> .♦lii;* "> v^ .!*•- 5)*'.^::.'.% ""^ ^^—'*%<^* V^^> %%.* 0** V- I** „. «V * -4.. * ■: .^°^ V ?^V ... V 't:j^->^ -o, *-^^.\o''^ -iT- A^"^ * er Cousin (F). Mother Grandfather | Mother Cousin (M), Brother r'..„„^.„„n,.r J ^*"'^'' Uncle. Sister <^'^*"<'""'"'*'^1 Mother Aunt. Constitution ; Phthisis. Scrofulous : Acute artic. rheumatism. Syphilis: Alcoholic : Defluvium capillorum: {frontal, occipital, temporal. Vertigo Revolving Convulsions. Swaying Oppressive feeling. Naso-pharyngeal Space. Coryza : Ozn-na. Pharyngitis : Tonsillitis hypertr. Adenoid Vegetation : Aprosexia. Mouth-breathing : Snoring : Hears better in a Noi Paracusis of Wlllla absent, present. Mense.s Leucorrha-a Abortion Pregnancies Chronic Metritis 111 . I Bone conduction: «i I Diminished ►2 SL^'PFl"'"' Air conduction ; Diminished Disappeared Negative Air conduction: Diminished Disappeared Negative ^ ( For Patulous "« i normal " ( narrow ^ f For Patulous .2P .j normal cS ( narrow Smoker. SnufTer. Tympanum. Hearing Distance before after the first Air-douche. Bone Conductions on Mastoid Process. Politzer Tuning-fork Hearing. Normal Wide Narrow Cerumen Lustre Slegle.^ normally Light cone Color Hammer handle Curvature Polllzer Always the same since : Rapidly decreasing: Slowly becoming worse : Fluctuations : Normal Wide Lustre (adherent )< normally- (. movable Light cone Cerumen j Color Eczema Hammer hf Pus Curvature Absent Weak Good Nostrils. Absent Weak Good I'ft ri,h, Normal Normal Narrow Narrow Impassable Vibration Bone conduction Air conduction • Vibration Bone conduction Air conduction tl. {J J Sclerosis J I Pain from Pres. I Sclerosis Pain from Pres. ^ rNaevi be "j Helix Lumps or Projections A y Eczema »4000 56000 42000 33G00 28000 24000 '. Soimding vibration per Sec. WOOO 56000 42000 33600 28000 24000 21000 18856 16800 15273 14000 1 Vibration per Sec. 6.5536 < Former Treatment: Therapeutics : Politzer's Method. Catheterization. Rarefaction. Probe Pressure. Tubal Massage. Injection in Meatus. Galvano-puncture. Galvanization. lodo-ethyl. Amyl nitrite. F'yrldin. Cociiine-atropine. Alcohol. Boric acid. Iodoform. lodol. Alumin. acid. tart. Unguent, jod. Pilocarpine. Acid, hydrobrom. Ferrum jod. Kali jod. 01. jecor. aselli. After the hearing has been tested the aurist should inspect the parts of the ears made visible by means of otoscopy, carefully noting the condition of the external auditory canal and drum-head ; and if the membrane be wholly or partly destroyed as the result of disease or EXAMINATION OF PATIENTS 63 accident, noting; the condition of the nuicoiis nicinljranc of the tympanum and other structures that may be visible. In most instances it is advisable to make a diagram or rude drawing of tlie condition of the tympanum, and in making notes as to the results of otoscopy to give one or more separate lines in the note-book in the same manner as when recording the results of the tests for hearing. The patency of the Eustachian tubes should next be tested by means of the Politzcr method and the aural stethoscope or, if necessary, the Eustachian catheter should be used. In many cases it is neither necessary nor desirable to make as elaborate an examination as that described above. Dr. Rohrer's diagnostic table, here inserted, although too elaborate for daily use, will be found convenient for refer- ence, and from it as a model a less complicated page may be constructed if the physician desires something of the kind on which to keep notes of his cases. The writer, however, after using for some years a somewhat elaborate record book, now uses a card-index, with simple plain cards, for his case records. THE NOSE ANATOMY OF THE NOSE The external nose is an arch-shaped framework, bony above and cartilaginous below, covered by integument externally and lined within by mucous membrane. It is separated into two portions, practically two noses, by the 7iasal septum. The bony arch or bridge of the nose (Fig. 50) is com- posed of the nasal processes of the superior maxillary and the nasal bones. Fig. 50. — Bones and cartilages of the external nose. A, Side view : a, Cartilage of septum ; b, upper and (c) lower lateral cartilages ; d, sesamoid cartilages ; e, cellular tissue ; f, nasal bone ; g, nasal process of superior maxillary bone. B, View from below : a, Lower lateral cartilage ; b, sesamoid cartilages ; c, cellular tissue. The cartilaginous arch consists of the upper and lower lateral cartilages and the sesamoid cartilages, usualh- three on each side of the nose. The cartilages are bound together by strong connective tissue, and by the action of muscles upon them the opening into the nose can be dilated or narrowed. 64 ANATOMY or' TlIK NOSF. 65 The alee or win^^s of tlic nose contain no cartilage, Init consist of a mass of cellular tissue and fat. The nasal septum consists of bone and cartilaL^^e covered by mucous membrane. Its cartila<^inous portion is the so-called triangular <:v?;'//7r?^r, because it fits into a triani^ular space between the perpendicular plate of the ethmoid and the vomer (Fig. 51). However, the cartilage of the septum Fig. 51. — Osseous and cartilao^inous septum of the nose : i, Triangular cartilage of the septum ; 2, median plate of the lower lateral cartilage, sometimes called columnar cartilage and cartilage of the aperture; 3, cartilage of Jacobson ; 4, supravomerine cartilage some- times present ; 5, vomer; 6, perpendicular plate of ethmoid; 7, ethmovomerinc suture ; 8, sphenoidal sinus ; 9, nasal bone ; 10, palate bone. (Arnold.) is quadrilateral in shape. Besides the perpendicular plate of the ethmoid and the vomer, the nasal crests of the superior maxillary, palate, and nasal bones, as well as the nasal spines of the superior maxillaries, enter into the formation of the septum, the rest of the septum fitting into a groove between these two sets of processes. The nasal septum is covered by mucous membrane, beneath which, near the nasal floor, is ill-developed erectile tissue, and above which are the specialized nerve-filaments of the sense of smell. 66 DISEASES OF THE NOSE, THROAT, AND EAR The skill covering the external nose, especially at the tip, is rich in sebaceous glands, the contents of which when diseased form the well-known comedones. At the tip of the nose beneath the skin is a cushion of fat which when hypertrophied aids in the production of " pug nose." The skin extends into the nose nearly to the anterior extremities of the inferior turbinated bones, and at the entrance into the nares it is usually covered with short thick hairs, the vibrissae. The imisclcs of the external nose are the levator alae nasi, depressor alae nasi, levator alae nasi props, and the musculis apicis. These muscles by their action dilate and make narrow the anterior nares during respiration. The arteries of the external nose are the lateralis nasi, a branch of the facial, nasal branches of the ophthalmic and infra-orbital, and the septal artery from the superior coronary artery. The nerves of the external nose are branches from the facial, infra-orbital, infratrochlear, and the nasal branch of the ophthalmic. The nasal cavities are the commencement of the upper respiratory tract. They extend from the anterior nares to the posterior wall of the pharynx, and consist of two chambers, divided from each other by the septum. The floor is sepa- rated from the roof of the mouth by comparatively thin structures and hence is parallel to it. The roof is formed by the nasal bones and nasal spines of the frontal bone, the horizontal plate of the ethmoid, and the anterior wall of the sphenoidal cells. The lateral walls are formed by portions of the frontal, lacrimal, ethmoid, and sphenoid bones. Upon the lateral walls of the nasal chambers are the supe- rior, middle, and inferior turbinated bones (Fig. 5 2). The in- ferior turbinated is a separate bone, but the superior and middle turbinated are portions of the ethmoid. At birth this portion of the ethmoid is often divided into three or even four turbinated bones by grooves that disappear later in life. Beneath the turbinated bodies are three respective meati : the superior, middle, and inferior meati. The inferior meatus extends backward and downward, and at the junc- tion of its anterior third with the posterior two-thirds receives AjVA'/va/v of tjik nosh 67 from beneath the inferior turbinated body the secretions of the eye through the nasal duct (Fi^-. 95). Its position upon the floor of the nose renders the inferior meatus the impor- tant drainage fossa of the nose, and along it the spray of an atomizer or the stream of a syringe should be directed if it is desired to wash secretions into the pharynx. Above the inferior turbinated body is the middle meatus, and because of the numerous ostea opening into it is an important fossa in nasal diseases. The superior turbinated body is a portion of the middle turbinate, separated from the rest of the middle turbinate by a groove, the superior meatus^ closed in front but opening posteriorly into the spheno-ethmoidal recess. The nasal cavities are divided into vestibular, respiratory, and olfactory regions, and the accessory cavities. The vestibidar region is all that portion of the nose anterior to the turbinated bodies. The respiratory region is the in- ferior nasal chambers posterior to the vestibular region, bounded above by the inferior edge of the middle tur- binated body. Through this region of the nose the respi- ratory air-currents arch on their way to and from the pharynx. The olfactory region lies above the inferior edge of the middle turbinated body. The mucous or Schneiderian membrane of the nose is a con- tinuation of the external tegument, and is continuous with that of the pharynx, the Eustachian tubes, and the accessory sinuses. It is sometimes called the pituitary (meaning phlegm-producing) membrane or the Schneiderian, after Schneider, an anatomist, who first proved that the nasal secretions were produced by it and not by the brain. In many portions of the nose it is thin and inseparable as a membrane from the periosteum or perichondrium beneath, but over the inferior turbinate and the adjacent portion of the septum, as well as the inferior edge of the middle tur- binate, it is thick and vascular. In these regions is the so- called erectile tissue, similar to that of the sexual organs, and consisting of cavernous blood-vessels imbedded in cellular tissue. When this tissue erects itself, that is, when its vessels fill with blood, the bulk of the nasal membrane enormously increases and may cause almost complete stenosis of the nasal chambers. 68 DISEASES OF THE NOSE, THROAT,. AND EAR The vestibular mucous membrane is covered by stratified pavement epithelium and contains sweat and sebaceous glands, and anteriorly vibrissse or short hairs that serve to prevent the entrance into the nostrils of coarse particles of dust and insects. The mucous membrane of the respiratory region is covered- by pseudostratified ciliated epithelium and contains goblet-cells. Mucous, serous, and lymphatic glands are numerous. The mucous membrane of the olfactory region contains no erectile tissue and to it are dis- tributed the specialized nerve-endings of the olfactory nerve. It is covered by a single layer of cylindric epithelium and Fig. 52.— Nerves of nose and sphenopalatine ganglion, from inner side : i. Network of external branches of olfactory nerve ; 2, nasal nerve, giving its external branch to outer wall of nose; the septal branch is cut short; 3, sphenopalatine ganglion; 4, ramiiication of large palatine nerve; 5, small, and 6, external palatine nerve; 7. inferior nasal branch; 8, superior nasal branch; g, nasopalatine nerve cut short; 10, Vidian nerve; 11, great superficial petrosal nerve ; 12, great deep petrosal nerve ; 13, the sympathetic nerves ascend- ing on internal carotid artery. contrasts by its yellow color with the bright pink of the parts below. In this thin pale membrane are the olfactory and sustentacular cells capable of receiving sensory impulses recognized as odors. The arteries of the nasal fossae are the anterior and pos- terior ethmoidal from the ophthalmic, the sphenopalatine branch of the internal maxillary, and the alveolar branch of the internal maxillary to the antrum. The nerves of the nasal fossae (Fig. 52) are the nasal branch of the ophthalmic to the septum and outer wall, anterior branch of the superior maxillary to the inferior turbinated PHYSIOLOGY OF MUCOUS MKMlikANES 69 body,and the floor ofthc nose. The sphenopahitine <;anL;H()ii gives off the Vidian nerve to the septum and superior tur- binated body and the superior nasal branch to tiie same regions, the nasopahitine to the middle of the septum, and the anterior palatine to the middle and lower turbinates. The olfactory or first cranial nerves from the olfactory bulb enter the nose through twelve or more openings on eacli side of the cribriform plate. They are distributed to the specialized nerve-endings in the mucous membrane of the olfactory region of the nose. The lymphatics of the nose are numerous. The more anterior terminate in the submaxillary glands, the posterior communicate with the pharygneal glands. PHYSIOLOGY AND PATHOLOGY OF MUCOUS MEMBRANES AND ^'CATCHING COLD^* During respiration the bulk of the air passes along the septum above the inferior turbinated body, describing a semi- circle in its course, and extending upward nearly to the roof of the nose. Abnormal dryness of the nasal mucous mem- brane, or nasal obstructions of a kind to interfere with the free access of air to the olfactory portion of the nose, inter- fere greatly with the acuteness of the sense of smell. Aitkin, experimenting with odorous substances, concludes that the sense of smell is excited not, as is generally as- serted, by small particles of such substances resulting from their evaporation, but by gases. The nose also serves as an additional resonant cavity during vocalization, so that obstruction of the nasal chambers invariably produces a peculiar nasal intonation during speech. Perhaps the most important function of the nose is to warm, moisten, and free from dust the inspired air. In health exhaled air invariably has a termperature of 98.5° F., and it has been proved experimentally that most of the heat supplied to inhaled air comes from the nose, the turbinated bodies being well adapted not only to warm the inspired air, but to moisten it and free it from particles of dust which adhere to its moist, sticky surface. Dust particles removed from the skin o{ the face and 70 DISEASES OF THE NOSE, THROAT, AND EAR from the vibrissae contain numerous bacteria from which cul- tures can be made. On the other hand, bacteria removed from the surface of the normal nasal mucous membrane evince little vitality and cultures are made from them with considerable difficulty. Hence it has been claimed that the nasal secretions possess sufficient antiseptic quali- ties to destroy some bacteria and inhibit the growth of others until they are removed from the nose by the use of the handkerchief The practical point from this is that irritat- ing antiseptic sprays before an operation are uncalled for, and by setting up what might be called a chemic rhinitis tend to promote the growth of bacteria rather than destroy them. This is particularly true of solutions of corrosive sublimate. INFLAMMATION OF MUCOUS MEMBRANES The most common forms are acute and chronic catarrhal inflammation, purulent, croupous, and diphtheritic inflam- mation. In acute catarrhal inflammation an increased blood-supply stimulates the epithelial layer of the mucous membrane to increased activity ; new cells are rapidly formed and cast off, while the glands pour out their secretion in excessive quanti- ties and an abundant liquor sanguinis transudes the vessels, the mucous membrane at the same time appearing red and swollen. Chronic catarrhal inflammation differs from acute catarrhal inflammation in that the subepithelial layer of the mucous membrane is more involved. Connective tissue is developed by a slow process of proliferation. Usually the mucous membrane is thickened and hypertrophied ; but, in some instances, the new tissue may be so placed as to press upon the glands and folhcles, giving rise to atrophy and the so- called atrophic or '' dry " catarrh. Also in catarrhal inflam- mation of the mucous membrane there sometimes occurs increased activity in the lymphoid cells, finally producing hypertrophy of the tonsils or other adenoid structures. Ac- tivity of morbid processes, confined largely to epithelial and lymphoid structures, belongs essentially to the younger rilYSIOLOCY OF MUCOUS M I:M i; KA XLS J I period of life ; while morbid activity in the connective-tissue structures belongs essentially to later life, rendering it much more difficult to bring about a cure in the catarrh of an adult than in that of a child. Croupous inflammation is of a higher grade than catarrhal ; for, while it commences in the same manner, with increased blood-supply, rapid cell-growth and proliferation, increased secretion, and a throwing off of immature cells, leukocytes, and liquor sanguinis, it differs from it in the fact that the exudate contains a large amount of fibrin and albumin, which coagulate upon the surface of the mucous membrane, form- ing a false membrane. This false membrane is at times so soft and almost granular in character as to be easily removed with a soft brush. At other times it is tougher and difficult of removal ; but, in either case, when removed, the mucous membrane is left intact or only deprived of some superficial epithelial cells. Diphtheritic inflammation is also characterized by the formation of a false membrane, but its pseudomembrane permeates the mucous membrane so densely that it can only be removed by bringing away with it the entire thick- ness of the mucous membrane to which it is attached, thus leaving the parts below completely denuded. A diphther- itic pseudomembrane is of a dark grayish color, resembling somewhat an ordinary slough of the mucous membrane, in contradistinction from a croupous membrane, which is of a bluish-pearl color, with no appearance as of sloughing of the parts. Pathology. — In inflammation of mucous membranes the secretions are either increased or decreased in quantity, so as to either flood the parts or leave them unnaturally dry. It should be borne in mind that the normal secretion of the nasal mucous membrane is over i6 ounces of clear watery mucus in twenty-four hours, a part of which in health passes unnoticed through the nasopharynx down into the esophagus and stomach. Only when by obstruction or irritation, due to any cause whatever, this easy outflow and abundant secretion is interfered with do we perceive a thick- ening and an accumulation of the secretion of the mucous membrane, which is designated as mucus, and is composed J 2 DISEASES OE THE NOSE, THROAT, AND EAR largely of epithelial cells in a state of fatty degeneration, mucous corpuscles, and the impurities filtered out from the inspired air. When mixed with pus or blood the secretions become yellow, green, or brown in color; and if retained upon the mucous membrane for a sufficient length of time the secretions become offensive as the result of putrefactive changes. " Catching cold " is the result of a transient influence upon the vasomotor system of nerves, producing an uneven dis- tribution of blood in the capillaries, especially manifesting itself as a congestion of the mucous membrane of the upper respiratory tract, followed in most instances by inflamma- tion, swelling, and either diminished or excessive perverted secretion. It is probable that the phenomena of " catching cold " is largely of a reflex nature, in which the peripheral sensory nerve fibrillae of the skin and extremities perceive the abstraction of heat as a shock, and being afferent in their conductive function, convey the impression to their respective ganglia, whence it is reflected by means of the efferent vasomotor fasciculi to the vessels, causing their di- latation and congestion, and, finally, inflammation of the structures containing them. This theory not only explains the ordinary phenomena of a *' cold in the head," but also the pain of neuralgia and rheumatism suddenly produced by " catching cold." Dilatation of the vasonervorum, resulting perhaps in the effusion of serum, produces pressure upon a nerve within its sheath and consequent pain in the muscle or skin containing it. The reason why the mucous membrane of the upper air- passages is the most frequent seat of an inflammation due to cold or a chilling of the surface of the body is that the sud- den change of temperature produces, in the first place, an effect upon the sensory nerve-fibers in the skin, which im- pression is communicated to the vasomotor centers, and con- sequently results secondarily in a contraction of the blood- vessels of that portion of the skin which has been affected. As there is a certain amount of blood in the vascular system at a given time, a sudden contraction of any portion of that system must, according to the law of hydrostatics, cause a corresponding dilatation at some other portion, DISEASES OE THE NOSE 73 which is tliat portion which is least able to resist tlie pres- sure. Inasnuich as our variable climate, the impurities of the atmosphere, and our artificial way of livin^^ have a tendency to weaken the capillaries of the upper air-pas- sages from early childhood, that portion of the human economy is therefore the region most liable to suffer from this unequal distribution of blood. There results, first, engorgement of the parts with increased secretion and, finally, inflammation. DISEASES OF THE NOSE Effect of Disease of the Nasal Passages on Other Parts of the Body. — Nasal disease may extend to the pharynx, ear, or larynx by continuity of structure, or affect the other res- piratory organs by abeyance of the functions of warming, moistening, and filtering the inspired air, so that it enters the pharynx cold, dry, and dust-laden, thus producing inflam- mation of the pharynx, larynx, and even of the parts below them. Chronic laryngitis frequently results from this cause ; and while it is not easy to prove that pneu- monic phthisis is directly the result of atrophic rhinitis, yet it is difficult not to suspect some such relationship between the two diseases. As the result of nasal disease there are often induced certain reflex phenomena, viz., nasal cough, nasal asthma, nasal vertigo, nasal epilepsy, nasal chorea, hay-fever, pareses of the palate and larynx, neuralgia and headache, reflex skin rashes, affections of the eye, both in- flammatory and muscular, and diseases of the ear. The term " reflex " is, doubtless, often misapplied, yet it has a definite significance, and the reflexes which originate in nasal or nasopharyngeal irritation and terminate in cough, laiyngeal spasm, or asthma, follow much the same pathway as the reflex known as sneezing. The nasal branches of the ophthalmic division of the fifth nerve and the nasal branches of the anterior palatine descending from Meckel's ganglion, which is in connection with the superior maxillary division of the fifth nerve, conduct the sensory impressions to the medulla. It is there reflected to the respirator}^ pneumo- gastric, and other centers, whence the deep inspiration, the 74 DISEASES OF THE NOSE, THROAT, AND EAR forced expiration, and the coincident spasm of the pharyn- geal and laryngeal muscles, termed a sneeze. Acute rhinitis is an acute catarrhal inflammation of the nasal mucous membrane. The synonyms are coryza ; cold in the head ; acute nasal catarrh ; in children, the snuffles. Etiology. — It is generally the result of exposure to cold and wet when the body is overheated. It may, however, be produced by breathing hot dry air or inhaling irritating vapors and dust, errors of diet, or come on apparently as the result of a venereal debauch. Chronic catarrh, syphilis, rheumatism, dyspepsia, or a debilitated state of the system renders an individual more liable to attack. According to some authorities pathogenic micro-organisms play an impor- tant part in the production of a *' cold in the head," and it has been claimed that the disease is infectious. Pathology. — At first the mucous membrane, though swollen and congested, is dry. As the disease progresses, there is an abundant serous discharge, which becomes more and more charged with broken-down epithelial cells, lymph- corpuscles, pus-globules, etc., until the discharge assumes the character of a thick, tenacious mucus or mucopus. The deeper lying tissues also participate in the process. The erectile tissue becomes gorged with blood and swollen, in some instances completely occluding the nares. Symptoms. — The onset may be simply an attack of sneez- ing, followed by increased and thickened discharges. In other cases the attack begins with chilly sensations and a general feeling of illness. There is a sensation of fulness and pain about the nose and forehead. The face may be flushed, the eyes suffused, and more or less fever be present. Sensations, almost suffocating in their character, may be present from occlusion of the nares, and the discharges be so irritating as to scald the skin of the alae and upper lip. A cold in the head lasts from two or three days to as many weeks. It generally ends in complete resolution, but fre- quently repeated is a common source of chronic nasal catarrh. In nursing children the child takes nourishment only with difficulty, frequently pausing to breathe through the mouth. DISEASES OF THE NOSE ^^ Treatment. — A cold in the head can often be aborted at its commencement by a hot bath and a bowl of hot lemon- ade at bedtime, with or without lo gr. of Dover's powder, followed in the morning by a saline purge and the wearing of extra warm clothing. The turgescence of the nasal mucous membranes and discharges can always be abated by the application of a 4 per cent, solution of cocain. This effect of the cocain can be kept up for several hours by spraying the interior of the nose with a 4 per cent, solution of antipyrin immediately after the application of the cocain solution. If repeated every day, this treatment gives great and immediate comfort to the patient and cuts short the course of the disease, while a soothing snuff (Formula 53) used by the patient in the intervals between the applications adds much to the efficiency of the treatment. In severe cases the patient had better remain in bed, and the presence of fever requires the administration of aconite in small doses at frequent intervals. Many pill makers manufacture what they term rhinitis tablets, the active ingredient of which is belladonna ; j-^q gr. of this drug, taken every two hours for four or five doses or until a sensation of dryness in the throat is produced and then at much longer intervals, yields decided relief in controlling the nasal symptoms. Simple chronic rhinitis is a catarrhal inflammation of the nasal mucous membrane, exhibiting but a slight tendency to spontaneous recovery. The syiionyms are chronic catarrh ; subacute rhinitis ; chronic cold ; chronic coryza ; rhinorrhea. Etiology. — It is generally the result of uncured rhinitis or frequent attacks of coryza. Pathology. — The mucous membrane of the nose presents precisely the appearance seen in acute rhinitis, only it is less swollen and less red in color. The discharge is either watery, if the upper parts of the nose, especially the mucous membrane of the middle tubinated bodies, are the parts most affected ; or it approaches mucopus in character if the disease is mostly locate(4 in the lower parts of the nose. The symptoms are precisely those of acute rhinitis, only less pronounced. There is a feeling of fulness about the "J 6 DISEASES OF THE NOSE, THROAT, AND EAR nose, a continual discharge, and the sufferer is continually " catching cold," when, of course, all his symptoms are in- creased in severity. Prognosis. — Untreated, chronic rhinitis may continue indefinitely, and finally result in hypertrophic rhinitis, the pharynx also gradually becoming affected. Treated in the following manner a cure is frequently brought about in from three to six weeks. Treatment. — Ordinarily the tone of the system is below par and a tonic is indicated. In such cases Formula 85 answers a most useful purpose. If the bowels are sluggish, it is advisable to direct the occasional use of a saHne cathar- tic. Cleanliness of the mucous mem.brane is of primary importance, and may be secured by the patient using at home, twice a day, a bland alkaline antiseptic wash (For- mulas I to 10) with an atomizer. The application of an alterative or an astringent to the nasal mucous membrane in these cases is of the greatest value, and the following formula has long been popular for this purpose : R lodini, gr. v ; Potassii iodidi, gr. xv; Glycerinae, f^j. — M. The result of the appHcation of this formula varies accord- ing to the amount of the solution used. When the nose is extremely sensitive only a small amount of cotton should be wrapped about the applicator, so as to form a brush capable of absorbing but a small amount of the solution, which should be carefully applied to those portions of the nasal mucous membrane where the inflammation seems greatest ; the cotton brush should also be passed along the floor of the nose and the application painted upon the pharyngeal mucous membrane. After the application of the iodin solution the use of some protective upon the nasal mucous membrane is advisable. This indication may be secured by means of a spray of fluid albolene, applied until the mucous membrane of the nose and nasopharynx is thoroughly coated with it. The albolene serves the pur- pose also of " spreading " the application previously made, DISEASES OE THE NOSE 77 vvhicli, to all intents and piir[)o.scs, becomes, after tlie use of the cosmolin, an (jintnient thoroiiL^lily coatinc^ the Schneiclerian membrane. Instead of plain albolcnc, what is frequently referred to as menthol-camphor-albolenc may be employed. The formula is : K Menthol, ^r. v ; Camphor, ^r. x\ ; Albolene, ^o'J- — '^^• In certain cases either of the following formulas when applied to the nose give quicker and better results than the iodin solution, especially in adults : li Buroglycerid, 50 per cent. R Acidi tannici, gr. xl ; Glycerina.', f3J. — M. . A case of simple chronic rhinitis is then perhaps best treated in the following manner : The patient is ordered a tonic, instructed to wash out his nose night and morning with either Dobell's solution or one of its modifications de- scribed above, and to present himself at the physician's office at least twice a week, but better every other day, for treatment. After first cleansing the nose with a spray from an atomizer filled with either alkaline solution, the physician should make an application of the iodin solution and follow it with a spray of menthol-camphor-albolene. Purulent rhinitis is an inflammation of the Schneiderian membrane in which the discharge from the beginning is purulent. It is usually chronic in character and more com- mon in children. Etiology. — It probably always results from specific infec- tion of some kind. It may occur during the course of one of the exanthemata, diphtheria, etc. Some cases occurring in young infants appear to be due to gonorrheal infection from the vagina during birth. Pathology. — The bacteria characteristic of the infection are found in the discharges or in the mucous membrane. Pseudomembrane usually occurs from the presence of y^ DISEASES OF THE NOSE, THROAT, AND EAR the Klebs-Loffler bacilli or some of the other bacteria. Primary nasal diphtheria without systemic involvement, or at least systemic symptoms sufficiently severe to confine the patient to bed, is not a very uncommon disease. Under such circumstances the most noticeable symptom is com- plete occlusion of the nares by the swollen mucous mem^- brane and pseudomembrane, a culture from which yields the characteristic bacillus of diphtheria. When the bacteria of purulent rhinitis are sufficiently virulent to cause actual destruction of tissue, deep ulcers occur, with final formation of scar-tissue. The disease in childhood is probably the most common cause of atrophic rhinitis in after life. Some cases are the result of inherited syphilis. Symptoms. — The disease is most common in children and is characterized by a fetid, thin, purulent discharge, some- times streaked with blood, which often excoriates the lip and alae of the nose. The nasal mucous membrane is red, swollen, and ulcerated, and may or may not be partly covered by a pseudomembrane. An infant is often able to nurse only with considerable difficulty, and hence such infants are frequently emaciated. An improvement in the infant's condition consequently results as soon as the disease subsides sufficiently to permit nasal breathing. Treatment. — The nasal mucous membrane should be cleansed at least twice a day with an alkaline spray. In infants the nose is more effectively cleansed by means of a syringe than by the spray from an atomizer, and the bulb rubber ear syringe (Fig. 48) is probably most useful for this purpose. Extreme gentleness should be used in syringing, in order to prevent fluid entering the middle ear. In children who have not yet learned to blow their nose, it is best to blow it for them by inserting the syringe tip into one nostril and forcibly compressing the syringe -bulb. By this means a current of air is forced into one nostril and out of the other, blowing the mucus and pus before it. After the nose has been cleansed of the major portion of the secretion, Dobell's solution may be dropped in by means of the syringe. A small quantity of gallic acid ointment, from 3 to 10 gr. to i ounce of vaselin, accord- ing to the age of the child, should then be placed within D/SKASKS OF 'J'lII': NOSE Jcj the nostrils with a brush. This home treatment shouhl be carried out twice a day. The physician himself should treat the child two or three times a week or oftener by cleansing the nasal mucous mem- brane as described above, using an air-douche either from a syringe or, in the case of larger children, the Politzer bag to blow mucus from the nose both before and after the use of the atomizer. When thoroughly cleansed the nose should be sprayed with albolene and dusted with powdered calomel or aristol by means of a powder-blower, care being taken that none of the powder reaches the pharynx and is swallowed. In scrofulous children hygienic measures are often as im- portant as local treatment. Cod-liver oil and syrup of the iodid of iron will be required in many instances. In primary nasal diphtheria with pseudomembranes, these should be removed with forceps and peroxid of hydrogen, and the underlying mucous membrane painted with a 6o-gr. solu- tion of nitrate of silver. The nasal mucous membrane should then be sprayed with menthol-camphor-albolene, and the parts covered with calomel or some other reliable antiseptic powder. In many cases of pseudomembranous rhinitis, where the Klebs-Loffler bacillus is present, there is an entire absence of constitutional symptoms, and it often requires some persuasion to induce the parents to keep the child away from school. However, quarantine, at least to the extent of avoiding contact with, other children, should be insisted upon. At home the nasal mucous membrane should be sprayed every two to four hours with 3 per cent, peroxid of hydrogen diluted with an equal quantity of Dobell's solution, and then with menthol-camphor-albolene. Hypertrophic rhinitis is a chronic inflammation and hyper- trophy of the nasal mucous membrane and submucous tissues with hyperemia or permanent dilatation of the blood-vessels. Hypertrophy of an organ is due to an increase in the size of the cells, wdiile hyperplasia is an increase in the number of cells. Both conditions imply an increase in the bulk of an organ. In the turbinated bodies of the nose the condi- tions can be differentiated from the fact that in hypertrophy 8o DISEASES OF THE NOSE, THROAT, AND EAR the parts are soft to the touch and shrink greatly under the appHcation of cocain or adrenahn, while in hyperplasia the parts are firm to the touch and do not shrink greatly under cocain. The sy7i07iyms are obstructive rhinitis ; hypertrophic nasal catarrh. Etiology. — It is invariably the result of long-continued simple chronic rhinitis or frequent attacks of coryza. It is said to occur most readily in the gouty and rheumatic. Pathology. — While in long-continued simple chronic rhi- nitis there is already some thickening of the epithelial layer of the mucous membrane, yet the disease only becomes hypertrophic rhinitis when the thickening involves the other elements of the mucous membrane and the submucous structures. As the result of frequent attacks of inflamma- tion the blood-vessels become permanently dilated and their walls thickened, glandular tissue is hypertrophied, infiltrations occur, which finally become organized into connective tissue, so that the thickened turbinated tissues cannot collapse as when normal, and remain permanently distended with blood. This thickening is most notice- able at the anterior and posterior parts of the middle turbinated bodies, where it is called an anterior or pos- terior hypertrophy. Generally as the result of trauma- tism, ecchondroses and exostoses occur upon the septum opposite the pendulous portion of the inferior turbinated bodies, thus increasing the nasal obstruction. Often a " bank " or " ridge " of cartilage and bone will extend for a long distance along the septum opposite the inferior turbi- nated body, or along the sutures of the cartilaginous and bony septum. Symptoms. — The most prominent symptoms are those of nasal obstruction, want of proper drainage from the nasal cavities, and increased secretions. When the obstruction is great and constant the patient becomes a " mouth- breather." The inspired air, under such circumstances, not being properly warmed, moistened, and freed from dust in its passage through the mouth, causes dry lips, a coated tongue, follicular phar}^ngitis, and sometimes chronic laryn- gitis. When the nasal occlusion is complete, the face DISEASES OE THE NOSE 8i assumes a stupid expression on account of tlie constantly open mouth. Should the habit of mouth-breathing^ be acquired in early childhood and continued for some years, even the shape of the bones of the face is altered and the habit of mouth-breathing retained long after the nasal ob- struction has disappeared. In most cases of hypertrophic rhinitis any position favoring the gravitation of blood into the hypertrophied parts is sufficient to cause their disten- tion ; hence, when the patient is in bed, first one nostril and then the other will become occluded, according to which side of the body is lain upon. This is especially true -H-* Fig. 53. — Nostril dilated by Bosworth's speculum, showing anterior hypertrophy (Seiler). when large posterior hypertrophies are present. Obstruc- tion and suppuration of the nasal duct not infrequently occurs as the result of inflammation of the duct, begin- ning at its nasal orifice. An anterior hypertrophy of the middle turbinated body pressing on the septal nerve, which is a branch of the ophthalmic, frequenth' causes reflex eye-symptoms, such as chronic conjuncti\-itis, slight paresis of accommodation, and irritable retina. The olfac- tory slit may become closed from hypertrophy of the middle turbinated body, and thus intei-fere with the sense of smell and also that of taste to a corresponding degree. Redness of the tip of the nose and acne are also apparently in some cases the result of interference with the blood 82 DISEASES OF THE NOSE, THROAT, AND EAR supply of the skin. Hearing may be gravely compromised from the pressure of hypertrophies interfering with the blood supply of the Eustachian tubes, the damming up of their secretions, or the extension of the disease to their lining mucous membrane. Headaches are often complained of, and a feehng of pressure or even of pain at the root of the nose, as the result of occlusion of the infundibulum. The patient frequently complains that he has " a bad breath." In many cases the offensive odor is due to decay- ing epithelium upon the tongue as the result of mouth- breathing or dyspepsia. At other times the " bad breath " of which the patient complains is perceptible only to him- self, and is probably due to irritation of the olfactory region of the nose, contrasting strongly in this respect with atrophic rhinitis. If any " catarrhal odor " of the breath of wM^mm mmMm . ■^^^^^M Fig. 54. — Jarvis' transfixing needles. an individual with hypertrophic rhinitis be present, it is always more annoying to himself than to a bystander. Treatment. — Each case should be treated as one of simple chronic rhinitis until the inflammation of the Schneiderian membrane has disappeared, when operations should be undertaken for the removal of any tissue causing obstruction. Removal of Anterior Hypertrophies. — If large, especially if the hypertrophy consists of hyperplastic tissue, that is, tissue that does not contract when cocain is applied, the operation with Jarvis' needles and snare (Figs. 54 and 55) will be found most satisfactory. The base of the hypertro- phy should be transfixed with a needle and the wire loop of the snare so placed that it surrounds the base of the hypertrophy beneath the needle. The loop being drawn tight, the milled nut of the instrument is turned slowly until the wire loop has cut through the tissues. If the operation is done slowly little or no hemorrhage results. Anterioi' DISEASES OE THE NOSE 83 y hypertrophies of the middle turbinated body may, however, be removed in the same manner without the use of a needle. Small anterior hypertrophies can be removed very satis- factorily by simply cutting through them with a sharp knife to the bone. This method is of advantage in children, where, as the result of eczema of the lip and aLne, and great inflam- matory swelling of the skin and mucous mem- brane, it is difficult to do any other operation. If cocain be used, the cutting causes no pain, and may be repeated as often as the cut heals, until the eczema and hypertrophy have dis- appeared, which often occurs within a few weeks. Anterior hypertrophies may also be de- stroyed by means of chemic caustics. These applications are, however, so unsatisfactory, in comparison with other measures at our dis- posal, that it is best not to employ them unless nothing better is obtainable at the time of the operation. Perhaps the best method of removing an- terior hypertrophies is by the galvanocautcry. A pledget of absorbent cotton, saturated w^ith a 3 per cent, solution of cocain, is introduced into the inferior meatus and allowed to re- main in contact with the hypertrophy until it has shrunken as much as possible and the parts are thoroughly anesthetized. A metal speculum is introduced after the removal of the cotton and the hypertrophy exposed. After the platinum wire of the cautery-knife is at a dull-red heat it is placed upon the thickest part of the hypertrophy, and by means of gentle to-and-fro movements is made to cut through to the bone, when it is carefully w^ith- drawn, so as not to detach the eschar which it has formed. The operator should be careful to cut down to the peri- osteum before withdrawing his cautery-knife or the results of the operation will be far from satisfactory ; for, although Fig. 55. — Jarvis' snare. 84 DISEASES OF THE NOSE, THROAT, AND EAR a superficial burn either with the galvanocautery or chromic acid heals very quickly and gives a certain amount of relief for a short time, yet the results are not as permanent as when the cautery-knife is made to penetrate the periosteum. No after-treatment is required beyond keeping the w^ound as dry as possible and endeavoring to avoid detaching the eschar before the healing process has been completed beneath it. Should, however, the eschar become detached an antiseptic and astringent powder may be applied with advantage to the w^ound to form an artificial scab. The day following the operation there may be some inflam- matory reaction and the nostril occluded by swelling of the wounded hypertrophy, tlie patient feeling as if he had caught cold in that nostril ; but this quickly subsides if all catarrJial inflainniation lias been renwveei before the operatio7i was nndcr- take)i. When this has not been done, slight elevation of temperature and inflammation of the tonsil and perhaps other lymphatics on the same side as the operated nostril sometimes occur, and indicate the presence of a mild infec- tion. Although nearly six weeks are sometimes required for the complete healing of a cautery w^ound, yet little inconveni- ence is usually experienced by the patient during the heal- ing process, except that during the first week the nostril is sometimes more obstructed than ever as the result of sw^ell- ing. At the end of about ten days the slough produced by the burning separates from the w^ound and decided' advantage from the cauterization is then first experienced. The improved respiration becomes greater and greater until the wound is finally entirely healed. The anterior portion of the turbinate then presents a somewhat pale appearance, with a depression indicating the seat oi the cautery appli- cation. The turbinate not only is diminished in size, but sudden change in its volume, with consequent obstruction of the nostril, is also prevented. The patient states he " does not ' catch cold ' as readily as before the operation." The cautery should be used judiciously, as great and permanent injury may result from the work of a careless or brutal operator. Large tracts of mucous membrane may be destroyed by application of the flat side of the cautery- DISEASES OE THE NOSE 85 knife or the spreadinij^ over ^- knives can be constructed from ordinary dry cells such as can be obtained in any electric supply store for about 30 cents a piece. For the laro;er knives it is safer to have as 88 DISEASES OF THE NOSE, THROAT, AND EAR many as twelve cells ; for the smaller knives, three or, at most, six cells will be sufficient. The cells then should be arranged in a box in series of three and multiples of two and four. (Fig. 59 shows the arrangement of cells and binding posts.) When the cautery-knife is connected with binding posts i and 2 but two series of three cells are in the circuit and there is little danger of melting the thin platinum of a small knife. When binding posts i and 3 are used, four series of three cells will be in the circuit and sufficient electricity will be furnished to heat the largest knives. The advantage of this arrangement is that when the cells become exhausted others readily can be purchased in any electric supply store. This arrangement of the cells cannot be used for small incan- descent lamps for purposes of transillumination, as the voltage of such lamps is commonly greater than that furnished by three cells in series. In fact, for purposes of transillumi-na- tion, it is convenient to have six cells in series. When the rhinologist's office is lighted from the wires of an electric supply station some form of " converter " may be used to secure a current suitable for the galvanocautery, snare, miniature lamps, and electric motor. Apparatus also may be purchased for obtaining from the companies' wires both a suitable galvanic and faradic current for medicinal purposes. Removal of Posterior Hypertropliies. — A Jarvis snare should be threaded with No. 5 imported steel piano wire, as the wire should have sufficient resistance not to bend away from the base of the hypertrophy after it has engaged the growth. The loop of wire should be bent to one side before being introduced into the nostril, so that it may the more readily be passed around the hypertrophy and remain Fig. 59.— Diagram showing arrange- ment of ordinary commercial dry cells for cautery : b^, V^, b^, Binding posts ; c, carbon; z, zinc. DISEASES OE 77/ E NOSE 89 in position when the loop is tightened. Ik-ini^ made as small as possible without distortini^ it by pullin<^ down the sliding tube upon the handle of the instrument, the loop is carefully introduced alon<^ the floor of the nose until the posterior wall of the pharynx is reached, when the loop is again enlarged by pushing upward the sliding tube, and the instrument at the same time is slowly withdrawn as its handle is carried toward the septum. By this means the wire is made to surround the hypertrophy and a resistance is finally felt as the instrument is withdrawn, caused by the bight of the loop coming in contact with the base of the hypertrophy. The wire loop is now quickly tightened around the hypertrophy by pushing forward the instrument within the sliding tube, and the milled nut is quickly screwed downward into place. Two or three additional turns are given to the milled nut to be certain that the wire is tight about the base of the growth and that the instrument is held firmly in place without danger of slipping, when the patient may be allowed to rest. The sudden tightening of the wire loop occasions the patient some pain, which, how- ever, soon subsides, when the loop may be still further tightened by turning the milled nut until the patient begins to again experience pain. In this way, proceeding slowly and carefully, the hypertrophy is finally squeezed off from its attachment, and is generally removed clinging to the end of the instrument by some fibers that have been drawn down into it with the wire. Should, however, the growth not be removed with the instrument, no attempt should be made to dislodge it from the nose, as it forms an efficient plug to prevent hemorrhage, and will probably drop into the fauces and be expectorated within twenty-four hours after the operation. From thirty minutes to two hours should be thus consumed in removing a posterior hyper- trophy in order to prevent severe hemorrhage, which, from its situation, might be difficult to control ; the patient should sit a while in the doctor's office before proceeding homew^ard, and should be cautioned against walking rapidly, violently blowing his nose, or hawking and spitting. Ordinarily there is very little blood lost at the time of the operation, but for some days afterward the patient expectorates a 90 DISEASES OF THE NOSE, THROAT, AND EAR blood-tinged mucus. Owing to the compression of the wire, the wound made by snaring a posterior hypertrophy is but small and generally heals rapidly. Where there are several posterior hypertrophies present in the nose, a second opera- tion may be done a week after the first. If a posterior hypertrophy is very small and sessile it may more easily be removed if the operator waits until his patient has caught cold, when the swollen growth is more readily grasped with the wire. Cocain should not be used as a local anes- thetic for the removal of posterior hypertrophies because it shrinks the tissues to such an extent that it is difficult to grasp the hypertropy with the snare. A lo per cent, solu- tion of stovain does not contract the tissues and hence is the preferable anesthetic for this operation. Ecchondroses and Exostoses of the Septum. — A localized cartilaginous thickening or projection from the cartilaginous septum is called an ecchondrosis, while a similar bony growth upon the bony septum is referred to as an exostosis or hyperplastic osteoma. Heteroplastic osteoma is a name given to rather a rare form of bony nasal growth which springs from the cellular tissue beneath the mucous mem- brane, is not continuous with the cartilaginous or bony framework of the nose, and is therefore movable. Fre- quently ridges or shelves of cartilage and bone are found extending along the septum nearly from the anterior to the posterior nares. Usually such growths are opposite the lower turbinated body or follow the suture between the vomer and superior maxillary or that between the triangular cartilage and the vomer. Etiology. — They are doubtless sometimes merely pro- visional callus that has escaped absorption and been de- posited upon an old fracture of the septum. The fracture may have been received during early childhood as the result of one of the numerous " bumps upon the nose " that children are constantly receiving. Symptoins. — Frequent nasal obstruction. Atrophy of the turbinated body opposite them is not uncommon, nor neuralgia of the whole side of the face as the result of intranasal pressure. Sometimes the crest of such growths is ulcerated, and a thin, irritating, sanious discharge results, DISEASES OE THE NOSE 9 1 impossible to cure except by the removal of the exostosis or ecchondrosis. The nostril bein^- obstructed in front, the breath current is interfered with in such a way that there is a constant rarefaction of the air at the orifice of the luista- chian tube at each inspiration, and as the result of " vacuum congestion " tinnitus and, finally, otitis media and deafness result. Operations. — Localized thickenings of the cartilaginous septum may be cut through and removed by means of a small probe-pointed tenotome. When the growth is hard and bony it is best removed by means of a chisel or saw. It should be borne in mind that only that portion of the growth should be removed which interferes with proper nasal respiration. This, of course, means in most instances the whole of the growth. In a roomy nostril, however, and in atrophic rhinitis the growth may in some instances be doing good by occupying a certain amount of space in a nostril already too large, and under such circumstances its removal w^ould probably cause postnasal catarrh and chronic pharyn- gitis. The patient is prepared for operation by placing a piece of absorbent cotton saturated with a 4 per cent, solu- tion of cocain within the nostril. The cocain should be allowed to remain in contact with the structures to be oper- ated on for at least tw^enty minutes that its anesthetic effects may penetrate as deeply as possible. After the removal of the cotton the nostril should be sprayed with a i : 1000 solution of adrenalin to render the operation as bloodless as possible. The line of incision should then be painted with a 10 per cent, solution of cocain. The parts to be operated upon should be exposed by means of the author's dilator (Fig. 21), which will be found very convenient for operations within the nose, because when once in position it is more nearly self retaining than any other nasal speculum, and is not easily displaced by the struggles of the patient during an operation. If a chisel is to be used the patient's head is made to rest against a firm support, and the edge of the chisel is placed against the anterior portion of the exostosis and made to penetrate as deeply as possible by pushing it forward with the hand. If necessary the operation is continued by hammering upon 92 DISEASES OF THE NOSE, THROAT, AND EAR the handle of the chisel with a lead mallet until the growth is felt to be severed ►from its attachment to the septum. Ordinarily, after the use of the chisel, a few sherds of mucous membrane still bind the growth to the septum. These are severed by passing the wire loop of a snare around the growth, and the exostosis withdrawn from the nostril by means of the snare or forceps. The advantage of the chisel operation is the quickness with which it can be performed ; but after the first cut has been made the nostril is deluged with blood and the operator has to com- plete the operation entirely by the sense of touch, being careful to hold his chisel, while hammering upon it, with its b-lade exactly parallel to the septum. The operation is brutal and is almost invariably followed by syncope, as the result, perhaps, of the concussion of the brain caused by the blows of the mallet. When the exos- tosis is large the results are frequently unsatisfactory, a large jagged wound generally resulting from frequent appHcations of the chisel. The operation, if justifiable at all, is only so in cases where the exostosis is attached to the septum by so narrow a base that it may be severed by a single thrust, as it were, of the chisel or gouge. When the saw is used, it should be entered belozv the growth and the sawing done in an upward direction, so as to obscure the field of operation as little as possible by blood, which, of course, flows downward from the wound. When the shelf of bone is large and hard the operation is necessarily tedious ; but at any stage of the operation the saw may be withdrawn and both operator and patient rest, a plug of absorbent cotton saturated with a 4 per cent, solution of cocain being again inserted within the nostril. Under these circumstances the cocain acts as a hemostatic, and the probability is that the nostril will be found free from blood when the cotton is withdrawn, so that the operator can readily see to replace the saw in the cut already made. However, if necessary the nose may be sprayed with a I : 1000 solution of adrenalin from time to time during the operation. It is possible in some instances to secure a prac- tically bloodless operation ; but it should be borne in mind that adrenalin contracts only the more superficial vessels, and DISEASES OE THE NOSE 93 that if a large vessel is severed, especially one deeply im- bedded in bone, the hemorrhage may be severe. Under such circumstances the operation should be completed as si)eedily as possible and the severed mass of bone removed. The nostril should then be quickly " packed " with cones of absorbent cotton saturated with peroxid of hydrogen, as described in the section on Nasal Hemorrhage. It is well before undertaking any operation to have several cones of cotton prepared so as to be able to quickly control hem- orrhage should it occur. There are many varieties of Jiasai saius for sale in the in- strument stores. That of Sajous (Fig. 60, a), Bucklin (Fig. d Fig. 60. — Nasal saws : a, Sajous' saw ; b, Bosworth's saw ; c, Bucklin's reversible saw. 60, r), with teeth arranged like a metacarpal saw, sever the bone more rapidly than the others, and hence are to be pre- ferred when the mass of bone to be removed is large and hard. Sajous' saw is the more rapid of the two. Not infrequently, after the bone has been completely severed, it will be found difficult to cut wnth the saw the shreds of mucous membrane by which it is still attached to the septum. These shreds usually can be easily cut with the nasal scissors. However, in most instances the snare (Fig. 54) is by far the preferable instrument. The snare is especially useful in cases where a small exostosis has appar- ently been completely severed, but has disappeared from 94 DISEASES OE THE NOSE, THR0A1\ AND EAR view in the blood within the nose. In some of these cases it is difficult to locate and grasp the mass with forceps, and impossible for the patient to blow it from the nostril because of a shred or two of uncut mucous membrane ; under these circumstances if the wire loop of a snare is passed beyond the position of the exostosis and then kept closely in contact with the septum as it is withdrawn from the nose, the loop will hardly fail to encircle any shreds that still connect the exostosis to the septum, and after these are severed by closing the loop the exostosis usually is with- drawn from the nose with the snare by means of fibers that have been drawn into the tube of the snare. Fig. 6i. — Nasal scissors. Drills. — The motive power for the drill is supplied through a flexible armpiece (such as is used by dentists) by a small electromotor suspended from a movable bracket attached to the wall, at one side of the patient's head. Many of the drills and trephines offered for sale are rendered so clumsy by the shield designed to protect the parts about the field of operation from injury that the trephine and shield cannot be introduced more than J inch within the nostril with- out hiding everything from view; while the instrument is too short to reach from the anterior to the posterior border of the septum (Fig. 62). There is, moreover, so much rattling of the trephine inside the shield as to interfere DISEASES OF THE NOSE 95 materially with the delicacy of the sense of touch throii<^h it. These faults are overcome by lengthening^ the shanks of trephines and burrs, and constructing^ the shield as shown in Fig. 63. So modified, the trephine seems to possess all the advantages of both chisel and saw for the removal of bony growths from the septum, and none of the disad- vantages of either instrument. The operation with the drill is per- formed in the following manner : A trephine sufficiently large to remove at once the major portion of the exos- tosis is selected, and with its shield is adjusted to the armpiece of the elec- tric motor in such a manner that the shield will protect all parts of the nose from injury except those to be cut away. The teeth of the trephine are now pressed into the anterior part of the growth, and as the instrument is pushed forward a piece of bone is cut from the exostosis, w^hich enters the cavity of the trephine, where a knife set at an angle cuts it into pieces suf- ficiently small to pass through a fenes- tra made for this purpose. Should a sufficient amount of the growth not be removed by the first passage of the trephine through the nasal fossa, the tre- phine may be reapplied as often as may be necessary to Fig. 62. — Electric-motor drills. Fig. 63. — Gleason's electric-motor dri remove the entire exostosis and leave a smooth, flat sur- face like that made by a saw. When an ecchondrosis or exostosis has attached itself to the inferior turbinated bone, so that a synechia or ** bridge " extends from the septum to the opposite side of the nostril, it is perhaps best removed by first sawing g6 DISEASES OF THE NOSE, THROAT, AND EAR through the portion next the septum, then snaring the attachment to the turbinate. Unfortunately, after such an operation the " bridge " is very hable to recur, owing to the granulations from the cut surfaces of each side of the nostril approaching each other during the healing process until they finally unite. To prevent this disaster, a steel probe may be used to break down the adhesions, or a piece of tin-foil or gutta-percha may be worn inside the nose between the cut surfaces until the healing process is complete. Ordinarily nasal operations, either with saw or chisel, require no after-treatment beside the free use of an alkaline wash by the patient, in order to keep the wound clean. There is but little inflammatory reaction and the w^ounds heal prompt^. Packing tlic nose with iodofom gauze or any other sub- stance after a nasal operation should be avoided if possible. It is only permissible to check hemorrhage or when the patient has to travel a considerable distance after leaving the surgeon's office before reaching home. Under such circumstances a narrow strip of iodoform gauze, previously saturated wath fluid albolene, should be placed in the nose in such a manner as to make gentle pressure upon the wound. Such a packing can generally be removed in from twelve to twenty-four hours, if care is taken to remove it gradually, so as not to remove the pressure from the wound too suddenly. When no dressing is used, which is by far the preferable method, blood-stained mucus is blov/n from the nose for some days after the operation. Tin'biuectoDiy, or removal of the whole or, at least, the greater portion of the inferior turbinated body, has been performed to secure increased breathing space, for the removal of malignant growths, and for other reasons. Turbinotomy, or the removal of a portion of the inferior turbinate, has been already described. The removal of a portion of the middle turbinate will be considered in the section on Ethmoiditis. Practically, turbinectomy of the middle turbinate is never performed. When sufficient nasal respiratim can be secured by operations on the septum, such as the removal of an DISKASKS OF 'J'lIE NOSE 97 exostosis or bringing a septal deviation into the median line, it is better not to remove any large portion of the infeiior turbinated body because of the great destruction of mucous membrane and erectile tissue. Moreover, a turbinectomy done to relieve the stenosis caused by a deviated septum would accomplish nothing toward nnproving the condition of the wider nostril. As a matter of fact, when middle-ear catarrh results from deviation of the nasal septum, it frequently begins in the ear of the same side as the wider naris. The operation is done in the following manner : The nasal mucous membrane is cleansed with spray from an atomizer containuig Dobell's solution or some other suitable alkaline fluid. The nasal mucous membrane is then sprayed with a I ; 1000 solution of adrenalin in order to prevent hemorrhage. The upper and lower portion of the attach- ment of the inferior turbinate is now cocainized with a 4 per cent, solution of cocain. All adhesions between the turbinate and the septum are broken down and the saw inserted just beneath the articulation of the turbinate with the maxillary bone. The sawing is done diagonally up- ward and inward until the articulation is severed. Should the saw fail to sever some shred of connective tissue and mucosa that still unite the turbinate with the superior maxilla, these are cut with a pair of scissors and the turbinate grasped with a pair of forceps and removed from the nose. Should hemorrhage render such a procedure necessary, the nostril is packed with iodofom gauze saturated with peroxid of hydrogen and the patient placed in bed. This packing is removed permanently after tw^enty-four hours unless renewed hemorrhage necessitates replacing the pack- ing. During the period required for the healing of the wound the nose is cleansed with Dobell's solution and the wound covered with a powder consisting of equal parts of aristol and stearate of zinc. Atrophic rhinitis is an atrophic condition of the nasal mucous membrane, usually also of the submucous tissues ; and occasionally of the turbinated bones and septum. The disease is characterized by a lessening in the size and thick- gS DISEASES OF THE NOSE, THROAT, AND EAR ness of the intranasal anatomy, a change in the color of the mucous membrane, and partial loss of function as the result of a decrease in the number of component cells, hence the formation of crusts of inspissated and putrid mucus which emit a fetid and offensive odor. The synonyms are dry catarrh ; atrophic nasal catarrh ; in children, scrofulous rhinitis; and where there is a stench, ozena. Etiology. — Atrophic rhinitis is said to result from long- continued hypertrophic rhinitis. An abnormal dryness of the atmosphere, like that produced by hot-air heaters, abnormal patulency of the nares, or anything else that causes a rapid evaporation of the nasal secretions, tends to produce atrophic rhinitis. Bosworth stated that in many instances the disease begins in childhood as a puru- lent rhinitis. Any infection with bacteria virulent enough to cause destruction of the nasal mucous membrane over comparatively large areas will produce atrophic rhinitis. The writer has seen it occur in the adult as the result of syphilis, and probably the larger majority of cases are the result of the destruction caused by pseudomembranous rhinitis and nasal diphtheria. Suppuration of the accessory sinuses also may be either a cause or the result of atrophic rhinitis, and there is said to be present in most cases the bacillus fcetidus ozaenae, which was formerly thought to be the cause of the disease. Bacteria of various kinds swarm in the semiputrid, half-dried secretions, and the stench is either directly the result of such masses, or may originate from the contents of suppurating accessory sinuses, or from masses retained in the crypts and folds of the third tonsil. The bony structures atrophy as the result of a rarefying osteitis affecting mostly the turbinates. Pathology. — When the disease is the result of long- continued hypertrophic rhinitis, the pressure of adventitious cellular tissue causes absorption of the glandular elements. The surface of the mucous membrane being thus nearly deprived of its secretions, is exposed to dust and irritants of every kind that accumulate upon it, and with long- retained and rotting semi-inspissated secretions, form bad- smelling scabs and crusts. Owing to pressure from these DISEASES OE THE NOSE 99 scabs, shallow ulcers occur beneath them, while the atrophy progresses until, in sonic cases, the turbinated bones have nearly disappeared and the septum has become, at certain parts, almost as thin as a sheet of writing paper. It is not uncommon for individuals to present themselves to the surgeon with hypertrophic catarrh existing in one nasal cavity, whilst atrophic rhinitis is present in the other. In such cases there is usully deviation of the septum toward the hypertrophic side. Cases are not infrequently seen with an inferior turbinated body and the adjacent mucous membrane atrophied, whilst the middle turbinated body immediately above is greatly hypertrophied. Concomitant disease of the ethmoid cells or of some one or more of the other accessory sinuses of the nose is not uncommon in atrophic rhinitis, and it has been claimed that atrophic rhinitis may result from suppuration of one of the accessory sinuses. When superficial necrosis results from bacterial infection the progress of the disease, after the for- mation of ulcers, is similar to that described above. Retained secretions putrefy and produce a characteristic odor, horribly offensive, the disease being then termed ozena. Similar stenches occur in syphilitics, the stench resulting usually not from fetid semi-inspissated mucus, but from sequestra of dead bone within the nose. Somewhat numerous varieties of bacteria are found in the secretions of atrophic rhinitis, the saprophytes, or those causing putrefaction, naturally being the most numerous. Attention has not infrequently been called to the large pro- portion of cases of pulmonary tuberculosis among patients with atrophic rhinitis ; for instance, Theisen reports 14 cases of pulmonary tuberculosis among 40 cases of ozena examined. It has been suggested that the large proportion of consumptives is due to the fact that atrophic rhinitis de- prives the nose of its power to arrest and destroy the bac- teria of inspired air. Symptoms. — A sensation of dryness and irritation within the nose and pharyngeal vault, with almost constant efforts to remove the accumulated secretions by hawking, spitting, and blowing the nose. The breath is usually fetid, but the patient, because of his defective sense of smell, is un- lOO DISEASES OF THE NOSE, THROAT. AXD EAR aware that his breath is horribly offensive. Upon inspec- tion, the mucous membrane is found diy and glazed, with scabs and pus adhering to certain portions of it. Sometimes the nostrils are so patulous that the posterior phar}mgeal wall can be plainly seen through them, and it also is usually in an atrophic condition. Reflex skin rashes and laryngitis are ver^' common as the result of this affection. Treatment. — The indications are to secure and maintain absolute cleanliness of the nasal mucous membrane, and replace, if possible, the atrophied parts. Cleanliness may Fig. 64. — Anterior nasal douche and method of using it (Casselberr\'). be secured by the patient's use of an alkaHne wash. For this purpose Dobell's solution or, in fact, any of the ten formulas mentioned on page 494 answers sufficiently well. When there is considerable trouble in loosening and re- moving dried secretions, peroxid of hydrogen diluted with I or more parts of Dobell's solution may be employed with an atomizer. Not infrequently the spray from an atomizer, in the hands of a patient, fails to dislodge accumu- lations, and under such circumstances Thudicum's douche (Fig. 64) is a permissible instrument, as in atrophic cases DISEASES OE THE NOSE lOI there is less danger of fluid entering the T^ustachian tubes than when the nostrils are blocked by hypertrophies. However, when one side of the nose is wider than the other the douche should alwa}'s be used from the narrower toward the wider side. A safer instrument for patients' use is the modification of the postnasal syringe shown in Fig. 65. This the patient is easily taught to introduce behind his palate. It is not only safer but more efficacious for removing secretions than the douche. It is nearly as safe as an atomizer. However, the fact should always be remembered that somewhat numerous cases of middle- ear suppurations have resulted from fluid penetrating the middle ear when sniffed from the hollow of the hand, a cup, an Alhngham douche, or the use of Thudicum's douche ; and hence these methods of cleansing the nose should not be emplo}'ed by the patient unless it is absolutely impossible to keep the nose clean by the use of an atomizer. Moreover, when the patient is wearing Gottstein's cotton cylinders within the nose there is usually no trouble in removing with an atomizer the secretions, as crusts usually cease to form. For the rhinologist's use in cleans- pio. 65.