid joint. In the third week of typhoid particularly, the laryngeal structures often become involved and present serious complication to the favorable out- come of the disease. Three classifications determine largely the character of the laryngeal involvement, each of which may merge one into the other. A classification as presented by Keen is perhaps the simplest and yet most comprehensive of any yet given. First, edematous laryngitis; second, ulcerative laryngitis; third, laryngeal perichondritis. Edem- atous laryngitis may become ulcerative or lead to involvement of the perichondrium. Ulcerative laryngitis may likewise involve the peri- chondrium, but rarely, if ever, becomes edematous. It is seldom that the larynx is involved in the first week of typhoid and relatively few cases have been reported where it has become involved in the second week, but the third week is the serious one from the intestinal-lesion standpoint as well as the most serious from the laryngeal. The fourth week the lesions again lessen in frequency. The natural depression of the patient makes his voice weak and uncertain, and the symptoms presented are naturally attributed to general bodily weakness rather than to local disturbance. Symptoms. — ^Hoarseness gradually merging into aphonia is the intro- ductory symptom of laryngeal involvement. Aphonia may also suddenly develop without the preceding disturbances in the pitch of the voice. Breathing is interfered with, becoming more labored and interrupted, and, if continued, dyspnea follows. Any evidence in the disturbance of voice or respiration should lead to an examination of the larynx with the laryn- geal mirror. Pain is present in some instances and may radiate along the sides of the throat to the ear. When the cricoid region of the larynx is involved dysphagia may be present. If the posterior laryngeal wall is invaded the induration and edema will necessarily be extended to the esophagus and the act of swallowing will be attended with pain or at least discomfort and may be altogether impossible. In the edematous type the under surface of the epiglottis, the ventric- ular bands, or the arytenoid region may be involved. In the ulcerative type the ulcers have occurred most usually on the postlaryngeal wall, although they have been found on the ventricular bands, in the ventricle of Morgagni, and upon the true cords. Osier has reported these ulcers occurring at the base of the epiglottis and on the aryepiglottideal folds, and Dupuy has found them on the ventricular bands and in the ventricles of Morgagni. Expectoration is increased in all three instances and in the ulcerative TYPHOID FEVER 605 type it is frequently mixed with blood. Profuse hemorrhage is rare, al- though one case is reported by Ruyer. Pressure on the cricoid cartilage will frequently elicit pain, particularly if moved laterally and backward toward the vertebral column. Dyspnea may also be brought about by a lateral pressure upon the cricoid. In the involvement of the perichon- drium great pain is present, although in some instances the patient is so depressed mentally that he gives little evidence of its existence. Little or no evidence of laryngeal involvement is to be made out by external examination, even in cases where it has gone on to abscess formation. Death may follow typhoid involvement of the larynx by sudden stenosis incident to edema; or the abscess may enlarge sufficiently to prevent respiration or rupture spontaneously and occasion infective pneumonia, or the cartilages may become destroyed in the process of perichondritis, permitting the walls of the larynx to close together, the resilient support being removed from the tissues, or, as is reported by Keen, there may be destruction of the abductor muscles or paralysis of the nerve supplying them, which permits of the closure of the larynx. In a number of instances involvement has healed spontaneously without treatment, but not with- out producing in the larynx some permanent condition interfering with its mechanism, either respiratory or vocal. Treatment. — When there are any evidences present of approaching stenosis, immediate tracheotomy should be performed. In cases of edema seen sufficiently early to overcome the obstruction to respiration, multiple puncture should be made to evacuate the extra vasated serum. Adrena- lin locally and hypodermiqally should be employed. Where ulceration exists cleansing applications should be made with weak solutions of peroxid and water followed by Dobell's solution, after which ten grains to the ounce of nitrate of silver should be applied locally. In cases of peri- chondritis deep incisions penetrating the perichondrium should be made under local anesthesia. Thyrotomy with removal of the diseased carti- lage has also been advised in these cases. In all cases the patient should have inhalations of steam laden with oil of pine mixture. (See formula, p. 464). There should always be on hand a tracheotomy set ready for use in emergency. Day and Jackson have employed successfully their laryngeal tubes in several of their cases of stenosis, but as an emergency measure tracheotomy may be relied upon with greater security. For the muscular paralyses electrical stimulation and the internal administration of strychnin appear to be the only measures which can possibly offer any hope of restoration to function. In a large number of instances the paralyses remain permanent. Where cicatrices tend to web in the laryngeal chink it is often necessary to cut the stricture and keep in place Schroetter's or O'Dwyer's tubes until healing has taken place. But often then, after the withdrawal of the tube, there is great tendency to reformation of the cicatrix. - Pharyngeal and Nasal Invohement. — The pharynx is frequently the site of ulcerations simulating those that occur in the larynx. The ulcer is usually the size of a split pea to begin with, but several may coalesce, forming a large sloughing area. Other than their persistence they present 606 THE NOSE AND THROAT IN GENERAL DISEASES no dangerous element in the course of the disease. Nasal hemorrhage is a special symptom of typhoid fever, particularly in its incubation period, when the hemorrhage results from the breaking of the mucosa over the part of the septum known as Kiesselbach's area. During the middle period of typhoid hemorrhage is not marked, but again in the later stages of the disease it may become very serious owing to the breaking down of the tissue either over this area or on the anterior inferior border of the tur- binates. The ulcer should be cleansed, cauterized with fused nitrate of silver or fused chromic acid, and kept well greased with carbolized vaselin. Cholera. — The changes in the voice which are sometimes spoken of in descriptions of epidemics have been called vox cholera. Laryngoscopic examinations show the larynx cyanotic and congested. Croupous inflammations of the mucosa have been described. All these phenomena have been supposed to be due to a trophic neurosis. The sudden ab- straction of large amounts of water from the submucosal connective tissue is quite sufficient to explain the cyanosis, and the peculiar voice of cholera is probably due to muscular changes caused by it. Anemia. — There are various manifestations referable to the larynx and pharynx seen in anemic patients which sometimes may be ascribed to hysteria and at other times to peripheral neurosis dependent upon the blood changes. In these patients a very moderate amount of laryn- gitis will frequently cause them to lose their voice, which, however, will return with the recovery from the laryngeal condition. Leukemia and Pseudoleukemia are sometimes associated with lym- phatic nodules in the mucous membrane and with large tonsils, and in addition the same phenomena as have been mentioned for anemia have been noted. There are various ulcerations of the throat already referred to as associated with these blood-lesions. Hemophilia, Purpura, Scurvy. — In these affections submucous hemor- rhages are often seen with epistaxis and bleeding from the mucosa. Rachitis. — Reference has been made to the laryngeal spasm seen in rachitis under the head of Laryngeal Neuroses. Acromegaly. — In this rare affection there is hypertrophy and hyper- plasia of the mucosa and of the cartilages of the internal nose as of other structures about the head. Gout. — Catarrhal affections of the nose and throat are described as being somewhat peculiar in gouty people. Dark red congestions are more or less constant in these cases and exacerbations occur. Otherwise they differ in no way from catarrhal affections in other people. The tophi which are seen in the larynx have been referred to elsewhere. The same may be said of ictus laryngis. It is mentioned here because in the few cases that have been observed, the history of gout has been relatively frequent. Chicken-pox, Smallpox, Vaccinia present pustulous eruptions on the mucous membranes of the mouth and pharynx, the two first not infre- quently, but vaccinia has only been observed rarely, having been accident- ally transferred from the original sore through the mucous membranes. Laryngitis and pharyngitis with accompanying tonsillitis are not infre- PLATE XI Purpura Hemorrhagica. Case of Dr. Max Goldstein. SCARLET FEVER OR SCARLATINA 607 quently seen in pneumonia. In addition to this, laryngeal ulcers occur and paralysis of the recurrents have been reported due to involvements of the nerves in the pleural process. Affections of the thymus and thyroid glands and other thoracic and cervical tumors are associated occasionally with paralysis, while in the general affections of arteriosclerosis we have frequent attacks of epistaxis. Disturbances of digestion and cirrhosis of the liver are occasionally asso- ciated with minor affections of the nose and throat and are probable causes of these local manifestations. Rheumatism. — Much has been said of rheumatism as a sequela of acute and chronic infection of the tonsils with microorganisms. It is a matter of common clinical observation that rheumatism is frequently seen in patients who are suffering from acute or subacute inflammations of the tonsils, but until it is positively proved that in the human subject septic cocci or bacilli are the primary factors in the etiology of rheumatism it is best to look upon the invasions of the system with germs from the tonsillar crypts as part of some systemic change in the fluids of the organism. There is good reason to believe that the coincidence of rheu- matism and of acute exacerbations of chronic tonsillar and pharyngeal affections are dependent upon an unknown common factor rather than that one is the sequel to the other. Peritonsillitis or quinsy of a recurring type is especially apt to be seen in rheumatic patients. There is one rare manifestation of rheumatism in the upper air passages that must be mentioned. We refer to involvement of the crico-arytenoid joint either in cases suffering from general rheumatic affections of the joints or in patients who are subject to such attacks or to those who manifest in their clinical histories an hereditary tendency to it. Pain, hoarseness, and tenderness to pressure over the arytenoid joint are all of them frequently marked in these cases, and it is doubtless due to this affection that one occasionally sees ankylosis of the crico-arytenoid joint with immobility of the vocal cord on that side either in the median or cadaveric position. Scarlet Fever or Scarlatina. — With this acute exanthema, there are regularly certain phenomena seen in the mouth and throat which are as characteristic of the disease as is the skin lesion. There is the peculiar strawberry tongue and a follicular pharyngitis which may be very severe, showing dark purple, congestion and edema and sometimes a thick membrane over the tonsils, which are always swollen. The membrane may spread to the pharynx and elsewhere. These cases of excessive throat manifestation are sometimes spoken of as the "anginose form" of scarlet fever. They may progress to necrosis; whether this is actually present or not there is considerable fetor of the breath due to the super- ficial ulceration and desquamation of the epithelium. Abscesses may occur about the neck. In this affection as in other systemic infectious diseases, the rapid necrosis characteristic of the condition known as noma is occasionally seen, rapidly leading to a fatal issue. The absence of the diphtheria bacilli and the presence of the skin eruption and the presence of other clinical symptoms will usually, after the disease is fully 608 THE NOSE AND THROAT IN GENERAL DISEASES developed, serve to distinguish it from diphtheria, but in the first few days of the lesion this is a matter often of considerable difHculty. Measles. — Rubeola. — ^The eruption of measles probably begins in the mucosa of the bronchi and trachea and extends upward throughout the mucous membrane of the upper respiratory tract and lastly extends to the skin. The initial cold and cough of measles are due to this eruptive condition and often the first definite evidence of its existence appears on the inside of the cheek, as was first described by Koplik. The nasal mucosa is red and puffy and the symptoms are the same as for an acute coryza. There is always more or less congestion of the mucosa of the fauces and the pharynx in measles, but it is usually not excessive. White spots are seen on the buccal mucosa and the lips and the dark red discoloration around them has been described as characteristic of the disease by Filatow and Koplik, but they are also seen in the throats of patients suffering from German measles. They are bluish-white in color, are usually seated opposite the lower molars in the line between the teeth when the jaws are closed; they are said to occur in 97 per cent, of the cases. Severe stomatitis is occasionally seen in the more grave attacks of measles and again the grave form of noma is occasionally observed. The parotid gland is affected in this and sometimes in the less grave forms of throat complications of measles. CHAPTER XXIII. LARYNGEAL NEUROSES. CENTRAL AND PERIPHERAL NERVE SUPPLY OF THE LARYNX. Cerebral Cortex. — ^The laryngeal motor centre in the cerebral cortex corresponds to the speech centre. While a lesion of the left cerebral cortex in this area may produce aphasia, it has never been proved that it has caused any loss of laryngeal movement, that having a bilateral representation. It is not very well understood why this should be so. The movement of the cords having become largely involuntary is repre- sented lower down. Speech being a function of high cerebration and under voluntary control, evolved at a much later date in epigenesis, requires the use of one hemisphere, the left; laryngeal movement existing in the lowest of animals is unaffected by the extirpation of either one or of both. The representation of the motor function of the larynx in the cerebral cortex for phonation is along the lower prefrontal convolution, but the localities differ a little for respiration, some localities existing the stimulation of which causes adduction of the vocal cords, and some represent the movements of abduction. The former are spoken of as phonatory, the latter as respiratory movements. These localizations in the cortex have been established for the most part by Krause,^ and by Semon and Horsley.^ Differing in various animals, both physiologically and anatomically, not satisfactorily demonstrated with exactitude in man, the subject nevertheless remains about as these authors and their numerous co- adjutors left it fifteen or twenty years ago, chiefly because they seem to have exhausted every resource possible for human ingenuity to suggest, and therefore their results must be accepted, if not as a final word on the subject, at least as near to the truth as seems possible even now. On the surface of the prefrontal gyrus the centre of abduction is lower than that for adduction. A reference to the illustration (Fig. 299), used by Semon to demonstrate the results of his investigations, will render the description intelligible. Semon and Horsley for the cat, and Risien Russel for the dog, showed (ab) movements of abduction alone existed in the anterior composite prefrontal gyrus of the cortex just in front of and below the centre for adduction (ad). The centre of thoracic movement (D) is unaffected by stimulation at least of the laryngeal centre which governs abduction ' Archiv f. Anatomie und Physiologie, 1884, Abt. Physiol., p. 203. ' International Medical Congress Transactions, vol. iv, 12, p. 132; and British Medical Journal, August 24, 1895, p. 481. 39 610 LARYNGEAL NEUROSES of the cords, since Semon observed rhythmical respiration taking place in animals while the dilators of the glottis kept it open constantly in answer to cortical stimulation. Though unilateral cortical stimulation produces bilateral movement of the larynx, even bilateral extirpation of the hemispheres of the brain in dogs produces no laryngeal paralyses nor does unilateral extirpation produce any difference in the movements of the two vocal cords. Anencephalic human monsters give forth cries which indicate undoubted laryngeal movement, but here, as by all these experiments on animals, it is quite impossible to say that they prove the presence or the absence of voluntary or involuntary laryngeal centres. Modern physiological and psychological researches have all but demonstrated that the line between reflex action and voluntary action is a broad and wavering domain, and that to locate one in the medulla exclusively and the other in the cortex exclusively has not proved possible under strict critical analysis. A discussion of the phylogenetic and evolutionary aspect of this subject has never, to our knowledge, taken place. Fig. 299 Laryngeal centres in the cerebral cortex of a dog. (After Semon.) ab, centre of abduc- tion; ad, centre of adduction; ac, centre for acceleration of inspiration. D, centre for deep inspiration. Not only has experimental observation shown that extirpation of one cortical centre of laryngeal movement has no effect on the cords in phonation and respiration, but Klemperer by setting up infectious disease in one centre was unable to note any paralysis of the cords on either side of the larynx, though subsequent postmortem examination showed the cortical centres extensively affected. Somewhat contradictory results have been attained by Masini, but they have not been confirmed. It seems definitely settled, for the lower animals, at least, that even a bilateral lesion does not produce laryngeal paralysis, but the status of the question is not so satisfactory for man. In the monkey the extreme point of the gyrus represents purely laryn- geal movement, but closely adjacent regions, when stimulated, give CENTRAL AND PERIPHERAL NERVE SUPPLY OF LARYNX 611 origin to pharyngeal movements. Stimulation of these areas in the experimental work on animals on one side produces bilateral movements, but in man some cases of apparently cortical unilateral lesion have been reported in which there was a laryngeal paralysis confined to the opposite side. The reports of these cases have been adversely criticised by the upholders of the doctrine of the bilateral representations of laryngeal movement in the cerebral cortex of man. Their criticism of these cases seems justified. The Corona Radiata and the Internal Capsule.— In the tissue inter- vening between the cortex and the medulla, fibers have been identified' in the knee of the internal capsule of animals as representing the laryngeal movements of respiration and phonation. Fibers from cortical areas pass through the corona and the internal capsule, the respiratory fibers being at first in the anterior portion and lower down, in the genu, while the phonatory fibers seem to run for the most part just posterior to the respiratory. In the monkey the phonatory fibers are associated with those governing movements of the tongue and pharynx. Here as in the cortex unilateral stimulation produces bilateral effects. Fig. 300 Floor of the fourth ventricle of the brain of a dog. (After Semon.) cqa, corpora quadri- gemina, anterior; cgp, corpora quadrigemina, posterior; cs, calamus scriptorius; ac, ala cinerea. The MeduUa and the Floor of the Fourth Ventricle. — According to Onodi^ severance of the medulla above the region of the nucleus of the vagus at once stops phonation but not respiration, and it seems likely in man as in animals the essential phonation centre is represented some- where between the corpora quadrigemina and the vagus centre in the floor of the fourth ventricle. ' Sir Felix Semon, Die Nervenkrankheiten des Kehlkopfes und Luftrohre, Handbuch der Laryngologie und Rhinologie (Heymann) 1895, Band i, Halfte 1, p. 578. 2 Anatomie und Physiologic der Kehlkopfnerven, 1902. 612 LARYNGEAL NEUROSES Bilateral representation only has been experimentally demonstrated for this region, but many of the clinical and pathological reports of laryn- geal paralysis, presumably due to cerebral lesions, are not in accord with these conclusions. However, there is no case, so far as we are aware, in which the evidence can be accepted as conclusive, inasmuch as it has been, and in all probability always will be, impossible to compare the condition of the whole neurocerebral tract postmortem with the clinical findings, and unless this is done justifiable doubt as to localization of the causative lesion will always be attached to such reports. On the other hand, animal experimentation cannot be accepted as conclusive when applied to man in a domain where the evolution which distinguishes man from the brutes has the most to say. The recent revelations of the pathology of arteriosclerosis do much to complicate the question from the standpoint of the clinician as well as from that of the pathologist. In the face of the experimental facts it must be admitted that any diagnosis of a lesion situated above the floor of the fourth ventricle resting on a unilateral paralysis of the larynx is scarcely justified. The base of the skull and the floor of the fourth ventricle is as high as the diagnostician can trace with any degree of probability the supposed situation of any unilateral lesion of the brain substance as a causation of laryngeal paralysis. Onodi brings this out very clearly in his analysis of the cases reported with clinical and pathological data. Darkschewitsch has stated that the dorsal nucleus of the vagus from which is derived the motor filaments of that nerve is coterminus with that of the spinal accessory, but this has not been confirmed by others. Laryn- geal paralysis due to a bulbar lesion we must therefore accept as having its origin at the lower part and beneath the floor of the fourth ventricle near the median furrow, for Grabower has shown that the motor roots of the vagus are anatomically separated from those of the spinal accessory, the latter having anatomically no cerebral origin, but the upper region of the vagus nucleus in the medulla is continuous with that of the facial anterior to it. As has been said, just behind the corpora quadrigemina Onodi has found laryngeal movement represented, but this has been denied by Klemperer and the matter is left in doubt. However this may be, there is a region along the floor of the fourth ventricle at its posterior portion where there are areas on each side of the median line representing bilateral movement, and this corresponds to the so-called nucleus vagi beneath the ala cinerea or respiratory centre and continuous with the nucleus of the origin of the glossopharyngeal. A few fibers pass into the funiculus solitarius and others into the nucleus ambiguus or accessory vagal nucleus. The sensitive fibers of the vagus are deri^'ed from the spinal cord and enter the ganglia of root and trunk (Gray). Posterior to the region representing bilateral movement in the floor of the fourth -ventricle and also a little externally and anteriorly there is a limited area where stimulation causes bilateral laryngeal move- ment only in adduction of the cord, but as this is the region of the origin of the vagus nerve, though in the restiform body, it is doubtful whether such an impulse is to be regarded as springing from the brain substance CENTRAL AND PERIPHERAL NERVE SUPPLY OF LARYNX 613 or the nerve substance. Above this region and nearer the centre Hne the ala cinerea represent the centres of respiration, also bilateral in their function. There are other regions in which bilateral movements may be elicited by stimulation of the floor of the fourth ventricle, but Semon asserts that a unilateral external movement of a laryngeal cord was not obtained experimentally. Notwithstanding this it seems probable' that unilateral lesions of this area in man (syphilitic softening) have produced unilateral laryngeal paralysis. Still this cannot be considered as assured. We have seen a number of cases in which the presumptive lesion was along the median furrow of the floor of the fourth ventricle in which the association of unilateral pareses and paralyses of the muscles of the face and pharynx and larynx was such as to lead to this conclusion. FiQ. 301 fa S V ah The cranial nerves at the baae of the skull. (After Testut and Onodi.) a, Spinal acces- sory, nerve trunk and roots; v, vagus, nerve trunk and roots; g, glossopharyngeal, nerve trunk and roots, fa, facial and auditory; ah, abducens; b, basilar artery. The Origin of the Motor Filaments of the Vagus Nerve.— The investi- gations of Grabower, Grossmann and Onodi have reversed the con- clusion drawn from the experiments of Claude Bernard and others. The spinal accessory can no longer be considered as the origin of the motor 614 LARYNGEAL NEUROSES filaments of the innervation of the larynx, and from the work of Rethi the same may be concluded for the innervation of the soft palate. Clinical observation, as has been said in regard to other points, has shed little light on these questions, though the cases of Oppenheim and Reusz' lend support to the conclusions drawn from animals and the same may be said for the case reported by Grabower.