-Postnasai douche, mg the nose of an atrophic case the Modified for pat.ems' use, dental bulb syringe (Fig. 38, r, with postnasal tip i) answers the most useful purpose. The distal extremity of the tip should be nitroduced behind the palate of the patient, who bends his head forward over a bowl. The rhinologist should then compress the bulb with considerable force, so that the fluid (which should be warm) flows in a rapid stream from the nasopharynx through the nostrils into the bowl. Excellent results follow applications of lignol diluted with an equal quantity of sweet oil (Formula 36). T. Bobone uses for the same purpose : I02 DISEASES OF THE NOSE, THROAT, AND EAR R Petroleum, gm. 40.00 ; Olei eucalypti odoris citri, gm. 0.50; Strychnine nitratis, gm. 0.02. — M. Good results follow massage of the atrophied mucous membrane with a cotton-tipped probe. Powders, possibly because of the mechanical irritation they cause, do good in some cases, and for many years the writer was in the habit of employing a powder composed of a small proportion of nitrate of silver diluted with starch (in the earlier days of rhinology) or stearate of zinc. More recently the main dependence, as far as applications are concerned, has been upon lignol (Formula 36). The best results are obtained in the treatment of atrophic rhinitis by the use of cylinders of absorbent cotton, as first advocated by Gottstein (Fig. 66), so placed inside the nose Fig. 66. — Allen's nasal applicator with Gottstein's cotton plug ready to be deposited inside the nose. After the cotton is within the nose the probe is detached from the cotton and withdrawn by turning it in a direction opposite to that by which the cotton was wrapped. as to perform the functions to a certain extent of the atro- phied turbinated bodies. If pharyngitis sicca is present, the cotton cylinders should be of sufficient length to extend the entire length of the nasal floor and project somewhat from the posterior nares. The presence of the cotton cylinders excites the atrophied mucous membrane to renewed action, so that the dried secretions are washed away in the increased discharge and the fetor of the breath corrected. The cotton cylinders soon become soaked with mucus, so that the air passing around them is warmed, moistened, and freed from dust, and enters the pharynx and larynx as if it had passed through a healthy nose. This is the result partly of mechanical irritation and partly of the rarefaction of the inspired air — a factor that should not be overlooked in the treatment of atrophic rhinitis, as irreparable damage results from the removal of an exostosis, especially if located well forward. DISKASKS OF J HE NOSE I03 A cotton cylinder is easily made by loosely wrapping ab- sorbent cotton about an applicator (Fig. 66) until it has as- sumed the desired bulk and shape. The cotton is then placed inside the nose and the applicator removed by turning it in a direction opposite to that by which the cotton was wrapped about it. The patient should be taught how to make and place these cotton cylinders inside his nose, and should insert fresh ones as soon as the old are removed by the use of the handkerchief If worn constantly they cause an immediate change for the better in all the symptoms of atrophic rhinitis and stimulate the renewed growth of the atrophied tissues. The average case of atrophic rhinitis without disease of an accessory sinus is best treated in the following manner: At the first office visit the nasal and nasopharyngeal mu- cous membrane is thoroughly cleansed and all adherent masses removed. Lignol (diluted with an equal amount of olive oil) is then thoroughly applied to the entire sur- face and carefully worked into all angles and spaces, such as those about the remains of the turbinated bodies. At the third or fourth office visit at intervals of three or four days the mucous membrane will have assumed a more normal appearance, and the patient should be taught to make and insert Gottstein's cotton cylinders. As soon as he has learned to do this properly and cleanse his nose efficiently the office visits should be made at less frequent intervals. He is ordered for home use a wash and instructed how to use it, either with an atomizer or douche. After cleans- ing the nose he should apply twice a day, by means of a brush, either lignol or Bobone's formula previously referred to. If pharyngitis sicca and reflex laryngeal symptoms are very annoying, small doses of iodid of potash (gr. ii to X, t. i. d.) may also be ordered with advantage to increase the secretions and diminish reflex action. Prognosis. — Atrophic rhinitis is one of the most unsatis- factory and tedious of nasal diseases to treat. Fetor of the breath and the other more annoying of the patient's symptoms are easily and quickly corrected in the majority of cases by the wearing of Gottstein's cotton cyHnders, and I04 DISEASES OF THE NOSE, THROAT, AND EAR something very like a cure of the disease, after some years, will be finally brought about. The writer occasionally sees cases that he treated ten or more years ago. Some of these cases are cured to the extent that there is no fetor of the breath or retained secretions requiring removal, except during periods when the patient has caught cold. Others of these cases still wear the cotton cylinders, although not constantly, and by this method and by the use of nasal washes manage to maintain a fair degree of comfort. In some cases there has been a partial restoration of the sense of smell. It is reported that actual cures have resulted from the employment of the Finsen ray. Attempts have been made with more or less success to restore the original bulk of the turbinals by the injection of paraffin wax (Formula 96) underneath the nasal mucous membrane. Syphilitic rhinitis is a diseased condition of the interior of the nose dependent upon the presence of syphilitic virus. The synonyms are syphilitic catarrh or ozena ; specific rhinitis ; and, according to the stage of the disease, nasal chancre; syphilitic coryza; nasal gumma; tertiary nasal syphilis. PatJiology. — It is exceedingly rare to find the primary lesion of syphiHs or chancre existing inside the nose, from the fact that the syphilitic virus is rarely introduced inside the nasal chambers, and that, should such an event occur, the secretions of the parts tend to wash away the morbid matter before inoculation takes place. Secondary lesions of the nasal mucous membrane are analogous to, and often coincide with, those appearing upon the skin. They vary from a mere erythema of the nasal mucous membrane with increased secretion to intense hyperemia and swelling, with the presence of mucous patches or shallow ulcers, secreting a sanious and offensive mucopus. During the tertiary period nasal gummata are by no means rare. They appear as irregular nodulated swellings distending the mucous membrane of any part of the interior of the nose. A nasal gumma may be absorbed, leaving in some instances a characteristic cicatricial contraction, or it may break down DISEASES OE 'J'JIE NOSE IO5 and produce an ulcer, before wliicli the cartila^^es and even the bony structures of the nose may melt away like wax as the ulceration rapidly extends, thus producing in a marvelously short time the most hideous deformity. ICx- uberant granulations may spring from the ulcerating gumma and completely fill the nasal chamber or even project from the nares, simulating a malignant growth. When the ethmoid has thus been necrosed and exfoliated, there may remain, after the healing process is complete, but a thin fibrous membrane between the interior of the nose and brain. The lateral wall of the nose may be destroyed entirely, so that the antrum of Highmore and the affected side of the nose become one large cavity. In other instances the septum, nasal processes of the superior maxillary, and the nasal bones may be partly destroyed in such a manner that the nose becomes flattened upon the face, producing a most serious deformity. In aggravated cases the soft parts may also be involved in the process, until finally the anterior nares are represented merely by an irregular hole in the face. During the ulcerative process of a gumma the breath is generally very offensive. Hereditary syphilis pursues the same course as the tertiary form of the acquired disease. Treatment. — Constitutional treatment is of primary im- portance. The primary and secondary lesions are probably best treated by the internal administration of a pill contain- ing \ gr. of the protoiodid of mercury (Formula 74). The patient may take from one to three of these pills three or four times a day and, if necessary, a sufficient quantity of opium should be administered to prevent their producing diarrhea. The pills are less likely to produce digestive derangements if taken after meals and at bedtime. Any ulceration upon the nasal mucous membrane should be touched every other day \vith the acid nitrate of mercury (i part to 4 parts of water) until they are healed; and the inflammation treated in the meanwhile as a case of simple chronic rhinitis. However, although the applications of acid nitrate of mercury are effectual in bringing about a rapid healing of the ulceration, they are somewhat painful ; and if the patient complains bitterly of the pain, a solution of nitrate of silver (60 gr. to i ounce) should be substituted Io6 DISEASES OF THE NOSE, THROAT, AND EAR or the ulcerations merely may be dusted with powdered calomel. In tertiary syphilitic rhinitis the mixed treatment answers a very useful purpose, for, while the iodid of potassium is not a specific in syphilis in the sense that mercury is, yet it gives a much quicker result in controlling tertiary manifesta- tions. One, two, or three teaspoonfuls of Formula 73 may be given three or four times a day, according to the emer- gencies of the case and the patient's susceptibility to mercury. Mercury may also at the same time be administered by inunction or fumigation, or, in cases where the most speedy effect possible upon the syphilitic lesion is desired, it may be administered hypodermically. From 8 to 20 minims of Formula 76 should be injected into the cellular tissue of the back every day or at less frequent intervals. If thrown into the cellular tissue of the back, a solution of corrosive subHmate not stronger than that of Formula j6 will not produce an abscess, but causes some pain. The first in- jection should be given deep into the cellular tissue beneath the skin under one shoulder-blade ; the second injection, beneath the skin of the other shoulder-blade ; the third, 4 inches below the first ; the fourth, 4 inches below the second, and so on down the back. But a few hypodermic injections are ordinarily required to limit the spreading of a gummatous ulcer, which speedily assumes a more healthy appearance. In cases where gummata are so situated as to cause obstruction to nasal respiration, pain, and intense headaches from pressure, the action of medicines upon the growth are too slow and operative procedures must be resorted to. A gumma may be removed from a turbinated bone with the snare or scraped from the septum with a large nasal curet. Such operations, however, should not be performed upon patients of debilitated constitutions, or those who are not, or cannot quickly be brought under the influence of mercury, as otherwise the wound made by the operation will not heal and may result in extensive ulceration. When a nasal gumma has broken down and is ulcerating the parts should be kept scrupulously clean by the use of an antiseptic solution (Formulas i to 10), and the wound stimulated to heal by the daily application of acid DISEASES OE THE NOSE I07 nitrate of mercury diluted with 4 parts of water. Wounds resulting from operations upon gummata should be treated in the same way until the healing process is complete. Tubercular rhinitis is an inflammation of the interior of the nose characterized by the presence of the tubercle bacilli. Etiology. — The disease is usually the result of the inocu- lation of the nasal mucous membrane by morbid material from another portion of the body of a tuberculous indi- vidual. Pathology. — The most common lesion observed is a small ulceration, usually on the septum or floor of the nose. Occasionally hyperplastic nodules and papillomata, pale in color and either pedunculated or sessile, are observed. Syniptouis. — Crusts form upon the ulcerations and are blown from the nose. The ulceration may progress to per- foration of the septum. The hyperplastic growths some- times attain sufficient size to cause nasal obstruction. DiagJiosis. — The disease in its ulcerative form somewhat resembles syphilis. However, as it rarely occurs except in individuals with advanced pulmonary tuberculosis, the diag- nosis usually is easy. The surrounding mucous membrane usually is much paler than in syphilis ; indeed, the whole mucous membrane of the nose is usually anemic. How- ever, in doubtful cases, iodid of potassium exhibited for a few days in lO-gr. doses every three or four hours will usually decide as to w^iether syphilis is the cause of the ulceration. Papillomatous outgrow^ths examined micro- scopically show the presence of tubercle bacilli. Treatment. — The local treatment consists of cleanliness of the nasal cavities brought about by the patient's use of an atomizer containing an alkaline wash, followed by spray- ing the nose with menthol-camphor-albolene. The phys- ician may cleanse the ulcerations and touch them with solid nitrate of silver fused on the end of a probe (Fig. 55). Large papilloma may be snared, but it is advisable to do no un- necessary surgery in a tuberculous nose. As the disease rarely if ever occurs except in advanced pulmonary tuber- culosis, the general treatment is more important than the local. I08 DISEASES OF THE NOSE, THROAT, AND EAR Lupus. — The name lupus is applied somewhat loosely to various skin diseases : Lupus erythematosa, lupus congestiva, lupus superficialis, lupus sebaceus. Lupus erythematosa first appears as grouped red spots that ultimately coalesce into slightly raised patches. The initial lesion is always erythematous and, unlike lupus vulgaris, there is no tend- ency toward ulceration. Lupus vulgaris sometimes originates at the tip of the nose, either upon the mucous or, more often, on the skin surface. Etiology. — The cause of the disease is tubercle bacilli. Pathology. — The lesion manifests itself as reddish-brown nodules. These atrophy, leaving scars, or ulcerate, involving sometimes large areas of skin, mucous membrane, and car- tilage. A large portion of the tip of the nose and septum may be destroyed. The ulcer is often covered by a brownish scab ; when this is removed the ulcer appears filled with a granular '* apple-jelly "-Hke mass, which can be readily scraped away with a curet. Deep cicatrices and deformities result from the healing of the ulcer. It may cicatrize at one extremity while the progress of the ulceration is active at the other. The disease is uncommon in America. Diagnosis. — Lupus so much resembles syphilis that the diagnosis usually has to be established by the " therapeutic test," which consists in the exhibition of iodid of potassium. From epithelioma it is differentiated by the microscopic findings. Treatment consists in the daily application of the ;r-ray. Rhinoscleroma is a disease of the mucous membrane of the nose extremely rare in North America, but occurring in Brazil, Russia, Italy, and other countries. Etiology. — According to some authorities the disease is the result of the presence of a characteristic bacillus. Pathology. — The disease produces nodular hypertrophies on the nose and sometimes within the nose, pharynx, and larynx. Ulcers appear upon the mucous surfaces resembling the lesions of tertiary syphilis. The contraction of dense cicatrices sometimes results in deformities. Symptoms. — There is little or no pain at any stage of the disease. The growth inside the nose may interfere with nasal respiration, and when the mouth and pharynx are in- DISEASES OF 77/ E AOSE I O9 volved it may be impossible for tlie patient to swallow solids. Involvement of the larynx may be sufficient to interfere with respiration as the result of cicatricial contraction. Treatment. — As the disease has a tendency to recur, operative interference is inadvisable, except tracheotomy when necessary to prevent death from stenosis of the larynx. Lang recommends salicylic acid locally and in io-i,n-. doses internally. Foreign Bodies in the Nose. — Children and insane persons occasionally insert into their noses buttons, cherry-stones, beads, beans, twigs, hair-pins, etc. Necrosed bones, when detached, act as foreign bodies and produce their charac- teristic symptoms. Rhinoliths, ascarides, and maggots are also found in the nose, and may be considered as foreign bodies. Syjuptonis. — Obstructed nasal respiration proportionate to the size of the foreign body. If the foreign body is large or causes pressure, headache and pain of a neuralgic character are complained of. At first the presence of a small foreign body in the nose of a child attracts but little attention un- less the child tells its parent there is something in its nose. After a time a discharge of glairy mucus occurs, which excoriates the skin of the lips and alae, but the discharge soon becomes purulent and may be streaked with blood and be fetid. A one-sided discharge from a child's nose is almost pathognomonic of a foreign body, and under such circumstances the most careful and painstaking search should be undertaken to discover the offending particle. Rhinoliths generally contain as a nucleus a foreign body around which the nasal secretions accumulate and deposit a coating of earthy salts, gradually increasing in thickness. The presence of a rhinolith causes practically the same symptoms as that of a foreign body of similar size and shape. Treatment. — The foreign body or bodies should be removed as soon as possible. This may be accomplished by means of a pair of forceps or a blunt ear curet. RJiinolitJis may sometimes be removed whole or may have to be broken up by means of a powerful pair of for- ceps in order to remove them from the nose. no DISEASES OF THE NOSE, THROAT, AND EAR Neuroses of the Nose. — Motor Neurosis. — Twitching of the nose and eyeHd is generally due to peripheral irritation of some branch of the facial nerve. It occasionally occurs as the result of the apphcation of the galvanocautery to an anterior hypertrophy. Paralysis of the dilatores nasi produces a collapse of the lateral walls of the anterior portion of the nose that decided- ly interferes with nasal respiration. Unilateral paralysis of the dilator nasi occuring in childhood, according to some of the older writers, is one of the causes of deviation of the nasal septum. The partial stenosis in long thin noses, due to the valvular action of the anterior portion of the sides of the nose by which inspiration is impeded, can be entirely alleviated by cutting a strip of requisite length from a visit- ing card, bending it, and placing it with its ends up inside the vestibule of the nose in such a manner that it acts as a spring holding the anterior nares open. However, in such cases the valve-like action of the anterior portion of the sides of the nose disappears permanently in many instances by increasing the breathing space by the removal of a small ecchondrosis from the septum or cauterization. Sensory Neuroses. — Anosmia, or complete loss of the sense of smell, may be congenital or acquired. If acquired, the condition may be due to syphilis, hysteria, or result from lesions of the olfactory bulbs produced by meningitis, tabes, or the pressure of a brain tumor. Disturbances of the sense of smell amounting to almost complete loss occur from any cause that prevents odorous particles reaching the portions of the nose where the peripheral nerve-endings of the olfactory nerves are distributed. An ordinary cold, hypertrophic rhinitis, or polypi fre- quently cause mechanically greater or less loss of the sense of smell, which returns after the mechanical ob- struction is removed. In atrophic rhinitis affecting the vaults of the nasal chambers there is generally great im- pairment of the-sense of smell, which in some cases is partly restored when crusts and accumulations no longer form. In purulent inflammation of the ethmoid cells, especially in those cases where the middle turbinates are sufficiently swollen to press on the septum, great impairment of the DISEASES OE 77/ E NOSE I I I sense of smell is usually present. In sueh cases the pro<^- nosis is not entirely unfavorable. HypcrosDiia is an increased sensibility of the olfactory apparatus. The ability to detect odors, generally stenches, is intensified. The condition is sometimes observed in nervous women. Parosmia is a perversion of the sense of smell associated with local or systemic disturbances, insanity, etc. The sensation of a bad odor is sometimes a part of the aura of epilepsy. Hyperesthesia and anesthesia of the nasal mucous mem- brane are occasionally encountered. Paresthesia^ or the sensation of imaginary stenosis or foreign bodies in the nose, occurs in a certain proportion of neurotics. It is not an unusual thing for such patients to complain of stenosis when the condition present is atrophic rhinitis with widely patulous nasal chambers. Reflex nasal neuroses are asthma, sneezing, cough, and certain skin rashes upon the nose and sides of the face. Cases of epilepsy have been reported as greatly improved, possibly cured, by the removal of nasal growths. The most common condition found in asthma of nasal origin is nasal polypi ; but semi-occasionally asthma is greatly alleviated by the removal of a septal exostosis or even by bringing about an improved condition of the nasal mucosa when no gross lesions are present. Hay-fever, or coryza vasomotoria periodica, is a chronic nasal affection depending upon a disturbance of the entire nervous system, and particularly of the various nerves supplying the nasal mucous membranes, and characterized by periodic exacerbations caused by inhaling dust or other irritants. The synonyms — hay-asthma, autumnal catarrh, rose cold, horse cold, cow cold, peach cold, snow cold, miller's asth- ma — are names given to the affection and supposed to indi- cate the irritant which is the direct cause of an attack of the disease. Etiology. — There are three factors in the causation of an attack of hay -fever, viz. : First, a pathologic condition of the nasal chambers ; this may comprise anterior or posterior 112 DISEASES OE THE NOSE, THROAT, AND EAR hypertrophies, exostoses, ethmoiditis ; but more especially the presence of hypersensitive areas, readily distinguished by their heightened color and slight elevation above the surrounding mucous membrane. Irritation of one of these spots with the end of a probe, even during the winter time, will bring on an attack of hay-fever lasting from an hour to several days ; second, a diseased or, at least, an irritable condition of certain nerve-centers, giving rise to a train of near and remote symptoms by reflex action ; third, the presence of an external irritant. The absence of any one of these factors is sufficient to prevent an attack. Symptoms of an attack of vasomotor coryza are those of coryza — a sense of dryness and itching in the nose, violent sneezing, occlusion of the nares, and profuse watery dis- charge. These symptoms are usually followed by conjunctivitis, lacrimation, photophobia, headache — often of a neuralgic character — a hacking cough, asthma, and a general feeling of malaise. Treatment, — The most effective treatment of periodical hyperesthetic rhinitis is a sea-voyage, lasting through the entire hay-fever season or residence in a region free from the presence of irritating pollens and dust, like that of the White Mountains of New Hampshire. For professional and business men, however, such a treat- ment involves hardships and loss of business opportunities that render it acceptable only as a last resort. Therefore any treatment that will enable the sufferer to remain at home in comparative comfort and attend to business is eagerly sought by the majority of workers suffering from hay-fever. The attention of the profession, chiefly through the writings of Seth Scott Bishop of Chicago, has been directed to the fact that the neurotic condition of the patient and the hypersensitiveness of the nasal passages were often due to an excess of uric acid in the blood, and that this excess could be eliminated by the ingestion of mineral acids. Probably any mineral acid would prove efficacious, but there are two which suggest themselves as peculiarly effica- cious : hydrobromic acid, because of its sedative qualities, and nitromuriatic acid, because it is thought to limit the production of uric acid. DISEASES OF THE NOSE \\% The writer's experience has been Hinited to the effects of nitroniLiriatic acid, which lias been prescribed in doses of 5 to I o drops of the freshly prepared concentrated acid after meals and sometimes also at night. The dose should be diluted with one-half tumblerful of water, and the patient, after taking the medicine, should rinse out his mouth and swallow another half-tumblerful of water. The results of the remedy are apparent within forty-eight hours, and the relief of all hay-fever symptoms are usually sufficient to enable the patient to remain at home and attend to his ordinary business engagements in comparative comfort. If, however, a simple dose is omitted, some symp- toms of hay-fever will appear within the succeeding twenty- four hours. This is especially true if the remedy is not taken after the evening meal, as, under such circumstances, the patient usually wakes up the next morning \\\\\\ occluded nares and suffused eyes. Between the attacks of hay-fever measures should be adopted to improve the patient's general health and correct any abnormality of the interior of his nose. The practi- tioner, however, should not be too sanguine as to the beneficial results to be obtained by such measures, for it should be borne in mind that hay-fever not infrequently occurs in vigorous individuals the interior of whose noses present no gross abnormality except during the hay-fever season. There is, however, one condition of the nose that is apparently present in all individuals suffering from hay- fever, and that is the presence of hyperesthetic areas upon the respiratory portion of the nasal mucous membrane, which when touched with a probe cause sneezing and lacrimation. The hypersensitive condition of such areas may be destroyed one or two at a time, even during the hay-fever season, without adding to the discomfort of the patient by either palliative or radical methods. The palliative method consists of cocainizing the nose and touching the sensitive area with a lo per cent, solution of chromic acid applied by means of a cotton-tipped probe. The radical method consists in destro}'ing the sensitive area 114 DISEASES OE THE NOSE, THROAT, AND EAR by means of the galvanocautery. A small cautery-knife should be selected, and the current should be sufficiently strong to instantly bring its tip to a white heat. After cocainizing the nose, the cautery tip is moved over the mucous membrane until a sensitive area is discovered. The current is then turned on for an instant and the cautery- knife withdrawn. Very little destruction of the membrane results, and should hemorrhage occur no undue haste should be used in controlling it, as the local depletion is beneficial rather than otherwise. Temporary relief may be obtained during the worst stages of the attack by spraying the nose with a weak alkaline I per cent, solution of cocain, and afterward with fluid vaselin as a protective. It is, of course, justifiable to use cocain during an office treatment, but cocain should not be pre- scribed for the patient's home use, as hay-fever victims are (often because of the neurotic temperament) the class of people most liable to contract the cocain-habit. As a home treatment the patient may spray the nose every hour or two, if necessary, with a solution of adrenalin hydrochlorate in the strength of i : 10,000 or i : 20,000. When the writer first began using this drug his results were not altogether satisfactory. Temporary relief was always obtained to a greater or less extent, but the use of the stronger solutions was always followed by a reaction similar to that of cocain solutions. Tlie results have been vastly better since very dilute solutions at frequent intervals have been employed. The solution should be freshly made and free from antiseptics, and for these reasons the drug is best prescribed for patients' use in the form of a small tablet which when dissolved in the proper amount of water forms a solution of the required strength. However, in many in- stances oily preparations are more efficient than watery solutions, and an ointment made up with lanolin and vaselin of a strength of i : 10,000 is of decided value. It is conve- niently dispensed in collapsible tubes, so that the patient can carry it about in his pocket and squeeze out from the tube from time to time the amount of ointment required. A piece the size of a pea may be inserted into each side of the nose every two hours by a brush or simply with the tip DISEASES OE EI IE NOSE I I 5 of the little fin^^er. The head is then thrown baek until the ointment melts and distributes itself over the nasal mucous membrane. After the attack has subsided, all pathologic conditions of the nose should be removed, and the sensitive areas cauterized with a small galvanocautcry-knifc, so introduced that its flat surface will rest upon the sensitive areas and make a superficial burn. Professor Dunbar, of Hamburg, has prepared hay-fever antitoxins by the inoculation of horses with the toxins obtained from the albuminoid body found in the starch particles of pollen. The serum obtained from the horse is dispensed either in a liquid or dry form, and is designed to be applied to the mucous membranes of the nose and that of the eyes when required. The serum has been named Pollantin, and two forms are on the market, one prepared from rye pollen, especially used for spring and summer hay-fevers or ** rose colds," and the other, prepared from ragweed pollen, designed as a remedy for the hay-fever occurring in the late summer and fall. Dunbar believes that hay-fever is the result of a specific poison found in pollens, and his antitoxin is designed to immunize patients against pollen toxins when used previous to the hay-fever season and also to palliate the symptoms in cases where the disease has already made its appearance. When applied to the inflamed mucous membrane of the nose or eye pollantin produces a sensation of ease and comfort which persists for some time. Prognosis. — It is not unfavorable. Many cases completely recover. The patient should be kept under observation and occasionally treated for at least three years after an apparent cure to prevent the danger of a relapse. Nasal hydrorrhea is a disease characterized by a clear watery discharge from one or both nostrils as the result of some irritation or disturbance, either peripheral or central, of the vasomotor supply oi the nasal mucous membrane. Etiology. — In one class of cases the flow of fluid from the nose is perfectly passive and causes no inflammation. Il6 DISEASES OF THE NO^E, THROAT, AND EAR The phenomenon is probably due in such cases to a paresis of the nasal branches of the trifacial nerve, which exercises an inhibitory action upon the normal exosmosis of serum in the nasal mucous membrane. In a certain number of these cases the fluid discharged has been claimed to be cerebrospinal fluid, by some pathologic process a com- munication having been established between the nose and the subarachnoid space. In a second class of cases the flow of serum is accom- panied by great congestion and swelling of the Schneiderian membrane, and the phenomena are the result of an irritation of the vasomotor nerves. In this second class of cases the congestion and inflammation of the nasal mucous mem- brane and the consequent watery discharge are greatly increased by cold and by inhahng dust and other irritants. Indeed, the symptoms are somewhat similar to those of hay-fever. Symptoms. — In the first class of cases there is an almost constant dropping of a clear watery fluid from one or both nostrils. In the second class of cases the "discharge is more remittent in character, according to the amount of irritation of the Schneiderian membrane. Treatment. — In some cases adrenalin acts as a specific. A solution of the strength of i : 20,000 up to i : 1000 should be sprayed upon the nasal mucous membrane sufficiently often to control the symptoms. From 2 to 5 gr. of the extract of suprarenal capsule also should be taken every three hours, the patient being instructed to cease taking the remedy should disagreeable heart symp- toms manifest themselves. In some cases a cessation of the discharge occurs within a few days, and the use of the remedy should then be discontinued. As the cause of this disease is generally somewhat obscure, the treatment is necessarily expectant. The dis- charge terminates in some instances as abruptly as it began, almost without medication. Atropin sometimes is more useful than the extract of suprarenal capsule ; a pill con- taining 2-^Q- gr. may be given every three or four hours. In patients who can be trusted to barely moisten their mucous membrane with the spray from an atomizer coa- D/SKASKS OF THE NOSE I I 7 taining J i^r. of atropin to i ounce of water, and not use the atomizer sufficiently often to cause [)Oisonous effects, a spray acts I'ar better tlian when atropin is taken by the stomach. The patients, of course, should be cautioned as to the very active nature of the poison and cautioned a^^ainst usinaix is covered with stratified, ciliated, columnar epithelium, the oropharynx with squamous epithelium, and the laryngopharynx with squamous and ciliated epithelium anteriorly. There are simple follicular glands, compound follicular, and racemose glands. Tonsils and Lymphatics of the Pharynx.— The laryngo- pharynx has few or no lymphatics. Above the supply is profuse, being located mainly in the mucous membrane of the superior and posterior wall. The tonsils are a part of an irregular ring of adenoid tissue surrounding the pharynx and continuous with the general lymphatic system. There are seven tonsils : the faucial, the tubal, the pharyngeal, and the lingual. The faucial tonsils are situated one on each side of the fauces between the anterior and posterior pillars of the fauces. The Hngual tonsils are situated at the base of the tongue, the tubal tonsils at the pharyngeal Eustachian orifices, and the pharyngeal tonsil in the vault of the pharynx posterior to the nasal orifices. Any of these tonsils when hyper- trophied may cause annoying symptoms, especially in child- ANATOMY OF TIIK PHARYNX \%J hood; the third or pharyngeal tonsil, the so-called adenoid vegetations. Above the tonsils and between the anterior and posterior pillars is situated the triangular /<'^5.y^ sitpratoisiUaris. Here a number of crypts extend vertically into the tonsil, the retention of whose excretions is supposed to play an im- portant role in the production of peritonsillar abscess. The number of crypts, both vertical and horizontal, rarely exceeds fifteen for each tonsil. They vary in length from \ to I inch or possibly even more in tonsillar hypertrophy (Fig. 122). The tonsils are frequently adherent to the anterior pillars in such a manner as to form pouches, which are most effective culture-tubes for the propagation of patho- genic organisms. The fuyictioiis of the tonsils are similar to those of other lymphatic glands. As a part of the hemopoietic system they form young leukocytes, most of which pass into the circulation, but some escape into the free mucous surface, where they may exercise a phagocytic action. They also excite old leukocytes, which probably carry off with them effete products. According to G. B. Wood, the faucial tonsils drain into the deep lymphatics and not the superficial lymphatics of the neck. The '* tonsillar gland," Wood states, is placed external and slightly anterior to the internal jugu- lar vein. Hypertrophy of this gland means its dislocation outward and forward, but generally it can be pushed back under the sternocleidomastoid muscle, which is not the case with hypertrophied superficial glands. In a child one week old this gland was but little larger than its fellows, while in children who were six or more months of age the " tonsillar gland " was twice to four times larger. *' Does it not seem possible," Wood states, " that this enlargement consequent to birth may be due to the absorption of toxins through the faucial tonsils ?" The tonsils are most active during youth, while the thy- mus, a large blood-forming gland, is atrophying. There is considerable difference of opinion as to the phagocytic action of the tonsils, some authorities claiming that they are not even able to protect themselves, and that the tonsils con- stitute a weak part of the throat and expose the system to 1 88 DISEASES OF THE NOSE, THROAT, AND EAR the inroads of diphtheria, tuberculosis, syphiHs, and other diseases. In evidence of the difference in the behavior of tonsillar epithelium toward dust and bacteriae, Jonathan Wright dusted carmin over the tonsil. Fifteen minutes later all the particles of carmin had passed through the epithehum. into deeper layers and could be detected in sections under the miscroscope ; while bacteria, situated at the exact point where the carmin entered, remained quiescent and unab- s orbed. Mechanically the Hngual tonsil is most apt to prove trou- blesome as the result of hypertrophy after middle life if at all, while hypertrophy of the faucial and pharyngeal tonsils are distinctly diseases of childhood. DISEASES OF THE NASOPHARYNX OR POST- NASAL SPACE Postnasal catarrh may be either secondary, as when a nasal catarrh discharges into the postnasal space, or the disease may be primary and extend to either the nose or Eustachian tubes. The nasopharynx may be blocked by posterior hypertrophies of the turbinated bodies or by polypi, cysts, fibroid tumors, or malignant growths, spring- ing from the posterior nares or from the vault of the pharynx. A somewhat common affection beginning gener- DISEASES OE THE NASOPHARYNX 1 89 ally in childhood is hypertrophy of the phar)'iigcal or Luschka's tonsil. Adenoid vegetations or hypertrophy of the pharyngeal ton- sil (Fii^. 115) is an overgrowth of the normal adenoid tis- sue of the pharyni^eal vault. The affection is often associ- ated with hypertrophy of the faucial tonsils, and generally commences in childhood, but may be met with in patients of any age. Fig. 116. — Typic appearance in adenoid vegetations: boy ten years old (Frtihwald). Symptoms. — If the adenoid vegetations are at all large, they block up the posterior nares and compel mouth-breath- ing, the pinched nostrils and half-open mouth giving the face a vacant and well-nigh idiotic expression (Fig. 116), which ordinarily disappears as soon as nasal respiration is reestablished. However, if mouth-breathing be continued into adult life permanent deformity of the bones of the face and even of the chest sometimes results. Breathing is audible, even during the day, and there is always loud snor- 190 DISEASES OF THE NOSE, THROAT, AND EAR ing during sleep. The voice is toneless, articulation is indistinct, and the hearing is often impaired. Treatmeyit. — Adenoid vegetations tend to no longer ob- struct nasal respiration as the individual passes into adult age and the nose and nasopharynx grows larger, but may, in the meantime, have produced irreparable injury to the ears, and even have altered the shape of the bones of the face. Application of Formula 33 to the postnasal space will some- times bring about a slow absorption of the hypertrophied tis- sue. In children, when the growth is not large, such applica- tions should be made by the surgeon two or three times a week, the parents in the meantime cleansing the nose night and morning with the spray from an atomizer containing an alkaline wash and afterward placing in each of the child's nostrils a mass of galUc acid ointment the size of a pea. 7. — Lowenburg's postnasal forceps. The child should then lie on its back for a few moments until the ointment melts and runs into the nasopharynx. The gallic acid ointment should be of the strength of 5 to 10 gr. to I ounce of vaselin, according to the age of the child. However, the only treatment adequate in the majority of cases is a thorough removal of the mass by surgical procedures. Often the masses of adenoid tissue are so soft that they can be scraped away by means of the forefinger introduced behind the soft palate. In adults Lowenburg's postnasal cutting forceps (Fig. 117) may be used ; the operator being careful to begin operating in the median line, and working from it in each direction until the entire mass is cut and torn away from its attachment, at the same time being exceedingly careful not to wound the orifices of the Eustachian tubes. DISEASES OE THE NASOPHARYNX I9I In children, or in adults in whom the pharyn<^cal tonsil is still comparatively soft, Gottstein's curet (Fig. 1 18) is a most efficient instrument. Young children should be seated in the lap of a nurse upon a piano stool opposite the operator, in the same manner as for an ordinary examination of the nose and pharynx. The nurse passes her arms beneath those of the child and places her hands, one on each side of the child's forehead, in such a manner as to control the movements of the head. The nurse then elevates her elbows so as to bring the child's arms into such a position that it is impossible for the child to reach its mouth with its hands. The curet is now passed behind the palate, and the handle of the instrument depressed until the outer edge of the ring is felt to rest against the septum. By sweeping the ring upward, backward, and downward against the pharyngeal wall the growth is brought within the curet and is scraped from its attachment. Without removing the instrument from the mouth the maneuver is quickly repeated Fig. 118. — Gottstein's improved nasal curet. at each side of the median line, in order to be certain that the major portion of the growth has been removed. The operation should be performed quickly, but with gentleness, little force being required to sever the growth from its attachment. The nurse then releases the child's head, and the operator passes his left arm around the child's head and thrusts his forefinger hard against the child's cheek, in such a manner that the cheek protrudes between the child's open jaws so as to form a most efficient mouth-gag. The operator then quickly passes the forefinger of his right hand behind the child's palate until the posterior edge of the septum is felt. The posterior nares, Rosenmuller's fossae, and the vault of the pharynx are inspected, as it w^ere, by the sense of touch. If any shreds of the growth remain they are removed with the finger-nail, scraping them from below, upward, 192 DISEASES OF THE NOSE, THROAT, AND EAR and forward. Before removing his finger the operator should spare no pains to assure himself by the sense of touch not only that nothing remains to obstruct nasal respiration, but that Rosenmiiller's fossae are freed from any mass likely to interfere with the blood-supply of the Eustachian tubes. However, it should be borne in mind that the third tonsil is normal to the nasopharynx, and that it is neither necessary nor desirable to remove the whole of the adenoid tissue, but simply that portion which interferes with nasal respiration and the functions of the Eustachian tubes. In very young children the parts of the growth removed by the curet are either swallowed, expectorated, or blown through the nose. The hemorrhage following the operation is generally trifling and the after-treatment consists simply in keeping the parts clean with an antiseptic wash (Formulas i to 10). When a general anesthetic is employed it should be ether and not chloroform, because in this condition, the so-called " habitus lymphaticus " of Kalisko, chloroform is especially dangerous, somewhat numerous deaths having been reported. The ether should not be pushed to complete abolition of the reflexes, as even when only partially etherized the patient will probably become momentarily blue from partial asphyxia caused by the quantity of blood that generally enters the larynx. Ether is rarely if ever necessary to secure an adequate removal of the hypertrophy. However, the major portion of successful operators prefer to operate under ether anesthesia, stating that the operation then can be done more deliberately, and there is less danger of failure to remove all portions of the hypertrophy that are pathologic. The use of the forceps and the cureting should not be so radical as to expose the fibrous tissue overlying the verterbae or expose or tear loose the upper border of the superior con- strictor of the pharynx. During the operation the patient's head should be turned to one side or allowed to hang down- ward over the edge of the table in order to favor the escape of blood from the mouth and nose. The improvement in nasal respiration and in pronuncia- tion following the operation is immediate and pronounced ; DISEASES OF THE NASOPHARYNX 1 93 and if hearing was impaired as the result of interference with the function of the Eustachian tubes, the acuteness of hearing rapidly improves after the operation. In adults the reaction from the operation is but trifling. Children, how- ever, sometimes complain for a few days that the throat is sore and that it hurts them to swallow. Thornwaldt's Disease or Chronic Bursitis. — The bursa of the pharyngeal tonsil was described by Luschka, and chronic inflammation of this structure was later eluci- dated by Thornwaldt, after whom the disease has been named. Symptoms. — When chronically inflamed the bursa of the third tonsil secretes a considerable amount of thick, tenacious mucus, globular masses of which may be hawked out by the patient from the pharynx several times a day. There are no other subjective symptoms in uncomplicated cases. When thoroughly cleansed by the postnasal syringe the bursa is discernible and may be explored to a variable depth by means of a probe suitably bent. Treatment. — The concensus of opinion seems to be that a permanent cure can only be effected by the radical destruction of the bursa by means of the galvanocautery or some other method, a most difficult matter to accomplish because of the anatomic situation of the bursa. However, almost complete cessation of the discharge, for the time being at least, can be brought about by thorough cleansing of the parts and applications to the interior of the bursa, by means of a cotton-tipped probe, of a solution of nitrate of silver (60 gr. to i ounce). In some cases the bursa can be cleansed by means of the syringe-tip 4, Fig. 38, suitably bent and inserted in the bursa either through the nose or the mouth. After wash- ing out the bursa with an alkaline solution, to which a portion of peroxid of hydrogen is added, a few drops of a 25 or 50 per cent, solution of argyrolmay be instilled into the cavity of the bursa through the same tube by means of syringe a, Fig. 38, two or three times a week. 13 194 I^^SEASES GF THE NOSE, THROAT, AiXD EAR DISEASES OF THE OROPHARYNX Acute Pharyngitis. — Acute pharyngitis is an acute inflam- mation of the mucous membrane and underlying structures of the pharynx. The synonyjus are acute sore throat; acute pharyngeal catarrh ; angina catarrhalis. Etiology. — Acute pharyngitis is generally the result of exposure to wet and cold, especially of persons of the rheumatic diathesis or of debilitated constitutions. It may also result from traumatism or the presence of a foreign body in the pharynx. Slight unilateral pharyngitis is not uncommon after an intranasal operation, and is probably due to a mild infection. It lasts for a day or two and then passes away. Pathology. — The inflammation is usually by no means evenly distributed, the glandular elements being always most affected. Their secretion is at first increased, but becomes after a time decreased, starchy, and glue-like in character. The tonsils are always involved to a greater or less extent, their inflammation becoming so great in some, instances as to mask the inflammation of adjacent structures. Symptoms. — The constitutional symptoms are usually trifling, a feeling of lassitude with slight fever. The throat feels sore, dry, and stiff The symptoms mayincrease until pain, especially when deglutition is attempted, becomes quite severe. The cervical glands are often swollen and painful to the touch. The voice is usually husky and a sensation as of a foreign body in the throat keeps the patient hawking and spitting. When the tonsils or larynx are seriously involved in the inflammation certain other symptoms are present, which will be described furtb.er on. Treatment. — A saline cathartic should be administered in sufficient quantities to secure one or more free movements of the bowels. A solution of nitrate of silver of the strength of i or 2 drams to i ounce of water should be freely painted over the inflamed lateral walls once or twice a day. It should be borne in mind that the application of solutions of the strength of i or 2 drams to i ounce of water is not painful, providing none of the solution is ap- DISEASES OF THE OROPIIA R YXX 1 95 plied to the posterior wall. It is immediately followed by a sensation of relief and comfort, and tends to materially shorten the course of the disease. Applied to the posterior pharyngeal wall solutions of silver nitrate of over 5 or 10 gr. to I ounce produce a sensation of dryness, stiffness, and discomfort. In this region a 10 per cent, solution of argy- rol sprayed upon the parts is preferable to the use of the nitrate. When acute pharyngitis is the result of the presence of a foreign body it should, of course, be at once removed and the inflamed pharynx treated as ordinary acute pharyngitis. When the rheumatic diathesis exists, the administration of guaiac (Formulas 138, 139) will be found to yield most excellent results, while in gouty sore throat colchicum should be prescribed. A spray of adrenalin chlorid (i : 5000) used every hour by the patient quickly relieves the congestion in most cases ; but other astringent sprays are sometimes equally efficient, the best probably is alunniol i dram to 4 ounces of water. If it is inconvenient for the patient to use an atomizer, lozenges may be prescribed. The camphomenthol lozenge (Formula 142) is sedative and relieves the feeling of dryness and stiffness by increasing the secretions, and the same may be said of a lozenge of guaiac and potassium iodid. However, one of the most popular lozenges in this condition is that of guaiac and tannic acid (Formula 140). Simple chronic pharyngitis is a chronic inflammation of the mucous membrane of the pharynx, generally the result of chronic rhinitis. The disease is often complicated by inflammation of the follicles of the mucous membrane, and is then called follicular pharyngitis. Synonyms. — Chronic sore throat ; granular pharyngitis ; follicular pharyngitis ; chronic angina ; relaxed throat ; chronic catarrh of the throat. Treatment. — It is all important to bring about a cure of the nasal disease to the presence of which the pharyngeal malady is due. After a cure of the primary nasal affection has been brought about, simple chronic pharyngitis will get well almost without treatment. During the treatment of the nasal affection, however, applications should be made to the vault of the pharynx of Formulas 33, 34, or 35 in the 196 DISEASES OE THE NOSE, THROAT, AND EAR following manner : A tongue-depressor (Figs. 10-12) should be used to hold down the tongue and the patient requested to try to breathe through his nose or say '' One," in order to relax the palatine muscles, when the application may be made without difficulty by means of an applicator, the end of which has been wrapped with cotton and bent to a suitable curve. Should, however, the palate lie closely in contact with the pharyngeal wall, considerable force will be required to carry the end of the applicator into the post- nasal space, while most of the solution with which the cotton on the end of the applicator has been saturated will be squeezed out and remain in the fauces. AppHcations made in such a manner tend rather to increase the existing inflammation than to subdue it, and it is always best to desist from making an application to the pharyngeal vault rather than employ force. When the uvula has become elongated or the mucous membrane of the fauces relaxed as the result of constant hawking, the daily application of the spray from an atomizer containing a solution of sulphate of copper (2 gr. to i ounce of water) will render material assistance in restoring the "relaxed throat" to a condition of health. In some instances it is necessary to amputate the relaxed and redundant mucous membrane at the tip of the uvula. Chronic follicular pharyngitis, or clergyman's sore throat, is a chronic pharyngitis characterized by inflamed and hypertrophied lymph-follicles. Pathology. — The pathology is similar to simple chronic phaiyngitis, except that the lymph-follicles are involved in larger numbers and to a greater degree. The subdivision of pharyngitis into pharyngitis and folHcular pharyngitis is a matter of convenience rather than fact, as in all simple inflammations of the pharynx the mucosa, the lymph- follicles, the submucosa, and often the muscles are usually involved in varying degrees. The watery portion of the secretions are decreased, and hence the expectorations are thick and glue-Hke from an increased proportion of mucin, epithelium debris, and mineral salts. Etiology. — The disease is generally the result of or part of a nasopharyngeal catarrh, excessive or faulty use of the DISEASES OF THE OROPIIAR YXX 1 97 voice, excessive use of tobacco and distillctl liquors, the rheumatic or gouty diathesis, indigestion, and, in women, pelvic diseases. SymptoDLS. — The secretions are usually somewhat scanty and viscid, but voided with considerable difficulty. There is a short, frequent cough, distressing alike to patient and friends ; the so-called ** useless cough," because it accom- plishes nothing, either in ridding the throat of secretions or the constant pharyngeal irritation of which many of these patients complain. The appearance of the pharynx varies somewhat ; usually there is venous hyperemia over the entire surface, but greatest in the neighborhood of patches of hyperplastic follicles. In other cases the pharynx is less congested, the hypertrophied follicles projecting above the surrounding surface and surrounded by varicosities. Sometimes a num- ber of inflamed follicles coalesce in such a manner as to form a red, sore, and swollen area of considerable size. If such patches be situated close to the posterior pillars, so that they are rubbed aiid irritated by these folds of mu- cous membrane with every motion of the pharyngeal mus- cles, the sufferings of the patient amount to actual pain. Treatment. — The irritability of the mucous membrane covering areas of hypertrophied follicles can be decreased by lightly painting with a 60-gr. solution of nitrate of silver. However, care should be exercised to prevent the silver solution spreading over the surrounding mucous surface, because strong solutions of silver nitrate are irritating when applied to the posterior wall of the oropharynx. A certain amount of relief is experienced by the use of demulcent lozenges, either slippery elm, red gum, campho- menthol (Formula 142), or, better still in many instances, a lozenge of orthoform. Where the so-called useless cough is a prominent symp- tom it should be controlled by appropriate doses of sodium bromid. For this purpose as much as 10 or 15 gr. after meals and at bedtime will be required. The matter is of considerable importance, as the constant coughing greatly irritates the pharynx and increases the existing inflammation. The condition of the tonsils should be carefully examined. DISEASES OF THE NOSE, THROAT, AND EAR Often they are slightly hypertrophied and the crypts contain cholesteatomatous masses. The removal of any con- comitant disease of the nasal cavities also will have much to do with the success of treatment. With many practitioners the radical de- struction of the diseased glands by means of the galvanocaiitcry is a favorite method of treatment. A very small cautery-knife should be selected, and great care should, be exercised not to burn too deeply, or the resulting scar will cause more trouble than the original disease. It is unwise to apply the galvanocautery-knife to more than two or three hypertrophied follicles at one time, or the treatment may be followed by a somewhat sharp attack of acute pharyngitis. Emil Mayer of New York curets away the offending follicles by means of a special curet (Fig, 1 19). By this method of treat- ment, which is much less painful than the use of the galvanocautery, all the hyper- trophied follicles are removed at a single Atrophic pharyngitis is an atrophic condi- tion of the mucous membrane and sub- mucous tissues of the pharynx. The synonyms are pharyngitis sicca ; dry pharyngitis. Etiology. — Atrophic pharyngitis generally results from long contact with the irritating discharges of nasal catarrhs. It frequently exists v/hen atrophic rhinitis is present, being probably the result of an extension of the atrophic process to the pharyngeal mucous membrane. A dry condition of the faucial mucous membrane, amounting almost to pharyngitis sicca, is found in all mouth- breathers, but disappears spontaneously as soon as the nose has been rendered sufficiently patulous. Symptoms. — The patient complains of his throat feeling Fig. iig.^Emil Mayer's pharyngeal curet. DISEASES OE 77JE OROPlfARVNX 1 99 dry and stiff. Upon inspection, the mucous membrane of the throat appears h'ght colored, thin, and as if varnislied. Frequently the mucous membrane is so thin that the outHne of each cervical vertebrae can be distinguished. Sometimes masses of inspissated mucus, perhaps dark colored from the dust inhaled, and swept into ridges by the motions of the soft palate, are seen adhering to the atrophied mucous membrane. Treatmc7it. — Attention should be mainly directed to the condition of the interior of the nose, because it is the experience of most rhinologists that when a cure of the nasal affection has been brought about the concomitant throat disease will get well almost without treatment. The general health should receive attention and, if necessary, tonics should be prescribed ; while a sluggish condition of the bowels may indicate the use of saline laxatives. If atrophic rhinitis has caused the affection, plugs of cotton, previously mentioned as useful in atrophic rhinitis, should be made long enough to project somewhat from the posterior nares into the pharynx, while a weak solution of nitrate of silver (gr. v-xv to f5J) should be applied to the atrophied mu- cous membrane, both above and below the soft palate, to stimulate the atrophied glands to increased secretion and bring about renewed growth of the atrophied structures. In certain cases it may be advisable to give for a short time some drug like iodid of potassium, phosphorus, or muriate of ammonia to stimulate the pharyngeal secretions. A pill containing j-^ gr. of phosphorus may be given after meals or the lozenge of guaiac and iodid of potassium, one every three or four hours, may be ordered. It should be borne in mind that the stomach does not tolerate well any lengthy administration of these remedies and \\\ most cases their use is best avoided. Mycosis of the pharynx is a parasitic disease involving in most cases the faucial, pharyngeal, and lingual tonsils, although other parts of the phaiyngeal mucous membrane do not escape in some instances. It is characterized by little white, conic elevations, sometimes as large as a grain of rice, due to the presence of fungi of the class mycosis, most frequently the leptothrix buccalis. 200 DISEASES OF THE NOSE, THROAT, AND EAR Etiology. — Leptothrix is so frequently found in the secretions of the mouth that it might almost be termed a normal constituent. It is especially prevalent in the mouths of individuals with carious teeth, accumulations of tartar, etc. Why it should in some individuals cause the horny, chalk-white growths characteristic of mycosis is not well understood. Pathology. — Leptothrix penetrates the lacunae of the tonsils and the glands of the mucous membrane of the pharynx Multiplication of the threads takes place, so that they grow through the epithelial cells and appear on the free surface of the mucous membrane, where they appear as whitish masses, generally cone shaped, the base of the cones adhering tightly to the mucous membrane and their apices projecting into the pharynx. Under the microscope the cones are seen to consist of granular material, a few epithelial cells, and numerous threads of leptothrix. These threads when stained are seen to be jointed and contain numerous spores. Symptoms. — A few masses of leptothrix may be present in the pharynx without causing any symptoms whatever. Under such circumstances the masses may be discovered, usually upon the tonsils, while examining the throat of a patient. Usually, however, patients with leptothrix com- plain of a tickling sensation in the pharynx and spasmodic cough. Treatinent. — On the tonsils and other easily accessible portions of the pharynx the little masses should be grasped one by one and pulled off. They are attached somewhat firmly and considerable force and a suitable forceps is necessary to remove them. The smallest size of Farnham's alligator-forceps or, better, Hartmann's ear forceps answers the purpose better than most, because so firmly adherent are the little masses that they are apt to slip from the grasp of forceps with smooth jaws. After the removal of the little masses the mucous membrane where they grew should be brushed with nitrate of silver (60 gr. to i ounce of water). In inaccessible localities, like the base of the tongue and beneath the epiglottis, leptothrix is better attacked with the galvanocautery-knife rather than the forceps. A very DISEASES OF THE ORorilAKYNX 20I small knife, suitably curved, should be selected, and the current should be powerful enough to instantly heat the very small platinum wire white hot, when it is applied to the leptothrix cone, and destroy it before the heat has time to burn the surrounding mucous membrane by radiation, as would be the case if a larger wire, heated only red hot, were used. As only a limited number of leptothrix cones can be destroyed at a sitting, the treatment in cases where they are very numerous is necessarily somewhat tedious. Some of the cones re-form after their removal. Applications of silver nitrate (60 gr. to i ounce) prevents this to a consider- able extent, and occasionally when applied to the surface where leptothrix is growing will cause the cones to disap- pear after frequent applications. Occasionally the growths disappear spontaneously. Erysipelas of the Pharynx. — Erysipelas of the face some- times extends to the pharynx or the disease may originate in the pharynx. Etiology. — Like erysipelas elsewhere the disease is the result of the presence of Fehleisen's erysipelas streptococcus. Pathology. — The fauces are dusky red and swollen. Vesicles form on the surface filled with seropus. The disease is evidently contagious under certain circumstances, as epidemics have been described, notably that in America in 1842. Erysipelas mayextend to the middle ear through the Eustachian tube or to the lungs through the larynx. Prognosis. — In the milder cases the prognosis is good. The phlegmonous variety of the disease is almost invariably fatal. Treatment. — The treatment is that of erysipelas elsewhere. Large doses of the tincture of the chloricl of iron (20 to 30 drops in water) should be given- every three hours, with strychnin, 3^ gr., if necessary. The nose and pharynx should be sprayed with an alkaline wash every three hours, followed by adrenalin solution (i : looo). The spray of adrenalin should be repeated at intervals of a few moments until the parts have somewhat blanched, after which they should be covered with a 20 per cent, solution of argyrol by means of the spray from an atomizer, 202 DISEASES OF THE NOSE, THROAT, AND EAR Phlegmonous pharyngitis is an acute infection of the phar- ynx, phlegmonous in character, extending to the deeper structures and usually terminating fatally in from five to ten days. Etiology. — The disease usually attacks those of broken- down constitutions or the aged. There is usually a history of slight traumatism, followed by virulent infection with some pus-producing organism. Pathology. — There is an enormous swelling of the fauces at an early stage of the disease, followed by a speedy for- mation of pus, which infiltrates the surrounding tissues and produces pyemia. The organism present in the pus is usually the streptococcus pyogenes aureus, or there may be a mixed infection. Symptoms. — The onset of the disease is sudden. The temperature rises to 103° or 104° F. The throat is sore and, as in a case observed by the author at the Philadelphia Hospital, the swelling may be so rapid as to necessitate tracheotomy within twenty -four hours to prevent suffocation. There are symptoms of general infection. There is a clammy perspiration, great weakness and debility, often fol- lowed by collapse and death. Treatment. — Local treatment is of little avail. If as- phyxia is imminent, tracheotomy should be resorted to, suspected abscesses should be opened, either externally through the skin by a free incision or in the pharynx if fluc- tuation is detected. Hourly hypodermic injections of anti- streptococcus serum should be given, with large hot enemas of normal salt solution every three or four hours. Stimu- lative enemas also will be necessary if the patient is unable to swallow, with hypodermics of strychnin (gi^ gr.) every three or four hours to prevent collapse. Simple Ulcer of the Pharynx. — Ulcers of the pharynx are localized areas of necrosis. Etiology. — Most ulcers of the pharynx are either syphiHs, epithelioma, or tuberculosis. However, there is an ulcera- tion of the pharynx or fauces, generally the result of mixed infection from the ever-present bacteria of the mouth, that is occasionally observed, generally in the feeble or debili- tated or those suffering from some error of metabolism. DISEASES OE THE OROPHARYNX 203 Some cases arc the result of traumatism followed by infec- tion. The symptoms vary according to the size and location of the ulceration. The pain will be severe, especially during swallowing, if the ulceration is so localized as to be irritated by the action of the faucial muscles. Under such circumstances there may be regurgitation of food through the nose. If the inflammation extends to the larynx there will be hoarseness or loss of voice, and if the tissues about the Eustachian tubes are involved by the inflammation, earache. Some of the older writers attached a consider- able amount of diagnostic importance to the fact that in epitheliomatous ulceration of the pharynx and larynx pain shooting up into the ear was a common symptom. How- ever, this symptom occurs in any pharyngeal ulceration, but is less common in syphilitic and tuberculous ulcers. If the ulceration is long continued there will be progressive loss of flesh. Upon inspection the ulcer is seen upon the pharynx either medianly or laterally, similar in appearance to ulcera- tions occasionally seen upon the tonsils. It may be round or oblong. The edges are usually well defined and the ulcer may be filled with sloughing tissue, or the floor of the ulcer may be comparatively clean and so deep that when situated medianly the bone of the vertebra is bared. Diagnosis. — The diagnosis in ulceration of the pharynx rests between syphilitic, tuberculous, epitheliomatous, and simple ulceration. The administration for a week or ten days of lo to 20 gr. of iodid of potassium after meals and at bedtime will clear up the diagnosis as far as syphilis is concerned. There is also the method of Justis : A hemo- globin estimate is made before and after a mercurial inunc- tion. If twenty-four hours after the inunction there is a decrease of 10 to 20 per cent, hemoglobin, the disease is probably syphilis. Cancer of the pharynx is differentiated by examining microscopically a small section removed from the edge of the ulcer, and tuberculosis by the tuberculin-test, the con- dition of the patient, or by microscopic examination of the sputum. 