^ By an examination of Fig. 301 it will be plainly seen how close together are the origins of the facial and acusticus, the abducens, the glosso- pharyngeal and the vagus from the medulla or contiguous regions. While the spinal accessory rises separately below the vagus, by virtue of its decussation with the ganglion of the root and the ganglion of the trunk, as seen in Fig. 301, it becomes anatomically inseparable from it and its distribution has had to be worked out physiologically and patho- logically. It will be seen how a single tumor or wound of this region of comparatively small dimensions might involve regions as widely separated as the eyeball and the vocal cord, while it frequently happens that cases present themselves with a syndrome of symptoms, paralysis of the face, the palate, the larynx and the trapezius muscle, in which it is only with great acuteness of diagnostic differentiation that a lesion of the fourth ventricle of the brain can be told from one at the lateral base of the skull, unless we accept the view of bilateral representation only, in the medulla of man. The Vagus and the Laryngeal Nerve. — ^The course of the vagus through the neck is in the common steath of the carotid artery, the internal above, the common below, and the jugular vein lying between them. It gives off its pharyngeal branch from the upper part of the inferior ganglion, which is a swelling of the trunk just below its emergence from the skull. The pharyngeal branch, the principal motor nerve of the pharynx, crosses the internal carotid and then divides into a number of branches, some uniting with the branches of the glossopharyngeal and sympathetic and superior laryngeal nerve. The superior laryngeal nerve is given off from the middle of the inferior ganglion of the vagus. It receives a filament from the cervical sym- pathetic, descends behind the internal carotid, divides there into an external and internal laryngeal branch. The external branch supplies the cricothyroid muscle. It gives branches to the inferior constrictor of the pharynx and communicates with the pharyngeal plexus and the superior cardiac nerve. The internal branch of the superior laryngeal nerve communicates with the recurrent laryngeal nerve, but penetrating the thyrohyoid membrane it is distributed to the laryngeal mucosa. This then is the part of the nerve supply which controls sensation and it is doubtless to the communication of this branch of the superior laryngeal nerve with the recurrent that is due the evidences sometimes apparent that the latter contains other than motor filaments. It seems to have been fairly well established that this is not the rule in man. The internal branch of the superior laryngeal, besides supplying the ' Arohiv f. Psychiatrie, Band xxxii. ' Archiv f. Laryngologie, 1900, Band x, p. 320. CENTRAL AND PERIPHERAL NERVE SUPPLY OF LARYNX 615 internal mucosa of the larynx, sends a twig to supply the mucous membrane lining the posterior or pharyngeal mucous surfaces of the plicse arytenoides and the cricoid cartilages. The innervation of this origin goes down as far as the edge of the true cords and sometimes to their under surfaces. By means of a twig from the external branch piercing the cricothyroid muscle the under surface of the vocal cord is supplied with sensation. The "ansa galeni" is chiefly made up of fibers of the inner branch of the superior laryngeal nerve which are meant in man for the upper part of the air passages, trachea, etc.; it further provides a way for the entrance of recurrent fibers into the path of the superior laryngeal nerve (Onodi). This branch is variously called the tracheal branch of the superior laryngeal nerve, the tracheal nerve, the accessory recurrent, according to the varying course of it as described by different authors. It lies in the neck internal to the recurrent, varying in its extent and distribution. The inferior or recurrent laryngeal nerve on the right side is given off from the vagus in. front of the subclavian artery and winds around back of it and ascends obliquely to the trachea. The left recurrent arising in front of the arch of the aorta pursues a like course. Both lie in the groove on each side between the trachea and the esophagus and behind the carotid artery, but the inferior thyroid artery may be in front of it or behind it (Gray). It gives off esophageal, cardiac, pulmonary, gastric branches and on its way up the neck it enters the larynx behind the in- ferior cornu of the thyroid cartilage beneath the lower part of the inferior constrictor of the pharynx. The recurrent nerve after it penetrates into the larynx divides into a lateral and a median branch; the latter, communicating with the loop of the superior laryngeal known as the ansa galeni, sends also one branch to the posticus muscle, while the other goes under and supplies the transversus. The lateral branch supplies the other laryngeal muscles with the exception of the cricothyroid. Whether this nerve supply of the larynx represents continuous individual fibers held in a common nerve sheath or whether they are merged into one another in a true plexus by virtue of the numerous and varying anastomoses has not been definitely settled. The communications of the laryngeal nerves with the cervical and thoracic sympathetic are numerous and subject to great variation. It seems probable from anatomical descriptions that the larger part of the anastomoses is concerned with the respiratory fibers of the laryngeal nerves rather than with the phonatory. Laryngeal movements in health whether respiratory or phonatory are purely bilateral, whether voluntary or involuntary. Any departure from this law, observed clinically, at once speaks for a pathological con- dition, either peripheral, neural, or central. A bilateral disturbance of these movements is usually of a functional nature when it is symmetrical. Complete equilateral paralysis is the chief exception to this statement and then it is practically never synchronous in its onset for the two sides when it depends on a structural lesion. The cases of bilateral 616 LARYNGEAL NEUROSES posticus paralysis furnish only an apparent exception to this. The fixation of one cord in the median line, not always producing dyspnea or hoarseness, may exist indefinitely without the voice being perceptibly affected; only when the posticus on the other side is paralyzed may attention be drawn to what then seems a synchronous bilateral paralysis by objective symptoms, and a laryngoscopical examination is made. THE ACTION OF THE INTRALARYNGEAL MUSCLES. Dilators of the Glottis. — The only muscles subserving this function primarily are the crico-arytenoidei postici usually referred to simply as the postici muscles. Closers of the Glottis. — These consist of the arytenoideus and the lateral crico-arytenoidei. The Tensors of the Vocal Cords. — These may be considered also as adjuvants to the closers. They are the external cricothyroids which, putting the cords on the stretch by virtue of their action in raising the anterior part of the cricoid cartilage carry also downward and backward the bases of the arytenoid cartilages, which rest upon the cricoid. By this action they also lengthen the anteroposterior diameter of the glottis. Their antagonists are the thyro-arytenoids which shorten and relax the cords. These consist of two parts, internal and external; their action is complex, inasmuch as they not only serve as closers of the glottis but as relaxers, and yet they coapt, chiefly by their internal division, the edges of the cords. The thyro- and aryteno-epiglottidei regulate the relative position of the epiglottis to the larynx and are inclosed in the folds known as the false cords or upper vocal bands. They doubtless do much, especially in glottic inflammations, in supplementing the actions of the true cords and they play their part in the spasms of the larynx, often hiding from the laryngoscopist the view of the true cords. These are the chief anatomical points and physiological data for the laryngologist to keep in mind in studying the pareses of the larynx so far as the muscles themselves are concerned. THE SENSIBILITIES AND THE REFLEXES OF THE LARYNX. Laryngeal sensibility, we have seen, depends upon the distribution of the terminal filaments of the superior laryngeal nerves. Very slight irritation is enough to cause the reflex act of coughing or spasmodic closure of the glottis, and the sensibility of the larynx is very persistent, the mucous membrane being sensitive in ether or other narcoses long after the cornea has lost its reflexes. The spot most susceptible to irrita- tion is the posterior surface of the larynx. DISTURBANCES OF SENSATION 617 RESPIRATION AND PRONATION. In phonation the cords are in the median hne and their vibrations past one another produce sound which is modified in tone by various changes in the position of the larynx not yet fully understood and in the position of the cords. Further modifications are produced by muscular adjustments of the pharynx, palate, tongue, and lips. In spite of the application of the laryngoscope in its inception fifty years ago to the examination of the larynx by Garcia for studying the production of sound, and in spite of the ingenious photographs taken of it by French thirty years ago and by others since then, the phonatory mechanism is still far from being understood in detail. It seems certain that the mechanism differs to a considerable degree in different larynges for the same tone. Most recently it is reported that an individual has been found who possesses the astonishing faculty of producing two notes of different pitch simultaneously with his larynx. In respiration the glottis is kept open or is narrowed, Semon believes, not by any intervention of the lateral muscles in the act of respiration, but by the varying tonicity of the postici muscles, the narrowers and tensors of the glottis being essentially the phonatory muscles. While in this view the postici act as the sole producers of respiratory laryngeal movement, that movement in quiet respiration does not always corre- spond with that of the thorax, that is, there is not always coincidence of abductor movement of the cords with thoracic inspiration; on the contrary, the inspired air on lary ngoscopical examination in quiet breathing seems to cause a gentle adduction of the cords. In deep inspiration, however, they are widely separated. It is misleading, therefore, to speak of the usual respiratory position of the glottis. It varies from momemt to moment and the internal configuration of one larynx differs much from that of another. The cadaveric position of the cords is also a poor term for total laryngeal paralysis, since not only, as Semon has shown, does the position of the cord vary between wide limits in the dead body, but a like variation is exhibited by cases of unilateral recurrent paralysis. However, some conventional name is necessary and with the understand- ing that the term indicates an immobility somewhere between the median line and extreme abduction serious objection need not be made to a term sanctioned by usage. DISTURBANCES OF SENSATION. Anesthesia. — ^Anesthesia of the larynx is most frequently seen in connection with paralysis of motion depending upon a central lesion. It is also present in combination with pharyngeal anesthesia as the result of diphtheria again accompanying involvement of motion in the pharynx and larynx. In the former category it is usually unilateral, in the latter it is usually bilateral. It is seen also in hysterical aphonia 616 LARYNGEAL NEUROSES posticus paralysis furnish only an apparent exception to this. The fixation of one cord in the median line, not always producing dyspnea or hoarseness, may exist indefinitely without the voice being perceptibly affected; only when the posticus on the other side is paralyzed may attention be drawn to what then seems a synchronous bilateral paralysis by objective symptoms, and a laryngoscopical examination is made. THE ACTION OF THE INTRALARYNGEAL MUSCLES. Dilators of the Glottis. — The only muscles subserving this function primarily are the crico-arytenoidei postici usually referred to simply as the postici muscles. Closers of the Glottis. — These consist of the arytenoideus and the lateral crico-arytenoidei. The Tensors of the Vocal Cords. — These may be considered also as adjuvants to the closers. They are the external cricothyroids which, putting the cords on the stretch by virtue of their action in raising the anterior part of the cricoid cartilage carry also downward and backward the bases of the arytenoid cartilages, which rest upon the cricoid. By this action they also lengthen the anteroposterior diameter of the glottis. Their antagonists are the thyro-arytenoids which shorten and relax the cords. These consist of two parts, internal and external; their action is complex, inasmuch as they not only serve as closers of the glottis but as relaxers, and yet they coapt, chiefly by their internal division, the edges of the cords. The thyro- and aryteno-epiglottidei regulate the relative position of the epiglottis to the larynx and are inclosed in the folds known as the false cords or upper vocal bands. They doubtless do much, especially in glottic inflammations, in supplementing the actions of the true cords and they play their part in the spasms of the larynx, often hiding from the laryngoscopist the view of the true cords. These are the chief anatomical points and physiological data for the laryngologist to keep in mind in studying the pareses of the larynx so far as the muscles themselves are concerned. THE SENSIBILITIES AND THE REFLEXES OF THE LARYNX. Laryngeal sensibility, we have seen, depends upon the distribution of the terminal filaments of the superior laryngeal nerves. Very sUght irritation is enough to cause the reflex act of coughing or spasmodic closure of the glottis, and the sensibility of the larynx is very persistent, the mucous membrane being sensitive in ether or other narcoses long after the cornea has lost its reflexes. The spot most susceptible to irrita- tion is the posterior surface of the larynx. DISTURBANCES OF SENSATION 617 RESPIRATION AND PRONATION. In phonation the cords are in the median line and their vibrations past one another produce sound which is modified in tone by various changes in the position of the larynx not yet fully understood and in the position of the cords. Further modifications are produced by muscular adjustments of the pharynx, palate, tongue, and lips. In spite of the application of the laryngoscope in its inception fifty years ago to the examination of the larynx by Garcia for studying the production of sound, and in spite of the ingenious photographs taken of it by French thirty years ago and by others since then, the phonatory mechanism is still far from being understood in detail. It seems certain that the mechanism differs to a considerable degree in different larynges for the same tone. Most recently it is reported that an individual has been found who possesses the astonishing faculty of producing two notes of different pitch simultaneously with his larynx. In respiration the glottis is kept open or is narrowed, Semon beheves, not by any intervention of the lateral muscles in the act of respiration, but by the varying tonicity of the postici muscles, the narrowers and tensors of the glottis being essentially the phonatory muscles. While in this view the postici act as the sole producers of respiratory laryngeal movement, that movement in quiet respiration does not always corre- spond with that of the thorax, that is, there is not always coincidence of abductor movement of the cords with thoracic inspiration; on the contrary, the inspired air on lary ngoscopical examination in quiet breathing seems to cause a gentle adduction of the cords. In deep inspiration, however, they are widely separated. It is misleading, therefore, to speak of the usual respiratory position of the glottis. It varies from momemt to moment and the internal configuration of one larjnx differs much from that of another. The cadaveric position of the cords is also a poor term for total laryngeal paralysis, since not only, as Semon has shown, does the position of the cord vary between wide limits in the dead body, but a like variation is exhibited by cases of unilateral recurrent paralysis. However, some conventional name is necessary and with the understand- ing that the term indicates an immobility somewhere between the median line and extreme abduction serious objection need not be made to. a term sanctioned by usage. DISTURBANCES OF SENSATION. Anesthesia. — Anesthesia of the larynx is most frequently seen in connection with paralysis of motion depending upon a central lesion. It is also present in combination with pharyngeal anesthesia as the result of diphtheria again accompanying involvement of motion in the pharynx and larynx. In the former category it is usually unilateral, in the latter it is usually bilateral. It is seen also in hysterical aphonia 618 LARYNGEAL NEUROSES and here it is usually bilateral. Exceptions to these rules are occasionally noted. Anesthesia of the larynx, partial or complete, exists usually in con- nection with paralysis of motion involving the cricothyroid muscle which is, as has been stated, part of a general laryngeal paralysis. It may rarely exist only in combination with motor insufficiency in the domain of the superior laryngeal nerve. Still less frequently the anesthesia may exist alone, the sensory filaments of the superior laryngeal nerve being alone affected. When the anesthesia is complete and bilateral, the condition is a grave one. This will be spoken of in connection with the disturbances of motion. Paresthesias. — Paresthesias of various kinds are seen in the neurotic and the hysterical and occasionally after attacks of influenza. Sensations having their origin in pharyngeal inflammation are still more common. The feeling of a foreign body after the passage of a fishbone or other rough body through the pharynx is very commonly referred to the larynx. In the neurotic, in cancrophobia, phthisiophobia, syphilo- phobia they are often the secret or avowed stimidants of an active imagination. These complaints are frequent. at the time of the meno- pause in women and those suffering from anemia. Neuralgias. — Actual pain in the larynx is also a frequent complaint of the above classes of patients. It is said to be due (rarely) to malaria and to be ciu"ed in these cases by antimalarial treatment. Neuralgia is to be diagnosticated carefully from the pain of various laryngeal lesions including that of rheumatic inflammation of the crico-arytenoid joint. Pressure on the larynx and its manipulation, eliciting pain and inflamma- tion, may act as guides in this differentiation. Hyperesthesia of the Larynx is seen not only in the classes of patients enumerated above, but it is the common condition in the symptomatology of acute and chronic inflammations of the larynx. In this category should be included various specific forms such as nervous cough, ictus laryngea, and with it are affiliated some of the spasmodic affections of the laryngeal muscles. DISTURBANCE OF MOTILITY. Laryngeal Spasm. — Nervous Laryngeal Cough. — Many cases reported as presenting symptoms due to reflexes excited in various organs, espe- cially in the nose, are from time to time to be found in literature, but the numbers have vastly diminished not only in literature but in practice, since the subsidence of the excessive enthusiasm directed to the nasal and pharyngeal neuroses in the early days of rhinological practice. There doubtless are many cases, among them a large proportion of perfectly healthy people, in whom a cough can be excited by titillation of the nasal or pharyngeal mucosa. Other cases are dependent upon a general neurotic temperament. This nervous cough has been chiefly known and was first fully described by Dr. Andrew Clarke in girls at and shortly after puberty. They are DISTURBANCES OF MOTILITY 619 referred to by Clarke as " barking girls." There is no necessity of creating a special class for this form of laryngeal neuroses, resting as it does upon an underlying lack of equilibrium in the general nervous system. In such patients it is often very distressing, but chiefly to their com- panions. Nerve tonics and iron preparations are conventionally given in these cases. PoUak, Onodi.i and others have recorded, as of unknown etiology, rare instances of the perverse or contrary action of the vocal cords. Patients were voiceless, not because of paralysis or contracture of the vocal cords and their motor mechanism, but because, when attempting to phonate, the cords instead of approaching the median line are thrown into extreme abduction, unilateral or bilateral. The efiicacy of purely local treatment either at the supposed origin of the reflex, especially operative, or of the larynx has been grossly exaggerated. Though the number of cases as well as the success of treatment has been magnified beyond rational belief, nevertheless, like all neurotic manifestations, there are a few cases whose symptoms of paroxysmal and continuous cough are so exceptional that they arrest the attention of the most veteran and skeptical observer. A continual hack, of which the patient himself is only semiconscious, a species of petit-mal or tic of the upper air passages, is perhaps the most familiar type. Irregularities of the nose are often found, but it has never been demonstrated that they are more common or more pronounced or that they occur oftener in people with a nervous cough than in those without it. A severe shock to the nervous system, like breaking a leg or a bloody and painful nasal operation, will frequently stop the cough even permanently, but this is not so for the majority of cases. The cough continues until some psychical change, wrought perhaps by the faith cure or the mind cure or some other fad of the day or until some systemic change like the menopause, or until some change in the general health brought about by better food, better air, more rational exercise, or a sea voyage, has taken place, when the habit usually more or less gradually disappears. In these remarks the treatment is sufficiently emphasized. The latter indications lead to the most satisfactory method of bringing about a cure because, while the shock of an operation or the excitement of a religious revival may do away with that special neurosis, some other disorder of the nervous system may take its place not the less distressing to the patient because it may not be so apparent to the observer nor be so likely to lead the patient to consult the same specialist. Ictus Laryngea, Laryngeal Vettigo, Laryngeal Epilepsy. — Under these headings are placed a few cases first observed by Charcot, in 1876, and reported in laryngological literature since then, finding regularly their place in the text-books, the etiology of which is unexplained by any theory hitherto advanced. An elderly man, sometimes a woman, or even a young person has a tickling in the throat and probably has a spasm of the glottis, for he turns blue, but he loses consciousness too quickly to ' Virchow's Arohiv, 1913, Band ooxiii, Heft 2-3, p. 461. 620 LARYNGEAL NEUROSES ascribe it to temporary asphyxia and recovers it too shortly to ascribe it to apoplexy. He falls to the floor or sinks in his chair, quickly (in less than a minute) regains consciousness and may not even be aware that anything unusual has occurred. Calling it a species of epilepsy or placing it in the same category with Menieres disease, carries little information to the inquiring mind. Later trends of clinical thought, founded on the demonstration of arteriosclerosis in the brain, may justifiably lead to the surmise that it is due to a spasm of some arteriole in the medulla near the laryngeal centres, but whatever inferential support this conjecture may have it lacks any satisfactory objective demonstration. SPASMS AND CONTRACTURES OF THE LARYNGEAL MUSCLES. Incoordination. — ^This is a condition which has its most striking illustration in cases of hysterical aphonia, but it is better to follow the conventional rule and treat of that affection under a separate heading. There still remain a few laryngeal phenomena, observed clinically, which belong in this category. The changing voice of boys at puberty is the most familiar of these. Tremor of the cords, short spasmodic movement are seen in various nervous affections of grave import, such as general paresis and the other parasyphilitic affections. It also sometimes is a veritable tic accompanying a similar twitching of the facial muscles. It is also seen in overstrain of the voice in public speakers and singers. Such conditions may last for a long time, but when dependent on no structural lesion, they sooner or later disappear with rest or other treat- ment directed to the underlying neurosis. Local treatment is of no avail. Laryngismus Stridulus or Spasmodic Croup in Children. — ^Predisposing Causes. — It occurs in rachitic children in the proportion, varying widely according to the report of different observers, of 50 to 90 per cent. It is most frequently seen at ages of from six months to six years. It is seen in the late winter and early spring more frequently than at other seasons. While children with other signs of rickets are the most frequent sufferers, it is also often seen in otherwise healthy children or in those suffering from some pharyngeal or nasal trouble, especially tonsils and adenoids. The larynx and the trachea, in these latter children especially, are often the seat of a catarrhal inflammation causing some swelling of the mucosa. It is frequently spoken of as true or false laryngismus stridulus, according as it is seen in rachitic or non-rachitic children. It may result fatally in the former, but this is rarely if ever the case in the other category. It is very much more common in boys. Children with gastro-intestinal disturbances and children whose general health is below par, even if they have no other manifestation of rickets, are more subject to it than those in a fair state of health. Etiology. — It is idle to discuss the fundamental systemic or local cerebral state upon which the disease directly depends. Semon and many observers attribute it to a congestion of or a spasm of the bloodvessels of the cerebral cortex, but the facts are too few on which seriously to SPASMS AND CONTRACTURES OF LARYNGEAL MUSCLES 621 base any etiological theory of this kind. Usually there are prodromal symptoms of gastric disturbance or of catarrhal inflammation of the upper air passages. Symptoms. — ^The laryngoscopical appearances, if they can be made out, show a spasmodic or even a clonic contracture of the false cords, or if these are for the moment open, the true cords are seen either- firmly pressed together or opening only incompletely and for very brief spaces of time. If the child has had previous attacks the prodromal symp- toms will be recognized by the parents, but if the child has not had a previous attack these may not attract attention. They are a slight hoarseness, mild coryza, slight elevation of temperature, indigestion, and constipation. One attack predisposes the patient to another. The initial evidences begin in the early evening with a hollow barking cough of slight severity and at infrequent intervals. Toward midnight both are exaggerated. If the attack is of a slight nature, the child may not awaken and the symptoms disappear without further manifestations. In the severer cases the child will be awakened suddenly during a paroxysm with efforts to get sufficient air. Inspiration is particularly difficult and results in stridor, recession of the suprasternal fossa, the supraclavicular spaces, the intercostal spaces and the epigastrium. Any excitement or undue physical activity increases both the frequency and the intensity of the spasm. Breathing is rendered slow and labored, and the voice is hoarse but not extinguished. The cough is of a hoarse, stridulous, metallic nature. The skin is clammy, and the face and brow are bathed in perspiration. The pulse is rapid but not weak. The temperature is rarely, if ever, very high, reaching only 101° F. as a rule. There is evidence of air hunger in the expression of the child and in its struggle to get breath. The lips are livid, as are also the tips of the fingers. There is often marked clonic contracture of the adductors of the wrists and ankles. Cyanosis is frequently present and there is marked prostration. Toward morning the symptoms ameliorate and the child sinks into sleep from exhaustion. During the succeeding day the haras- sing symptoms of the night before have nearly all disappeared and there remain only the hoarseness, a slight croupy cough, the coryza and the inflamed pharynx. The following night the symptoms may prove equally severe unless treatment has been successful, but the second and third night the patient, as a rule, is free from distressing symptoms. Diagnosis. — Laryngismus stridulus or catarrhal croup must be difl^eren- tiated from membranous croup or true croup which is caused usually by the diphtheria bacillus, from the presence of a foreign body in the air passages, and from perichondritis or other inflammatory or neoplastic obstruction of the air passages. In diphtheria the onset is not so sudden, the evidences of inflammation both in the fauces and in the larynx is more severe. The dyspnea is not so spasmodic and other manifestations of systemic involvement are progressive without remission. The cough in membranous croup is muffled and suppressed while it is resonant and brassy in spasmodic croup. The inspiratory stridor is more marked in spasmodic croup; inspiration and expiration are equally difiicult in 622 LARYNGEAL NEUROSES true croup. There is seldom any evidence of membrane in the fauces in spasmodic croup, while in diphtheria it is often, though not always, seen in the oropharynx. The presence of the Klebs-Loffler bacillus may determine the nature of the case. Foreign bodies usually give a history of their presence and the pre- sumptive evidence should lead to direct laryngoscopy or bronchoscopy which will usually definitely determine their presence or absence. Perichondritis is seen in rheumatic, tuberculous, or syphilitic children, and is usually accompanied by tenderness on pressure. The onset is gradual and the laryngeal picture determines the character of the lesion. The laryngoscopy in spasmodic croup, however, is often impracticable. Treatment. — Always isolate the case, as there exists a possibility of its being diphtheria until opportunity is found for differentiation. The first endeavor is then directed toward relieving the laryngeal spasm. In a steam kettle or a pot of suitable kind with a spout, water is placed to which has been added benzoin, thymol, oil of white pine, five or ten drops of each, with a tablespoonful of lime water or a teaspoonful of the milk of magnesia. This is brought to boiling under a tent in which the patient has been placed. Cold compresses to the neck frequently at once relieve the spasm. Give antimony and ipecac, each one-hundredth grain, every ten or fifteen minutes until free vomiting occurs. Twenty minims of the syrup of ipecac given every fifteen minutes may be substituted for this. Antimony should not be given after the third dose or at least after three-hundredths of a grain has been taken, owing to the depression liable to ensue. It is well to give an enema in any case, as free evacuation of the bowels lessens the severity of the attack. After the vomiting ceases, one grain of antipyrin for each year of the child's age given at four-hour intervals brings about restful sleep. The ipecac and antimony should be given the next day at intervals of four hours. At bedtime, two grains of anti- pyrin will in all probability prevent the recurrence of unfavorable symp- toms. Should medication be unavailing, one may be compelled to resort to the intubation tube, but tracheotomy is only to be employed in A-ery ex- ceptional cases. Careful attention should be directed after the attack toward preventive treatment. Adenoids and tonsils, elongated uvula, should be removed by surgical procedures and any other disease of the upper air passages should receive appropriate treatment. Fresh air, cold sponging, a,nd tonics may be prescribed. The patient should lead an out-of-door life and should not be coddled. These measures persist- ently and conscientiously carried out will as a rule lessen the frequency of recurring attacks. Laryngismus Stridulus in Adults.