204 DISEASES OE THE NOSE, THROAT, AND EAR Treatment. — The treatment of syphilitic, epithehomatous, and tubercular ulcerations has been described elsewhere. In simple ulceration tonics and lo or 15 gr. of pepsin should be given. The ulcer should be cleansed each day with Dobell's solution or peroxid, and an application made of nitrate of silver (60 gr. to i ounce of water), after which the floor of the ulcer should be dusted either with ojr thoform or a mixture of iodoform, tannic acid, bismuth, and mor- phin (Formula 58). Both the orthoform and the above powder are analgesic and relieve pain. They are also anti- septic and adhere to the ulcerated surface sometimes for hours. Of the two, the compound iodoform and tannic acid powder gives the better results. Syphilitic pharyngitis is an inflammation of the pharynx due to the presence in the system of the syphihtic poison. The primary sore is not infrequently seen. Mucous patches are by no means rare, while gummata or their characteristic cicatrices are very often met with in the pharynx, especially in dispensary practice. Sympto77is. — In primary syphilis, examination shows a whitish abrasion, soon followed by swelling of the glands about the angle of the jaw. Secondary lesions may present either the form of mucous patches or erythema, characterized by a diffuse redness of the entire fauces or, more commonly, in the milder attacks, by a broad red line extending upward upon each of the anterior pillars, and ending abruptly and symmetrically at the root of the uvula. Mucous patches and erythematous patches in the throat are almost always symmetric ; that is, both sides of the throat are attacked in corresponding localities by similar lesions, while tertiary lesions do not as frequently present this symmetry. Gum- mata more frequently involve the tonsils or soft palate than other parts of the throat. A gumma may be absorbed under treatment or, breaking down, result in a rapidly spreading ulceration. When an ulcerating gumma is situated upon the posterior wall of the pharynx, the cervical vertebrae or even the cervical cord itself may finally become involved, and a fatal issue result. In such cases also the utmost care is required to prevent union of the soft palate and uvula to the pharyngeal wall, when the ulceration has DISEASES OE THE OROPHARYNX 205 also involved the posterior surface of the palate. Where union has actually taken place, it is almost impossible at any subsequent period to permanently restore satisfactory communication between the oropharynx and nasopharynx by any operation, because of cicatricial contraction after the operation. Treatinc7tt. — In pharyngeal syphilis, as in syphilis else- where, constitutional treatment is of primary importance, and the same remedies may be employed internally as already recommended in the treatment of nasal syphilis (Formulas 73-75). If the symptoms are urgent, the hypodermic method of administering mercury should be employed, as it gives the most speedy results. Local treat- ment consists in maintaining perfect cleanliness of the diseased parts and stimulating mucous patches and ulcera- tions to heal by daily applications of the acid nitrate of mercury, diluted with 5 parts of water, and the application, by means of the powder-blower, of a small quantity of Formula 58 or 59. Tuberculosis. — The presence of the tubercle bacilli is sometimes demonstrable by means of the microscope in the secretions of a mild chronic pharyngitis of nurses and at- tendants in the tuberculous wards of hospitals. Primary tuberculous pharyngitis with marked lesions is rare. Second- ary tuberculous pharyngitis in phthisic patients is somewdiat common, and is usually observed as ulcerations resembling those of tertiary syphilis. Infection probably reaches the pharynx through some locaHzed solution of continuity from the secretion of the tuberculous lungs. Tubercles form in the submucosa which finally break down and ulcerate. Treatment. — In cases where there are no marked lung lesions and the diagnosis is obscure, antisyphilitic remedies should be administered until the surgeon has satisfied him- self by the " therapeutic test " that the disease is not syphilis. The hemoglobin-test of Justis may be employed to assist in the diagnosis. When ulceration has occurred the ulcers should be cleansed with peroxid of hydrogen, cocainized, and touched wdth lactic acid once in two or three days. As these apphcations are somewhat painful, even after 2o6 DISEASES OF THE NOSE, THROAT, AND EAR cocainization, it is well not to employ a stronger solution than 25 per cent, until the amount of pain and reaction caused by the application has been ascertained, after which the concentrated syrupy acid may be employed if deemed advisable. Rarely is it necessary to employ the curet, and the prognosis as regards heahng is favorable. Lupus vulgaris is a form of inflammation involving the mucous membrane and submucous tissues of the pharynx, generally ending in ulceration due to the presence of the tubercle bacilli. Etiology. — The disease is said to be more common on the continent of Europe than in America. It occurs in tuber- culous families and* in those frequently brought into contact with tuberculous patients. Symptoms. — -The general condition of the patient may be that of good health. The disease is insidious and causes little annoyance until the ulcers are sufficiently large to interfere with the functions of the parts. Early in the disease soft reddish nodules about the size of sago grains appear on one or both sides of the pharynx. These finally break down, producing ulcers which may spread to the pillars of the fauces, the palate, or the larynx, one portion of the ulceration healing while another is extending. Pathology. — Portions of the diseased tissue cureted away show, under the microscope, typic tuberculous giant cells. However, tubercle bacilli are found only in small num- bers and with difficulty. Diagnosis. — The ulcerative stage may be mistaken for herpes, syphilis, or epithelioma. The short duration of herpes and the more rapid progress of epithelioma should serve to differentiate the disease from lupus. In suspected syphilis the " therapeutic test " serves to clear up the diagnosis. The tuberculin-test gives a positive reaction, causing local hyperemia and some rise of temperature, which subsides in twenty-four hours. The microscope shows typic tubercle giant cells. Treatment. — The parts should be thoroughly cureted and the solid stick of nitrate of silv^er applied. Cures have been reported by the use of the ;r-ray. Glanders, farcy, or equinia is a contagious, specific disease DISEASES OE THE OROPHARYNX 207 with both local and constitutional symptoms, usually con- tracted from infected horses. It is due to the presence of the bacillus mallei. Symptoms and Course. — Pemphigus-like vesicles appear at the point of infection, usually the face. The vesicles ulcerate and the parts sometimes become gangrenous. Metastatic abscesses occur on the face, trunk, and extrem- ities. In milder cases vesicles and abscesses heal in a short time and the patient recovers. In severer cases there is marked prostration, with rapid rise in temperature, head- ache, pain on swallowing, dryness of the throat, and enlarge- ment of the submaxillary and cervical glands. Foul-smell- ing pus flows from the nose and pharynx and a purulent bronchitis is usually present. The more severe form of the disease is usually fatal. Treatment. — Local treatment consists in cleansing the nasal and pharyngeal mucous membranes with diluted peroxid of hydrogen and detergent washes and then spray- ing the nose and pharynx with carbolated albolene. The systemic treatment should be supportive. There is no known specific remedy for the disease. Actinomycosis is a parasitic, infectious, inoculable disease, first observed in cattle and later in man. It is due to the presence of the leptothrix streptothrix or ray fungus. The most frequent and curable form of the disease is when abscesses form about the jaws or fauces. When the parasite has found a nidus in the lungs or digestive tract the disease is fatal. Etiology. — Actinomycosis is the result of inoculation with the ray fungus, which gains entrance to the mouth, pharynx, or nose from ingesta or inspired air. The disease may originate primarily in either of these cavities and, more rarely, in the larynx or ear. Pathology. — A slow swelling occurs, usually first at the angle of the jaw, which renders swallowing difficult. Upon inspection, if suppuration has not already occurred, the mass will be found to be firm to the touch and involve one or more of the cervical glands or the tonsils. At the seat of infection a nodule occurs which breaks down and discharges pus containing typic granular masses, which, upon com- 208 DISEASES OF THE NOSE, THROAT, AND EAR pression, forms star-like bodies, yellowish in color, with a center which stains blue with Mallory's stain. Symptoms. — The symptoms and pathology of the disease, as affecting the human tonsils, was first described by Jonathan Wright (1904). The symptoms are those of gran- ulating, painless abscess with general systemic infection. The laryngologist is usually first consulted by the patient for catarrh and hypertrophied tonsils. One or more crypts of the tonsils may be suppurating and lined with granula- tions. TreaUnent. — The affected tonsil or tonsils should be amputated. Where this cannot be done the application of the galvanocautery is the best form of treatment. Each nodule or suppurating crypt should be thoroughly destroyed. Abscesses occurring in localities other than the tonsils should be opened, cureted, and cauterized with the solid stick of nitrate of silver. lodid of potassium in large doses is stated to inhibit the growth of the ray fungus, and Sawyer reports favorable results from the injection into tumors of from 15 to 30 minims of a i per cent, solution of the iodid. Retropharyngeal abscess is an abscess of the posterior phar>mgeal wall. It may be hidden above and behind the soft palate and require the rhinoscope to ascertain its outHne ; it may be situated opposite the larynx, and only be seen in its entirety with the laryngoscope, or it may be situ- ated in such a manner as to be hidden by one of the posterior pillars of the pharynx. However, the most common seat of abscess is the posterior wall of the pharynx opposite the oral cavity on one side or the other of the median line. Etiology. — Abscess may occur as the result of phleg- monous inflammation of the cellular tissue of the pharynx, scrofula and syphiHs being predisposing causes. Traumatism and necrosis of the vertebrae are sometimes causes of the affection. Symptoms. — There is usually but slight systemic disturb- ance. Chilly sensations may perhaps be complained of, but local symptoms are usually the first to attract attention. When the abscess is situated high up upon the pharyngeal wall, a sensation as of a foreign body causes almost constant DISEASES OE THE OROPHARYNX 209 hawking and spitting, while thcrcmay be present obstructed nasal respiration with more or less pain and tinnitus. When the abscess is opposite the larynx, dyspnea is a marked symptom, appearing in " spasms " which may endanger the patient's life, while swallowing of liquids or solids is dan- gerous, owing to their frequent passage into the larynx. In the case of an eighteen-months'-old child seen in consul- tation by the writer, the mere attempt to introduce a tongue- depressor into the mouth was followed by collapse and apparent death. The child's life was saved only by a rapid tracheotomy with the only available instrument, a penknife. The next day after the operation the cause of the obstructed respiration was discovered to be a retropharyngeal abscess situated low down in the pharynx opposite the larynx. The abscess was opened and the child made a good recovery. An abscess in the pharyngeal wall opposite the oral cavity presents none of these symptoms unless very large. T}'cat})ic)it. — Left to itself, a retropharyngeal abscess will discharge either into the throat or at some more remote point, but as soon as a diagnosis is estabUshed an incision should be made into the abscess at its lowest part, and the opening maintained patulous by the daily passage of a probe as long as necessary to bring about a cure of the affection. Prognosis is favorable except in those cases where the spinal vertebme are involved. In all operations upon the posterior wall of the pharynx it should be borne in mind that a large artery is occasionally found in this position, probably the vertebral, which sometimes enters its osseo- fibrous canal as high up as the fourth or even second vertebra. It has been seen to leave its canal at the third vertebra, to re-enter it at the atlas. Tumors. — Any of the varieties of tumor found in other parts of the body may occur in the pharynx. They are most frequently located in the lateral walls and may involve the surrounding structures. In the following order of frequency there is found in the pharynx gumma, sarcoma, carcinoma, lupus, papilloma, cyst, fibroma, osteoma, en- chondroma, adenoma, and aneurism. Symptoms. — When the growth is large it may become an 14 210 DISEASES OF THE NOSE, THROAT, AND EAR obstruction to deglution or even respiration. In carcinoma and ulcerating lupus pain is also present, which in many instances radiates into the ean Treatment. — Except in the case of gumma, the treat- ment of which has been already described, early extirpation with the knife, galvanocautery, or snare should be practised. NEUROSES OF THE PHARYNX The more common neuroses of the pharynx are anes- thesia, hyperesthesia, paresthesia, neuralgia, and paralysis, either unilateral or complete. Anesthesia, as encountered in the office of the rhinologist, is most often the result of hysteria. The pharyngeal re- flexes are abolished ; there is a more or less complete loss of pharyngeal sensation when the parts are touched with a cotton-tipped probe. The condition is observed in cases of progressive bulbar paralysis and in the general paralysis of the insane. Treatment. — ^Treatment depends on the cause of the con- dition. In hysteria it may be advisable to use the strong galvanic or induced current with strychnin internally, possi- bly in increasing doses. Hyperesthesia is generally the result of some disease of the nose and nasopharynx that has rendered the secretions viscid and sticky, so that frequent hawking is necessary to dislodge them. The excessive use of tobacco, especially chewing-tobacco, will produce the same condition. In some cases of hyperesthesia of the pharynx the reflexes are in- creased to such an extent that barely touching the pharynx is sufficient to produce emesis. There is, of course, hyper- esthesia of the pharynx in practically every case of acute pharyngitis. Treatment. — Cessation of the excessive use of tobacco or cure of the nasopharyngeal catarrh that has produced the condition is ordinarily sufficient to reduce the hyperesthesia to normal and diminish the reflexes. Temporary relief is aflbrded by the administration of sodium bromid in doses of lo or 15 gr. three times a day. When the reflexes are not increased to an extent to produce vomiting whenever the pharynx is sprayed, the patient should spray his pharynx DISEASES OF THE OROPJIARYNX 211 three or four times a day with an atomizer containin;^ a solution of sulphate of copper (2 to 5 <^^r. to I ounce of water). Paresthesia is most frequently manifested as a sensation as of a small foreign body in the pharynx. This sensation and burning, itching, or tickling, as well as spasm of the pharyngeal muscles, the well-known " globus hysterias," are not uncommon in hysteric females. However, in the larger proportion of these so-called hysteric cases some lesion will be found to account for the symptoms if the pharynx be carefully inspected. The most common lesions are inflamed follicles or an erosion on either side of the pharynx, posterior to the posterior pillar, or in any other position where two folds of mucous membrane rub together in deglutition. Treatment. — The symptoms are usually quickly relieved by 10 or 15 gr. of bromid of sodium after meals and at bedtime. After relief has been secured by the use of the bromid, a general tonic treatment should be prescribed for building up the nervous system — rest, iron, quinin, phos- phorus. Pil. sumbul comp., one or two after each meal, frequently yields very satisfactory results. When inflamed follicles or any erosion is found in a position where it is irritated by each movement of the pharyngeal muscles, it should be touched every day or two with a 60-gr. solution of nitrate of silver. Paralysis of the Pharynx. — Etiology. — Paralysis of the pharynx may result from diphtheria or syphilis, or be the result of a cerebral affection involving the nerves that supply the pharyngeal muscles. Transient paralysis of the palate, either unilateral or bilateral, is common as the result of diphtheria ; more rarely are the pharyngeal muscles also paralyzed in severe cases. Pathology. — One or both sides of the pharynx may be involved, and one or all three of the pharyngeal con- strictors be paralyzed, as well as the velum palati ; but paralysis of the soft palate, either unilateral or bilateral, occurs independently as a "reflex" in ethmoiditis. Symptoms. — Difficult deglutition ; liquids being more easily swallowed than solids, but more frequently passing 212 DISEASES OF THE NOSE, THROAT, AND EAR into the larynx ; or, when the soft palate is also paralyzed, both solids and fluids may be forced into the posterior nares through the efforts of the tongue to assist deglutition. Treatment. — The central cause of the affection should be carefully sought and treated. In suitable cases strychnin, in gradually increasing doses until the limit of toleration has been reached, will do good ; while arsenic and tonics are especially valuable where the paralysis is of diphtheritic origin. Schroeter's forceps. Foreign bodies of two classes are found in the pharynx : First, those whose bulk does not allow them to pass through the esophagus, and secondly, sharp-pointed objects, hke pins, needles, fish-bones, etc., that are forced into the pharyngeal walls by contraction of the constrictor muscles. Symptoms. — Large objects may cause death by holding down the epiglottis. Sharp-pointed objects cause a prick- ing sensation, sometimes felt at two places in the pharynx, as in the case of a pin or needle. Localized spots of inflam- mation, when situated low down upon the pharyngeal wall, give rise to the sensation of a foreign body, and this fact, DISEASES OE THE OROrHARYNX 2l3 as well as the imaginary foreign body of hysteric women, should be remembered after an unsuccessful search for a foreign substance in the pharynx. Treatment. — It is not always possible to use the laryngo- scope to advantage when the foreign body is situated low down in the pharynx, and in such cases the finger should be introduced into the pharynx, and if a foreign body be felt an effort should be made to scratch it loose with the finger-nail and withdraw it. When the offending substance can be seen, a pair of forceps, either straight or curved (Fig. 120), according to its position, should be used to with- draw it. It should be remembered that after the removal of a foreign body sometimes a sensation as of its presence remains for some days. THE TONSILS DISEASES OF THE TONSILS Acute tonsillitis is an inflammation of the tonsils and adjacent structures. There are two common varieties — the croupous and the phlegmonous. The synonyms are quinsy ; amygdalitis ; cynanche ton- sillaris ; angina tonsillaris ; angina faucium ; follicular ton- sillitis ; croupous tonsillitis. Etiology. — The croupous variety of the disease (Fig. 121) is the result of infection, the disease being infectious, but probably not contagious. The phlegmonous variety (Fig. 123) is apparently often the result of exposure to cold and wet. Recurrent attacks of peritonsillitis are often the result of chronic mflammation of the tonsils, with or without hypertrophy. The cheesy secretion that is retained within the crypts (Fig. 122) becomes from time to time a source of infection and inoculates either the tonsillar structure itself or, more frequently, the surrounding cellular tissue. Deposits of fetid material between the tonsil and the anterior pillar, when the tonsil is partially adherent to it, also are capable of inoculating the adjacent cellular tissue and causing recurrent attacks of peritonsillar abscess. For these reasons excision of hypertrophied tonsils is not always followed by a cessation of recurrent attacks of quinsy, unless, after the excision, care is taken to destroy with the galvano- cautery-knife all crypts that may remain in the stump of the tonsil and dissect the latter loose from the faucial pillars, should it be adherent, in order to destroy all recep- tacles capable of retaining putrid secretions. However, recurrent quinsy occurs in individuals who be- tween the attacks have apparently normal tonsils. In such cases the rheumatic and gouty diathesis also plays its part 214 J) I SK ASKS OF 'J HE TONSILS 215 in the production of an attack of acute tonsillitis, l^hlcg- monous tonsillitis is a disease of adolescence and early adult life, and does not so frequently attack individuals who arc over thirty-five years of age. Pathology. — The inflammation may be only superficial (erythematous tonsilljtis) or may involve the parenchyma of the gland (parenchymatous tonsillitis). When the inflam- mation is deep seated, an abscess may occur either in the tonsil or more frequently in the cellular tissue about the tonsil, but the brunt of the inflammation is frequently borne by the crypts of the tonsils, which pour out an abundant fibrinous secretion, which, adherincr to the surface of the Fig. 121. — Follicular tonsillitis. A Fig. 122. — Crypts in cases of tonsillitis : A, Acute lacunar ; B, chronic hypertrophic ; a. surface- epithelium : h, accumulated con- tents of crypt ; c, lymphoid follicles surrounding crypt. (Kaufmann.) tonsil, presents somewhat the appearance of a diphtheritic membrane (croupous tonsillitis). Diagnosis. — By croupous tonsillitis is meant an inflamma- tion of the tonsil, originating in the crypts and accompanied by the formation of a pseudomembrane which, at first con- fined to the neighborhood of the crypts, often finally extends over the entire tonsil or tonsils, if both be involved. In typic cases occurring in ^ C--^N [k Fig. Ermold's tonsillotome. DISEASES OE THE TONSILS 223 seated in the lap of an assistant, who holds the child's le^^s between his own to prevent struggling. The assistant then passes his arms under the child's arms and grasps the child's forehead with his two hands in such a manner as to control the movements of the child's head. When the assistant elevates his elbows the child's arms are extended in such a manner as to prevent the child reaching his face with his hands and interfering with the operation. The tonsillotome is introduced into the child's mouth flat- wise, like a tongue-depressor, and serves to hold down the root of the tongue and afford a good view of the lower border of the tonsil. The ring of the tonsillotome is now passed around the tonsil from below in order to be sure that the lower border of the tonsil is encircled by the ring, which is pressed firmly against the wall of the pharynx. The blades of the instrument are now closed and tonsillo- tome and tonsil removed together from the mouth. If the operator is provided with two tonsillotomes it is generally feasible to remove the second tonsil before releasing the child, unless bleeding is excessive to a degree to interfere with a view of the fauces. The operator should be provided with a set of at least three tonsillotomes, in order that he may select one with a ring of just sufficient size to snugly fit around the tonsil to be removed. After encircling the tonsil the instrument should be closed somewhat deliberately, and the operator should be careful to make no effort to remove the tonsillo- tome from the mouth until the tonsil has been completely severed. It should be borne in mind that the tonsils are not very sensitive. Indeed, they can be touched with the red-hot cautery-knife without causing much pain. The operation, therefore, is not especially painful, and probably causes less discomfort to the patient than the administration of ether, which, of course, if used adds an increased risk to the operation. However, there is no great objection to administering ether for tonsillotomy. Under such circum- stances the tonsils are removed with the child's head turned to one side and hanging over the end of the table, to prevent as far as possible the flow of blood into the larynx. 224 DISEASES OF THE NOSE, THROAT, AND EAR The operation with the galvanocautcry is performed in the following manner : A small galvanocautery-knife is introduced (cold) into one of the crypts of the tonsils and, being heated while in situ, is made to burn its way out. Two or three such burns may be made at a sitting upon a tonsil, and will be followed by con- siderable shrinking of the hypertrophied gland. But one of the tonsils should be operated upon with the galvano- cautcry at any one time, and from five to fifteen such operations are required to reduce the gland to satisfactory di- mensions. When it is necessary to operate under ether, the tonsils can sometimes be removed with less hemorrhage by means of a snare than by the tonsillotome. For this purpose Peters' ton- sil snare is the most useful instrument; as by means of the powerful leverage afforded by this instrument the wire severs the tonsil almost as rapidly as the knife of a Fig. 129. — Myles' tons punches. Fig. 130. — Reflex spasm of the glottis, caused by a large hypertrophy of the lingual tonsil (Rice). tonsillotome. The wire loop is made to encircle the tonsil, which is then drawn out of the space between the pillars by means of Kirkpatrick's tonsil tenaculum forceps. The wire loop is pressed firmly against the pharyngeal wall as DISEASES OE THE UVULA 225 the tonsil is pulled out through it by the forceps, and finally encircles the base of the tonsil so that as the loop is tjf^ht- ened the tonsil is comi)letely enucleated from its bed. Hemorrhage is controlled by packing a strip of iodoform gauze into the space between the anterior and posterior pillars from which the tonsil was removed. Sometimes in the case of bleeders and others it is desir- able to remove the tonsil piecemeal. P'or this purpose one of the so-called tonsil punches (Fig. 129) may be used. Fig. 131. — Kirkpatrick's lingual tonsil scissors. Hypertrophy of the Lingual Tonsil. — Occasionally the mass of adenoid tissue at the base of the tongue becomes suffi- ciently hypertrophied (Fig. 130) to cause a reflex cough. Under such circumstances the redundant tissue may be cut away by means of Kirkpatrick's scissors (Fig. 131). The serrated edges of the instrument do not allow the flabby tissues to slip, while the curve of the blades is such as to fit the base of the tongue. DISEASES OF THE UVULA Inflammation of the uvula may occur primarily or as the result of extension of inflammation from the tonsils or palate. Occasionally it becomes edematous. The disten- tion may be so great as to produce dyspnea. The treat- 15 226 DISEASES OE THE NOSE, THROAT, AND EAR ment consists in cocainizing the uvula, seizing it with a pair of mouse-tooth forceps, and freely incising the mucous membrane in a number of places in order to allow the fluid to escape. The same object may be accomplished some- times more conveniently by snipping off the mucous mem- brane at the tip of the uvula. Pseudo7nembranoiis Uvtt litis. — The extension of a pseudo- membrane from the tonsils to the uvula is somewhat characteristic of diphtheria. However, this occurs in other forms of pseudomembranous pharyngitis. Treatjnent of Inflammation of the Uvula. — As inflamma- tion of the uvula generally is only part of an inflammation involving the rest of the fauces, it is best to begin treatment by spraying the fauces with a i : lOOO solution of adrenalin ; the uvula should then be painted with a lo per cent, solu- tion of nitrate of silver. This should be done in the physician's office once or twice a day, the patient in the intervals either spraying his fauces every two or three hours with a I : 10,000 solution of adrenalin or a 3 per cent, solution of alumnol. Ulceration of the Uvula. — The uvula sometimes becomes ulcerated as the result of traumatism and infection. Syph- ilis, lupus, or tuberculosis may be primarily located in the uvula. The uvula is sometimes destroyed by an ulcerating gumma. Occasionally these cases are first seen by the laryngologist when the ulcer has made considerable prog- ress and the uvula hangs, as it were, by a string of mucous membrane. Under these circumstances the uvula some- times can be saved by the daily subcutaneous injection of bichlorid of mercury (Formula 'jG), which, although painful, probably yields quicker results than other methods of treat- ment. Where an increasing gumma involves the posterior wall of the pharynx as well as the uvula and soft palate, there is great danger of cicatricial adhesions occurring that may entirely shut off communication between the posterior naris and oropharynx. Deformities of the Uvula. — Bifid Uvula. — The uvula when present is always bifid in cleft palate as the result of the same cause that produces the palate deformity. Hence, ordinary bifid uvula might be considered as an incomplete DISEASES OE 77 IE UVULA , 22/ cleft palate. The deformity varies from a little dent at the free extremity of the uvula, which is usually club shaped, to a complete division separating the uvula into two lateral halves. Trcatjncnt. — Bifid uvula, when it causes no symptoms, is best let alone. However, the parts may be freshened by means of a V-shaped incision and sewed together. If the uvula is thoroughly cocainized and then sprayed with adrenalin the operation is both painless and bloodless. For anesthetizing the uvula simply painting the parts with a lo })er cent, solution of cocain is not sufficient. The operator should be provided with a small cup at the end of a long handle. This is partly filled with a 4 per cent, solution of cocain and held under the palate in such a manner that the uvula soaks in the cocain solution for a few moments before the operation. Elongation of the Uvula. — The whole mass of the uvula may be hypertrophied. More frequently, however, merely the mucous membrane is relaxed and hangs as a conic tip below the uvula proper. In rare cases a warty growth is attached to the end of the elongated uvula. Etiology. — It is generally the result of chronic pharyn- gitis, the constant hawking to dislodge masses of mucus from the pharynx having a tendency to cause the affection. Paralysis of the palate is a reflex sometimes observed in cthmoiditis, and in such cases paralysis of the azygos uvulae muscles and consequent elongation of the uvula are concomitant with the affection. Symptoms. — Patients complain of ** a tickling in their throats." The elongated uvula hanging in contact wath the base of the tongue causes an almost constant short cough as an effort to dislodge a supposed foreign substance. These efforts are sometimes persisted in until nausea and vomiting result. Snoring is usually marked and the sleep is disturbed by dreams. Trcatmoit. — The redundant portion of the uvula should be amputated. This is ordinarily only relaxed and re- dundant mucous membrane at the tip of the uvula. It is rarely or never necessary to remove any of the muscular structure of the organ, and amputation of the entire uvula 228 DISEASES OF THE NOSE, THROAT, AND EAR close up to the soft palate is done only for the removal of malignant disease or as the result of the ignorance or awk- wardness of the operator. The operation is perhaps best done in the following manner : The uvula is grasped at a point just below where it is decided to amputate with a pair of long hemostats, which are then clamped. The position of the hemostat marks the spot on the uvula where it has been decided to amputate ; so that there is no danger of cutting off too much or too little. The uvula is stretched well forward and cut off close to the forceps by a single cut of a pair of somewhat heavy scissors, curved upon the flat, and held with their concavity upward in such a manner that the uvula is cut somewhat obHquely upward ; and the wound, being upon the posterior surface, is protected from contact with food during the healing process. Generally there is but little inflammatory reaction and the wound heals promptly, but occasionally a mild acute pharyngitis occurs as the result of the operation when the uvula is thick and fleshy. THE LARYNX ANATOMY OF THE LARYNX The larynx is an expansion of the upper portion of the trachea, so that there is formed a musculo-cartilaginous- membranous box constituting the essential organ of voice. It lies in front of the pharynx, of which it, with the base of the tongue, forms the lower anterior wall. Its superior aperture slopes downward and backward toward the pharynx and is partly closed from before backward during degluti- tion by a leaf-shaped lid, the epiglottis. The larynx is connected by ligaments and muscles with the surrounding tissues, the muscles serving to draw it upward during vocalization and deglutition. Cartilages. — The cartilages of the larynx are nine in number, three single and three in pairs : The thyroid, cri- coid, and epiglottic cartilages, the arytenoid cartilages, the cartilages of Wrisberg, and those of Santorini. The shapes of these, their relative size, and their manner of articulation and relative position to the hyoid bone is shown in Figs. 132 and 133. The thyroid cartilage, so called from its resemblance in shape to a shield, is composed of two plates or wings, united in front at an angle in such a manner as to project forward beneath the skin of the throat as an elevation — the "Adam's apple." To its outer surface are attached the sternothyroid, thyrohyoid, and inferior constrictor muscles. To its inner surface are attached the epiglottis, the thyro-arytenoid, thyro-epiglottidean muscles, and the true and false vocal cords. The superior border of the cartilage curves backward from a median notch to the superior cornua or horns. To this border is attached the thyrohyoid membrane or ligament (Figs. 132, 133). The lower border gives attachment to the cricothyroid mem- 229 230 DISEASES OP THE NOSE, THROAT, AND EAR brane or ligament in the median line, and on each side to the cricothyroid muscles (Figs. 134, 135). The posterior borders and superior and inferior horns give attachment to the stylo- and palatopharyngeus muscles. To the apices of the superior cornua is attached the thyrohyoid liga- ment. The inferior cornua articulate with the cricoid car- tilage. Fig. 132. — Articulations and lig-aments of the larynx, anterior view : A, Hyoid bone, with a its greater, and a' its lesser cornua ; 1-5, ligaments; 6, lateral cricothyroid artic- ulation ; 7, junction of cricoid and trachea. (Testut.) Fig. 133. — Articulations and ligaments of the larynx, posterior view: ^, Hyoid ; B, thyroid, with b and b' its cornua ; C, cricoid ; D, arytenoids ; E, cartilages of Santorini ; F, epiglottis ; G, trachea ; 1-6, ligaments ; 2, opening for superior laryngeal artery ; 7, junction of trachea and cricoid. (Testut.) The cricoid cartilage, so called from its seal-ring shape, lies below the cricoid with its seal or broad surface pos- teriorly ; laterally it articulates with the inferior cornua of the thyroid by means of small articular facets, and on the superior border posteriorly are two other facets for articu- lation with the arytenoid cartilages. To its lateral surfaces are attached the crico-arytenoideus posticus muscles and the longitudinal fibers of the esophagus (Figs. 134, 135). ANATOMY OF TIIR LARYNX 231 To its upper border are attached the cricotliyroid nienibrane and the crico-arytenoidei lateralis muscles ; to its lower bor- der a fibrous membrane connecting it with the upper ring of the trachea. Fig. 134. — Larynx with its muscles, pos- terior view : I, Epiglottis ; 2. cushion; 3, aryepigiottic ligament ; 4, cartilage of Wris- berg ; 5, cartilage of Santorini ; 6. oblique arytenoid muscles ; 7, transverse arytenoid muscle; 8, posterior crico-arytenoid muscle; 9, inferior cornu of thyroid cartilage ; 10, cricoid cartilage ; 11, posterior inferior cera- tocricoid ligament; 12, cartilaginous por- tion; 13, membranous portion of trachea. (Stoerk.) Fig. 135. — Larynx and its lateral muscles after removal of the left plate of the thyroid cartilage : i, Thyroid cartilage ; 2, thyro- epiglottic muscle; 3. cartilage of Wrisberg; 4, aryepiglottic muscle ; 5. cartilage of San- torini ; 6, oblique arytenoid muscles ; 7, thyro-arytenoid muscle ; 8, transverse aryte- noid muscle ; 9, processus muscularis of arytenoid cartilages ; 10, lateral crico-aryte- noid muscle ; 11, posterior crico-arytenoid muscle ; 12, cricothyroid membrane ; 13, cricoid cartilage ; 14, attachment of crico- thyroid muscle ; 15, articular surface for the inferior cornua of the thyroid cartilage ; 16, cricotracheal ligament ; 17, cartilages of trachea ; 18, membranous part of trachea. (Stoerk.) The arytenoid, or " pitcher-shaped " cartilages, articulate with the upper posterior border of the cricoid (Figs. 132- 135). To the anterior surface are attached the false vocal cords and thyro-arytenoideus muscles ; at the anterior angle 232 DISEASES OE THE NOSE, THROAT, AND EAR or vocal process are attached the true vocal cords and the thyro-arytenoideus muscles. To the posterior surface is attached the arytenoideus muscle. To the posterior angle, or processus muscularis (Fig. 137), are attached the crico- arytenoideus lateralis and posticus muscles (Figs. 134, 135). The median surfaces of the arytenoid cartilages are covered with mucous membrane and face each other; their apices articulate with the cartilages of Santorini. Cartilages of Santoririi are two small cartilages at the apices of the arytenoid cartilages, to which are attached the aryteno-epiglottidean folds. Cartilages of Wrisberg are two little masses of cartilage contained in the arj^teno-epiglottic folds. Fig. 136. — Diagram to illustrate the thyro-arytenoid muscles ; the figure represents a transverse section of the larynx through the bases of the arytenoid cartilages : Ary, Ary- tenoid cartilage : /.;«. processus muscularis ; /.z', processus vocalis; 77i, thyroid carti- lage; f .7', vocal cords; Oe \% placed in the esophagus; vi.thy.ar.i, internal thyro-ary- tenoid muscle; inthy.ar.e, external thyro-arytenoid muscle; m.thy.ar.fp, -p^rt of the thyro-aryepiglottic muscle, cut more or less transversely; vt.ar.t, transverse arytenoid muscle. (Redrawn from Foster.) Epiglottis. — The cartilage of the epiglottis is leaf shaped and attached by its apex to the thyroid's inner surface just below the median notch by the thyro-epiglottidean Hgament (Figs. 132, 133). The epiglottic cartilage is covered by mucous membrane. Its base is free and points backward from the root of the tongue, to which its anterior surface is attached by three glosso-epiglottic folds of mucous mem- brane, and to the hyoid bone by the hyo-epiglottic ligament. The lateral margins are connected with the arytenoid carti- lages by the aryteno-epiglottic folds. Its posterior surface ANATOMY OF THE LARYNX 233 covers the superior aperture of the hirynx when food passes down the pharynx. Ligaments. — The hirynx has nineteen hgaments — three extrinsic, binding the larynx to the hyoid bone, and six- teen intrinsic, binding its various cartilages to- gether. The extrinsic ligajiients are the thyrohyoid mem- brane and two lateral liga- ments (Figs. 132, 133). The intrifisic ligaments are the cricothyroid mem- brane, the cricothyroid capsular ligaments (two), crico-arytenoid ligaments (two), crico-arytenoid cap- sular ligaments (two). In the false cords or ventric- ular bands the superior thyroarytenoid ligaments (two). In the true vocal cords the inferior thyro- arytenoid ligaments (two), the hyo-epiglottic liga- ment, the thyro-epiglottic ligament, and the three glosso-epiglottic folds. Muscles. — There are four pairs of lateral mus- cles and one central muscle, the aryteyioidcns , which extends from the posterior surface and outer border of one aryte- noid cartilage to the corresponding parts of the other. There are both oblique and transverse fibers, and the action of the muscle is to draw the arytenoids together and close the pos- terior portion of the chink of the glottis (Fig. 1 34). It is sup- plied by both the superior and recurrent laryngeal nerves. Fig. larynx cushion ; t37. — Vertical transverse section of the I, Posterior face of epiglottis, with i', its 2, aryteno-epiglottic fold; 3, ventricular band, or false vocal cord ; 4, true vocal cord ; 5, central fossa of Merkel ; 6, ventricle of larj'nx, with 6', its ascending pouch ; 7. anterior portion of cricoid ; 8, section of cricoid ; 9, thyroid, cut surface; 10, thyrohyoid membrane; 11, thyro- hyoid muscle ; 12, aryteno-epiglottic muscle; 13, thyro-arytenoid muscle, with 13', its inner division, contained in the vocal cord ; 14, cricothyroid muscle; 15, subglottic portion of larynx; 16, cavity of the trachea. (After Testut.) 234 DISEASES OF THE NOSE, THROAT, A/vD EAR The four pairs oi lateral muscles are : The crico-arytenoideus lateralis, extending from the pos- terior angle of the base of the arytenoid to the upper lateral border of the cricoid cartilage. This muscle rotates the arytenoid inward and, with its fellow of the opposite side, closes the glottis except for the posterior portion, closed as described above by the action of the arytenoideus, bring- ing the bases of the arytenoid cartilages together. The lateral crico-arytenoids are supplied by the recurrent laryn- geal nerve. The cricothyroid, extending from the front and side of the cricoid cartilage to the lower and inner border of the thyroid (Fig. 136), The action of this muscle is to tilt the thyroid forward upon the cricoid and thus stretch and render tense the vocal cords. It is supplied by the superior laryngeal nerve. The crico-arytenoideus posticus extends from the pos- terior angle of the base of the arytenoids to the posterior portion of the cricoid (Figs. 134, 135). Its action is to rotate the arytenoids outward and open the glottis while keeping the cords tense. It is supplied by the recurrent laryngeal nerve. The thyro-arytenoideus extends from the angle of the thyroid cartilage and the posterior surface of the cricothyroid membrane into the base and anterior surface of the arytenoid (Fig. 137). Its action is to shorten and relax the vocal cords by bringing the thyroid and arytenoids closer to- gether and to compress the sacculus laryngis. It is supplied by the recurrent laryngeal nerve. The action of the intrinsic muscles may be studied by reference to Fig. 136 and the other figures illustrating the anatomy of the muscles of the larynx. Briefly, the chink of the glottis is closed by the action of the arytenoideus and the crico-arytenoideus lateralis. The cords are tight- ened and made tense by the action of the cricothyroid. The cords are relaxed by the action of the thyro-arytenoid- eus and separated by the action of the crico-arytenoideus posticus. The study of the action of the muscles of the larynx may be also facilitated by inspecting the figures illustrating laryngeal paralysis (Figs. 1 54-161). ANATOMY OF TIIK LARYNX 235 The muscles of the epiglottis are three double muscles, all supplied by the recurrent laryn<^eal nerves. Their action is to depress the epiglottis and compress the sacculus laryngis. The epiglottic muscles are the thyro-epiglottideus, between the inner surface of the thyroid and the epiglottis and aryteno-epiglottic folds ; the aryteno-epiglottideus superior, between the apices of the arytenoids to the aryteno- epiglottidean fold ; and the aryteno-epiglottideus inferior, from the arytenoid cartilage just above the ventricular bands to the sacculus laryngis. The vocal cords, sometimes called the true vocal cords in contradistinction to the false vocal cords or ventricular bands, extend anteroposteriorly across the larynx from the angle of the thyroid cartilage to the anterior angle of the arytenoids (Figs. 133-136). They each consist of a fold of mucous membrane containing the inferior thyro-arytenoideus ligament with the thyro-arytenoideus muscle parallel to it (Fig. 137)- The ventricular bands are two folds of mucous membrane containing the superior thyro-arytenoid ligament extending across the larynx above the ventricles of the larynx (Fig 137)- The glottis, or rima glottidis, sometimes called the chink of the glottis, is the space between the vocal cords. When the cords are separated during forced inspiration it is triangular in shape, with the apex of the triangle anterior. Its length rarely is i inch in the male, and its width posteriorly during inspiration does not exceed \ inch. The ventricles of the larynx are oval depressions between the ventricular bands and the cords leading upward toward the sacculus laryngis. The sacculus laryngis is the upper portion of the ventricle of the larynx. It contains sixty or seventy small mucous glands, whose secretion lubricates the cords. It is of conic shape and is covered by the aryepiglottideus inferior muscle medianly and the thyro-epiglottic muscle laterally. Both muscles by their action compress it and expel its contents (Fig. 137)- The mucous membrane of the larynx is somewhat thin. It is covered with ciliated columnar epithelium below the 236 DISEASES OF THE NOSE, THROAT, AND EAR level of the ventricular bands, extending up in front as high as the center of the epiglottis. Over the rest of the mucous membrane of the larynx is stratified squamous epithelium. The abrupt change in the character of the epithelium of the larynx probably accounts for the rarity of infection of the pharynx extending into the lower air-passages ; as it is a well-established fact that infections of mucous membranes generally respect anatomic boundaries when the character of the epithelium covering suddenly changes. The arteries of the larynx are the laryngeal branches of the superior and inferior thyroid. The most important of these from an operative standpoint is the cricothyroid, which extends transversely across the cricothyroid membrane to anastomose with its fellow of the opposite side. This artery is seldom large enough to require ligation in deliberate operating. However, in emergency cases, where it is necessary to open the cricothyroid membrane as quickly as possible, it is better to cut the cricothyroid membrane trans- versely in order to avoid wounding this vessel. The veins empty into the superior, middle, and inferior thyroid veins. Ordinarily these are vessels of small size, but in obstructed respiration from stenosis their size is greatly increased. The nerves of the larynx are the superior and recurrent branches of the pneumogastric joined by branches of the spinal accessory and the sympathetic. The superior laryn- geal is mainly a nerve of sensation. It enters the larynx through an opening in the thyrohyoid membrane and supplies the mucous membrane, the cricothyroid, and ary- tenoideus muscles. The recurrent laryngeal is a motor nerve. It winds from before backward around the subclavian artery on the right side and around the arch of the aorta on the left side, and supplies all the laryngeal muscles except the cricothyroid. In its course it gives off cardiac, esophageal, tracheal, and pharyngeal filaments. It anastomoses with the superior laryngeal. Aneurism of the aorta or subclavian pressing on the re- current laryngeal nerve produces characteristic paralysis of the laryngeal muscles, and the same is true of hypertrophied ANATOMY OF TI/E LARYNX 237 or tubercular lymphatics in the mediastinum or in the neck. The size of the larynx varies greatly, being much larger in males than in females and children. At the age of puberty in boys the voice undergoes a rapid change in character and pitch. During this period of change the mucous membrane of the larynx is usually at least some- what congested, and occasionally individuals are unable to control the pitch of their voices to the extent that they will begin a sentence in a high-pitched voice and end it in a bass voice or the reverse. Musical notes used in singing have a range of about 3^ octaves, and voices are classified according to their position in the musical scale into soprano, mezzosoprano, contralto, tenor, baritone, and bass. Soprano, mezzosoprano, and contralto voices are usually found in women, while the male voice is usually either tenor, baritone, or bass. Voice production is the result of the vibration of the vocal cords amplified by the resonant cavities above ; that is, the pharynx, the mouth, the nose ; in the same manner that the sound of a tuning-fork is amplified and made many times louder by approaching the vibrating fork toward the open- ing in a wide-mouthed bottle of a sufficient depth to con- tain a column of air capable of vibration in unison with the fork. The sound produced by the vibrations of the vocal cords is feeble and practically inaudible until it is amplified and made loud by the vibration of the air in the mouth, pharynx, and nose. The size of this cavity can be greatly reduced by the contraction of the palate, shutting off the cavity of the nose and nasopharynx from the space below, and the size and shape of the cavity of the mouth and oropharynx can be changed by the action of the muscles of the tongue and pharynx ; so that it is possible to produce a space containing a volume of air capable of vibrating in unison with and amplifying a sound of any pitch produced by the vibration of the vocal cords. The larynx possesses the characteristics of both reed and string musical instruments. The pitch of a sound produced by the vibration of the vocal cords depends upon their length, thickness, and tension. What is called the falsetto voice is 238 DISEASES OF THE NOSE, THROAT, AND EAR the result of the cords vibrating not as a whole, but in two or more segments. The resulting sound is high pitched, far above the natural range of the individual's voice, and possessing a timbre or character usually disagreeable. Voices differ greatly in range, that is, some individuals have no more than a few notes of the musical scale, while others have 2 and even 2\ octaves at their command, and above the natural range of their voices a falsetto voice, also of considerable range. Musical notes (see p. 237) have three qualities — loudness, pitch, and timbre or character. We have already learned how loudness of voice is the result of the amplification of the sound produced by the resonant cavities of the mouth, pharynx, and nose. The loudness also is dependent on the force and amplitude of the vibrations of the vocal cords. The timbre or character of the voice is as varied as the dispositions of individuals. It is that quality by which we recognize the voice of an individual as different from all other individuals. In singers the timbre of the voice may be sweet and pleasant or rough, coarse, and unpleasant. It may be nasal, from the presence of adenoids or other growths that render the use of the nose as a resonant cavity impossible. Timbre of the voice is probably the result of the relative size and shape of the resonant cavities, the position of the teeth and lips, and the thousand and one anatomic peculiarities of an individual's vocal organs. In this connection it is Avell enough to insert a word of caution as to the impropriety of suddenly greatly altering the size or shape of the upper respiratory tract, as, for example, by the ablation of very greatly hypertrophied tonsils in the case of professional singers, for fear that the character of their voice may be changed for the worse rather than the better. The singing voice differs from the speaking voice mainly that in singing the tone is sustained at the same pitch for an appreciable length of time, while in speaking the voice is continually sliding up and down the musical scale on the vowel sounds. DISEASES OF THE LARYNX 239 DISEASES OF THE LARYNX Anemia. — The presence of laryngeal anemia is of especial importance: (i) When associated with functional aphonia. (2) When, during the course of an attack of chronic laryn- gitis, the mucous membrane covering the aryepiglottic folds, arytenoid cartilages, and ventricular bands is abnormally pale while the vocal cords are the seat of indolent conges- tion, the patient not being generally anemic. Each of the above conditions are premonitory of laryngeal phthisis. Hyperemia of the larynx is a congestion of the mucous membrane of the larynx, most marked where the submucosa is loose, fat, and thick, as upon the aryepiglottic folds, ventric- ular bands, and ventricles ; the epiglottis, vocal cords, and inferior cavity of the larynx being but little altered in color. Its presence renders an individual more prone to contract acute or chronic laryngitis. Etiology. — Hyperemia of the larynx is oftenest the result of excessive smoking, especially of cigarette smoking. It also results from working in dusty rooms and amid irritat- ing chemic fumes. Acute laryngitis is an acute inflammation of the mucous membrane of the larynx, sometimes extending to the sub- mucous tissue and muscles. Synonyms. — Acute mucous laryngitis ; acute catarrhal laryngitis. Etiology. — Acute laryngitis is generally the result of ex- posure to wet and cold, the same causes that produce an ordinary coryza, acute laryngitis being in many instances simply an extension of the disease downward. Many in- dividuals have an hereditary or acquired tendency toward laryngeal inflammations. The affection also occurs as a complication in measles, variola, scarlatina, typhoid, rotheln, and chicken-pox, and also as the result of traumatism, such as the inhalation of steam or irritating vapors. When acute laryngitis results from traumatism, the inflammation fre- quently assumes the edematous form of the disease, as the result of the submucous tissues being involved, while in children the croupous form is frequently met with, the 240 DISEASES OF THE NOSE, THROAT, AND EAR mucous membrane of the larynx being covered with false membrane. Symptoms. — The voice is altered in almost all cases, 'be- coming in some almost aphonic, and its use extremely fatiguing and sometimes painful. In adults the respiration is generally unembarrassed, embarrassed respiration indicat- ing that the inflammation is assuming the more serious character of edema. In children, on the contrary, em- barrassed respiration is often the first symptom of the attack, the embarrassed respiration quickly assuming the spasmodic character of croup. The expectoration in adults is at first clear, frothy, mucopurulent, but somewhat scanty, abundant expectoration indicating that the disease has extended to the bronchi. Expectoration in children being always very scanty probably explains why the paroxysms of dyspnea Fig. 138. — Laryngitis involving chiefly Fig. 139. — Swelling below the vocal the false cords as the cause of false cords from laryngitis hypoglottica croup (Friihwald). chronica (after Ziemssen). are so severe and prolonged, the pain, tickling, and sense of tightness in the throat being in them more severe. The color of the mucous membrane of the larynx as seen in the laryngoscope is always heightened, but varies in different parts of the larynx and according to the degree of the in- flammation, the cords in slight attacks being quite white, while in severe attacks they are so red as to be scarcely distinguished from the surrounding parts. The ventricular bands are also sometimes so swollen as to entirely cover the vocal cords or the cords may be prevented from approximation by swelling of the posterior glottic com- missure. Treatmejtt. — It is well to begin with the administration of a saline cathartic. The patient should remain in a warm room, avoid using his voice, and draw into his larynx every DISEASES OF 77/ E LARYXX 24 1 two hours the spray from an atomizer containing a i : 10,000 solution of adrenalin. This is readily done by the patient inserting the nozzle of an atomizer in his mouth and inhaling deeply as he presses the bulb of the atomizer. The patient will feel the spray enter his larynx and should continue the use of the atomizer until the laryngeal rriucous membrane is well covered by the spray. An application should be made to the interior of the larynx once or twice each day of a sedative and slightly astringent powder (Formula 59) by means of a powder-blower (Fig. 45). In making such an application to the interior of the larynx the patient is re- quested to grasp the tip of his tongue with a napkin and hold the tongue well forward. The operator, holding the laryngeal mirror in his left hand, introduces the mirror into the fauces in such a manner that he sees the reflected image of the glottis. The powder-blower should be held in the operator's right hand, and its nozzle is placed in the pharynx in such a position that it is seen reflected in the laryngeal mirror, and moved until it is observed to point toward the glottis. The patient is requested to say " a," and at the same instant the powder should be blown from the powder-blower into the larynx. When an individual says "a" or, indeed, makes any other sound with his vocal organs, the cords are brought together in order to produce it, so that any application made at that instant is limited to that part of the larynx above the cords. Should it be deemed necessary to apply the powder to the larynx below the cords, it may be accomplished by using the powder-blower while the patient holds his breath, or the powder may be carried deep into the bronchi if the powder- blower be used while the patient is inspiring. After the more acute stage of the disease has passed, Formula 57 or even 56 sliould be used instead of Formula 59 as an applica- tion to the interior of the larynx. In the more severe cases powders of any kind are not well borne, and under such circumstances sprays of cocain, adrenalin, and menthol- camphor-albolene should be employed. The application of cold or heat to the skin over the laiynx gives decided relief in the more severe cases. As to the selection of heat or cold the sensations of the patient would 16 242 DISEASES OF THE NOSE, THROAT, AND EAR seem to be the best guide. In the writer's experience heat is usually the more grateful. Cold may be applied by means of a Leiter coil, a small ice-bag, or a napkin wrung out of ice-water and applied to the neck over the larynx. It should be changed sufficiently often to maintain the degree of cold desired. Heat may be utilized by applying a Leiter coil upon the skin over the larynx in the usual manner and allowing hot water to flow through the coil. A folded napkin should be placed under the coil to protect the skin, and the tempera- ture of the water should be as high as can be borne com- fortably by the patient. The more severe forms of acute laryngitis, fortunately rare, will require careful watching, and the physician should be prepared to prevent suffocation from edema by scarifying the epiglottis or, if necessary, by intubation or tracheotomy. Subacute laryngitis is an inflammation of the mucous mem- brane of the larynx subacute in character. Etiology. — Subacute laryngitis commonly results from the same causes as the acute form of the disease. It generally attacks individuals of feeble constitution or it may result from neglecting to treat properly the acute affection. Usually slight dyspnea and hoarseness are prominent symp- toms. The former, generally worse at night, sometimes occasions the patient alarm. Feeble individuals, especially children who spend most of their lives indoors, are more liable to attacks of this disease than the robust and those who are much outdoors. A frequent predisposing cause is the admixture of the products of combustion with the hot air supplied from furnaces. A careful supervision of the workman each fall when the furnace is put in order for the winter, to make sure that the parts of the fire-box are fitted too tightly to allow of any escape of carbon-dioxid gas into the hot-air chamber, will sometimes prevent every member of the household suffering from recurrent attacks of sore throat during the entire winter. Dusty occupations and the frequent inhalation of irritat- ing fumes produce chronic laryngitis and acute exacerbations of the inflammation. By far the most common cause is exposure to cold. However, it is not usually normal res- DISEASES OF THE LARYNX 243 piration of cold air that is responsible for attacks of acute laryngitis, because as long as the nose is normal the air in- spired through it is moistened and its temperature raised sufficiently to render it harmless to the larynx. This is not the case in individuals whose noses are sufficiently abnormal to necessitate mouth-breathing, and it is somewhat curious to note in this connection that during the first few years of a chronic nasal catarrh each cold is essentially nasal ; but in the later stages of the disease the brunt of such attacks is borne by the larynx and trachea. This is probably not due to an extension of the catarrhal disease by continuity of sur- face, but to increasing hypertrophy of the turbinated bodies, rendering the individual a mouth-breather as soon as he inhales cold air. It is not the inspiration of cold air that always is responsible for an attack of acute laryngitis. Most individuals take cold through their feet. The ground is a better conductor of heat than the atmosphere and therefore the soles of the shoes should be of heavy material. The shoes should be loose about the ankles so as not to impede the circulation, and so constructed as not to prevent the evaporation of moisture. A dentist friend and patient in- formed me that he suffered for years with cold feet until he adopted the plan of wearing low shoes the entire year. During the winter his woolen underdrawers were made long enough to extend over the ankles and protect them. He wore cotton or light wool stockings. Treatment. — The treatment is similar to that of acute laryngitis. A most important part of the treatment of acute laryngitis is rest, especially of the inflamed larynx. All unnecessary talking should be avoided and no effort made to talk above a whisper. In the case of singers, orators, and actors, where it is of the utmost importance that a normal voice should be regained as speedily as possible, absolute rest in bed in a warm room will do much to hasten the desired result ; \ gr. of calomel with 5 gr. of bicarbonate of sodium should be given every hour until six doses have been taken or the bowels freely moved. If the attack is of suffi- cient severity to cause some elevation of temperature and a hot, dry skin, i-drop doses of tincture of aconite root should be given every fifteen minutes until three or four doses have 244 DISEASES OF THE NOSE, THROAT, AND EAR been taken, and then every hour until the skin has become moist. Of the other internal remedies, yerba santa usually yields the most speedy and satisfactory results, especially in cases unaccompanied by fever and a hot, dry skin. A pill containing i or 2 gr. of the extract combined with yl^- gr. of strychnin should be given every two hours, or the patient may take half a teaspoonful of malto-yerbine every one or two hours. The patient should inhale the spray from an atomizer containing a i : 10,000 solution of adre- naHn every one or two hours. Both cocain and antipyrin have sedative and astringent effects upon the inflamed mucous membrane of the larynx. The application of the former gives relief for only half an hour, and is followed by increased congestion. The effect of cocain can be maintained by frequent instillation of the drug or by following its use by a spray of antipyrin, which will maintain the local sedative effects of the cocain in many instances for from two to four hours. After the more acute stages of the disease have passed, and in the milder attacks of hoarseness affecting singers, astringents yield better results than adrenaHn, and the spray from an atomizer containing a 2 to 4 per cent, solution of alumnol may be inhaled by the patient every hour or two with decided advantage. In singers and actors with slight laryngitis the neurotic element plays an important part, and voice-failure when on the stage is largely due to nervous- ness and fear. Under such circumstances a pill containing 2^ gr. of strychnin or a teaspoonful of the fluidextract of coca in a glass of sherry wine, taken immediately before the curtain rises, will do much to secure a satisfactory control of the voice during the performance. Chronic laryngitis is a chronic inflammation of the mucous membrane of the larynx. Etiology. — It is generally the result of faulty use of the voice by singers or public speakers, and also of excessive smoking, especially cigarette smoking. The smoking of cigarettes is particularly injurious, not on account of the paper wrappers or any peculiarity of tobacco, but from the habit all cigarette smokers soon acquire of inhaling the smoke and bringing it directly into contact with- the sensitive DISEASES OE THE LARYXX 245 mucous membrane of the larynx. It is the very "mildness" of the smoke from cigarettes, in comparison with cigar smoke or tliat of a pipe, that makes them more injurious. The convenience and cheapness of cigarettes also causes the cigarette smoker to light a cigarette whenever he has a few moments to spare and under circumstances when he would not think of smoking a cigar or a pipe, the ill effects of which are generally confined to the pharynx. Dusty occupations and the frequent drinking of undiluted distilled liquors are also causes of the disease, while the affection is sometimes simply the expression of the rheumatic diathesis. The presence of tumors inside the larynx usually are the result rather than the cause of chronic laryngitis. Symptoms. — The voice, as a rule, is chronically hoarse, but the degree of hoarseness varies materially from time to time. In singers the injury to the voice \\\\\ be manifested in loss of range, diminished endurance, and loss of control. As the disease advances all vocal efforts will be obviously strained and labored. Cough is by no means a constant symptom. The secretion is at no time very great in amount and diminishes as the disease advances. It is thick, starch- like, and tenacious. Small amounts of mucus frequently collect in the interarytenoid space and, being suddenly detached by coughing, are thrown out through the mouth to a considerable distance, while little bridges of mucus are sometimes seen with the laryngoscope extending from cord to cord in the larynx. There is a constant feeling of con- striction, as of a foreign body in the air-passages. Upon inspection certain portions of the mucous membrane of the larynx appear redder than normal ; and sometimes the entire mucous membrane of the larynx is of a uniform red color, w^ith the exception of the cords, which may be some- what lighter in color than the surrounding parts. The mobility of the cords is frequently impaired, either from swelling of the mucous membrane covering the arytenoids or from slight muscular pain. Erosion of the interarytenoid space is frequently seen. Prognosis. — Recovery from chronic laryngitis is always slow, and depends upon the faithfulness with which the treatment is carried out. 246 DISEASES OF THE NOSE, THROAT, AND EAR Treatment, — Constitutional remedies, except in rheumatism of the larynx, are not of the greatest importance ; but, as in every other chronic affection, the general health should be improved as much as possible. Local treatment should consist of the application by the patient several times a day to the affected mucous membrane of a sedative or astringent solution by means of the spray of an atomizer, a 4 per cent, solution of alumnol being especially useful for this purpose. As an office treatment applications of argyrol (10 per cent.) twice a week sometimes yield excellent results, and the occasional application of nitrate of silver solution in obstinate cases is very beneficial. The use of the remedy requires some care, and a very little of the solution should be used until it is ascertained that its use is not followed by spasm of the glottis. Most larynxes will stand the applica- tion of a cotton-tipped applicator dripping with a solution of silver nitrate (10 gr. to i ounce), and solutions of i dram to I ounce can cautiously be employed. The unusually slight irritation produced by the appHcation of even the stronger solutions sometimes lasts for several hours, but is followed by decided relief of hoarseness and congestion of the parts. In the more severe cases pain, congestion, and hoarse- ness are sometimes quickly relieved by the insufflation of powdered orthoform or antipyrin. A milder astringent powder consists of i part alumnol and 2 parts milk-sugar. It may be used with good effect in all cases of chronic laryngeal congestion. Sulphate of zinc (from 15 gr. to i ounce of milk-sugar up to equal parts of sulphate of zinc and milk-sugar) yields good results in some cases. Laryngitis Sicca. — In rare cases catarrh of the larynx results in an exhaustion of the fluid elements of the laryn- geal secretion as the result of atrophy of the glandular elements of the mucous membrane. The disease is generally associated with atrophic rhinitis and pharyngitis. Pathology. — The appearance of the laryngeal mucous membrane is similar to that of the nose and pharynx in atrophic rhinitis and pharyngitis. In some cases the parts are simply dry and glazed, looking as if varnished ; in other cases there are accumulations of inspissated mucus, DISEASES OE THE LARYNX 247 often greenish in color and emitting an offensive odor similar to that observed in atrophic rhinitis. The gross structural alterations that are seen in the nose in atrophic rhinitis are not observed in atrophic laryngitis. It is a disease characterized by diminished and perverted secretions rather than by atrophy of mucous membrane, submucous structures, and laryngeal cartilage. The masses of inspis- sated secretions cling to portions of the larynx where the glands are most numerous — the subglottic region and the upper surface of the ventricular bands. SyinptoDis. — In cases where there are no accumulations the larynx feels dry and irritated. The voice is slightly hoarse and tires upon the slightest exertion. In cases charac- terized by accumulation of fetid secretions the sufferings of the patient are mainly due to the irritation produced by the presence of these secretions and by the effort to rid himself of them. His strength is exhausted by ceaseless and use- less coughing, usually worse at night. Occasionally a little mass will be ejected from the larynx with considerable vio- lence, bringing with it a small area of laryngeal epithelium, and producing a slight capillary hemorrhage which alarms the patient. In the few cases which the writer has seen — for the disease is somewhat rare — the patients were fairly well nourished. Trcatvicnt. — In cases where the disease is the result of atrophic rhinitis, efforts should be directed toward improving the condition of the nose, so that the important function of warming and moistening the inspired air is restored. The wearing of cyhnders of absorbent cotton within the nose, as directed for the treatment of atrophic rhinitis, is also valuable in bringing about an improved condition of the laryngeal secretions. Patients with atrophic rhinitis do well in a moist climate. In one case all laryngeal symptoms had disappeared upon the return of a patient to Philadelphia after a year's absence in the Philippines. Internally may be given stimulating expectorants or drugs, such as iodid of potassium and hydriodic acid, that increase the secretions of the upper respiratory tract and render them more fluid. Inhalations of steam or the use of the bottle-inhaler with 248 DISEASES OF THE NOSE, THROAT, AND EAR hot water and tincture of benzoin aid greatly the patient's efforts to get rid of the annoying laryngeal accumulations. Great relief sometimes follows spraying the larynx with equal parts of hydrogen dioxid and Dobell's solution, because the action of the dioxid upon the accumulations softens them and increases their bulk, and hence aids their expulsion from the larynx. The irritation of the larynx is best controlled by spraying the parts with a 2 per cent, solution of antipyrin. Inflammation of tlie Submucous Tissue of the Larynx. — Acute edema of the larynx usually is the result of phleg- monous inflammation with infiltration of the surrounding submucous tissue, frequently endangering life by occlusion of the rim a glottis. Synonyms. — Edematous laryngitis ; phlegmonous laryn- gi*js ; acute edema of the larynx ; edema of the glottis. Fig. 140. — Phlegmonous laryngitis, with phthisic ulcer: a, Epiglottis; b, left aryepi- glottic fold ; c^ left pyriform sinus. (From v. Ziemssen, after Tiirck.) Etiology. — Edema of the glottis may result from trauma- tism, such as the swallowing of corrosive liquids. It occurs rarely as a primary affection, resulting from exposure to cold and wet in persons of debilitated constitution. In most instances, however, the disease is secondary, and re- sults from syphilitic or tuberculous perichondritis (Fig. 140), retropharyngeal abscess, Bright's disease, glycosuria, etc. Pathology. — The infiltration consists essentially of a serous or seropurulent fluid, most abundant beneath the mucous membrane of the aryepiglottic folds, the ventricular bands, and the ventricles. The submucous tissue is most abundant in these regions of the larynx, but the edema is not always limited to that part of the larynx above the vocal cords, but may extend to the submucosa beneath the DISEASES OF 77 /h L.IA'VjVX 249 vocal cords. liifra^^Iottic edema, as the disease is tlicn called, is almost invariably secondary in. its ori<^in and always serous in character (Fig. 139). Symptoms. — In some cases there are no symptoms what- ever prior to a fatal suffocation or syncope. The voice is usually rou^h and deep or altogether lost, due to thicken- ing and heaviness of the cords. In the early stages of an attack the chief difficulty in breathing is during inspiration, but, as the disease advances, expiratory distress occurs, with the result of producing complete apnea. A short cough is present and deglutition is both difficult and painful. When the edema is considerable the sense of suffocation is most oppressive. With the laryngoscope edema is quickly recognized ; the infiltrated portion of the larynx being greatly swollen and semitransparent in appearance. When the edema is subglottic, the swollen mucous membrane of that region will almost always be seen of a more intense red than the cords above. Prognosis. — Recovery from severe primary edema is always doubtful, and the prognosis in secondary edema depends upon the circumstances of the primary cause of the disease. The patient can hardly be said to be out of danger under two or three weeks from the commencement of an attack, and may even then become the subject of chronic infiltration. When death occurs it is almost always the result of carbonic-acid-poisoning, and may be the direct effect of stenosis or spasm of the glottis. Another danger is the possible occurrence of suppuration — abscess of the larynx. Treatment. — Free diaphoresis should be produced in suitable cases by the hypodermic use of -^^ to \ gr. of pilocarpin. The temperature of the room in which the patient lies should be carefully regulated, and cold, dry applications kept upon the throat over the- larynx. As soon as edema is seen within the larynx local scarifi- cation with the laryngeal lancet (Fig. 141) should be performed. If, in spite of scarification and the use of pilo- carpin, edema continues with increasing respiratory distress, general enfeeblement, and symptoms of carbonic-acid- poisoning, intubation or tracheotomy should be performed 250 DISEASES OF THE NOSE, THROAT, AND EAR at once. Many lives probably have been sacrificed by hesitation and delay. Laryngitis syphilitica is an inflammation of the larynx due to syphilis. Synonyms. — Specific laryngitis ; laryngeal syphilis ; syph- ilis of the larynx. Etiology. — Syphilis of the larynx most frequently occurs as a manifestation of the tertiary period, three to thirty years after the primary infection. As a manifestation of secondary syphiHs laryngeal symptoms may occur with- in a few weeks or may not appear until two or three years after syphiHs has been contracted. PatJiology. — In secondary syphilis the laryngeal symptoms may consist of a mere hyperemia, giving rise to the symptoms of simple laryngitis. Ulcerations may also be present and are usually symmetric, that is, if an ulcer is present upon one part of the larynx, there is usually a similar ulcer also upon the corresponding part of the opposite side of the larynx. Syphilitic warts or con- dylomata are also frequently found in the larynx during the secondary stage of syphilis. They may under- go ulceration or disappear sponta- neously. Tertiary manifestation con- sists of gumma, which may break down and cause deep ulcerations, with perichondrosis and necrosis of the cartilages ; while stenosis may result from cicatricial contraction after the healing of syphilitic ulcers. Symptoms. — The patient usually first complains of a slight hacking cough, hoarseness, and sometimes difficult and painful deglutition. Inspection with the laryngoscope reveals some of the lesions already specified. [41. — Tobold's laryngeal lancet. DISEASES OE THE LARYNX 251 Treat If lent. — ConstitutioiKil remedies already mentioned (see Syphilitic Rhinitis) should be employed. Alumnol or some other astringent should be prescribed for the patient's use at home, in the same manner as for simj)le laryngitis, while an application of Formula 58 should be made to the interior of the larynx every other day with the powder-blower. If shallow ulcers are present they should be touched each day with the solid nitrate of silver melted on the end of a probe. This may be accomplished by melt- ing a few crystals of the nitrate on a silver coin and dipping the end of a cold silver probe into it. Enough of the silver nitrate will adhere to the end of the probe to make one application. If, how- ever, the ulcers are deep, such ap- plications will not be sufficient to secure a speedy healing of the ulcers. They should then be touched by means of the cotton applicator every other day with Fig. 142. — Browne's hollow laryn- geal dilator with cutting blade [\ meas- urement). Fig. 143 — A. Cicatricial stenosis before treatment ; B, the same after use of cutting dilator (Lennox Browne). the acid nitrate of mercury diluted with 5 parts of water, application of nitrate of silver being made on alternate days. After a time, when the process of repair is beginning to set in, these applications become painful and should be omitted, 252 DISEASES OF THE NOSE, THROAT, AND EAR but insufflations of Formula 58 should be continued until the larynx presents its normal appearance. Should partial stenosis occur as the result of cicatricial contraction, the laryngeal stenosis may be overcome by the use of laryn- geal bougies or some suitable cutting instrument (Fig. 142). Tubercular Laryngitis. — Tubercular laryngitis is a chronic laryngitis due to the specific poison resulting from the presence of the tubercle bacilli. It is sometimes called laryngitis phthisica and throat consumption. Etiology. — It is generally secondary to pneumonic phthisis, although this is a debatable question. In most all instances the cellular tissue of the larynx is the structure first affected. The inoculation in this locality may occur through the lymph-channels, the blood-vessels, or by means of an abrasion in the mucous membrane exposed to tubercular sputum from the lungs. Inoculation of tuberculosis in syphilitic ulcers in the larynx has been observed, and it is stated that the presence of simple catarrhal laryngitis, either acute or chronic, is a predisposing cause of tubercular laryngitis when tuberculosis of the lungs is already present. Hospital reports, mostly German, vary from 6 to 50 per cent, as to the frequency of laryngeal involvement in post mortems on individuals dead from pneumonic phthisis. Probably about one-third of the cases of lung consumption in this country, sooner or later, develop laryngeal lesions. That the larynx is not frequently inoculated by the inspira- tion of pulverized dried phthisic sputum is probably due to the fact that under ordinary circumstances particles of dust in inspired air are arrested within the nose or pharynx and do not reach the larynx ; and in this connection it is interest- ing to note that certain observers have claimed that those suffering from atrophic rhinitis are proportionately more frequently attacked by pneumonic phthisis than those with normal noses. Most frequently tubercular lesions of the larynx occur on the same side as the lung most affected by the disease, although this is not invariably the case. Pathology. — The lesions in the larynx are similar to those found in tuberculosis elsewhere : Tubercles are formed and the bacilli are disseminated into the surrounding tissues, partly by their own multiplication and partly by lymph- d/seasils of the larynx 253 currents, so that the extent of the tissue involvement is always much greater than it appears to the eye of the observer. As the result of nature's efforts to limit the spread of the infection, leukocytes appear about the affected area and a reticulum of connective tissue is formed. Degen- eration of the tubercle then occurs as the result of lack of nutrition, and manifests itself either as a local sclerosis or as a tissue necrosis, with a resulting ulcer that may involve not only the mucous membrane and cellular tissue but also muscles and cartilages as well. Bacilli appear in the discharges and the tuberculous process extends. In tuberculous individuals there is often observable an ashy gray appearance, differing from the ordinary paleness Fig. 144.