— When of an idiopathic nature, that is, when not depending upon some lesion or pressure upon the peripheral distribution, nerve trunks, or nerve centres, it is of great rarity. It is not seen chiefly at night as in children. A few cases have been reported in which the cause was said to be due to reflex action having its origin in some lesion of the upper air passages, or even in some irritation in other SPASMS AND CONTRACTURES OF LARYNGEAL MUSCLES 623 regions of the body, as, for instance, a bullet in the arm. In the reports, invariably, removal of these supposed sources of the trouble cured the condition. The reports of such cases date back chiefly to an era of un- limited enthusiasm and uncritical study of the etiology of disease of the upper air passages. It is, however, occasionally seen in a mild form in adults of a neurotic temperament, and in those whose nervous system has been overworked and whose voice has been overtaxed. The history of the case will suggest the proper treatment. Rest of the voice is indi- cated. The spasm may be overcome by teaching the patient to hold his breath for a rnoment and then make short frequent respirations. In tabes dorsalis^ unilateral adductor spasm occurs and is occasionally noted in a routine laryngoscopical examination. Bilateral adductor spasm in tabes doubtless frequently depends on some pareses of the abductors, but in any event it often forms the chief phenomenon of the laryngeal crises of that disease. It may frequently recur or only rarely. The patient may die suddenly in one of the attacks. It must be left to the judgment of the physician and the consent of the patient whether or not tracheotomy is to be performed. The need for it is at times pressing in order to saVe the patient's life, and it is sometimes advisable in order to guard against a fatal attack in the future. It is to be differentiated from paralysis of the postici muscles. This will be more extensively considered in dealing with that condition. Spasm of the Postici Muscles. — Spasm of the openers of the glottis doubtless may occur, but since the only reliable observation we know of is one referred to by Semon, in which the patient was suffering from hy- drophobia, when, in the laryngoscope, the reporter (Pitt) saw the cords in extreme abduction, one may regard the occurrence as one of academic interest only. Like the explanations for all spasmodic affections of the larynx the etiology depends largely upon theoretical surmises, to which it is not necessary to attach a great deal of weight. Hysterical Aphonia. — ^This is now classed among and forms the most frequent and striking of the examples of incoordination of laryngeal movement. It is usually of sudden onset. The cords move freely but no sounds issue, except in a few cases when laryngoscopical examination or some mental impression caused by the medical attendant produces a sudden, usually a temporary, restoration of the voice. Rarely this sud- den restoration of the voice becomes permanent or extends over a con- siderable interval before the advent of a fresh attack. To limit the treatment to such spectacular restoration of function is to assume more or less an attitude of charlatanry. The treatment should be one of tonics and the correction, so far as is possible, of vicious habits of mind and of deleterious states of the body (anemia) with improvement in defective sanitary methods of life (bad air and bad food). While by hysteria of the larynx we naturally think of aphonia depen- dent upon an inability of the cords to coordinate in approaching the median line in such a manner that sounds issue forth, as a matter of fact ' Die Laryngealen Storungen der Tabes Dorsalis, Burger. 624 LARYNGEAL NEUROSES this is only the preponderating and classical picture, and laryngeal spasm of various kinds, nervous cough, apsithyria or inability to whisper, may all be included in its manifestation. It usually occurs in young women, but men are not exempt from it. It certainly cannot be said to be due to any voluntary will defect, as we cannot imagine such a state when uncon- sciousness intervenes from asphyxiation and the body is given up to a reflex nervous mechanism. We have seen a case in a patient who lost con- sciousness and who was near death from suffocation, tracheotomy and the prolonged wearing of a tube being necessary. She presented the classical signs of hysteria and years afterward she was seen in an attack of typical hysterical aphonia with lack of coordination of the cords. Unilateral paralysis of adduction is reported as having been observed by A^arious authors due to peripheral or reflex causes, and one should be on one's guard not to mistake it for complete unilateral paralysis. The affected cord is in a position of extreme abduction and complete aphonia results. In hysteria both cords are sometimes seen in this position,, but it is in all probability a temporary state, as after prolonged observation some move- ment can practically always be detected. It cannot be regarded as an essential paralysis. Lack of experience compels us- to refrain from expressing a similar opinion as to the unilateral condition. The treatment of hysteria of the larynx in all its forms should be conducted on the lines pursued in that of the treatment of the general affection. Laryngeal Paralysis. — ^Etiology. — Owing to the nature of the case a division of laryngeal paralysis cannot be made on an etiological basis, but it is necessary to say a few words on the etiological factors which may cause laryngeal pareses. Anatomical Lesions. — Cortical tumors, hemorrhages, degenerations, meningeal inflammations, and cranial depressions, after what has been said in the description of the anatomy and the physiology of the cortical centres may be dismissed from extended consideration because of the uncertainty that they are ever alone the lesions upon which laryngeal paralysis depends. It is scarcely necessary to remark that cases of aphasia must be carefully separated from those of paresis. A lesion in the neigh- borhood of the prefrontal gyrus we know produces aphasia, but we 'do not know that it produces laryngeal pareses and it is with these we are here concerned. There is no pathological evidence sufficiently strong to warrant us in concluding that cortical disturbances produce paralysis or spasm or incoordination of the laryngeal muscles. This being so, it is necessary to bear in mind that lesions lower down in the cerebral and neural track of innervation may be associated with a cortical lesion and a part of the manifestation of a general vascular or inflammatory lesion — softenings from arteriosclerosis, descending or ascending degenerations, due to syphilis, disseminated meningitis or sclerosis, even extensive tumors and hemorrhages may involve not only the cortex but the bulb and the lesion may be more or less marked in either region. Syphilitic and Parasyphilitic Lesions. — If we were to judge from clini- cal experience alone we should be justified in asserting that the central PLATE XII FIG. 2 Paralysis of the Left Crieo-aryten- oideus Postieus Mu-sele (Deep Inspiration). Bilateral Paralysis of Lateral Crieo-arytenoid. FIG. 3 FIG. 4 Bilateral Paralysis of Internal Thyro-arytenoid and Arytenoid. Bilateral Paralysis of the External Tensors. SPASMS AND CONTRACTURES OF LARYNGEAL MUSCLES 625 lesion which apparently most frequently produces laryngeal paralysis is syphilitic disease in the floor of the fourth ventricle. The association of the facial, palatal, pharyngeal and laryngeal paralysis is too frequent to allow us to disregard the evidence that in man a unilateral lesion in the bulb may produce unilateral paralysis of the larynx on the same side or on the opposite side, according to. whether the lesion is above or below the decussation of the nerve supply. That a bilateral lesion in this region may also produce bilateral paralysis of the larynx we would also be rea- sonably sure of from clinical observation, but that bilateral lesion of the cortex, most prominent in pseudobulbar paralysis, does so is not so cer- tain, though it would seem probable, even considering the experimental evidence, that phonatory laryngeal movement, the inward movement of the cords, may be weakened or abolished by a bilateral cortical lesion. The doubt as to this is considerable. In such cases inward movements are usually seen, though they may be due, it is true, to the varying to- nicity of the muscles of respiration, the abductors. In the disseminated sclerosis of this disease we can never be sure that other localities than the bilateral cortical areas, lower down, are not affected. The fact that anen- cephalic monsters possess phonatory movements of the larynx, that cor- tical centres of respiration also have been demonstrated experimentally tends still further to befog the question. On the whole, however, the in- ference is warranted, as Semon insists, that bilateral cortical lesion may interfere with the laryngeal movement of phonation even when due to other lesions (hemorrhage?) than disseminated sclerosis. The lesions in the bulb causing laryngeal paralyses are probably for the most part of syphilitic or parasyphilitic origin. Among these we may place not only the local gummatous softenings but the lesions of tabes dorsalis. How far other degenerative bulbar lesions may have a syphilitic basis it is at present impossible to say; but the advent of serological diagnosis and the discovery of the spirocheta pallida have rendered necessary a reconsidera- tion of the etiology of many brain and cord lesions. The same may be said for the more thorough understanding of vascular lesions of a non- syphilitic character, discussed in the text-books under the heading of Arteriosclerosis. Into this it is impossible to enter here. Hemorrhages with resultant softenings, tumors, the lesions upon which depend the congery of symptoms known as progressive bulbar paralysis, disseminated sclerosis, amyotrophic lateral sclerosis, syringomyelia, all of them may include among their manifestations those of laryngeal paralysis, complete or partial, spasmodic contracture or continuous pareses. Inasmuch as in paralyses the abductor nerve supply is the one first involved in pro- gressive lesions, and inasmuch as a unilateral median position of the cord often does not give rise to obtrusive symptoms affecting the voice and respiration, even the sudden involvement of phonation does not speak necessarily for the sudden advent of posticus paralysis from a bulb or a nerve lesion. This is erninently illustrated in the laryngeal paralysis of tabes dorsalis. A large number of cases of tabes, without laryngeal symptoms, when examined laryngoscopically have revealed a condition of unilateral posticus paralysis. The cases of tabes with laryngeal 40 626 LARYNGEAL NEUROSES symptoms coming under observation are naturally chiefly those with a double posticus paralysis or those with complete unilateral paralysis or those afflicted with spasmodic contractures of the larynx, the laryngeal crises of tabes having been well recognized for a long time. The actual proportion of cases in which laryngeal pareses occur in tabes can be estimated from Semon^ having found as high as fourteen in a hundred unselected cases and eight of these were unilateral posticus paralysis. His figures are supported by similar ones from Gerhardt's observations. Singular to say, of these observers, Gerhardt alone saw one and only one case of double recurrent paralysis. In the tabetic cases of laryngeal neuroses the pulse rate is often increased. It is said to be due to the involvement of the cardiac sympathetic plexus of the recurrent nerve, but it may as well be ascribed to the vagus nerve or vagus centre itself. In tabes dorsalis this laryngeal involvement, it is important to note, may for many months be the only nerve manifestation of tabes, so that the possibility of this explanation of an apparently idiopathic case of laryngeal paralysis, especially posticus paralysis, must always be borne in mind. Lesions of the Laryngeal Nerves. — ^Malignant tumors at the base of the skull involving one or more nerves issuing from the jugular foramen, enlarged glands of the neck, thyroid hypertrophy, especially malignant, wounds and operations along the course of the recurrent nerve, aneurysms, especially on the left side of the arch of the aorta, (innominate or right subclavian, aneurysms being very rare). Other thoracic tumors, scoliosis of the cervical vertebrae, pleural inflammations, especially of the left pul- monary apex in phthisis, all are represented in the etiology of laryngeal neuroses. Cancer of the esophagus or of the pharynx may interfere not only with the larger nerve trunks, but by extension may involve their branches and their distribution and even mechanically interfere with the muscles and the crico-arytenoid joint. Toxic Paralysis — Various toxic agents enumerated by Heymann,^ lead, copper, antimony, phosphorus, arsenic, alcohol, atropin, morphin, cocain, the toxins associated with diphtheria, gonorrhea, typhoid fever, influenza have been reported as causing laryngeal paralysis in isolated cases. Idiopathic. — ^There is a class of paralyses, well called idiopathic, which represents a certain number of cases in which a transient immobility of one cord is observed. To refer these all to the peripheral toxic paralysis is unscientific in the absence of evidence of the existence of other toxemic symptoms or history. We may suspect some of these may be due to in- fluenza or diphtheria unrecognized, or that they may be due to inflamma- tion of the crico-arytenoid joint, or that they may be due to a transient inflammation of or a transient pressure on the recurrent laryngeal nerve. Some follow excessive pharyngeal inflammation. We have seen one or two from drinking carbolic acid by accident or with suicidal intent. In the absence of other symptoms it is well, however, to admit that no sufficient 1 Heymann's Handbuch der Laryngologie und Rhinologie, Band i, Abt. 1. 2 Archiv (. Laryngologie, 1896, v, Fraenkel's Festschrift. SPASMS AND CONTRACTURES OF LARYNGEAL MUSCLES 627 evidence exists for satisfactorily identifying any of the toxic etiological factors thus far mentioned as causative influences. This class is not a large one. It is small in ratio with the acuteness and persistence with which the diagnostician follows the history and carefully observes the case and with the length of time the case, can be held under observation. Such extremely rare cases as peripheral myopathic laryngeal affections may be elucidated postmortem and may still further cut down the number of so-called idiopathic pareses, but they are not apt to enter the domain of practical diagnosis. The nature of the anatomical lesions caused by pressure upon or in- filtration of or degeneration of the nerves of the larynx and degeneration of the muscles they supply is the same as that familiar to pathologists in like conditions elsewhere. In abductor paralysis one often finds a very much larger portion of the recurrent nerve affected than one would expect from the involvement of the nerve supply of one muscle alone. This may well lead to the conjecture that long-existing unopposed shortening of the laryngeal closure muscles, due to loss of the tonicity and the power of the abductors, finally induces a fixation in the median line, and that this for a time remains unchanged by the gradual involvement and destruction of other fibers in the recurrent nerve than those initially affected. Fig. 302 Complete left recurrent paralysis. Compensation of the right cord advancing beyond the median line. Laryngoscopic Appearances and Diagnostic Symptoms of Complete and Partial Laryngeal Paralysis. — ^Because of the uncertainty which reigns not only in anatomical and physiological description of the innervation of the larynx, but also on account of the uncertainty which very frequently obtains in the differential diagnosis of paretic states of the larynx as to the nature and situation of the etiological factors, it seems best to take up the subject now from the purely objective standpoint of laryngoscopic appearances, and in the course of the differential diagnosis to review the information which has preceded applying it to the objective category under consideration. Total Unilateral Laryngeal Immobility with the Vocal Cord of the Af- fected Side in the " Cadaveric" Position. — First it is necessary to say that by total immobility we mean abolition of all but passive movement. In 628 LARYNGEAL NEUROSES unilateral paralysis a certain amount of motion may be imparted to the affected side by the movements of the sound side. Especially in long- standing cases the active cord in attempts at phonation crosses the middle line and its attachment at the vocal process lays itself against its fellow and imparts a passive motion to it. This is usually so slight as scarcely to be noticed by the novice and hence does not tend to obscure the con- dition, for the experienced observer readily makes allowance for this pas- sive motion. As seen in Fig. 302 the affected cord, not tense but short- ened, lies in a vertical plane somewhere between the median line and ex- treme abduction. The arytenoid cartilage may tip forward slightly and the cord in its loose state may vibrate with forcible expiration. Redness of both cords to a certain degree may be observed, that of one cord due to its exaggerated movement across the median line, that of the other due perhaps to some vasomotor dilatation, but since normal cords differ greatly in color effect the important thing to notice is that there is an inequality in the color of the two cords. Even this is not of pathognomonic import, but accompanied as it is by a difference in the breadth of the two cords, in attempts at phonation, the active cord being the broader, it completes a picture of unilateral loss of function which, while varying with each case, soon becomes unmistakable to the experienced observer. In making a larj-ngoscopical examination under any circumstances it is desirable — in laryngeal paralysis it is imperative — that the transverse plane of the mirror should be held parallel and not obliquely with the transverse plane of the glottis. Otherwise there may appear minute relative variations in the planes of the two cords when none exist, or vice versa. In complete unilateral paralysis the vocal process of the sound cord, with the above precautions, is often seen overlapping its fellow to some extent, the vocal process and the cord of the sound side passing the median line and the vocal process of the sound side lying behind and per- haps pushing forward the vocal process of the lame side. While the pa- tient may first present himself when the aspect of the larynx corresponds to this description, it must be remembered that except in cases of sudden severance of the recurrent nerve, in all probability there has been in accord with the Rosenberg-Semon rule, as already referred to, a stage in which the cord was in the median line, due to the abductor nerve supply being first interfered with by the invading disease. Phonatory symptoms in this stage usually do not attract attention. It may be well to add here that difference in the vulnerability of the posticus muscle and its innervation has been ascribed: (1) to the greater exposure of the muscle to injury from the passing food and air in the larynx and pharynx; (2) to the greater exposure of the abductor nerve •filament, as demonstrated by Risien Russell, in the recurrent nerve; (3) to the difference in the biochemical composition of muscle, nerve and nerve centre. All these explanations are based on theoretical considera- tions rather than on objective evidence. Symptoms.— This brings us to the subjective history and the objective vocal signs of total unilateral laryngeal paralysis. The patient may have experienced some shortness of breath and hoarseness, possibly referable SPASMS AND CONTRACTURES OF LARYNGEAL MUSCLES 629 to the antecedent stage of abductor paralysis, but usually these have not been sufficiently marked to cause the patient to seek relief. Indeed a surprisingly good voice is sometimes retained in fully developed cases, this depending to some extent on the patient's natural pitch of tone. A low, deep voice is not incompatible with unilateral paralysis, for the active cord crossing the median line often appears to adapt itself sufficiently to its fellow to prevent a complete loss of function or sufficiently great to attract the notice of the patient or his friends. Naturally this is excep- tional, most patients being on the contrary almost entirely voiceless. The voice is reduced to a hoarse whisper and practically always, we believe, the loss of function is readily noted when the patient attempts to produce high notes. These, if produced at all, are shrill and cannot be maintained. The slight dyspnea from which they suffer may be due to pressure on the trachea by the causative lesion. Severe dyspnea accompanying the lesion always indicates this or the existence of some cause other than the posi- tion of the affected cord. While aneurysm of the arch of the aorta is by far the most common cause, as it is of the paralysis itself, the observer must keep in mind that other lesions are sufficiently frequent to require confirmatory evidence for the diagnosis of aneurysm, even in a left-sided laryngeal paralysis. Total Double Laryngeal Paralysis. — This is exceedingly rarely observed. When it occurs the patient is often so near death from the extent of the lesion causing it, as, for instance syphilitic bulbar softening or thyroid and esophageal cancers, that the laryngeal condition is little noted by the patient's attendants, and so naturally only exceptionally comes under the notice of the laryngologist. The exceptions that occur most frequently are those cases in which, there having been a unilateral paralysis from a vagus lesion of the trunk or of the bulbar nucleus, advancing degeneration of an ascending nature in the nerve, or of an extension from a unilateral to a bilateral situation in the bulb, changes the picture in a larynx, already under observation, from a unilateral to a bilateral immobility. Of course there then supervenes still further extinction of the voice, usually accompanied by evidence of the greater involvement of other nerves of the group represented at the base of the skull or in the bulb. Diagnosis. — From what has preceded, the recognition of the condition as seen in the laryngoscope is simple enough, and such consideration as is necessary to distinguish total unilateral laryngeal paralysis from that of separate muscles will be taken up in the short account of the points involved in the description of each, while the distinction to be made be- tween real paralysis and mechanical fixation of the crico-arytenoid joint will immediately follow. Differential Diagnosis. — Under this heading must be included : First : Diagnosis from a condition which essentially is not paralysis at all, but fixation of the crico-arytenoid joint. Second : Diagnosis of the nature and situation of the causation lesion. Fixation of the Crico-arytenoid Joint. — A patient presents himself with more or less immobility of a vocal cord in a position slightly or consider- ably external to the median line. The first question that presents 630 LARYNGEAL NEUROSES itself is, Does the immobility really depend on muscular paralysis? This is not always easy to determine. A certain amount of passive motion may be imparted from the impact of the sound cord or from the musculature of the unaffected side. Careful and prolonged observation should be made to determine if the cord is not made tense on phonation, even though the vocal process does not move. If this can be definitely settled, we may well doubt the existence of a real paralysis. Slight tugging movements beneath the mucosa may be detected. As the condition is frequently a part of a rheumatic history, this can be ascertained from the patient, but it sometimes happens that this is not the case. Pressure on the larynx by manipulation so as to move the crico-arytenoid articulation will fre- quently elicit pain, while a history of excessive sharp pains in the larynx may form part of the patient's history. Careful examination by the laryngoscope must be made to be sure there is no inequality of the mucous surface of the larynx, especially on its pos- terior wall. A slight swelling may indicate the existence of an intrinsic cancer of the larynx of which the first objective symptom is immobility of the cord. This occurs especially in those neoplasms developing in the submucous tissues which lie between the lower pharynx or upper esoph- agus and the larynx. Pressure frequently elicits pain dependent upon this condition and not upon an affection of the joint itself. In ankylosis of the joint pressure with a probe on the top of the arytenoid cartilage may elicit pain on that side. Absence of sensation on that side points to other conditions. With a rheumatic history, administration of the sali- cylates is indicated and may abolish the symptoms and thereby clear up the diagnosis. Immobility of the cord from visible neoplasms or ulcerations or infiltration of course at once renders improbable a nerve affection. Ankylosis of the joint may occur in the course not only of rheumatism, but of typhoid fever or diphtheria and, Semon says, of gout and the ossification of the cartilages in old age. Differential Diagnosis of the Nature and of the Situation of the Lesion. — These are, with the exceptions to be inferred from what has been said, not apparent from laryngoscopical examination. Bulbar Lesion. — Laryngeal paralysis due to bulbar lesions is nearly always associated with that of the face, tongue and pharynx, and with involvement of the sternocleidomastoid and the trapezius muscles or with some combination of them, but no combination excludes the possibility that the lesion is at the base of the skull instead of in the floor of the fourth cerebral ventricle. This syndrome of symptoms has frequently been re- ferred to and lesions at the base of the skull are so infrequent that it is difficult thus to account for all the cases. The same may be said of the regularity of the combination of the nerves involved. Evidences of in- volvement of other nerves in the processes affecting laryngeal movement are seen in unilateral paralysis and atrophy of the tongue, the tip of which is deviated to the affected side, relaxation of the soft palate and nasal speech, unilateral paresis of the facial muscles, anesthesia of the pharynx and larynx, deafness and vertigo, acceleration of the heart's action. These may be seen associated with abductor laryngeal paralysis, but SPASMS AND CONTRACTURES OF LARYNGEAL MUSCLES 631 usually accompany complete unilateral paralysis. Of course the bilateral paralysis of the other muscles are seen, but much less frequently. Lesions at the Base of the Skull. — These are rare, but must not be for- gotten. Tumors of the upper cervical vertebrae, inflammations and scoli- osis of the vertebrae, inflammations and caries of the base of the skull, tuberculous glands may press upon the vagus nerve and its neighboring trunks. Palpation and movements of the head and vertebrae, the study of the association of nerve syndromes with such signs will be the chief means of detecting the existence of a causative lesion. Testing the larynx for sensation may show that the nerve fibers of the superior laryngeal are involved, when we should think of a lesion above the inferior ganglion of the vagus, or one involving it or the course of the vagus below it, together with that of the superior laryngeal nerve. Nerve Lesion. — ^A search for physical signs of an aneurysm of the aorta can best be elucidated by reference to a text-book on internal medicine. "Tracheal tugging" is a symptom of aneurysm of the aorta, occasionally present, which can be appreciated by firm pressure on the trachea in the episternal notch, when a sensation of motion is imparted to the finger caused by the pressure of the pulsating aneurysm upon the trachea or its primary branches below. An enlarged gland may also transmit such a motion from the bloodvessel to the trachea. It is not a sign on which to place implicit confidence. The diagnosis of the nature and the location of the lesion causing laryn- geal paralysis will frequently tax the diagnostic skill of the observer to the utmost. Prognosis. — As a rule laryngeal paralysis, especially total recurrent paralysis, is a condition from which the patient does not recover because it is itself the result of a lesion necessarily irremediable and often leading to death. Among the idiopathic cases there are a certain number that recover. Cases of recovery have been reported in the toxic category. In the rare cases due to pharyngeal and laryngeal burns the paralysis is as a rule not permanent. On the whole, however, complete unilateral laryngeal paralysis is, of all others elsewhere, one in which recovery is not to be looked for. The longer the time which has elapsed since the onset, the less is the chance of recovery. We may say after a year's time the probability of recovery in these cases is very small. Many of them will subsequently develop symptoms of aneurysm or of tabes or of some other previously unrecognized disease. It occasionally happens, without a diminution of the paralysis, that after the lapse of considerable time the voice will improve, as to intensity of sound at least, owing to compensatory changes in the adaptation of the intralaryngeal mechanism to which reference has been made. Treatment. — In those idiopathic cases which eventually recover, we are not aware that any treatment by electricity or otherwise hastens the restoration of function. A case has been reported by J. Shelton Horsley' in which after nearly complete severance of the recurrent nerve by a gun- ' New York Medical Record, January 22, 1910. 632 LARYNGEAL NEUROSES shot followed by laryngeal paralysis, restoration to function took place after the healing of the nerve, the ends of which he had sutured together. Whether such a result would follow suturing the completely divided nerve is a matter of doubt. There is every reason why, when feasible, it should be attempted. This is especially to be borne in mind by operators on the thyroid and on other tumors in the neck where by accident or design the nerve has been cut. In syphilitic cases, antisyphilitic medication would be indicated for the general affections referred to under the head of Diagnosis, yet little can be hoped for in ameliorating the laryngeal paralysis. In ankylosis of the crico-arytenoid joint due to rheumatic disease, the administration of the salicylates frequently restores the joint and the larynx to its normal functions. While galvanization may be resorted to, when there is hope that by stimulating the contraction of the laryngeal muscles We may delay nerve degeneration in the idiopathic or other not necessarily fatal cases and thus increase the chance of a restoration of function when the nerve channels are freed from obstruction or when an ankylosis is being broken up, common-sense should place a limit upon futile efforts, as they attend simply to discredit the good faith of the operator. Paralysis of Individual Laryngeal Muscles. — Paralysis of the Openers of the Glottis. — Posticus Paralysis, Unilateral. — As paralysis of the posticus muscle or the dilator of the glottis, nearly always precedes that of total laryngeal paralysis, it is the most frequently observed of all the single muscle paralyses. Although the laryngoscopical picture may remain con- stant, it is probable that nerve involvement or muscle involvement is seldom long confined to their original limits as heretofore suggested. Practically the same etiology may be ascribed to the posticus paralysis as to that of complete paralysis. It usually produces no appreciable symptoms except in those who cul- tivate the voice, and even in singers, as observed by Semon in one case, it may exist for years without noticeable impairment of the voice. This is unusual, and even a fairly good voice is not always retained. Sometimes a hoarseness or a change in the quality may attract attention. In adults there is no dyspnea, the opposite cord making wider excursions in abduc- tion when necessary. There is said to be an exception to this rule in chil- dren in whom dy-spnea often occurs. After a time other muscles are in- volved, when hoarseness and other symptoms supervene. The vocal cord is seen immovable in the middle line, while its congener moves in ab- duction. The cord is not always tense and the appearances are altered when combined with paralyses of the other muscles. After a time this often happens, the thyro-arytenoideus and the transversus or aryte- noideus being involved, and more marked impairment of the voice supervenes. The cord may remain in the middle line, but on phonation it is not so exactly adapted to its fellow. The upper border of the ary- tenoid cartilage pitches forward, gets out of line with its fellow, anterior to it. Finally there is usually presented the picture of complete laryngeal paralysis. SPASMS AND CONTRACTURES OF LARYNGEAL MUSCLES 633 Double Posticus Paralysis.-— A very different state of affairs is found in double, posticus paralysis. The cords are seen closely approximated, if laryngoscopy is possible. If the internal tensors are involved or some of the other muscles, enough air on quiet respiration may sustain life, but any extra exertion may cause apnea and death in a few minutes. Sonorous respiration during sleep is a symptom of bilateral abductor paralysis, even when the patient does not suffer from dyspnea markedly, during the day. A fatal attack may, however, supervene at any time. Several such cases we have seen, one or two having rejected the proposal of trache- otomy because they were fairly comfortable and could phonate in a meas- ure, though prolonged conversation is always impossible. They are extremely liable to die suddenly when they fail to accept such advice. Differential Diagnosis. — When the observer sees such a case in extremis, the differentiation of this condition from that of those extremely rare cases of prolonged functional spasm of the closure muscles of the glottis can only be made after a tracheotomy has relieved the threatening suf- focation. In the latter condition, on taking the tube out, the cords are usually seen to move at least temporarily in abduction before the advent of another spasmodic contracture. If the laryngoscope can be used it can scarcely be confounded with any other laryngeal condition. The his- tory of the case will do much to elucidate the nature of the laryngeal con- dition and of the lesion on which it depends. Previous attacks may not always prove the existence of a spasm, but persistent dyspnea on exertion and the laryngoscopical appearances are pretty sure to enlighten the careful observer. The laryngoscopical appearances and the preservation of the voice are sufficient guides in unilateral paralysis. Treatment. — Unilateral posticus paralysis may be treated in the same way as suggested for total laryngeal paralysis on one side, but a double posticus paralysis necessitates prompt tracheotomy. A proposal has been made to extirpate the vocal cords, and O'Dwyer and some of *his followers have employed intubation, but as cases may survive for years in this condition, if air is admitted, tracheotomy is to be preferred. It is truly surprising to note how small an aperture serves to admit air enough to prolong life in endurable fashion, but that should emphasize rather than diminish the realization of the observer that the patient is in the utmost peril. This is of course somewhat lessened by the advent of paralysis of the internal closers and especially of the transversus muscle, but the peril is still pressing. Paralysis of the Closers of the Glottis. — ^Paralysis of the Thyro-aryten- oideus and Crico-arytenoideus Lateralis. — The thyro-arytenoideus may be considered for our purposes as the synergist of the crico-arytenoideus lateralis, though their attachments and courses differ a little. We have already spoken of the paralysis of the internal thyro-arytenoid muscle in connection with that of the posticus. A more common and a less serious instance of this is seen in some cases of severe laryngitis where a per- ipheral paresis, more or less pronounced, seems to be present, not always easy to distinguish from the mechanical interference offered by the swollen mucosa. The affection is nearly always bilateral. On closure the 634 LARYNGEAL NEUROSES chink of the glottis assumes the form of a double ellipse, as indicated in (Plate XII, Fig. 2) . It is seen occasionally in extreme anemia, frequently combined with hysteria, but not seen in the classical form of hysterical aphonia. It is the common form of voice fatigue in speakers. Aside from its association with other forms of laryngeal paralysis due to central or nerve lesions, this form yields to treatment directed to the local congestion, to rest or to the general treatment for anemia and its complicating general neurosis. Paralysis of the Transversus. — ^This is much more rare than the preceding in its isolated form, but is also seen in acute laryngeal inflammations and here we are still further justified in doubting the existence of an essential peripheral neuritis. The swellings of the posterior laryngeal wall are often of a chronic nature, and when there is an exacerbation the mechanical in- terference with the approximation of the bases of the arytenoid cartilages carrying the posterior insertions of the vocal cords is considerable. The laryngoscopic appearance is striking in the cases of posticus paralysis of which we have spoken, and varied according as it is accompanied by par- alysis of the openers or by that of the internal closers (Plate XII, Fig. 3). In those cases in which it alone is affected a triangular opening exists posteriorly, but when it is apparently dependent. upon inflammation of the mucosa and submucosa it is far from presenting so sharp cut a picture. Paralysis of the External Tensor, the Cricothyroideus. — This, aside from its involvement in more extended pareses and aside from laryngeal par- alysis in cases in which, as rarely happens, the cricothyroid is innervated from the recurrent stem, takes place but rarely and presents the picture shown in (Plate XII, Fig. 4) . Accompanied by a loss of sensation in these cases it may be found in paralysis following diphtheria. It may be the result of advancing bulbar paralysis. A few cases have been observed by Semon (loc. dt.), by EiegeP and by Klein^ and may be found described in the text-books, but the cases are very rare. Symptoms. — The anesthesia of the larynx which accompanies it allows food or drink to penetrate to the trachea and is often accompanied by a cough due to secretions dripping from the pharynx. Pneumonia from the penetration of this foreign matter into the lower bronchi may result. The vocal cord is described as lax even when meeting its fellow in phonation and as having a wavy upper surface. Low-pitched hoarse tones charac- terize the voice. The danger from the paralysis of the tensor is negligible, but the accompanying anesthesia from the involvement of the sensory filaments of the superior laryngeal nerve adds a serious element of peril to the case. Treatment— Ihe patient may be compelled to take nourishment through a tube or perhaps may swallow fluids with the head lowered to avoid their entrance in the larynx. Further than this, suggestion as to treatment is embodied in the remarks on Complete Laryngeal Paralysis. ' Deutsch. Arch. f. klin. Med., 1870, Band vii. 2 Ref., Centralblatt f. Laryngologie und Rhinologie, 1904, p. 456. PLATE XlII Skiagraph of Button in Trachea. PLATE XIV Foreign Body in Larynx. (Maekenty.) CHAPTER XXIV FOREIGN BODIES IN THE LARYNX AND BRONCHI AND THEIR REMOVAL. FRACTURES AND WOUNDS OF THE LARYNX AND THEIR TREATMENT. ANOMALIES AND CICATRICIAL STENOSES OF THE NOSE AND THROAT AND OPERATIONS FOR THEIR RELIEF. DISEASES OF THE ESOPHAGUS. FOREIGN BODIES IN THE LARYNX AND BRONCHI. Previous to any instrumentation the patient should be inverted and vigorous slaps on the back instituted to try if possible to eject the foreign substance. The amount of residual air in the lungs, when forcibly ex- pelled, is sufficient in many circumstances to relieve the larynx and trachea from the invading substance, and if this is successfully carried out it cer- tainly relieves the patient of unpleasant and unnecessary operative meas- ures. If the patient is tractable the next alternative is to investigate the larynx by the indirect method of examination to see if the foreign body may be feasibly removed in this manner. Before attempting to remove the body the larynx should be properly cocainized by dropping into it one or two drops of a 20 per cent, solution of cocain with a suitable laryngeal syringe. After this has taken effect a pair of forceps which are adapted to grasping the body should be employed, but care should be exercised not to exert too much force in extracting the body, as laryngeal spasm and traumatic edema may result therefrom. If these measures fail recourse to direct laryngoscopy is necessary. It is of material advantage to the operator if a description of the supposed foreign body is obtained before the effort to extract it, as there may be in his armamentarium just the proper instrument for its extraction through the tube spatula. A number of instruments have been devised, many of which have been described under the heading of Direct Laryngoscopy. The same method of cocain- ization as has been described for examination is employed in the removal of foreign bodies. Nearly every conceivable object capable of entering the trachea and bronchi has apparently found its way there. In the majority of instances the object has been successfully removed, provided the operator has had sufficient experience in this line of work, although unfortunate conse- quences have sometimes followed. Globular objects such as buttons, coins, pebbles, etc., are more difficult of removal than those presenting angles which can be readily grasped by the extracting instrument. Bodies which have been lodged in the trachea and bronchi for a long time and have induced tumefaction of the surrounding parts, even at times ulcera- 636 FOREIGN BODIES IN THE LARYNX AND BRONCHI tion of the mucosa, offer the greatest difficulty in removal. It is frequently necessary to employ some suction apparatus to draw off the secretions, such as blood, pus, and mucus which have accumulated in the lumen of the bronchus above the location of the foreign body. Sponges on the ends of applicators are frequently inadequate to remove these secretions. The suction tubes may be separate from the bronchoscope, or as in Jack- son's and others, a part of the instrument itself. In the latter way they offer the additional advantage of removing the mucus at the same time that the eye of the operator is searching for the body. Open safety pins, needles, tacks, nails, and other sharp-pointed objects require special in- struments for their removal, particularly so if they lodge with their points upward. If cicatricial stenoses of the larynx or trachea exist more difficulty is experienced in passing the bronchoscope under local anesthesia. When the patient is suffering from dyspnea from the presence of a foreign body in the bronchus no attempt should be made to examine the throat or bronchus without preparations for immediate tracheotomy, for at any time during the passage of the bronchoscope the patient may cease breathing and it may become necessary to remove the instrument to perform an immediate tracheotomy. When either the right or left bron- chus is shut off by an occluding body, the necessity for a lateral opening in the bronchoscopical instrument becomes imperative, otherwise the tube in entering the bronchus would shut off respiration from the other part of the lung, and result in asphyxia. With the presence of these openings sufficient air will pass by the side of the bronchoscope into them to permit of respiration during the extraction of the body. The opening should be some distance from the end of the bronchoscope, otherwise a sharp-pointed body such as a pin or a nail may enter this opening and being fixed in the wall of the bronchus, an effort to remove it will cause embarrassment to the operator and danger to the patient. In all bronchoscopical work the operator should wear glasses sufficiently large to protect his eyes against expectorated mucus, pus, blood, etc., other- wise he runs great risk of infection as well as the annoyance of hav- ing his pupil dilate under the effect of the cocain-laden expectorate entering his eye. The pulp or kernel of nuts, peanuts, beans, etc., or any substances which will swell when subjected to heat and moisture, are the most difficult of removal. They also occasion great inflam- matory disturbances in the bronchi themselves. It has been noted by a great many observers that peanut fragments present the most serious consequences of any inspired body. Whether this is due to the small size of the material entering some of the smaller bronchioles, or due to some peculiarly irritating substance within the peanut itself, is un- known. It is impossible to outline the method of procedure for every foreign body that may enter the lungs, and the character, size, position- of the body, and the age of the patient render each case separate unto it- self. An operator must possess both surgical and mechanical ingenuity properly to meet -the requirements of bronchoscopical work, and unless he possesses these in addition to his manual dexterity, cases will arise in which his efforts will be unsuccessful. FRACTURES AND WOUNDS OF THE LARYNX 637 FRACTURES AND WOUNDS OF THE LARYNX. Dislocation of the Cartilages of the Larynx. — Occasional dislocation of the arytenoid cartilages occurs, due either to blows or sudden excessive strain of the voice; also dislocation of the thyroid from the cricoid cartilage which produces some overriding of the thyroid upon the superior rim of the cricoid. These lateral dislocations are easily diagnosed and overcome, but the dislocation of the arytenoid is difficult to manage. Under thorough cocainization the cartilage can sometimes be forced into place by either a cotton-wound laryngeal applicator or a blunt-pointed, non-cutting Macken- zie forceps. Care should be exercised not to wound the mucosal covering. Rest of the larynx and ice externally, to prevent serous extravasation into adjacent structures, must follow the attempt at reduction. It is also well to have the patient under a croup tent so that the inspired air may be moist and laden with non-irritating medication. In subluxation of the cricoid it is sometimes necessary to put on roller splint bandages, held in place by straps of adhesive plaster over which an ample gauze dressing with external bandages is placed. These should be kept in position for about a week and the patient cautioned not to attempt speaking above a whisper, otherwise the effort on the part of the extrinsic muscles to aid voice production will tend to pull the cartilages back into the dislocated position. Fractures of the Larynx. — Fractures are of unusual occurrence in the cartilages of the larynx, and are confined to the thyroid and cricoid. They occur ordinarily in adults in whose cartilages calcification has al- ready begun. They are the result of external violence and should be treated by rest of the voice and local fixation of the larynx with splints or bandages. Intubation may be necessary. Wounds of the Larynx. — ^They may be divided into penetrating, incised, and gunshot. The penetrating wounds usually are due to attacks by an enemy with a stiletto or knife, or to such accidents as falling upon palings, railings or sometimes in children falling upon the branches of a tree in which they have been climbing. The wound should be opened, hemor- rhage controlled, antiseptic dressings applied, and the wound permitted to granulate from the bottom. Incised wounds are the outcome in most instances of homicidal or suicidal attempts. Treatment. — Frequently only the overlying laryngeal tissues are in- jured and the cartilage escapes almost entirely, but in those instances where the cartilage is included in the wound, it is better to pack and allow the secretion and drainage to take place from within outward, than to attempt closing the outside wound and of necessity forcing the secretions into the larynx through the incised cartilage. For if the wound is closed, and the drainage forced into the larynx, granulations will spring up around the point of exit and prolong the treatment. If the greater vessels of the neck escape injury in this procedure, the wound usually heals more or 638 ANOMALIES OF DEVELOPMENT less kindly, but if an attempt is made at closing it infection almost invariably results. First control the hemorrhage and render respiration easy. The trachea or larynx should be exposed and examined. If the injury is serious a low tracheotomy should be performed, as the swelling incident to the injury may shut ofl the air, and the infection which is likely to ensue may reach the lungs. This is prevented by a tracheotomy. Should the trachea or larynx not be too lacerated, a few stitches can be made to approximate the lips of the wound. If great laceration has occurred a rubber tube may have to be inserted into the lumen of the trachea above the cannula to preserve the integrity of the parts, and the extremity of the tube carried out through the pharynx and mouth and fixed externally with adhesive strips. Even after healing has taken place dilatation may be necessary to prevent contraction. Prognosis. — Grave. Death may result from asphyxia, inhalation of blood, or from edema. Pneumonia is frequently a sequence to these wounds. Stenosis may follow as the result of cicatrices, and loss of voice from injury to the vocal mechanism. Gunshot wounds are usually serious affairs and death often ensues from infection, hemorrhage or pneumonia. The injury itself, if the great vessels and nerves escape, is less grave as regards prognosis, and surgical attention must be rendered in accord with preceding advice. ANOMALIES OF DEVELOPMENT IN THE ANATOMY OF THE NOSE AND THROAT. Theoretically the line between these conditions and those sometimes classified as teratoma is not very sharp so far as the definition is con- cerned, but practically those anomalies of development which obtrude themselves on clinical observation as absence of, displacement of, or dis- tortion of gross anatomical structure seem fairly well separated from der- moid cysts and teratoma in general, though the latter quite as well as the former are anomalies of development. Anomalies of the Nose. — ^Without more than referring to anencephaly or the absence of the cranial and facial development of the fetus, we may refer to the external nose as occasionally though rarely entirely absent. It is a question whether in those cases in which the absence of the nasal septum has been ascribed to lack of development, it is not in reality due to some pathological process which has obtained after birth. We have already spoken to some extent of the defects and anomalies in the devel- opment of the accessory sinuses, as this is taken up in connection with sinus surgery. We have seen that very frequently the frontal sinuses are lacking inasmuch as they, being off-shoots from the ethmoidal cells, have not gone on to development in the embryo. This important abnormality it is well to mention here again, if only for the sake of emphasis, as in the consideration of the practice of sinus surgery it must not be forgotten. The most common defect of the nose with which surgeons, and indeed the ANOMALIES OF DEVELOPMENT 639 public in general, are familiar is the hare-lip and cleft palate. We have seen how the nose and the maxillary processes are developed in conjunction with the growth of the first branchial arch and the globular processes of the nose. When these are not united in front we have all manner of de- fects. There may be a cleft only in the upper lip or it may extend back- ward on one or both sides to the nasopharynx, the whole palatal g,rch being absent and the interior of the nose with its turbinated structure exposed to view. Defect to this extent, however, is rare. It may be united in front and show nothing but a cleft uvula behind, or the failure to close may involve not only the soft parts of the upper Up, but on either side of the intermaxillary process there may be a lack of union or the inter- maxillary process itself may be attached to the septum of the nose, as this is developed normally on each side from the globular process, which enters into the formation as well, of the external nose. The cleft when it affects the middle in this way divides the vomer in two, but the thin plates of the vomer may be absent and the whole cavity of the nose com- municate with the mouth. When, as rarely happens, the cleft is on each side of the intermaxillary process, the latter may contain the two median incisors or may include all four of them. In the former case the suture is lacking between the internal and external division of the intermaxillary process. In the latter the suture between the lateral maxillary division and the superior maxillary process has failed to unite. There are many modifications and variations of these faults of development. Anomalies of the Naso- and Oropharynx. — Under this heading we may refer to those conditions most frequently seen which may be sometimes mistaken for neoplasms. Prominence of Tubercle of the Atlas and of the Vertebral Muscles. — Occasionally prominence of the tubercle of the atlas is so marked that it presents a swelling on the posterior pharyngeal wall just above the level of the soft palate, and mention of it here is necessary only that the examiner may have the condition in mind and not mistake it for other conditions. Here also may be mentioned a condition sometimes observed, so pro- nounced as to cause confusion in the mind of the observer. We refer to the prominence of the anterior muscles of the vertebral column. These occasionally project on each side in the lumen of the pharynx in such a way as to present a deep sulcus between them. Another condition is referred to as pulsating arteries of the pharynx. This is usually due to an abnormal course of the ascending pharyngeal arch on one or both sides. A loop of the vessel sometimes presents on the inside of the pharyngeal aponeurosis near the supratonsillar fossa. About the same position may be assumed by the abnormal course of the internal carotid artery. These conditions have an importance in the surgery of the tonsils which it is necessary to keep in mind. In fact, it is always wise before excision of the tonsils to explore the region lying posterior and above them for these abnormal vascular distributions. Defects are occasionally seen in the anterior and posterior pillars of the pharynx. It is diflBcult to distinguish these from the results of ulceration, perforations, and absence of one or more of the pillars being observed. 640 CLEFT PALATE Bifid uvula is the most frequent abnormality seen in the pharynx, but this is in reality due to a slight lack of closure of the palatal processes or bran- chial arches in the embryo described under the category of Anomalies of the Nose. Anomalies of the Larynx in the Anterior Cervical Region. — Embryos have been born with entire absence of the larynx, trachea, and lungs. They are born sometimes with skin and cartilaginous webs across the trachea and have perished because they are not able to breathe. The lesser degrees of this ingrowth of webs across the larynx frequently persist till adult life, when, probably through some inflammatory process being grafted upon the condition, necessity for surgical interference arises. Instead of the trachea being divided into two bronchi, triple bronchi have occasionally been seen. Some of the cartilages may be lacking, the cricoid, for instance; the epiglottis, which often is more or less notched, may be split into two lateral halves. Sometimes there are extra folds in the mu- cosa of the larynx, and under this heading perhaps it may be well to say that infants are occasionally born with papillomata already existing upon the mucous membrane. Laryngocele. — Some of the apes have enormous laryngeal sacs which communicate with the ventricles of the larynx and are distended when the animals howl. Twenty-four cases of dilatation of the ventricle of the human larynx have been reported, according to Avellis.