- — I>aryngeal tuberculosis with characteristic pyriform swelling of the arytenoid cartilages (Lennox Browne). Fig. 145. — First stage of tuberculosis of larynx. Ulceration of right cord and swell- ing of interarytenoid region with formation of folds. May be early ulceration here (Sahli). of anemia of mucous membranes at the junction of the hard and soft palate. The same color is also less frequently observable in the larynx. There is sometimes slight local- ized congestion of the cords, one of which may be partially paralyzed and sluggish in its movements from the pressure of a hypertrophied tuberculous lymphatic upon the recurrent laryngeal nerve. The voice under such circumstances is somewhat aphonic and perhaps slightly hoarse at times. Characteristic lesions are submucous infiltrations, gener- ally club-like in shape, sometimes involving one or both arytenoids, '* pyriform arytenoids " (Fig. 144), orproducingthe " turbine-shaped " epiglottis. Minute tubercles break down upon the cords, producing ulcers that give the cords a " moth-eaten " appearance (Fig. 145). Fungus-like thicken- 254 DISEASES OF THE NOSE, THROAT, AND EAR ing of the interarytenoid mucous membrane is common in laryngeal tuberculosis. Deep ulcerations involving necros- ing cartilage is a later stage, from which there are few re- coveries. Usually the concomitant lung lesions have also reached an advanced stage, and the fatal end is hastened by the patient's inability to swallow or even breathe without pain. Differential Diagnosis. — In certain cases the differential diagnosis between malignant ulceration and tuberculosis is one of extreme difficulty. In malignant ulceration the in- flamed and reddened appearance of the unaffected mucous membrane of the larynx contrasts strongly with the pale and anemic appearance in tuberculosis. There is the lung involvement in tuberculosis, the greater involvement of the cervical glands in malignant disease. There are two other conditions of the larynx that sometimes closely simulate tuberculosis in appearance — syphilis and lupus. It should be borne in mind that tuberculosis is sometimes engrafted upon a syphilitic ulcer. Syphilitic ulcer of the larynx follows the breaking down of a gumma. There is usually a history of syphilis or syphilitic lesions may be found upon the body elsewhere. The diagnosis will be cleared up by the administration of antisyphilitic remedies. Lupus is tuberculosis of the larynx resulting from the inoculation of the larynx with an attenuated tubercle bacilli, is usually secondary to lupus of the mouth or pharynx, and is an extremely rare disease. Symptoms. — In the earlier stages of the disease there are practically no symptoms except perhaps occasional transi- tory hoarseness or very slight aphonia. These voice symptoms increase as the disease progresses until the voice may be a mere whisper and very hoarse. The interference with vocahzation may be due to pressure upon the recur- rent laryngeal nerve, interarytenoid thickening interfering mechanically with the approximation of the cords, tuber- cular infiltration of the muscles or involvement of the arytenoid articulations or ulcerations upon the cords. Thick, tenacious mucus coughed up from the trachea or supplied by the larynx if ulcers are present may adhere for a time to the cords and interfere with vocalization until DISEASES OE THE LARYNX 255 dislodged. This usually occurs after several ineffectual efforts — the mass being expelled through the mouth with considerable force. A hacking, dry cough is often present when there is interarytenoid thickening. Wiien ulceration is present the secretions are more abundant and contain the tuberculous bacillus. The secretions are sometimes streaked with blood, but abundant hemorrhage from tubercular ulcerative laryngitis probably never occurs. Pain on swallowing occurs where the infiltration of the arytenoids or epiglottis is great, and there is a sense of obstruction in deglutition as if from a " lump in the throat." Deglutition becomes exquisitely painful when ulceration has occurred upon the epiglottis or in the aryepiglottic fold. Ulceration within the larynx gives rise to little or no dys- phagia and liquid gives rise to less pain than solid food. So exquisitely painful is the act of swallowing in some cases that patients have been known to refuse food or drink for days rather than endure the torture of swallowing it. Prognosis. — Ciires have been reported even in the ulcera- tive stage of the disease, but the progress of the disease in all cases is usually slow and tedious. Harland states that the chances of improvement in tuberculosis of the larynx are nearly as follows : " I. Larynx free from disease; prognosis so far good. 2. Congestion of cords (vasomotor) ; prognosis good ; examination of lungs indicated. 3. Superficial ulcer, local- ized infiltration or tuberculoma ; chances of improvement about 60 per cent. 4. Deep ulceration ; chances of im- provement about 38 per cent. 5. Lesions of vocal cord, ventricular band, or interarytenoid fold ; chances of improve- ment about 89 per cent. 6. Lesions of epiglottis or aryepi- glottic fold ; chances of improvement about 29 per cent." Treatment. — The treatment of the milder forms of the disease should be largely systemic. It should be borne in mind that the disease only does great harm when it causes pain or prevents the taking of food, and that occasionally large ulcers have been seen to heal with practically no local treatment. Cutting operations with the expectation of eradicating the local disease are probably, in most cases, 250 DISEASES OF THE NOSE, THROAT, AND EAR worse than useless, as it is impossible to know how far the bacilli have penetrated the apparently sound tissue about a lesion. Of course, if tubercle papilloma in the interary- tenoid or other regions attain such a size as to produce dysp- nea, as they rarely do, an effort should be made to remove them with forceps or snare ; otherwise those growths should be let alone. They frequently recur after removal. Ulcerations should be cleansed with equal parts of Dobell's solution and peroxid of hydrogen by means of a spray from an atomizer. After the parts have been cleansed the ulceration should be dusted by means of a powder-blower with Formula 59. Owing to the bulk of the tannic acid contained in this powder the amount of morphin in the quantity thrown by the powder-blower into the larynx is very minute, but if Fig. 146.— Harland's laryngeal curet. In order toreach all localities in the larynx the curet is provided with a flexible shaft that can be bent to enter any ordinary larynx, and has an edge that cuts upward and backward, and another that cuts downward and forward. for any reason the morphin is objectionable, it may be omitted from the formula. Excessive pain on swallowing may, of course, be relieved by cocainizing the larynx, either with an atomizer or a laryngeal applicater. A lozenge containing ^ to J gr. of cocain, dissolved in the mouth before meals, yields fairly satisfactory results. However, for the relief of painful deglutition no remedy yields such satisfactory results, eveiything considered, as orthoform. This nearly insoluble substance has the property of pro- ducing analgesia when applied to exposed nerve-endings. It is, therefore, especially valuable as an application to irri- table ulcers after they have been cleansed with Dobell's solution and peroxid of hydrogen. Its anesthetic effects are increased by a previous application of a solution of DISEASES OE THE LARYNX 2^7 cocain and persist for four or five hours. When insufflated into a tuberculous larynx the powder produces a momen- tary smartinf;^, followed by analijcsia more or less complete, which persists as long as the powder adheres to an abraded surface or an ulcer. The powder possesses decided anti- septic qualities and promotes the healing of tuberculous ulcerations. It has little effect upon the unbroken mucous membrane. A nurse or one of the patient's friends can be taught to insufflate orthoform into a tuberculous larynx ten minutes before each meal, and in many instances thus secure com- plete relief from dysphagia. Orthoform is said to be non- toxic, and hence may be used locally in liberal quantities. It may, of course, be prescribed in the form of a lozenge, but with not nearly as satisfactory results as when the powder is insufflated into the larynx. A spray of menthol in albolene (logr. to i ounce) may be used by the patient inhaling each time he compresses the bulb of the atomizer. It yields fairly satisfactory results in a few^ cases. However, before using any applica- tion to the larynx himself the patient should, of course, cleanse it as thoroughly as possible under the circum- stances by inhaling the spray from an atomizer containing equal parts of Dobell's solution and peroxid of hydrogen. Fluids, especially if iced, commonly cause much less pain on swallowing than solids, and iced milk can some- times be taken through a tube with the patient's head hanging over the bed when it would be much more painful to sit up and drink the fluid ; but in extreme cases the stomach-tube and rectal alimentation will have to be em- ployed. Syrupi lactic acid is a remedy that is said to have the property of destroying tuberculous structures without attacking the surrounding sound tissues. Its application to a tuberculous ulcer is so painful that its use should always be preceded by thoroughly cocainizing the larynx with a lo per cent, solution of cocain. The applications can be made at intervals of four or five days and be pre- ceded, if necessary, by cureting the cleansed ulcer. It is best to commence by lightly touching the parts with a 25 17 258 DISEASES OF THE NOSE, THROAT, AND EAR per cent, solution of the syrupy acid and gradually increas- ing the strength from visit to visit as the patient becomes accustomed to the pain. The remedy undoubtedly hastens cicatrization of ulcers and, it is claimed, promotes the ab- sorption of deposits. It should be used with judgment and caution, as the edema is frequently increased for a day or two if lactic acid is applied too freely or an attempt is made to " rub in " the remedy upon the floor of a tuber- culous ulceration. T^¥^eA«Z m'f--^ 'Wa Fig. 147.— Pachydermia laryngis (X 60) : i, Cylindric epithelium; 2, area of transition into (3) stratified squamous epithelium ; 4, papillary body ; 5, dilated blood-vessels of tunica propria; 6, mucous glands. (Diirck.) Laryngeal Tumors. — The tumors most commonly met with in the larynx are papilloma, fibroma, angioma, myxoma, cyst, sarcoma, and carcinoma. Symptoms. — The most noticeable symptom is mechanical obstruction to breathing and phonation proportionate to its size and location. If the tumor is small and situated upon a vocal cord, dysphonia results from interference with its vibration, while, if the growth is situated in the anterior commissure between the cords, aphonia results from the tumor preventing their approximation. If, however, the DISEASES OE THE LARYNX 259 tumor is small and situated above the vocal bands, but slight, if any, subjective symptoms will be noticed. As the growth of a laryngeal tumor increases dyspnea increases and asphyxia may suddenly occur unless prompt relief is at hand. Cough is not usually present unless the growth is of such a character as to vibrate in the breath-current and titillate, as it were, the interior of the larynx (Fig. 148), when cough and laryngeal spasms may occur. Chronic laryngitis is usually present as the result of laryngeal tumors. Papillomata found in the larynx of children offer some peculiarities. They are soft and usually multiple. They are usually associated with a catarrh of the nasopharynx and hypertrophied tonsils, and sometimes disappear under the application of astringent powders to the larynx and Fig. 148. — Pedunculated fibroma upon the under surface of the left vocal cord ; position during inspiration (v. Zeimssen). successful treatment of the nasal and pharyngeal affection, to the existence of which in many instances they seem largely due. The papillomata of adults are harder than those of chil- dren, and are usually situated on the vocal cords or ventric- ular bands. Etiology. — Any long-continued irritation of the laryngeal mucous membrane may result in hyperplasia and the growth of warts. When the result of long-continued catarrhal inflammation, papillomata usually occupy the interarytenoid space and the posterior extremities of the vocal cords. Papillomatous growths are sometimes seen about tuber- cular ulcerations and upon the mucous membrane covering gummata and tumors lying underneath the laryngeal 26o DISEASES OF THE NOSE, THROAT, AND EAR mucous membrane. Under such circumstances a piece re- moved by the forceps from the larynx may under the microscope present the appearance of papilloma, and in its deeper parts that of carcinoma, and hence give rise to the erroneous impression that papillomata are prone to gen- erate into carcinomata. In case the papillomata occur in connection with laryn- geal phthisis, syphilis, or a laryngeal tumor, they result from the irritation to the laryngeal mucous membrane caused by the primary disease. Laryngeal carcinomata may be divided into intrinsic and extrinsic. Intrinsic carcinoma attacks the ventricular bands, Fig. 149. — Papilloma of larynx (Stoerck). the ventricle, and the vocal cords. Extrinsic has its origin upon the epiglottis, the arytenoid folds, and the pyriform sinus. In extrinsic carcinoma the lymphatic glands are affected almost from the commencement, the disease rapidly ad- vances toward a fatal termination, and is rarely, if ever, cured by operation. Intrinsic carcinoma is a less grave affection ; its advance is less rapid and the neighboring lymphatics often remain for a long time uninvolved. Extirpation, either partial or entire, should not be undertaken except the disease be intrinsic and limited entirely to the larynx. Treatment. — Tumors springing from the epiglottis can usually be removed by means of a Jarvis snare with a DISEASES OF THE LARYNX 26 1 curved lip, while cysts may be opened with the laryngeal lancet (Fig. 141) and their contents allowed to escape, after which the end of a probe on which nitrate of silver has been fused should be passed into the cyst and its interior thor- oughly cauterized. Papillomata (Fig. 149) and soft or pe- dunculated tumors should be removed by means of the laryn- geal forceps (Figs. 151, 152), if necessary picking off piece after piece until the entire tumor has been removed. In every case of tumor of the larynx the emergencies of the case govern the operative procedures necessary. If the removal of the tumor is very urgent to prevent suffocation, Fig. 150. — Carcinoma of the larynx (Stoerck). and the patient's throat is too irritable to permit instru- mental interference without danger of fatal result from induced spasm of the glottis, tracheotomy should, of course, be performed before the removal of the tumor is attempted. If the growth is malignant, extirpation of the larynx, either in part or as a whole, gives the only hope of bringing about a cure of the affection. The operation should be performed as soon as a certain diagnosis is established. In inoperable cases the x-x'd.y may be used. It is generally useless to attempt the removal of any laryngeal growth with the forceps until the larynx has been so thoroughly cocainized that no spasm occurs upon the 262 DISEASES OF THE NOSE, THROAT, AND EAR introduction of a probe. This can almost always be accom- plished by painting the interior of the larynx with a 10 per cent, solution of cocain by means of a laryngeal applicator Fig. 151.— Cusco's laryngeal forceps. until no spasm occurs when the applicator or probe is intro- duced into the larynx. In the larynx cocain anesthesia occurs more rapidly than in the nose, but lasts for only a short time. 152. — Mackenzie's laryngeal forceps. Foreign Bodies in the Larynx. — Smooth substances, such as small pebbles, shoe-buttons, seeds of various kinds, etc., are not apt to lodge in the larynx, but are either removed DISKASES 01' TJIK LARYNX 263 by a fit of coui^hin^ or drop into the trachea. Substances with sharp points, hkc fish-bones or pins (Fig. 153), arc often partially imbeded in the tissues of the larynx. Treatment. — The foreign body should be removed with the laryngeal forceps when possible. In rare cases a wound of the interior of the larynx is rapidly followed by edema of the glottis. Under these circumstances tracheotomy should be performed before any attempt is made to remove the offending substance. TJiyrotoiny. — This operation consists in the separation of the two wings of the thyroid cartilage by means of an incision through the angle of the thyroid cartilage, thus exposing the interior of the larynx for the removal of tumors or foreign bodies that cannot be removed readily Fig. 153. — A pin imbedded in the posterior portion of the right vocal cord (Seiler). through the mouth. The operation is done under chloro- form anesthesia and in the tracheotomy position. An incision is made through the skin from the thyro- hyoid space to the upper tracheal rings exactly in the median line. The underlying structures are divided care- fully by means of a knife and a grooved director. The thyroid prominence bulges out of the wound and can be opened by passing one blade of a stout pair of angular scissors through the cricothyroid membrane into the larynx. The larynx can also be opened by means of a stout bistoury or, when ossified, by means of a Sajous saw (Fig. 66). The edges of the wound are now separated Avith retractors in the hands of an assistant, and spasm of the laryngeal muscles, which always occurs when the larynx is opened, 264 DISEASES OF THE NOSE, THROAT, AND EAR is controlled by brushing the laryngeal mucous membrane with a 4 per cent, solution of cocain. The operation is a comparatively bloodless one and exposes in a very satis- factory manner the interior of the larynx for the removal of a foreign body or a tumor. After the removal of the tumor or foreign body the severed edges of the cartilage are united by one or more catgut sutures and the skin wound brought together by sutures of worm-gut Union usually occurs by first in- tention, but the ultimate condition of the voice depends upon the amount of damage done to the interior of the larynx. The removal of a foreign body or small tumor is not followed by any very appreciable impairment of the voice. The after-treatment after removal of a small tumor by this method consists in keeping the patient quiet in bed for a week or so and forbiddiug the use of the voice. For the first few days the diet should be liquids. NEUROSES OF THE LARYNX Neuroses of the larynx are divided into sensory and motor neuroses. Sensory neuroses are anesthesia, hyperesthesia, and pares- thesia. Anesthesia of the mucous membrane of the larynx, sometimes accompanying motor paralyses of the larynx, is occasionally observed in hysteria and in the insane. Hyperesthesia acompanies all forms of laryngeal inflam- mation except some forms of early tuberculosis. It is frequently present in neurotics. Paresthesia manifests itself chiefly as a sensation of chok- ing or as of a foreign body in the larynx of hysteric individuals. These sensations are sometimes the result of disease of the pharynx or tonsils, and when this condition exists it should receive appropriate treatment. In the mean time considerable relief will follow the administration of 10 to 15 gr. of the bromid of sodium three times a day. Motor neuroses are spasm incoordination and paralysis of the laryngeal muscles. D/SKASES OF THE LARYNX 265 Spasm of the laryngeal muscles appears in three forms — si^asmodic cough, spasm of the adductors, and spasm of the tensors of the cords. Spasmodic laryngeal cough or laryngeal chorea is a condition commonly described under this heading, although other respiratory muscles beside those of the larynx are involved in the paroxysms of coughing, which is of a peculiar bark- like character resembHng that of a big dog. The parox- ysms of coughing occur at frequent intervals during the day, but cease during sleep. The disease occurs more frequently in neurotic females than in males. It is not associated with chorea in any manner whatever, nor is there any evidence of laryngeal inflammation on examination with the laryngoscope. Trcatmoit should be directed toward improving the individual's general health. Good results generally follow the prolonged use of some nerve tonic like pil. sumbul comp., one after meals, and at bedtime, but quicker relief can generally be obtained from bromid of sodium, 10 to 15 gr., after meals and at bedtime. The use of the induced current, one sponge on the skin on each side of the larynx, does good probably from the impression it makes on the mind of the patient. To accomplish this the electricity should be used as strong as it well can be borne by the patient. Aside from the use of electricity local treatment is not indicated. Spasm of the Tensors of the Vocal Cords. — This is a rare condition affecting singers, actors, and orators, somewhat analogous to the spasm of the muscles observed in the muscles of the hand in writers' cramp. Syviptoms. — The voice is suddenly lost, possibly in the midst of a sentence, by a spasm (sometimes painful) of the cords. The greater the effort to speak or sing, the tighter and longer the spasm. After a moment the spasm subsides and the voice is normal for several minutes, when another spasm may occur. Examination with the laryngoscope during a spasm shows the cords tightly approximated in the position for vocalization. There may or may not be slight hyperemia of the larynx. Treatment consists in rest of the voice, preferably in the 266 DISEASES OF THE NOSE, THROAT, AND EAR country or at the seashore, tonics, and attention to personal hygiene. Spasm of the adductor muscles or laryngismus stridulus, false croup, generally involves the crico-arytenoidei externi and the arytenoideus. Etiology. — The condition usually occurs in neurotic chil- dren under three years of age. There is frequently some pathologic condition of the nose and nasopharynx that ren- ders the nerve-endings of the upper respiratory tract more irritable, and in neurotic children is sufficient to induce a reflex spasm of the adductor muscles of the vocal cords from trifling causes, such as a slight lowering of the temperature during the night after the child has gone to bed, kicking off the bedclothing, etc. In some adults the entrance of a small particle of food or dust into the larynx produces a condition similar to laryngismus stridulus. In such individuals applications to the nasopharynx of iodin-potassium-iodid-glycerin ; solu- tions of sulphate of zinc or any of the other routine applica- tions to the nasopharynx may be followed by alarming spasms of the laryngeal adductor muscles if a drop of the solution by any mischance happens to drip into the larynx. The same thing occurs in such individuals after the applica- tion of an ordinary remedy to the larynx. To the inexperienced laryngologist the symptoms are sufficiently alarming. After the laryngeal application the patient suddenly becomes cyanosed and, with protruding eyeballs, clutches at his throat. The patient gasps. The respiration is loudly "crowing," Hke that of a child with laryngismus stridulus, and death from suffocation seems imminent. These alarming symptoms disappear as suddenly as they occurred if the patient makes an effort to pronounce words. The practitioner in a loud voice should command the patient to say " One, two, three," or in an equally loud and commanding voice inquire, " What is your name ?" When the patient makes an effort to answer the spasm of the glottis vanishes and breathing becomes at once normal. In the first stages of locomotor ataxia there is occasion- ally a history of spasms of the adductor muscles resembling laryngismus stridulus, and in an adult such a history in the DISEASES OF THE LARYNX 267 absence of foreign bodies gainini^ entrance into the larynx should be a sufficient warrant to search for other symptoms of this disease. SyniptoDis. — In children the attack appears suddenly dur- ing the night in apparently healthy children. The child suddenly sits up in bed gasping for breath. At the height of the attack it is markedly cyanosed, when suddenly there is a deep inspiration and the symptoms rapidly disappear. There remains no symptoms of laryngeal inflammation except that during the day there may be a slight " croupy " cough. Prognosis. — The attacks of false croup not infrequently recur at intervals for weeks or months. It is said that in very young children the attacks sometimes terminate in eclampsia or convulsions. Treatment is directed to the prompt relief of the laryn- geal spasm. This can sometimes be accomplished by mak- ing the child sneeze by tickling the nose with a feather or a pinch of snuff. When sneezing occurs the spasms cease. The inhalation of a few drops of chloroform from a hand- kerchief is generally effective. Extreme heat or cold to the skin over the larynx or 3 drops of adrenalin chlorid solution (i : looo) hypodermically will sometimes relieve the spasm. Any or all of these measures should be tried while a hot mustard-bath is being prepared. The child should be placed in this and, after remaining for a few moments, taken out and carefully wrapped in a warm woolen blanket before being replaced in bed. For very severe attacks Coakley advised the following as a rectal injection : R Chloralis hydratis, gr. vj ; Potassae bromidi, gr. x ; Aquse, q. s. ad. fgj. — M. Sig. Use as a rectal injection for a child six months old. As a prophylactic between the attacks all sources of irri- tation should be sought for and removed. These may include errors of digestion, carious teeth, or nasopharyngeal disease. Hearty suppers and lunches at bedtime should be forbidden. Somnos in J-teaspoonful doses should be given eveiy 268 DISEASES OF THE NOSE, THROAT, AND EAR three hours during the day for a week or more or until the immediate danger of a recurrence of the attack seems to have disappeared. The child should then take syrup of the iodid of iron after meals, i drop for each year of its age, up to I o drops, with or without cod-liver oil. Syrup of the hypophosphites may be substituted for the iron at the physician's discretion. In adults and nervous children sodium bromid answers a useful purpose. Pil. sumbul comp. or some other combina- tion of iron, valerian, and asafetida may be given. Laryngeal Vertigo or Epilepsy. — This is a rare laryngeal neurosis occurring more frequently in males than females. Etiology. — The disease occurs in neurotic individuals, and the symptoms are probably due to an incoordination of the respiratory centers implicating the laryngeal muscles in such a manner as to produce closure of the glottis. Symptoms. — The prodromes are a tickling sensation in the larynx and a fit of coughing. The patient draws a long breath. The glottis closes and the inspired air is con- fined in the lungs. There follows vertigo, cyanosis, and sometimes loss of consciousness. The " fit " then passes off, to be repeated at intervals. The laryngoscope shows no characteristic lesion ; a nor- mal larynx or sHght catarrhal inflammation being commonly observed. Disease of the nose and pharynx catarrhal in character is frequently present in such cases. Prognosis. — The prognosis as regards life is favorable. There may, however, be a recurrence of the attacks of laryn- geal vertigo extending over a period of years. Treatment. — The treatment, like that of other neuroses, consists in hygienic measures calculated to improve the in- dividual's general health, and if the attacks are frequent the administration of antispasmodics. Galvanic electricity, the positive pole over the larynx, may be employed. Paralysis may affect but one laryngeal muscle or pair of muscles ; or it may affect several of them at once, and may be either unilateral or bilateral. Paralysis of the larynx may be divided clinically into paralysis of the adductors, paralysis of the abductors, and paralysis of the tensors of the cords. Etiology. — The laryngeal muscles receive their nerve-sup- DISEASES OE 77/ E 7.ARYNX 269 ply by means of two branches of the pncumof^astric — the superior laryn<^eal and the recurrent hiryngeal. The pneumo- gastric, at its origin, is a sensory nerve, but receives motor fibers from the spinal accessory, so that it possesses both sensory and motor functions above the point where the superior laryngeal is given off. Paralysis of the laryngeal muscles may be due, Hke paralysis of other muscles, to (i) disease or injury of the brain involving the cerebral portion of the nerves that supply the larynx; (2) injury or pressure of the nerves below their cerebral portion ; (3) an abnormal condition of the muscles themselves, and (4) some systemic dyscrasiae, like rheumatism or hysteria, because of which the muscles are unable to respond to nervous influence. Fig. 154. — Bilateral paralysis of the adductors (crico-arytenoid lateralis and arytenoideus). Appearance in attempted phonation (Lennox Browne). Adductor Paralysis. — Adduction of the vocal cords being performed by means of the lateral crico-arytenoid muscles and the arytenoideus muscle, paralysis of these muscles causes the cords to remain in a state of extreme abduction. This condition is in most instances due to hysteria, rheuma- tism involving either the muscles or the cricothyroid joint, or chronic poisoning by lead or arsenic. If bilateral paralysis exists, the vocal cords will be seen in the laryngeal mirror separated to the utmost degree (Fig. 154), and the voice will be completely lost. If paralysis of the arytenoideus muscle alone exists, which, however, is rarely the case, the anterior two-thirds of the vocal bands can be approximated ; but a triangular space will be left behind the vocal processes during phonation, through which the breath escapes and renders the voice feeble, and its use in singing and speaking 270 DISEASES OF THE NOSE, THROAT, AND EAR both fatiguing and unsatisfactory. This condition of affairs may occur during the course of either acute or chronic laryn- gitis from extension of the inflammation to the arytenoideus muscle (Fig. 155). In unilateral adductor paralysis only one cord is seen in extreme abduction during phonation, and the opposite cord will be observed to pass beyond the median line, so as to approach as near as possible to its motionless companion (Fig. 156). Although aphonia exists, the whispered words are usually perfectly comprehensible. Abductor Paralysis. — Abduction of the vocal cords is accomplished solely by means of the crico-arytenoid muscle, Fig. [55. — Bilateral paralysis of the aryte- noideus (Lennox Browne). Fig. 156. — Unilateral paralysis of ad- ductor of left cord. Appearance in at- tempted phonation (Lennox Browne). and hence the complete paralysis of both of them will pre- vent separation of the cords, and almost completely prevent the entrance of air into the lungs ; a mere slit posteriorly, which represents the action of the arytenoideus, being the extent of the available breathing space. During expiration, however, the vocal cords are forced apart by the ascending air-current impinging upon their under surfaces, which curve upward from the sides of the larynx. The voice is unim- paired in this affection, but where complete paralysis of the abductors exists it may be necessary to perform tracheotomy to prevent suffocation occurring as the result of slight inflam- matory swelling of the mucous membrane of the larynx as DISEASES OF THE LARYNX 2^1 the result of a cold. Paralysis of the abductors may result from a tumor in the brain involving the origin of both pneu- mogastrics and spinal accessory nerves. In such cases the abductors of the larynx are first paralyzed, but as the tumor increases in size paralysis of the muscles of the larynx results, the cords assuming the " cadaveric position " (Fig. 157). Paralysis of both posterior crico-arytenoid muscles may result also by pressure upon the recurrent laryngeal nerves by an aneurism, a goi- ter, or carcinoma of the esoph- agus, or the lesion may be located in the muscles them- selves. When unilateral paral- ysis only is present, the af- fected cord will be seen to remain always in the median hne, even during forced in- spiration, but subjective symp- toms will be so slight as to hardly attract attention. The voice will be perfect and the breathing space ample, except during violent exercise (Figs. 158, i59). Two forms of paralysis of the tensors of the vocal cords are met with, one due to paralysis of the cricothyroid muscle, which is rare, and the other one to paralysis of the thyro-arytenoids, which is not uncommon. Paralysis of the former muscle causes the edges of the cords to assume a wavy line, touching each other at irregular intervals during phonation (Fig. 160), while the voice is coarse and remains always at the same pitch. The upper surface of the cords appears convex during expiration and concave during inspiration. When the thyro-arytenoids are paralyzed, the cords assume a slightly curved appearance when an attempt is made to bring them together during phonation, and a slight space remains between their centers (Fig. 161). The J^s^ Fig. 157. — Appearance of the normal larynx after death, showing the "cadav- eric position" of the vocal cords. 1'his is also their position in quiet breathing (Lennox Browne). 2/2 DISEASES OF THE NOSE, THROAT, AND EAR voice is husky, high pitched, and weak, the air escaping through the elHptic space between the cords, necessitating great effort on the part of the patient in order to speak. Treatment. — The cause of the paralysis should be care- fully sought and treated, the success of the measures adopted depending, of course, upon the nature of the primary ailment In suitable cases strychnin should be administered in gradually increasing doses until the limit of , toleration has been reached, and galvanism or faradism used by means of the larjmgeal electrode (Fig. 162), applied within the larynx as near as possible to the affected muscles. An ordinary sponge electrode is held by the patient or an Fig. 159. — Unilateral paralysis of the left abductor. Appearance in phonation. Fig. 158. — Bilateral paralysis of the The affected cord is seen to be in the abductors (crico-arytenoidei postici). cadaveric position, while the other is ad- Appearance with deep inspiratory effort vanced beyond the median line (Lennox (Lennox Browne). Browne). assistant upon the skin over the larynx, while the operator guides the tip of the electrode into the larynx, watching its progress with the laryngoscope, until it is in the desired position. The finger-rest on the top of the handle of the instrument is now depressed and the current passes. Each application should last but a few seconds, and be repeated three or four times at each sitting, at intervals of one or two minutes. Electricity may be used in this manner every other day, the current used not stronger than is sufficient to secure contraction of the affected muscles. At first the mere introduction of the electrode into the larynx causes retching and gagging, and it may be necessary to apply a DISEASES OF THE LARYNX 273 10 per cent, solution of cocain to the interior of the larynx by means of a pledget of cotton wrapped about the end of a probe and dipped into the solution in order to anesthetize the parts sufficiently to admit of free manipulation at the first sitting. After a few trials, however, the parts become Fig. 160. — Bilateral paralysis of the thyro-arytenoidei and of the arytcnoideus (Lennox Browne). Fig. 161. — Bilateral paralysis of the sphincter of the glottis (thyro-arytenoidei) (Lennox Browne). Fig. [62. — Mackenzie's laryngeal electrode. more tolerant and applications can be borne, in the majority of instances, without trouble. Diphtheria is an acute infectious disease characterized by a pseudomembrane which usually appears in the fauces, and is associated with a rapid pulse, moderate elevation of temperature, and depression. 18 2/4 DISEASES OF T^E NOSE, THROAT, AND EAR Etiology. — Diphtheria is endemic in all large cities, especially in the' more crowded localities, and from time to time becomes epidemic, spreading to the outlying districts. It is more prevalent in the spring, autumn, and winter than in the summer. The specific cause is the Klebs-Loffler bacillus. Pathology. — The location and extent of the pseudomem- brane varies in each case. It may be limited to the tonsils or it may cover the entire fauces and extend into the nares and the larynx. It sometimes extends through the Eustachian tubes to the middle ear. When a diphtheritic membrane is forcibly removed it invariably leaves a bleeding surface. The bacilli are deposited in the fauces first and cause the membrane to become red, inflamed, and swollen. The poison kills the superficial layer of epithelial cells, which undergo coagulation necrosis. There is a migration of white blood- cells, which also undergo coagulation necrosis. These proc- esses may only extend through the superficial layer of the mucous membrane, but sometimes extend deep into the tissues and produce gangrenous ulcers. The color of the pseudomembrane is gray or grayish white at first. It some- times becomes yellow, but more often is white and flaky, like leaf-lard ; it may also assume a dirty brown color, due to hemorrhage or to the local use of iron solutions. Post mortem, the heart and blood-vessels show degenera- tive changes. The heart may contain a blood-clot. The lungs frequently show evidence of fibrinous pleurisy, bron- chopneumonia, or capillary bronchitis. The liver and spleen show little if any change. The kidneys frequently show cloudy swelling. Degenerative processes have also been found in the nerve-trunks. Classification. — Diphtheria may be classified as viild, well marked^ severe, and malignant. When classified according to location, as fazicial, nasal, and laryngeal. There nearly always is, or has been, some evidence of the disease in the fauces when either nasal or laryngeal diphtheria exists. Symptoms. — In some cases of diphtheria there are very few or no symptoms at all, except a slight indisposition on the part of the child, and the true nature of the disease may DISEASES OE 77/ E LA7 Glycerin, Aqua, aa f^j.- -M. Sii g. To be used every hour or two by means of a swab. 280 DISEASES OF THE NOSE, THROAT, AND EAR The solvents — lactic acid, pepsin, caroid, trypsin — have many advocates. Lennox Browne is very partial to lactic acid applied pure twice daily, and diluted to three or four times its bulk with water, applied by the attendant every two or three hours. Loffler's toluol solution gives good results in some cases, but care must be used in applying it. Applications of a solution of nitrate of silver (60 gr. to i ounce of water) carefully to the tonsils, palate, and lateral walls of the pharynx twice or thrice a day when they are alone affected seems to check the extension of the mem- brane, but whatever remedy is selected, the practitioner should see that it does not increase the inflammation or else it will do more harm than good. Constitutional Treatment. — Iron and mercury are the two drugs we have to rely upon in the treatment of this disease. They may be used alone or combined as follows : R Tr. ferri chloridi, ^ij ; Syr. limonis, Glycerin, da l^iij ; Aqua, q. s. ad. f^iij.— M. Sig. I teaspoonful every hour or two for a child four years old. R Hydrarg. chlor. corros., . gr. i-ss ; Tr. ferri chlor., fjij ; Syr. limonis, Glycerin, aa f;^iij ; Aqua, q. s. ad. f^iij. — M. Sig. I teaspoonful every hour or tviro for a child four years old. Instead of the bichlorid, calomel may be given (ro"?^- doses every two hours). Stimulants are indicated from the beginning ; alcohol is undoubtedly the best and should be pushed to its physio- logic limit in severe cases. After the exudate disappears the whisky should be gradually withdrawn and digitalis substituted. When the stomach is irritable, digitalin should be given. A child five years old can be given ^ to -^-^ gr. or more if necessary. Strychnin is also useful, especially in the later stages. It can be given in larger doses than is ordinarily employed. The Serum Therapy. — To obtain the best results antitoxin DISEASES OE THE LARYNX 28 1 should be used early in the disease, and should be used in all cases of suspected diphtheria. In mild cases looo units, repeated the next day, will be all that is necessary. In severe cases it is well to begin with 2000 units as the initial dose and repeat every six, twelve, or twenty-four hours, until the symptoms begin to subside. When the disease persists it is sometimes necessary to give as high as 20,000 units in divided doses. Antitoxin of the highest potency should always be selected, for this gives the maxi- mum number of units and the minimum amount of serum. It should be injected under antiseptic precautions to pre- vent abscesses, which occur in spite of antiseptic precautions in about i case in 500. Operative intervention is indicated: (i) When the patient is cyanosed, together with marked retraction of the supra- clavicular, substernal, and subcostal spaces, great rest- lessness, cold and clammy sweats. (2) When the symp- toms of obstruction in the larynx are not so marked, but are rapidly growing worse, intubation preserves the strength of the patient. (3) When the symptoms of obstruction are not progressing, but are sufficient to prevent the patient obtaining rest. (4) In severe cases of nasal and faucial diphtheria which develop laryngeal symptoms, intubation permits the patient to die easy. Intubation. — Select a tube suitable for the age of the patient, pass a strong silk thread through the eye of the tube (about 20 inches long) and tie the two ends together. Then screw the obturator on the introducer and place the tube on the obturator. Next, wrap the patient tightly in a sheet with his hands at the side to prevent them from interfering with the operator. Have the nurse sit in a chair and hold the patient upon her lap with his back to her left chest and his legs between her knees. The operator should sit in a chair facing the patient and place the gag in the left corner of the mouth. An assistant standing behind the nurse holds the gag and steadies the patient's head between his hands. Then the operator, taking the intro- ducer in his right hand and holding the thread attached to the tube on one finger, rapidly introduces the index-finger 282 DISEASES OE THE NOSE, THROAT, AND EAR of the left hand over the tongue until it is behind the epi- glottis and the laryngeal orifice is felt. Then the tube is introduced over the tongue, being careful to keep it in the median line, until the tip of the finger at the opening of the larynx is felt (Fig. 164). Next, elevate the handle of the introducer until the tube is in a vertical position and it readily slips into the larynx. When the tube is in the larynx press forward the button on the top of the introducer, Fig. 163. — O'Dwyer's intubation set. which releases the obturator. The finger should be placed on the head of the tube until the obturator is entirely with- drawn. Next, remove the gag, but hold the end of the string until you are satisfied the tube is in the larynx and the child has obtained relief. This usually requires three or four minutes. After respirations become easy, the string should be removed or plastered on. the side of the face. To remove the string the gag should be placed in the mouth DISEASES OE THE L/IRYNX 2S3 and the finger should be held on the top of the tube until the thread is removed, to prevent removin<^ the tube also. Accident Folloivuig Intubation. — Occasionally the mem- brane of the larynx becomes detached and is pushed down before the tube, completely obstructing^ respiration. It does not often happen, but when it does the tube should be removed at once by pulling- on the thread attached to the tube. Fig. 164.— Intubation: inserting the tube {American Text-book of Diseases of Cliildren). This is followed by a forced expiratory effort, which, as a rule, expels the membrane. When it does not, trache- otomy should be performed immediately. After intubation deglutition is difficult, the patient being able to swallow only liquids and semisolids. The tempera- ture may remain normal, but, as a rule, it rises to 102° to F., and remains from i to 2 degrees above normal the tube is in the larynx. When intubation gives 103- while 284 DISEASES OF THE NOSE, THROAT, AND EAR perfect relief, the respirations are free and easy and the child is entirely comfortable. The coughing attendant upon deglutition is sufficient to keep the tube patulous ; but should it become occluded or the respirations labored, the tube should be removed and cleansed. The reintroduction should depend on the character of the respirations after removal of the tube. In some cases the patient coughs up the tube when it becomes occluded, but when the tube is being constantly coughed up it indicates that it is too small and a larger size should be used. In favorable cases the time for removal of the tube will depend to a great extent upon the age of the patient. In children six or seven years old the tube may be removed in four or five days ; in younger children it should remain five to seven days. When death results after intubation it is almost always due either to the extension downward of the membrane or to broncho- pneumonia. An amazing and distressing complication that sometimes arises is the inability of the patient to breathe without the tube. Children sometimes are obhged to wear the tube one hundred and ten days, being entirely well, except that they could not breathe without it. The prolonged wearing of the tube sometimes produces ulcers in the larynx, which may result in complete occlusion of that organ or so constrict the lumen that a tracheotomy is necessary. Extiibation. — The patient is prepared in the same manner as for intubation. The gag is introduced and an assistant steadies the head of the patient. The operator introduces the left index-finger in the mouth until the tube is felt behind the epiglottis. Then with the extractor in his right hand the beak is glided over the tongue until the tip of the finger is felt at the opening of the tube, when the handle is elevated and the beak of the extractor slips into the tube. Then, pressing the lever on top of the handle, the blades of the beak separate and hold the tube securely until it is with- drawn. Treatment for Intubation Patient. — When the nares are involved they should be syringed several times daily with the normal salt solution, otherwise local treatment is un- necessary and may be harmful. Steam generated in the pres- DISK ASKS OK TJIK LARYNX 285 ence of the patient is no longer considered necessar}'. Constitutionally, stimulants should be given as required, preference being given to alcohol and strychnin. Calomel in small doses often seems to do good in limiting the inflam- mation and preventing bronchopneumonia. Iron mixtures are difficult to swallow and are just as well omitted. A simple cough mixture containing ammonia carbonas and syrup of ipecac often aids in liquefying and expelling the mucus from the throat. The most important element in the treatment is the nourishment. Milk should be given freely. Broths of all kinds, beef-tea, milk-toast, and ice- cream may be given freely. The method of adjniiiistration of food -AXidi medicines is a much-mooted question. Nursing infants take nourishment readily from the nursing-bottle. In such cases lowering the head makes swallowing easier, as none of the food gets into the tube. In older patients it is best to permit them to take their food from a glass or in any way they prefer. Struggling to make the patient take it in a specified way produces exhaustion and is harmful. When children will not take food, they should be fed by introducing a soft- rubber catheter through the nose into the stomach. Tracheotomy is indicated in the same cases as intubation and for the same reasons. In addition, it is indicated in those cases of intubation where the membrane has extended below the tube. It is also performed in cases of foreign bodies in the larynx or lower air-passages, malignant or benign growths in the larynx, edema of the larynx, fracture, gumma, tuberculosis, and spasm of the larynx. High and Loiv Operations. — The high operation is an opening into the trachea through the cricothyroid mem- brane, including in some instances, the cricoid cartilag-e and . . . the first ring of the trachea. The incision into the trachea is above the thyroid isthmus. The low operation is an incision of the trachea belozv the thyroid isthmus. In this situation the opening into the trachea can be made longer, and for this and other reasons is usually the preferable operation. Tracheotomy has been characterized as one of the most easy or one of the most difficult of surgical operations. 286 DISEASES OF THE XOSE, THROAT, AND EAR The difficulties of the operation are enormously increased by the presence of a fat short neck and venous conges- tion. Anesthetic. — In diphtheria and where there is stenosis of the larynx from any cause or great inflammation or irritability of the larynx and trachea, chloroform is the preferable anesthetic. In cases where the supply of oxygen has been deficient for some time it seldom requires more than a few whiffs of chloroform to produce unconsciousness. The chloroform, therefore, should be used with great care. Cocain may be employed locally in adults by injecting one-quarter of a i per cent, solution subcutaneously along -jX-m-ft4/am:?i ^ ^ 4 Fig. 165. — Tracheotom}' instruments: i, Blunt retractor; 2, sharp tenaculum, preferably grooved on convex side ; 3, 4, sharp and probe-pointed scalpels. the line of incision. From 2 drams to J ounce of the solu- tion should be necessary to produce local anesthesia. Instniniciits Required, — The instruments required are a small scalpel, a bistoury, stout angular scissors, dissecting forceps, one-half dozen artery clamps, two grooved directors, catgut ligatures, tenaculum, two blunt retrators (Fig. 165, l), Delaborde's tracheal dilator (Fig. 166), and tracheotomy- tubes (Fig. 168). Preparation of the Patient. — The patient is placed on the table with a small hard pillow, preferably one filled with sand. DISEASES OE THE LARYNX 187 under his shoulders in such a manner as to brin^^ the trachea prominently into view (Fig. 167). However, it is best not to adjust the sand-pillow until after the anesthetic has been /f (I Fig. 166. — Delaborde's tracheal dilator. given. The skin of the neck is scrubbed with green soap and washed with benzene and then with alcohol. Wet bichlorid towels are then placed over the chest and scalp and under the neck and shoulders. |^HH|^^HHHHHHHHH|MH|HH|^H|^ ^ ^- -. ._M Fig. 167. -Position of patient tor tracheotomy {Aiiiericai Children). Text-book of Diseases of The High Operation or LaryngotracJieotouiy . — For the high operation an incision is made in the median line from the top o{ the thyroid cartilage to the second tracheal ring. 288 DISEASES OE THE NOSE, THROAT, AND EAR The handle of the scalpel is used to uncover the cricothy- roid membrane (Fig. 132), on which will be seen, extending transversely across, the cricothyroid artery and vein. Push- ing these to one side a transverse incision is made through the membrane and mucous membrane of the larynx. A tracheotomy-tube is then inserted. This is the simplest and easiest form of the " high opera- tion " and is properly called laryngotomy. It is useful in cases of imminent suffocation, when there is not time to perform a deliberate low tracheotomy. In cases where sufficient room is not secured by a trans- verse incision of the cricothyroid membrane ImyngotracJie- otoniy is necessary. This consists in dividing the cricoid car- tilage and the first ring of the trachea. Below this point there is danger of wounding the isthmus of the thyroid gland and causing profuse hemorrhage. The cricoid and first ring of the trachea are divided either by the scissors, one blade being inserted within the trachea through the incision in the cricothyroid membrane, or the trachea is steadied by the tenaculum and a bistoury is inserted in the wound and made to cut through the cartilage. In adults the cricoid is not infrequently partially ossified, so that a somewhat stout pair of scissors is required to sever it. TJie Low Operation, — The incision should extend from the cricoid cartilage to within I inch of the sternum. When the skin is divided the transverse fascia will be brought into view. An opening is made in this near the middle of the wound by lifting it up with the dissecting forceps and incising it sufficiently to permit the introduction of a grooved director, which is thrust upward to the upper border of the wound. No vessel of any size being visible over the director, the fascia is incised. This is repeated in the lower half of the wound. The deep fascia uniting the two pairs of muscles, the sternohyoid and sternothyroid, is now brought into view and is treated in the same manner, but care should be exercised in using the knife and grooved director that the cuts in the fascia extend completely to each angle of the wound to prevent it becoming funnel shaped by the time the trachea is reached. A layer of areolar tissue and fat is now encountered con- DISEASES OF TlfE LARYNX 289 tainin^^ many cnijor^cd veins. These, if possible, are pushed to one side as the operator proceeds with <^rooved director and knife to uncover the trachea. If it is impos- sible to push a vein to one side, two ligatures are passed under it and tied some distance apart, after which the vein is cut. The wound is now widely opened by means of blunt retractors in the hands of an assistant. Its depth, especially at the lower extremity, may perhaps appall the inexperienced operator, wdio, however, can assure himself that he has not "missed the trachea" by tracing its course in the wound from above downward with his finger-tip. His fears wall be quieted when, after carefully separating the fat and loose connective tissue in the median line, the trachea finally is uncovered, first at the upper end of the wound, where it lies most superficially. In this locality also during the operation will probably appear the isthmus of the thyroid gland. This should be pulled upward out of the way by an assistant or, should that prove impossible, the isthmus can be cut between two ligatures. The trachea having been reached and the wound dry and free from blood, the tenaculum is inserted in it in the median line near the upper portion of the wound with the point of the tenaculum directed upward. The use of the tenaculum is necessary because of the constant movement of the trachea. The trachea being steadied by the tenaculum, the point of a bistoury or scalpel is inserted in the trachea in such a manner as to pierce its mucous membrane, but not to cut the posterior wall of the trachea. Cutting carefully and avoiding long sweeps of the knife, which might endanger the posterior wall, three rings are cut, one after the other, with a perceptible snap, yielding in an adult an incision in the trachea about |- inch in length. The knife is now^ withdrawn and Delaborde's tracheal dilator (Fig. 166) in- serted and opened, widely separating the edges of the tracheal incision. The moment the trachea is opened, any blood in the wound is sucked into the trachea and immediately violently expelled together with any mucus contained in the trachea. 19 290 DISEASES OF THE NOSE, THROAT, AND EAR The lungs then seem to empty themselves of air and the patient stops breathing for a period which may be an anxious one to an inexperienced operator. Finally, a long, deep breath is taken and from then on the respiration is normal. The tracheotomy-tube should now be inserted and be secured by tapes (Fig. 168, b). The upper end of Fig. i58. — Tracheotomj' A, Tracheotom3--tube with pilot; tion (Stoney). B. tracheotomy- tube in posi- the wound is secured by sutures, a portion at least of the lower end being allowed to remain open for drainage. A rectangular piece of iodoform gauze sufficiently large to cover the wound is slit in such a manner that it can be in- serted underneath the shield of the tube next the skin, and is held in place by the tape. A handkerchief is tied loosely about the neck in such a manner that a flap falls down over the tube and prevents the entrance of dust and other materials, and also receives secretions which are coughed out through the tube and immediately sucked back into the trachea unless absorbed by the handkerchief or gauze and removed by the attendant. In diphtheria cases the inner tube should be removed and cleansed by the nurse every two hours or oftener should the circumstances require J)/SKASI':S Of 77//': LA/ ._^^^^^^ ^^ canal. Its outer surface is concave, d .x_-_ ^^ ^^ From above, the malleus handle may l| ^-j^jj jfej p be seen extending downward and some- m'-^^^^77 p what backward from a tubercle, its short ^^ik^^ process, and endino; near the center of /'"• .171— Outer surface , , ., . , . 01 the ri,a:nt membrana t3'm- the drum-head at a depression, the pani: a, Membrana flaccida 1 T-v • 1-r 1 -11 • A -K or Shrapnell's membrane; umbo. Durmg life, when lUummated, k. posterior fold; c, short the membrana tympani generally pre- ru\Ticuia"tio:;.\"'maiKs sents a triangular lis:ht spot or " cone •^f"^'^; "• umbo; g, cone 01 light, having its apex at the umbo and extending downward and forward to the periphery (Fig. 171). The mucous membrane of the inner surface of the drum-head is folded upon itself as it passes over the chorda tympani nerve, so that two pouches are formed, opening dowaiward, one in front of and the other behind the manubrium (Fig. 172). Vessels of the Membrana Tympani. — The dermoid layer is supplied with arterioles by the deep auricular branch of the internal maxillary artery ; the mucous membrane, by the tympanic branches of the internal maxillary, internal carotid, and stylomastoid arteries. Nerves of the Membrana Tympani. — To the external layer are distributed filaments from the superficial branch 296 DISEASES OF THE NOSE, THROAT, AND EAR of the fifth nerve, while the mucous layer is supplied by the tympanic plexus. The cavity of the tympanum is of irregular shape. It measures about \ inch anteroposteriorly, \ inch vertically, and \ inch transversely. It is situated in the petrous por- tion of the temporal bone above the jugular fossa, having the carotid canal in front, the mastoid cells behind, the auditory canal externally, and the labyrinth internally. It communicates with the pharynx by means of the Eustachian tube and with the mastoid antrum by means of the aditus ad antrum. The upper portion of the tympanum is called the attic or recessus epitympanicus. It extends outward Fig. 172. — Outer half of sagittal section of entire left middle ear : o, Anterior and, p, posterior pouches of von Troltsch ; op, ostium pharyngeum tubse ; te. Eustachian tube; it, isthmus tubae; int, membrana tympani, with the malleus and incus and the chorda tympani nerve ; n, attic or recessus epitympanicus ; an, mastoid antrum ; iv, lu, mastoid cells. (Politzer.) over the auditory meatus, from which it is separated by a wedge-shaped mass of bone, sometimes called the shute. On the shute lie the head of the malleus and body of the incus. The handle of the malleus and long process of the incus descend through the narrow opening from the attic into the atriiiiii or lower cavit}^ of the tympanum. The roof of the tympanum consists of a thin plate of bone, the tegnicn tympani, which separates the tympanic cavity from the meninges of the brain. The floor of the tympanum is narrow and separates the cavity of the tym- panum from the jugular fossa beneath. Near the inner wall is a small foramen for the passage of Jacobson's nerve. ANATOMY OF THE EAR 297 The outer wall consists of the nicnibran.i tympani and the bony ring into which it is inserted. In this bony ring, the // I I.N V.N- Fig. 173.— Sections through the tympanum parallel to its inner wall ; median aspect of the specimens : 77. Horizontal semicircular canal ; H.N', horizontal portion of aquse- ductus Fallopii; KA^. vertical portion. In the upper specimen the section is somewhat more median than in the lower, in order to open the horizontal semicircular canal and the aqujeductus Fallopii. It will be observed that in the lower specimen the tubercle, H, con- taining the semicircular canal is more lateral than the hard ridges of bones below it, HN'. containing the facial canal. In the upper specimen the stapes is in the oval window, and the topography of the inner wall of the tympanum, the aditus, and the mastoid antrum is well shown in both specimens. (Author's specimen.) anniilus tympanicus, are two small orifices, the iter chordae posterius and iter chordae anterius, for the entrance and exit of the chorda tympani nerve. Just in front of and above 298 DISEASES OF THE NOSE, THROAT, AND EAR this bony ring is the Glaserian fissure, in which is lodged the long process of the malleus, and which also gives passage to some tympanic vessels and the anterior ligament of the malleus. The inner tympanic wall (Fig. 173), which is nearly vertical, bulges outward as an eminence, the promontory, corresponding to the first turn of the cochlea. Below, pos- teriorly, is the niche, at the bottom of which lies the fenestra rotunda or " round window," closed by the membrana tym- pani secundaria. This membrane is protected by the exter- nal wall of the niche, in which it so lies that it is impossible to injure it by means of a straight instrument thrust from without through the membrana tympani. Above, poste- riorly, is the fenestra ovalis or " oval window," closed by the foot-plate of the stapes. Above the oval window is the eminence of the aquseductus Fallopii, which transmits the facial nerv^e. The pyramid is a hollow conic projection con- taining the stapedius muscle, whose tendon escapes by an opening at its summit. In the posterior wall above is the opening into the mastoid antrum, the aditiis ad antrum. The anterior wall separates the cavity of the tympanum from the carotid canal, which lies immediately below and in front of it. In the upper por- tion of the anterior wall is the orifice of the Eustachian tube. Just above is the canal for the tensor tympani muscle. The Eustachian tube is sepa- rated fron the canal for the tensor 174.