^ It will doubt- less be urged by Darwinists that this is an atavistic trait. Whether all these cases were due to a congenital aberration in the development of the branchial furrows is doubtful, though some of them surely were. The neck above the wing of the thyroid cartilage is distended upon forcible crying or coughing or forcible expiration. This is sometimes as large as an orange. Surgical Treatment. — Naturally every case is a law unto itself so far as operative procedure is concerned. Under the following captions an at- tempt will be made to refer briefly to those conditions most likely to call for interference on the part of the laryngologist. CLEFT PALATE. For surgical consideration cleft palate may be classified as, (1) fissure in the velum palati only; (2) fissure in the velum and part of the hard palate; (3) cleft involving the entire soft and hard palates; (4) cleft involving both hard and soft palates, together with the bifurcation of the superior maxilla; (5) double separation including the hard palate, divided by the vomer, with a wide fissure almost, if not completely, obliterating the velum. Anatomical Considerations. — Before an attempt is made at closing the cleft the extensive hypertrophy of the turbinated bones, particularly the posterior tips, must be gradually reduced. These tips have hypertrophied » Archiv f. Laryngologie und Rhinologie, 1907, Band six, p. 464. CLEFT PALATE 641 to_ meet the physiological demand which the palate in its separation has failed to supply, and the mucous membrane has become hardened and thickened by contact with food, brought about by their occupying the position the palate would occupy to prevent ingested matter from entering the postnasal space. If the clefts are suddenly closed one or the other of these turbinated bodies will be compressed so that union may take place between it and the surrounding tissues, thereby producing permanent stenosis; or there may occur from pressure a deviation to one side or the other of the posterior septal wall; consequently it is advisable, before repair of the cleft is made, that external pressure be gradually exercised until both hard and soft palates are brought into closer union, and in so doing reduce the turbinated structures gradually as the requirement for their supplemental physiological function is diminished. If in addition to the cleft palate there is a hare-lip, either single or double, which is continuous with the cleft, it is well to overcome the lip deformity before an attempt is made to correct the palatal cleft, although some operators, particularly Lane, of London, advocate the correction of both deformities at the same surgical sitting and without any previous effort being made to get the tissues into closer approximation by external pressure. Others prefer to overcome the cleft palate before attending to the hare-lip. While formerly it was the custom to operate on infants within a few weeks after birth, it has been urged that operative measures should not be begun too early. A definite time, however, is determined largely by the physical condition of the patient to be operated upon. If the child is healthy and well-nourished, it is not necessary to postpone operation, provided the previous efforts at approximation of the tissues has been suc- cessful. One object to be kept constantly in view is to avoid the formation of incorrect habits of speech which are difficult to overcome, and operative procedures should be instituted before these habits have been permanently fixed. Pre-operative Measures. — Great advantage may be obtained by ex- ternal pressure constantly applied over a long period of time, which will tend to coapt the opposite sides of the cleft in both hard and soft palates. This mechanical pressure may be further aided by traction splints applied between the parts of the hard palate within the mouth, the sides of which may be fixed over the teeth (Fig. 303), if the patient has them, or if without, by running a silver wire through the alveolar pro- cesses of the two sides, fastening the extremities by means of lead plates and exercising pressure from without inward by twisting the wire within the arch of the palate. An extra twist may be made every two or three days, and this itself will create sufficient pressure to pull the sides together in infants and very young children. The great disadvantage of this method is the unavoidable sloughing which follows from the prolonged pressure. The mouth, gums and buccal cavity should be frequently cleansed with warm Dobell's or boric acid solution, so that it will be kept in as perfect order as possible. In addition to this the pharynx, palate, and posterior turbinal tips should be frequently manipulated so that this area will become less sensitive to the presence of foreign bodies, otherwise 41 642 CLEFT PALATE gauze packing and stitches employed in the operation will create consider- able gagging and retching, which tend to pull the sutures out. Some operators, particularly McKernon, advocate a tracheotomy pre- vious to beginning correction of the palatal cleft. The advantages are: Economy in time of operation; prevention of blood and secretions enter- ing the larynx and stomach; removal of the anesthetic from the site of operation; the ability to pack the pharynx and mouth with sterile gauze after the operation, thereby holding the flaps in closer apposition. The pharynx being thus packed, there is no undue pressure exerted by the tongue against the wound, and alimentation being per rectum, the attri- tion of food and drink does not disturb the palatal surface. The dangers attendant upon tracheotomy can be materially lessened by placing the Fig. 303 Method of bone operation to reduce the width of unusually unfavorable fissure, a, b, nut and screw bar, and bands cemented upon the teeth; c, lines of cutting to weaken the bow resistance. (Brown.) patient under a croup tent immediately after operation, also by perform- ing the tracheotomy under cocain anesthesia and, as is often advocated, on the day previous to performing the palatal operation. Pneumonia is now extremely infrequent in tracheotomy cases and if performed by a surgeon skilled in this specialty, the danger is considered to be of minor surgical importance. The fear of tracheotomy previously felt was caused by the fact that it was performed in the majority of instances as an emergency measure without proper surgical care, and with conditions existing which made pneumonia a frequent sequel. Chloroform is advocated by some, and, if administered through the tracheal tube by means of a sponge held over the extremity of the tube, it induces a quiet and effective anesthesia. The same dangers, however, are CLEFT PALATE 643 attendant upon it administered in this way as when given by the mouth, and as a general proposition it may be stated that ether is the safer of the two. In infants chloroform appears to afford a quieter anesthesia, and to induce less secretion of mucus, but with these exceptions ether is to be pre- ferred. When chloroform is administered it is advisable to have the head on a level with the shoulders or extended over the edge of the table. If ether is employed, however, it is permissible to have the head raised at times to meet the convenience of the operator. When the operation is per- formed after a tracheotomy the patient's head may be more conveniently placed in the position requisite for easy operation, but if a tracheotomy has not been previously performed the Trendelenburg position is desir- able in order to prevent the blood and secretions from entering the larynx. To keep the field properly free of blood and secretions it is necessary either to have one assistant devoted entirely to this object or to employ the Bier suction pump. Fig. 304 The Whitehead gag with tongue depressor. Technique. — After the patient is under the anesthetic a gag is placed in the mouth, selected in accordance with the personal preference of the operator. The Whitehead gag with a tongue depressor attached is employed by a large number of operators. Brophy has a gag of his own construction which he employs universally in his very suc- cessful operative work. In England and by some operators in America the Smith gag renders effective service. The parts are now cleansed with antiseptic solutions, either of iodin or of formaldehyde, and rendered perfectly dry by gauze sponging. The laryngopharynx is then packed off, if. the tracheotomy has been previously performed, by one or more large, flat, gauze sponges, to each of which is attached a string, which is secured on the outside of the cheek with a hemostat. This prevents the blood and secretions entering the trachea. The edges of the cleft are now pared by grasping the edge of the tissue to be removed with a pair of long-handled mouse-tooth forceps, the superficial tissue being removed with a pair of long-handled, curved scissors. When it is impossible satisfactorily to employ the scissors a sharp scalpel may be substituted, and as little of the tissue of the soft parts removed as possible, commen- 644 CLEFT PALATE surate with obtaining raw surfaces for proper coaptation. With a periosteal elevator the mucoperichondrial tissues are then elevated from the hard palate, beginning at the anterior angle of the cleft and going backward to the junction of hard and soft palates. This elevation should extend laterally over the curve of the hard palate until sufficient tissue is liberated to supply a superfluity for coaptation by the thus detached mucoperiosteum from the palatal arch. When the uvula is reached special care must be observed to preserve what muscular tissue remains and only as much of the epithelial covering should be removed as will insure union. Interrupted sutures are now introduced, beginning at the tip of the soft palate and coming forward as far as the liberated soft parts will permit of coaptation without tension. When the sutures appear to be drawing on the soft parts, a curved incision is made in the cleft palate, internal to the hamular process and extending downward until it stops just before the fibers of the pillar are severed. To close the bony cleft it is now necessary to run a silver-wire suture through the alveolar process from one side to the other and by torsion to bring the edges of the cleft in closer approximation. The silver wire is then fixed by a lead plate within the cheek, and the points bent inward so as not to create trauma. The liberated tissue over the hard palate on either side of the cleft now hangs in a loose flap so that they may be brought together with sutures the same as the soft palate. An alveolar incision is now made close to the border of the jaw, extending through the mucous membrane and periosteum down to the bone, the length of the incision being governed by the long axis of the cleft and the necessity for a flap. The incision should begin just behind the front teeth and be carried backward sufficiently far to permit the released fiaps to overlap the median line, which will insure against retraction on the sutures in the process of healing. The needles best adapted to the introduction of the sutures are right and left, short, curved needles, capable of carrying a medium-sized silk. Some operators prefer to use iron-dyed silk, but silver wire has by experience proved to be much less irritating to the tissues, and therefore may be left in place much longer. Horsehair, silkworm gut, and other suture materials are less effective. After the silver-wire sutures have been drawn through the soft parts and proper coaptation accomplished, the extremities of the suture are fixed with small leaden placques on either sid^ of the line of coaptation and these plates act as splints to the wound. The sutures should be placed within the tissues at distances of one-fourth to one-half inch. Hemorrhage from the lateral incisions in the tissue over both the hard and soft palates is controlled by packing with strips of gauze soaked in adrenalin, or by packing with hot normal saline solution. Hemorrhage from the rest of the operative site may be controlled by hot packing. In the tracheotomy cases the packing in the laryngopharynx may now be withdrawn and fresh packing, wrung out in hot boric acid solution, may be introduced and the whole pharynx and mouth packed firmly so that it acts as a splint to the newly sutured soft parts. It is advisable to await the patient's coming out from under the anesthetic to see if CLEFT PALATE 645 there is retching or vomiting, and if the latter occurs the parts should be cleansed and new packing introduced. To obviate the strain upon the stitches subsequent to. closing the cavity, which is induced by crying, swallowing, and tongue pressure, Mackenty has devised an obturator made on a cast taken of the mouth. Fig. 305 Fig. 306 Mackenty's wire obturator for cleft palate operation. Mackenty's blunt retraction hook for cleft palate operation. Fig. 307 This obturator is made of platinoid wire, thick at the rim and cross- barred with additional wires. The points of crossing are soldered. After the completion of the operation, the obturator is either sewed to the gums in infants or tied to the teeth in those cases having teeth and left in situ until the stitches are removed. He has also advocated the employment of flat-faced hooks which he inserts in the incision made along the sides of the palate, behind the gingival margin, the extremities of which are tied together across the palate. These hooks are held in place by a strong linen thread attached to their extremities, after which the free end of the thread is secured to the obturator to prevent their being accidentally swallowed if de- tached. In cases where there is sufficient tissue to obviate the necessity for lateral slits, he employs similar hooks with pronged ends so that they may be engaged in the flap on either side and tied across in the same manner as the others. In this way tension is materially relieved along the line of coaptation of the flaps. Instead of silver wire, silk or horsehair, Mackenty employs Pagenstecher's thread, which in his experience has resulted in far less trauma than the silver wire and less softening of the tissues than the silk. Postoperative Measures.— Rectal feeding is essential in the trache- otomy cases and should be carried on at frequent intervals, small quan- Mackenty 's sharp retraction hook for cleft palate operation. 646 HARE-LIP titles of food being given at each time, one-half hour preceding which the bowels are washed out. After the nutritive enema has been given the nurse should be instructed to hold a towel against the anus for twenty minutes to prevent expulsion of the material. The packing in the pharynx and laryngopharynx should be removed within twenty-four hours, and replaced by new moist dressings. At the next dressing, which should take place on the third day after operation, a glass of peptonized milk should be given, followed by a glass of warm sterilized water to cleanse the parts. Nourishment by mouth is increased to a pint of milk at each dressing as the case proceeds. By this means loss of weight is obviated and strength is maintained. McKernon has reported a series of successful cases treated after this manner with a minimum of failures. If silk sutures have been employed it is necessary ordinarily to remove them at the end of eight or ten days, but if silver wire is used they may be left in place at least two weeks. It is inadvisable to remove all the sutures at one time and only those sutures which seem to be drawing or cutting the tissues should be first removed. The tracheotomy tube should be removed about the tenth day or sooner if the patient is able to swallow food with ease, and there seems little probability of the sutures pulling out. During the time the tracheotomy tube is in, the patient should be under a croup tent where the air is kept moist and warm by a continuously boiling kettle in which the oil of pine mixture is placed. HARE-LIP. Where the cleft palate extends entirely forward through the lip into the nose, either by a single or double cleft, and the premaxil- lary bone projects forward, it is advisable to employ external pressure for some months by means of adhesive straps until the premaxillary bone is brought back somewhat into position and the width of the cleft lessened. With these existing conditions the majority of operators prefer to close the hare-lip first and leave the cleft palate for subsequent opera- tion. When, however, the cleft does not extend entirely through the palate and the hare-lip appears to be a separate and distinct deformity the cleft palate is closed first and the hare-lip is cared for later. Operation (Owen's). — Chloroform is often preferred in operating upon hare-lip. The lip and cheek are freed by incision, followed by muco- periosteal elevation for a wide distance superiorly and laterally so that the edges of the lip may be approximated across the gap without tension. Bleeding, which is profuse, particularly from the coronary arteries, must be controlled by hemostats and ligatures. The red border of the lip is then seized with mouse-tooth forceps and the mucous membrane economically pared, care being exercised to destroy as little of the mucous surface as is possible, yet providing ample denuded surface for coapta- tion. A thick flap is then cut from the longer side of the lip and brought across to the denuded border of the opposite side. The thickest part of LARYNGEAL, PHARYNOEAL, AND PALATAL STENOSES 647 the flap forms the prolabium, while that part which was previously the mucous border of the vertical cleft becomes the horizontal border at the bottom of the obliterated fissure. The angular space from which this flap is removed is filled in by the denuded part of the opposite side, which is dovetailed between the superior and inferior cut surfaces. Deep sutures should be taken, employing either silkworm-gut or pre- pared horsehair sutures so that the transplanted flaps should be held firmly in place. There should also be a superficial line of sutures taken in the mucous membrane on the dental side of the lip. It is frequently necessary to reduce the size of the nostril or to correct its deformity. In order to do this it may be necessary to separate the cartilages from the bone and pull them in at their inferior border, where they may be held in place by wire sutures. After proper cleansing of the parts, dressing, consisting of a strip of gauze dipped in collodion, is stretched from cheek to cheek over the lip, which is pursed up by the finger and thumb of the assistant, which reduces as far as possible the tension on the sutures. On the next day this is removed, by making traction upon the extremities of the gauze so that the force exerted all pulls toward the centre, thus avoiding dragging upon the sutures. If the wound is in proper coaptation a few of the stitches may be removed. At the end of four or five days the majority of the sutures should be out, but the parts must be kept in position for a longer time by gauze and collodion dressing or by water-proof strapping. In cases of double hare-lip it is often necessary to lower the prolabium before it can be made available for a new lip, but in those cases where adhesive straps have been prop- erly and persistently applied the prolabium will come into place without the necessity of operation. The prolabium should never be removed as it results in a sinking in of the tissues at that point and produces marked deformity. LARYNGEAL, PHARYNGEAL, AND PALATAL STENOSES, WEBS, ADHESIONS OR BANDS FOLLOWING SYPHILITIC INVOLVEMENT. Stenosis [of the Larynx. — ^In all cases of syphilis of the larynx, particularly if the cartilage has been involved, there is more or less constriction of its lumen, and provided this condition is obviated there may result either adhesions or bands of cicatricial tissue from one point to another. When contractions occur they should never be forcibly dilated as a secondary perichondritis may be set up thereby. The difficulty must be overcome by gradual dilatation carried on for a number of months and even years, von Schroetter, of Vienna, as early as 1871, devised two methods by which these constrictions might be dilated; one by the use of an olive-shaped bougie after tracheotomy had been performed; the other by the introduction through the mouth of hard, hollow, rubber tubes inserted through the mouth without tracheotomy. The O'Dwyer ()4S LARYNGEAL, PHARYNGEAL, AND PALATAL STENOSES intubation tube or a modification of it has been successfully employed in cases of contraction either with or without a preliminary tracheotomy. These tubes have been modified by Rogers so that there is a window in the main tube opposite the tracheotomy wound into which is screwed a secondary tube projecting out through the wound, which will fix the intubation tube in position. Rapid dilatation, though followed by intu- bation, has not proved as successful as was expected at first. Rogers' tubes differ somewhat from the original O'Dwyer tubes, but the principle is the same. It was claimed by O'Dwyer that the cartilaginous forma- tion or constricting fibrous bands resulting from pressure would ultimately disappear, if the tube was held in contact with this point for a sufficiently long time. This same principle is carried out in the employment of the Rogers tubes. Webs in the Larynx. — Webs forming between the true cords themselves, or between the false cords, can be easily cut with any of the laryngeal knives designed for the purpose, especially the disappearing knife of Tobold (Fig. 284). After severing the web it is then necessary to dilate the larynx and keep it dilated just as in stenosis. Bands and Adhesions in the Larynx. — Bands of cicatriciail tissue and adhesions between the epiglottis and arytenoids or across the lumen of the larynx, may be divided in like manner and dilatation instituted as in the other cases. Where cicatricial tissue involves nearly the entire lumen of the larynx a thyrotomy may be performed, the cicatricial tissue removed, and a mucous membrane graft placed thereon. In some cases this has proved of benefit, but in the majority of instances the scar tissue following is almost as bad as that previous to the operation. In one case reported by Bryan cicatricial adhesions of the cords disappeared under the administration of potassium iodid and mercury. Hard-rubber intubation tubes are probably better than those of gold or silver, as salts are less liable to form on the external surfaces. A gumma may form within the trachea or from involvement of the lymph nodes between the trachea and esophagus and cause obstruction. The usual point of constriction is either just below the larynx or just above the bifurcation, the middle portion seeming largely to escape involvement. Dilatation should be carried out first with soft-rubber catheters and later with bougies. Daily treatment is necessary, but good results have followed this procedure. It is best to diagnose by direct tracheoscopy the nature of the lesion and its position before attempting to treat the case. Adhesions and Deformities of the Soft Palate. — ^Adhesions of the soft palate to the posterior pharyngeal wall are frequently seen, especially in the class of cases attending clinics. The obstruction varies from a partial to a complete closure of the postnasal space, although of the latter kind there are but few instances, as one is able in most cases to pass a small silver probe between the palate and posterior pharyngeal wall. Palatopharyngeal adhesions are either syphilitic, traumatic, diphtheritic, tubercular, congenital, or inflammatory, and in frequency LARYNGEAL, PHARYNGEAL, AND-PALATAL STENOSES 649 occur about in the order mentioned. In a report of sixty-nine cases of adherent palate fifty-eight were due to tertiary syphiUs. In those cases due to syphilis there is more marked cicatricial contraction due to the extensive destruction of tissue than where the adhesions result from other conditions. The uvula also is more frequently destroyed in syphilitic cases, and the central point of stricture is situated where the greatest gummatous deposit has existed. In those cases resulting from trauma, operations have been the most frequent cause, particularly operations for the removal of tonsUs and adenoids. The use of both chemical and electrocautery in the nasopharynx has likewise resulted in adhesions between the palate and pharyngeal wall. Difficulty of respiration is not proportionate to the degree of stenosis, since patients often breathe with comfort through a very small opening. Sometimes, however, both nasal respiration and pharyngeal drainage are embarrassed. The patient being .unable to blow the nose, quantities of nasal secretions accumulate and become fetid in character. The Eusta- chian tubes are occasionally involved in the cicatricial mass, or if not there is sufficient collection of secretions in that neighborhood to occa- sion catarrhal deafness, and instances are cited where the patient has become almost entirely deaf from these causes, in whom hearing was restored after the reestablishment of nasal respiration. Treatment. — If the case is seen in the gummatous condition the immediate administration of salvarsan together with the internal administration of mercury will prevent a great many of the cicatrices in syphilitic cases. Many methods dealing with the condition have been practised, such as the use of mechanical dilators, caustics, permanent obturators and suturing, but none of these have proved of great benefit and only plastic operations followed by either digital or obturator dila- tation has been of permanent benefit. Smith and Delavan advocate the use of monochloracetic acid to the cut surfaces after liberating the cicatrices. The eschar from the acid remains upon the surfaces a suffi- ciently long time to permit of healing beneath, so that when approxi- mated they do not become adherent; but in some instances while the immediate result is good, contraction gradually takes place upon the sides until the beneficial effect is almost entirely lost. Nichols intro- duced silk sutures at the side of the palatal adhesion as far distant from the median line as it was desired to liberate the palate, which were left in situ for a sufficient length of time for a healed channel to take place around them, after which the palate was liberated from the median line up to this channel and kept free by frequently introducing an obturator. This prevented the contractions taking place over the distal extremity of the liberation and resulted in a permanent opening. Roe and Dundas- Grant, having the same object in view, modified this procedure by employ- ing a double-twisted silver wire, around which the tissues healed with greater facility. It is necessary to leave these sutures in from three to_ six weeks, at which time the palate is liberated from the median opening out to the silver wire, care being exercised not to destroy the groove through which 650 LARYNGEAL, PHARYNGEAL, AND PALATAL STENOSES the wire has been drawn, so that at that extremity a healed surface is presented to obviate the beginning contraction at the outer angle of the wound. It is necessary to preserve the patency of this opening by fre- quently introducing either an obturator, a large sound, or the finger. A more successful method of overcoming this condition is that of trans- planting a mucous-membrane flap from the side wall of the pharynx, so that the mucous surface will come in contact with the cut pharyngeal surface and thereby prevent union and cicatricial contraction. A suc- cessful method has been presented by Roe, in which a broad flap of mucosa is liberated from the side of the palate and the inside of the cheek, which is turned backward and upward around the outer and lower border of the soft palate after the adhesions are separated. This movable flap is first turned up behind the palate and fixed by sutures passed directly through its tip and the palate and tied upon the anterior surface of the soft palate. The middle portion of the soft palate is left to hang free from the pharynx without any attempt being made to cover the denuded portions with new mucous membrane (Fig. 309). Fig. 308 Fig. 309 Atresia of nasopharynx, outline of flap. (Roe's operation.) Flap in position. (Roe's operation.) A simpler method has been devised by Mackenty which has been employed by him in several instances with marked success. He takes advantage of the continuous mucosal covering of the anterior surface of the palate and the posterior pharyngeal wall even as far downward as the laryngopharynx. This mucosa is so intimate that there is no line of demarcation and the lateral pharyngeal pillars are sufficiently in evi- dence to designate the original boundaries of the nasopharynx, which is essential to guide the operator in the extent of his liberation of the adhesions. As there is ordinarily a sufficient opening in the middle space to admit a probe, the superior border of the atresia is defined by passing the probe upward into the open space of the nasopharynx and extending it laterally and downward until the adhesion becomes apparent. In order to make the operation successful it is necessary to preserve LARYNGEAL, PHARYNGEAL, AND PALATAL STENOSES 651 sufficient mucous membrane of the pharynx below the Hne of atresia to cover with mucous membrane the under surface of that part of the palate which is liberated from its adhesion to the posterior pharyn- geal wall. Consequently these flaps are taken off the pharyngeal wall sufficiently low down to cover the atresia when liberated from the nasopharyngeal wall and are turned upward after separation. " A curved needle armed with fine silkworm gut is introduced into the mucous membrane of the posterior pharyngeal wall just to the outer side and about 1 to 2 cm. below the central opening mentioned above and carried laterally to emerge at the edge of the posterior pillar. A similar stitch is taken on the other side. The points of entrance and emergence are about 1| cm. apart. With a sharp scalpel the flaps are now outlined, beginning at the outer side of the points of emergence of the stitches, curving, downward and inward, then upward to end at the entrance of the small probe opening into the nasopharynx. Then with Fig. 310 Fig. 311 Mackenty's operation for adhesions of palate. Outline of flaps with retraction sutures in position. Illustrating flaps drawn up posteriorly and points of emergence of the retention sutures. (Mackenty.) an angular knife or a curved scissors introduced through the opening into the nasopharynx, the atresia is separated out to the lateral pharyn- geal walls and downward to the outlined flap incisions. The stitches are held as traction sutures, keeping the tissues taut while the flaps are being separated from the pharyngeal wall. "Now we will observe that the nasopharynx lies wide open and from the lower margin of the soft palate hang two flaps transfixed near their lower margins by two sutures. All that remains to do is to turn these flaps backward and upward against the raw posterior surface of the palate and stitch them in position. Four ends of sutures project from the mouth. Each end is threaded on a sharply curved needle. The needle is held in a special holder which grasps the needle parallel with the long axis of the handle. The needle is passed well up behind the palate and its point drawn forward through the palate above the raw area on the posterior surface. Similarly each of the four needles are 652 DISEASES OF THE ESOPHAGUS brought through on a line with their relative places in the flap. By drawing them taut the flaps ascend and take their positions against the posterior surface. Fine perforated shot are threaded on each suture and clamped in position near the anterior surface of the palate, care being taken to allow for considerable postoperative edema. Fig. 312 Fig. 313 Illustrating anterior aspect of palate with shot Diagrammatic drawing showing manner holding flaps in position. (Mackenty.) in which flap is drawn up and fixed pos- teriorly. "The contraction which takes place on the posterior pharyngeal wall, from which the flaps are taken, is negligible, since the surface is soon covered by a mucous-membrane graft from the edges. The stitches are removed in four or five days. Two weeks after the operation the finger is passed into the nasopharynx. This is repeated every four or five days for a month. Then if deemed advisable, the patient is given a dilator to use at home, to be passed by him twice a week for three or four months. This dilator is a cone set at a right angle upon a handle and made in sizes to suit the individual case."' DISEASES OF THE ESOPHAGUS. Diverticula. — These are not uncommon and can now be definitely located by means of the esophagoscope. Their outline may be determined by injecting into the cavity bismuth paste, after which a radiograph may be made and the size and extent of the diverticulum shown. The symptoms simulate a foreign body insofar that when the diverticulum is filled there will be a regurgitation of food, but the patient can always swaUow with more ease than when a foreign body exists. Surgical intervention is the only rational procedure. Cardiospasm. — This consists in a spasmodic contraction of the cardiac end of the stomach and a consequent dilatation of the muscular walls -of ' Mackenty, Medical Record, November 25, 1911. DISEASES OF THE ESOPHAGUS 653 the esophagus. It simulates in its symptoms that of a diverticulum. Surgical procedure will in most instances effectively overcome the condition. Strictures. — ^These occur as the result of ingestion of escharotics, steam, hot fluids, of inflammatory ulcerations, syphilis, tuberculosis and malignant growths, pressure from aneurysm, tumors, abscesses, enlargement of the mediastinal glands, and occasionally of the cervical glands. There is difficulty in swallowing, regurgitation of food, localized pain at the point of stricture, emaciation, and constitutional evidences of starvation. Dilatation when the stricture is not of malignant nature or due to extrinsic pressure should be begun by bougies, which must be graduated to fit the lumen of the esophagus at the point of stricture. It may often be necessary to pass an extremely small bougie of filiform size, which is gradually increased until a dilatation has been obtained sufficient to permit of the passage of food. In some instances there is such firm cicatricial stenosis that it is impossible to dilate the stricture; it then becomes necessary to open the esophagus at its lower extremity and by means of a silk string passed through the mouth and out through the lower opening, the fibrous bands are severed and the stricture may then be kept open by the frequent passage of bougies. When passing the bougie the operator must always keep in mind that ulceration may have occurred adjacent to the stricture and the tip of the bougie may be easily passed through the walls of the esophagus at this softened area. Non-malignant Tumors. — ^Myxoma, myxofibroma, and other non- malignant tumors have been found in the esophagus and their obstruc- tive symptoms such as regurgitation and difficulty in swallowing have often simulated both strictures and malignant growths. The esophago- scope enables the examiner to determine the character of these growths, as there is seldom ulceration, bleeding, or constriction of the lumen of "the tube where th^y exist. Polypi, particularly, are frequently pedun- culated and cases have been known where the growth has been regur- gitated, caught by the operator before being drawn back into the esophagus and removed. By means of the esophagoscope these growths can be readily snared or cut out. Their recurrence is unusual. Cancer. — There are three points at which cancer frequently occurs: (1) at the level of the cricoid cartilage; (2) at the bifurcation of the trachea; (3) at the diaphragmatic portion. Cancer occurs most frequently in males; only a relatively few cases are on record of cancer in females. The age of the patient is usually from forty to sixty, although there are two cases recorded in which, one was nineteen and the other twenty-one, and there is also another case of cancer of the esophagus occurring at the age of eighty-four. Symptoms of Esophageal Cancer.