— The malleus, tvmpani musclc by a thin bony plate, incus, and stapes of left ear: i 7 / • /- • A, Malleus; B, incus; C, thc pVOCCSSIlS COClUcariJOliniS. ^'^P^^' The ossicles are three small bones so arranged as to form a movable chain connecting the mem- brana tympani with the fenestra ovalis. These three bone- lets are the malleus or hammer ; the incus or anvil ; and the stapes or stirrup (Fig. 174). The iiialleiis is a somewhat irregularly shaped bone, con- sisting of an oval head, articulating with the incus ; a neck, a short and long process ; and a manubrium or handle, imbedded in the membrana tympani. The head and neck ANATOMY OF THE EAR 299 of the malleus, which project into the tympanic cavity, are entirely free from the membrana tympani, the surface of the head, which articulates with the incus, being directed back- ward. The Xow^g and short processes are situated at the junction of the neck and handle of the malleus. The short process pushes the membrana tympani outward before it and is generally plainly visible during life as a tubercle at the upper extremity of the malleus handle. The long process passes forward into the Glaserian fissure, with the under wall of which it unites in adult life. The malleus is held in posi- tion within the tympanum by four ligaments — the anterior, Fig. 175. — Ligamentous support of ossicles, viewed from above : l-h. Attachment of the iigamentum mallei externum ; X-, head of hammer ; ?', body of incus ;y", point of its short process ; a, entrance to the Eustachian tube from the tympanum; r, stapes ; d, tendon of stapedius muscle : /', tendon of the tensor tympani leaving the cochlear process; g~S, chorda tympani, marking the free edge of the folds of mucous membrane bounding the pouches; ti, the upper tendinous fibers of the ligamentum mallei anterius, originating above the spina tympanica major, m; j, malleo-incudal joint. (Helmholtz.) superior, external, and posterior. Of these ligaments the anterior is by far the strongest, the posterior and external ligaments being, in a mechanical sense, but one ligament, to which Helmholtz has given the name " axial ligament of the malleus." The incus is the middle one of the three ossicles, its name being derived from the shape of its upper part. This bonelet consists of a body, a short or horizontal process, and a long or descending process. The incus is attached at the extremity of its horizontal process to the posterior tympanic wall by somewhat weak ligaments (Fig. i/S)- The long process of the incus curves downward, and at first 300 DISEASES OF THE NOSE, THROAT, AND EAR somewhat outward, toward the auditory meatus, its tip bending sharply inward to articulate with the head of the stapes by means of the lenticular process. The malleo-inciidal joint is a ginglymus or hinge-joint, like that of the knee or elbow. The ligaments of the malleus are so arranged that the bone performs the part of a lever whose fulcrum is just below the short process. The manubrium is the long arm of the lever and, consequently, all its movements are repeated in an opposite direction by the head of the malleus. Each inward movement of the membrana tympani and manubrium causes a slight outward movement of the head of the malleus. The incus being also suspended as a lever, when its upper part moves out- ward with the head of the malleus its long process swings inward and pushes the stapes before it, so that the foot-plate is forced into the oval window. The stapes is the smallest bone in the body. It consists of a head, articulating with the lenticular process of the incus, two branches, or crura, joining the base, which is con- nected by ligamentous fibers with the margin of the oval window. The stapes (Fig. 174, (7) measures 4 mm. from its head to the foot-plate, the latter measuring 2 J mm. in its horizontal diameter. The foot-plate of the stapes is some- what kidney shaped. When in position its long axis is nearly horizontal, with its convex edge looking upward and with its concave edge looking downward. A thin membrane, the ligamentum obturatorium stapedius, stretches across the space between the base and the crura. Muscles of the Tympmuim. — The tensor tympani originates from the under surface of the petrous bone, the cartilaginous Eustachian tube, and its own osseous canal. It is inserted into the handle of the malleus near its root. Its action is to draw the membrana inward and increase its tension. The tensor tympani muscle is supplied by a nerve from the otic ganglion. The laxator tympani major and minor have already been described as anterior and posterior ligaments of the malleus. The stapedius muscle originates from the interior of the pyramid (Fig. i jG) and is inserted into the head of the stapes. Its action is to lift the anterior part of the foot-plate of the ANATOMY OF THE EAR 301 stapes out of the oval window, thus antagonizing to a certain extent the action of the tensor tympani muscle. The stape- dius obtains its nerve-supply by a filament of the facial nerve. Arteries of the Tyinpainnu. — The tympanic branch of the internal maxillary enters the Glaserian fissure and is dis- tributed to the membrana tympani. The tympanic branch of the internal carotid also supplies the membrana tympani. The stylomastoid extends from the posterior auricular to the back part of the tympanum and mastoid cells. The petrosal artery, a branch of the middle meningeal, enters the car through the hiatus Fallopii, and a branch from the ascending pharyngeal passes up the Eustachian tube. Chprda Typif' Fig. 176. — Inner wall of tympanic cavity (Gray). Nerves of the Tyvipaimni. — The tympanic branch of the glossopharyngeal (Jacobson's nerve) supplies the mucous membrane of the tympanum and fenestrae. The tympanic branch of the facial nerve supplies the stapedius muscle and a branch from the otic ganglion supplies the tensor tympani muscle. The chorda tympani nerve passes across the tympanum between the handle of the malleus and the long process of the incus, without branches. It enters the tym- panum by the iter chordae posterius and emerges through the iter chordae anterius. Tlie Tympanic Plexus. — Jacobson's nerve (tympanic branch of the glossopharyngeal) divides into three branches, lying 302 DISEASES OE THE NOSE, THROAT, AND EAR in grooves upon the promontory (Fig. 176). One joins the carotid plexus ; a second, the greater superficial petrosal nerve; and a third, passing upward and forward, finally becomes the lesser superficial petrosal nerve. The Eustachian tube, which is about i J inches long, passes fi'om the middle ear downward, forward, and inward to enter the pharynx. It affords communication between the air in the pharynx and that contained in the middle ear. The outer third consists of bone, commencing at the lower part of the anterior tympanic wall, and gradually narrowing to terminate at the angle of junction of the petrous and squamous portions of the temporal bones. The inner two- thirds of the Eustachian tube consist of elastic cartilage and fibrous tissue, which unite the inferior portion of a curved cartilaginous plate so as to form a tube. The mucous membrane Hning the Eustachian tube is a continuation of that of the pharynx and is covered with stratified ciliated epithelium. The jnuscles that dilate the ^ustachiaji tube are the leva- tor palati muscle, which, arising from the petrous bone and cartilaginous portion of the tube, is inserted into the tissues of the soft palate, and the tensor palati, a flattened muscle which, arising from the sphenoid bone and the car- tilaginous tube, passes as a broad tendon around the hamu- lar process to form the broad aponeurosis of the soft palate. The action of both these muscles is to dilate the tube. Some of the fibers of the tensor tympani and tensor palati are blended, and an aponeurotic connection always exists along the Eustachian tube, so that probably these two muscles have no action entirely independent of each other. When the soft palate is drawn upward the membrane is also retracted by the tensor tympani and the Eustachian tube is at the same time dilated, so that, although a current of air enters the tympanum, it is prevented from forcing the mem- brane too far outward and interfering with the equilibrium of auditory tension. The tensor tympani . and tensor palati receive nerve-filaments from the otic ganglion, but the levator palati is supplied by a branch from Meckel's ganglion. The Eustachian tube receives its arterial supply by the ANATOMY OF TJIK EAR 303 following arteries : The ascending pliaryngeal, branches from the middle meningeal and internal maxillary, and a branch from the stylomastoid artery. Its nerves are, in addition to those supplying muscles of the tube, derived from the fifth and seventh pair and the glossopharyngeal. The Mastoid Process of the Temporal Bone. — At birth the mastoid process consists of a small flattened tuberosity con- taining but one cell and that of considerable size — the vias- toid iDitnnii. At puberty the mastoid process has become a distinct prominence, conic in shape, with its apex down- ward. The substance of the mastoid process consists of small cavities varying greatly in number, size, and shape in different individuals. Some of them communicate with each other and are lined with a continuation of the mucous membrane of the tympanum, which is here covered by squamous epithelium. THE INTERNAL EAR OR LABYRINTH Osseous Boundaries. — At all points the various channels and cavities of the labyrinth are deeply imbedded in the petrous portion of the temporal bone. The bony labyrinth consists of a central cavity, called the *' vestibule," from the walls of which spring, like arches, the semicircular canals, while through the anterior wall of the vestibule a canal leads into the snail-shaped cavity of the cochlea (Fig, 177). Contents of the Osseous Labyrinth. — The vestibule contains fluid and two distinct membranous sacs, the utricle and saccule (Fig. 178). The saccule communicates with one of the membranous tubes of the cochlea, the ductus cochlearis, by means of a slender membranous tube, the canalis reuniens, while the cavity of the utricle is continuous with that of the membranous semicircular canals, so that the membranous labyrinth may be said to consist of a system of cavities with membranous walls containing a fluid, the endolymph, and nearly surrounded by another fluid, the perilymph. A diaphragm, consisting partly of bone (lamina spiralis ossea) and partly of membrane (membranabasilaris), divides the cavity of the cochlea into an upper and low^er space of 304 DISEASES OF THE NOSE, THROAT, AND EAR nearly equal size (Fig. 179). The upper, the scala ves- tibuli, communicates with the cavity of the vestibule, and the lower, the scala tympani, ends abruptly at the round window. The upper space (scala vestibuli) is divided by a diaphragm (Reissner's mem- brane) placed at an angle of 45 degrees with the membrana basilaris, into the scala vestibuli proper and the scala media or ductus cochlearis, which, as already described (Fig. 178), communicates with the sac- cule by means of the canalis reuniens. The scala media or ductus cochlearis contains endolymph and the organ of Corti (Fig. 180). The organ of Corti rests upon the membrana basilaris about midway between the lamina spiralis ossea and the 10 Fig. 177. — The bony labyrinth laid open : I, Recessus ellipticus for utricle ; 2, recessus sphaericus for saccule ; 3, re- cessus cochlea ; 4, pyramis vestibuli ; 5, round window ; 6, posterior semicircular canal ; 7, external semicircular canal ; 8, cupola of the cochlea; 9. superior semicircular canal ; 10, lamina spiralis ossea projecting from the modiolus into the calibre of the canal of the cochlea, and terminating in the cupola as a hook- like process called the " hamulus." Auditory ner\'e with its vestibu- lar and cochlear branches. Ant. semicircular canal. Ampulla. Canalis reuniens. Ductus Ampulla, endolymphaticus. Fig. 178. — Membranous labyrinth of the right ear from five-months'-old human embryo (from Schwalbe, after Retzius). outer wail of the ductus cochlearis. It extends from the vestibule to the cupola of the cochlea, and to it are distrib- ANATOMY OF THE EAR 3<^5 uted nerve-fibers from the cochlear branch of the auditory- nerve. Corti's or, nerve-fibers of the ramulus basilaris ; ii^->fi, outer bundles of the spiral nerve-fibers ; rf, radiating tunnel fibers ; at, inner part of Nuel's space ; ;;//>, upper layer of the membrana basilaris ; ;«//, lower layer of the membrana basilaris ; tf', layer covering the tympanic surface of the membrana basilaris ; iis, ligamentum spirale. (Gruber, after Retzius.) at the outside of the arch four rows of ciliated cells and at the inner side one row, which receive terminal filaments from the cochlear branch of the auditory nerve. The 20 306 DISEASES OF THE NOSE, THROAT, AND EAR name " hearing cells " is sometimes applied to these hair- cells. There is a peculiar fenestrated membrane, the lamina reticularis, into whose net-like structure project the cilia of the outer hearing cells, which are covered and protected by a glue-like substance, the membrana tectoria. The rods of Corti have been estimated at about 10,500, while the num- ber of hair-cells is estimated to be about 21,300. The membranous semicircular canals occupy scarcely one- third of the space inside the bony canals, except at the ampullae, where they hug the bony walls more closely. The space between the membranous canals and the bony wall is occupied by connective tissue rich in blood-vessels rather than with free fluid, as in the cochlea (Fig. 181). The otoliths are granular, amorphous, sometimes crystal- line particles found along the walls of the utricle, sac- cule, ampullae, membranous canals, on the periosteum of the osseous semicircular canals, and in the fluid of the cochlea. They consist of about 75 per cent, mineral matter, mostly carbonate of lime, and organic material re- sembling mucus in its physical and chemic characteristics. The function of the otoliths has not been determined, but it has been suggested that they exert a damping action upon the vibrations of the terminal fibers of the hair-cells. In some of the lower animals they are huge in size com- pared with those of man and assume fantastic shapes. The auditory nerve originates by three fasciculae from the superior vermiformis process of the cerebellum and from the inner and outer nuclei, formed chiefly by the gray sub- stance of the posterior p^^ramid and restiform body. The nerve emerges, superficially, from a groove between the olivary and restiform bodies at the lower border of the pons. At the bottom of the internal auditory canal it divides into the cochlear and vestibular divisions, both of which contain ganghon cells. The cochlear nerve divides into numerous filaments to enter the modiolus and sends branches to each of the hair-cells (Fig. 180). The vestib- ular nerve divides into three branches : The filaments from the upper branch enter the vestibule through the macula cribrosa at the bottom of the internal meatus, and are dis- tributed to the utricle and the ampulla of the external and ANATOMY OF THE EAR 307 superior semicircular canals; the niicklle branch is distributed to the saccule, and the inferior branch passes to tlie ampulla of the posterior semicircular canals. Function of the Semicircular Canals. — They appear to be a peripheral space-organ, and through centers in the brain regulate the movements of the muscles of the eye and probably all the muscles of the body for the preservation of equilibrium. The power of maintaining equi- librium is derived from the edu- cation of touch and sight and information derived from the peripheral space-organ within the ear, which informs the brain of the position of the head and regulates the movements of the muscles for the preserva- tion of equilibrium. If pres- sure be made upon the membrane of the round window, dizziness and an inclination to fall backward are produced as the result of the pressure transmitted to the ampulla of the posterior canal. If the foot-plate of the stapes be pressed upon, a rocking sensation of the head from side to side will be felt, indicative of the transference of the pres- sure to the ampulla of the superior canal. It is impossible to transmit pressure to the fluid of the horizontal canal, and when strong pressure is made upon the fluid within the vestibule there is produced dizziness without sensation of falling in any especial direction. Functions of the Vestibule and Cochlea. — Except that in a general way the vestibule and cochlea have to do with the sense of hearing, the functions of these parts of the ear are not clearly understood. It is supposed that the individual hair-cells and rods of Corti vibrate to single tones, and that a compound sound causes the vibration of a number of hair- cells proportionate to its composite character. Fig. 181. — Section through the osseous and membranous semicircuhir canals : a. Osseous semicircular canal ; /■, place of attachment of the membranous semi- circular canal ; c. elevations on the inner surface of the membranous semicircular canal ; d, vascular bands of connective tissue. (Politzer.) 3o8 DISEASES OF THE NOSE, THROAT, AND EAR TESTS FOR HEARING Hearing is the faculty of the perception of sound. Sound is a pecuHar sensation excited in the organs of hearing by the vibratory motion of bodies, the effects of which are transmitted to the ear through an elastic medium. Sound is a sensation and should be distinguished carefully from the vibrations that produce it ; which vibrations, of course, may exist without the presence of an organized being to perceive them. Sources of Sotuid. — Sound is produced by the rapid vibra- tions that take place in the molecules of bodies when they are disturbed by shock or by friction. When a resonant body is struck its molecules alternately approach and recede from one another with a velocity and amphtude of vibrations corresponding to the form, size, and molecular composition of the body ; and this motion is transmitted by contact to any surrounding elastic medium, such as air. Sound-waves so produced are in part reflected in passing from a rarer to a denser medium, as, for example, when passing from air into water. If, however, a tense membrane, free to vibrate, is interposed between the air and any fluid or solid medium, the aerial vibrations are not reflected, but are transmitted into the more solid medium with little loss of their intensity. But for the membranes of the middle ear, sound-waves trans- mitted from the ear to the lymph of the labyrinth would lose intensity to such a degree as to be inaudible. Acoustics is that department of physics which treats of sounds. A rudimentary knowledge of the laws of acoustics is essential to an understanding of the physiology of the ear. The science of music treats of a peculiar class of sounds and combination of sounds calculated to produce pleasur- able emotions. Such sounds are distinguished from noises, which are sounds either of very short duration, like the re- ports of firearms, or are a mixture of many discordant sounds. Pcndiiltun Vibration. — If a needle be attached to one arm of a vibrating tuning-fork, and if in contact with the end of the needle a piece of smoked paper be moved at a uniform velocity, a tracing of the vibrations of the needle will be TESTS FOR IIKARLXC 3O9 scratched upon the paper (Fig. 182). This tracin^^ is a record of the miviber of vibrations of tlie fork during a given time and of the aniplitiidc of the vibrations. The record is regular and uniform, and so simihir to that produced by a pendulum under similar circumstances that Huxley has de- scribed this form of vibration under the name of poidiiluin vibration. A tone is a sound produced by a simple pendulum vibra- tion. It has the characteristics of quality or *' timbre " ; in- tensity, volume or loudness ; and pitch (high or low tone). The quality of a tone depends largely upon the material of the substance which produces the tone. The quality of the note emitted by striking a strip of wood is entirely dif- ferent as regards its quality or " timbre " from that produced by striking a rod of metal. A note produced from an organ, a violin, and a cornet may in each case have the same pitch r^r>i\r\rv/vvsrvNrv/Nf\r\rvrN/\rs Fig. 182. — Tracing on smoked paper produced by the vibrations of a tuning-fork. and volume, but will differ widely from one another as re- gards quality or timbre. The intensity of a tone depends upon the force and ampli- tude of the vibrations which produce it. When a tuning- fork is first made to vibrate, its tone is comparatively intense or loud, because the force and amplitude of its vibrations are comparatively great, but as it continues to vibrate its tone is heard less and less distinctly, because the force and amplitude of its vibrations are becoming less and less. The pitch of the tone, however, remains the same until the fork ceases to vibrate. The pitcli of a tone depends upon the rapidity of the vi- brations that produce it. The more rapid the vibrations, the higher the pitch. The human ear is generally able to distinguish the tone produced by a tuning-fork vibrating only 16 times during a second, and also that of a fork vi- brating 38,000 times a second. The capacity, however, to 310 DISEASES OF THE NOSE, THROAT, AND EAR distinguish sounds of very low or very high pitch varies greatly in individuals, but the ears of most persons are more sensitive to sounds of low than to those of high pitch. Prof Tyndall says :. " The squawk of the bat, the sound of the cricket, even the chirp of the common house-sparrow, are unheard by some persons who for lower sounds possess a sensitive ear." The inability to hear high notes increases with age, and generally also as the result of disease of the labyrinth or acoustic nerve ; and in testing the acuteness of hearing by means of tuning-forks and Galton's whistle it is well to bear this fact in mind. For careful tests as to the sensitiveness of the perceptive apparatus it is well for the aurist to be provided with at least five forks, the lowest (c-2) giving 32 Fig-. 183.— Galton's whistle with rubber bulb. The pipe below the opening is filled by a plunger advanced or withdrawn by a screw, each turn being shown by the scale upon the enlarged tube, and its tenths by that on the revolving collar. It gives an audible sound from 0.5 (theoretically, 84,000 v. s) to 10 or 12 (4200 or 3500). vibrations during a second and the highest (cj yielding 2048 vibrations in a second. Galton's whistle (Fig. 183) and Konig's rods will be found useful also for making tests of this kind. Konig's rods are ten steel cylinders, 20 mm. in diameter, suspended by cords attached to them at a distance from each end of one-fifth of the length of each rod. The rods are of such a length that when struck with a hammer they produce tones, the lowest of which give 4096, and the highest 32,768, vibrations per second. Galtoji's zvliistlc for testing the higher tones of the scale is more convenient than Konig's rods. It consists of a metal tabe so perforated as to cause a whistle when air is blown through it by means of a rubber bulb attached to the proximal extremity of the instrument. The distal extremity is closed by a metal rod capable of being moved backward TESTS FOR IIEARIXG 311 and forward within the tube by a micrometer screw. The length of the column of air within the tube beyond the per- foration, and consec^uently the pitcli of the note emitted by the w^histle, are determined by the position of tlie rod within the tube. The micrometer screw is graduated to indicate single numbers, while on the side of the tube is a scale to show tens ; so that by turning the micrometer screw the metal rod within the hollow cylinder can be placed in any position indicated by a number on a scale having a range of from I to 120. The following table indicates the number of vibrations per second of the note emitted by the whistle corresponding with the numbers on its scale : Vibration per second Scale 84000 10 56000 15 42000 20 33600 25 2 8c 00 30 24000 35 21000 40 18666 45 Vibration per second Scale 16800 50 15273 55 14000 60 12933 65 12000 70 1 1200 75 ■°r gSac 85 Vibration per second Scale 9330 90 8842 95 8400 100 8000 105 7591 110 7305 115 7000 120 Helmholtz states that the human ear is able to distinguish as musical notes tones lying betw^ecn 16 and 38,000 vibra- tions per second, or a range of about 1 1 octaves, but that the lowest note used in orchestral music is e-^ or one of 40 vibrations per second. In pianos the lowest note in general use is c-,„ 32 vibrations per second ; and the highest, 7 octaves above it, is c^, 4096 vibrations during a second. The fol- lowing table is from Appun : C-'=32 D-»=36 E-2=4o F-=42.es 0-2=48 A-==53,35 H-2=6o C-^=64 D-i = 72 E-i=8o F-' =85.33 0-1=96 A-i = io6,66 H-» = I20 c =128 d =144 e =160 f =170,66 g =192 a =213,33 h =240 0^=256 di -=288 e*=32o f'=34i.32 g'=3S4 al=420,66 hi =480 C»=5I2 d= =576 e==64o f==682.e. g= = 768 a===853.32 h2=96o C 3 =^1024 d^ =1152 e3=i28o <^=i365.28 g3=i536 a3 = 1706,64 h3=I920 c*=2048 d* =2304 e*=256o f*=27IO,36 g4=3072 a*=34i3.29 h*=384o c»=4096 ds =4608 e==5i2o P = 542I.,2 g«=6i44 a^=6826,5e h-'^=768o c8u=8i92 d6 =9216 6^ = 10240 f6=I0842,34 g6 =12288 3^=13653.12 h6 = i536o 0^=16384 d^ =18432 e'' =20480 f-=2i684.^8 g7 = 24576 a^=273o6.24 h" =30720 Hannoiiy. — If the rates of vibration in a second of two notes simultaneously produced stand to each other in the ratio of simple multiples, so that while the low note makes I vibration the high note makes 2, 3, 4, etc., the notes are said to be in harmony or concord, and the result is con- sonance. These are the ratios of the human voice in ordinary speaking or singing, and, accordnig to Wolf, 312 DISEASES OF THE NOSE, THROAT, AND EAR speech has a compass of 5 octaves, from c to c^. The simplest ratio is \, and to this the name octave is given. In this case the higher note has double the number of vibra- tions of the lower. The ratio of the notes in the diatonic major scale is as follows: C. D. E. F. G. A. B. c f f * 1 f ¥ 4 The timing-fork used to test the hearing should be large enough to secure sufficient intensity or loudness of tone. It is not absolutely necessary, but desirable, to have the tuning-fork provided with movable clamps, so as to deaden overtones. While it is more convenient, as stated, for the aurist to be provided with at least five forks of different pitch, yet one sounding the note Cj (512 vibrations per second) will generally answer the purpose of ordinary TJ':S'J\S FOR HEARING 313 clinical investigations. It is convenient to have at hand a small tuning-fork emitting a tone of feeble intensity (Fig. 185), in order to confine the sound to one ear; because when a very heavy tuning-fork is employed in examining patients whose hearing is greatly impaired only in one ear, it is impossible to be certain that the sound of a large fork is not heard by the ear in which the hearing is better. When the fork is used for testing the hearing of the ear in which the hearing is more de- ficient, a large fork, provided with movable clamps, can, however, generally be made to answer the same purpose by placing the clamps sufficiently low dowai upon the tines of the instrument. Weber's Test. — E. H. Weber demonstrated that w^hen a vibrating tuning-fork is placed against the teeth or on a point of the cranium the tone is heard better by a person with normal hearing if the ears are closed by the fingers. If only one ear is closed, the fork is heard best in that ear. Weber, Rinne, and Toynbee attributed this phenomenon to in- creased resonance ; Mach, to the obstruction of the outlet of sound-waves through the auditory canal. Probably each of these factors should be given due weight as a cause of the phenomenon. It should be borne in mind that any obstruction to the exit of sound-waves from the middle ear when a tuning- FiG. 185. — Small tuning-fork. is vibrating with its handle in contact with the teeth fork or at a point upon the cranium midway between each ear, will cause the sound of the fork to be heard most distinctly in the obstructed ear. The cause of obstruction may be impacted cerumen in the external auditory meatus, occlu- sion of the Eustachian tube, mucus within the tympanum, or thickening of the membrana tympani as the result of catarrh of the middle ear. Hence, if a patient is deaf in only one ear from any of these causes, a vibrating tuning-fork, with its handle in contact with the teeth or on a point on the cranium midway between the ears, will be heard by him better in the deaf ear. If, how^ever, the hardness of hearing 314 DISEASES OF THE NOSE, THROAT, AND EAR is due to impairment of the labyrinth or of the auditory nerve, the note of the tuning-fork will be heard less dis- tinctly ill the deaf ear. In practising Weber's method of examining the hearing, the observer should bear in mind that the answers of some patients will largely be determined by their imagination, and that they at first will say that they hear the sound of the fork most distinctly in that ear in which the hearing is better, simply because tliey think they sJioidd do so. The test should be repeated sufficiently often to convince the observer that his patient's answers are rehable. It will, in all instances, be judicious to request the patient, while the fork is still vibrating upon the cranium, to close first one ear and then the other with a finger, and only after this has been done to ask him in which ear he now hears the sound of the fork most distinctly. Rinne's Test. — Rinne observed that when a vibrating tun- ing-fork, with its handle in contact with the tissues over the mastoid process, ceased to be heard, the sound of the fork reappeared if it was held in front of the ear. Aerial con- duction is superior to tissue-conduction in individuals with normal ears. If the tuning-fork is heard best by aerial con- duction, the fact may be noted as Rinne+ ; or Rinne— if the contrary is the case ; or, to be more exact, the number of seconds that the tuning-fork is heard upon the mastoid and in front of the auditory meatus may be given in the form of a fraction, the numerator of which will be less than the denominator if Rinne's method yields a positive result, and the contrary will be the case if Rinne's method gives a negative result. Thus, if the note of a Cg tuning-fork whose handle is in contact with the mastoid process is heard for twenty seconds, and for fifty seconds when its tines are held close to the external auditory meatus, the fact may be noted thus : Rinne + ||. If, however, the fork is heard for thirty seconds when its handle is in contact with the tissues over the mastoid process, and only ten seconds when its prongs are held close to the meatus, the fact should be noted as Rinne — f ^ (R. — |^). In the first instance any hardness of hearing is due to impairment of the nervous part of the ear ; in the latter case it is due to the result of TESTS FOR HEARING 315 disease or to imperfection of the external or middle ear, or both. It is a well-known fact that any rii^idity of the conducting apparatus so alters the relation of tissue to aerial conduction that the former finally exceeds the latter. This change begins with the low notes. If Rinne's method be employed on a patient in whom there is only a slight impairment of the patency of the Eustachian tubes, with congestion of the mucous membrane of the tympanum, the result will be nega- tive with forks emitting a very low-pitched note and positive for that of a higher pitch. That is, the sound of the fork of low pitch will be heard louder and longer when its handle is firmly pressed upon the mastoid process than when the tines of the fork are held in front of the meatus. This, however, will not be the case if a fork emitting a high-pitched tone be employed. In conditions in which there is great rigidity of the transmitting apparatus of the ear, the receptive apparatus remaining healthy, Rinne's test will yield a negativ^e result with forks of high as well as low pitch. Generally under such circumstances tissue-conduction will be apparently in- creased ; that is, a tuning-fork with its handle pressed upon the tissues ov^er the mastoid will be heard louder and longer than normal. When, instead of this being the case, tissue- conduction as well as aerial conduction is decreased, impair- ment of the functions of the internal ear should be suspected, although it should be borne in mind, when testing the hearing of patients past middle life, that tissue-conduction of sound is always decreased as the result of senility, and sometimes as the result of other causes besides disease of the internal ear. In any case, however, in which the acuteness of hearing is reduced to the perception of words spoken in a loud voice close to the ear, if tissue-conduction is greater than aerial conduction only for forks of low pitch (C^ to c) while those of high pitch (c.^, cj are heard very imperfectly, if at all, either by aerial or tissue-conduction, the receptiv^e apparatus, as well as the middle ear, is impaired. In such cases, although the tension of the structures of the middle ear can doubtless be removed by operative procedures, the perform- ing of such an operation will not result in a great improve- ment in the patient's hearing. 3l6 DISEASES OF THE NOSE, THROAT, AND EAR Schwabach's Test. — This test consists in comparing the number of seconds a tuning-fork is heard on the mastoid and at the meatus in a normal ear with the time the fork is heard in these positions by the ear being examined. Gelle's Test (Pressions Centripetes). — If the air within the auditory canal be compressed by means of Siegle's speculum or any suitable instrument, a normal ear wall hear the sound of a tuning-fork vibrating on the cranial bones with dimin- ished intensity. This phenomenon is due to increased laby- rinthine pressure, because when the air within the auditory canal is condensed the chain of bonelets with the foot-plate of the stapes is pressed inward. If ankylosis of the stapes exists or if there is great immobility of the ossicles the tone of the tuning-fork will remain unchanged during the test, while if the labyrinth is diseased and the stapes is movable the application of Gelle's test will produce dizziness. Bing's Test. — If a tuning-fork is vibrated upon the mastoid process of a normal ear, after its sound is no longer audible it can be made to reappear if the meatus is tightly closed with the moistened finger. In cases of severe deafness, according to Bing, if this test yields a negative result, the hardness of hearing is due to a middle-ear affection, while if the result of the test is positive, the deafness is the con- sequence of a labyrinthine affection. Dr. Bing uses also, as an aid to diagnosis, what he terms the " entotic " use of the speaking-trumpet, which consists in speaking into a speaking-tube connected by means of an air-tight joint with a catheter introduced into the mouth of the Eustachian tube. If the voice is heard better by this method than when the speaking-tube is used in the external meatus, there is hindrance to sound-conduction at the mal- leus or the incus, and the foot-plate of the stapes is freely movable in the oval window. To test the hearing by a watch the patient should be seated with his face so covered by a napkin or towel that it is impossible for him to see the watch, because many patients imagine that they hear a watch which they see held close to their ear. It is well also to request the patient to close firmly with his forefinger the ear that is not being tested. The aurist should hold the watch in his hand with its case open close 7'ESTS FOR HEARING 317 to the patient's ear until tlie latter hears it distinctly, then move his hand to a considerable distance and slowly bring the watch tow^ard the ear being examined, observing the exact distance the watch iswhen^r^Y heard. The result of the examination may be expressed by a fraction, the numer- ator of which is the distance at which the patient hears the watch and the denominator the distance at which the watch can be heard by a normal ear. For example, if the watch used in making the test is heard by a normal ear at 40 inches, and the patient hears it only at 15 inches, the fact may be recorded thus : Hearing for watch is if (H. W.-== l|). If the watch is heard only on contact with the auricle, the record should read, Hearing for watch is ^J^ ; or, if it is only heard by exerting considerable pressure with it upon the auricle, Hearincf for watch is E!!!^^. The room in which the hearing is being tested by the watch should be as free from noise as possible, and the watch should invariably be made to approach the patient's ear from a distance as directed above, and the point be noted at which it is first heard, because, while the patient still hears the watch if it is slowly carried away from his ear, it will be found that he will continue to hear it at a much greater dis- tance than that at which he would first hear it if it were made to approach his ear from a distance. The hearing may be tested in a similar manner by means of the acoumeter, an instrument devised by Politzer. The acoumeter gives the note c with about the same loudness as the sound of a loud-ticking watch. In testing the hearing by the voice the patient should close the ear not being tested firmly with his forefinger, and either close his eyes or look in such a direction that it will be impos- sible to see the motion of the aurist's hps ; the distance in feet should then be observed at which words are heard when spoken in a whisper, ordinary conversational tone, or a loud voice if the patient be very deaf In making this test of the hearing-power it is best, in most instances, to employ single words of only one syllable. The result of the exam- ination may be noted as a fraction, the numerator of which is the distance in feet at which the patient hears the words 3l8 DISEASES OF THE NOSE, THROAT, AND. EAR and the denominator the distance in feet at which a normal ear can hear the same words. For example, if the patient hears whispered words 3 feet from his ear, and should hear them at 10 feet, the fact may be recorded thus : Whisper j^^. PATHOLOGIC CONDITIONS OF NOSE AND PHARYNX CAUSING DISEASE OF EAR As the result of long-continued chronic nasopharyngeal catarrh the Eustachian tubes and middle ear become affected in a proportion of cases. Especially if the catarrh be of the hypertrophic variety, so that nasal respiration is inter- fered with by the presence of anterior and posterior hyper- trophies, ecchondroses or exostoses from the septum, etc., is disease of the Eustachian tubes prone to result. The same is true of a deflection of the septum sufficiently great to cause marked obstruction of one nostril. In many instances catarrh of the Eustachian tube and middle ear is the result of the extension by continuity of surface of a similar affection of the nasopharynx. However, when one or both nasal chambers are obstructed other causes probably bring about the same result. Posterior to the obstruction, in nearly all cases of nasal stenosis, a partial vacuum is formed during inspiration ; as the result, the nasal mucous membrane is constantly engorged with blood in this locality. This condition may extend back far enough to involve the phar^mgeal mouth of the Eustachian tube. Probably most cases of one-sided deafness on the same side as an obstructed nostril may be explained in this manner. The hearing in such cases frequently improves rapidly after the removal of the nasal stenosis, but a posterior hypertrophy may be so situated as to produce venous stasis in that locality. By far the commonest cause of Eustachian salpingitis, in chil- dren at least, is hypertrophy of the pharyngeal tonsil. When the adenoid overgrowth is situated so as to interfere with the return of blood from the mucous membrane of the Eustachian tubes, stenosis results because of engorgement and inflammation, and the hearing deteriorates more and more as the result of each succeeding attack of coryza. Under such circumstances, if the hypertrophy has not NASAL CONDITIONS CAUSING DISEASE OE EAN 319 existed too Ioiil;', a complete restoration of the liearini; may be expected to follow the removal of a portion of the hypertrophied gland. However, it must not be supposed that by removing the nasal disease which produced the aural affection a complete restoration of the hearing will result in every instance. In most cases of this kind careful treatment of the tubal or middle-ear disease is absolutely necessary. The pharyngeal mouths of the Eustachian tubes, bordered by their cartilaginous lips, appear as crater-shaped eleva- tions in front of Rosenmiiller's fossa. The mucous mem- brane at the entrance of the tube is, in the normal state, paler than that in its vicinity, which is of a deep-red color over the cartilaginous lips. In atrophy of the tube-mouths the mucous membrane covering the lips of the tube is pale in color and the parts appear shrunken. In catarrh of the Eustachian tube the mouth of the tube will sometimes appear dilated by a mass of mucus exuding from it, and under such circumstances the tube-mouth is generally greatly swollen. Patency of Eustachian Tubes. — The methods most com- monly used to test the patency of the Eustachian tubes and introduce air into the middle ear are Valsalva's, PoHt- zer's, and catheterization of the Eustachian tubes. Valsalva's inetJiod consists in a forced expiration, the mouth and nose being closed. In this method air is forced from the pharynx through the Eustachian tubes into the middle ear. If the aurist examines the membrana tympani while the patient inflates the middle ear by Valsalva's method the drum-head will be observed to move outward, and in most instances it will become slightly congested. If an aural stethoscope be used a slight noise will be heard as the air enters the patient's middle ear. The aural stethoscope or aiisc2iltation-tiibe consists of about 3 feet of thin rubber tubing into the ends of which appro- priate ear-pieces are inserted. One ear-piece should be of white bone for the aurist's own ear, and the other end of hard rubber, to be inserted into the auditory canals of his patient's ears. In using the aural stethoscope for the auscultation of the right ear of a patient the aurist should 320 DISEASES OF THE NOSE, THROAT, AND EAR first insert the white end-piece into his own right ear= The patient is then instructed to place the hard-rubber ear-piece loosely in his ear and hold it in position with his thumb and finger. In Poliizer's method the patient is directed to hold a small quantity of water in his mouth until he is told to swallow. The aurist then takes the nose-piece of Politzer's air-bag (Fig. 187) between his thumb and finger and inserts it into one of the patient's nostrils, and closes both nostrils firmly about the nose-piece by pressure with his middle finger and forefinger. The patient is then told to swallow ; as the patient's larynx is seen to rise at the commencement of the act of swallowing the aurist quickly compresses the air- FiG. 186. — Toynbee's auscultation-tube. bag held in his right hand, thus forcing air through the nose and Eustachian tubes into the middle ear. If the auscul- tation-tube is used during this procedure, the air will be heard to enter the middle ear with the same audible click observed when Valsalva's method of inflating the middle ear is employed. During the act of swallowing the soft palate rises, thus cutting off all communication between the posterior nasal chamber and the mouth, and at the same time the Eusta- chian tubes are rendered more patulous by the action of the levator palati and other muscles, so that air forced into the nose by Politzer's method, having no other way of exit, readily finds its way into the middle ear through the tubes. The same thing may be accomplished with greater con- venience by requesting the patient to " puff out his cheeks " PATENCY OF EUSTACHIAN TUBES 321 and compressing the air-bag while the mouth is thus inflated with air. Pronouncing certain syllables, like the words Jiicky hack, /lock, also causes an elevation of the soft palate and a dilatation of the Eustachian tubes, so that the middle ear can readily be inflated by means of Politzer's air-bag. The middle ear of young children is usually more easily inflated by means of Politzer's air-bag than those of adults, while in the case of infants air readily enters the middle ear if Politzer's air-bag be used while the child is crying. No more force should ever be employed in compressing the rubber bag than is abso- lutely necessary to force air into the middle ear, and it is far better for the aurist to make several unsuccessful efforts to accomplish this purpose than to drive air into the middle ear with suf- ficient force to cause pain. While it is probably impos- sible to rupture a normal membrana tympani with Po- litzer's air-bag, yet several cases have been reported in which an atrophied or diseased drum-membrane has been ruptured by the incautious use of this instrument. The Eiisiachian catheter is a tube of rubber or metal curved at its distal extremity, as shown in Fig. 188. The proximal end of the instrument is so constructed that the nozzle of Politzer's air-bag will fit loosely into it, and it is provided with a ring or mark of some sort by wdiich the aurist is informed of the position of the beak of the instru- ment when it has been inserted in the nose. At least three sizes of this catheter should be in possession of the aurist — respectively i, 2, and 3 millimeters in diameter. The hard-rubber catheters have the advantage of cheapness, but they are not so easily disinfected as are the metal ones, 21 Politzer's air-bag. 322 DISEASES OF THE NOSE, THROAT, AND EAR which can be dropped into water and boiled or sterilized by pouring some alcohol over them and setting it on fire. Moreover, the hard-rubber instruments have a diameter larger in proportion to the size of their caHbre than that of the silver catheters. The best catheters are made of pure or, as it sometimes is called, " virgin " (in contradistinction to " coin ") silver, which insures a certain degree of flexibility. The cheap brass, nickel, or silver-plated instruments are clumsy, and are so hard, brittle, and inflexible that the curve of the beak cannot be slightly changed readily, as in the case of the softer pure silver instruments. The distal extremity should be slightly knobbed, smooth, and round. What is known as Hartmann's catheter is probably the best model (Fig. i88). It should be only sufficiently long to project about I inch from the anterior naris when the beak of the instrument is placed in the Eustachian tube-mouth. Fig. i88.— Hartmann's silver Eustachian catheter. In 1724, M. Guyot, a postmaster at Versailles, proposed to treat ear diseases by injections into the Eustachian tube by means of a catheter introduced through the mouth, "for the removal of obstructions in that canal and also the middle ear." In 1 741, Archibald Cleland, an English army surgeon, pubHshed an account of " instruments proposed to remedy some kinds of deafness proceeding from obstructions of the external and internal auditory passages." Cleland recom- mended " lubricating " the Eustachian tube by throwing a little warm water into its pharyngeal orifice through a flexible silver tube introduced through the nose into the Eustachian tube. The proximal end of Cleland's catheter had affixed to it a sheep's ureter, '' whereby warm water may be injected, or they will admit to blow into the Eusta- chian tube and so force the air into the barrel of the ear and dilate the tube sufficiently for the discharge of the excre- mentitious matter that may be lodged there." K US TA cm AN CA THE TER 323 Clcland also used probes or bougies to exi)lore the Eustachian tube through the nose. The use of bougies through the l^^ustachian catheter soon became quite popular and was shamefully abused, according to Wilde, who prac- tically abandoned their use by contenting himself witli in- troducing into the Eustachian tube for a short distance only a decalcified bone bougie, the end of which was made flexible by boiling water. His contemporary, Kramer, a distinguished Berlin aurist, used catgut bougies, which he stated he pushed along the tube in certain cases until the tip was visible between the handle of the malleus and incus. Introduction of the Beak of the Catheter into the Eustachian Tube. — The operator should first inspect the anterior narium and note the position, size, and shape of any obstruction, such as a septal exostosis, which will interfere with the passage of the catheter. The operator should hold the proximal extremity of the catheter between the thumb and fingers of his right hand, somewhat in the manner of a pen- holder, and lift up the tip of the patient's nose with the thumb of his left hand. The beak or distal extremity of the catheter is then inserted within the nares and is made to rest upon the floor of the nose, while the proximal end of the instrument is elevated until it is parallel with the floor of the nose. Still keeping the beak of the instrument in contact with the floor of the nose, the catheter is pushed gently inward until the beak of the instrument is felt to be in contact with the posterior wall of the pharynx. At this stage the operator has the choice of the three methods of procedure in common use. Probably the one most frequently employed is that of Lowenburg, who directs that when the beak of the instru- ment is felt to be in contact with the pharyngeal wall the catheter should be rotated medianly through an angle of 45 degrees, and drawn forward until the beak of the instrument is felt to touch the posterior edge of the septum, when it is rotated outward through rather more than an angle of 90 degrees, and should then be in the mouth of the Eustachian tube. The operator may feel satisfied that this is the case if the beak of the catheter is found to be somewhat firmly fixed in the position it has assumed, so that it is impossible 324 DISEASES OF THE NOSE, THROAT, AND EAR to rotate the beak of the instrument upward or carry it backward or forward without exerting considerable force. Gruber directs that when the beak of the catheter is felt to be in contact with the pharyngeal wall it should be withdrawn until its curved portion comes into contact with the posterior margin of the hard palate. It should then be again pushed inward a distance of about \ inch, and rotated outward toward the ear through an angle of a little more than 45 degrees, when, if these maneuvers have been suc- cessful, the beak of the instrument will be within the mouth of the Eustachian tube. When the beak of the instrument is felt to be in contact with the pharyngeal wall it may be immediately rotated out- ward 45 degrees, which will carry the beak of the instru- ment into Rosenmiiller's fossa. The catheter should now be drawn gently outward until its beak is felt to slip over the posterior lip and into the mouth of the tube. An operator soon learns by the sensation imparted to his hand whether the beak of the instrument is or is not in the Eustachian tube. Obstacles to CatJictcrizatioii of the Eustachian Tubes. — Deviation of the septum may render the passage of a Eustachian catheter through that side of the nose impos- sible. Under such circumstances both Eustachian tubes may be catheterized through the unoccluded nostril. To reach the tube of the opposite side it will be necessary to have the beak of the catheter somewhat longer than that of the instrument shown in Fig. 188. Ecchondroses or exostoses of the septum frequently in- terfere with the easy passage of the catheter through the inferior meatus of the nose. Under such circumstances the beak of the catheter can sometimes be passed over them and made to rest upon the floor of the nose or the soft palate behind. In some such instances a soft-rubber cathe- ter can be used to advantage. In passing the catheter through the nose the instrument should be held very lightly between the thumb and finger, and a tendency to rotate on its long axis should not be resisted, because by allowing the instrument to rotate its beak will sometimes glide around an obstruction and finally find its way into the pharynx. OBS TA CL ES TO CA THE TERI'/A 7 'ION 325 Another obstacle to catheterization of the Eustachian tubes results from spasmodic contraction of the muscles of the palate and pharynx, which tightly grasp the beak of the instrument and interfere with its proper manipulation. Gentleness and patience on the part of the surgeon will generally overcome this difficulty. The patient should be requested to inhale deeply through his nose, to ** swallow," or say " One," and thus produce a temporary relaxation of the parts, which, if repeated from time to time, will gener- ally enable the surgeon to guide the beak of the catheter into the mouth of the Eustachian tube. Fig. 189. — Auscultation of the ear. When the beak of the catheter is felt to be within the mouth of the Eustachian tube it should be held in position with the thumb and forefinger of the left hand and steadied by two fingers resting upon the patient's face (Fig. 189). The nozzle of the air-bag is then fitted loosely into the prox- imal end of the catheter and compressed with the right hand. If the aitsadtation-tiibe be employed at the same time, air will be heard to enter the patient's middle ear with a sound somewhat similar to that produced by inflating the 326 DISEASES OF THE NOSE, THROAT, AND EAR middle ear by Valsalva's or Politzer's method. However, when the catheter is employed the sound seems as if pro- duced nearer the surgeon's ear. The inflation of the middle ear by means of the Eustachian catheter is not altogether devoid of risk. Deaths have been reported. The fatal results in these instances may have resulted from injection of air through a rent in the mucous membrane made by the beak of the catheter, which subse- quently found its way beneath the mucous membrane to a position where the emphysema caused sufficient obstruction to respiration to occasion suffocation. The writer saw 2 cases where young and inexperienced operators had injected a sufficient amount of the air con- tained in a Politzer bag through a Eustachian catheter into the cellular tissue to cause decided swelling of the tissues of the neck. In these 2 cases the patients simply suffered a certain amount of discomfort for a few hours, the air in the tissues being finally absorbed. Solutions may be sprayed through the catheter by means of an ordinary atomizer by inserting the nozzle of the atom- izer into the catheter. Either the compressed-air apparatus or the hand-bulb maybe used to produce the spray. Under ordinary circumstances the spray probably does not pene- trate the tube further than the isthmus, except the patient be told to swallow, when the spray may be heard through the auscultation-tube to enter the tympanum, sounding not unhke drops of rain falling on a tin roof When compressed air is used to produce the spray it should be employed gently and with due caution. The automatic cut-off should be manipulated in such a manner as to throw the spray gently and by successive puffs into the Eustachian-tube orifices. The drip of the solution that condenses in the catheter should, at the completion of the treatment, be blown into the Eustachian tube by means of Politzer's bag. Instead of employing an atomizer, fluid may be inserted within the catheter by an ordinary glass medicine-dropper and thrown into the tube with Politzer's bag, or fluid may be syringed through the catheter into the Eustachian tube, and when the drum-head is perforated, through the Eusta- chian tube and tympanum into the external auditory canal. CArilETEKrAATION OF rilE MWDLE EAR 327 For this purpose syringe a, Fig. 38, with nozzle 7, fitted into an ordinary Eustachian catheter, answers the purpose, or the apparatus of Clevenger (Fig. 190) may l^e employed. When the drum-head is intact fluid enters a narrow Eustachian tube be- yond the isthmus only with great dif- ficulty, having to compress before it the air contained in the middle ear. As soon as the pressure is relaxed the spring or rebound of the com- pressed air generally throws into the pharynx fluid contained in the tube. However, during the act of swallow- ing fluid may be made to penetrate into the cavity of the tympanum through the Eustachian tube even when the drum-head is intact, the muscular action in opening and shut- ting the tube during swallowing doubt- less playing an important role under such circumstances. In this manner sea-water or fresh water introduced into the pharynx while bathing some- times reaches the tympanum and al- most invariably produces an acute otitis media. The writer has observed the sam.e thing occur during the use jof the Birmingham douche or even from sniffing normal salt solution into the nose from the hollow of the hand. The introduction of watery solu- tions, even of the blandest character, is therefore not devoid of risk unless the drum-head is lacking or contains a large perforation. Bland oily fluids, on the other hand, can be sprayed or syringed into the middle ear with impunity. When a watery fluid is used to wash out the Eustachian tube the operator should be careful to inflate the middle ear several times by means of Politzer's method in order Fig. 190. — Clevenger's in- strument for direct medication of Eustachian tube. 328 DISEASES OF THE NOSE, THROAT, AND EAR to remove any excess of fluid that might otherwise re- main. Solutions of protargol, lo to 50 per cent., nitrate of silver, J to I per cent., potassium iodid, i per cent, (in syphilis), raay safely be introduced into the mouth of the Eustachian tube. An Allen's probe (Fig. 35), sufficiently long to extend \ inch beyond the catheter mouth, may be used as an appli- cator by wrapping a few fibers of cotton about its tip and dipping the end of the probe into the solution to be used. After the beak of the catheter is in position the cotton- tipped probe is passed through it and an application of the remedy made to the first \ inch of the Eustachian tube, or the end of a cotton-tipped Allen's probe, after being dipped into any appropriate solution, may be passed like a catheter through the nose into the nasopharynx and the cotton- tipped end inserted into the mouth of the Eustachian tube. Eustachian bougies are occasionally used for the dilation of strictures of the Eustachian tube and other purposes. They are filiform in character and a number of sizes are obtainable, made of whalebone, hard rubber, celluloid, or gold, for electrolysis of stricture. They are inserted into the Eus- tachian tube through a catheter. Great gentleness should be used in passing a Eustachian bougie for the first time through an inflamed tube, for it is easy to penetrate tissue with so small an instrument and make a false passage. The length of the catheter employed should be marked upon the bougie and also the length of the Eustachian tube, which is about I J inches ; and this last mark cannot be passed with- out danger of injury to the tympanic contents or penetrat- ing the drum-head. Not much force is necessary to pass a Eustachian bougie through a normal tube. When a stricture is encountered gentle pressure will usually finally overcome the obstruction, after which the bougie passes readily onward. The most frequent position of stricture is at the isthmus. Before attempting to pass the bougie a few drops of albolene should be inserted in the catheter and blown into the Eustachian tube by means of Politzer's bag. If a stricture is passed the bougie should be allowed to remain DISEASES OE THE EXTERNAL EAR 329 in position for five or ten minutes. After the bougie is with- drawn the middle ear should be gently and cautiously in- flated. If there be reason to suppose that during the pas- sage of the bougie the mucous membrane has been torn, it will be safer to dispense with inflation, lest air penetrate the cellular tissue. Electrolysis of Eustachian strictures has been done by Duel by means of an insulated Eustachian catheter and gold bougies, of which he has designcfl three sizes. The amount of current necessary to overcome an obstruction and promote absorption of a stricture is 3 to 5 milliamperes, which should be turned on as soon as an obstruction is felt and continued for not longer than three to five minutes. The negative pole of the battery is attached to the bougie, the positive held in the patient's hand or applied to the nape of his neck. There is little pain produced by the procedure, which may be repeated at intervals of a week. Inflation should not be practised immediately after the use of the electric bougie, but the patient may return the next day to have his middle ear inflated. DISEASES OF THE EXTERNAL EAR Congenital Defects. — The auricle may be wanting entirely or there may be a plurality of auricles (Fig. 191). The auricle may be abnormal as regards position or shape or it may only be partially developed. Malformations of the auri- cle are generally associated with defects or absence of the external auditory canal (Fig. 192) and sometimes imperfect development of the deeper portions of the auditory appara- tus. A congenital fistula is sometimes seen about the ex- ternal ear and may communicate with the tympanic cavity (Fig. 193). Excessive development or lack of development of the external ear is due to excessive or imperfect develop- ment in the closure of the first branchial cleft during embry- onic life. Various operations have been devised to correct deformities of the auricle and open a way down to the tym- panum in cases of stenosis of the external auditory canal. Plastic operations in this locality do well as regards the healing process. Operations for the correction of atresia or 330 DISEASES OF THE NOSE, THROAT, AND EAR stenosis of the external auditory canal hitherto have not been successful. Othematoma or perichondritis of the auricle (Fig. 194) is generally the result of direct violence — self-inflicted in the Fig. 191. — Supernumerary auricle in the neck {Lancet, 1888). insane, among whom the disease is not uncommon. This affection is characterized by an effusion beneath the peri- chondrium of the auricle, causing swelhng, tension, and pain Fig. 192. — Congenital deformity of the auricle (Sexton). Fig. 193. — Convoluted auricle with congenital fistula (Sexton). in the part. , The effusion may finally escape through an external opening which it has made for itself, remain as a swelling for an indefinite time, or slowly be absorbed. Even DISEASES OF THE EXTERNAL EAR 331 when rcabsorption of the effusion does occur, considerable deformity of the auricle may result (Fig. 195). Trcatnioit. — In the insane, hematoma of the auricle is best let alone, unless the local inflammation is suffi- ciently great to indicate that infection has occurred and that the effusion has become purulent. If necessary inflammation should be combated by the application of ichthyol ointment, 20 per cent, in lanolin (adeps lanae hydros us), and progressive effusion by painting the affected Fig. 194. — Medium-sized othematoma of the auricle (Sexton). Fig. 195.— Deformity of the auricle due to othematoma (Sexton). parts with contractile collodion and the use of a press- ure bandage. Absorbent cotton is placed between the auricle and the head and a pad of cotton over the auri- cle, and pressure maintained by means of a roller bandage over the auricle and around the head. The bandage should not be applied with sufficient firmness to cause pain or great discomfort. If, notwithstanding these measures, the collec- tion of fluid beneath the perichondrium increases, the parts should be aspirated with antiseptic precautions — a measure that will probably need repetition from time to time. In cases where the inflammation is great and the effusion be- neath the periosteum is evidently purulent, it is best to lay 332 DISEASES OF THE NOSE, THE OAT, AND EAR the parts freely open, wash out the pus-cavity with subU- mate solution, and pack with iodoform gauze. The incision should be sufficiently free to permit of easy dressing and the ready removal of sloughing cartilage as soon as separated from the living tissue. Fortunately the number of cases where the injury to the auricle is sufficently severe to cause sloughing of even a small portion of the cartilage are com- paratively few. Chronic perichondritis is a chronic inflammation of the cartilage of the auricle observed in boxers and others whose ears are constantly subjected to irritation or slight traumatism. Treatment consists in gentle massage and applications of ichthyol ointment (20 per cent.) at bedtime, with the avoid- ance of the cause of the irritation. Incised and punctured wounds after thorough cleansing should be sutured in such a manner as to leave as httle scar as possible upon the lateral surface of the auricle. In contused and lacerated wounds perichondritis almost invari- ably occurs, and it is well to anticipate such an attack by the application of a wet bichlorid dressing for twelve to twenty-four hours. An attempt should be made to save as much tissue as possible and no part which possibly may have sufficient vitality to live should be removed. As a primary measure but few sutures should be used, as after the circulation has been thoroughly established it is ordinarily a simple matter to secure more perfect coaptation of the parts and prevent deformity. The sutures should not be passed through the cartilage unless absolutely neces- sary, although no great harm usually results from a suture through the cartilage of the auricle. Fracture of the base of the skull involving the temporal bone may extend into the auditory canal in some cases without rupture of the membrana tympani. Hemorrhage from the ear may be somewhat profuse or scanty. In addition to the general treatment the ear should be thor- oughly cleansed of clots by gentle syringing with a warm bichlorid solution (i : 1000), dried, and covered with pow- dered boric acid, except where oozing persists, when the auditory canal should be very lightly packed with sterile DISEASES OE THE EXTERNAL EAR 333 iodoform gauze. The ear should be gently cleansed once a day with the bichlorid solution and packed with gauze as long as oozing persists ; after which the parts are best kept as dry as possible by cleansing when necessary with bi- chlorid solution, thoroughly drying the parts, and insufflat- ing powdered boric acid. A light plug of iodoform gauze may be loosely inserted into the concha for a few days. Boric acid in sufficient quantity to cover the w^ound is apparently sufficient to prevent infection. Packing the canal maintains a warm and moist condition of the w^ound that should be avoided. Cleft lobule, which is generally the result of the tear- ing out of an earring, is common and may be uemedied by the following operation : The sides of the cleft are freshened in the same manner as for a hare-lip operation ; but, to avoid as far as possible the formation of a con- spicuous scar, the sutures should be introduced and tied on the inner side of the lobule, and should involve only the deeper layers of the skin of its outer surface. After the parts have been accurately adjusted and the sutures tied, the wound should receive further support by the application of iodoform collodion. If the operation be done under antiseptic precautions it is generally successful. Keloid of the auricle, orio-inatino; in the scar resulting from piercing the ear for earrings, is not uncommon, espe- cially in the negro. The growth consists of a hard nodule of fibrous tissue, generally tender on pressure. If large it should be removed by the knife. There is a tendency for the grow^th to recur. Encouraging results have been reported from the application of the .f-ray in cases where the growth has recurred after removal by the knife. CUTANEOUS DISEASES OF THE AURICLE The cutaneous diseases w^hich sometimes attack the auricle are hyperemia, frost-bite, burns, eczema, dermatitis, comedo, erysipelas, syphiloderma, herpes, lupus, and im- petigo contagiosa. Hyperemia may be either active or passive, transient or chronic in character. There is an increase in the blood 334 I^ISEASES OF THE NOSE, THROAT, AND EAR supply of the auricle and generally of the canal, so that the skin appears redder than normal and feels hot to the patient. Mild cases are due to some transient vasomotor disturbance that usually soon passes away without treat- ment. In some individuals a single comparatively small dose of quinin, salicyHc acid, or chlorid of calcium will produce hyperemia of the auricle and canal that may per- sist for some time. Active hyperemia of the auricle may result from exposure to cold, sunburn, or other irritants. Passive hyperemia of the auricle and canal are sometimes present as the result of gout, valvular disease of the heart, or any organic disease capable of producing localized blood stasis. Treatment. — The best local application is probably liquor plumbi subacetatis, which may be painted on the parts once or twice a day. Nervous cases will need building up ; the gouty, a correction of the constitutional dyscrasia. Dermatitis is an inflammation of the skin generally result- ing from some injury, such as the bite of an insect, a blow, fall, stab, wound, etc. The symptoms vary from slight inflammation of the skin at the point of injury to localized gangrene. Treatment. — This varies with the severity of the inflam- mation and the character of the infection. Mild cases do well by simply painting with liquor plumbi acetatis. The severer cases require a wet dressing of bichlorid of mercury, as in infected wounds of other parts oi the body. The dermatitis following the sting of insects is treated by a wet dressing of 20 per cent, bicarbonate of sodium. Frost-bite. — In cold climates frost-bite of the auricle is by no means uncommon. At first the auricle is cold and numb and sometimes stiff, as if actually frozen solid. Later on the symptoms are those of traumatism, involving only the skin or the skin and deeper structures. The skin is hot and swollen, frequently excoriated or covered by vesicles. In the severer cases the symptoms are those of perichondritis, followed sometimes by cartilaginous necrosis and the formation of sinuses upon either surface of the auricle. Treatment. — When the auricle is frozen its temperature DISEASES OE THE EXTERNAL EAR 335 should be restored gradually by gentle friction with snow or pounded ice, and afterward by gentle manipulation with the fingers. If only the skin is involved by the subsequent inflammation satisfactory results will follow the application of a 10 percent, ichthyol ointment in vaselin, which should be applied sufficiently often to keep the parts constantly covered and protected by the ointment. In some cases pain and soreness are greatly relieved by wrapping the auricle in absorbent cotton after using the ointment and applying gentle pressure by means of a bandage. When perichon- dritis follows frost-bite of the auricle it should be treated in the manner already described. When sinuses have formed, they should be laid open, the necrosed tissues removed, and the wounds allowed to heal by granulation. If care is taken to keep the parts properly supported but little deformity sometimes results. Burns. — The auricle is liable to burns, sometimes severe, and involving not only the surrounding neck and scalp but also the auditory canal. A common cause of slight burn of the auricle sufficient to raise a blister is hot appli- cations for the relief of the pain of otitis media. TrcaUncnt. — Pain is best relieved by the local use of cold, applied either in the form of an ice-bag or napkins wrung out of ice-water. The application of cold should be con- tinued as long as it affords relief Charred and dead tissue, if the burn is a severe one, should be at once removed, and the parts cleansed from soot and dirt by means of copious washings with a solution of bicarbonate of sodium. The parts are then dusted with orthoform or smeared wath a 3 per cent, carbolized petro- leum, a bandage applied, and over this an ice-bag is placed as long as the cold seems necessary for the relief of pain. Excessive pain not quickly relieved by these measures will require a hypodermic of morphin. When the skin is unbroken the best dressing is the so- called carron oil (equal parts of linseed oil and lime-water). This is smeared thickly on patent lint and applied to parts after they have been cleansed with bicarbonate of sodium solution. Herpes. — Herpes of the auricle is similar to the disease 336 DISEASES OF THE NOSE, THROAT, AND EAR when it occurs upon the skin in other locahties. It is characterized by vesicles filled with a clear serum, appearing singly or in groups, upon the helix or about the lobule. The surrounding skin is reddened, slightly swollen, and tender to the touch. There may be slight fever, pain, and itching of the auricle. The affection is due to some nervous disturbance. The vesicles ordinarily dry up and disappear by the end of ten days or two weeks. Treatment, — The milder cases are best treated by gentle purgation with citrate of magnesia or one of the other saHnes. The vesicles should be painted three or four times a day with camphorated tincture of opium (paregoric). This application seems to allay the slight itching and burn^ ing better than most others and hastens absorption. Should the contents of the vesicles become purulent the vesicles should be opened and the parts washed with bichlorid solution and dusted with powdered calomel. Impetigo contagiosa is an acute contagious disease of the skin sometimes encountered upon the skin of the auricle or nose in dispensary practice. It begins as small discrete or confluent vesicles, which rupture and leave a granular surface resembling closely a vaccination sore. It is contagious, but no characteristic organism has as yet been isolated. Recovery usually occurs within a week under antiseptic treatment. Treatment consists in keeping the parts clean by washing with bichlorid solution and applying either powdered cal- omel or an ointment of ammoniated mercury. Lupus vulgaris is a chronic tuberculosis of the skin of the auricle, either primary or extending to the auricle from the skin of the face. The disease begins as a tubercle deep in the skin. The dull reddish tubercles are sometimes years in developing, but finally break down into a characteristic ulceration which may heal at one extremity while it is spreading in another direction. The disease is exceedingly chronic and years may go before a large portion of the auricle is involved. After healing has occurred the auricle is shriveled, shrunken, and deformed. Diagnosis. — The diagnosis is usually made by the appear- ance of the ulcer and the history of extreme chronicity. DISEASES OF THE EXTERNAL EAR 337 The disease might be mistaken for cither sypliihs or epithe- Homa, but each is much more ra[)id in its course. Treatment. — The internal medication consists in the admin- istration of cod-Hver oil and arsenic. The local treatment consists in a thorough cureting of the ulceration and the application of the solid stick of nitreite of silver. This should be followed by cautious applications of the ;i'-ray for ten minutes every other day. Syphilis. — Primary sypliilis of the auricle is naturally rare, but the auricle may become inoculated by a bite or other cause. Chancre of the auricle differs in nowise from the primary lesion elsewhere upon the skin. It is an ulcer with indurated edges and a hard base generally conforming to the papular type. The lymphatics of the neclc are swollen. Secondary sypliilis of the auricle is generally part of a syphiloderm involving more or less of the whole body. Tertiary syphilis of the auricle consists of a gumma either before or during the stage of ulceration. Diagm^sis of the primary lesion is sometimes difficult unless there is the history of a bite or injury by a syphilitic individual. The diagnosis in the secondary stage is usually easy. In the tertiary stage, however, an ulcerating gumma may be mistaken for either lupus or epithelioma, and it will usually be necessary to administer iodid of potassium in increasincT doses before comino" to a definite conclusion. Treatiueiit. — The constitutional treatment differs in nowise from that of syphilis of the nose, pharynx, or laiynx already described. Congoiital syphilis is usually of the tertiary variety. Its treatment differs in no respect from the acquired disease. The writer remembers only i case observ^ed by him, that of an infant about eight months old, with an ulcerating gumma of the meatus. The external orifice of the meatus was nearly occluded by exuberant granulations, which were snared away and the parts kept clean and dusted with cal- omel powder. The internal treatment consisted of gray powder and inunctions of mercury. The infant made a good recovery. Erysipelas is the result of infection of the skin with the 22 338 DISEASES QE THE NOSE, THROAT, AND EAR streptococcus erysipelatosa of Fehleisen. It is presumed to only invade the skin through some traumatism, possibly so minute as to be overlooked. The writer saw in consul- tation 2 cases that had their origin in a blister produced by painting the mastoid process with cantharidal collodion. In both these cases, occurring in old men, the erysipelas ex- tended to the scalp ; in one with a fatal result. Er}'sipelas of the auricle may extend along the canal and involve the drum-head. Symptoms are those of erysipelas in other localities. The disease is usually ushered in by a chill and high temperature. There is headache and anorexia. The infected area is red and swollen and the swelling and red- ness somewhat rapidly spreads until sometimes the entire auricle is involved and the disease has attacked adjacent skin areas. Vesicles filled with serum may or may not appear. Treatment. — The patient, if in a hospital, should be isolated from other surgical cases. It is well to begin treatment with a calomel purge (-1-gr. every hour until i^gr. hav^e been taken), followed by a bottle of the solution of citrate of magnesia. As soon as the bowels have acted freely the patient should take 20 drops of the tincture of the chlorid of iron every two or three hours and 3^ gr. of strychnin every four hours. It is said that some cases can be aborted by painting the infected and adjacent skin area with carbolic acid, which is allowed to remain until it has blanched the skin surface. The excess of acid is then washed off with alcohol. Most of the writer's cases have been treated locally by applica- tions of 20 per cent, ichthyol in lanolin, which was smeared thickly on patent lint and applied to the parts. The treat- ment is effective, but somewhat dirty. Those cases of facial erysipelas seen in the Philadelphia Hospital during his terms of service there were treated locally by applications of patent Hnt kept moist with a 10 per cent, solution of protargol. Apparently one treatment was about as effective in con- trolling the local symptoms as the other. Phlegmonous erysipelas is a severe form of erysipelas involving the deeper structures beneath the skin with the formation of abscesses. It is generally the result of mixed DISEASES OE THE EXTERNAL EAR 339 infection, the streptococcus eiysipelatosa and the strepto- coccus or staphylococcus pyogenes being found in the dis- charges. The symptoms are those of severe crysipehis — high fever, redness, pain, and great swelHng of the auricle, with forma- tion of pus and exfoliation of cartilage. Trcatmoit. — The auricle should be covered with a dressing kept constantly wet with bichlorid solution (i : 1000). As soon as the presence of pus is suspected the parts should be freely incised down to the cartilage. The wound should be syringed daily with a bichlorid solution and, if necessary, packed with gauze in such a manner as to secure perfect drainage. Gangrene is, in modern times, an extremely rare disease, but is said to occur occasionally either in the moist or dry form. Treatment. — This is similar to that of phlegmonous er- ysipelas. Iron and strychnin should be given internally. The parts should be kept covered with a wet bichlorid dressing and every effort made to secure asepsis. Necrotic tissue should be removed as soon as possible. Localized pain can be controlled by dusting with iodoform and, when this is ineffective, with orthoform. The disease is very contagious, at least to other surgical cases. Therefore the patient should be carefully quaran- tined and all dressings, towels, etc., used about the case destroyed. Eczema is by far the commonest of the skin diseases affect- ing the auricle. It may also involve the auditory canal and even the dermoid layer of the membrana tympani. Intertrigo resulting from the invasion by the disease of the fissure formed by the junction of the auricle with the mastoid region is of frequent occurrence in infants and young children. Treatment. — In adults the disease is sometimes the result of the rheumatic or gouty diathesis, and, in addition to local treatment, such cases require the administration of alkaHes, with iodid of potassium, salicylate of sodium, or arsenic. In children the disease is frequently associated with struma, and for such cases cod-liver oil or syrup of 340 DISEASES OF THE NOSE, THROAT, AND EAR the iodid of iron should be prescribed. Eczema intertrigo is best treated by the frequent application of powders, and oxid of zinc or subnitrate of bismuth may be prescribed for this purpose. The commonest cause of eczema of the auricle in children is an irritating discharge from the middle ear. In the ne- glected infants of the poor the discharges resulting from purulent inflammation of the tympanum are frequently smeared by the fingers of the child over the entire auricle and over the skin in front of and behind the ear. Under Fig. 196. — Dermoid of the auricle and nevus of the palpebral conjunctiva (after Lannelongue). Fig. 197. — Cartilaginous tumor in front of the left ear of a newborn infant (Friih- wald). such circumstances the auricle and surrounding skin be- come covered by eczematous scabs and crusts. These the surgeon should carefully remove by means of pledgets of cotton saturated with peroxid of hydrogen, and rub well into the affected parts an ointment consisting of 6 or 8 gr. of the yellow oxid of mercury to I ounce of petrolatum. A single thorough application of this remedy is sometimes sufficient to bring about great improvement, even in cases in which the disease has existed for several months. Per- fect cleanliness in all cases should be enjoined, and if fre- DISEASES OF THE EXTERNAL EAR 34 1 qucnt cleansinf^ of the auditory canal with absorbent cotton, followed by insufflations of powdered boric acid, is not sufficient to keep the concha dry and free from the discharge, the skin of this part of the ear should be protected by some bland ointment. Ik^nzoated zinc ointment, if frcsJi and properly made, answers very well for this purpose. The new growths that occur on the auricle are sebaceous cyst, fibroid tumor, epithelioma, nevus, sarcoma, and cornu cutaneum. The treatment is the same as if the new growths occurred elsewhere. Nevi in suitable cases should be treated by electrolysis. The other growths ordinarily require excision. DISEASES OF THE EXTERNAL AUDITORY CANAL The more common affections of the external auditory canal are acute circumscribed inflammation or furunculosis, acute and chronic diffuse inflammation, diphtheritic inflam- mation, hyperostosis, exostosis, and foreign bodies. Furuncle or Acute Circumscribed Inflammation. — Recurrent attacks of furunculosis of the auditory canal seem, in many instances, to be the result of irritation from carious teeth or from disease of the interior of the nose and throat. The affection is commonest in gouty or anemic and debilitated individuals and in women suffering from menstrual disorders. Pathology.