— Difficulty in swaUowing is the first and most prominent symptom which increases as the disease progresses. Regurgitation of food begins early in the disease and is more prevalent in those cases in which the involvement takes place at the upper point, the level of the cricoid. Pain is first experienced during the act of deglu- tition and is- often referred to the back between the shoulder blades. 654 DISEASES OF THE ESOPHAGUS It may also extend to the side of the neck and to the ears. Paralysis of the recurrent laryngeal nerve is often noted and is unilateral. Early in the disease there is vomiting in addition to regurgitation and the vomited matter will contain blood, epithelial debris, and is sometimes of a particu- larly foul nature. There is rapid loss of weight early in the involvement, due more to forced starvation than to the inroads of the disease. The patient becomes anemic and later cachectic. There is slight rise of temper- ature, the pulse becomes rapid and feeble, and general bodily weakness with syncope prevails. Involvement of the upper portion of the esopha- gus is more rapidly fatal than that of the lower portion, owing to the early inability to ingest food. Foods of a farinacious order present the greatest difficulty in swallowing. There is expectorated considerable frothy mucus, foul smelling and blood tinged. The mediastinal glands are frequently involved by metastases. Death results from inanition, exhaustion, and septic pneumonia. Diagnosis may be made out from the general symptoms and by the employment of the x-rays, which will often denote circumscribed involvement of the gullet. Bougies will also determine the location of the constriction, but as strictures may occur from other causes they only give a clue to part of the trouble. Direct esophagoscopy will usually reveal the nature of the disease, if employed by one familiar with the appearance of the tumor in the gullet. If the diagnosis is still in doubt a piece may be removed for microscopical examination through the tube. Primary sarcoma of the esophagus is rare, but as secondary to sarcoma of the lungs, the mediastinal and cervical glands, the thyroid gland, the larynx and the vertebrae, it is not infrequent. The symptoms are virtually the same as those of carcinoma. Treatment. — Radium. — Einhorn reports the result of its employment in six cases of cancer of the esophagus as follows: All felt better after treatment; five could swallow better; three of the five were able to take semisolid food and occasionally solid food, while pain was lessened in all five; in three the stricture did not become passable for bougies of 43 to 52 size, French measurement. Operative treatment is unsatisfactory because of the lateness of the diagnosis usually arrived at. If taken early before involvement of the neighboring structures, particularly of the pneumogastric nerve, a method of resection advocated by Jainu may prove efficient. Success- ful operative cases have been reported by Torek, of New York, and Zaaiger, of Linden, Holland. Gastrostomy with alimentation through the artificial opening will usually be necessary to alleviate the pain of swallowing or obviate death from starvation. INDEX. A Abraham's antrum drill, 148 needle, 145 Abscess following submucous resection, 210 of larynx, endolaryngeal operation for, 531 of lingual tonsils, 367 of nasal septum, 215 peritonsillar, 303 postpharyngeal, 313. iSee Retrophar3m- geal abscess, retropharyngeal, 313 of septum, external nasal deformity and, 64 of tongue, 427 Acromegaly, nose in, 606 Actinomycosis of mouth, 419 of pharynx, 419 Adams' nasal forceps, 64 Adenectomy, after-treatment, 363 anesthesia. See Anesthesia in tonsil and adenoid operations, hemorrhage in, control of, 363 instruments, adenoid curettes, 361 Beokmann's, 361, 362 Chappell's, 362 Gottstein's, 361, 362 Thompson's, 361, 362 Brandigee and Knight forceps, 360 Gradle adenotome, 361 La Force adenotome, 361 methods of, 360 Adenocarcinoma of larynx, 512 of nose, 260 Adenoid curettes, 361 BecKman's, 361, 362 Chappell's, 362 Gottstein's, 361, 362 Thompson's, 361, 362 forceps, 360 Brandigee, 360 Knight's, 360 layer of nasal mucosa, 92 and tonsil operations, sequelae of, 364 Adenoma of larynx, 475 of nose, 243 of oropharynx, 432 of tongue, 429 Adenomata of trachea, 529 Adenotome, Gradle, 361 La Force, 361 Myles' lingual, 369 Adhesions in larynx, 648 of soft palate, 648 in syphilis of pharynx, 554 Adolescence, epistaxis in, 216 Ala cinerea or respiratory centre, 612 Alcohol in larjmgitis, 462 - in pachydermia laryngis, 472 Alexander's tongue depressor, 24 Altitudes, high, epistaxis in, 217 Alveolar operation on maxillary sinus, 158 sarcoma of oropharynx, 435 Amyloid degeneration of laryngeal mucosa, 492 tumors of larynx, 496 Anaphylaxis, diphtheria and, 402 Anatomy of bulla ethmoidalis, 78 of external nose, 62 of frontal sinus, 135 of frontonasal duct, 136 of hiatus semilunaris, 78 of inferior turbinated body, 77 of infundibulum, 78 of internal nose, 77 of larynx, 448 of middle turbinated body, 77 minute, of nasal mucosa, 86 adenoid layer of, 92 bloodvessels and contractile elements, 82 bone structure of, 93 Bowman's glands, 90, 91 connective tissue, 92 contractile elements in stroma, 85 influence of adolescence on, 85 elastic elements of, 85 epithelium, 87 basal membrane of, 88 columnar, 88, 89 ciliated, 88, 89 . olfactory, 89 distribution of, 89 squamous, 88, 89 erectile tissue, 82 distribution of , 83 glands, 90, 91 racemose, 90, 91 tubular, 90, 91 leukocytes in, 92 lymphatics, 93 of nasal septum, 79 sinuses, 133 656 INDEX Anatomy ot nasofrontal duct, 79 of processus uncinatus, 78 of spheno-ethmoidal recess, 79 of sphenoid sinus, 137 of superior turbinated body, 78 Anemia, larynx in, 606 pharynx in, 606 Anesthesia, 50 cocain, laws governing use of, 50 general, 50, 341 in bronchoscopy, 50 Jackson on, 51 Briining on, 51 chloroform in, 343, 532 in esophagoscopy, 50 ethyl chlorid in, 341 gas and ether in, 342 oxygen in, 342 in gastroscopy, 50 in laryngoscopy, 50 nitrous oxid gas, ether and essence of orange, 341 somnoform, 341 of larynx, 617 local, 50, 341 in bronchoscopy. White's technique for, 51 of mucous membrane of nose, 234 of pharynx, 447 in tonsil and adenoid operations, 341 in tonsillectomy, 341 for tracheotomy, 532 ^^esthetics, other than cocain and general, 50 Angeioma of larynx, 493 of nose, 246 of tongue, 429 Angina, Lugwig's, in acute pharyngitis, 306 Vincent's, 379 Anosmia, 232 essential, 232 prognosis of, 232 respiratory, 232 S3Tnptoms of, 232 treatment of, 233 Anterior rhinoscopy, 30 of growths, 31 of inferior turbinated body, 30 of middle turbinated body, 30 of nasal septum, 30 Anthrax, 426 Antipyrin eruption, 412 Antitoxin in diphtheria, 394 Antrum of Highmore, 33. See Maxillary sinus. Aphonia, hysterical, 623 AphthEE, Bednar's, 377 Aphthosa stomatitis, 377 Appendix of larynx, 460 Applicators, 29 Goldstein's chromic acid, 114 laryngeal, 29 Schadle's chromic acid, 113 Arteriosclerosis, nose in, 607 Artery of septum, 81 Arytenoid cartilages, 449 Arytenoideus muscle, 451 Asch operation for deviated septa, 199 septum scissor's, straight and angular, 199 Asthma, 236. See Hay fever. Atlas, tubercle of, prominence of, 639 Atrophic laryngitis, 467 pharyngitis, 316, 318 etiology of, 318 treatment of, 325 rhinitis, 219 deviation of septum and, 219 ulcers in perforation of nasal septum, 211 Aural conditions resulting from nasal and postnasal obstruction, 365 Autoclassis of pharyngeal tonsil, 326 of tonsil, 432 B Bacillus of diphtheria, 383 of Frisch, 589 of leprosy, 602 mallei, 425 Bacteria of tonsil, 288 Bacterial infection in upper air passages and taking cold, relation of, 292 Baeteriemia in acute pharyngitis, 302 in peritonsillitis, 302 Bacteriological diphtheria, 382 Bacteriology of influenza, 403 of Vincent's angina, 379 Ballenger-Canfield operation on maxil- lary sinus, 161 Ballenger's ethmoturbinate knives, 186 septal chisel; 195 swivel knife, 151 Bands in larynx, 648 Basal-cell carcinoma of Krompecher of oropharynx, 436 epithelioma of larynx, 509 Base of skull, lesion at, in laryngeal paralysis, 631 Basement membrane in larynx, 456 Beck's plastic frontal sinus operation, 174 syringe for paraffin injections, 67 tonsillotome, 353 Beckman's adenoid curettes, 361, 362 Bednar's aphthae, 377 Benign neoplasms, nasal, 243 tumors of esophagus, 653 of larynx, 470 of pharynx, 429 Berens' operation for correction of exter- nal nasal deformity, 65 Bier's suction pump in acute empyema of frontal sinus, 150 of maxillary sinus, 144 Bifid uvula, 640 Bilateral posticus paralysis, 633 Birkett's frontal sinus illuminator, 32 INDEX 657 Birmingham douches, 55 Bite block for direct laryngoscopy, 38 Black tongue, 418 Blake's snare, 185 Blastomycosis, 423 Bleeding in malignant tumors of nose, 262, 264 septal polyp, 246 Blennorrhea, Stoerk's, 589 Blood, diseases of, epistaxis in, 216 supply of larynx, 451 of nose, 80 Bloodvessels and contractile elements of nasal mucosa, 82 intralaryngeal, 459 Bone cysts of middle turbinate, 130 destruction in gumma of nose, 550 in syphilis of nose, 550 in tonsils, 372 Bosworth's fenestrated nasal specula, 25 septal saw, 195 tongue depressor, 24 Bowman's glands in nasal mucosa, 90, 91 Boyce's position for 'bronchoscopy, 40 for direct laryngoscopy, 36 Bracket, movable arm, for illumination, 18 Branchial clefts, embryology of, 272 cysts, 433 of oropharynx, 433 Brandigee adenoid forceps, 360 Brewer's operation for total laryngec- tomy, 538 Bridge, falling, deviations of nasal sep- tum and, 211 of nose, falling in of, following sub- mucous resection, 211 splint, Carter's, 72 Bronchi, foreign bodies in, 635 Broncho-electroscope, Briining's, 43, 44 Bronchopneumonia in diphtheria, 388 Bronchoscopes, Bruning's, 46 Ingals', 46 light carrier, 46 Jackson's, 46 Killian, 46 von Schrotter, 46 Bronchoscopy, 40 anesthesia in, general, 50 local. White's technique for, 51 Boyce's position in, 40 Mosher's position in, 40 recumbent position in, 40 sitting position in, 40 special instruments for, 48 Bruning's forceps, 49 coin and button tube, 48 Jackson's forceps, 48 Mosher's forceps for intubation, 49 safety-pin catcher, 48 - closer, 48 von Schrotter forceps, 49 Bruning's autoscopic laryngoscopic spatula, 46 broncho^electroscope, 43, 44 42 Bruning's bronchoscope, 46 chair for direct laryngoscopy, 35, 36 esophagoscope, 47 forceps for bronchoscopy, 49 and Killian' s sweatbox in treatment of acute rhinitis, 105 laryngoscopic spatula, 44 Buccal cavity, inflammation of, 377 mycoses of. See Mycoses of mouth and pharynx, 419 drug eruptions, 411 lesions in dermatoses, 406 Bulbar lesion in laryngeal paralysis, 631 Bulla ethmoidalis, anatomy of, 78, 136 Burns of nose, plastic operations for, 74 Burr, Ingal's hoUow, for frontal sinus, 166 Burrowing of pus in acute pharyngitis, 312 in peritonsillitis, 312 Cabinet, office, 17 Cachexia and loss of weight in malignant disease of larynx, 515 Cadaveric position of glottis, 460, 617 Caldwell-Luc operation on maxillary sinUs, 158 Calomel fumigations in syphilis, 557 Canine fossa operation on maxillary sinus, 158 Carcinoma of esophagus, 653 of larynx, 505 of nose, 260 of oropharynx, 436, 438 of trachea, 528 Cardiac involvement, follicular tonsillitis and, 311 in peritonsillitis, 311 Cardiospasm of esophagus, 652 Carotid arteries, external, ligation of, for mali^ant tumors of nose, 268 Carter's bone transplanting operation for external nasal deformity, 72 bridge splint, 72 in correction of external nasal deformity, 65 operation for depressed deformity of external nose, 70 operation for total destruction of nose, 74 ridge forceps, 209 Cartilages of arytenoids, 448 cricoid, 448 epiglottis, 448 knives, Freer's angular, 202 of larynx, destruction of, from syphilis, 554 dislocation of, 637 of nose, 63 of Santorini, 448 thyroid, 448 in tonsils, 372 Wrisberg, 48 Caseous rhinitis, 228 658 INDEX Casselberry's operation for removal of uvula, 376 Catarrhal sinusitis, acute, of ethmoidal cells, 141 of frontal sinus, symptoms of, 141 of maxillary sinus, symptoms of, 141 symptoms of, 141 chronic, of frontal sinus, 143 of maxillary sinus, 141 stomatitis, 377 Cautery and suction pump, combined, electric, 21 in treatment of laryngeal cancer, 524 Cerebral cortex, area for larynx, 609 Cerebrospinal rhinorrhea, 241 Cervical tumors, larynx in, 607 Chair, French's, for removing tonsils and adenoids, 344 office, for patient, 19 Chancre of mucous membrane, 545 Chancroid, 548 ChappeU's adenoid curettes, 362 portable operating table, 358 submucous laryngeal syringe, 584 Chicken-pox, mouth in, 606 pharynx in, 606 Chisel, Ballenger's septal, 195 Hajek's septal, 208 KUlian's gouge, 172 Spratt's septal, 195 Chloroform for general anesthesia, 343, 532 Cholera, nose in, 606 voice, 606 Cholesteatomatous masses in nasal fossae, 228 Chondritis in abscess of nasal septum, 215 Chondroma of larynx, 495 of nose, 249 of tonsil, 434 Chondroosteoma of larynx, 513 Chondroosteomata of trachea, 529 Chondrosarcoma of nose, 259 Chromic acid applicator, Goldstein's, 114 Schadle's, 113 Cirrhosis of liver, nose in, 607 throat in, 607 Cleft palate, 639, 640 surgery of, 640 anatomical considerations of, 640 operation in, MacKenty's obturator for, 645 hooks for, 645 technique of, 643 postoperative measures in, 645 preliminary tracheotomy in, 642 pre-operative measures in, 641 Climacteric, epistaxis at, 216 Climate in chronic hypertrophy of tonsils, 330 Coakley's transilluminator for the sinuses, 32 Cocain, use of, laws governing, 50 in throat examination, 35 Coffin's hypophyseal operation, 178 Coin and button tube in bronchoscopy, 48 Coley's toxins in malignant tumors of nose, 268 Compressed air, 21 Pynchon and Hubbard's tank, 21 Concretions in tonsil, 372 Connective-tissue changes in chronic rhi- nitis, 110 in hypertrophic rhinitis, 116 cysts of larynx, 491 of nasal mucosa, 92 tumors of nose, 257 Constitutional disturbances and atrophic rhinitis, 223' Cords, false, of larynx, 460 Corona radiata and internal capsule, 611 Coryza, 100. See Rhinitis. Cough in atrophic laryngitis, 467 in benign epithelial lar3Tigeal neo- plasms, 476 in chronic pharyngitis, 320 in laryngeal tumors, 47 in malignant disease of larjmx, 514 nervous laryngeal, 618 Crico-arytenoid muscle, paralysis of, 633 posterior, 451 Cricoid cartilage, 448 Cricothyroid muscle, 451 paralysis of, 634 Croup kettle, 58 spasmodic, 620. See Laryngismus strid- ulus. Croupous rhinitis, acute, 108 symptoms of, 108 treatment of, 108 constitutional, 108 local, 108 Crusts in atrophic rhinitis, 224 Curettes, Beckmann's adenoid, 361, 362 ChappeU's adenoid, 362 Gottstein's, adenoid, 361, 362 Thompson's adenoid, 361, 362 Curtiss gouge for antrum, 148 Cushing's hypophyseal operation, 177 Cuspidor, dental, 21 Cutaneous manifestations in acute empy- ema of accessory nasal sinuses, 154 Cyanosis in benign epithelial laryngeal neoplasms, 476 Cylindroma of nose, 261 Cysts, bone, of middle turbinate, 130 braJichial, of oropharynx, 433 dermoid, ranula and, 429 of larynx, 491 endolaryngeal operation for, 531 of nasopharynx, 440 of nose, 250 Davidson spray, 57 Deformities, external nasal, 63 of soft palate, 648 of uvula, 374 Degeneration, amyloid, of laryngeal mu- cosa, 492 INDEX 659 Degeneration, polypoid, of nasal mucosa, 125 Denker operation on maxillary sinus, 161, 162 Dental cuspidor, 21 Dermatoses, 382. See Pharyngitis with systemic symptoms, buccal lesions in, 406 mouth lesions in, 406 Dermoid cysts, ranula and, 429 Deviations of nasal septum, 191, 192 De Vilbiss spray, 57 Diet in tuberculous laryngitis, 581 Digestion, disturbances of throat in, 607 Diphtheria, 382 age and, 383 anaphylaxis and, 402 bacillus of, 383 cultures of, 385 location of, 386 staining of, 383 bronchial pneumonia and, 388 diagnosis of, 392 epithelium changes in, 388 etiology of, 382 extubation in, 401 false membrane in, 388 heart involvement in, 402 histology of, 387 intubation in, 397 by direct laryngoscopy, 400 dorsal method of, 400 feeding in, 400 indications for, 397 O'Dwyer's technique for, 397 position of patient in, 397 kidney lesions in, 402 Klebs-Loffler bacillus in, 383 location of membrane in, 387 middle-ear disease in, 403 paralyses in, 391 pathology of, 387 prognosis of, 392 pulse in, 391 sequelse of, 402 serum sickness in, 402 sex and, 383 symptoms of, 389 local, 389 system.ic, 390 temperature in, 391 tracheotomy in, 402 treatment of, 393 antitoxin, 394 constitutional, 394 dietetic, 393 hygienic, 393 local, 395 prophylactic, 393 Dislocations of cartilages of larynx, 637 Disseminated sclerosis in laryngeal par- alysis, 625 , T I . /o Distal illuminating tube, Jackson s, 4d Diverticula of esophagus, 652 Dobell's solution, 56 Doctor's office stool, 20, 21 Douches, 54 Birmingham, 55 dangers of use of, 55 Douglass', 54 postnasal, 54, 55, Douglass douches, 54 Drug eruptions on mucous membrane of mouth, 411 Drugs, poisoning from, epistaxis in, 217 Ductus nasofrontalis, 79 Dundas-Grant laryngeal forceps, 478 Dyspnea in benign epithelial laryngeal neoplasms, 476 in gumma of larynx, 553 in malignant disease of larynx, 514 in syphiUs of larynx, 553 El Ears in acute empyema of accessory nasal sinuses, 154 Ecchondromata of trachea, 529 Eczema of mouth, 418 of mucous membranes of mouth, 418 Edema, follicular tonsilUtis and, 312 of larjmx in acute pharyngitis, 312 in peritonsilUtis, 312 Edematous polypi of nose, 125 of larynx, 491 Einhorn's esophagoscope, 47 Electric cautery and suction pump, 21 Elevator, Kurd's submucous, 204 Elongation of uvula, 373 Embryology of branchial clefts, 272 of epiglottis, 275 of ethmoid cells, 61 of frontal sinus, 60 of maxillary sinus, 60 of mouth cavity, 275 of nose, 60 of olfactory pit, 275 of pharynx, 272 of septum, 60 of sphenoid sinus, 61 of thyroid, 275 of tongue, 275 of tonsils, 273 of turbinated bodies, 61 Emigration of leukocytes, 280 Empyema of ethmoid cells, 151 of frontal sinus, 149 of maxillary sinus, 143 of sphenoid sinus, 153 chronic, of accessory nasal sinuses, 154 of ethmoid cells, 178, 184 of frontal sinus, 163 of maxillary sinus, 155 of sphenoid sinus, 175 Endolaryngeal operation for abscess of larynx, 531 for cysts of larynx, 531 for extravasation of blood in larynx, 531 660 INDEX Endolaryngeal operation for extravasation of serum in larynx, 531 for removal of benign growths of larynx, 529 of specimens for microscopical examination, 529 treatment of larjmgeal cancer, 524 Endothelioma of larynx, 512 of nose, 259 Enucleation of tonsil, finger, 354 scalpel, 354 Sluder's technique for, 348 snare, 348 Epidermidosis bullosa hereditaria, 409 Epiglottis, cartilage of, 448 embryology of, 275 Epilepsy, laryngeal, 619 Epistaxis, 216 in acute infectious diseases, 216 in adolescence, 216 at climacteric, 216 in diseases of blood, 216 of kidney, 216 of liver, 216 etiology of, 216 examination in, 217 in fracture of base of skull, 217 in high altitudes, 217 in internal organic disease, 216 in malignant tumors, 217 in poisoning from drugs, 217 in traumatism, 217 treatment of, 217 in typhoid fever, 606 in vascular disease, 216 Epithelial changes in chronic rhinitis, 109 tumors of larynx, benign, 470 Epithelioma of larynx, 507 of nasopharynx, 446 of nose, 260, 261 of tongue, 429 of tonsil, 438 Epithelium, action of cilia, 99 changes in, in diphtheria, 388 of larj'nx, 453 of nasal mucosa, basal membrane, 88 columnar, 88, 89 ciliated, 88, 89 olfactory, 89 distribution of, 89 squamous, 88, 89 of pharynx, 280 Epulis of oropharynx, 433 Erectile tissue of nasal mucosa, 82 distribution of, 83 Erysipelas of pharynx, 305 in acute pharyngitis, 305 Erythema migrans, 418 treatment of, 418 of mouth, 414 of mucous membranes, 414 Esophagoscopes, Briining's, 47 Einhorn's, 47 Jackson's, 47 Kirstein's, 47 Esophagoscopes, Mosher's, 47 Esophagoscopy, 41 contra-indioations to, 42 general anesthesia in, 50 Jackson's procedure in, 41 position of patient in, 41 Esophagus, cancer of, 653 gastrotomy in, 654 location of, 653 radium in, 654 symptoms of, 653 treatment of, 654 diameter of, at four constrictions, 47 diseases of, 652 diverticula of, 652 length of, at different ages, 47 strictures of, 653 tumors of, malignant, 653 non-malignant, 653 Essential anosmia, 232 Ethmoid cells, catarrhal sinusitis of, acute, 141 symptoms of, 141 embryology of, 61 empyema of, acute, 151 examination in, 152 symptoms of, 151 treatment of, 152 operative, 152 therapeutic, 152 chronic, 178 Ballenger's operation for, 186 intranasal operations for, 186 Mosher's operation for, 187 suppuration in, closed, 178 open, 179 symptoms of, 178 treatment of, 184 posterior, sphenoid sinus and, rela- tion of, to optic nerve, 180 sinus, anatomy of, 138 Ethyl chlorid for general anesthesia, 341 Examination of patient, position for, 30 External carotid arteries, ligation of, for malignant tumors of nose, 268 nasal deformities, 63 nose, anatomy of, 62 cartilages, 63 Extravasations of blood in larynx, endo- laryngeal operation for, 531 of serum in larynx, endolaryngeal operation for, 531 Extubation, 401 Exudative stage of acute rhinitis, 103 Eyes in acute empyema of accessory nasal sinuses, 154 disturbance of, in malignant tumors of nose, 264 Facial contour in chronic hypertrophy of tonsils and adenoids, 333 False cords of larynx, 460 membrane in diphtheria, 388 INDEX 661 Farlow's tonsil snare, 347, 348 Faucial tonsil, 277, 278. See Tonsils (faucial, pharyngeal and lingual). Fibrinoplastic rhinitis, acute, 108 symptoms of, 108 treatment of, constitutional, 108 local, 108 Fibro-angeioma of larynx, 493 Fibrochondroma of oropharynx, 434 Pibrolipoma of oropharynx, 434 Fibrolymphadenoma of oropharynx, 434 Fibroma of larynx, 492 of nasopharynx, 439 of nose, 247 of oropharynx, 432 papillare of larynx, 472 of tongue, 429 Fibromata of trachea, 528 Fibromyxoma of larynx, 492 of oropharynx, 434 Finger enucleation of tonsil, 354 Flies in nasal passages, 230 Floor of fourth ventricle and medulla, 612 Folhcular tonsillitis in acute pharyngitis, 302 Forceps, Adams' nasal, 64 Brandigee adenoid, 360 for bronchoscopy, Briining's, 49 Jackson's, 48 von Schrotter, 49 Carter's ridge, 209 Dundas-Grant laryngeal, 478 Foster-Ballenger septum, 207 Griinwald's, 159 Kurd's ridge, 208 for intubation, Mosher's, 49 Knight's adenoid, 360 Krause's laryngeal, 477, 478 Luc's, 187 Mackenzie's laryngeal, 477 Foreign bodies in bronchi, 635 causes of failure to locate by means of s-ray, 34 in larynx, 635 location of, by i-rays, 33 Foster-Ballenger's septum forceps, 207 Foster's nasal speculum, 26 Fracture of base of skull, epistaxis in, 217 of larynx, 637 Frankel's tongue depressor, 24 Freer's angular cartilage knives, 202 incision for submucous resection, 201 French's chair for removing tonsils and adenoids, 344 Frisch, bacillus of, 589 Frontal sinus, anatomy of, 135 catarrhal sinusitis of, acute, symptoms of, 141 chronic, 143 diagnosis of, 143 prognosis of, 143 symptoms of, 143 treatment of, 143 . embryology of, 60 empyema of, acute, 149 Frontal sinus, empyema of, acute, diag- nosis of, 150 symptoms of, 149 transillumination in, 150 treatment of, 150 surgical, 151 chronic, 163 Beck's plastic operation in, 174 external operations in, 167 Good's operation in, 164 Ingals' operation in, 165 intranasal operations in, 163, 164 Ja,nsen's operation in, 168 Killian's operation in, 170 Kuhnt's operation in, 169 Ogston-Luc operation in, 168 symptoms of, 163 treatment of, 163 Watson Williams' osteoplastic operation in, 169 frontonasal duct, 136 rasp. Good's, 165 transillumination of, 33 x-ray plates of, 33 Frontonasal duct, anatomy of, 136 Fulguration, 22 in laryngeal tumors, 481 in larynx, position and technique for, 23 short circuiting in, 23 Fumigation, calomel, in syphilis, 557 Gag with tongue depressor, Whitehead, 643 Galvanocautery in chronic hypertrophy of tonsils, 330 Gangrenous stomatitis, 377 Gargles in acute pharyngitis, 308 Gas and ether for general anesthesia, 342 and oxygen for general anesthesia, 342 Gastrostomy in cancer of esophagus, 654 Gastroscope, an elongated esophagoscope, 47 Jackson's, 47 Miculicz's, 47 Gastroscopy, 42 appearance and movabihty of stomach in, 42 general anesthesia in, 60 illumination in, 43 Jackson's distal illuminating tube, 43 Kirstein's head lamp, 43 indications for, 42 instruments for, 43 technique of, 42 Geographical tongue, 418 treatment of, 418 Giant-cell sarcoma of larynx, 513 of nose, 269 Gland changes in hypertrophic rhinitis, 117 Glanders, 424 bacillus mallei in, 426 662 INDEX Glanders, etiology of, 425 pathology of, 425 treatment of, 425 Glands of nasal mucosa, 90, 91 Bowman's, 90, 91 racemose, 90, 91 tubular, 90, 91 racemose, of pharynx, 281 Glandular cysts of larynx, 491 Gleason operation for deviated septa, 197, 198 Glioma of nose, 261 Glottis, cadaveric position of, 617 closers of, paralysis of, 633 symptoms of, 634 treatment of, 634 muscles of, closer, 616 dUators, 616 tensors, 616 openers of, paralysis of, 632 differential diagnosis of, 633 tracheotomy in, 633 treatment of, 632 respiratory position of, 617 Glilck's operation for total laryngectomy, 538 phonation apparatus, 526 Goldsmith's operation for perforation of nasal septum, 213 Goldstein's chromic acid applicator, 114 plastic flap for preforation of nasal septum, 212 Gonococcal stomatitis, 378 Good's frontal sinus operation, 164 rasp, 165 Gottstein's adenoid curettes, 361, 362 Gout, nose in, 606 throat in, 606 Gradle adenotome, 361 Granular pharyngitis, 316 Granuloma of nose, rhinosporidium Kinealyi, 250 Griinwald's bone forceps, 159 Gumma in abscess of nasa,l septum, 215 of larynx, 552 of mouth, 550 of nose, 546 of pharynx, 550 of throat, 546 Gunshot wounds of larynx, 638 H Hajek's incision for submucous resection, 202 septal chisel, 208 Hare-lip, 639 Owen's operation for, 646 surgery of, 646 Hartman's bivalve nasal speculum, 25, 26 Hay fever, 236 age and, 238 etiology of, 236 nasal polypi and, 126 occupation and, 238 Hay fever, occurrence of, 238 polypi and, relation of, 237 prognosis of, 239 race and, 239 region and, 238 season and, 238 sinusitis and, relation of, 237 symptoms of, 239 treatment of, 240 Hays' electric pharyngoscope, 27 uvulotome, 376 Hazeltine's plastic flap for perforation of nasal septum, 214 Head in acute empyema of accessory- nasal sinuses, 154 lamp, Kirsteiii's, 43 mirrors, 26 electric, Phillip's, 27 Heart, involvement -.of, in diphtheria, 402 Hemangioma of oropharynx, 434 Hematoma, deviations of nasal septum and, 210 of nasal septum, 214 Hemilaryngectomy, 537 in treatment of laryngeal cancer, 524 Hemophilia, nose in, 606 Hemorrhage in acute pharyngitis, 312 after operation, 354 control of, during and after tonsil operations, 354 in malignant disease of larynx, 514 nasal, in typhoid fever, 606 in peritonsillitis, 312 prophylaxis of, 354 submucous, of mouth, 414 in pharynx, 414 at time of operation, 354 tonsillar hemostats in, 356 Butts', 356 Hurd's, 357 Mickuliez-Stoerck's, 356 in tumors of nose, treatrflent of, 269 Hemorrhagic laryngitis, 464 Heredity in hypertrophy of tonsils, 328 Herpes iris et circinatus, 406 of mouth, 406 tonsurans, 424 Hiatus semilunaris, anatomy of, 78, 136 High frequency, apparatus, 22 Oudin resonator, 22 fulguration, 22 tracheotomy, 533 Hoarseness in acute pharyngitis, 302 in benign epithelial laryngeal neoplasms, 476 in laryngeal fumors, 476 in malignant disea,se of larynx, 514 Holmes' electric nasopharyngoscope, 28 Hook, Yankauer's submucous, for septal operations, 204 Hurd's ridge forceps, 208 submucous elevator, 204 nasal speculum, 206 tonsil separator, 346 Hyaloid fibrous layer in larynx, 466 INDEX 663 Hydroa, 406 Hydrops antri, 190 treatment of, 