- — In most instances the starting-point of the disease is a sebaceous gland or a ceruminous follicle, which has become inoculated with the staphylococcus pyogenes aureus or other pus-forming bacteria by scratching the ear with a dirty finger-nail, hairpin, match-stick, etc. Metastatic abscess in the canal is said to sometimes occur in gonor- rhea. The inflammation usually soon becomes a circum- scribed perichondritis or periostitis of the auditory canal. The pathology of acute circumscribed inflammation of the external auditory canal is similar to that of boils and felons occurring elsewhere on the body. Symptoms. ^ThQVQ is at first an itching within the canal, a portion of which is found tender to the touch, and soon becomes painful. Little by little the pain and tenderness increase, until in some instances the patient's sufferings 342 DISEASES OF THE NOSE, THROAT, AND EAR become almost unendurable. In severe cases the pain, which at first was confined to the ear, extends to the whole side of the head, is throbbing in character, and is increased by movements of the jaw in talking, eating, etc. There is some elevation of temperature in the severest cases. Deaf- ness is not a marked symptom until the swelling is large enough to close the canal at the part involved, but tinnitus is present in the majority of cases. The furuncle will rup- ture spontaneously in from two to eight days, according as the inflammation is superficial or deep seated. The dis- charge is purulent, sometimes quite profuse ; and its appear- ance is speedily followed by a subsidence of acute pain ; the parts, however, remain sore for several days. A " core." or small slough of the skin, as in boils elsewhere, usually exfoliates before the parts heal. Treatment. — Speedy relief generally follows a free incision through the swollen parts down to the cartilage or bone, even though no pus be found. The incision should be followed by syringing the canal with hot boric acid solution, the insertion into the canal of a cone of absorbent cotton covered with a lo per cent, ointment of cocain in lanolin, and the application of heat. In cases where incision is not advisable a cone of cotton should be well covered with an ointment of the yellow oxid of mercury (6 gr. to i ounce of vaselin), and so placed within the canal that it will exert pressure upon the swollen parts. For a few moments this procedure increases the pain somewhat, but it is followed by a feeling of decided relief and comfort. The ointment is rubbed into the skin of the canal by each movement of the jaw in talking and eating, and if the treatment is applied early enough many cases of furunculosis of the auditory canal may be aborted before suppuration has occurred. Cotton cones are readily made by selecting a piece of absorbent cotton about 2 inches long and about f inch wide. The two ends of the piece of cotton are then frayed out until the center of the cotton is thicker than the edges. The cotton is then folded through its central thick portion, so that the thin edges are brought together and a wedge is thus formed, one edge being very thick and the other thin. This wedge is now DISEASES OF 11 IE EXTERNAL EAR 343 vvrapjXid somewhat firmly about the end of an Allen's ear probe (Fii^. 199), the thick edge of the cotton wedge toward the handle of the instrument in such a manner that the thin edge of the cotton wedge forms the pointed end of the cone. Th.c cone thus made should be firmly enough wrapped about the probe to be smooth and taper evenly Fig. 198. — Method of wrapping cotton about the end of an Allen's probe to form a brush for cleansing the canal, applying pigments, etc. from apex to base. When made it is coated thickly with the appropriate ointment and inserted gently into the canal until its wedge-like pressure begins to cause pain. The probe is then dislodged from the cone by turning it in the opposite direction to that in which the cotton was wrapped about it and steadying the cone with a touch of the left Fig. 199. — Method of wrapping cotton about the end of an Allen's probe so as to form a cone for applying pressure within the auditory canal. A piece of absorbent cotton is frayed out to thin edges, folded through the center (dotted line a), and wrapped about the end of the probe. forefinger so that the cone is not withdrawn from the canal with the probe. If after a "few moments the pressure of the cone instead of affording relief causes increased pain, the patient can withdraw it slightly and after an interval again push it more deeply into the canal. Some relief from pain follows the application of a 10 per cent, ointment of cocain in lanolin or a i per cent, ointment 344 DISEASES OF THE NOSE, THROAT, AND EAR of atropin. Heat, however, generally gives speedy relief from pain. It may be applied by gently syringing the canal with hot water, by the application of a poultice, or by resting the head upon a hot-water bag or a bag of hot salt or of hops. In severe cases it is advisable to secure a free evacuation of the bowels by means of small, frequently repeated doses of calomel and bicarbonate of sodium ; I -drop doses of tincture of aconite-root, repeated every hour, will control to a certain extent fever and pain. In all cases the cause of the attack should carefully be sought and measures adopted to prevent a recurrence. To prevent inoculation of other parts of the canal and producing a so-called crop of boils, the canal should be carefully cleansed either by syringing gently each day with a warm i : looo bichlorid solution or by simply wiping out the pus with absorbent cotton and afterward sterilizing the skin of the canal by painting it with nitrate of silver solution (3j to fsj of w^ater). Otitis Externa Diffusa Acuta. — Diffuse inflammation of the auditory canal varies in character from a simple erythema of the skin of the auditory canal to severe periostitis. The disease usually attacks the osseous portion of the canal, but it may extend to the auricle, and, by periosteal conti- nuity, to the periauricular and mastoid regions, causing abscess and necrosis. Etiology. — The disease usually occurs in persons w^hose general health is impaired. It is sometimes consecutive to an attack of otitis media acuta or it may be caused by an irritating discharge from the middle ear. The affection, which usually begins in the skin or cellular tissue, may extend to the periosteum and bone. Symptoms. — The symptoms are similar to those of fu- runcle of the auditory canal, except that the pain is usually more intense and appears at an earlier stage of the disease, while deafness and tinnitus are more marked and long con- tinued. On inspection the tissues of the auditory canal appear red and swollen. The swelling is usually greatest in the bony portion of the canal, where it may be so great as to completely obliterate the canal and prevent a view of the drum-head from being obtained. Generally the skin is DISEASES OE 71/ E EXTEA'NAL EAR 345 excoriated lit points where the innaniination is greatest, and usually there is desquamation and a slight watery dis- charge. Treatment. — Incision of the swollen tissues is rarely necessary unless an abscess has formed. Pain can generally be alleviated very much, if the case is seen early, by the application of a large leech to the skin in front of the tip of the mastoid, as closely as possible beneath the audi- tory canal. A leech also may be applied in front of the tragus and one on the mastoid, as close to the canal as possible. In many cases it will be necessary to prescribe morphin to completely control the pain and secure sleep; but Jicat, applied in the manner already described, will be all that is necessary in the majority of instances. The canal should be cleansed and carefully dried with absorbent cotton and the parts painted with a 60-gr. solution of nitrate of silver and dusted with powdered calomel. This should be done every day as long as the symptoms are acute, and afterward, as the disease subsides, at longer intervals. In using an insoluble powder like calomel within the canal care should be exercised not to more than lightly cover the skin and not employ a quantity sufficient to form a hard crust, which by its pressure will cause pain. Otitis externa diffusa chronica occurs in individuals whose health- is impaired, or it may be the result of the gouty or rheumatic diathesis, or the irritation caused by carious teeth, or disease of the nose and throat. The growth of Asper- gillus within the inflamed canal may be a compHcation or a cause of disease. Symptoms. — Patients complain of itching and a sense of heat within the canal. Pain is usually absent, except dur- ing acute exacerbations. Upon inspection the skin of the auditory canal is found to be red and swollen, especially in the deeper portions. The inflammation may be of the eczematous or desquamative type and accompanied by a watery discharge or seborrhea. Treatment. — The cause of the affection should be care- fully sought. Patients of the strumous diathesis or in feeble health will require the administration of cod-liver oil and 346 DISEASES OF THE NOSE, THROAT, AND EAR tonics, and appropriate remedies should be prescribed for those in whom the disease seems to be the result of the rheumatic or gouty diathesis. If carious teeth are present they should receive the attention of a skilful dentist, and any disease of the nose or throat that may be present should be properly treated. The local treatment of chronic diffuse inflammation of the external auditory canal varies according to the stage and variety of the disease present. When the disease is of the eczematous type, all scales and scabs should be removed by means of a pledget of absorbent cotton wrapped about a probe and dipped into a solution of the peroxid of hydrogen and yellow oxid of mercury Fig. 200.— a, Aspergillus glaucus : B, Aspergillus niger ; C, ripe fructiferous head of Asper- gillus niger throwing off spores (Burnett). ointment (Formula 41), well rubbed into the parts. When there is considerable secretion of watery fluid the canal should be dried thoroughly and brushed with a solution of nitrate of silver (60 gr. to I ounce of water) and covered with powdered calomel. Mycosis or otomycosis is an inflammation of the external auditory canal due to the presence of a fungus. Asper- gillus glaucus (Fig. 200, a) and Aspergillus niger (Fig. 200, B, c) are the varieties most frequently met with. The pres- ence of moulds in chronic inflammation of the external auditory canal may be the cause of the inflammation or only a complication of the disease. The symptoms are those of an acute or chronic inflam- DISEASES OF THE EXTERNAL EAR 347 mation of the canal, except that when there is a large mass of mould present filling the fundus of the canal the patient will be deaf from the accumulation. This is usually a pasty, whitish material interspersed with black spots, looking not unlike a wad of wet newspaper. The micro- scope will detect the presence of either or both the Asper- gillus glaucus or niger or some other species of Aspergillus or Mucor. Treatment. — When Aspergillus is present, the canal should be cleansed thoroughly each day with peroxid of hydrogen and an application made of a 60-gr. solution of nitrate of silver or of absolute alcohol. It is essential that the canal should at all times be kept absolutely dry, because nothing more favors the growth of Aspergillus than moisture. Discharges should be absorbed by the applica- tion of powdered boracic acid or a mixture of powdered boracic acid and aristol. Otitis Externa Diphtheritica. — Diphtheritic inflammation of the integument of the external auditory canal is an inflamma- tion characterized by the presence of a pseudomembrane, which when removed leaves a bleeding surface. The pseudo- membrane should contain the Klebs-Lofifler bacillus characteristic of true diphtheria, as other bacteria are capable of causing a pseudomembrane within the auditory canal and upon mucous surfaces. Etiology. — The disease occurs usually as a complication of diphtheria of the throat and middle ear. Primary diph- theria of the walls of the external auditory canal has been observed during epidemics of diphtheria. Symptoms. — In the primary form there are deafness and tinnitus, with pain. The meatus is greatly swollen. The lymphatics at the angle of the jaw are also swollen and tender to the touch. There is usually systemic depression and slight elevation of temperature. Examination discloses the pseudomembrane covering the swollen skin and bathed in discharges, so that the canal is nearly occluded, or, if the disease has occurred in a case where the drum-head has been previously destroyed, only the mucous membrane of the tympanum may be occupied by the diphtheritic mem- brane. 348 DISEASES OF THE NOSE, THROAT, AND EAR The secondary form of the disease sometimes causes de- struction of the membrana tympani and the tympanic con- tents. Occasionally, as in scarlet fever, necrosis of portions of the temporal bone occurs. Treatment. — The canal should be syringed with a warm bichlorid solution (i : looo). The pseudomembrane should then be removed with the forceps and peroxid of hydrogen. After the parts have been cleansed of membrane they are dried with absorbent cotton and painted with a 6o-gr. solution of nitrate of silver in water and covered with a thick coating of boric acid. Pepsin, trypsin, caroid, and other substances will dissolve the pseudomembrane, but their use is not desirable in the ear because the pseudomembrane soon ceases to re-form when the parts are constantly covered by antiseptics. Otitis externa crouposa is an acute inflammation of the external auditory canal characterized by the presence of a pseudomembrane which does not contain the characteristic bacilli of diphtheria. Diagnosis. — The membrane when removed commonly leaves a bleeding surface, as is the case with the pseudo- membrane of diphtheria, because croupous membranes rarely if ever occur except upon a skin not already excoriated. The bacteria are said to be those of a mixed infection, usually streptococcus and staphylococcus. Symptoms. — The symptoms are practically those of diph- theria of the external auditory canal, except that the cer- vical glands are rarely as much swollen and inflam.ed. There is earache, tinnitus, and a greatly swollen meatus, with purulent discharge and, generally, shght fever. Treatment is the same as in diphtheritic otitis. The pseudomembrane is removed with forceps and peroxid. After the parts are dried with absorbent cotton they should be thoroughly painted with a 6o-gr. solution of nitrate of silver and covered with a thick coating of boric acid by means of a reservoir powder-blower. This treatment should be repeated once or twice a day. It is probable that after two or three applications the pseudomembrane will cease to appear, but daily treatment should be persisted in until the skin of the canal has assumed a normal appearance. CD DISEASES OE EIIE EXTERNAL EAR 349 Exostosis and Hyperostosis (Osteomata). — The name " ex- ostosis " was applied formerly to all bony outgrowths within the auditory eanal. At the present time, however, the name is restricted to bony growths at the junction of the carti- laginous and bony portions. Exostoses of the meatus are usually single and pedunculated. Hyperostoses are situated at the inner end of the meatus close up to the membrane, are sessile, and generally multiple (Fig. 201). Both exos- toses and hyperostoses are whitish prominences, firm and hard when touched with a probe. Etiology. — Hyperostoses in most instances are probably congenital, and in all cases their presence and growth are painless, while an exostosis is always preceded by inflammation. V A subperiosteal abscess forms over the mastoid, the pus finding its way into the meatus at the junction of the cartilaginous and bony portions of the canal. The ^'" ^""'--^T^;'!^^. '^^^^^^ mouth of the sinus in this posi- tion becomes occupied by exuberant granulations from the bone, which become converted into bone. Syiuptovis. — Hearing is not impaired unless the bony growth or growths are large enough to entirely block the lumen of the meatus. The smallest opening is sufficient to transmit sound-waves. If, however, such a small opening is occluded by a drop of fluid, or by a few scales of epithe- lium, or by a small mass of cerumen, the hearing at once is grealy impaired. When purulent disease of the middle ear is present the presence of hyperostoses will greatly interfere with drainage and render the disease difficult to cure. Treatment. — If an exostosis is large and attached by a rather small pedicle to the auditory canal, especially if the growth be slightly movable, it can readily be detached by means of a small chisel and extracted wath a pair of forceps. Exostoses of this character should always be removed. Occasionally sessile exostoses are encountered that extend the whole length of the bony canal and encroach upon the position of the drum-head. Under such circumstances it is best to secure additional room for the necessary chiseling 350 DISEASES OF THE NOSE, THROAT, AND EAR by detaching the auricle and cartilaginous canal and pushing it forward out of the way in the same manner as in the radical mastoid operation. The bony canal should be en- larged by the removal of rather more bone than that com- prising the exostosis, in order to provide for cicatricial contraction during the healing process. If the cartilaginous portion of the canal is contracted, it should be slit up and the parts adjusted in position in the same manner as after a radical mastoid or Stacke operation. The more superficial parts of the exostosis are very readily removed by a suitable gouge or chisel ; but when the neighborhood of the drum- head is reached it is well to employ a dental burr if the bone is found to lie closely in contact with the drum-head. Hyperostoses are best let alone, even in those cases in which they encroach upon the canal to such an extent as to decrease greatly its lumen. If from time to time the patient becomes deaf from an accumulation of cerumen between the hyperostoses, this should be picked carefully away by means of an appropriate instrument. The syringe should not be used unless absolutely necessary, because it is often difficult to remove fluid from behind the exostoses after syringing, and it may be the cause of an inflammation of the auditory canal and drum-head exceedingly difficult to control. Where the presence of hyperostoses seriously interferes with proper drainage in cases of purulent otitis an attempt should be made to effect a removal of one or more of the growths by means of a drill propelled by an electric motor. Foreign Bodies. — Animate and inanimate objects, impacted cerumen, and laminated epithelial plugs are found in the auditory canal. Animate objects that may enter the auditory canal are flies and other insects, the larvae of insects, and various moulds. The treatment when the auditory canal is invaded by a growth of Aspergillus, Mucor, or other moulds has already been detailed (p. 347). Insects can generally be removed readily by means of the syringe. The larvae of insects are not usually present unless there be suppuration of the mid- dle ear, but cases have been reported of the presence of maggots within the auditory canal when the drum-head was intact and no suppuration existed. Larvae can be killed DISEASES OE THE EXTERNAL EAR 35 1 with chloroform vapor and then removed by means of the syringe. It is not permissible to drop chloroform into the auditory canal as a blister may result. A part of a drop may be ab- sorbed by a small amount of cotton, which in turn is sur- rounded by sufficient cotton to make the plug fit snugly into the canal. Used in this manner the chloroform evapo- nites from the cotton into the canal, and the vapor produces a sensation of warmth and comfort. However, if, after a few moments, the application becomes painful it indicates that the chloroform vapor has penetrated the auditory canal in too large an amount, and the plug of cotton should be loosened or withdrawn from the canal entirely for a few moments, and then, if necessary, reinserted. Generally the pain caused by the movements of the insects ceases within a few seconds after the use of the chloro- form vapor and the insect may then be removed by syring- ing or, if necessary, with the forceps. In the case of ants, wood-ticks, or other insects that sometimes attach them- selves to the canal or the drumhead by their strong mandi- bles or jaws the death of the insect is not always followed by a release of its hold upon the tissues. Under such cir- cumstances the dead body of the insect can be removed by a pair of forceps. In the case of the wood-tick a portion of the tissue to which it has attached itself may be drawn out with the insect. This is a matter of no great consequence when the insect has attached itself to a portion of the canal ; but irreparable mischief might be done by ill-considered efforts at removal when the insect has attached itself to the drum-head. In cases where, because of the nervousness of the patient or swelling of the canal, it is impossible at once to remove an insect that has been chloroformed, the canal should be filled with fluid vaselin or some other bland oil to prevent the resuscitation of the insect should the amount of chloroform vapor have proved insufficient to have caused its death. Inanimate Objects. — Shoe-buttons, pebbles, glass beads, the ends of lead- and slate-pencils, and other objects are sometimes placed by children within their ears in a spirit of mischief. It is not rare for aurists to find parts of an onion 352 DISEASES OF THE NOSE, THROAT, AND EAR or pieces of cotton that were placed within the auditory canal by patients perhaps months or years before and for- gotten. The writer removed from an old gentleman's ear three little wads of cotton which had been placed there several years before when he was treating himself for what he stated was " a boil in his ear." On one occasion, having demonstrated the removal of a foreign body from the ear of a dispensary patient before a ward class of ten or twelve senior students, the WTiter was requested by one of these students to examine his ear as he thought he had got sand in it while bathing at Atlantic City the previous summer. There was removed not only a small amount of sand but also a cherry stone, shrunken and black from age, which the student stated he dimly remembered having placed in his ear when a child. From the ear of another member of this same class was removed a small wad of cotton which the student stated must have been placed there the winter before. These stories are worth relating, as they illustrate how little annoyance foreign bodies in the ear sometimes cause. On the other hand, impacted cerumen and other foreign bodies are said to have been the cause of persistent cough, nausea, and even epilepsy. As some sensitive patients cough almost continually while their ear is being cleansed and more especially when the floor of the canal at the junc- tion of the cartilaginous and bony portion is rubbed with a probe, while others become faint and nauseated under simi- lar circumstances, it readily is understood how in a neu- rotic or hysteric individual the presence of a foreign body in the ear might be the cause of such unusual s)miptoms. Among the foreign bodies may be classed impacted ceru- men and laminated epithelial plugs. Removal of Foreign Bodies. — Leaves of the onion, wads of cotton, and other soft objects are readily grasped by mouse- toothed forceps and extracted. Hard, round objects, such as shoe-buttons and glass beads, should at first be attacked by means of a syringe. A fine cannula should be placed in such a position that a stream of fluid can be thrown into the auditory canal past the object. If careful syringing in this manner fails to dislodge the foreign body, a delicate DISEASES OF 771 E EXTERNAL EAR 353 hook, made by bending the end of an Allen's probe at a right angle (^hig. 202), should be introduced into the canal between its wall and the object, and an effort made to ro// the object cnitward through the canal. I lard, irregularly shaped bodies that cannot be rolled out with a hook or grasped by the forceps will often tax the ingenuity of the surgeon to effect their removal. In such cases strong cement or glue may be smeared on the outer surface of the foreign body and then a small mass of cotton applied. After a day or two, when the cotton is firmly attached to the foreign bod}', the cotton can be grasped with forceps and the foreign body removed. Efforts at removal of foreign bodies should always be made with extreme gentleness, for fear of injuring the drum- head, and the surgeon should bear in mind that rather than incur the risk of doing so it is preferable to detach the auri- cle from the bony meatus by means of an incision made Fig. 202. — Allen's probe bent to hook cerumen, etc. posterior to the auricle, and turn the auricle and cartilag- inous meatus forward upon the cheek. In children it is generally necessary to give an anesthetic to secure that perfect quiescence of the patient necessary for the delicate and careful manipulation of instruments. In difficult cases it is best not to prolong unsuccessful efforts to remove a foreign body, for often it will remain in the audi- tory canal for years without producing any serious symptoms. In cases where it has been impossible to remove the foreign body at the first sitting, time should be given for the inflam- mation to subside, and after all swelling of the auditory canal has subsided efforts for the extraction of the foreign body will finally prove successful. Seeds and other objects that have swollen by the absorption of w^ater may be dehy- drated and shrunken by the instillation of alcohol. Cases in which the uninitiated, by injudicious and unsuc- cessful efforts to remove a foreign body, have ruptured the drum-membrane and caused acute purulent inflammation 23 354 I^ISEASES OF THE NOSE, THROAT, AND EAR of the middle ear, and in which so much sweUing of the canal has arisen that nothing can be seen, should be treated by frequent syringings with warm water and by the use of a hot-water bag, if necessary, to relieve pain until the inflam- matory symptoms have subsided and the foreign body can be seen. No attempt at its removal should be made until swelling has subsided and the speculum can be used with- out causing pain. Impacted Cerumen. — Subjective Symptoms. — There usu- ally is a sense of fulness and itching, and the patient com- plains that he has suddenly become deaf in one ear without any previous symptoms of inflammation. The explanation of this fact is that so long as there is the smallest conceivable opening through a mass of cerumen it will be sufficient to transmit sound-waves and the hearing will not be greatly impaired. Sometimes a small opening through a mass of cerumen will close from time to time during damp weather and open again when the atmosphere becomes dry. This phenomena may be repeated many times, the patient being deaf only during damp \veather. Even when impacted ceru- men is present in both auditory canals the patient usually be- comes deaf in one ear first. Under such circumstances the larger amount of inpissated cerumen may be removed from the ear in which the hearing is the most nearly perfect ; sometimes after the patient has protested that " there is nothing the matter with that ear." Etiology. — Increased secretion of cerumen is usually the result of disease of the middle ear or of catarrh of the nose and throat. It is rather unusual to find the hearing perfect after the removal of a mass of impacted cerumen. The introduction of irritants within the auditory canal increases the secretion of cerumen. This is true of dusty employments, like coal-mining, stoking, or milling. Under such circumstances the mass of cerumen removed may consist partly of coal-dust or flour introduced into the canal by the dirty fingers of the workman while endeavoring to relieve the irritation of the canal by scratching it. Impactions result from ill- advised efforts to cleanse the canal by inserting into it the screwed-up corner of a towel or the clumsy use of a match- D/SKASKS OF THE EXTERNAL EAR 355 stick or car-spoon. When such articles are used dead epithehal scales and inspissated cerumen are thrust deep into the canal, which, if left to themselves, would have scaled off or exfoliated and dropped out of the canal. Hence the well-known saying that has come down to us from the aurists of half a century or more a[(o, '* An individual should not put into his own ear any instrument smaller than his elbow." Trcatnioit. — If the mass be soft, syrin^^ing with warm water will cpiickly remove it, inspissated cerumen being soluble in water. If, however, the accumulation is very hard and dry and is mixed with a considerable proportion of epithelial scales, the mass may be softened by directing the patient to fill the canal with warm water several times a day before efforts at removing the mass are attempted. This plan is probably advisable for those who have had little experience with the manipulation of instruments within the auditory canal. Although inspissated cerumen is perhaps as readily soluble in water as any other bland fluid except peroxid of hydrogen, olive oil or a mixture of water, glycerin, and bicarbonate of sodium (20 gr. to I ounce) is sometimes prescribed, to be dropped into the ear several times a day, to soften inspissated cerumen before efforts are made to extract the mass by syringing. However, it should be borne in mind that the hearing will be temporarily impaired as the result of dropping any fluid into the auditory canal when it contains a considerable quantity of cerumen, for reasons stated above. After the lapse of a few hours the wax may in rare instances have been increased in bulk sufficiently to cause pressure pain. When the surgeon is sufficiently expert with hook and syringe, it is never necessary to employ any fluid to soften the cerumen, the removal of the hardest and largest specimens being the work of only a few moments. When the impacted cerumen is very hard and firmly fixed w^ithin the auditory canal it is probably best not to attempt to remove it by syringing until the mass has been rendered movable by manipulation with instruments. For this purpose the tip of an Allen steel probe, bent at a right angle (Fig. 202), should be introduced flatwise between the 356 DISEASES OE THE NOSE, THROAT, AND EAR wall of the canal and the cerumen until it has penetrated a short distance, when the hook should be turned into the mass of cerumen and gentle traction exerted. Generally there will be detached a small portion of the impacted cerumen, which can easily be removed from the canal. Proceeding carefully in this manner, it is sometimes possible to remove, even in those cases in which the wall of the canal is very sensitive, the entire mass of impacted cerumen without causing even the slightest pain or congestion of the Fig. 203. — Washing impacted cerumen from canal. Showing how to hold auricle to straighten canal and where to direct the stream of water. drum-head, the procedure being v^astly less disagreeable to the patient than syringing. However, it is best in many instances to desist as soon as the mass of cerumen is felt to be movable and resort to the syringe. The syringe used by dentists to cleanse carious cavities in teeth (Fig. 38, c, with nozzle 8) is an admirable instrument for syringing ceru- men from the ear. The stream of fluid should be thrown be- hind the impacted cerumen through the opening that has been made by an instrument (Fig. 203). One or two syringe- fuls of warm water will probably suffice to remove the greater DISEASES OF THE EXTERNAL EAR 357 portion of the cerumen, after wliicli the auditory canal should carefully be cleansed of any remaininf^ flakes by a dossil of absorbent cotton wrapped about the end of an Allen probe and dipped into a solution of peroxid of hydrogen. A metal ear-spout (Fig. 204'j will be found convenient to receive the fluid from the auditory canal during the syring- ing. It should be borne in mind that .syringing an ear is at best a disagreeable procedure, and that the injection of water either too cold or too hot or with too much force into the auditory canal is usually followed by syncope. The writer once saw in the dispensary a patient drop from the stool on which he was seated as suddenly as if he were shot. A student was attempting to remove impacted cerumen by syringing, and had inadvertently injected cold water into the patient's ear with con- siderable force. Where the quantity of cerumen is so large that it is impossible for the first syringeful to reach the drum-head, it is justifiable to inject with considerable force, but as the tympanum is approached judicious gentleness should be employed. Especially where the drum-head is lacking, syringing the ear may be made absolutely intolerable by want of gentleness and judgment on the part of the operator. Keratosis Obturans or Epithelial Plug.— The name " kera- tosis obturans " was applied by Weeden of St. Petersburg to epithelial lamina impacted within the auditory canal in contradistinction to "cerumenosis obturans " or impacted cerumen. In masses of impacted cerumen there are more or less epithelial laminae. However, the typic laminated epithelial plug consists almost entirely of laminae of epithe- lium packed one about the other. The external end of such a mass is generally covered by inspissated cerumen which, of course, is easily removed by syringing when the laminae of closely packed epithelial scales are exposed to view, looking not unlike a plug of wet chamois skin. It is impossible to remove such an accumulation by syringing. Fig. 204.— Metal ear-spout. 358 DISEASES OF THE NOSE, THROAT, AND EAR It is necessary to effect its removal layer by layer by means of a hook, a curet, or by forceps. A laminated epithelial plug is composed of the horny layer of the cutis of the auditory canal, which accumulates, layer by layer, within the canal as the result of desquamative inflammation. After the removal of a laminated epithelial plug the membrana tympani will probably be found normal in appearance and the hearing be perfect. Usually this is not the case when the collection within the canal consists, of a cholesteato- matous mass. Aural Cholesteatoma. — The name " aural cholesteatoma " is sometimes applied to a true new growth within the tem- poral bone, similar to cholesteatomata found in other bones of the skull. Ordinarily, " cholesteatomatous mass " means an accumulation within the auditory canal and tympanum of a mass consisting of epithelial scales, cholesterin crystals, and inspissated pus, derived by desquamative inflammation from the Hning membrane of the tympanum or mastoid cells. The presence of cholesteatomatous masses usually causes impaired hearing, tinnitus, and sometimes nausea and dizziness. The bony and soft structures often become absorbed as the result of the pressure caused by the accumu- lation of cholesteatomatous material, so that cholestea- tomatous accumulations are sometimes found occupying large cavities — so large, indeed, that in one instance the cavity from which a cholesteatoma was removed involved the greater part of the auditory canal, the whole of the tympanum, and a large part of the mastoid and petrous portion of the temporal bone. Small collections of cholesteatomatous material are com- mon at the upper and posterior portion of the auditory canal in cases in which perforation of Shrapnell's membrane has occurred. The mass often extends into the attic of the tympanum, sometimes into the mastoid antrum. Choles- teatomatous masses are usually not easily detected at the first glance. Sometimes a small mass projecting into the meatus will be the only evidence of the presence of a cho- lesteatoma of considerable size. If, however, the small mass projecting into the canal be removed, other masses DISEASES OE THE EXTERxWAL EAR 359 will bo foiincl, until in sonic instances a cavity of consider- able size will have been emptied of its contents. The beginner in otology should be on the lookout for accumu- lations of this kind and should not consider his otoscopy completed until all visible parts have received the closest scrutiny and been thoroughly cleansed. Etiology. — When the membrana tympani is perforated as the result of disease or operative interference the opening in the drum-head generally promptly closes. If, however, a large pt)rtion of the drum-head is destroyed as the result of long-continued suppuration, the epidermis of the canal proliferates over the margins of the perforation and prevents its being filled by granulations ; so that the perforation tends to become permanent. Furthermore, under certain conditions the epidermis of the canal proliferates over the walls of the cavities of the middle ear, and a greater or lass extent of surface assumes a skin-like character and appearance. The entire tympanum, aditus and antrum, may become epidermized, but generally the epidermis extends but a short distance into the tympanum. When the attic and antrum become epidermized their lining membrane exfoliates as the result of chronic inflam- mation, and epidermic scales unless removed accumulate until the entire cavities become filled, as shown in Figs. 233, 234. Occasionally the presence of a small collection of choles- teatomatous material in the attic will cause a small amount of discharge through a fistula over the drum-head, and this scanty discharge, drying almost as it is secreted, sometimes forms closely adherent casts of the drum-head that might easily be mistaken for the drum-head itself. The removal of such casts from the drum-head is generally followed by considerable improvement in the hearing. Although Toynbee refers to collections of cholesteato- matous material under the name of " pearly or molluscous tumors," and evidently thought that they were derived from the epidermis of the auditory canal, and Hinton, Kupper, and Wendt refer to similar collections derived from the epi- dermis of the drum-head, yet the majority of authors who wrote previous to the last decades taught that cholesteato- 360 DISEASES OF THE NOSE, THROAT, AND EAR mata were due to the retention of the products of inflam- mation of mucous membranes. The fact that cholestea- tomata are not infrequently found within the middle ear when the drum-head is intact and there is no communication between the auditory canal and the cavity containing the mass seemed to favor this view, but it should be borne in mind that perforations of the drum-head may persist for years and finally close. DISEASES OF THE MIDDLE EAR THE MEMBRANA TYMPANI When inspecting those parts of the ear visible by otos- copy the attention of the observer should be particularly directed to the size oi the auditory canal and the condition of its wall. Every little scale of epidermis or mass of ceru- men that can possibly hide an abnormal condition should carefully be removed by means of a cotton-tipped probe. The observer's eye should next seek the umbo or depression near the cen- ter of the drum-head, and the glance should then be directed upward along the handle of the malleus until Shrapnell's membrane is brought into view. This portion of the membrane should receive the most careful scrutiny, an effort being made to discover, if possible, the presence of the so-called foramen of Rivini or anything abnormal in this region. Attention should next be directed to the condition of the anterior and posterior folds, after which the glance of the observer should be directed around the periphery of the drum-head. By ob- serving always this or some other definite plan of examina- tion during otoscopy it will hardly be possible that any abnormal condition of importance will escape observation. Fig. 205. -Foreign-body and polyp forceps (after Hartmann). DISEASES OF Till': MIDDLE KAR 361 Particular attention should be directed to the size, shape, and position of the cone of ligiit, the apparent len<^th and position of the malleus handle, and the dei^ree of promi- nence of the short process; the color, lustre, apparent thickness, curvature, and position of the drum-head; as well as the presence or absence of perforations, cicatrices, chalk deposits, localized spots of atrophy or thickening, polypi, abscesses, exudation-cysts, or other pathologic con- ditions. Changes Occurring in the Curvature of the Membrana Tym- pani. — The membrana may bulge outward as the result of pressure from fluid within the tympanum or there may be a Fig. 206. — Politzer's ear forceps. localized " pointing " of pus at any position on the drum- head. The normal curvature of the drum-membrane depends largely upon the tension of the tensor tympani muscle. It is claimed that the rectractile effect of this muscle is increased after death by rigor mortis and in certain conditions the muscle is constantly contracted during life to an extreme degree. An unduly depressed condition of the membrana tym.- pani also occurs as the result of unequal pneumatic pressure upon its two surfaces, when obstruction of the Eustachian tube interferes with the proper ventilation of the tympanic cavity. Sometimes the retraction of the membrane is quite abrupt at points near the periphery, so that a sort of terrace is formed at that point. Under such circumstances a bright 362 DISEASES OF THE NOSE, THROAT, AND EAR line will be seen at the point where the abrupt change of curvature occurs. Should such an abrupt change of cur- vature occur at the position of the cone of light it will appear as if broken transversely into two parts, that nearest the periphery assuming a crescentic shape. Whenever the membrane is retracted as a whole there is usually some change in the Hght spot. It often loses the triangular form, because of which it has received the name " cone " or " pyramid of light," and becomes narrow, reduced to a mere point, or perhaps entirely disappears. The posterior fold becomes large and prominent when the drum-membrane is greatly retracted and the malleus handle Fig. 207. — Retracted membrane of a girl of ten years, with long-standing nasal and tubal obstruction, showing foreshortening of malleus handle, prominence of the posterior fold, and visibility of the margin of the pocket of von Troelsch as it passes forward to the manubrium. The light spot is short- ened, and beyond it anteriorly are two parallel curvilinear bright lines, marking the edges of abruptly depre.ssed areas of the drum-head, one within the other (Randall). Fig. 208. — Left membrana tympani of a boy of six years, with nasal and tubal ob- struction. Manubrium drawn up almost out of sight, the tip being higher than the short process; behind it the incudostapedial joint is visible, and below and posteriorly the dark niche of the round window is discernible. There is a faint reflection of light near the normal position, and a stronger one on the promontory near the stapes (Randall). foreshortened (Fig. 207) or displaced, usually backward (Fig. 208). The two diagrams (Figs. 209, 210) represent the means by which the apparent shortening of the malleus handle is produced. Myringitis is an inflammation of the membrana tympani, characterized by swellinp;, and sometimes ulceration of the membrana tympani, pain, and tinnitus ; but hearing is not greatly impaired unless the inflammation also involves the entire tympanic cavity. The pain is increased by movements of the jaw, pressure in front of the tragus, or traction upon the auricle ; it is generally shooting rather than throbbing in character. Etiology. — The commonest cause of myringitis is ex- DISEASES OE rilE MIDDLE EAR 36: posurc to cold, especially the direct impact of a cold wind upon the membrana tympani in persons whose auditory meatus is unduly open. It is sometimes the result of direct violence, as, for example, a blow upon the auricle or the impact of a wave in surf-bathin^^. In some cases the etioloL,^y is obscure and the disease seems to be the result of struma or of the rheumatic or gouty diathesis. Symptoms. — Severe pain, shooting in character, tinnitus, and more or less deafness. Upon inspection, if the disease is seen in its earlier stages, the membrane will be found markedly congested at the periphery and behind the malleus handle. Large vessels will be seen in these positions and radiatinir branches will extend from the blood-vessels behind Fig. 209. — Diagram of the normal posi- Fig. 210. — Diagram of a retracted mem- tion of the malleus and membrana tympani. biana tympani, showing the malleus handle The apparent length of the malleus handle drawn backward imtil its tip is in contact to the eye of an observer is represented by with the promontory. Ihe apparent length the distance a-b. of the malleus handle to the eye of an ob- server is represented by the distance a-c, the apparent length of the malleus handle having been "foreshortened" about one- half. the malleus handle to inosculate with those coming from the periphery. The surface of the membrane becomes lus- treless and rough from loosening of its epithelium, and thick and opaque and of a uniform reddish color from infiltration and increased congestion, until all landmarks except the short process of the malleus handle are hidden from view, this too finally disappearing beneath the swelling, the mem- brane being, at this stage of the disease, of a lively red color and apparently either flat or actually convex in form. As the integument in the neighborhood of the drum-head is also congested it is difficult to make out its boundaries, 364 DISEASES OF THE NOSE, THROAT, AND EAR the red and convex membrane appearing not unlike a poly- pus projecting into the canal, for which it has been mistaken. In the course of the disease the epidermis exfoliates, wholly or partly, and there appears ah abundant secretion, which is at first serosanguineous, but later becomes purulent. Exudation-cysts, filled with serum or pus, sometimes appear upon the surface of the drum-head. Pressure with a probe will indent such collections of fluid between the layers of the drum-head and the indentation will remain visible for some time (Fig. 21 1), which is not the case in localized pointings of pus from within the tympanum. If abscesses rupture or are incised, ulcers result, which may either heal or perforate the drum-head. As the inflammation subsides the portion of the membrane at the umbo is the first to resume its normal appearance. The periphery of the drum-head and a triangular portion, whose base includes Shrapnell's membrane and whose apex is at the tip of the malleus handle, re- main red and swollen for some days. Finally the swelling and congestion dis- appear from these parts of the mem- brane, the light spot becomes distinct, , , „ and the drum-head assumes its normal Fig. 211 . — Interlamellar abscesses of right membrana appCaranCC. ;^"Te'pSTatelTy Rclapscs arc not infrequent or an KrarfLrn^twn^and Hcutcattack may assumc the chronic forward (Schwartze). form of thc disCaSC. Treatment. — In acute cases pain may be relieved by the application of leeches and afterward by the use of hot fomentations. When a discharge appears the parts should be thoroughly cleansed by means of a dossil of cotton dipped into peroxid of hydrogen and the membrane should be covered with a thin coating of powdered boric aid. In traumatic cases the pain and con- gestion rapidly subside under i-drop doses of tincture of aconite-root administered every hour. A 4 per cent, solu- tion of cocain should meanwhile also be dropped into the auditory canal sufficiently often to keep the parts moist- ened until the pain subsides. DISEASES OE THE MIDDLE EAR 365 Chronic Myringitis. — Chronic inflammation of the drum- head is practically always present in chronic otorrhea ori<^- inating in the tympanic cavity. In such cases the chronic myringitis is part of the intratympanic inflammation and generally subsides after the discharge has ceased. The per- foration, if not too large, then closes spontaneously or can be made to close by one of the methods described in the section on Perforations of the Membrana Tympani. However, chronic myringitis is occasionally encountered without a history of previous middle-ear otorrhea, and then generally is part of a chronic inflammation involving at least the deeper portion of the auditory canal. Etiology. — Gout, rheumatism, or struma may account for the cases of chronic myringitis when there is no history of a previous otorrhea. Most cases are, however, the heritage of a middle-ear suppuration, and in cases where there is a scanty fetid discharge in the fundus of the canal it is well to inspect the posterior upper quadrant of Shrapnell's mem- brane closely for a fistula leading into the attic before being satisfied that the drum-head is intact. Syniptoins. — The subjective symptoms are a sensation of fulness and itching within the ear. As the drum-head has little to do with the function of hearing, the hearing in these cases is only slightly impaired unless the intratympanic structures are involved. There is sometimes a very scanty fetid discharge. This discharge adheres to the drum-head and collects in small amounts upon the adjacent lower por- tion of the canal. When wiped away with cotton and per- oxid the drum-head is reddened, either as a whole or in spots where the epithelium has exfoliated. Some of these areas mark the position where a minute abscess has rup- tured and may be covered with granulations or minute polypi. In cases where there is no discharge the drum- head lacks lustre and is rough from the loosening of its epithelium. The color of the drum-head varies according to the degree of the inflammation from a dull red to a yel- low or dirty white. It is no longer translucent, but is thick and opaque. The cone of light is absent or small and dis- torted. Prognosis. — The course of the disease is slow. Chalk 366 DISEASES OF THE XOSE, THROAT, AXD EAR deposits and areas of localized thickening or atrophy are not uncommonly seen when the disease has run its course. Treatment. — When chronic myringitis is part of an in- flammation of the other anatomic structures of the tympa- num the treatment is largely that of the intratympanic condition. In cases where there is a discJiarge from the dermic sur- face of an intact drum-head, this should be cleansed care- fully by syringing first with warm water and afterward with sublimate solution. The canal should then be dried thoroughly by means of absorbent cotton wrapped about the end of an Allen's probe and painted with a 60-gr. solu- tion of nitrate of silver. Abscesses, if present on the drum-head, should be evacu- ated and the interior of the abscess touched with nitrate of silver by means of a bead of the salt fused on the end of a probe. Graiudar spots and small polypi upon the drum-head should receive special attention. Where the granulations are small, simply thoroughly applying at intervals of three or four days a 60-gr. solution of silver nitrate is sufficient to bring about a cure. When the granulations are larger and coarser it will be necessary to destroy them with a 50 per cent, solution of chromic acid or by touching them with trichloracetic acid. These applications should be made with care, so that no dip of acid is allowed to flow or spread be- yond the bounds of the granular area. Polypi too small to be removed with a snare should be scraped away from their place of origin on the membrana by means of Buck's sharp curet or removed by means of Hartmann's curet forceps (Fig. 205). In cases where the- granulations on the drum-head are coarse or a small polypus has been removed, the patient should be instructed to drop into his ear 95 per cent, alco- hol (diluted if necessary) every three hours between his visits to the aurist (Formula 49). Nitrate of silver in strong solutions was extensively used by the aurists of half a century ago as an application to the drum-head. Wilde believed that it brought about exfolia- tion of the dermic layer of the membrana and thus dimin- DISEASES OF THE MIDDLE EAR 367 ished its thickness. While these views of this distinguished Dubhn aurist are not exactly in harmony with modern teaching, yet it is probable that the silver oxid deposited upon the dermic layer of the drum-head as the result of applications of nitrate is partly absorbed by the deeper structures, acts as a sedative, and promotes the absorption of inflammatory products. For cases that result from a rheumatic or gouty diathesis, alkalies, with iodid of potassium or salicylate of sodium, should be prescribed, while for cases where the disease re- sults from struma or debility the use of tonics and cod-liver oil and the employment of hygienic measures should be advised. Deposits of chalk (Fig. 218) are usually the result o{ loug- continncd inflaminatioi of the membrana tympani. Their presence does not indicate that the patient has the gouty diathesis. Only when large do they greatly interfere with the acuteness of hearing by stiffening the drum-head and interfering with its vibrations. Rupture of the drum-head may result from the direct impact of a foreign body or from the instruments used in extracting a foreign body. Many cases are the result of the sudden compression of the air in the auditory canal pro- duced by falls or blows upon the ear or the discharge of large cannon when the patient occupies a position near the mouth of the gun, etc. ; and when the membrane is diseased, from the use (abuse) of Politzer's air-douche, Siegle's pneumatic speculum (probably the more dangerous instru- ment), and even from violently blowing the nose. The writer observed a case of this kind in an old lady of about seventy, whose drum-head, aside from the usual senile changes, so far as could be judged by her history and the appearance of the other drum, was normal previous to the accident. Another case was that of a robust young man who attributed his ruptured drum-head to a kiss on his ear. The drum-head may or may not be ruptured in fractures of the base of the skull. Even in such cases, where there is hemorrhage from the meatus, the blood may come through the roof of the canal and the membrana tympani be intact, as in a case observed post mortem by the writer. DISEASES OE THE NOSE, THROAT, AND EAR Injury to the drum-head may result from contrccoup or be explained by the irradiation theory of Aran. One of the writer's cases, a lad of about sixteen years, exhibited rupture of both drum-heads as the result of a blow from a baseball received on the left mastoid. It is stated that gunshot wounds of the mastoid may cause rupture of the drum-head apparently as the result of the jar from the impact of the bullet. However, it should be remarked in this connection that a hard blow from the bare fist on the ear is far less likely to produce rupture of the drum-head than a lighter blow from the palm of the hand or a boxing- glove, the rupture in the latter case resulting from the condensation of air in the canal. _ In rupture of the drum-head resulting from the concussion of cannon shots, burst- ing shells, etc., there is apparently, if one may judge by the stellate scars seen in cases where the victims have escaped with their lives, actually a tearing out of a por- tion of the drum-head, usually just below the tip of the malleus. The subjective symptoms are sudden deaf- FiG. 2i2.-Rupture ncss, tinuitus, vertigo, and hemorrhas^e or ot the antero-inierior t i r ^ half of the drum-head, a scrous dischargc from the ear. caused by a box on r^-i , • ^ ,^ , ,• the ear (after Poiitzer). 1 Hc pvogHosis as rcgaros tuc rcstoration of hearing depends upon the amount of damage done to the other structures of the ear. Most uncomplicated cases recover satisfactorily and speedily, but sometimes purulent inflammation of the middle ear follows as the result of the injury or injudicious treatment. Treatment. — Cleanse the external auditory canal care- fully, so as to remove all blood-clots or other material that might favor the growth of bacteria. Use Politzer's air- douche if necessary to remove blood from the middle ear or little shreds remaining between the edges of the wound to retard union ; apply by means of the powder-blower a thin layer of boric acid upon the drum-head, and let the ear entirely alone until the healing process is complete, un- less pain or the appearance of a purulent discharge renders further interference necessary. diseasp:s of the middle ear 369 Perforation of the membrana tympani sometimes occurs as the result of ulceration from the dermic surface of the drum-head during an attack of acute myrini^itis. Under such circumstances the ulcer is usually central. The com- monest cause, however, of perforation of the membrane is ulceration from within, the result of otitis media puru- lenta. Syniptcmis. — Examination by means of the concave mirror and speculum usually discloses the presence of the perfora- tionj which, if large, is readily seen. In most cases inflation of the middle ear by the Politzer method produces a char- acteristic " perforation whistle," readily heard by means of the auscultation-tube (Fig. 189). Indeed, the perforation whistle is often so loud that it can be heard at a distance of many feet from the patient. If suppuration of the middle ear is present pus will es- cape through the perforation in the form of bubbles during inflation. The subjective symptoms vary according to the size and position of the perforation and other dis- eased conditions of the ear that may be present. A perforation of Shrapnell's membrane (Fig. 2 1 3), when it has been present for some time, is usually accompanied by considerable hardness of hearing, because purulent inflammation of the attic, the commonest cause of perforation in Shrapnell's membrane, generally involves the articulations of the ossicles and produces lesions which greatly impair the acuteness of hearing. When the perforation is near the center of Shrap- nell's membrane the neck of the malleus is exposed, while perforation through the anterior portion of the drum-head, being directly over the tympanic extremity of the Eustachian tube, yields a loud perforation whistle. Rivini has described a perforation or foramen existing in the membrana flac- cida as a normal condition. Although such a " foramen " 24 Fig. 213. — Right memlirana tympani of a boy of five years, with constant discharge for three years. A perforation about 1.5 mm. in diameter is with difficulty seen above the short process, and intratympanic injections bring away epithelial flakes and masses of fetid secretion. The rest of the membrane is slightly opaque, thickened, and injected (Ran- dall). 370 DISEASES OF THE NOSE, THROAT, AND EAR is frequently seen just above the short process, it is be- Heved by most aurists to be pathologic. When a large perforation in the membrana vibrans in- volves a considerable part of the malleus handle the tip of this process is usually destroyed by necrosis ; should, how- ever, the malleus handle become attached to the promontory this does not occur. Large perforations may exist in the membrana vibrans without the hearing being greatly im- paired, unless the perforation be so placed as to impair the support that the membrana normally gives to the ossicles. Prognosis. — Perforations of considerable size permit free access of dust, cold, moisture, an'd other irritants into the tympanic cavity, and predispose the patient to recurring Fig. 215. — Inflation of the middle ear forces the delicate cicatrix out like a bubble into the meatus, where it seems larger than the opening- and hides its edges and the handle of the malleus. In a few minutes the distended sac loses its tension and be- comes plicated as it collapses, soon to re- sume its old position in contact with the inner tympanic wall (Randall). Fig. 214.— a large rounded loss of sub- stance of the membrana tympani below reaches up to the tip of the manubrium, which projects slightly into the upper mar- gin. It is closed by a delicate cicatrix applied to the promontory and molded upon its inequalities. The edges of the de- pression are sharp cut and overhang, so that the area seems an unclosed perforation (Randall). attacks of otitis media. Sometimes the perforation grad- ually becomes closed by cicatricial material. Indeed, nearly the whole drum-head may be replaced in this manner. But, although the tympanic cavity is by this means protected from cold or dust-laden air, the acutencss of hearing is generally more or less impaired if the surface of cicatricial tissue be large, and such cicatricial areas break down readily during attacks of acute catarrh of the middle ear. When seen by reflected light cicatricial areas generally appear somewhat depressed below the level of the rest of the drum-head, and they are .Sometimes so transparent that the structures within the tympanum are readily discernible DISEASES OE 77 /E Mli)7)I.E EAR 3/1 through them (Fig. 214). If rarefaction of the air within the auditory canal is produced by Sieglc's pneumatic spec- ulum, a cicatrice will be seen to move farther outward than the rest of the membrane. When large and very thin and lax, a " ballooning " of the cicatrice results from inflating the middle ear by means of Politzer's air-douche (iMg. 215). Treatment. — When all discharge has ceased from the tympanum an effort should be made to close the perforation in order to prevent the irritating effects of dust and cold upon the exposed intratympanic mucous membrane. Closing of the perforation, when small, can be brought about by rubbing its edge from time to time with a few fibers of absorbent cotton wrapped about the end of an Allen probe and saturated with fuming nitric acid. The acid destroys the epidermal scales or cells which otherwise would extend from the external or dermal surface of the drum-head and prevent the growth of granulations. By keeping the edge of the opening in the drum-head *' raw " — that is, free from epidermis — by means of the acid, the granulations finally unite in the center of the perforation, which then becomes closed. The same thing can usually be accomplished by the method devised by Blake, which consists in placing a little disk of writing-paper over the perforation. A disk of sufficient size to cover the opening is cut from ordinary writing-paper and is soaked for a few moments in corrosive sublimate solution (i : 5000). It is then placed on the end of a cotton-tipped Allen probe and carried through a speculum to the drum-head over the perforation. It adheres somewhat firmly to the edge of the perforation because of the sizing or glue which all writing- paper contains. The paper disk acts as a stimulant and support to the granulations springing from the edge of the perforation, so that they finally unite in the center and the opening is closed. It is somewhat instructive to note from week to week the changing position of the disk of paper. Roughly speaking, the epidermal scales grow from the center of the drum- head toward its periphery, and thence outward along the canal, and hence the disk of paper which was placed over the perforation in the drum-head within a few weeks is 372 DISEASES OF THE NOSE, THROAT, AND EAR seen to be upon the wall of the canal. If, in the meanwhile, the perforation in the drum-head has not closed, another disk of paper should be placed over it, and so on until the perforation has closed. ^!y^ When a perforation is so large that the support of the tympanic membrane to the ossicles is destroyed the chain of small bones tends to sag outward by its own weight, and the acuteness of hearing is considerably impaired. If the Toynbee ^^^^ artificial membrana tym- pani (Fig. 216) be so placed as to give the requisite amount of sup- port when this condition exists, considerable im- provement of the acute- ness of hearing will re- sult ; but little disks of paper, linen, silk, or com- pressed cotton answer a still better purpose, and a thread may be passed through the center of such a disk to facilitate its removal from the auditory canal. Gruber has contrived an apparatus (Fig. 217) for the introduction of such artificial drum-mem- branes by the patient himself, who, after □ a little preliminary instruction, can usu- ally introduce one in a manner to secure the crreatest increase of the hearing- power Fig. 216. — Toynbee's artificial drum-head. Fig. 217. — Contrivance for introducing artificial drums (Gruber). It is astonishing how tolerant the ear sometimes becomes to the presence of such objects, which can often be used for a long time without any deleterious results. It is not a matter of indiffer- ence as to the material employed in the manufacture of the artificial drum- heads. Some patients hear best with disks made from one material, some with those made from another. Fig. 218. — Calcareous deposits in the drum- head after middle-ear in- flammation (Spalding). DISEASES OE THE MIDDLE EAR 373 When a large cicatrix is present which bulges greatly after inflation — /. c, is very freely movable — the hearing can often be improved greatly by the application of a small quantity of contractile collodion (Formula 88). The collo- dion is best applied by means of a small camels'-hair brush after the inflation of the tympanum. The application of collodion should not be repeated at too frequent intervals or too much applied at one time, because pain and myrin- gitis may result. DISEASES OF THE TYMPANUM Otitis Media Catarrhalis Acuta. — Acute catarrhal inflam- mation of the middle ear is an acute inflammation of the mucous membrane of the tympanum, Eustachian tube, and, sometimes, of the mastoid cells, characterized by increased secretion of serum or mucus, but not of pus. Clinically, cases of acute catarrh of the middle ear are divided into two classes: One in which the attic of the tympanum and mastoid antrum are involved by the diseased process ; the other, in which the disease is confined to the Eustachian tube and atrium of the tympanum. Synonyms. — According to the character of the secretions the names applied are otitis media serosa acuta, otitis media mucosa acuta, and otitis media non-purulenta; according to the parts principally involved in the diseased process : Otitis media catarrhalis ex tubae, otitis media catarrhalis cum ostltide mastoidae, acute Eustachian salpingitis, etc. Etiology. — The disease is in almost all instances the result of exposure to cold. Chronic catarrhal affections of the upper respiratory tract render many individuals susceptible to recurring attacks of inflammation of the middle ear, while in many instances carious teeth have the same effect. Very often pain commences as a toothache, which pain ex- tends to the ear. In many cases the disease is the result of surf-bathing or of diving into water from a considerable height. In cases where acute catarrh results from diving and surf- bathing the direct impact of water upon the drum-head produces sufficient traumatism to cause the disease. A large auditory meatus, a cicatricial drum-head, or a perfo- 374 JO)ISEASES OF THE NOSE, THROAT, AND EAR rated drum render the middle ear more liable to traumatism while bathing, and such individuals should never dive or bathe in the rough surf without stopping the ears with ab- sorbent cotton saturated with vaselin to exclude the water. All amphibious animals have valves which exclude water from the auditory canal during the time the animal is under water and hunting dogs taught to dive sooner or later be- come deaf However, it is not always the forcible entrance of even cold water into the auditory canal that is responsi- ble for an attack of acute aural catarrh. Not infrequently in surf-bathing a wave will strike a bather in the face at a time when he is swallowing or performing some other func- tion that opens the Eustachian tubes, and under such cir- cumstances the water sometimes penetrates as far as the tympanum, and if not speedily removed is capable of caus- ing acute intratympanic inflammation. An accident of this kind once occurred to the writer and was accompanied by a certain amount of vertigo and syncope, and it seems not improbable that some cases of drowning may be the result of the entrance of water into the ears during surf-bathing or swimming in rough water. Occasionally fluid used as a nose-wash penetrates the Eustachian tubes and occasions acute tympanic catarrh or even suppuration, although the wash may be as bland and unirritating to the nasal mucous membrane as the normal salt solution. Bland oils may be thrown into the Eustachian tube with impunity, but watery solutions frequentl}^ cause mischief. The use of such contrivances for cleansing- the nasal mucous membrane as Thudicum's douche, the Ber- mingham douche, etc., are by no means as safe as an atom- izer, and acute catarrh of the middle ear has resulted from simply sniffing normal salt solution into the nose and blow- ing the nose forcibly immediately afterward, so that some of the fluid reached the tympanum. Should water reach the tympanum during bathing or a watery nose-wash be inad- vertently injected into the middle ear while cleansing the nose, PoHtzer's or Valsalva's method of inflation immediately should be employed sufficiently often to free the middle ear from the fluid. The exanthematous fevers, and occasionally typhoid and n/sKAs/'.s o/-- yy/A' a///)/)/./-: ear 375 tuberculosis, operations in the [)()sterior portion of the nares, in the postnasal space, and even upon the t(j»nsils occasion- ally cause acute otitis. PatJiolooy, — The affection in most cases be^i^ins as a catarrh of the pharyngeal orifices of the Eustachian tubes, accom- panying- similar disease of the nose and nasopharynx. If the pharyngeal orifice of the luistachian tubes is inspected by means of the rhinoscope at the beginning of an attack the mucous membrane of the tube-mouths will be found so congested and swollen as to either completely close the tubes or at least greatly interfere with the proper ventilation of the middle ear. Later on the secretions from the tubes are abundant, becoming more consistent in most instances as the disease advances, so that a bulb of thick glue-like mucus may project from the orifices of the Eustachian tubes into the pharynx. The mucous follicles are sometimes swollen, giving a granular appearance to the tube-lips. The appearance of the membrana tympani varies some- what at the commencement of the disease. Generally it is pinkish in color, as the result of the congestion of the inner or mucous layer, and the manubrial plexus of blood-vessels is congested. Often the membrana is more dull and opaque than it is normally. Often a line as fine as a hair, extending across the drum-head, indicates the upper level of the fluid within the tympanum (Fig. 219). If the fluid within the tympanum is thin and mobile, it will be seen to alter its position with the movements of the patient or during the use of the pneumatic speculum. By inflating the middle ear by the Politzer method the fluid can sometimes be broken into foam and the dim outlines of minute air-bubbles dis- cerned through the drum-head (Fig. 220). The bacteria found in the secretion varies. However, there is practically never a mixed infection. The staphylo- coccus and the pneumococcus of Friedlander probably are the forms most commonly present. The prognosis under appropriate treatment is favorable. Most cases completely recover. In neglected cases, how- ever, the disease often assumes the purulent form or re- lapses into the chronic condition. Symptoms. — Generally there is pain, increased by move- 376 DISEASES OF THE NOSE, THROAT, AND EAR ments of the jaw, pressure over the tragus, or gently pulling the auricle outward. Hardness of hearing will be greater than in simple myringitis, if, indeed, myringitis ever occurs without the inflammation involving, to a certain extent, the entire mucous membrane of the middle ear. There will be present tinnitus and perhaps vertigo. The appearance of the membrane varies according to the amount of myringitis present. It may bulge outward at certain spots from the pressure of fluid within the tympanum or the entire mem- brane may be flattened or even bulging as the result of the pressure of fluid within the tympanum. The color of the membrane may be nearly normal in appearance. There may be more or less congestion about the periphery or the Fig. 219. — Collection of fluid exudate in the lower part of the tympanum, m'arked by a glistening line across the membrane. From the right ear of a young man in the middle of an acute coryza. Cure by Polit- zerization (Politzer). Fig. 220. — Foamy secretion in the tympa- num after inflation, in a case of serous accumulation. From a patient with acute nasopharyngeal catarrh (Politzer). region of the malleus handle. In the later stages of the disease, if rupture of the drum-head be delayed, the swell- ing of the drum-head is so great that the outline of the malleus handle is lost to view and the drum-head is not distinguishable by color from the surrounding red and swollen skin of the canal. Treatment. — In most cases of acute catarrh of the middle ear, if seen early, it is advisable to prescribe J gr. of cal- omel combined with 5 gr. of the bicarbonate of sodium, to be taken every hour for six hours, for the double purpose of securing free evacuation of the bowels and the alterative effects of the calomel, as it has been maintained that small, frequently repeated doses of calomel have the power of controlling inflammation of mucous membranes. \ DISEASES OF 77 /E MID DEE EAR 377 The pain is often relieved by the use o( leeches. It is cus- tomary, in cases where there is severe pain, to apply at least three leeches, one in front of the tragus, one on the mas- toid as close to the auricle as possible, and one just beneath the auricle in the angle between the jaw and mastoid proc- ess. These points are selected because they are the posi- tions where the circulation of the middle ear is most readily depleted. The leeches should be the largest procurable and the wounds should be encouraged to bleed for a time after their removal. A half-century ago leeches were much more freely used in the treatment of acute aural catarrh than at present. Some writers of this period recommend that as many as ten leeches be applied to the margin of the auditory canal in relays ; that is, as fast as one leech filled and dropped off a fresh leech was applied as nearly as possible to the same spot. It is certainly true that in order to relieve the pain of acute catarrh of the middle ear or myringitis the blood-let- ting should be somewhat free and that little relief will follow the use of less than three leeches. The use of leeches in the hyperemic stage of acute otitis media when the pain is severe will not only relieve the pain but also will often cut short the progess of the inflammation. After the use of leeches hot applications should be made to the ear. This can be done by filling the auditory canal with hot water and afterward applying a hot flaxseed poultice over the auricle, but in most cases pain is more quickly and completely re- lieved by the instillation of anodynes into the ear and the application of djy heat. The patient may lie with the affected ear upon a hot-water bag or a bag of hot salt, and i or more drops of a 4 per cent, solution of cocain be placed within the auditory canal from time to time. In some cases, however, a combination of morphin and atropin (Formula 31) seems to act better as an anodyne than cocain. A hypodermic tablet of atropin and morphin maybe dissolved in a few drops of warm water and dropped into the ear. It is best to use a certain amount of caution in the use of powerful narcotic poisons within the auditory canal, as cases of poisoning have been reported. It is a safe rule never to drop into the auditory canal a larger 3/8 DISEASES OF THE NOSE, THRO AT, AND EAR amount of atropin or morphin than can safely be adminis- tered by the stomach. It should be borne in mind in using anodynes within the ear that when the mucous membrane of the middle ear is exposed watery solutions are more readily absorbed than oily solutions or ointments, but that the contrary is the case when the drum-head is intact and absorption must take place through the surface of the skin ; also that inflamed surfaces, whether of skin or mucous membrane, absorb anodynes much more slowly than when no inflammation is present. A 3 per cent, solution of cocain painted upon the exposed mucous membrane of the middle ear quickly reHeves the pain of tympanic neuralgia, and more slowly that of active inflammation, but w^here the drum-head is intact a lo per cent, ointment of cocain and lanohn will give greater relief from pain than a watery solution. However, in either the relief from pain is somewhat tardy if considerable inflam- mation be present. When fluid is present within the tympanum an attempt should be made to evacuate it by the use of the Politzcr air- douche. The nose and nasopharynx should first be cleansed by the spray from an atomizer containing an alkaline solu- tion (Formulas i to lo) and a piece of absorbent cotton, saturated with a 4 per cent, solution of cocain, inserted with- in each nasal chamber. After contraction of the turbinated bodies has been secured, the nasal chambers and the vault of the pharynx should be sprayed with a 4 per cent, solu- tion of antipyrin to maintain the effects of the cocain for several hours and relieve congestion of the pharyngeal lips of the Eustachian tubes. The Politzer air-bag should now be filled with the vapor of menthol-chloroform and used with no more force than is necessary to free the tube and middle ear from mucus. This treatment should be repeated once or twice a day, omitting the use of the cocain and anti- pyrin if the nasopharyngeal mucous membrane be not suffi- ciently swollen to require it. If, notwithstanding antiphlogistic and other measures, there is bulging of the tympanic membrane, with indications that a perforation is likely to occur, it should be punctured by a paracentesis needle at the most prominent point of bulg- DISEASES OE 7 HE MIDDLE EAR 379 ing or in the posterior inferior quadrant. This operation is harmless if antiseptic precautions be observed. The canal should be cleansed by wiping it out with a pledget of cotton wrapped about an Allen probe saturated with peroxid of hydrogen. It should then be syringed gently with warm corrosive sublimate solution (i : 2000). After being steril- ized a knife (Fig. 229, c or/) should be thrust through the membrane. If the malleus handle is not invisible as the result of swelling, the operator should make the puncture on a level with the tip of the malleus handle and midway between it and the periphary of the drum-head, and cut downward as far as possible while the knife is being with- drawn. If this technic is observed it will tend to avoid puncturing the bulb of the jugular vein, which in some cases lies immediately beneath the mucous membrane of the floor of the tympanum, without an intervening lamina of bone. Should the vein accidentally be punctured the hemorrhage for a moment may be quite free, but is readily controlled by packing the canal with iodoform gauze. Puncturing a normal drum-head after the parts have been cocainized is not a very painful procedure, but when inflamed, paracentesis causes severe pain even after the fundus of the canal has been soaked in a 4 per cent, solution of cocain for ten or fifteen minutes. Therefore, if the operation is per- formed without a general anesthetic, it should be done with the utmost quickness. The thrusting of the knife through the drum-head is sometimes followed by the escape of air with an audible hiss. At other times there is an escape of fluid which quickly fills the entire canal, but in some cases there is little fluid secreted for some hours after the opera- tion. The canal in either case should be stopped with a loose plug of sterile iodoform gauze, which should be changed as often as it becomes saturated by secretions. The relief from pain occurs in some cases within a few moments after the operation. In other cases an hour or more elapses before the pain begins to subside. There are but few if any cases where no relief from pain is afforded by the operation. Otitis Media Catarrhalis Subacuta. — The name is some- times applied to that stage of catarrhal disease intermediate 380 DISEASES OE THE NOSE, THROAT, AND EAR between the acute and chronic forms. However, by stib- acute catarrh of the middle ear or simple acute otitis media is generally meant an inflammation less severe in type than the acute. Pain is neither severe nor long continued and the patient is deaf only for a short time. The attacks occur at frequent intervals. Upon examination the membrana tympani is found pinkish in color and is decidedly opaque and lacks its usual lustre. The cone of light is either smaller than normal or has entirely disappeared. As the drum- head never ruptures, permitting an examination of exudates, the kind of bacteria present is a matter of conjecture. It is doubtful if any be present, as, according to Hassleur and Preysing, no bacteria are present in the normal middle ear. Etiology. — The disease is commonest in children as the result of disease of the nose and pharynx, hypertrophied pharyngeal tonsil being an exceedingly common cause of the affection, Bad nutrition, carious teeth, and frequent attacks of coryza are common predisposing causes. The treatment should be directed toward improving the patient's general health and removing any predisposing cause of the affection. If the teeth are carious they should receive the attention of a skilful dentist, while the efforts of the aurist should be carefully directed toward the removal of any morbid condition existing in the nose and nasopharynx, because experience has amply demonstrated that in most cases attacks of subacute aural catarrh cease to recur as soon as a cure is brought about of the concomitant naso- pharyngeal disease. The knowledge of this fact, however, is not an excuse for neglecting local treatment of the ears while the nose and nasopharynx are receiving attention. Adenoid growths and hypertrophied faucial tonsils should be reduced in size, the former by means of Gottstein's curet and the latter by the tonsillotome or by ignipuncture in the manner already described. At each biweekly or triweekly visit of the patient the nose and nasopharynx should be cleansed by means of an atom- izer filled with an alkaline antiseptic wash (Formula i or 2), after which the ears should be carefully inflated by means of Politzer's air-bag. If the inflammation of the middle ear is not too active, *' massage " should be applied to the drum- \ DISEASES OF THE iM I J) J) J.I': EAR 38 1 head and the ossicles by the aid of Siei^le's pneumatic specu- lum, after which there should be made to the interior of the nose and nasopharynx an application of an iodin solution (Formula 33) in the case of children, or an astringent solu- tion (Formulas 34, 35) in the case of adults, and the parts covered with albolene by means of the spray from an atom- izer. The hygienic surroundings of the patient should receive careful attention and tonics and cod-liver oil prescribed in suitable cases. In children catarrhal inflammation is gener- ally of an adenoid character ; that is, the lymphatic elements of the mucous membrane bear the brunt of the disease, so that children and young adults do well upon iodin compounds applied locally and given internally. Syrup of the iodid of iron should be prescribed for internal use, with or without cod-hver oil, as the circumstances of the case require, while hypertrophy of the lymphatic glands underneath the skin of the neck should be treated by inunctions at bedtime of a 10 per cent, ointment of ichthyol in lanolin. The ointment should be rubbed lightly into the skin and the bedclothing protected by waxed paper and a bandage about the child's neck. Catarrh in adults is often characterized by inflammation o( the mucous glands and interstitial elements of the mucous membrane ; and it is in such cases that sedative applications and astringents are most useful. The vapors of various volatile substances are sometimes applied to the middle ear by means of Politzer's air-bag. The most useful of these substances are iodin, menthol, and chloroform. Glass- stoppered bottles, each partly filled with one of these drugs (Formulas 90-93), should be at hand in the office, so that the Politzer air-bag can readily be filled with the vapor of the drug which it is desired to use by inserting the nose-piece of the instrument within the neck of the bottle. The vapor can then be made to reach the mucous mem- brane of the middle ear by Politzer's method or by the employment of a Eustachian catheter. The vapor of iodin, when thrown into the middle ear, acts as an alterative and gentle stimulant, that of menthol as a sedative, while chloro- form vapor is probably simply a stimulant. It is generally 382 DISEASES OE THE NOSE, THROAT, AND EAR easier to inflate the middle ear when the air-bag is filled with chloroform vapor than when it contains simply air. Otitis Media Catarrhalis Chronica. — Chronic catarrh of the middle ear is a chronic non-suppurative inflammation of the mucous membrane and submucous tissues of the middle ear, producing deafness, tinnitus, and sometimes vertigo and other symptoms of altered auditory functions. There are two varieties of the disease — the hyperplastic and the atrophic — which are simply stages of the same disease. Synonyms. — According to its stage, the disease is some- times known as moist and dry catarrh, hypertrophic and atrophic, catarrhal, and proliferous inflammation of the middle ear. Pathology. — Gradual progressive changes take place in the mucous membrane and submucous tissues of the middle ear, similar in character to those that occur in the mucous mem- branes of other parts of the body, and analogous to cirrhosis of the liver, kidneys, or lungs and sclerosis of the brain and spinal cord. There is first hyperemia and hypertrophy, then hyperplasia and, finally, sclerosis. The first stage of the disease is a dilatation and engorge- ment of the capillaries, with an exudation of serum and round cells, both from the surface of the mucous membrane and also into its substance. The capillaries are engorged, the mucous membrane is swollen and edematous ; an exudate is con- stantly moistening its surface. The inflammatory exudate within the substance of the mucous membrane contains rounds cells, w^hich proliferate and increase in size by a proc- ess of elongation, so that they are finally converted into newly formed connective tissue, sometimes causing cords, bands, and membranes similar in appearance to cicatricial tissue following suppuration. During the earlier stages of the disease the thickened mucous membrane is redder and rougher than normal, soft, and easily depressed with the end of a probe. As a result, however, of the gradual increase of connective tissue and the absorption of the more fluid parts of the exudate, the mucous rnembrane, while still much thicker than normal, is pale and quite smooth. This condition represents a stage intermediate between hypertrophy and atrophy of the tym- DISEASES OE THE MIDDLE EAR 383 panic mucous nicnibranc. It is h)'pcr[)lasia of the mucous membrane. As a mechanical result of the contraction of the newly formed connective tissue the L^landular elements of the mucous membrane disap{)ear and it finally resembles scar- tissue. The mucous membrane becomes smooth, thin, and secretes but little fluid. In some cases atrophy or sclerosis of the mucous membrane of the tympanum rapidly occurs without any pre-existing stages of hypertophy. Such cases are often the result of syphilis or they follow purulent inflam- mation of the mucous membrane with or without perfora- tion of the drum-head. It should not be supposed that the changes in structure above described progress evenly throughout the entire mucous membrane. Often depressed, scar-like spots of atrophy are seen in the midst of the rough, succulent, and swollen mucous membrane characteristic of the hypertrophic stage of chronic aural catarrh. Not only are the mucous and submucous structures involved in long-continued catarrh of the middle ear, but the bony structures are affected as well and, ultimately, the labyrinth also. The cavity of the tympanum becomes more roomy, and as a result of interference with the nutrition o{ the parts chalk deposits take place in the deeper layers of the mu- cous membrane close to the bone, in the membrana tympani, the membrane of the round and oval windows, and in the li"-a- ^'g- 221.— schematic , ., I'll section of a case of at- ments and cartilages connected with the tachment of the manu- ossicles. The ossicles frequently become ["JryTp'-iit'-eo/"^'''"''" ankylosed, and adhesions form which bind them to one another or to the surrounding bony walls of the tympanum, while bands of newly formed connective tissue may extend across the tympanum or mastoid an- trum. The membrana tympani and manubrium sometimes become adherent to the promontory (Fig. 221). Ordinarily, catarrh of the middle ear is but part of a diseased process involving the nose, throat. Eustachian tubes, and mastoid cells. The stage of the disease and the 384 DISEASES OF THE NOSE, THROAT, AND EAR degree of inflammation may vary in the different parts affected. In most instances the Eustachian tube is the first part of the middle ear affected. In some instances the disease progresses by continuity of structure from the pharyngeal mouths of the Eustachian tube into the tympanum ; while in others stenosis of the tube, from swelling of the lining mucous membrane or accumulation of secretions, interferes with the proper ventilation of the tympanum, thus produc- ing a partial vacuum within the cavity, a constant dry cup- ping, as it were, of the tympanic mucous membrane, with consequent engorgement of its capillaries. Etiology. — It is generally the result of an extension of a similar disease of the nasopharynx through the Eustachian tubes. The chronic condition may become established after repeated attacks of acute catarrhal inflammation of the mid- dle ear. Carious teeth cause chronic catarrh of the middle ear as the result of reflex irritation. Syphilis sometimes causes chronic catarrh of the middle ear, but more often suppuration occurs as the result of diphtheria, measles, scarlatina, or typhoid fever. Those constantly exposed to loud noises as the result of working at certain trades, like boiler-making, are especially prone to lose their hearing. Syphilis, scrofula, and any condition of lowered vitality, inherited or acquired, may be enumerated as predisposing causes of the disease. Subjective Symptoms. — There is gradually increasing deaf- ness. The decrease in the power of hearing is, however, by no means uniform. Successive attacks of subacute exacerba- tions of the catarrhal inflammation produce comparatively great impairment of the hearing power, which in turn some- what improves. In this manner the disease progresses, the hearing being better or worse from week to week, but be- coming gradually less impaired from year to year. Many patients hear better during clear, dry weather than on rainy or damp days. This is not the result of any change in the acuteness of hearing, but due simply to the fact that dry, cold air is a better conductor of sound than moist air. The acuteness of hearing may not decrease to the same degree for all sounds. Many patients hear a watch tick at almost the normal distance, but hear spoken words very indistinctly. i DISEASES OE THE MIDDLE EAR 385 In Other cases the impairment of hearing is most manifest for musical tones, Hke those emitted by a tuning-fork. i\ common remark from some patients is that* they hear the sound of the voice distinctly, but are unable to distinguish the words spoken. This slow hearing is probabl}' due to the sluggish action of the tensor tympani and stapedius muscles, whose action changes the tension of the ossicular chain, so that under normal conditions it is instantly tuned to the pitch of each sound. Hence most deaf persons hear words best not when spoken in a loud voice, but when spoken slowly and distinctly. A sense of fulness and discomfort within the ear and cer- tain modifications of the hearing are not uncommon during the course of chronic aural catarrh, the commonest modi- fication of the hearing power X^o^iw^ paracusis Willisii or in- creased hearing power in the midst of noise, as, for example, when the patient is on a moving railroad train. This phenomenon has been ascribed to great rigidity of the ossicles and contraction of the tensor tympani muscle, and it is of sinister import as to the ultimate effects of treatment. Dysacousvia or dysesthesia acoustica is a condition in which loud noises or even those of moderate intensity cause painful sensations. When the patient hears his own voice, somewhat altered in character and pitch, as if it came from a distance or through the tissues of his head, the symptom is called autoplioiiy. Paracusis duplicata and paracusis diplocusis are names given to the phenomenon in which the patient hears sounds as if repeated twice, the second sound seeming somewhat like an echo of the first. Probably in most cases of chronic catarrhal deafness sounds are not only altered in intensity but also in pitch and character as well. It is difficult, however, to observe any subjective alteration in the character or pitch of musical notes, except in the case of musicians who are deaf only in one ear. In such cases not infrequently the note of a tuning-fork will seem to be of a different character and pitch when sounded before the deaf ear from that emitted by the same fork when sounded before the patient's normal ear. When subjective alteration of the character and pitch of sounds is sufficiently 25 386 DISEASES OF THE NOSE, THROAT, AND EAR manifest to be a source of discomfort to the patient the name psciLdacousnia, or false hearing, is appHed. Tinnitus, subjective ringing or hissing sounds heard in the ear, is a symptom of aural catarrh rivalHng in importance even progressive hardness of hearing. It is sometimes the only symptom of which the patient complains, the fact being that, although he is somewhat deaf, yet his hearing is still sufficiently acute for the ordinary purposes of his life and occasions no discomfort. Some such patients are actually surprised when tests of their hearing demonstrate that it is defective. This is especially the case when only one ear is diseased. Tinnitus is usually worse at night and it may not be present at all in some cases during the daytime. It is subject to great variations in degree in some cases of aural catarrh, disappearing for months at a time and then reap- pearing. Usually tinnitus disappears in the later stages of the disease. Involvement of the labyrinth may increase or decrease tinnitus, according as the nerve-fibers are simply irritated or destroyed. Vertigo is a symptom of chronic otitis media, usually transitory in character. In all cases it is probable that aural vertigo is due to some condition within the semicircular canals of the labyrinth : generally it is an alteration of the normal interlabyrinthine pressure produced by increased tension exerted through the fenestrae or by a contracted tensor tympani through a rigid chain of ankylosed ossicles. Only when striLctural changes have occurred to the tissues within the labyrinth should the name " Meniere's disease " be given to a condition which otherwise is simply aural ver- tigo and one of the symptoms of disease of the middle ear. The most important objective symptoms are those revealed by inspection of the membrana tympani, ascertaining the condition of the Eustachian tubes, and testing the hearing by means of the voice, the watch, and tuning-forks. Although the condition of the membrane is not invari- ably an index of the condition of the tympanum, yet certain inferences may be drawn from its appearance that are the more valuable because it is the only visible part of the tym- panum. The lustre and color of the drum-head may be nearly normal both at the commencement of chronic otitis DISEASES OE 77/ E MIDDLE EAR 387 media and also at a stage of the disease when the atrophic changes are not far advanced. In the latter condition, how- ever, the membrane is generally abnormally translucent, so that a red reflex from the promontory is discernible, and also the outlines of the descending process of the incus and the incudostapedial articulation. During the hypertro- phic period of catarrh of the middle ear evidences of in- volvement of the drum-head are usually not lacking. There may be patches of opacity or the whole drum-head may have lost its translucency and appear white, rough, thick, and opaque. The light spot may not occupy its normal position as the result of an indrawing of the drum-head or it may be smaller than normal because of a roughening of its surface, and from the same cause or from local depres- sions it may divide into two or more macular. If the drum- head is greatly depressed a light spot sometimes appears over the short process, which projects outward through the tightly drawn tissues like the knuckle of a finger. The handle of the malleus is, under such circumstances, fore- shortened, appears shorter than normal, or it maybe drawn so far backward as to lie almost horizontal beneath the pos- terior fold. Spaces abnormally white and opaque may be interspersed upon the same membrane with spots abnor- mally thin and translucent. It is always a matter of considerable importance to deter- mine the resiliency and tension of the membrane. This may be effected by observing the movements of the drum through Siegle's pneumatic speculum (Fig. 31) during rare- faction and compression of the air within the auditory canal. When the air within the canal is rarefied by means of this instrument a drum-head so far indrawn that it rests upon the promontory may be sucked outward until it appears like a balloon, a groove upon its convex surface indicating the position of the malleus handle. Sometimes isolated areas upon the drum-head will exhibit abnormal mobility. Ordinarily such spots are cicatrices formed by the closure of a perforation. This appearance may be produced, how- ever, by localized atrophy. Deep localized depressions are found at spots where ad- hesions have occurred between the membrane and promon- 388 DISEASES OF THE NOSE, THROAT, AND EAR tory (Fig. 222), such spots appearing much darker than the surrounding area. Sharply defined deposits of chalk, more especially in the posterior half of the drum-head, are not uncommonly seen (Fig. 218). The patency of the Eustachian tube is tested by the Polit- zer method of inflation. During the earlier stages of the disease the tubes are usually somewhat obstructed, but during the later stage they are abnormally patulous. A favorable prognosis may be given the patient if after infla- tion of the tympanum the hearing is greatly improved. Under such circumstances the impairment of hearing is largely due to obstruction of the Eustachian tubes — a con- dition amenable to treatment. If, however, the tympanum is easily inflated by the Politzer method and there results Fig. 222. — Residua of middle-ear suppuration. Transverse section (schematic), show- ing-adhesions of drum-head to promontory. Front view, showing old cicatricial center lesions (Spalding). considerable outward movement of the membrana tym- pani without much improvement in the hearing, the pros- pect of speedily improving the acuteness of hearing without operative interference is not encouraging. In the hyperemic and hypertrophic stages oi catarrhal deafness hearing for the voice is usually proportionately better than for the watch and tuning-fork ; in the atrophic form of the disease, however, the reverse is usually the case. If only one ear be affected, a vibrating tuning-fork placed on the vertex, forehead, or teeth (Weber's method) is heard best in the affected ear so long as the functions of the audi- tory nerve and labyrinth are unimpaired. When, however, serious involvement of the labyrinth has occurred, tissue- conduction, as tested by Weber's method, will be found DISEASES OF THE MIDDLE EAk 389 greatly diminished or even abrogated upon the affected side. Before involvement of the receptive apparatus has occurred a vibrating tuning-fork with its handle upon the mastoid will be heard better than when its vibrating tines are held in front of the ear (Rinne negative). Rinne's test is posi- tive when the labyrinth is seriously involved, and under such circumstances hearing both by tissue and aerial conduction is more greatly impaired for the higher notes of the musical scale than for the lower notes. The prognosis is only favorable in cases in which the dis- ease has not progressed beyond the early hypertrophic stage of the disease. Fluid exudates will be absorbed as the result of treatment and simple inflammation of the mucous membrane of the tympanum will disappear. The prognosis is all the more favorable if the disease is the result of pathologic conditions within the nose or naso- pharynx, because in such cases, when the nose and throat are restored to a nearly normal condition, chronic aural catarrh of recent origin usually subsides as the result of appropriate local treatment. The progress of the disease can, in most instances, be delayed, but when new connectiv^e tissue has formed it remains and atrophied parts cannot be regenerated. The prognosis is generally hopeless, so far as improvement of the hearing is concerned, in cases in which the labyrinth is seriously involved. However, this may be said for the comfort of those to whom an unfavorable prog- nosis is given : Chronic middle-ear catarrh is, to a con- siderable extent, a self-limited disease that progresses irreg- ularly and with greater or less rapidity to a certain degree of deafness, after which the progress is slow. None be- come completely deaf. Treatment. — An effort should be made to improve the hygienic surroundings of the patient and to so improve his general health as to render him less liable to contract colds. The nose and throat, if necessary, should receive appropriate treatment. Hypertrophies, ecchondroses, and exostoses of the nasal chambers and adenoid vegetations in the pharyn- geal vault should be removed ; hypertrophied faucial tonsils should be reduced to their normal dimensions. While the immediate effect of any measure to secure free nasal 390 DISEASES OF THE NOSE, THROAT, AND EAR respiration may not be apparent in improved hearing, the freedom from frequent stenosis of the nares from colds and consequent irritation of the middle ear will, after a month or two, scarcely fail to attract the patient's attention. Triweekly or even daily inflation of the Eustachian tubes is of great importance. For this purpose Politzer's method, when possible, should be employed in hypertrophic cases. In atrophic cases, however, the irritation produced by the introduction of the Eustachian catheter is sometimes of marked benefit. Either simple air or air saturated with the vapor of chloroform, iodin, menthol, or turpentine may be used for producing the inflation (Formulas 90-93). In cases where the labyrinth is involved Politzer's method of inflation should be used with extreme gentleness if at all. Ordinarily in atrophic cases the Eustachian tubes are widely dilated, and the violent use of Politzer's bag causes a most unpleasant sensation to the patient and an immediate de- crease in the hearing power, which gradually grows worse from repetition of the treatment. Many cases of atrophy not too far advanced are greatly benefited by a spray of menthol and camphor in fluid albo- lene (Formula 17), thrown into the middle ear by means of the Eustachian catheter and atomizer. After introduc- ing the catheter and applying the auscultation-tube the patu- lency of the Eustachian tube is tested by means of Politzer's bag (Fig. 187). The nozzle of an atomizer then is inserted within the proximal extremity of the catheter. In cases where the Eustachian tube is widely dilated the spray from the atomizer will be heard to enter the tympanum ; but in most instances it enters the Eustachian tube for but a short distance except during the act of swallowing by the patient. After a time a certain amount of oil condenses in the catheter and Eustachian tube. This should be blown as far up the tube as possible by means of Politzer's bag. It is convenient to use an air receiver to work the atom- izer in order to secure steadiness of its tip when inserted into the catheter, but with a little care an ordinary hand atom- izer may be employed without inconvenience to the patient. It is doubtful if a large amount of the oil actually enters the tympanum in the majority of instances, and an excessive DISEASES OF THE MIDDLE EAR 39 1 quantity if present would be removed when Politzerization is employed after the use of the atomizer, and hence the method is entirely free from danger. When the Eustachian tube is contracted the oil seems in some instances to act like a Eustachian bougie and secures dilatation. Stricture of the Eustachian tube may be dilated by care- fully passing a Eustachian bougie through the stricture, but the use of this instrument requires the utmiost care to avoid a disastrous or even fatal result from emphysema as the result of tearing the tubal mucous membrane. The diagnosis of stricture of the tube is made by means of the catheter and auscultation-tube. Air is not heard to enter the tympanum. This may be due to simple swelling of the mucous membrane, transient in character, which can be made to yield by blowing a drop or two of a 4 per cent, cocain solution from the catheter into the tube, followed in a few moments by an oily spray of adrenalin (i : 1000) through the catheter. If after a few moments air is heard to enter the middle ear through the catheter, the Eustachian tube may be sprayed with menthol-camphor-albolene in the manner previously described. If, however, these measures fail to secure the entrance of air into the middle ear, employment of the Eustachian bougie is a justifiable procedure. As long as no stricture is encoun- tered the bougie can be passed somewhat readily from the catheter along the Eustachian tube. If resistance is felt it may be due to the normal narrowing of the tube at the isthmus. The bougie should be marked in millimeters in such a manner that it is possible, by referring to these markings, to know the exact position of the distal end of the bougie and when it has entered the isthmus or junction of the cartilaginous and bony portions of the tube. It is not desirable to push the bougie much beyond this portion of the tube. If a stricture is encountered a resistance will be felt to the onward passage of the bougie, which usually can be overcome by gentle pressure for a few moments. After the bougie has passed beyond the stricture it should be allowed to remain in position for a few minutes and then withdrawn. When it is impossible to pass a bougie of hard rubber or 392 DISEASES OF THE NOSE, THROAT, AND EAR whalebone, an attempt may be made to destroy the stricture by electrolysis. Duel has devised gold bougies of three sizes for this purpose, one of which is passed through a rubber-covered catheter into the tube until the stricture is encountered. The sponge from the positive pole of the battery is applied to the patient's neck and the negative pole is connected with the bougie. The current is then gently turned on to a strength not exceeding 3 to 5 milliamperes. The bougie is held firmly in contact with the stricture and after a moment is felt to pass through it. The treatment causes no pain and may be repeated at intervals of once a week. It is safer not to attempt to inflate the middle ear immediately after the passage of a bougie. The patient, however, may return the next day to have his ears inflated. The bougie may be passed into the Eustachian tube after the passage has been oiled with the spray from an atom- izer containing albolene or a few drops of a 50 per cent, solution of argyrol may be dropped into the catheter before passing a hard-rubber bougie through it into the tube. Massage of the Middle Ear. — Next in importance to infla- tion of the middle ear is systematic massage by means of Siegle's pneumatic speculum or some other massage instru- ment (Figs. 31-33), by means of which the air within the auditory canal can alternately be rapidly condensed and rarefied, and motion be thus imparted to the membrana tympani and ossicles. This procedure is almost invariably followed by an ameHoration of tinnitus if this symptom be present, and it probably constitutes the most satisfactory treatment for this annoying symptom, although freezing the tissues over the mastoid process by means of the spray from a tube of ethyl chlorid and exhausting the air within the auditory canal by a plug of oiled absorbent cotton sometimes yield good results. Systematic massage of the middle ear by means of the patient's finger-tips is of the greatest value, for while it is somewhat dangerous to instruct an individual to inflate his middle ears by Valsalva's method, as its frequent use is liable to be followed by atrophy of the drum-head and increased deafness, automassage with the finger-tips is DISEASES OE THE MIDDLE EAR 393 entirely harmless and may be used for the relief of tinnitus whenever it becomes annoying. The forefinger should be slightly moistened and slipped into the meatus with the nail posterior. With rapid piston-like movements of the finger- tip inward and outward a patient can easily exercise alterna- tions of pressure and rarefaction of the air within the audi- tory canal, and hence massage the intratympanum almost as thoroughly as if a pneumatic speculum were used. He maybe instructed to employ the method several times a day with increasing relief of tinnitus in many instances and, generally, improvement of the acuteness of hearing. It is seldom that the method fails to afford at least temporary relief from the feeling of fulness or pressure within the ear. Phono mas sage, by means of sounds conveyed to the ear through rubber tubes from various musical instruments or similar contrivances, has been employed in the treatment of catarrhal deafness and tinnitus. If the ears of an individual with catarrhal deafness be subjected for a length of time to musical tones of about the same pitch as the tinnitus from which he suffers, the subjective noises will either entirely disappear or be greatly alleviated, probably as the result of fatigue of the portion of the internal ear adapted for the perception of sounds of that pitch. This method of treatment has been largely abandoned in favor of more rational methods. Pnannomassagc with, electromagnetic and other machines (Fig. 33) capable of producing rapid alternate rarefaction and condensation of the air in the auditory canal is undoubt- edly of benefit in a large proportion of chronic middle-ear catarrhs, but is probably in no way superior to massage with the pneumatic speculum or the tip of the forefinger. The same remark also applies to direct massage of the chain of ossicles by means of Lucca's pressure probe, which is a spring probe, the cup-shaped end of which fits over the short process of the malleus to prevent slipping ; and also to the so-called " internal massage," where short, sharp puffs of compressed air from an air-receiver are, by means of an ''automatic cut-off" (Fig. 42), rapidly worked wdth the tip of the thumb, thrown through a catheter into the Eustachian tube. 394 DISEASES OF THE NOSE, THROAT, AND EAR The wedging of a little ball of absorbent cotton into the space above the short process of the malleus, where its weight and pressure serve constantly to push outward the malleus handle and the long process of the incus, thus diminishing pressure on the stapes, in a certain number of cases will afford efficient aid in the treatment of tinnitus and hardness of hearing. The Httle mass of cotton should be moistened with a suitable antiseptic solution, so that it can be molded to the parts when inserted above the malleus handle, and may with benefit in certain cases be worn for several weeks at a time. It is not readily dislodged from its position by massage either with the pneumatic speculum or the finger-tip, and sometimes gives immediate and ultimately permanent relief from tinnitus. Tension of the transmitting apparatus of the middle ear may also be decreased by operative procedures, such as repeated paracenteses of the drum-head, tenotomy of the tensor tympani and stapedius, or removal of the membrana tympani and one or more of the ossicles. The liead noises complained of by patients are almost as numerous as the individuals affected, but may be divided into three classes — the pulsating, the continuous, and sounds more or less elaborated, like the ringing of bells, music, and words and sentences uttered with more or less distinctness — the latter class only being referred to a point outside the head. Tinnitus is more often pulsating than patients are willing to admit until the fact is demonstrated to them by placing the hand upon their pulse and beating time to it with a finger. Sometimes the result of anemia or, more rarely, of an aneurysm, pulsating tinnitus ordinarily indicates arterial congestion of the middle ear or of the labyrinth. The differential diagnosis between the two conditions can be made with a limited amount of accuracy by pressure upon the carotids or on the vertebral arteries at the point where they cross the atlas, because a branch of the carotid supplies the tympanum and a branch of the vertebral supplies the labyrinth. The faint pulsating tinnitus due to anemia is diminished by the patient's lying down, and in many instances can be DISEASES OF THE MIDDLE EAR 395 permanently cured by hygienic measures and suitable tonics, among which the well-known pil. sumbul comp. is especially useful. Pulsating tinnitus due to congestion, on the other hand, may be alleviated by the bromids, of which, for a reason that will appear below, dilute hydrobromic acid, in doses of from 15 to 60 drops three times a day, is probably the best. The earlier stage of chronic catarrh of the middle ear is ordinarily accompanied by tinnitus, generally constant in character. Later on, as deafness becomes profound, tinni- tus often disappears as the result of diminished sensibility of the internal ear. Tinnitus due to middle-ear catarrh is sometimes alleviated by large doses of the bromids ; but better results can be obtained in a limited number of cases by the patient taking after meals, for a few weeks, a pill containing \ gr. of nitrate of silver, \ gr. of extract of hyoscyamus, and ^ gr. of strychnin. Inflammation of the external auditory canal, foreign bodies, impacted cerumen, and polypus are capable of pro- ducing tinnitus and, in rare cases, vertigo, nausea, cough, or even epileptiform convulsions. Not always is tinnitus the result of diseases of the ear, but rather is a reflex phenomenon due to the irritation of some correlated region — the nose, teeth, or, more frequently, the digestive tract. Just as acute dyspepsia is ordinarily accompanied by vertigo, so the more chronic ailments of the digestive tract sometimes occasion a tinnitus the cause of which is little suspected. The manner in which disease of the digestive tract, teeth, or nose produces tinnitus is, as pointed out by Woakes, through the nervous connection, more or less direct, of these organs with the inferior cervical sympathetic ganglion, which supplies the nervi vasorum to the occipital artery and its branch, the internal auricular. Irritation of the inferior cervical sympathetic ganglion would cause tinnitus as the result of dilation of the arterioles of the cochlea, which, at first pulsating, would afterward become constant in character as the result of trophic changes resulting from increased blood supply. Quinin, the salicylates, and certain other drugs are capable of producing tinnitus, either as the result of aural hyperemia 39^ DISEASES OE THE NOSE, THROAT, AND EAR or by their toxic action upon the internal ear. There is also reason to suppose that in lithemia the products of indi- gestion exert a similar action in the production of tinnitus. It is, therefore, in cases where dyspepsia and lithemia have done their share in the production of tinnitus that acids, including hydrobromic acid, are especially useful in con- trolling this annoying symptom. Proper regulation of the diet and regular exercise in the open air and sunlight will, in cases where there is neither disease of the ear, nose, nor teeth to account for tinnitus, generally result in a disappear- ance of the head noises. The more elaborate subjective sounds, heard as if pro- duced outside the body — such as the ringing of bells and spoken sentences — are the result of disease of the ear acting on an easily excited brain. Some of the cases are at least on the border-line of insanity, and not only hear voices but see visions, either religious or otherwise in charac- ter. Benefit sometimes results from treating the concom- itant aural disease. Otitis Media Suppurativa Acuta. — Acute purulent inflam- mation of the middle ear is an acute purulent inflammation of the mucous membrane of the tympanum, and usually also of that of the Eustachian tube and mastoid cells. Pathology. — The tympanic mucous membrane is of a bright red color, much swollen, and devoid of its epithelium. There is cellular and serous infiltratiom of its connective- tissue layer and much exudation of mucopus or pus from its surface. Perforation of the membrana tympani occurs in the majority of cases, the pus being then discharged through the perforation into the auditory meatus ; occasion- ally the discharge is tinged with blood. Etiology. — Generally the disease is the result of a cold or of traumatism, or it may occur as a complication during diphtheria, scarlatina, small-pox, measles, typhoid fever, syphilis, or tuberculosis. Purulent inflammation of the mid- dle ear is very common in children. Carious teeth and nasopharyngeal disease are pedisposing causes of the affec- tion. Suppuration presupposes bacterial infection, which probably takes place in most instances by way of the pharynx and Eustachian tube. It is a general rule that the DISEASES OF THE MIDDLE EAR 397 infection at first at least is monobacterial, but that after the niembrana is ruptured polybacterial infection commonly occurs from the canal. Efforts should, of course, be directed to prevent if posssible this mixed infection. The micro- organisms most commonly found in otorrheal pus are strep- tococcus pyogenes, pneumococcus, staphylococcus aureus and albus, typhoid and tubercle bacilli. Of the monobac- terial infections, that of the streptococcus is most likely to run a severe course, possibly ending in severe mastoid complications. Syiriptoiiis. — An attack is ushered in by pain in the ear, shooting over the side of the head. Sometimes the pain originates in a diseased tooth and extends to the ear. Chilly sensations and fever are sometimes present, the temperature reaching as high as 102° or 103° F. The ear feels full and there are tinnitus and deafness, the pressure of confined pus upon the secondary membrane sometimes interfering with the functions of the labyrinth. When perforation takes place there occurs a rapid alleviation of the pain and tinnitus. The appearance of the drum-head is that of acute myringi- tis. At the end of a few hours to several days or even weeks from the beginning of the attack a bulging at some point upon the drum-head indicates the position where the pus will burrow its way through the membrana. When, however, the attic and mastoid antrum contain pus which cannot readily drain into the atrium because of swelling of the mucous membrane about the ossicles, this pus will sometimes burrow underneath the skin of the auditory canal and find an exit either at some point within the canal or behind the auricle. Those cases in which no perforation occurs run a tedious course and some permanent impair- ment of the hearing usually ensues. The duration of the disease from the occurrence of a perforation to its closure is very variable. In cases where the perforation occurs early it may remain open only for a few days. Three or four weeks are ordinarily required for the closure of a small perforation. If the perforation is large it will probably remain open long after suppuration has ceased, to finally close by cicatri- cial material destitute of all fibers of the membrana propria. 398 DISEASES OF THE NOSE, THROAT, AND EAR and will bulge inward and outward with the varying inter- tympanic pressure. Extensive destruction of the structures of the middle ear sometimes occurs during acute otitis media. This is espe- cially apt to take place when the disease appears as a compli- cation of scarlatina, variola, or diphtheria. The whole of the drum-membrane and all of the ossicles may come away within a few days from the onset of the middle-ear disease as an enormous slough. In other cases ulceration, starting from the perforation, proceeds more slowly, but it accom- plishes equally disastrous results. Inflammation of the mastoid is occasionally a serious complication of acute otitis media, and the labyrinth sometimes participates in the purulent inflammation of the tympanic cavity, the ultimate result in such cases being intracranial compHcations, often fatal. Infants affected by acute suppuration cry constantly, turning their heads restlessly from side to side, placing the hand frequently upon the affected ear. High temperature, reaching 103° or 104° F,, is usually present and convulsions sometimes occur. The infant sleeps only when completely exhausted or under the influence of opiates. Upon inspec- tion the drum-head is often found enormously swollen, pro- jecting into the canal like a polypus, for which it has been mistaken. Sleeplessness, high temperature, and restlessness quickly disappear after evacuation of the pus. The prognosis of acute purulent inflammation of the mid- dle ear, when it occurs in an otherwise healthy individual, is usually favorable, but the severity of the attack depends largely on the variety of bacteria causing the infection and their virulence. However, the disease frequently assumes the chronic form, and in tuberculous individuals this is the usual outcome of the affection. Treatment. — In the early stages of the disease leeches, hot applications, and the other measures for the relief of pain already specified are useful for the relief of pain in catarrhal inflammation of the middle ear. Paracentesis of the mem- brane should be done as soon as bulging occurs. The cut should be 2 or 3 millimeters long and should be made through the point at which the bulging occurs or at the so- DISEASES OE THE MIDDLE EAR 399 called point of election in the posterior quadrant of the mem- brana tympani, midway between the malleus handle and the periphery (see p. 379). When there is considerable swell- ing of the upper posterior part of the auditory canal, indicat- ing the presence of pus beneath the skin of this region, the thrust should be through Shrapnell's membrane, and the knife be so withdrawn that its point will cut through the swollen tissues at the upper posterior portion of the canal to the bone, in order to secure free drainage. After incision of the drum-membrane or when rupture has occurred spontaneously the major part of the pus within the auditory canal should daily be removed by means of absorbent cotton wrapped about the end of a probe, and the pus within the tympanum expelled through the opening in the drum-head by the Politzer method of inflation. After Fig. 223. — Blake's polypus snare. this has been accomplished the auditory canal should be cleansed thoroughly by means of a cotton-tipped probe wet with a 15-volume solution of peroxid of hydrogen, the parts thoroughly dried, and covered wath powdered boric acid by means of the powder-blow'er. If exuberant granulations sufficiently large to obstruct free drainage from the tympanum occur, they should be removed by means of a snare (Fig. 223), by Hartmann's forceps (Fig. 205), or by touching them with cJiromic acid fused on the end of a probe. Considerable caution is required in the use of chromic acid. The granulations or small polypi should first be dried thoroughly by means of absorbent cotton, in order to prevent the acid dissolving and flowing over adjacent structures. No more of the acid should be applied than is necessary to accomplish the desired result, and any excess remaining \vithin the canal should be neutralized by 4O0 DISEASES OF THE NOSE, THROAT, AND EAR syringing with a warm alkaline solution. Small polypi and exuberant granulations are most apt to occur and obstruct drainage when the pus has found its way through an open- ing in Shrapnell's membrane at a point on the upper and posterior part of the auditory canal. Otitis Media Suppurativa Chronica. — Etiology, — Chronic purulent inflammation of the middle ear is generally caused by neglect or improper treatment of acute purulent disease of the middle ear and the failure to secure adequate drain- age. Adenoids, nasopharyngeal disease, and malnutrition prevent sometimes a prompt secession of an otorrhea. The affection may, however, develop primarily as the result of syphilis or tuberculosis. Numerous cases are the result of scarlatina. Symptoms. — There is a mucopurulent or purulent dis- charge, sometimes tinged with blood. The acuteness of hearing varies according to the amount □ of destruction of the structures of the middle ear or to the presence of polypi or semi-inspissated secretions blocking the canal or interfering with the func- tions of the ossicles. In some instances the hearing is nearly normal, while in others deafness is nearly absolute. Tinnitus may or may not be present. Fig. 224.-Residuaofmid- jj-^g presencc of a discharo^e in die-ear suppuration. JN early J^ o total loss of the drum-head, thc auditory caual from the middle Handle of hammer resting , ^ on mucosa of promontory Car prCSUppOSCS thC preSCUCC OI a pCr- ^^P^'^'"^^- foration of the drum-head. The per- foration, on the one hand, may be so minute as to escape ob- servation by otoscopy, its presence being only revealed by a "perforation whistle" during inflation of the ear either by Politzer's or Valsalva's method. On the other hand, the de- struction of the drum-head maybe so extensive as to expose the cavity of the typanum to view and reveal all of the structures of the inner wall (Fig. 224). In some cases the remains of the drum-head may be represented only by a narrow ring ; in other cases the ossicles may have also dis- appeared, either from ulceration and sloughing of their liga- ments or by necrosis of the bones themselves. Necrosis of DISEASES OF THE MIDDLE EAR 401 some portions of the tympanic walls may also exist. To a considerable extent the position and size of the perforation will indicate the position and extent of the necrotic process (Fig. 225). The appearance of the tympanic mucous mem- brane varies somewhat. In one class of cases it is simply red and swollen, while in another class it appears granular and polypi may be present, perhaps covering the orifice of a sinus leading to exposed bone. Politzer states that usually there is a destruction of the ciliated epithelium and a thickening of the mucous mem- brane from infiltration of round cells with a dilatation and Fig. 225. — 1-5, Simple suppurations of the drum-cavity and the Eustachian tube; 6-8, caries of the incus ; 7, caries of the. head of the malleus ; 0, attic suppuration with possible caries of both malleus and incus; 10, 11, caries of the head of the malleus; 12, caries of the incus and suppuration of the antrum, and, possibly, associated cholesteatoma. (Leutert.) new formation of blood-vessels. That fungiform excres- cences cover the thickened mucous membrane, which con- tains small cysts lined with cylindric epitheljum and con- taining epithelial cells, leukocytes, and detritus. The bacteria of the discharges are staphylococci, strepto- cocci, and saprophytes. Prognosis. — Untreated, some cases, after discharging for a year or two, finally cease discharging, the perforation in the membrana closes, and the hearing, while not entirely normal, becomes fairly good. This result is most likely to occur in cases with perforations similar to those shown in Fig. 225, 1-3. In other cases, where there is a large destruc- tion of the membrane, the discharge ceases for a time only to recur at intervals. In this class of cases there is only occa- sionally an apparent discharge, which for long intervals 26 402 DISEASES OF THE NOSE, THROAT, AND EAR never appears externally. A scanty discharge, mixed with dust and other materials, dries at the fundus of the canal until it becomes a source of irritation, when, perhaps partly as the result of a cold, an abundant otorrhea is set up which sweeps away the old inspissated accumulations. Gradually this abundant otorrhea subsides until for another period no discharge appears externally. This is not an infrequent termination in cases where there is a large destruction of the membrane, as in Figs. 224 and 225, 4. In cases of this character occasional careful cleansing of the ear and in the case of a recurrent discharge one or two applications at intervals of a day of a 10 per cent, solution of argyrol will maintain the ear in a fairly satisfactory con- dition. Often the hearing is fairly good. The mucous mem- brane of the inner wall of the tympanum rarely epiderma- tizes and becomes entirely dry. Occasionally, where there is as nearly a complete destruction of the drum-head as in Fig. 224, the opening will become closed by a huge thin cicatrice, which, ballooning inward and outward with every change in intratympanic pressure, is rather a hindrance than an aid to hearing, but serves to exclude cold, dust, and other irritants. Cases where there is a small opening in or just below Shrapnell's membrane leading to carious bone or an accu- mulation of filth (cholesteatomatous material) discharge indefinitely a scanty, watery fluid which sometimes dries upon the tympanum, forming an accurate cast of that struc- ture when removed. Such so-called "attic cases" (Fig. 225, 6-12) are always a source of greater danger in the produc- tion of mastoid and intracranial complications than other forms of chronic otorrhea; although many attic cases reach a ripe old age, with no more serious discomfort than partial deafness and a scanty discharge. In clironic otorrhea, the result of tuberculous infection, it is very difficult to bring about a cure of the suppuration even by the most radical operations. However, such cases usually die from the concomitant phthisis before the tuber- culosis of the ear has progressed sufficiently to render a radical mastoid operation justifiable. The treatment of uncomplicated cases consists in daily DISEASES OF THE MIDDLE EAR 403 thorough cleansing of the interior of the drum, already de- scribed as necessaiy in the treatment of acute purulent in- flammation of the middle ear. If the perforation through the membrana is not sufficiently large to permit of this being readily accomplished it should be enlarged or a counter- opening made, and the interior of the drum syringed by means of Blake's middle-ear cannula (Fig. 38, 2, 3, or 4). When, with a large perforation, pus is seen to flow down- ward from the attic into the tympanum, the nozzle of the curved cannula should be introduced into the attic through the perforation, so as to thoroughly cleanse this cavity. After the cavity has been thoroughly cleansed it should be dried carefully by means of absorbent cotton wrapped about a probe and the parts covered by powdered boric acid. The success of the treatment depends upon the thor- oughness with which the cleansing is accomplished at each daily visit of the patient. If the tympanic mucous membrane is .granular the routine treatment outlined above will not be sufficient to secure a speedy cessation of the discharge until the granulations are destroyed. Alcohol has the power to cause a shrinking of the granulations because of its dehydrating qualities, and absolute alcohol may be applied by means of a cotton-tipped probe at each daily visit of the patient after the ear has been thoroughly cleansed. The application of absolute alcohol causes some pain, and it may augment the discharge for a few days. Alcohol (95 per cent.) may also be prescribed for the patient's use at home, a few drops being instilled into the ear several times a day, care being exercised that the patient's head is held in such a position each time that the alcohol dropped into the ear will be sure to reach the cavity of the tympanum. For the first {^\n days it may be necessary to dilute the alcohol somewliat because of pain. However, it should be remembered that the dehydrating properties of. 50 per cent, alcohol are practically nothing. A good method of prescribing alcohol is to instruct the patient to mix in a 2-dram vial equal parts of alcohol and water for the first day's use. If this mixture causes only momentary pain, to use the next day 2 parts alcohol 404 DISEASES OF THE NOSE, THROAT, AND EAR and I part water, and so on from day to day until 95 per cent, alcohol can be used without great distress. Before dropping alcohol into his ear the patient or one of his friends should be instructed to remove all accumulations of pus from the ear in the following manner : The auditory canal is first straightened by drawing the auricle upward, backward, and outward. A cotton-tipped wooden tooth-pick is then inserted gently to the bottom of the canal, allowed to rest there sufficiently long to absorb pus, and then with- drawn and discarded. This procedure is repeated until the cotton fails to absorb and bring away any discharge. In case of a child, where the parent or nurse cleanses the ear, the child should be placed in front of a window before the canal is straightened, so that the light may be directed into the ear and a view of the fundus of the canal obtained, Cleansing the ear by some method is absolutely neces- sary before dropping alcohol into it, as otherwise the alcohol will be diluted and the tissues protected by a layer of pus so thick in most instances that the alcohol will never reach the diseased parts. If it is deemed wise to order the patient to cleanse his ears with a syringe, he should be carefully instructed as to the proper method (p. 356), and, what is probably of as great importance, the proper method of drying the ear. Discharging ears do better under a treatment in which syringing has little or no part. Nevertheless it is well at the first treatment of a patient with chronic otorrhea to begin by a thorough cleansing of the canal and tympanum by syringing with- sublimate solution. The writer has very serious doubts as to the value of home syringing, either by the patient or his friends. A girl about twelve years of age was brought to the Medico-Chirurgi- cal Ear Dispensary some years ago almost totally deaf and with double facial paralysis as the result of scarlet fever. The odor from the child's ears was indescribably fetid. The mother stated that she had syringed the child's ears every day for the past six months. From the child's left ear there was quickly syringed a fetid mass of pus, the malleus, the incus, and part of the annulus tympanicus ; from the right ear, fetid pus and the malleus. In six months of daily syr- DISEASES OF THE MIDDLE EAR 405 inging the parent had evidently failed to remove any of the accumulation at the fundus of the auditory canal, but had simply syringed away some of its superficial portion. The case illustrates the value of home syringing of the ear as ordinarily performed. For the patient's use the syringe made of a single piece of soft rubber (Fig. 48) is probably the safest and most effective instrument. All things considered, a warm satu- rated solution of boric acid is the most convenient deter- gent ear-wash for home use. The patient should be in- structed to place I or 2 teaspoonfuls of the crystals in a wide-mouthed bottle holding about 4 ounces, fill the bottle with warm water, syringe the ear, and afterward cork the bottle. At each subsequent syringing a sufficient amount of boiling water from the teakettle is added to bring the saturated solution of boric acid up to a temperature suit- able for syringing the ear. As the crystals of boric acid are dissolved more should be added from time to time in order to maintain a saturated solution of boric acid con- veniently ready for use. While the above furnishes a cheap and convenient method of cleansing the ear, the writer's feeling is that most cases of acute and chronic suppuration, under ordinary circum- stances of ready access to the aurist's office or the dispen- sary, do better without home syringing ; and that when alcohol or other drops are prescribed for home use, they are best dropped into the ear after a dry cleansing with absorbent cotton. Aural Polypi. — When the granulations are isolated they may be scraped away with a sharp curet or be removed with the forceps. Large granulations and polypi are best removed with a snare. It should be borne in mind, when removing a polypus with a snare, that, although the pol}-- pus is absolutely devoid of sensation, the wall of the audi- tory canal, as the result of long maceration in pus, is often exquisitely sensitive, and in guiding the wire loop of the snare over the polypus it is advisable to avoid, as far as possible, touching the auditory canal. If the polypus is large an effort should be made to locate its pedicle by means of a probe. The wire loop of the snare should then be 406 DISEASES OF THE NOSE, THROAT, AND EAR worked gradually inward over its surface until, if possible, the pedicle of the polypus is encircled. The wire loop should then be tightened to cut through the polypus. If the ope- rator has not succeeded at the first attempt in removing the Fig. 226. — Sexton's combination forceps. w^hole of the polypus, this maneuver may be repeated until the desired result has been accompHshed. Bleeding may be checked at any stage of the operation by means of a tampon of absorbent cotton saturated with a i : 1000 solution of Fig. 227. — Gleason's polypus snare. adrenalin, and by afterward cauterizing the stump of the polypus with nitrate of silver fused on the end of a probe. For the removal of polypi Blake's snare (Fig. 223) is per- haps the most convenient instrument, but Sexton's, Gruber's, or Wild's snare is almost equally efficient. The author DISl'lASKS OF J'l/E MIDDI.K EAR 407 I has luid made an aural polypus snare consistin<^^of a needle and cannula, so constructed as to be used as an auxiliary " tip " with Sexton's combination forceps, so that when the eye of the needle is threaded with wire the loop so formed can be enlarged or diminished at the pleasure of the opera- tor — a matter of some importance in guidin<^ it along the auditory canal over a large polypus. Other advantages of this instrument are the quickness and ease with which it can be manipulated, and the fact that when the wire is in position around a small polypus the canimla can be thrust forward over the wire loop, and thus prevent the wire slipping over the polypus instead of excising it (Fig. 227). Pathology. — Aural polypi (Fig. 228) may be divided into four classes. About 50 per cent, of all aural polypi are granulation tumors, having the same structure as ordinary granu- . "' lations, but covered by cither squamous or columnar epithe- lium; 90 per cent, of aural polypi, other than granulation tumors, are mucous papillomata. They are extremely vascular and some- times bleed at the slightest touch. Their structure consists of cap- illary loops surrounded by a stroma of somewhat imperfectly developed connective tissue con- taining cuboidal epithelial cells. They are covered by a pave- ment-epithelial layer of varying thickness. Fibroid polypi (fibromata), which are somewhat rare, are usually found as large, dense, pale polypi developed from the perios- teal or deeper layer of the tympanic mucous membrane. Fibrous polypi are also covered by several layers of pave- ment epithelium. Myxomatous polypi are very rarely found in the human ear. Aural polypi are not malignant, the treatment outlined above being sufficient to prevent a recurrence of the q-rowth. It should be borne in mind, however, that epitheliomata, sarcomata, and gummata some- FiG. 228. — Polypi (Steudener)- 408 DISEASES OE THE NOSE, THROAT, AND EAR times occur in the middle ear and present the appearance of polypi, but such growths are rare in this situation. Symptoms. — Long-continued discharge, often streaked with blood, is usually the only subjective symptom. Cer- tain reflex symptoms, the result of peripheral irritation caused by the presence of an aural polypus, have been de- scribed as occurring in rare cases. Most aural polypi have their origin at the posterior and upper part of the tympanum. They may, however, arise from any part of the tympanic cavity or even from the der- mic layer of the drum-head. Sometimes they originate at the mouth of a sinus extending through the skin of the auditoiy canal to carious or necrosed bone. Caries and Necrosis. — Caries or necrosis of the temporal bone may occur during the course of long-continued sup- puration of the middle ear or as the result of syphilis, tuber- culosis, trauma, osteomyelitis, and diabetes. The upper and posterior part of the auditory canal, the mastoid, and the tegmen of the tympanum and antrum are the portions most usually first attacked. Caries most frequently attacks the cancellous, necrosis, the compact bone. Symptoms. — Circumscribed caries may exist within the tympanum during chronic purulent disease of the middle ear and present no symptoms other than that exposed and roughened bone can be detected by means of a probe. Sudden paralysis of the facial nerve may occur as the result of necrosis of the inner wall of the tympanum involving the facial canal ; how^ever, a considerable portion of the facial canal may be opened and the nerve be bathed in pus for some time before symptoms of Bell's palsy occur. The labyrinth may be opened, generally through the horizontal semicircular canal, and brain-abscess occur. The tegmen tympani and tegmen mastoideum not infrequently are de- stroyed as the result of necrosis or caries. Under such circumstances there commonly occurs a local pachymen- ingitis, which prevents the spreading of the disease upon the dura mater. Pus may find its way into the naso- pharynx or beneath the tissues about the auricle. If caries or necrosis attacks the mastoid antrum or the mastoid cells, there are pain, sw^elling, and infiltration of the DISEASES 01' 77/ K MIDDLE EAR 4C9 skin at the posterior inner portions of the meatus. At first hard, the swelling becomes soft and fluctuating when pus forms. Pain is often severe, of a boring character, and worse at night. The discharges are usually abundant and characteristically fetid, due to the presence of saprophytic bacteria. In necrosis involving the labyrinth there is often nausea, vertigo, and a tendency to fall toward the affected side, the fluids of the labyrinth may escape, producing total deaf- ness. Temperature varies from slightly above normal to 105° F. in the more acute cases. In the absence of tem- perature the leukocytes are less than normal and ane- mia is usually present. Polymorphonuclear leukocytes are found in cases of rapid necrosis and high temperature. The necrosed bone in the more chronic cases is usually imbedded in exuberant granulations, through which a probe detects, by the sensation of a rough surface, necrosed bone. If a cotten-tipped probe is used the rough surface catches in the fibers of cotton, producing a characteristic sensation. Treatvicnt. — If a sequestrum has formed it should be re- moved with forceps. Politzer's forceps (Fig. 206 ) are usually strong enough for this purpose, but Sexton's foreign-body forceps can often be used to better advantage. If it be found impossible to remove the sequestrum through the auditory canal because of the granulations and polypi that obstruct the canal, they should be removed by means of a snare ; after a few days, in some instances, the seques- trum will have been pushed outward by the granulations behind it into a position where it can readily be grasped by forceps and removed. In cases of caries or where the necrotic process has not progressed to the formation of a sequestrum, the diseased bone should be scraped away by means of a sharp curet and the parts covered with powdered boric acid. When ca- ries or necrosis affects the promontory, only