190 Hyperesthesia of larynx, 618 of pharynx, 447 Hyperkeratosis of mouth, 416 Hypernephroma of larynx, 513 Hyperosmia, 233 Hypertrophy of tonsils, chronic, 326 Hypophyseal tumors, 177 Coffin's operation in, 178 Cushing's operation in, 177 symptoms of, 177 treatment of, 177 operative, 177 Hysterical aphonia, 623 Ichthyosis of mouth, 416 Ictus laryngea, 619 laryngis, 606 Idiopathic laryngeal paralysis, 626 Illumination, source of, 17 Incised wounds of larynx, 638 prognosis, 638 tracheotomy in, 638 treatment, 638 Incoordination of laryngeal muscles, 620 Infants, acute rhinitis in, 107 treatment of, constitutional, 107 local, 107 prophylactic, 107 Infectious diseases, acute, epistaxis in, 216 Inferior meatus of nose, 77 turbinated body, examination of, 30 Inflammation of buccal cavity, 377 of lingual tonsils, 367 of nasal sinuses, 138 of pharynx, 291. See Pharyngitis. of throat, acute, 291. See Pharyngitis. of uvula, 373 Influenza, 403 bacteriology of, 403 history of, 403 pathology of, 403 prognosis of, 405 symptoms of, 404 treatment of, 405 Infundibulum, anatomy of, 78 Ingals' bronchoscope, 46 flexible pilot probes, 166 frontal sinus operation, 1 65 hollow burr for frontal sinus, 166 light carrier in bronchoscopy, 46 operation, gold drainage tube for, 167 Inhalation and inhalations, 57 in acute pharyngitis, 308 croup kettle, 58 Maw's inhaler, 58 mixture, 59 Thermos bottles, 68 in tuberculous laryngitis, 582 vacuum bottle, 59 Injections, intramuscular, in syphilis 559 Injuries of larynx, 637 Insufflations, 67 in tuberculous laryngitis, 582 Intumeseent rhinitis, 115 Internal capsule and corona radiata, 611 Intralaryngeal bloodvessels, 459 muscles, action of, 616 Intramuscular injections in syphilis, 559 Intratracheal injections in tuberculous larjmgitis, 582 Intubation in diphtheria, 397 by direct laryngoscopy, 400 dorsal method, 400 extubation, 401 feeding in, 400 indications for, 397 O'Dwyer technique for, 397 position in, 397 technique of, at Willard Parker Hos- pital, 400 Inunctions in syphilis, 557 Jackson's bronchoscope, 46 bronchoscopy forceps, 48 distal illuminating laryngoscopic spatula, 45, 46 tube, 43 ^ esophagoseope, 47 gastroscope, 47 general anesthesia in bronchoscopy, 51 method for esophagoscopy, 41 Jacobson's organ, 90 Jansen's frontal sinus operation, 168 Jarvis snare, 184 K Keratosis of mouth, 416 of pharynx, 416 of tonsils, 70 Kidney, disease of, epistaxis in, 216 lesions in acute pharyngitis, 311 follicular tonsillitis and, 311 in peritonsillitis, 311 Killian's bronchoscope, 46 cannula for maxillary sinus, 145 frontal sinus operation, 170 gouge chisel, 172 incision for submucous resection, 202 laryngoscopic spatula, split tubular, 45 suspension laryngoscopy, 52 advantages of, 53 instruments for, gallows, 52 hook spatula, 52 Kirstein's lamp in, 53 lateral, introduction of spatula in, 53 technique of, 53 Kirstein's esophagoseope, 47 head lamp, 43 664 INDEX Kirstein's lamp in Killian suspension laryngoscopy, 53 Klebs-Loffler bacillus, 383 culture of, 383 distribution of, in diphtheria, 386 staining of, 383 Knight's adenoid forceps, 360 nasal forceps, 29 Knives, Ballenger's ethmoturbinate, 186 Koplik's spots, 406 Krause laryngeal forceps, 477, 478 Kuhnt's frontal sinus operation, 169 Lactic acid in treatment of tuberculous laryngitis, 582 Lacunar tonsillitis in acute pharyngitis, 302 La Force adenotome, 361 Laryngeal applicators, 29. cough, nervous, 618 epilepsy, 619 forceps, Dundas-Grant, 478 Krause, 477, 478 Mackenzie's, 477 mirrors, 28, 29 mucosa, amyloid degeneration of, 492 neoplasms, 470 benign, 470 connective tissue, 488 classification of, 488 symptoms of, 497 objective, 498 subjective, 498 treatment of, 502 cautery in, 503 evulsion in, 503 external operation in, 503 snare in,^503 topical, 502 epithelial, 472 in adults, treatment of, endo- laryngeal operations, 476 extralaryngeal operations, 479 in children, 476 treatment of, 479 internal, 479 surgical, 480 thyrotomy in, 480 collapse of trachea in, 481 complications of, 481 cough in, 476 cyanosis in, 476 disturbance of phonation in, 481 dyspnea in, 476 etiology of, 472 adenoma, 475 benign epithelioma, 472 fibroma papillare, 472 pachydermia laryngis, 472 papilloma, 472 histology of, 472 Laryngeal neoplasms, benign epithelial, hoarseness in, 476 illustrative case histories, 482 measles in, 481 partial stenosis in, 481 pneumonia in, 481 respiration in, 476 symptoms of, 476 treatment of, 476 . fulguration in, 481 postoperative care in, 481 x-rays in, 481 Moritz-Schmidt's classification of, 472 occurrence of, 470 sex and, 470 transformation of, to malignant, 504 malignant, 504 age and, 506 connective tissue, 512 etiology of, 506 ■ heredity and, 506 metastatic growths in, 513 occurrence of, 506 prognosis of, 519 sex and, 506 symptoms of, 514 objective, 515 subjective, 514 treatment of, 522 paUiative, 522 surgical, 523 S3anptomatic, 522 neuroses, 609-634 paralysis, 624 anatomical lesions in, 624 complete, diagnostic symptoms in, 627 laryngoscopic appearances in, 627 diagnosis of, 629 differential, 629 bulbar lesions in, 630 from fixation of crico-arytenoid joint, 629 lesions at base of skull in, 631 nerve lesions in, 631 disseminated sclerosis and, 624 etiology of, 624 idiopathic, 626 nerve lesions and, 626 parasyphilitic lesions in, 624 partial, diagnostic symptoms in, 627 laryngoscopic appearances in, 632 prognosis of, 631 symptoms of, 628 syphilitic lesions in, 624 tabes dorsalis and, 625 total bilateral, 629 unilateral, cord in cadaveric posi- tion, 627 toxic, 626 treatment of, 631 pharynx, anatomy of, 271 pouch, 460 scarrifier, Tobold's, 531 INDEX 665 Laryngeal snare, Sajous', 477 spatula and mouth gag, Mosher's, 39 syringe, Chappell's submucous, 584 tonsil, 459 vertigo, 619 Laryngectomy, hemi-, 537 partial, 537 in treatment of laryngeal cancer, 524 total, 537 Brewer's operation, 538 Gltick's operation, 538 indications for, 525 tracheotomy preliminary to, 537 in treatment of laryngeal cancer, 524 Laryngismus stridulus, 620 in adults, 622 in children, 620 diagnosis of, 621 etiology of, 620 predisposing, 620 false, 620 symptoms of, 621 true, 620 treatment of, 622 Laryngitis, 462 acute, 462 alcohol in, 462 appearance of, 463 course of, 464 etiology of, 462 histology of, 462 nasal obstruction in, 462 occupation in, 462 symptoms of, 464 treatment of, 464 atrophic, 467 alcohol in, 462 appearance of, 467 cough in, 467 etiology of, 462 histology of, 462 nasal obstruction in, 462 occupation in, 462 odor in, 467 symptoms of, 467 treatment of, 467 voice in, 467 chronic, 465 alcohol in, 462 appearance of, 465 etiology of, 462 histology of, 462 nasal obstruction in, 462 occupation in, 462 symptoms of, 466 treatment of, 466 hemorrhagic, 464 Laryngooele, 640 treatment of, 640 Laryngofissure, 534 Laryngoscopic spatula, Briinings, 44 autoscopic, 46 Jackson's distal illuminating, 45, 46 Killian's split tubular, 45 Mosher's open, 46 Laryngoscopy, anesthesia in, general, 50 direct, 35 advantages of, 40 bite block for, 38 Boyce's position in, 36 Brtining's chair for, 35, 36 dorsal position in, 36 duties of assistant in, 36 Mosher's lateral position in, 38 sitting position of patient for, 35 technique of, 35 thimble gag for, 38 indirect, 34 reflected image of larynx in, 34 Killian suspension, 52 advantages of, 53 instruments for, gallows, 52 hook spatula, 52 operation table, 52 Kirstein's lamp in, 53 lateral introduction of spatula in, 53 technique of, 53 Laryngotomy, median, 534 Laryngotracheotomy, 534 Larynx, abscess of, endolaryngeal opera- tion for, 531 adenocarcinoma of, 512 adenoma of, 475 adhesions in, 648 amyloid tumors of, 496 symptoms of, 502 anatomy of, 448 anemia, 606 anesthesia of, 617 angeioma of, 493 anterior cervical region of, malforma- tions of, 640 appendix of, 460 atrophic rhinitis, 225 bands in, 648 basement membrane in, 456 blood-supply of, 451 cachexia in, 515 cancer of, coexistence of, with other diseases of larynx, 514 cough in, 514 duration of, without operation, 521 dyspnea in, 514 treatment of, 522 external, 505 extrinsic, appearance of, 517 on epiglottis, 517 prognosis of, 519 in pyriform sinuses, 517 in thyro-epiglottic folds, 517" hemorrhage in, 514 hoarseness in, 514 internal, 505 intrinsic, prognosis of, 519 laryngectomy in, hemi-, 524 partial, 524 total, 524 indications for, 525 loss of weight in, 615 666 INDEX Larj'nx, cancer of, odor in, treatment of, ■522 pain, in, 514 treatment of, 522 pharyngotomy in, 524 subhyoid, 524 suprahyoid, 524 phonation in, artificial aids to, 526 symptoms of, 514 late, 518 objective, 515 subjective, 514 tracheotomy in, 523 treatment of, 522 endolaryngeal, 524 non-surgioal, 522 palliative, 522 surgical, 523 arguments in favor of, 525 against, 525 dangers of, 525 symptomatic, 522 vocal cords in, movements of, 515 cartilages of, 448 dislocations of, 637 in cervical tumors, 607 chondroma of, 495 symptoms of, 502 chondroosteoma of, 513 cysts of, 491 connective tissue, 491 endolaryngeal operation for, 531 glandular, 491 edema of, in acute pharyngitis, 312 follicular tonsillitis and, 312 in peritonsillitis, 312 endothelioma of, 512 epithelioma of, 507 basal-celled, 509 differential microscopical diagnosis of, 511 extracellular relations of, 508 ' intracellular changes in, 508 pathology of, 507 epithelium of, 453 external tumor of, paralysis of, 634 extravasation of blood in, endolaryngeal operation for, 531 of serum in, endolaryngeal operation for, 531 fibro-angeioma of, 493 symptoms of, 499 fibroid neoplasms in, 488 fibroma of, 492 papillare in, 472 symptoms of, 499 fibromyxoma of, 492 symptoms of, 499 foreign bodies in, 635 fractures of, 637 giant-celled sarcoma of, 513 gumma of, 552 dangers of, 553 dyspnea in, 553 location of, 553 Larynx, gumma of, phonation in, 553 hyaloid fibrous layer in, 456 hyperesthesia of, 618 hypernephroma of, 513 inflammation of, 462 injuries of, 637 in leukemia, 606 ligaments of, 449 lipoma of, 493 symptoms of, 501 lymphangeioma of, 492 symptoms of, 498 lymphatics of, 458 lymphoma of, 493 symptoms of, 502 membranes of, 449 metastatic growths of, 513 motility of, disturbance of, 618 mucous membrane of, minute anatomy of, 453 muscles of, 449 contractures of, 620 incoordination of, 620 paralysis of individual, 632 spasms of, 620 myxochondroosteoma of, 495 myxochondroosteosarcoma of, 513 myxoma of, 492 symptoms of, 499 myxosarcoma of, 513 neoplasms of, 470. See Laryngeal neoplasms, nerve endings in, 459 supply of, central, 609 peripheral, 609 neuralgias of, 618 operations on, 529 endolaryngeal, 529 laryngectomy, hemi-, 537 partial, 537 total, 537' laryngofissure, 534 laryngotomy, median, 534 laryngotracheotomy, 534 pharyngotomy, 536 thyrotomy, 534 tracheotomy, 532 ossification of, 459 papillae of, 456 papilloma of, 472 pathology of, 472 type of cell in, 474 paresthesia of, 618 in pneumonia, 607 polypi of, edematous, 491 symptoms of, 498 in pseudoleukemia, 606 racemose glands in, 457 in rachitis, 606 reflexes of, 616 sarcoma of, 513 sensation in, disturbances of, 617 sensibilities of, 616 singer's nodules in, 489 symptoms of, 489 INDEX 667 Larynx, singer's nodules in, symptoms of, objective, 490 subjective, 489 treatment of, 490 prophylactic, 490 surgical, 490 spasm of, 618 stenosis of, 647 surgical considerations of, 448 syphilis of, 545 aphonia in, treatment of, 558 cicatrization in, 554 dangers of, 553 destruction of cartilages in, 554 dyspnea in, 553 treatment of, 558 hoarseness in, treatment of, 558 initial lesion in, 548 location of, 554 pain in, treatment of, 557 phonation in, 553 secondary lesion in, 549 sequelae of, 554 symptoms of, 548 tertiary lesion in, 550 treatment of, 556 ulcers in, treatment of, 558 in thymus affections, 607 in th^oid affections, 607 thyroid tumors of, 497 symptoms of, 502 tuberculosis of, 562 appearance of, 575 argyrol in, 582 etiology of, 562 f ormalm in, 582 guaiacol in, 582 ichthyol in, 582 inhalations in, 582 insufflations in, 582 intratracheal injections in, 582 lactic acid in, 582 pain in, treatment of, 582 prognosis of, 577 pulmonary tuberculosis and sprays in, 582 submucous injections in, 582 symptoms of, 573 treatment of, 578 constitutional, 581 diet in, 581 local, 579, 582 medicinal, 581 surgical, 583 tumors of, 470. See Laryngeal neo- plasms, ventricles of, 460 prolapse of, 497 symptoms of, 502 webs of, 648 wounds of, 637 gunshot, 638 incised, 637 prognosis of, 638 tracheotomy in, 638 Larynx, wounds of, incised, treatment of, 638 Latent tuberculosis of nose, 562 Leland tonsil knives, 345 Lepra bacillus, 602 Leprosy, nose in, 602 Leptothrix buccalis, 424 Leukemia, larynx in, 606 Leukocytes, enumeration of, 280 in nasal mucosa, 92 Leukoplakia of mouth, 416 Lichen ruber planus of mouth, 414 Ligaments of larynx, 449 extrinsic, 449 intrinsic, 449 Ligation of external carotid arteries for malignant tumors of nose, 268 Light in treatment of tuberculous laryn- gitis, 583 Lingual adenotome, Myles', 369 tonsil, 277, 280. See Toilfeils (faucial, pharyngeal, and lingual). Lipoma of larynx, 493 of tongue, 429 of trachea, 528 Lipoproteid in acute pharyngitis, influence of, 296 Lips, psoriasis of, 416 syphilis of, 545 Liver, cirrhosis of, nose in, 607 throat in, 607 disease of, epistaxis in, 216 Low tracheotomy, 533 Ludwig's angina, 306 in acute pharyngitis, 306 treatment of, 312 Lupus erythematodes of mouth, 415 of nose, external nasal deformity and, 64 plastic operations for, 74 pernio, 571 symptoms of, 574 vulgaris, 569 Lymph nodes of pharynx, histology of, 283 Lymphangioma of larynx, 492 of nose, 249 Lymphangeiomata of oropharynx, 434 Lymphatics of larynx, 458 of nasal mucosa, 93 of nose, 82 of pharynx, 288 Lymphoid tissue of pharynx, 282 Lymiphomata of trachea, 528 Lymphosarcoma of nose, 257 differentiation of, 258 of oropharynx, 435 M McKebnon's hoUow rubber nasal spUnt, 63 MacKenty's operation in adhesions and deformities of soft palate, 650 for collapsed ate, 75 668 INDEX MacKenty's wire obturator for cleft palate operation, 645 Mackenzie's laryngeal forceps, 477 tonsillotome, 347 • Macroglossia, 428 . treatment of, 428 Maggots in nasal passages, 230 Malformations of nasopharynx, 639 of nose, 638 of oropharynx, 639 Malnutrition in atrophic rhinitis, 219 Mathieu's tonsillotome, 346, 347 Maw's inhaler, 58 Maxillary antrum, 33. See Maxillary sinus, sinus, anatomy of, 133 catarrhal sinusitis of, acute, symptoms of, 141 chronic, 142 diagnosis of, 143 prognosis of, 143 syifiptoms of, 142 treatment of, 143 embryology of, 60 empyema of, acute, 143 Bier's suction pump in, 144 diagnosis of, 144 symptoms of, 143 transillumination in, 146 treatment of, 146 chronic, 155 alveolar operation in, 158 of Ballenger-Canfield operation on, 161 canine fossa operation in, 158 advantages of, 160 after-treatment of, 160 Caldwell-Luc operation in, 158 Denker's operation in, 161, 162 diagnosis of, 155 intranasal operations in, 157 after-treatment of, 158 symptoms of, 155 transillumination in, 155 treatment of, 157 x-rays in, 156 transillumination of, 33 x-ray plates of, 33 Measles in benign epithelial laryngeal neoplasms, 481 nose in, 608 throat in, 608 Meatus of nose, inferior, 77 middle, 78 superior, 79 Median laryngotomy, 534 position of vocal cords, 460 Medulla and floor of fourth ventricle, 612 Melanoglossia, 418 Membrane, false, in throat, differential diagnosis of lesions showing, 426 Membranes of larynx, 449 Membranous rhinitis, 102 acute, 108 symptoms of, 108 Membranous rhinitis, acute, treatment of, constitutional, 108 local, 108 relationship of, to diphtheria, 102 tonsiUitis, 298, 303 acute pharyngitis and, 298, 303 treatment of, 311 Mercury eruption, 412 histology of, 412 pathology, 412 treatment of, 413 Metastatic growths of larynx, 513 Metzenbaum's septal speculum, 206 Mial's septal saw, 195 Michel-Frankel rhinoscopio mirror, 28, 29 Michel's metal suture, 553 extractor, 355 Mioulicz's gastroscope, 47 Middle-ear disease in diphtheria, 403 meatus of nose, 78 turbinated body, examination of, 30 Mirrors, head, 26 laryngeal, 28, 29 Michel-Frankel rhinoscopic, 28, 29 nasopharyngeal, 28, 29 Mon'ochloraoetio acid injections in fibroma of nasophai-ynx, 443 • syringe. Smith's postnasal, 433 Mosher's esophagoscope, 47 forceps for intubation, 49 laryngeal spatula and mouth gag, 39 lateral position for direct laryngoscopy, 38 open laryngoscopic spatula, 46 position for bronchoscopy, 40 safety-pin catcher, 48 closer, 48 technique for intubation, 400 Motility of larynx, disturbance of, 618 Motor filaments of vagus, 612 Moure's operation in malignant tumors of nose, 267 Mouth, actinomycosis of, 419 etiology of, 419 histology of, 420 treatment of, 423 cavity. See Buccal cavity. embryology of, 275 in chicken-pox, 606 eczema of, 418 erythema of, 414 gag, Murdoch's, 359 gumma of, 550 herpes of, 406 etiology of, 406 histology of, 407 pathology of, 407 prognosis of, 408 symptoms of, 407 treatment of, 408 zoster of, 407 hyperkeratosis of, 416 ichthyosis of, 416 impetigo herpetiformis of, 408 keratoses of, 416 INDEX 669 Mouth, keratoses of, treatment of, 417 palliative, 417 surgical, 417 leucoplakia of, 416 lichen ruber planus of, 414 lupus erythematodes of, 415 distribution of, 415 histology of, 415 mucous membrane of, drug eruptions in, 411 antipyrin, 412 mercury, 412 histology of, 412 pathology of, 412 treatment of, 413 mycoses of, 419 pemphigus of, 408 etiology of, 408 foliaceus, 409 histology of, 410 occurrence of, 408 prognosis of, 411 symptoms of, 410 treatment of, 411 vulgaris of, 409 pharynx and, mycoses of, 419 psoriasis of, 416 scleroderma of, 416 in smallpox, 606 submucous hemorrhages of, 414 syphihs of, 545 initial lesion in, 548 secondary lesion in, 549 symptoms of, 548 tertiary lesion in, 550 tuberculosis of, appearance of, 575 ulcers of, 418 appearance of, 418 etiology of, 418 treatment of, 418 urticaria of, 413 histology of, 413 in vaccinia, 606 Mucocele, 189 occurrence of, 189 symptoms, 190 Mucopurulent stage of acute rhinitis, 104 Mucous membranes, chancre of, 545 in chronic rhinitis. 111 erythema of, 414 infection of, with tuberculosis, 565 of mouth, drug eruptions on, 411 eczema of, 418 of nose, anesthesia of, 234 minute anatomy of, bloodvessels and contractile elements, 82 of pharynx, minute anatomy of, 277 patch, 545 Mulberry hypertrophic rhinitis, 117 Murdoch's mouth gag, 359 Muscles of larynx, 449 extrinsic, 450 intrinsic, 450 arytenoid, 451 cricothyroid, 451 Muscles of larynx, intrinsic, lateral crico- arytenoid, 451 posterior crico-arytenoid, 451 thyro-arytenoid, 451 paralysis of individual, 632 Mycosis of buccal cavity, 419 fungoides, 424 of mouth, 419 of pharynx, 419 tonsillaris, 370. See Keratosis of tonsil. Myles' back-cutting trocar, 147 lingual adenotome, 369 Myxochondroma of oropharynx, 433 Myxochondroosteoma of larynx, 495 Myxoohondroosteosarcoma of larynx, 513 Myxoma of larynx, 492 of nose, 249 Myxosarcoma of larynx, 513 N Nasal bones, 62 deformities, external, 63 abscess of septum and, 64 burns and, 64 collapsed alae, 75 Mackenty's operation for, 75 paraffin injections in, 75 correction of, 64 Beren's operation for, 65 Carter's bone transplantation, 72 bridge-sphnt in, 65, 70 old fractures in, 64 operation for, 72 paraffin injections in, 65 accidents in, 68 technique of, 67 lupus and, 64 ' paraffin injections. Beck's paraffin syringe, 67 "saddle-back" nose, 65 scalds and, 64 syphilis in, 64, 554 total destruction of, operation for, 74 Carter's, 74 plastic, 74 traumatism in, 63 destruction, internal, in syphilis, 554 forceps, Adams', 64 Knight's, 29 Pomeroy's, 29 Wilde's mouse-toothed, 28 smooth, 28 fossae, cholesteatomatous masses in, 228 granuloma, rhinosporidium kinealyi, 250 hemorrhage in typhoid fever, 606 mucosa, action of epithelial cilia on, 99 adenoid layer off, 92 appearance of, in chronic rhinitis, 111 in hypertrophic rhinitis, 120 bone structure of, 93 connective -tissue of, 92 670 INDEX Nasal mucosa, contractile elements in stroma of, 85 influence of adolescence on, 85 elastic elements of, 85 epithelium of, 87 basal membrane, 88 columnar, 88, 89 ciliated, 88, 89 olfactory, 89 squamous, 88, 89 erectile tissue of, 82 distribution of, 83 glands of, 90, 91 Bowman's, 90, 91 racemose, 90, 91 tubular, 90, 91 Jacobson's organ of, 90 leukocytes in, 92 lymphatics of, 93 minute anatomy of bloodvessels and contractile elements of, 82 olfactory epithelium of, distribution of, 89 simple inflammations of, 100 smooth muscle cells of, 86 neoplasms, benign, 243 diagnosis of, 251 pathology of, 243 symptoms of, 251 treatment of, 254 malignant, 256 bleeding in, 262, 264 duration of, 265 etiology of, 256 eye disturbance in, 264 occurrence of, 256 pain in, 263 pathology of, 256 prognosis of, 266 symptoms of, 262, 264 treatment of, 266 palliative, 268 surgical, 266 external, 266 internal, 266 obstruction in atrophic laryngitis, 462 passages, flies in, 230 foreign bodies in, 228 appearance of, 228 deposits of lime salts in, 228 diagnosis of, 228 symptoms of, 229 treatments of, 230 maggots in, 230 parasites in, 230 rhinoliths in, 228 appearance of, 228 deposit of lime salts in, 228 diagnosis of, 228 symptoms of, 229 treatment of, 230 screw-worms in, 230 and pharyngeal hygiene in tuberculous laryngitis, 581 involvement in typhoid fever, 605 Nasal polypi, accessory sinus disease and, 125 chronic sinusitis and, relation of, 184 hay fever and, 126 relation of, 237 histology of, 127 symptoms of, 129 treatment of, 130 rhinorrhea, 240 treatment of, 241 septum, abscess of, 215 chondritis in, 215 gumma in, 215 perforations from, 215 prognosis of, 215 treatment of, 215 anatomy of, 79 deviations of, 191, 192 abscess and, 210 Asch's operation for, 199 etiology of, 191 falling bridge and, 211 Gleason's operations for, 197, 198 hematoma and, 210 pathology of, 191 perforation and, 211 Roe's operation for, 199 Sluder's operation for, 197 spurs of, 79 submucous resection in, 200 anesthesia in, 200 contra-indications in, 200 dressing in, 209 elevation of mucous membrane in, 203 incision in, 201 Freer's, 201 Hajek's, 202 Killian's, 202 through cartilage and eleva- tion of opposite side, 205 Yankauer's, 202 removal of cartilage in, 205 of crest in, 208 of perpendicular plate of ethmoid in, 207 sequels in, 210 treatment of, 196 Watson's operation for, 199 examination of, 30 hematoma of, 214 mucous membrane of, 79 perforation of, 211 acute infections in, 211 atrophic ulcers in, 211 etiology of, 211 following submucous resection, 211 Goldsmith's operation in, 213 Goldstein's plastic flap in, 212 Hazeltine's plastic flap in, 214 Shmiey's operation in, 214 symfitoms of, 211 syphilis in, 211 trauma in, 211 treatment of, 211 INDEX 671 Nasal septum, perforation of, treatment of, medical, 211 surgical, 212 tuberculous ulcers and, 211 spurs of, 191, 192 after-treatment of, 196 etiology of, 191 pathology of, 191 treatment of, 194 sinuses, accessory, acute empyema of, 154 cutaneous manifestations in, 154 ears in, 154 eyes in, 154 head in, 154 symptoms of, 154 nasal, 154 inflammatory diseases of, 133 anatomy of, 133 hydrops antri, 190 inflaromation of, 138 etiology of, 139 mucocele of, 189 optic neuritis from involvement of, 179 specula, 25 Bosworth's fenestrated, 25 Foster's, 26 Hartmann's bivalve, 25, 26 Kurd's submucous, 206 Yankauer's self-retaining, 26 splints, McKernon's hollow rubber, 63 Simpson-Bemay sponge, 63 Nasofrontal duct, anatomy of, 79 Nasopharyngeal mirrors, 28, 29 Nasopharyngitis, 317 Nasopharyngoscope, Holmes' electric, 28 Nasopharynx, anatomy of, 270 in atrophic rhinitis, 224 cysts of, 440 epithelioma of, 446 fibroma of, 439 age in, 439 location in, 440 prognosis of, 442 symptoms of, 441 treatment of, 443 malformations of, 639 papilloma of, 440 sarcoma of, 445 teratoma of, 440 tumors of, 439 benign, 439 occurrence of, 439 prognosis of, 442 symptoms of, 441 treatment of, 443 electrolysis in, 444 galvanocautery in, 444 monochloraoetic acid injections, in, 443 other operative procedures in, 444 preliminary tracheotomy in, 445 malignant, 445 Nasopharynx, tumors of, malignant, treat- ment of, 446 Nebulizer, 59 Neck, phlegmons of, follicular tonsillitis and, 311 in peritonsillitis, 311 Nerve endings in larynx, 459 lesion in laryngeal paralysis, 631 supply of nose, 82 Nervous laryngeal cough, 618 Neuralgias of larynx, 618 Neuritis, optic, from involvement of nasal sinuses, 179 Neuroses, laryngeal, 609 of nose, 231 reflex, 234 Nichol's procedures in adhesions and deformities of soft palate, 649 spoke-shave for septal cartilage, 195 Nitrous oxid gas, ether and essence of orange, for general anesthesia, 341 for general anesthesia, 341 Noma, 377 Normal salt solution, 56 Nose, in acromegaly, 606 adenocarcinoma of, 260 adenoma of, 243 diagnosis of, 253 pathology of, 243 symptoms of, 253 treatment of, 254 angioma of, 246 diagnosis of, 253 pathology of, 247 symptoms of, 253 treatment of, 254 in arteriosclerosis, 607 bleeding from, 216. See Epistaxis. blood-supply of, 80 bridge of, falling of, following submucous resection, 211 burns of, plastic operation for, 74 cancer of, diagnosis of, differential, 590 illustrative cases of, 591 in cholera, 606 chondroma of, 249 chondrosarcoma of, 259 in cirrhosis of liver, 607 coUapsed alse of, 75 MacKenty's operation for, 75 paraffin injections in, 75 cylindroma of, 261 cysts of, 250 in disturbances of digestion, 607 embryology of, 60 endothelioma of, 259 epithelioma of, 260 external, anatomy of, 62 cartilages of, 63 fibroma of, 247 diagnosis of, 253 pathology of, 247 symptoms of, 253 treatment of, 254 glioma of, 261 672 INDEX Nose in gout, 606 gumma of, 550 bone destruction in, 550 odor in, 550 pain in, 550 in hemophilia, 606 internal, anatomy of, 77 leprosy of, 602 etiology of, 602 histology of, 602 lepra bacillus in, 602 pathology of, 602 lupus of, external nasal deformities and, 64 plastic operations for, 74 tuberculosis and, 584 treatment of, 585 lymphangeioma of, 249 lymphatics of, 82 lymphosarcoma of, 257 malformations of, 638 in measles, 608 meatus of, inferior, 77 middle, 78 superior, 79 mucous membrane of, anesthesia of, 234 tuberculosis of, 565 myxoma of, 249 nerve supply of, 82 neuroses of, 231 reflex, 234 olfactory organ, 98 classification of odors, 98 region of, 80 osteochondrosarcoma of, 259 osteoma of, 248 diagnosis of, 255 pathology of, 248 symptoms of, 255 treatment of, 255 osteosarcoma of, 259 papilloma of, 248 diagnosis of, 254 pathology of, 248 symptoms of, 254 treatment of, 254 physiology of, 94 action of epithelial cilia on, 99 for filtering air, 96, 97, 98 for moistening air, 96, 97, 98 olfaction, 98 classification of odors, 98 disturbance of, 98 for warming air, 96, 97, 98 in purpura, 606 rhabdomyoma of, 261 in rheumatism, 607 rhinoscleroma of, 586 bacillus of Frisch in, 588 diagnosis of, differential, 590 illustrative cases of, 591 microscopical, 588 duration of, 589 etiology of, 586 histology of, 587 Nose, rhinoscleroma of, occurrence of, 586 pathology of, 587 prognosis of, 689 symptoms of, 588 treatment of, 689 rodent ulcer of, plastic operations for, 74 in rubella, 608 "saddle-back," 65 sarcoma of, 259 giant-cell, 259 spindle-cell, 258 in scarlatina, 607 in scarlet fever, 607 in scurvy, 606 synechia of, 216 etiology, 216 symptoms, 216 treatment, 216 syphilis of, 545 bone destruction in, 550 chancroid, 548 diagnosis of, differential, 590 illustrative case of, 591 of microscopical, 647 gumma in, 560 initial lesion, symptoms of, 548 intramuscular injections in, 569 nasal deformities in, 664 occurrence of, 646 odor in, 650 pain in, 560 treatment of, 557 potassium iodide in, 559 primary chancre of mucous membrane, 546 salvarsan in, 560 contra-indications to, 662 number of doses in, 561 preparation of, 560 secondary lesions in, 545 symptoms of, 549 sequelae of, 554 spirocheta pallida in, demonstration of, 548 diagnostic value of, 648 symptoms of, 548 tertiary lesions in, 546 symptoms of, 550 treatment of, 567 constitutional, 65i9 treatment of, 556 teratoma of, 262 total destruction of, operations for. Car- ter's, 74 tuberculosis of, 562 appearance of, 676 differential microscopical, 571 diagnosis of, differential, 590 illustrative cases of, 591 etiology of, 562 latent, 562 point of entrance of, 662 prognosis of, 677 symptoms of, 573 INDEX 673 Nose, tuberculosis of, treatment of, 585 tumors of, 243, 256. See Nasal neoplasams. of connective-tissue, 257 typhoid fever in, 603 hemorrhages in, 606 symptoms of, 603 treatment of, 604 Nucleus vagi, 612 Obtubator for cleft palate operation, MacKenty's, 645 Occlusion of pharjmx, treatment of, in malignant tumors of nose, 269 Ocular manifestations in relation to accessory sinuses, 183 ethmoid cells, posterior, 183 frontal, 183 maxillary, 183 • sphenoidal, 183 Odor in atrophic laryngitis, 467 rhinitis, 223 in gumma of nose, 550 in maUgnant tumors of nose, treatment of, 269 in syphilis of nose, 550 O'Dwyer's technique for intubation in diphtheria, 397 Office equipment, fixed, 17-24 movable, 24-30 Ogston-Luc frontal sinus operation, 168 Olfaction, 98 classification of odors, 98 disturbance of, 98, 231 Olfactometer, Zwaardemaker, 233 Olfactory epithelium, distribution of, 89 pit, embryology of, 275 region of nose, 80 OUier's operation in malignant tumors of nose, 268 Onodi's syringe for paraffin injections, 66,67 Operating table, Chappell's portable, 358 Operations on larynx, 529. See Larynx, operations on. Optic nerve, relation of, to sphenoid sinus and posterior ethmoid cells, 180 neuritis, direct infection in, 181 from involvement of nasal sinuses, 179 symptoms of, 181 Oropharynx, adenoma of, 432 occurrence of, 432 anatomy of, 270 in atrophic rhinitis, 224 branchial cysts of, 433 carcinoma of, 436, 438 basal-cell epithelioma of Krompecher, 436 pavement-cell, 436 symptoms of, 436 treatment of, 436, 439 43 Oropharynx, carcinoma of, tubular, 436 epulis of, 433 fibrochondroma of, 434 fibroUpoma of, 434 fibrolymphadenoma of, 434 fibroma of, 432 fibromyoma of, 433 fibromyxoma of, 434 hemangeioma of, 434 lymphangeioma of, 434 malformations of, 639 myxochondroma of, 433 papilloma of, 431 histology of, 432 sarcoma of, 435, 437 alveolar, 435 lymphosarcoma, 435 rhabdomyosarcoma, 435 small round-cell, 435 spindle-cell, 435 treatment of, 437 teratoma of, 433 tumors of, 431 benign, 431 symptoms of, 434 treatment of, 435 malignant, 435 Ossification of larynx, 459 Osteochondrosarcoma of nose, 259 Osteoma of nose, 248 of tonsil, 434 Osteosarcoma of nose, 259 Otitis media, follicular tonsillitis and, 311 Oudin resonator for high frequency, 22 Owen's operation for hare-lip, 646 Ozena. See Atrophic rhinitis. Pachydermia laryngis, 472 alcohol in, 472 chronic rhinitis and, 472 etiology of, 472 location of, 472 street hawkers and, 472 Pain in acute pharyngitis, 302 in chronic pharyngitis, 320 in gumma of nose, 550 in malignant disease of larynx, 514 tumors of nose, 263 treatment of, 269 in syphilis of nose, 550 in tuberculous laryngitis, treatment of, 582 Palate, cleft, 639, 640 soft, adhesion and deformities of, 648 MacKenty's operation for, 650 Nichols' operation for, 649 Roe and Dundas-Grant's opera- tion for, 649, 650 treatment of, 649 perforation of, in syphilis, 554 Papillae of larynx, 456 Papillary hypertrophic rhinitis, 117 674 INDEX Papilloma of larynx, 472 of nasopharynx, 440 of oropharynx, 431 of trachea, 528 Paraffin injections in atrophic'rhinitis, 227 in collapsed alse, 75 in external nasal deformity, 65 accidents in, 68 technique of, 67 syringes, Beck's, 67 Onodi's, 66 Smith's, 66 Paralysis of closers of glottis, 633 of crico-arytenoideus muscle, 633 of cricothyxoideus muscle, 634 in diphtheria, 391 of individual muscles of larynx, 632 laryngeal, 624 of openers of glottis, 632 of pharynx, 447 posticus, 632 of thyro-arytenoideus muscle, 633 of transversus muscle, 633 Parasites in nasal passages, 230 Parasyphilitic lesions in larjfngeal paraly- sis, 624 Paresthesia of larynx, 618 of pharynx, 447 Parosmia, 233 Pavement-cell carcinoma of oropharynx, 436 Perforation, deviations of nasal septum and, 211 of nasal septum, 211 Peritonsillar abscess, 303. See Peri- tonsillitis. Peritonsillitis, 303 in acute pharyngitis, 302 after-treatment of, 311 bacteriemia in, 302 burrowing of pus in, 312 cardiac involvement in, 311 complications of, 311 edema of larynx in, 312 follicular tonsilHtis and, 298, 311 hemorrhage in, 312 kidney lesions in, 311 phlegmon of neck in, 311 symptoms of, 304 treatment of, 307 surgical, 310 Pharyngeal branch of vagus nerve, 614 and nasal involvement in typhoid fever, 605 tonsil, 278. See Tonsils (faucial, pharyngeal, and Mngual). autoclasis of, 326 lateral, 319 Pharyngitis, acute, 291 bacteriemia in, 302 burrowing of pus in, 312 cardiac involvement in, 311 complications of, 311 duration of, 302 edema of larynx in, 312 Pharyngitis, acute, erysipelas of pharynx in, 305 etiology of, 291 examination in, 300 follicular tonsillitis in, 302 gargles in, 308 hemorrhage in, 312 histology of, 297 hoarseness in, 302 inhalations in, 308 kidney lesions in, 311 lacunar tonsillitis in, 302 Upoproteid in, influence of, 296 Ludwig's angina in, 306 treatment of, 312 membranous tonsillitis and, 298, 303 treatment of, 312 pain in, 302 peritonsillitis in, 303 phlegmon in, 311 treatment of, 312 quinsy and, 298, -303 symptoms of, 304 relation of cold-taking and bacteria in upper air passages to, 292 rhinorrhea in, 302 septic pharyngitis in, 305 sprays in, 308 surface tension in, 293 ssrmptoms of, 299 treatment of, 307 constitutional, 308 . local, 309 nasal, 308 prophylactic, 307 surgical, 310 after-treatment, 311 vasomotor influence in, 294 atrophic, 316, 318 chronic, 316 cough in, 320 discomfort in, 320 examination in, 321 histology of, 316 pain in, 320 symptoms of, 319 treatment of, 322 constitutional, 324 local, 322 granular, 316 septic, in acute pharyngitis, 305 with systemic symptoms or dermatoses, 382 Pharyngomycosis, 326 Pharyngoscope, electric, 27 Hays', 27 Pharyngoscopy, 31 Pharyngotomy, 536 subhyoid, 536 suprahyoid, 537 in treatment of laryngeal cancer, 524 Pharynx, actinomycosis of, 419 etiology. of, 419 histology of, 420 treatment of, 423 INDEX 675 Pharynx, anatomy of, 270 in anemia, 606 anesthesia of, 447 in atrophic rhinitis, 224 boundaries of, 270 in chicken-pox, 606 development of, 272 dimensions of, 270 divisions of, 270 embryology of, 272 erysipelas of, 305 in acute pharyngitis, 305 gumma of, 550 histology of lymph nodes of, 283 hyperesthesia of, 447 iaflammation of, 291. See Pharyngitis, keratoses of, 416 treatment of, 417 palliative, 417 surgical, 417 laryngeal, anatomy of, 271 . in leukemia, 606 lymphatics of, 288 lymphoid tissue of, 282 mucous membrane of, minute anatomv of, 277 mycoses of, 419 neuroses of, 447 occlusion of, in malignant tumors of nose, treatinent of, 269 paralysis of, 447 paresthesia of, 447 . pillars of, defects of, 639 in pneumonia, 607 in pseudoleukemia, 606 psoriasis of, 416 pulsating arteries of, 639 racemose glands of, 281 in smallpox, 606 spasms of, 447 submucous hemorrhage in, 414 syphilis of, adhesions in, 654 initial lesion in, 548 perforation of soft palate in, 554 secondary lesions in, 549 sequelae of, 554 symptoms of, 548 tertiary lesions in, 550 tuberculosis of, 562 symptoms of, 573 treatment of, 581 in vaccinia, 606 Phillips' electric head mirror, 27 Plullips-White office chair for patient, 19 Phlegmon in acute pharjmgitis, 311 treatment of, 312 of neck, follicular tonsillitis and, 311 in peritonsillitis, 311 Phonation, 617 apparatus, Gluck's, 526 artificial aids to, 526 distiu-bances of, in laryngeal tumors, 481 in gumma of larjmx, 553 in syphilis of larynx, 553 Phonatory position of vocal cords, 460 Physiology of nose, 94 action of epithelial cilia on, 99 for filtering air, 96, 97, 98 for moistening air, 96, 97, 98 olfaction, 98 classification of odors, 98 disturbance of, 98 for warming air, 96, 97, 98 Pigments in treatment of tuberculous laryngitis, 582 Pilot probes, Ingal's flexible, 166 Pituitary membrane, 79 Pityriasis lichenoides, 418 Pneumonia in benign epithelial laryngeal neoplasms, 481 bronchial, diphtheria and, 388 in laryngeal tumors, 481 larynx in, 607 pharynx in, 607 Poisoning from drugs, epistaxis in, 217 Poljrpi, edematous, 125 etiology of, 125 of larynx, 491 pathology of, 125 symptoms of, 129 treatment of, 130 ethmoidal, polypoid degeneration of middle turbinate and, 186 nasal, chronic sinusitis and, relation of, 184 hay fever and, relation of, 237 septal, bleeding of, 246, 253 Polypoid degeneration, 125 etiology of, 125 histology of, 127 pathology of, 126 symptoms of, 129 treatment of, 130 Pomeroy's nasal forceps, 29 Posterior commissure, 617 nasal artery, 80 rhinoscopy, 31 Postici muscles, spasm of, 623 Posticus paralysis, 632 bilateral, 633 unilateral, 632 Postnasal douches, 64, 66 syringe. Smith's, for monochloracetic acid, 443 Postpharyngeal abscess, 313. See Retro- pharyngeal abscess. Pouch, laryngeal, 460 Probes, Ingal's flexible pilot, 166 Processus uncinatus, anatomy of, 78 Prodromal stage of acute rhinitis, 103 Prolapse of laryngeal ventricles, 497 Pseudoleukemia, larynx in, 606 Pseudomembranbus rhinitis, acute, 108 symptoms of, 108 . treatment of, constitutional, 108 local, 108 Psoriasis of mouth, 416 of pharynx, 416 Pulmonary tuberculosis, tuberculous lar- yngitis and, relation of, 667 676 INDEX Pulse in diphtheria, 391 Purpura, nose in, 606 Pynchon and Hubbard's compressed-air tank, 21 Pynchon's sphenoidal forceps, 153 Q Quarantining in diphtheria, 383 Quinsy, 303. See Peritonsillitis, acute pharyngitis and, 298, 303 R Racemose glands, dilatation of, ranula and, 429 in larynx, 457 of pharynx, 281 Rachitis, larynx in, 606 Radium in cancer of esophagus, 654 in malignant tumors of nose, 269 Ranula, 429 dermoid cysts and, 429 dilatation of racemose glands and, 429 of sublingual duct and, 429 of submaxillary duct and, 429 of thyroglossal duct and, 429 etiology of, 429 treatment of, 429 Recurrent laryngeal nerve, 615 Reflex neuroses of nose, 234 Reflexes of larynx, 616 Respiration, 617 in benign epithelial laryngeal neoplasms, 476 Respiratory anosmia, 232 centre, 612 position of glottis, 617 of vocal cords, 460 Retropharyngeal abscess, 313 etiology of, 313 symptoms of, 313 treatment of, 314 Rhabdomyoma of nose, 261 Rhabdomyosarcoma of oropharynx, 435 Rheumatism, nose in, 607 throat in, 607 Rhinitis, acute, 100 bacteria in, 100 compUcations of, 104 in Eustachian tube, 104 in sinuses, 104 croupous, 108 symptoms of, 108 treatment of, constitutional, 108 local, 108 effusion into tissues in, 101 et-iology of, 100 fibrinoplastic, 108 symptoms of, 108 treatment of, constitutional, 108 local, 108 in infants, 107 Rhinitis, acute, in infants, treatment of, constitutional, 107 local, 107 prophylactic, 107 membranous, 102, 108 relationship of, to diphtheria, 102 symptoms of, 108 treatment of, constitutional, 108 local, 108 pathology of, 101 pseudomembranous, 108 symptoms of, 108 treatment of, constitutional, 108 local, 108 sequelae of, 105 sympathetic system in, 100 symptoms of, 103 first or prodromal stage, 103 second or exudative stage, 103 third or mucopurulent stage, 104 treatment of, 105 inhalations in, 107 internal, 106 irrigation in, 106 local, 105 prophylactic, 105 sweatbox of Brilnings and Kil- lian's in, 105 vasomotor system in, 100 atrophic, 219 age at onset and, 223 constitutional disturbances and, 223 crusts in, 224 deviation of septum and, 219 etiology of, 219 internal nose in, 224 larynx in, 225 malnutrition in, 219 nasopharynx in, 224 odor in, 223 oropharynx in, 224 pathology of, 220 prognosis of, 225 sinusitis and, 219 symptoms of, 223 syphilis in, 219 trachea in, 225 treatment of, 226 cleansing in, 226 internal, 228 paraffin injections in, 227 stimulant, 227 caseous, 228 chronic, 108 acute catarrhal sinusitis in, 141 empyema of accessory nasal sinuses and, 154 of ethmoid cells and, 151 of frontal sinus and, 149 of maxillary sinus and, 143 of sphenoid sinus and, 153 chronic catarrhal sinusitis in, 142 empyema of frontal sinus and, 163 of maxillary sinus and, 155 of sphenoid sinus and, 175 INDEX 677 Rhinitis, chronic, connective-tissue changes in, 110 epithelial changes in, 109 etiology of, 108 hypophyseal tumors and, 177 inflammation of sinuses and, 138 intumescent, 115 mucous membrane in. 111 nasal polypi and sinusitis and, rela- tion of, 184 ocular manifestations in relation to accessory sinuses and, 183 optic neuritis from involvement of nasal sinuses and, 179 pachydermia laryngis and, 472 pathology of, 109 perforation of nasal septum and, 211 of septum in. Ill sequelae of, 125-190 symptoms of. 111' subjective, 112 treatment of, constitutional, 112 local, medicinal, 113 surgical, 114 chromic acid in, 114 galvanocautery in, 115 removal of spurs and deflec- tions in, 114 vascular changes in, 110 hypertrophic, 115 connective-tissue changes in, 116 gland changes in, 117 mulberry, 117 occurrence of, 119 papillary, 117 pathology of, 115 symptoms of, 119 treatment of, general, 121 local, medical, 121 surgical, 122 Grunwald's ethmoidal forceps in, 123 Holmes' curved scissors in, 122 Jackson's turbinated scissors in, 122 packing in, 124 snare in, 122 Yankauer's operation in, 123 vascular changes in, 116 vasomotor, 235 RhinoUths in nasal passages, 228 Rhinorrhea in acute pharyngitis, 302 cerebrospinal, 241 nasal, 240 Rhinosoleroma, 250 of nose, 586 Rhinoscopic mirror, Michel-Frankel, 28, 29 Rhinoscopy, anterior, 30 Rhinosporidium kinealsd, 250 Rigg's disease, 380 Ringworm, 424 Robertson's tonsil scissors, 354 Rodent ulcer of nose, plastic operations for, 74 Roe operation for deviated septa, 199 Rose cold, 236. See Hay fever. Rouge's operation in malignant tumors of nose, 267 Rubella, nose in, 608 throat in, 608 "Saddle-back" nose, 65 Safety-pin catcher, Mosher's, 48 closer, Mosher's, 48 Sajous' laryngeal snare, 477 Salvarsan in syphilis, 560 contra-indications to, 562 number of doses of, 561 preparation of, 560 Santorini, cartilages of, 449 Sarcoma of esophagus, 654 of laiynx, 513 of nasopharynx, 445 of nose, giant-cell, 259 spindle-cell, 258 of oropharynx, 435, 437 of tongue, 431 of trachea, 528 Saw, Bosworth's septal, 195 Mial's septal, 195 Scalpel enucleation of tonsil, 354 Scarlatina, nose in, 607 throat in, 607 Scarlet fever, nose in, 607 pharynx in, 366 throat in, 607 Scarrifier, Tobald's laryngeal, 531 Schadle's chromic acid applicator, 113 Schneiderian membrane, 79 Scissors, Robertson's tonsil, 354 Scleroderma of mouth, 416 Sclerosis, disseminated, laryngeal paralysis and, 624 Screw-worms in nasal passages, 230 Scurvy, nose in, 606 Seller's solution, 56 Sensation in disturbances of larynx, 617 SensibiUties of larynx, 616 Septal chisel, Ballenger's 195 Hajek's, 208 Spratt's, 195 polyp, bleeding of, 246, 253 saw, Bosworth's, 195 Mial's, 195 speculum, Metzenbaum's, 206 Septic pharyngitis, 305 in acute pharyngitis, 305 Septum, deviation of, atrophic rhinitis and, 219 embryology of, 60 forceps, Foster-Ballenger's, 207 nasal, abscess of, 215 anatomy of, 79 deviations of, 191, 192 spurs and, 79 hematoma of, 214 678 INDEX Septum, nasal, mucous membrane of, 79 perforations of, 211 in chronic rhinitis. 111 scissors, Asch's straight and angular, 199 Serum sickness in diphtheria, 402 Shurly's operation for perforation of nasal septum, 214 Simpson-Bernay intranasal splint, 63 Singer's nodules in larynx, 489 Sinus and sinuses, accessory, diseases of, histology of, 128 ethmoidal cells, posterior, 183 frontal, 183 maxillary, 183 nasal, acute empyema of, 154 ocular manifestations in relation to, 183 sphenoid, 183 disease, nasal polypi and, 125 ethmoid, anatomy of, 138 frontal, acute catarrhal sinusitis of, symptoms of, 141 empyema of, 149 chronic catarrhal sinusitis of, 143 empyema of, 163 maxillary, acute catarrhal sinusitis of, symptoms of, 141 empyema of, 143 chronic catarrhal sinusitis of, 142 empyema of, 155 nasal, anatomy of, 133 hydrops antri of, 190 inflammation of, 138 mucocele of, 189 optic neuritis from involvement of, 179 sphenoid, acute empyema of, 153 chronic empyema of, 175 Sinusitis, acute catarrhal, diagnosis of, transillumination in, 141 of ethmoidal cells, 141 of frontal sinus, 141 symptoms of, 141 of maxiUary sinus, 141 symptoms of, 141 prognosis of, 141 prophylactic measures in, 142 . of sphenoid sinus, symptoms of, 141 symptoms of, 141 treatment of, 142 purulent. iSee Empyema, acute, and atrophic rhinitis, 219 chronic catarrhal, 142 of frontal sinus, 143 of maxillary sinus, 141 nasal polypi and, relation of, 184 purulent. See Empyema, chronic, hay fever and, relation of, 237 Sluder operation for deviated septa, 197 tonsillotome, 348, 349 Small round-ceU sarcoma of oropharynx, 435 Smallpox, mouth in, 606 phajynx in, 606 Smith's postnasal monochloracetic acid syringe, 443 sjnringe for paraffin injections, 66, 67 Smooth muscle in nasal mucosa, 86 Snare, Blake's, 185 Farlow's tonsil, 347, 348 Jarvis', 184 Sojous larjmgeal, 477 Wright's, 184 Snoring in chronic hs^ertrophy of tonsils, 333 Snuflling in chronic hypertrophy of tonsils, 333 Solutions for treatment, Dobell's, 56 normal salt, 66 I Seller's, 56 i Somnoform for general anesthesia, 341 ' Sporotrichosis, 424 Spasm of larynx, 618 1 of pharynx, 447 j Spasmodic croup, 620. See Laryngismus ! stridulus. Speculum, Metzeribaum's septal, 206 Spheno-ethmoidal recess, anatomy of, 79 Sphenoid sinus, anatomy of, 137 embryology of, 61 empyema of, acute, 153 examination in, 153 symptoms of, 153 treatment of, 153 operative, 153 therapeutic, 153 chronic, 175 symptoms of, 175 treatment of, 175 Watson Williams' operation in, 176 posterior ethmoid cells and, relation of, to optic nerve, 180 K-ray plates of, 33 Sphenopalatine ganglion, 81, 82 Spindle-cell sarcoma of nose, 258 differentiation of, 258 of oropharynx, 435 Spirochseta pallida, demonstration and diagnostic value of, 548 Spoke-shave for septal cartilage, 195 Spratt's septal chisel, 195 Sprays in acute pharyngitis, 308 glass, Davidson's, 56, 57 de Vilbiss', 56, 57 in tuberculous laryngitis, 582 Spurs of nasal septum, 191, 192 treatment of, 194 Stenosis of larynx, 647 partial, in laryngeal tumors, 481 Sterilizers, gas and electric, 24 Stoerk's blennorrhea, 589 Stomatitis, 377 aphthosa, 377 histology of, 378 treatment of, 378 catarrhal, 377 gangrenous, 377 histology of, 378 INDEX 679 Stomatitis, gangrenous, treatment of, 378 gonococcal, 378 histology of, 378 treatment of, 378 varieties of, 377 ^ Stool, doctor's, 28, 21 Street hawkers and pachydermia laryngis, 472 Strictures of esophagus, 653 Submaxillary duct, dilatation of, ranula and, 429 Subhyoid pharyngotomy, 536 Sublingual duct, dilatation of, ranula and, 429 Submucous hemorrhage of mouth, 414 in pharynx, 414 injections in tuberculous laryngitis, 582 resection of nasal septum, 200 abscess and,^210 anesthesia in, 200 contra-indications in, 200 dressing in, 209 elevation of mucous membrane in, 203 falling of bridges and, 211 hematoma and, 210 incision in, 201 Freer's, 201 Haiek's, 202 Kiliian's, 202 through cartilage and elevation opposite side, 205 Yankauer's, 202 perforation and, 211 position of patient inj 200 removal of cartilage m, 205 of crest in, 207 of perpendicular plate of eth- moid in, 207 sequete of, 210 Superior laryngeal nerve, 614 meatus of nose, 79 turbinated body, anatomy of, 78 Suprahyoid pharyngotomy, 537 in cancer of laryrix, 524 Surface tension in etiology of pharyngitis, 293 Sympathetic system in acute rhinitis, 100 Synechia of nose, 216 Syphilis in atrophic rhinitis, 219 in external nasal deformity, 64 of larynx, 545 aphonia in, treatment of, 558 cicatrization in, 654 dangers of, 553 destruction of cartilages in, 554 dyspnea in, 553 treatment of, 553 hoarseness in^ treatment of, 558 initial lesion m, 548 location of, 554 pain in, treatment of, 557 phonation in, 553 secondary lesion in, 549 sequeke of, 554 Syphilis of larynx, symptoms of, 548 tertiary lesion in, 559 treatment of, 556 of lips, 545 of mouth, 545 initial lesion in, 548 secondary lesion in, 549 tertiary lesion in, 659 treatment of, 656 of nose, 545 bone destruction in, 560 chancroid, 548 diagnosis of, differential, 590 microscopical, 547 gumma in, 550 initial lesion in, symptoms of, 548 intramuscular injections in, 559 nasal deformities in, 554 occurrence of, 554 odor in, 550 pain in, 550 treatment of, 657 potassium iodide in, 569 primary chancre of mucous mem- brane, 545 salvarsan in, 560 contra-indications to, 562 number of doses in, 561 preparation of, 561 secondary lesions in, 545 ssrmptoms of, 648 sequelae of, 654 Spiroohseta pallida in, demonstration of, 648 symptoms of, 548 tertiary lesions of, 546 symptoms of, 650 treatment of, 557 constitutional, 559 treatment of, 555 of pharynx, adhesions on, 554 of throat, 545 chancroid in, 548 diagnosis of, differential, 690 microscopical, 547 gumma of, 646 initial lesion in, symptoms of, 648 intramuscular injections in, 659 mucous membrane of, primary chancre of, 646 patch in, 646 occurrence of, 545 potassium iodide in, 559 salvarsan in, 660 > contra-indications to, 562 number of doses of, 561 preparation of, 660 secondary lesions in, 545 Spirochseta paUida in, demonstration of, 548 symptoms of, 548 tertiary lesion of, 546 symptoms of, 550 treatment of, 667 constitutional, 559 680 INDEX Syphilis of throat, treat ment of, 554 constitutional, 557 Syphilitic lesions in laryngeal paralysis, 624 Syphiloma, 250 Sjrringe, Chappell's submucous laryngeal, 584 paraffin, Beck's 67 Onodi's, 66 Smith's, 66 postnasal. Smith's, for monochloracetic acid, 443 Tabes dorsalis, laryngeal paralysis and, 625 Table, accessory, for office, 20, 21 Temperature in diphtheria, 391 Teratoma of nose, 262 of nasopharynx, 440 of oropharynx,' 433 Thermos bottles as inhalers, 58 Thimble gag for direct laryngoscopy, 38 Thompson's adenoid curettes, 361, 362 Throat, cancer of, diagnosis of, differential, 590 illustrative oases of, 591 in cirrhosis of liver, 607 examination of, use of cooain in, 35 in gout, 606 gumma of, 546 inflammation of, acute, 291. See Pharyngitis, in measles, 608 mucous membrane of, tuberculosis of, 565 in rheumatism, 607 in rubella, 608 in scarlatina, 607 in scarlet fever, 607 syphilis of, 545 chancroid in, 548 diagnosis of, differential, 590 illustrative cases of, 591 microscopical, 647 gumma of, 546 initial lesion in, symptoms of, 548 intramuscular injections in, 559 mucous membrane of, primary chancre of, 546 patch in, 545 occurrence of, 545 potassium iodide in, 559 salvarsan in, 560 contra-indications to, 562 number of doses of, 561 preparation of, 560 secondary lesions in, 545 symptoms of, 549 sequelse of, 554 Spirochseta pallida in, demonstration of, 548 diagnosis of, 548 symptoms of, 648 Throat, syphiUs of, tertiary lesion of, 546 symptoms of, 650 treatment .of, 567 constitutional, 559 treatment of, 554 constitutional, 557 tuberculosis of, 562 appearance of, 575 differential microscopical, 571 diagnosis of, differential, 590 illustrative cases of, 591 etiology of, 662 latent, 562 point of entrance of, 562 prognosis of, 577 symptoms of, 573 treatment of, 581 typhoid fever in, 603 symptoms of, 603 tracheotomy in, 605 treatment of, 604 Thrush, 418 Thymus affections, larynx in, 607 Thyro-arytenoid muscle, 451 paralysis of, 633 Thyroglossal duct, dilatation of, ranula and, 429 ThjToid affections, larjmx in, 607 cartilage, 448 embryology of, 276 tumors of larynx, 497 Thyrotomy, 534 in laryngeal tumors in children, 480 TiUey's hand di-ill, 149 Tobold's laryngeal scarifier, 533 Tongue, abscesses of, 427 adenoma of, 429 angioma of, 429 black, 418 depressors, 24 Alexander's, 24 Bosworth's, 24 Frankel's, 24 Tiirck's, 24 wooden spatula as, 24 embryology of, 275 epithelioma of, 429 pathology of, 429 symptoms of, 431 treatment of, 431 fibroma of, 429 geographical, 418 lipoma of, 429 sarcoma of, 431 tumors of, 429 benign, 429 malignant, 429 Tonsil and adenoids: autoclasis of, 432 bacteria of, 288 bloodvessels of, 288 bone in, 372 carcinoma of, 438 cartilage in, 372 chondroma of, 434 INDEX 681 Tonsil, concretions in, 372 dissector, Yankauer's blunt, 346 embryology of, 273 epithelioma of, 438 faucial, 277, 278 pharyngeal and lingual, chronic hyper- trophy of, 326 adenectomy in, 360 Brandigee and Knight's forceps in, 360 control of hemorrhage in, 363 Gradle adenotome in, 361 instruments for, 360 La Force adenotome in, 361 adenoids in, 331 in adults, 337 in children, 335 cUmate and, 330 clinical appearance in, 330 colds in, 335 » environment and, 329 etiology of, 328 examination in, 337 facial contour in, 333 faucial tonsils in, 330 heredity and, 328 in infants, 335 occurrence of, 330 pathology of, 326 pharyngeal tonsils in, 331 removal of faucial tonsils, 345 Beck's tonsiUotome in, 353 Farlow's tonsil snare in, 348 finger enucleation in, 354 Mackenzie's tonsiUotome in, 347 Mathieu's tonsiUotome in, 347 Robertson's scissors in, 354 scapel enucleation in, 354 separating pillars in, 345 Sluder's tonsiUotome in, 348, 349 snoring in, 333 snuffling in, 333 submerged tonsils in, 330 symptoms of, 332 tonsillar hemostats in, 356 Butts', 356 Kurd's, 357 Mickulicz-Stoerck's, 356 treatment of, 339 anesthesia in, 341 general, 341 local, 341 galvanocautery in, 340 local, 340 surgical, 340 control of hemorrhage during and after operation, 354 position in, 343 without adenoids, 338 finger enucleation of, 354 function of, 289 keratosis of, 370 differential diagnosis of, 371 Tonsil, keratosis of, differential diagnosis of, from mycosis, 371 etiology of, 370 pathology of, 370 symptoms of, 371 treatment of, 371 knives, Leland, 345 laryngeal, 459 Ungual, 277, 280 abscess of, 367 inflammation of, 367 etiology of, 367 prognosis of, 369 symptoms of, 368 treatment of, 369 galvanocautery in, 370 medical, 369 surgical, 370 lipoid material in, 284 osteoma of, 434 pharyngeal, 278 lateral, 319 sarcoma of, 437 scalpel enucleation of, 354 scissors, Robertson's, 354 separator, Kurd's, 346 snare, Farlow's, 347, 348 Tonsillectomy, 340 anesthesia in, 341 general, 341 local, 341 control of hemorrhage during and after, 364 operation, methods, 345 position of patient in, 343 preparation of patient in, 357 TonsilUtis, follicular, 311 in acute pharyngitis, 302 cardiac involvement and, 311 edema of larynx and, 312 kidney lesions and, 311 otitis media and, 311 peritonsiUitis and, 298, 311 phlegmons of neck and, 311 recurrent attacks of, 312 sequelae of, 311 treatment of, 312 lacunar, in acute pharyngitis, 302 membranous, acute pharyngitis and, 298 303 TonsilloUths, 372 TonsiUotome, Beck's, 353 Mackenzie's, 347 Mathieu's, 346, 347" Sluder's, 348, 349 Tophi on vocal cords, 492 Toxic laryngeal paralysis, 626 Toxins, Coley's, in maUgnant tumors of nose, 268 Trachea, adenomata of, 529 anatomy of, 461 in atrophic rhinitis, 225 carcinoma of, 628 chondroosteomata of, 529 collapse of, in laryngeal tumors, 481 682 INDEX Trachea, echondromata of, 529 fibromata of, 528 lipoma of, 628 lymphomata of, 528 neoplasms of, 526 diagnosis of, 528 occurrence of, 526 prognosis of, 529 symptoms of, 528 treatment of, 529 papilloma of, 528 sarcoma of, 528 tumors of, 526. See Trachea, neo- plasms of. Tracheitis, 468 Tracheotomy, 402, 532 anesthesia in, 532 general, 532 chloroform in, 532 advantages of, 532 dangers of, 532 ether, 532 local, 532 in diphtheria, 402 high, 533 after-care in, 533 cannula in, 533 in incised wounds of larynx, 638 instruments for, 533 in laryngeal cancer, 523 low, 534 in paralysis of openers of glottis, 633 position in, 533 preUminary to total laryngectomy, 537 in tumors of nasopharynx, 443 Transillumination, 31 in acute empyema of frontal sinus, ISO of maxiUary sinus, 146 Birkett's frontal sinus illuminator, 32 Coakley's transilluminator for the sinuses, 32 in diagnosis of acute catarrhal rhinitis, 141 of frontal sinus, 33 in maxillary empyema, 155 sinus, 33 sources of error in, 31 technique of, 31 Transversus muscle, paralysis of, 633 Trauma in perforations of nasal septum, 211 Traumatism, epistaxis in, 217 in external nasal deformities, 63 Trychophyton, 424 Tuberculoma, 250, 569 of mouth, appearance of, 575 of mucous membrane of nose, 565 of nose, 562 in perforation of nasal septum, 211 of pharynx, 562 of uvula, appearance of, 575 Tuberculosis of lar3aix, 562 appearance of, 575 argyrol in, 582 etiology of, 562 Tuberculosis of lar3Tix, formalin in, 562 guaiacol in, 562 ichthyol in, 562 inhalations in, 582 insufflations in, 582 intratracheal injections in, 582 lactic acid in, 582 pain in, treatment of, 582 prognosis of, 577 pulmonary tuberculosis and sprays in, 582 submucous injections in, 582 symptoms of, 573 treatment of> 578 constitutional, 581 diet in, 581 local, 579, 582 medicinal, 581 surgical, 583 of mouth, appearance of, 575 of nose, 562 appearance of, 575 differential microscopical, 571 diagnosis of, differential, 590 etiology of, 582 latent, 562 point of entrance of, 562 prognosis of, 577 symptoms of, 573 treatment of, 585 of throat, 562 appearance of, 575 differential microscopical, 571 diagnosis of, differential, 590 etiology of, 562 latent, 562 point of entrance of, 562 prognosis of, 577 symptoms of, 573 treatment of, 581 of uvula, appearance of, 575 Tuberculous laryngitis, pulmonary tuber- culosis and, relation of, 567 Tubular epitheUoma of oropharynx, 436 Tumors, amyloid, of larynx, 496 of esophagus, malignant, 653 non-mahgnant, 653 hypophyseal, 177 of nasopharjmx, 439 of nose, 243, 256. See also Nasal neo- plasms, connective-tissue, 257 malignant, epistaxis in, 217 of oropharynx, 431 thyroid, of larynx, 497 of tongue, 429 of trachea, 526. See Trachea, neo- plasms of. Turbinate, middle, bone cysts of, 130 formation of, 132 symptoms of, 133 polypoid degeneration of, ethmoid polypi and, 186 Turbinated bodies, embryology of, 61 inferior, anatomy of, 77 INDEX 683 Turbinated bodies, middle, anatomy of, 77 superior, anatomy of, 78 Ttirek's tongue depressor, 24 U Ulcers, atrophic, perforations of nasal septum and, 2H of mouth, 418 tuberculous, perforations of nasal sep- tum and, 211 Uncinate process, 78 Unilateral posticus paralysis, 632 Urticaria of mouth, 413 Uvula, bifid, 640 deformities of, 374 elongation of, 373 inflammation of, 373 etiology of, 373 • treatment of, 374 removal of, 375 Cassellberry's operation for, 376 tuberculosis of, appearance of, 575 Uvulotome, Hay's, 376 Vaccinia, mouth in, 606 pharynx in, 606 Vacuum bottle inhaler, 59 Vagus nerve, origin of motor filaments of, 612 nucleus, 612 Vascular changes in chronic rhinitis, 110 in hypertrophic rhinitis, 116 disease, epistaxis in, 216 Vasomotor influence in acute pharyngitis, 294 rhinitis, 235 system in acute rhinitis, 100 Ventricles of larynx, 460 prolapse of, 497 Ventricular bands, 460 - appearance of incipient cancer on, 517 Vertigo, laryngeal, 619 Vincent's angina, 379 bacteriology of, 379 etiology of, 379 histology of, 380 sequelae of, 381 symptoms of, 380 treatment of, 380 Vocal cords, appearance of incipient cancer on, 516 movements of, in malignant disease of larynx, 515 position of, 460 cadaveric, 460 Vocal cords, position of, median, 460 phonatory, 460 respiratory, 460 tophi on, 492 Voice in atrophic laryngitis, 467 Von Schrotter bronchoscope, 46 forceps for bronchoscopy, 49 Vox cholera, 606 W Waldbybr's ring, 283 Watson's operation for deviated septa, 199 Watson-WilKams' osteoplastic frontal sinus operation, 169 sphenoid operation, 176 Webs of larynx, 648 White's technique for local anesthesia in bronchscopy, 51 Whitehead's gag with tongue depressor, 643 Wilde's, nasal forceps, mouse-toothed, 28 smooth, 28 Willard Parker Hospital technique for intubation, 400 Wooden spatula as tongue depressors, 24 Wounds of larynx, 6-37 Wright's snare, 184 Wrisberg, cartilages of, 449 X-BAYS, cause of failure to locate foreign body by, 34 in diagnosis of maxillary empyema, 155 in laryngeal tumors, 481 plates as aid to diagnosis, 33 of frontal sinus, 33 of maxillary sinus, 33 of sphenoid, sinus, 33 use of, in locating foreign bodies, 33 Yankatjer's blunt tonsil dissector, 346 incision for submucous resection, 202 operation in hypertrophic rhinitis, 123 self-retaining nasal speculum, 26 submucous hook for septum operation, 204 ZwAAKDEMAKER On classification of odors, 98 olfactometer, 233 P iS* ■Fr'fE t" imlil -"■■-■'-■' tWiMBSHMniBIBtgmnH*graBiKBBrR*Wnw .„___ iH^^WTOjBnBSM^^^^^SJWrPFp^rWKTf^'^^ _- ....... iig^'^^^