the most super- ficial cureting is justifiable, but the parts should be kept scrupulously clean and as dry as possible by means of fre- quent insufflations of powdered boric acid. Cases where necrosed bone can be felt in a portion of the tympanum in- accessible to the curet are best treated by instillations twice 410 DISEASES OF THE NOSE, THROAT, AND EAR a day of enzymol (Formula 13), a preparation containing pepsin. By this means the middle ear is, as it were, con- verted into a stomach capable of digesting the dead bone. Pepsin, of course, has no effect on living tissue. The ear should first be cleansed by syringing with warm water. The patient should then lie down with the diseased ear upper- most and fill the canal full of enzymoL By pressing the tragus inward a few times with the finger-tip the fluid is Syr- inbred, as it were, back and forth as far as the aditus and antrum. The excess of fluid is allowed to escape when the patient assumes the erect posture. Several hours are required for pepsin to produce its effect as a digestant and the presence of granulations may prevent its coming into contact with dead bone. It is well, therefore, after enzymol has been used for a few days, to employ instillations of alcohol for a day or two. The prognosis, of course, varies according to the part of the tympanum attacked by necrosis. In individuals other- wise healthy the prospects of a favorable result are en- couraging, even when a large portion of the temporal bone is involved by the disease. In tuberculous individuals, however, the disease sometimes progresses toward a fatal termination notwithstanding all efforts to prevent it. The prognosis is doubtful where there are symptoms of intra- cranical involvement, pyemia, or metastatic abscess. Fatal hemorrhage may occur from the carotid when its bony canal is involved. The rupture of the vessel usually occurs at " Hassler's site of predilection," that is, at the knee of the carotid in the bony canal, where it abruptly changes its course from the vertical to the horizontal. SYSTEMIC DISEASES CAUSING OTIC INFLAMMATION* The systemic diseases most frequently causing otitis are scarlet fever, measles, diphtheria, la grippe, typhoid fever, pneumonia, syphilis, tuberculosis, and diabetes. The appearance of otic inflammation in most of these diseases is a very serious complication, and although the subject has been already discussed in sections on the eti- ology and pathology of the various forms of otitis, it seems I DISEASES OE THE MIDDLE EAR 4II best to state briefly the peculiiirities of the otitis rcsultin^j from these systemic diseases and the modification of treat- ment necessary. Scarlatina. — The middle ear is frequently involved during scarlet fever. In some cases the inflammation seems to be simply catarrhal in character, probably due to closure of the Eustachian tube rather than the actual presence of the mi- cro-organism causing the disease. Such cases run a mild course. There may not be perforation of the membrana. The deafness resulting in those cases where no perforation has occurred is often considerable. When the ear complication occurs during the eruptive stage of scarlet fever it usually assumes a severe purulent type. The membrana and ossicles may come away as a slough in a surprisingly short space of time and, finally, large sequestra of bone. The purulent inflammation may involve the labyrinth, with resulting total deafness, or the facial nerve, causing facial paralysis. There is one practical point the practitioner should never forget, which is that the contagion sometimes lin- gers for several months in the discharge from the ear, and that a child with scarlatinal otorrhea may be the source of infection to other children. The treatment of scarlatinal otitis differs in no respect from that of otitis from other causes, providing the condi- tion of the patient will permit of its being carried out. The nose and throat should be cleansed once a day by the med- ical attendant with an atomizer containing Dobell's solution. The nose, if stenosed, should then be sprayed with adrenalin solution (i : 5000) to overcome the stenosis and, finally, the mucous membrane covered with the spray of menthol-cam- phor-albolene and powdered calomel. The ears should then be politzerized and, if discharging gently, syringed with a saturated boric acid solution and a piece of iodoform gauze placed loosely in the meatus. Every other day sublimate solution (i : 2000) may be substituted for the boric acid solution should the gravity of the case seem to require it. In some cases the patient, especially if a child, will be too weak or indocile to permit of so lengthy a treatment, and 412 DISEASES OF THE NOSE, THROAT, AND EAR the practitioner may have to content himself with simply syringing with boric acid and subHmate solution. Sequestra of necrosed bone, polypi, mastoid complica- tions, and intracranial involvement, if the condition of the patient permit, should be treated in the manner described in other sections. Measles. — The ear is usually affected in measles, but with less virulence than in scarlatina. The condition is usually that of the catarrhal type, acute or subacute. Rarely does perforation occur. Treatment is the same as in similar types of otitis from other causes. Diphtheria. — Otitis media purulenta is not very infrequent in diphtheria. When the drum is perforated pseudomem- branes may extend from the middle ear onto the excoriated skin of the canal. In those with otorrhea, diphtheritic pseudomembranous infection may occur in the tympanum if they are brought into contact with diphtheritic patients. Treatment is similar to otitis from other causes. When the membrana has ruptured and a pseudomembrane is visi- ble the condition should be treated as described in the sec- tion on Diphtheria of the Meatus. La Grippe. — Aural complications in epidemics of influenza are very frequently encountered. Minute hemorrhages into the drum-head or beneath the epidermis of the canal are not infrequently encountered and are somewhat character- istic of the disease. The aural complications vary from a subacute catarrh, from which recovery takes place within a short time, to severe otitis media purulenta with intracranial complications. The possible gravity of an aural complication in a case of influenza should not be underestimated, and such a case should receive the most careful attention from its onset. The treatment is similar to otitis from other causes. Typhoid Fever. — The hebetude and apparent deafness of typhoid is due to the effect of the toxins of the disease on the internal ear. Occasionally internal-ear impairment of hearing is encountered years after recovery from the fever. Purulent inflammation of the middle ear is the result of invasion of the bacterium coli into the middle ear. Day DISEASES OE THE MIJ)DLE EAR 413 and Jackson, of Pittsburg, describe three types of purulent otitis in typhoid — the hemorrhagic, the slow, and the ful- minating. The disease is usually rapid in its onset and characterized by intense pain. Day and Jackson state that in 10 cases no otitis was manifest one or two days previous to spontaneous rupture of the membrana. In the Medico-Chirurgical Hospital during the Spanish war, of 268 soldiers sick from typhoid fever 3 had severe otitis media purulenta as a complication of the disease. The ear compUcations of typhoid occur usually in the third or fourth week. The symptoms vary from those of subacute catarrh to the severe form of middle-ear suppura- tion. Hemorrhagic blebs similar to those encountered in aural influenza have been observed by Day and Jackson previous to rupture of the drum-head. The treatment is that of otitis elsewhere when the condi- tion of the patient will permit. The danger of heart failure from sitting up in bed, and nasal hemorrhage as the result of using the spray and Politzer bag should be borne in mind. A troublesome nasal hemorrhage apparently did originate in one of the cases treated in the Medico-Chirurgical Hos- pital from the use of the atomizer. In some cases, for a few days at least, it is best to be content with simply syringing the meatus with boric acid solution twice a day and inserting a little iodoform gause loosely into the concha. It is better to avoid inserting gauze into the canal, especially if the dressing be entrusted to a nurse, for fear that the gauze will become impacted from some cause, possibly the finger of the patient. The gauze should be changed as often as it becomes saturated. Pressure-pain with bulging of the drum- head will indicate paracentesis. Tuberculosis of the middle ear is probably always second- ary to phthisis. Tuberculous deposits occur in the middle ear, which, after a time, break down, causing more or less rapid destruction of tissue. The most marked symptom is the painless cJiaracter of the otitis media purulenta that results in perforation of the membrana. After a considerable destruction of the drum-head has occurred the parts not infrequently become sensitive, probably as the result of mixed infection. Ordinarily the disease pursues a chronic 414 -DISEASES OF THE NOSE, THROAT, AND EAR course and the otorrhea may even cease for a time and reappear. Sometimes the destruction of tissue is rapid and the dis- ease extends to the mastoid, necessitating operation. Caries of the bone may involve the facial nerve and cause facial paralysis or the internal ear may be invaded. Pus, in the more severe forms of the disease, is abundant and fetid, but tubercle bacilli are not usually numerous nor easy to find in the discharges. It should be borne in mind in this connection that otitis media purulenta may occur in a tuberculous individual without the disease being due to tuberculosis. Treatment. — The general treatment is of primary impor- tance and consists of a diet largely of milk and raw eggs, outdoor life, and tonics. Local treatment is usually not very successful in bringing about a cessation of the discharge. The parts, however, in middle-ear suppuration should be kept clean, either by the dry method or by syringing with boric acid and sublimate solution. It should be borne in mind that the discharges are contagious and care should be exercised to destroy all dressings used about the ear. Pneumonia. — As in typhoid, otitis media purulenta gener- ally occurs late in the disease, if at all. The pneumococcus is not infrequently found in the pus of an otorrhea occur- ring independent of pneumonia. The treatment is the same as in otitis occurring from other causes. Syphilis. — The middle ear is frequently inflamed during the period of secondary skin rashes and sore throat. In a case observed by the author facial paralysis occurred. The middle ear may become the seat of a gumma in the tertiary period of the disease. The symptoms at first are those of pressure within the middle ear, deafness, tinnitus, and some- times vertigo. Sooner or later suppuration with perforation of the membrane occurs, and the disease assumes the ap- pearance of chronic otitis media purulenta. The destruction of tissue is often considerable. Treatment. — The local treatment is that of otitis ; the constitutional treatment being of greater importance. In cases where the diagnosis of gumma is made early, inunc- I OPERATIONS UPON THE MIDDLE EAR 415 tions of mercury with iodid of potassium internally may result in absorption of the gumma before it breaks down. Blight's Disease. — In advanced Brii^ht's disease all opera- tions under a general anesthetic about the nose, throat, and ear are dangerous because of the possibility of fatal coma. Diabetes. — Recurrent furunculosis of the canal may result from glycosuria. Mastoid wounds and large wounds about the upper respiratory tract do not heal as rapidly in w^ell- marked glycosuria as in a normal individual, and otitis media purulenta runs a more severe course with greater destruction of tissue. OPERATIONS UPON THE MIDDLE EAR Operations are performed upon the middle ear for the improvement of hearing, the relief of tinnitus aurium or vertigo, and to bring about the cure of a persistent discharge from the middle ear. The operations that have been performed from time to time are quite numerous, the following being a partial list: Paracentesis^ single or multiple ; excision or destruction by caustics of a portion of the membrana tympani for the pur- pose of establishing a permanent opening ; plicotomy or divi- sion of the posterior fold ; section of the anterior ligament of the malleus ; tenotomy of the tensor tympani or stapedius muscle, or both ; division of adhesions between the mem- brana and promontory or between the ossicles, etc. ; excision of a portion of the membrana ; disarticulation of the incudo- stapedial articulation or division of the descending process of the incus and mobilization of the stapes ; plastic opera- tions for uniting either the incus or stapes with the mem- brana tympani ; and removal of one or more of the ossicles. Myringotomy is performed for the evacuation of fluids from the cavity of the tympanum or as an exploratory incision to determine the mobility of the stapes before attempting a more radical operation. When the operation is done for the evacuation of fluids, the cut is generally made in the posterior inferior quadrant, and it should be at least 2 or 3 millimeters in length. The exploratory incision, which is made from just behind the short process, should extend im- 4l6 DISEASES OF THE NOSE, THROAT, AXD EAR mediately beneath the posterior fold for a sufficient distance to cause considerable gaping of the wound, and to allow the operator to test the mobility of the stapes and observe the condition of the tympanum (Fig, 231). The operation does in u ri i / \ ■®n^ n\ Fig. 229. — Dench's set of ear instruments. not usually require general anesthesia, but cocain and adre- naHn may be injected beneath the skin of the canal by Ballin's method (Formula 20). The hearing should be tested before and after the operation and any improvement noted. The wound of the exploratory incision is brought together and is held in position by the insufflation of a small quantity of boric acid. OPERATIONS VPOX TI/E MIDDLE EAR 4I7 Methods of Producing a Permanent Opening in the Mem- brana Tympani. — A portion of the nicnibranc maybe excised with a knife (Fii;". 229, e) or reinoved by tlie method of Simrock. A minute portion of concentrated sulphuric acid is held against the membrana at the desired spot by means of a cotton-tipped probe. The acid immediately attacks the membrane and destroys that portion with which it is brought into contact, so tliat in the course of a few moments an opening can be made by pushing a blunt probe through the eschar. But little reaction commonly follows the operation, and the opening generally remains patulous for some time if it is let aloiic, and in some cases produces considerable improvement of the acuteness of hearing. A little pow- dered boric acid should be insufflated upon the parts as a dressing after the operation. Multiple Incisions of the Membrana Tympani and Tenot- omy of the Tensor Tympani. — These operations have been performed for improvement of the hearing and for the relief of tinnitus. But temporary improvement can be expected as the outcome of either operation. Section of the tensor is probably best performed in the following manner: An angular knife (Fig. 22g,f or g) is thrust through the mem- brana tympani close in front of, or immediately behind, the malleus handle, and just below the short process. Section of the tendon is accomplished from below upward, the cut through the membrana being extended upward at the same time. The tenotomy should be followed by a vigorous inflation of the tympanum by Politzer's method, in order, if possible, to restore the drum-head to its normal posi- tion. Removal of the Membrana Tympani, Malleus, and Incus in Chronic Catarrh of the Middle Ear. — The operation is performed for the relief of tinnitus and to improve hearing when milder measures have failed to check the progress of the disease or secure relief from tinnitus. Before deter- mining the advisability of operating, the hearing should care- fully be tested by means of tuning-forks. If it is found that the acuteness of hearing has been seriously impaired, largely as the result of impairment of the functions of the laby- rinth or auditory nerve, but little if any improvement of the 27 41 8 DISEASES OF THE NOSE, THROAT, AND EAR hearing power can be expected as the result of the opera- tion. TecJinic. — Perfect control of the patient should be secured by the administration of ether, and the operation should be performed with antiseptic precautions. The auditory canal should first be cleansed thoroughly and syringed with a strong bichlorid solution. An electric lamp attached to the forehead (Fig. 230) will be found a convenient means of illumi- nating the field of operation, although some operators prefer dayhght reflected into the canal by means of the forehead mirror. The advantage of the arrangement shown in the fig- ure is that the lantern, containing an ordinary 2- or 3-candle, Fig. 230.— Gleason's electric light for intratympanic surgery. 4- to 6-volt lamp, can be attached in place of the reflector to the head-band the aurist is accustomed to wear ; and if the electric light within the lantern burns out during an opera- tion it can almost instantly be replaced by a new one. In combination with a small 3-cell storage battery it yields a 2 to 3 candle-power light for one and a half hours, and is an extremely light and portable outfit. In a very light room 2 or 3 candle-power lamps are not entirely adequate, but by means of a current controller lamps of any candle power up to 8 may be employed. Suitable lamps for this purpose can be obtained in almost any electric supply store. Unfor- tunately, in the course of fifteen or twenty minutes, the appa- OPERATIONS UPON 77/ K MI7)DLE I'lAK 419 ratus becomes too hot for comfort if touched with the hand when lamps of 8-candle power arc used. However, most operations on the middle car do not require a very bright lifjht for a loni^ period, and when the current is turned off the apparatus quickly cools. An adjustable lensc focuses the light upon the field of operation and is sufficiently bril- liant to be of value in a room into which the sunlight pene- trates. An incision is first made through the membrana, com- mencing at a point posterior to the short process and fol- lowing a curve just below the posterior fold until the middle of the posterior part of the ring is reached. If the incision has been made carefully with a sharp knife in the clear part of the membrana no bleeding will occur ; when the flap is pressed downward there will be brought into view the incudostapedial articulation, which is next divided by means of an angular knife (Fig. 22g,f or g) passed into the tym- panum, either in front of or behind the incus shank. By slight traction outward the knife is made to hug the incus shaft, while at the same time the articulation is divided by a downward stroke. Care should be exercised that the articulation is thoroughly divided before attempting any further manipulations. A puncture should now be made with the sharp knife (Fig. 229, d) through the membrane at its lowest portion, sufficiently large to permit the intro- duction of a probe-pointed knife (Fig. 229, c), w^hich is made to cut its way upward until the inferior extremity of the original incision is reached. The blade of the knife is now turned in the opposite direction and the membrana is incised anteriorly up to the anterior fold. Up to this point httle or no bleeding will occur to obscure the field of operation. The next step is to divide the attachments of Shrapnell's membrane and the strong anterior ligament of the malleus. This should be done rapidly, as the hemorrhage will be somewhat profuse. The sharp-pointed knife (Fig. 229, c), with its handle depressed until it touches the low^er margin of the speculum, is made to pierce Shrapnell's membrane just above the short process, and is thrust inward and upward into the fornix tympani, and is then made to cut its 420 DISEASES OF THE NOSE, THROAT, AND EAR way out downward and backward, thus severing the external and posterior hgaments of the malleus and the posterior portion of the membrana flaccida. The knife is then quickly turned, its point carried over the short process, and made to cut through the anterior segment of Shrapnell's membrane and the strong anterior ligament of the malleus. As soon as the hemorrhage, which may obscure the field of opera- tion, has been checked, the malleus is grasped with Sexton's foreign-body forceps, and, being first pressed inward to free its head from the ledge on which it lies, is brought down and extracted. The superior ligament and the tendon of the tensor tympani both being weak no force is necessary to rupture them. After the somewhat free hemorrhage following the extrac- tion of the malleus has been controlled and the blood removed by means of absorbent cotton wrapped about a probe, the incus, if in sight, is seized with the forceps and removed, traction being exerted first inward, then downward and out- ward. Frequently the shank of the incus will not be in sight, having been displaced downward and backward during the removal of the malleus. Under these circumstances it is sought for by means of the curved probe (Fig. 229, k or /). The end of the probe is carried into the tympanum with its curve directed backward and then rotated upward, until the incus is brought into view. The maneuver will perhaps have to be repeated several times before this result is accom- plished. After the operation all blood should be removed from the tympanum and canal by means of absorbent cotton wrapped about the end of a probe and a plug of iodoform gauze loosely inserted in the auditory canal. Many operators advise the removal of the incus before the malleus. If, after the incudostapedial articulation has been severed, the incus shank is clearly discernible, it is best, in most instances, to at once grasp and remove it with a suitable pair of forceps, thus avoiding the necessity of searching for and perhaps being unable to discover it at a subsequent stage of the operation. Before closing the audi- tory canal with gauze it is best in all instances to test the mobility of the stapes. If this bone is bound down by OPERATIONS UPON THE MIDDLE EAR 42 I adhesions they should be severed, and if the adhesions are so extensive as to render it probable that they will so re- form as to interfere with the mobility of the stapes, the head of this bone should be f^rasped with forceps and extracted or it may be removed by means of a hook. Great care should be exercised not to dislocate the bone inward into the labyrinth while executing these maneuvers. After the operation the tympanum should be dried with absorbent cotton and lightly dusted with iodoform, and the tympanum and canal very loosely packed w^ith a narrow strip of iodoform gauze in order to check any oozing and to serve as a drain. The packing is removed at the end of twenty-four hours and, if necessary, another strip of iodo- form gauze inserted, after cleansing and drying the parts by means of absorbent cotton wrapped about the end of an Allen probe (Fig. 35). Further treatment will depend upon the amount of reaction following the operation. Rarely, severe pain occurring a few hours after the operation requires the removal of the packing and very gentle syringing with hot distilled water to which boric acid or carbolic acid may be added. The ear should be protected by means of a pledget of absorbent cotton placed loosely in the canal, and should be changed by the patient if it becomes saturated with discharge. The parts should be inspected once a day by the surgeon, and if no discharge is present the middle ear at least should not be disturbed. If, however, there be a discharge, the parts should be gently but carefully cleansed by means of absorbent cotton dipped in a solution of peroxid of hydrogen and a little powdered boric acid dusted over the parts after they have been thoroughly dried. A slight serous discharge for a few days after the operation is not uncommon, but suppuration rarely occurs. Vertigo and nausea are generally complained of for a few days if the stapes has been roughly manipulated or removed. Prognosis.— -TmmXMS is usually at least alleviated, but the results as regards the hearing are so uncertain that there has been a growing disposition manifested to abandon this operation for simpler procedures. The operation has the advantage of permitting free access to the tympanum for subsequent mobilization of the stapes or the division of ad- 422 DISEASES OF THE NOSE, THROAT, AND EAR hesions should it be necessary. Ordinarily the drum-head is replaced, in whole or in part, by cicatricial tissue, which, if it interferes with the acuteness of hearing, will require removal, the operation being repeated as often as necessary ; while the absence of the drum-head permits the entrance of dust and other materials into the middle ear, which conse- quently may readily become infected. Apparently the idea that the presence or absence of the membrana tympani greatly increases or decreases the hearing when the Eusta- chian tube is patulous is a myth, but the chief function of this structure — namely, the exclusion of dirt from the mid- dle ear — is of the greatest importance, and should not be impaired by an operation for the relief of deafness and tin- nitus unless absolutely necessary. In many instances equally good results, as far as the relief of tinnitus and the improvement of the hearing are concerned, can be secured by severing the incudostapedial articulation and mobilizing the stapes — with or without tenotomy of the stapedius muscle. Severing the Incudostapedial Articulation and Mobilizing or Extracting the Stapes.— A general anesthetic may be admin- istered, but it is preferable to operate under cocain anesthesia in order to secure the co-operation of the patient and to test his hearing from time to time during the different stages of the operation. The field of operation is prepared, upon the preceding day, by carefully cleansing the auditory canal with a solution of peroxid of hydrogen and syringing with a I : 2000 solution of corrosive sublimate, after which the auditory canal is stopped with a plug of iodoform gauze. All instruments, the absorbent cotton, and the solutions of cocain are sterilized in the usual manner by heat. Anesthe- sia is secured by the method of Ballin, which consists in subcutaneous injection into the roof of the canal of a mix- ture of equal quantities of a i per cent, solution of cocain and a i : looo solution of adrenalin (Formula 20). TccJinic. — Commencing rather below the middle of the posterior periphery of the drum-head, an incision is made and prolonged upward with the probe-pointed knife (Fig. 229, { bone re- moved should be sufficient to permit ample drainage from the infected dural surface, which is usually covered by gran- 4/6 DISEASES OF THE NOSE, THROAT, AND EAR ulations. The necessity for exposing a considerable area of dura mater by cureting away carious bone need occasion the operator no uneasiness, as the dural surface granulates and heals with the rest of the mastoid wound. Leptomeningitis is an inflammation of the pia and arach- noid in contradistinction to pachymeningitis, which signifies an inflammation of the dura; although, as ordinarily em- ployed, the word meningitis has practically the same signif- icance as leptomeningitis, which may be either serous or purulent ; general, involving the brain and cord, or local, involving, for example, only a portion of the convex surface of one side of the brain. The avenues of infection in otic leptomeningitis are the tegmen, the sigmoid sinus, the carotid canal, the labyrinth, the facial canal, and the lymphatics or blood-vessels. It generally occurs as the result of caries or necrosis. Serous leptomeningitis begins as a general hyperemia of the pia and arachnoid, followed by a serous exudation. The dura and the ventricles become distended by the exudate with resulting pressure symptoms. Slight cerebral irritation, especially in children, probably meningitis, frequently accompanies acute inflammation of the middle ear. The symptoms are localized headache re- ferred to the temporal or occipital region, which may be tender on percussion. Morning and evening fever is some- times present and, in infants, convulsions. These symptoms may disappear within a short time as the result of purgation with calomel, bromid of potash, and an ice-cap, or the pulse may become rapid, the temperature rise, the pupils cease to react to light, and hebetude with loss of consciousness may occur. In a boy about fourteen years of age, seen at the Philadelphia Hospital, who presented these symptoms on the fifth day of a purulent otorrhea, immediate relief fol- lowed the withdrawing of \\ ounces of cerebrospinal fluid by lumbar puncture. Lumbar puncture is performed as follows : The patient either sits up or lies upon the side, with the back arched and the knees flexed against the abdomen. The spine of the fourth lumbar vertebra should be located (a line drawn from one posterior superior spine of the ilium to the other passes INTRACRANIAL COMPLICATIONS OF OTIC DISEASE 477 across it) and the puncture made J inch to one side, at the level of its lower end. The needle should be inclined at an angle of about 45 degrees to the surface of the skin, and should be thrust in a distance of from 2\ to 3 inches. The most scrupulous asepsis must be observed. The spinal fluid flows readily, either in a stream when the pressure is high or drop by drop if it is normal. In purulent menin- gitis it is cloudy and contains pus-cells ; in tuberculous meningitis it is usually clear ; in cerebral hemorrhage it may be bloody, but as admixed blood may be due to the injury of a vessel by a needle, the diagnosis should be made with caution. The quantity obtained varies from 2 or 3 to 80 or 90 ccm. — /. c'., from a few drops to 3 fluidounces. Purulent Leptomeningitis. — In purulent meningitis the exudate becomes cloudy and mucopurulent in appearance from the presence of leukocytes. The bacteria present vary and are usually those found in the otorrhea that has caused the condition. Pathology. — The vessels of the pia and arachnoid are in- fected and the membranes become cloudy. A serofibrin- ous or purulent exudate distends the dura or may exist only in patches. The cerebral membranes may be involved either as a whole or in part. In severe cases those of the spine are affected as well. The brain or cord may be softened in places or, as Ander's states, no gross lesions, either of meninges, brain, or cord, even microscopic, are found post mortem in many cases presenting the clinical picture of meningitis. Symptoms. — The temperature is usually from 101° to 105° F., and exhibits but slight variation during the day and night. There are severe headache, photophobia, vomiting, and localized or general convulsions. Dehrium is common in young subjects, but in adults the patient is at first wake- ful, but slowly passes into a condition of fatal coma. Pa- ralysis of the pupil, strabismus, and ptosis are the most frequent forms of paralysis present. There is often retraction and fixation of the head. Re- flexes are at first increased and later diminished or absent. There is hyperesthesia of the skin. The pulse, at first full and rapid, later in the disease is slow, but becomes again 478 DISEASES OF THE XOSE, THROAT, AND EAR rapid in the last stage. The pupils finally become dilated. There is general paralysis and death, occurring as early as two or three days or the fatal termination may be post- poned for some weeks. Treatment. — Where the symptoms are simply those of cerebral irritation, perfect rest in bed, large doses of the bromids, purgation with small, frequently repeated doses of calomel and saHnes. Sometimes the local abstraction of blood from the ear by means of leeches and an ice-cap are effectual in checking the attack. Where lumbar puncture gives relief, it should be repeated as often as deemed necessary. The procedure is of value not only as a method of treatment, but as a matter of diag- nosis. The amount of fluid flowing freely through the needle indicates the degree of pressure, and the microscope will disclose the presence of pus and the bacteria causing the infection. As purulent leptomeningitis is invariably fatal unless checked in time, surgical measures, to be of value, must be instituted early. When there is no doubt as to the diag- nosis the mastoid antrum should be opened, and if the amount of disease met with is not sufficient to account for the symptoms, the cranial cavity also, in search of an extra- dural abscess. Even if no pus be found, the opening into the cranium with the consequent local depletion and relief of tension is the best possible treatment and has been fol- lowed by recovery in some severe cases. Abscess of the Cerebrum and Cerebellum. — Abscesses of the brain following otitis are probably invariably located on the affected side. They may be single or multiple. It is the white substance that is generally involved. The bacteria found in the pus are various, generally those found in the discharges of the ear that has been the cause of the infec- tion. Saprophytes or the micro-organisms developing in putrid material are sometimes present. The disease is generally the result of chronic purulent otitis and necrosis. A localized pachymeningitis as the result of adhesions about the necrosed bone prevent the spread of the infection and a subdural abscess is formed, which in turn infects the brain substance. INTRACRANIAL COMPLICATIONS OF OTIC DISEASE 479 Symptoms. — Cerebral abscess may present no symptoms for many months, but at any moment acute meningitis may occur or increased intracranial pressure result in coma and death. In the early stages the diagnosis is usually not easy. Severe, deep-seated pain and tenderness over the temporal region, optic neuritis, and localized paralysis may be present to a greater or less degree. There may be a sudden rise of temperature lasting for a short time, followed by normal or subnormal temperature, mental dulness, slowness of speech, increasing cachexia and debility, ending sometimes in coma. The symptoms of cerebellar abscess are more obscure even than in cerebral abscess and the diagnosis extremely difficult. Subjects of cerebellar abscess may present ab- solutely no symptoms, and yet suddenly die as the result of the rupture of the abscess into the fourth ventricle. Treatment. — Surgical intervention in all cases of intra- cranial suppuration is the only adequate remedy. As a general rule the cranial cavity should only be entered after removing diseased structures from the middle ear. After the antrum and attic have been cleansed the original skin- wound is enlarged to a sufficient degree by an incision directly backward and the periosteum detached. The groove for the lateral sinus is then cautiously opened by means of a mallet and chisel and the sinus examined care- fully for thrombus. If no clot is found the opening into the skull is enlarged by means of the trephine, chisel, or cutting forceps (upward to reach the middle or down- ward to reach the posterior cranial fossa). While pro- ceeding with the operation it is possible that an extradural abscess may be opened. Under such circumstances free drainage should be secured and the wound dressed. If no such collection of pus is discovered while enlarging the cranial opening a flexible grooved director should be passed in different directions between the dura and the skull in search of pus, and finally the tegmen of the antrum and attic removed, as an extradural abscess is not infrequently located upon this thin plate of bone. In using a trephine for exploration of the cranial cavity one of at least \ inch should be employed. If the center 480 DISEASES OF THE NOSE, THROAT, AND EAR pin of a trephine of this size be placed upon the bone \ inch behind the center of the meatus and \ inch above Reed's base Hne (which is an imaginary line passing through the center of the meatus, touching the lower border of the orbit and extending backward to the occipital protuberance), w^hen the disk of bone is removed from the skull it will expose the lateral sinus, which usually is reached more quickly than when the chisel alone is used. For epidural abscess the center pin of the trephine should be placed upon the skull i inch above the center of the meatus. The resulting opening in the skull, if sufficiently enlarged with the rongeur forceps, will enable the operator to explore the surface of the tegmen of the antrum and tympanum. The posterior cranial cavity may be explored by means of a trephine opening if the center pin of the in- strument be placed i^ inches behind the center of the meatus and \ inch below Reed's base line. Both the middle and the posterior cranial cavities can be explored by means of a trephine opening if the center pin of the instrument be placed \\ inches behind the center of the meatus and \\ inches above Reed's base line. As the skull in this position is comparatively thin, it is easy from such a trephine open- ing with the rongeur forceps to tear away the skull either downward into the posterior fossa or forward into the middle fossa. If cerebral abscess be present near the surface the dura will bulge without pulsation into the wound. Selecting a spot, a small sterilized hollow needle is carefully inserted in the brain. Should pus escape or the needle yield a fetid odor when withdrawn, the dura is incised and a trocar passed in the required direction. If a definite pus-cavity be emptied of its contents it should be washed out gently with a warm, steriHzed, saturated solution of boric acid, a drainage- tube inserted into the tract of the trocar, the wound closed, and a dressing applied. The abscess-cavity should be washed out each day with warm borated water and the drainage-tube shortened at each dressing until the abscess- cavity has closed. Whiting has devised an instrument which he calls an encephaloscope, through which the interior of the abscess- INTRACRANIAL COMPLICATIONS OF OTIC DISEASE 48 1 cavity can be inspected. The instrument somevvliat resem- bles an car speculum and through it the abscess-cavity can be irrigated and packed with gauze without injuring the normal brain tissue. An abscess-cavity, having been located by means of a hollow needle or grooved director, the brain tissue is incised, the encephaloscope inserted, and the cavity irrigated. Iodo- form gauze, previously saturated with a solution of peroxid (1 : 4 of water), is then gently packed into the cavity and the encephaloscope withdrawn. The packing is changed each day until the abscess-cavity has closed. The wound in the dura is then allowed to heal and the skull wound to fill with granulations and close as in a radical mastoid operation. If exploration of the middle cranial fossa does not yield results sufficiently definite to account for the symptoms the wound in the skull is enlarged downward sufficiently to permit access to the structures below the tentorium. The exploration in this region should be conducted on the same general principles as in the middle cranial fossa, but, of course, the utmost care should be exercised in the use of the exploring needle. Sinus Thrombosis. — The lateral sinus may be infected by way of the superior petrosal sinus as the result of attic sup- puration. Usually, however, the infection proceeds from the mastoid cells by way of the numerous small veins that reach the sinus through the bone. An early stage of the process is the occlusion of the sinus by a firm fibrinous clot which may extend backward as far as the torcular He- rophiU or downward into the internal jugular vein. The de- velopment of septic bacteria within the clot leads to general septic infection ; and if the patient survives long enough, secondary abscesses appear in various organs of the body, septic pneumonia being the most common complication ; but it should not be forgotton that sinus thrombosis may produce secondary sinus thrombosis and brain abscess on tJie opposite side. Occasionally sinus phlebitis occurs as the result of the contact of necrosed bone, so that the sinus is easily torn during the mastoid operation, with resulting severe hemorrhage. 31 482 DISEASES OF THE NOSE, THROAT, AND EAR Symptoms. — The progress of the disease is exceedingly insidious and the symptoms vague. The most reliable is a sudden great rise of temperature, followed by an abrupt fall at successive intervals as the result of the breaking down of a portion of the clot and the passage of septic material into the general circulation. Unless the thermom- eter be used every two or three hours during the day the characteristic variation in temperature may readily escape notice. In uncomplicated cases intracranial symptoms, such as severe headache, paralysis, or convulsions, are absent. Sooner or later symptoms of general sepsis occur — asthenia, emaciation, an ashy hue of the skin, and profuse perspira- tion. Severe rigors may or may not occur. A certain number of cases of primary thrombosis recover spontaneously, although it is impossible to state how many die subsequently of secondary cerebral abscess and other sequelae of the disease. Treatment. — Early operation if the diagnosis is certain. The only therapeutic measures of value are those which combat the asthenia. Nutritious food, by mouth or rectum, large doses of quinin, and alcoholic stimulants. When the mastoid antrum has been previously opened the original opening should be enlarged backward and downward, and the dura exposed as far as the occipitotem- poral suture. After the sinus has been exposed the presence of a clot may be ascertained by the sense of touch or by in- serting a sterilized hypodermic needle. If a thrombus is present pus or foul-smelhng blood are usually withdrawn, but if the channel is normal, fluid blood alone enters the syringe. To remove an infectious thrombus the sinus is freely incised and its cavity emptied by the delicate use of a curet until decidedly free hemorrhage supervenes. The cavity should then be packed with iodoform gauze. When the clot has extended downward into the jugular vein, as evidenced by tenderness along the anterior border of the sternocleidomastoid muscle and a cord-hke structure occupying the position of the vein, the vessel should be exposed, laid open between two ligatures, and the clot re- moved as from the lateral sinus. Any large tributary vein JNl'RACRANIAL COM PLICATIONS OF OTIC DISK ASK 483 should, however, be tied before dividing the jugular. If the operation is performed before secondary abscess or profound systemic infection has occurred it may result in the re- covery of the patient. Facial paralysis or Bell's palsy is a paralysis or paresis of some or all of the muscles supplied by the facial nerve. In the graver form of the disease there is complete immobility of the muscles of expression of the affected side of the face, slight deafness from involvement of the stapedius muscle, unilateral paralysis of the uvula and the palate, and unilat- eral impairment of the sense of taste at the anterior two- thirds of the tongue, through involvement of the chorda tympani nerve. Etiology. — The disease may be central^ as the result of basilar meningitis, tumors or exostoses at the base of the brain, syphilitic lesions in this situation, or aneurysm of the vessels at the base of the brain. Not a {q.\n cases are apparently rheumatic and result from exposing one side of the face to a draft, sitting in a damp room, or suddenly chilling the body when overheated. The disease is of interest to the aurist chiefly from the fact that it may occur as a complication in a large variety of middle-ear affec- tions, or as a result of the nerve being bruised or wounded during the course of an operation upon the middle ear, or from packing the wound too tightly after the operation. It should be borne in mind that the facial canal arches back- ward over the oval window and then descends almost per- pendicularly through the temporal bone. As the result of the oblique position of the drum-head the facial canal ap- proaches in some skulls to wdthin i millimeter of the annu- lus, at a position about midway between the floor and the roof of the canal. The pressure of a polypus or an accu- mulation of epithelium or cerumen on the nerve through the thin bone in this region is sufficient in some cases to produce paralysis of the facial nerve, usually remediable by the removal of the offending body. General h% however, the facial nerve in its passage through the middle ear is de- fended by comparatively thick and hard bone. In some in- stances, however, the bone covering the nerve above the oval window is as thin as tissue-paper, and congenital dehiscences 484 DISEASES OE THE NOSE, THROAT, AND EAR of the bone of this region are by no means uncommon, so that the nerve in such cases lies almost immediately under the mucous membrane. Such a congenital lack of bone in this position explains the occasional occurrence of facial paraly- sis as the result of simple non-suppurative catarrh of the middle ear. Suppuration of the middle ear is a common cause of facial paralysis, sometimes so slight that the lack of mobiHty of the affected side of the face can be detected only by the closest scrutiny ; at other times the paralysis is complete and involves all the muscles supplied by the facial nerve on the affected side of the face. Such cases are doubt- less the result of pressure on the nerve caused by spreading of the inflammation from the mucous membrane to the bony wall of the facial canal and the sheath of the nerve, and are the more favorable instances of the disease ; for after the subsidence of the inflammation and the absorption of the exudation the facial paralysis disappears spontaneously. Facial paralysis occurs during caries and necrosis of the temporal bone if the inflammation and destruction extend to the nerve ; but caries of the facial canal is not always accompanied by paralysis, for instances are on record where, as the result of caries, the nerve has been exposed and bathed in pus for months without the occurrence of facial paralysis. Facial paralysis in more than one instance has followed the simple removal of the drum-head and larger ossicles, and is not uncommon as the result of the mastoid operation. Most of these cases ultimately completely re- cover, sometimes even when there was reason to suppose that the nerve had been completely severed. When work- ing in the neighborhood of the facial nerve some operators are in the habit of directing their assistant to watch for slight twitching of the muscles of the face, and desist im- mediately should this occur. When twitching of the face occurs under these circumstances it is an indication that mischief has already been done to the nerve, and, unless absolutely necessary, the vicinity of the facial nerve should be studiously avoided during the Stacke and mastoid opera- tions. Many operators are accustomed, when performing Kiister's operation, to guard the position of the facial canal with a bent probe or similar device introduced into the tym- INrKACRANIAL COMPLICATIONS OF OTIC DISEASE 485 panum through the opening in the mastoid bone. Doubt- less this is a useful procedure in some instances, but the use of the probe in this manner is apt to produce a misleading sense of security, and there are reasons for believing that in some instances the injury to the nerve has been done by the slipping of the probe entrusted to the hand of an assistant rather than by the instrument in the hands of the operator. The wound in the bone after a middle-ear operation should be only lightly packed with gauze, especially in the case of children. Symptoms. — Double facial paralysis is somewhat rare. When it does occur and is complete the face is absolutely expressionless and as immobile as that of a graven image. In a case observed by Troltsch the cornea was partly dried as the result of ectropion of the lower lid, the under lip hung loosely down, and the chin had to be pushed up in speaking and eating. Facial paralysis sometimes appears quite suddenly, but in many instances there are premonitory symptoms of pain in the side of the head and twitching of the muscles of the side of the face. A patient suffering from complete facial paralysis is unable to wrinkle the brow or close the eyes, although the upper eyelid often descends somewhat during the effort. On account of the paralysis of the orbicularis the puncta lacrimalia drop away from the globe and the eye is constantly suffused with tears, and, being no longer protected from dust and cold by the mo- tionless lids, soon becomes inflamed. The ala nasi on the affected side cannot be distended during inspiration and hence nasal respiration and the sense of smell are impaired on the affected side. The angle of the mouth drops a little and is drawn somewhat toward the unaffected side. While drinking, some of the fluid dribbles from the corner of the mouth ; and the food collects between the cheek and the teeth, so that it is necessary while eating to remove it from time to time with the finger. If the cheeks are distended air escapes at the corner of the mouth, and because of the paralysis of the palate-muscles it is usually necessary to employ the Eustachian catheter if the ears require inflation. The hearing is usually somewhat impaired as the result of paralysis of the stapedius muscle, but sometimes becomes 486 DISEASES OF THE NOSE, THROAT, AND EAR still worse, if care is not exercised, from Eustachian salpin- gitis resulting from the paralysis of the tubopalatine muscles. When an attempt is made to smile the entire lower part of the patient's face seems to move toward the unaffected side. If recovery does not occur the affected muscles sometimes undergo atrophy, so that the affected side of the face looks smaller than the other. Contractures and spasms of the affected muscles in some cases finally occur, the spasms being clonic in character and not painful. As the result of contracture the angle of the mouth is sometimes drawn up- ward and the nasolabial fold deepened until at the first glance it would appear as if the unaffected side of the face were the paralyzed one. In many instances the paralysis of the facial muscles is not complete, the muscles of the lower portion of the face being the ones most affected. In some instances, however, the muscles of the lower portion of the face and those of the forehead as well will be almost completely paralyzed, while the eye can still be completely shut, although with considerable effort. As this form of paralysis is the most common after middle-ear operations, it would appear that the fibers of the nerve supplying the muscles of the lower part of the face and the forehead occupied a more super- ficial position within the facial canal than those supplied to the orbicularis palpebrarum. Diag7iosis. — In the variety of the disease due to a central lesion the paralysis usually occurs after an apoplectic seiz- ure and other muscles are generally affected besides those of the face. Generally in such cases the muscles of the forehead and the orbicularis palpebrarum are affected to a considerably less degree than those of the other parts of the face, and the electric contractility of the affected mus- cles is not affected in the slightest degree, no matter how profound the paralysis may be. In a certain proportion of cases the unilateral paralysis of the palate, impairment of the function of taste at the anterior two-thirds of the tongue, and the presence of a disease of the middle ear that is capable of causing a lesion of the seventh nerve are points that will help to clear up the diagnosis. In peripheral facial paralysis it is sometimes possible to determine with a cer- INTRACRANIAL COMR/.ICA TIONS OF OTIC DISEASE 4 Aquoe, q. s. f^ij. — M. This formula is extremely useful as a daily application to the larynx in all forms of laryngeal inflammation. A brush or a dossil of absorbent cotton wrapped about a bent probe should be saturated with the solution and applied to the glottis. The appli- cation of antipyrin solutions of the strength of 50 per cent, and upward produces a burning sensation, quickly followed by a sen- sation of relief and comfort. Applied in this manner to the larynx antipyrin is not an anesthetic, but an analgesic whose effects persist for several hours. In the strength of 5 to 10 per cent, solutions antipyrin is superior as an antiseptic to Van Swie- ten's liquid. In therapeutic doses antipyrin acts as an antispas- modic, diminishing the reflex excitomotor power of the spinal cord, and also as an analgesic, relieving the pain of neuralgia and migraine, whether due to reflex nasal irritation or to some other cause. Applications of strong solutions of antipyrin to the larynx should be supplemented by the patient inhaling five or six times a day the spray from an atomizer containing a 4 per cent, solution. The effects of antipyrin upon the heart should, of course, be borne in mind and the patient, if weak, should be cautioned not to swallow any portion of the spray deposited in the mouth, and not to use too large a quantity of the solution at one time, although in a 4 per cent, solution there is in i ounce only about 20 gr. of antipyrin, and much more than this amount 506 DISEASES OF THE NOSE, THROAT, AND EAR in twenty-four hours probably could be used with impunity by most patients. 31. R Atropise sulphatis, gr. iv ; Morphife sulphatis, ^^j ; Aquae, f^j. — M. One or two drops may be applied inside the auditory canal for relief of the pain incident to acute inflammation of the middle ear and myringitis. 3-- Sig. R lodoformi, Ether, Use as a spray for the larynx. PIGMENTS gr. Ix ; |ij.— M. ■hi- R lodini, Potassii iodidi, Glyceriiii, gr. v; gr. XV ; f^j._M. 34- Boroglycerid, 50 per cent. 35- R Acidi tannic], Glycerini, gr. xl; f5J.-M. Formula 35 is an excellent application to the nasopharynx in the postnasal catarrh of adults. In children, Formula ^iZ gen- erally yields better results. Formulas 33-35 may be used in the treatment of chronic and hypertrophic rhinitis. The effects of the applications vary with the amount of the solution used. No more of the iodin solution should be applied at one time than will produce a momentary sensation of discomfort. Applied inside the crypts of the tonsils by means of a cotton-tipped probe bent at a right angle it often brings about a rapid absorption of the hypertrophied glands. Either of the solutions may be applied by means of a suitable cotton-tipped probe to the mucous membrane of the nose or nasopharynx. 36. R Lignol, Oleum olivae, da f^j. — M. Lignol is an oily or tarry substance resulting from the dis- tillation of a special lignite. It is soluble in ether and oils, but not in water. It contains phenol, guaiacol, xylenol, etc., prob- ably combined with pyridin bases. It has antiseptic properties equivalent to a i : 1000 bichlorid solution, and when properly diluted is not irritating to mucous membranes. It is a useful OfNTMRNTS 50/ application in atrophic rhinitis, dihitcd with an c(|ual amount of sweet oil or albolene. Z1- U Petroleum, gm. 43.00 ; Olei eucalypti odoris citri, gm. 0.50 ; Strychni;t nitratis, gm. 0.02. — M. T. liobone. Useful as a pigment in atrophic rhinitis. OINTMENTS 38. li Ichthyol, ^ij ; Adeps lance, Pelrolati, ad f^y — M. Useful as an inunction over the mastoid in commencing mas- toiditis, and as an inunction over hypertrophied lymphatic glands in the neck. 39. R Unguenti hydrargyri, Unguenti iodini, aa ^]. — M. Useful as an inunction over the mastoid in commencing mas- toiditis, and as an inunction over hypertrophic lymphtic glands about the angle of the jaw. 40. li Unguenti hydraigyri, Unguenti iodini, Unguenti belladonnse, dd ^j. — M. Useful as an inunction within the auditory canal in furunculous and diffuse inflammation. 41. U Hydrargyri oxidi flavi, gr. vj ; Olei petrolati, q. s. Petrolati, 5J. — M. Useful as an application in eczema of the auricle after all scabs and crusts have been removed by means of peroxid of hydrogen. This ointment should be well rubbed into the inflamed tissues, and a single application is sometimes sufficient to bring about a cure if care be exercised that purulent discharges from the tym- panum are not allowed to come into contact with the skin of the auricle. 42. R Plumbi iodidi, gr. xlv ; Ammon. chloridi, gr. xlv ; Ichthyol, ^] ; Adeps lanae, q. s. ad. ^j. — M. Ft. unguentum. Sig. External use in glandular inflammations. 5o8 DISEASES OF THE NOSE, THROAT, AND EAR 43. R Cocain hydrochloridi, gr. xij ; Adeps lanae, ^ij, — M. Useful in relieving the pain of subacute catarrh of the middle ear, furunculosis, etc. An ointment penetrates the skin of the canal more readily than a watery solution. For the relief of the pain of aural neuralgia or acute catarrh the ointment is simply placed as deeply within the canal as possible. For the relief of the pain of furunculosis the ointment is smeared upon a cone of cotton, which is wedged into the meatus with as much pressure as the patient conveniently can bear. The pressure, at first pain- ful, ultimately relieves congestion and discomfort. CAUSTICS With the exception of the galvanocautery the caustics most em- ployed in rhinology and otology are chromic and trichloracetic acids. As the destruction of tissue produced by applications of even the solid stick of nitrate of silver is very superficial, it scarcely can be considered a caustic. ASTRINGENTS 44. B Zinci sulphatis, gr. x-xx ; AquDe, f^j.— M. Useful as an application by means of a brush or a dossil of ab- sorbent cotton to the pharynx and larynx in subacute and chronic laryngitis, and to the nasopharynx in subacute nasopharyngeal catarrh. 45. K Tinctura ferri chloridi, Glycerini, ad f^ss.— M. Useful as an application to erosions over varicose vessels in chronic nosebleed. 46. R Acidi gallici, gr. v-x ; Petrolati, SJ-— M. Sig. For patient's use in recurrent nasal hemorrhage and in the chronic rhinitis of children. A piece the size of a pea should be inserted in each nostril night and morning. 47. R Pil. atropiae sulphatis, gr. ■^^-^. Sig. I every three or four hours. Useful in controlling excessive nasal secretion in coryza, hay- fever, and nasal hydrorrhea. ASTRINGENTS 509 48. K: Atropia: sulphatis, gr. ss-iss ; At[UCE destil., fjij. — M. Sig. Use with an atomizer every two hours. Useftil in nasal hydrorrhea. The patient should be informed that the solution is highly poisonous, and cautioned against using a larger quantity than sufficient to barely moisten the nasal mu- cous membrane each time the atomizer is used. 49. li Alcohol, 95 per cent. Useful as an application to the tympanic mucous membrane when it is covered by granulations and small polypi. For the patient's use at home, to cause shrinking of granulations and polypi, alcohol, diluted with an equal amount of water, may be prescribed, to be dropped into the auditory canal several times a day. Should this cause only momentary smarting, the patient should on the next occasion use alcohol 2 parts diluted with water I part, and so on until undiluted 95 per cent, alcohol is dropped into the ear four or five times a day. Practically the ear will then contain alcohol all the time. It acts as a dehydrating agent on polypi and exuberant granulations, destroying their vitality and promoting cicatrization. Its value as an antiseptic also plays its part in bringing about a good result. Boric acid dissolved in the alcohol is sometimes prescribed for the patient's use, but, as under such circumstances when the alcohol evaporates the boric acid is deposited as sharp-pointed crystals on the mucous membrane, it is probable that the boric acid is a source of irri- tation. The same may be said to a less degree of the addition to the alcohol of other dehydrating agents like glycerin and sulphuric ether. In order to secure the best results from instillations of alcohol the patient should lie down with the affected ear upper- most and then straighten the canal upward, outward, and back- ward. The canal should then be filled with alcohol, which should be forced into the tympanum by manipulating the tragus. This procedure also serves to float outward particles of pus and other materials. Polypi of considerable size may be destroyed by this method, but it is somewhat tedious if the polypi are large, and hence such growths should be removed by snare or forceps. 50. R Argenti nitratis, gr. x-^ij ; Aquae, f^j. — M. Silver nitrate (3J to i ounce of water) is useful as an applica- tion to the pharynx or tonsils in acute pharyngitis or tonsillitis. When applied sufficiently early it will often abort the disease if 5IO DISEASES OF THE NOSE, THROAT AND EAR used two or three times a day. When painted upon the lateral walls of the pharynx it produces at once a feeling of relief and comfort which persists for some time ; when painted upon the posterior wall of the pharynx, a sensation of dryness and great discomfort. Hence it should not be used in this portion of the pharynx except for touching small areas of granulation tissue, etc. However, lo-gr. solutions are permissible. Solutions of silver nitrate (60 gr.) also may be used as an astringent application to small polypi and exuberant granulation tissue in the tympanum. However, for this purpose it is far in- ferior to strong alcohol. Even the solid stick of silver nitrate when applied to granulations in the ear produces only a super- ficial destruction of tissue, and in this respect is far inferior to chromic or trichloracetic acids. 51. R Protargol. 52. H Argyrol. The above are two of the best of the organic compounds of silver. Of the two, argyrol is probably the more valuable in con- trolling inflammations of mucous membranes. Protargol may be used as a spray to the pharynx or larynx in 10 per cent, solutions and argyrol in 20 per cent, solutions. Both produce ugly stains on linen, but do not stain the skin. They stop up atomizer tubes somewhat quickly, and hence are not well adapted for patient's use at home. Protargol and argyrol, when applied to mucous membranes, are somewhat astringent antiseptics, are devoid of the irritating effects of silver nitrate, and penetrate the tissues more deeply. Argyrol in 10 per cent, solution is especially serviceable in the recurrent attacks of otorrhea where the drum- head has been destroyed. If applied at an early stage of the attack a single application by means of a cotton-tipped probe will usually abort the attack. It is valuable as a non-irritating antiseptic injection by means of Blake's cannula into the attic of the tympanum in attic otorrhea, often bringing about a cessation of the discharge. Purulent inflammation of the accessory sinuses of the nose may be treated by first cleansing them by injections of sterile water, peroxid of hydrogen, etc., and then injecting a small quantity of a 20 per cent, solution of argyrol, which is allowed to remain. The non-toxic and non-irritating properties of this antiseptic permits this being done with impunity. Under such circum- stances the discharges are stained brown and are rapidly changed in character from purulent to mucoid. D USTING- PO WDERS 5 1 1 DUSTING-POWDERS 53. li Menthol, gr. j; Sodii bicarb., gr, ij ; Magnesii carb. (l^^'vis), gr. iij ; Cocain hydroclikM., gr. iv ; Sacchari iaclis, ^iss. — M. Sig. Use as snuff every two or three hours. The most marked relief follows the use of this powder, and a itw applications will do much to abort acute rhinitis. Its effects are immediate, highly agreeable to the patient, and continue for a number of hours. The preparation should be dispensed in a tightly-corked vial to prevent evaporation of the menthol, and a pinch should be sniffed up into each nostril every two or three hours or sufficiently often to maintain the nose in a putulous con- dition and limit the secretions. As the result of the use of the snuff the patient remains practically free from all nasal symp- toms during the attack, and there is no danger of contracting the cocain-habit where the laws, as in Pennsylvania, forbid the refill- ing of a prescription containing cocain without the consent of the physician. 54. H Argenti nitratis, gr. x ; Zinci stearatis, ^j. — M. 55. H Argenti nitratis, gr. xx ; Zinci stearatis, ^ij. — M. Formulas 54 and 55 are useful in the treatment of atrophic rhinitis. Formula 54 should be applied with the powder-blower to the nasal mucous membrane as long as its use is followed by a moderate amount of smarting and increased nasal discharge. When this ceases to occur Formula 55 may be used. 56. B; Zinci sulphatis, Sacchari lactis, dd ^\] ; Acacise, gr. x. — M. 57. B Alumnol, ;5J ; Sacchari lactis, ^ij. — M. Useful as applications to the laryngeal mucous membrane in acute and chronic laryngitis. In cases in which bronchitis as well as laryngitis is present the powder should be applied during deep inspiration, in order that it may reach the trachea and bronchi. 5 12 DISEASES OF THE NOSE, THROAT, AND EAR 58. li lodoformis, gr. xxx ; Acidi tannici, ' gr. xx ; Sacchari lactis, gr. xxx. — M. Useful as an application in syphilitic and tuberculous laryn- gitis. 59. R Bismuth, subnitratis, SU > Acacise, gr. x ; lodoformis, 5^ss ; Morphise sulphatis, gr. xx; Acidi tannici, gr. xxx. — M. Useful as an application to the laryngeal mucous membrane in tuberculous and syphilitic laryngitis, in the earlier stages of acute laryngitis, or in any laryngeal affection characterized by irrita- bility and pain. 60. R Orthoform. This nearly insoluble substance has the property of producing analgesia when applied to exposed nerve-endings. It is, there- fore, especially valuable as an application to irritable ulcers after they have been cleansed with Dobell's solution or peroxid of hydrogen. Its anesthesic effects are increased by a previous application of a solution of cocain and persist for four or five hours. When insufflated into a tuberculous larynx the powder produces a momentary smarting, followed by analgesia more or less complete, which persists as long as the powder adheres to an abraded surface or an ulcer. The powder possesses decided anti- septic qualities and promotes the healing of tuberculous ulcera- tions. It has little effect upon the unbroken mucous membrane and its prolonged application to the skin in the neighborhood of ulcerations sometimes causes eczema, A nurse or one of the patient's friends can be taught to insufflate orthoform into a tuberculous larynx ten minutes before each meal, and in many instances thus secure complete relief from dysphagia. Orthoform is said to be non-toxic, and hence may be used locally in liberal quantities. 61. R Pulvis acidi borici. It is absolutely necessary that the powdered boric acid, in- sufflated within the tympanum as an application in the treatment of purulent inflammation, should be impalpable and free from all grit, as the sharp-pointed crystals of this substance are extremely irritating. A good plan is to test the powdered boric acid by rubbing a small quantity upon the lip with the tip of a finger, D USTING-PO WDKkS 5 I 3 rejecting as unfit for use inside the ear those specimens that are "gritty." It is important also that too large a quantity of boric acid should not be thrown into the ear at one time or it may form a hard mass and thus prevent the escape of discharges. This is less likely to occur if the powdered boric acid be triturated with tincture of calendula officinalis, as advised by Sexton. The following powders are of use in the treatment of otorrhea : 62. B Chinolini salicylatis, 3ss-j ; Pulvis acidi boric!,- ^j. — M. Burnett. 63. U Aluminii, gr. x ; Pulvis acidi borici, ^j. — M. 64. R lodoformi, ;5J ; Pulvis acidi borici, ^j. — M. 65. R Pyoktanin, 3J ; Acidi borici, 3^~E'i- — M. Sig. Use as a dusting-powder in otorrhea where the opening through the drum-head is sufficiently large to permit the entrance of the powder into the tympanum. Pyoktanin (J>us destroyer) or methyl-violet is an anilin dye occurring in the form of a paste and in crystals. It is said to penetrate the tissues and act upon deeply imbedded pathogenic micro-organisms. It has been used somewhat more extensively than at present in the treatment of otorrhea. The chief objec- tion to its use is the deep-blue stain imparted to the skin of the auricle by discharges containing pyoktanin when they escape from the canal. This stain, however, is somewhat readily re- moved by washing with alcohol. Solutions of pyoktanin of the strength of i : tooo or even I : 100 may be injected into the attic in chronic otorrhea after a preliminary cleansing with water and peroxid of hydrogen. Under such circumstances it penetrates somewhat deeply and is rapidly absorbed by any bacteria present. These are deeply stained and are said to be killed or at least rendered inert by the dye. Pyoktanin may also be used as a dusting-powder combined with boric acid, as in the above formula. The paste is sometimes molded into the form of pencils and used to rub into syphilitic ulcerations, etc. A variety of the drug is yellow, but is said not to be so active as the violet pyok- tanin. 33 514 DISEASES OE THE NOSE, THROAT, AND EAR Pyoktanin, when given internally in doses of 2 or 3 gr. three times a day, stains the urine a deep blue, and after the drug has been taken for two or three days the urine of such persons will remain aseptic for three weeks, even when exposed to the air in an open vessel. While pyoktanin undoubtedly possesses con- siderable value as a comparatively safe antiseptic, its usefulness has been greatly restricted, both in the treatment of otorrhea and in genito-urinary surgery, because of the objectionable blue stains w^hich it produces, 66. H Acetanilid, ^ ^h 5 Acidi borici, * ^j. — M. Sig. Use as a dusting-powder to infected or foul-smelling wounds after mastoid operations. Acetanilid, a derivative of anilin, is a white powder but slightly soluble in water and possessing decided antiseptic prop- erties. It is, either alone or diluted with boric acid powder, a somewhat popular hospital dressing for superficial wounds ' ' that are not doing well." It is especially useful in wounds after a mastoid operation where the discharges are foul smelling and the chiseled bone remains long uncovered by granulations. The powder, under such circumstances, should be thickly dusted into the wound. lodin is liberated when the substance is brought into contact with organic matter and acts as an antiseptic. 67. R Nosophen. Sig. Use as a dusting-powder for the nose or middle ear. This compound, obtained by the action of iodin upon a solu- tion of phenolphthalein, is free from odor or taste and contains 60 per cent, of iodin. It is free from irritating effects when applied to the mucous membrane of the nose or tympanum and may be used as a dusting-powder as a substitute for iodoform after operations in such localities. 68. R Aristol (dithymol diiodid). Sig. Use as a dusting-powder for the nose or middle ear. Aristol is probably the most valuable of all the ''substi- tutes for iodoform," as it has a faint but agreeable smell some- what resembling thymol. It is used somewhat extensively as a dusting-powder to the wound after operations on the middle ear, nose, and pharynx to promote cicatrization. It is not irritating to the nasal mucous membrane. Aristol is a reddish- brown, amorphous powder, containing about 45 per cent, of iodin, which is slowly liberated into a wound dusted with this powder and packed with sterile gauze. AJ/IKRA riVES 515 69. H lodoinulli. 70. H Bismuth, .subiodidi. Either of the above are sometimes useful as dusting-powders in otorrhea where a sufficient amount of the drum-head has l^een destroyed to permit their being thrown upon the exposed mucous membrane of the tympanum. 71. H Pulvcris ahimiiii compositoc. E. R. Squib >S: Sons. 'rhe compound aUim powder of Squib is often useful in pro- moting early epidermization of the tympanum after the radical mastoid operation. 72. Xeroform. H Bismuth oxid, 49 \)&x cent. Tribromphenol, 50 per cent. Xeroform or bismuth tribromphenol is an odorless synthetic product of the manufacturing chemists, and presumably has the sedative and astringent properties of bismuth combined with the marked antiseptic qualities of bromin and carbolic acid. As it has been given internally (5 to 7 gm. daily) by Hueppe, during the cholera epidemic at Hamburg, in 1893, with excellent results, it may be assumed that its local application to wounds and mucous membranes is absolutely devoid of danger of toxic effects. Upon wounded or inflamed mucous membranes it is an astringent, anal- gesic, and an antiseptic. Somers i^Neiu York Med. Jour., December 24, 1898) speaks with enthusiasm of the value of xeroform in aural practise. He has used it in more than 100 cases of chronic suppurative otitis media. It does not stain like pyoktanin or cake like boric acid, and it greatly modifies the character of the discharge from the middle ear. It promotes epithelial growth and cicatrization and relieves the annoying pruritus which tends to delay the repair of the tissues. ALTERATIVES 73. R Hydrargyri bichloridi, gr. j ; Potassii iodidi, :^ij ; Aquee, fgiij. — M. Sig. I to 3 teaspoonfuls after meals. This formula, sometimes called '' i, 2, 3 mixture," may be ordered when it is desired to employ the mixed treatment in syphilis. 5l6 DISEASES OF THE NOSE, THROAT, AND EAR 74. ^ Tablet triturat. hydrarg. protiodidi, gr. \. Sig. I tablet may be taken three or four times a day or even oftener, with a sufficient quantity of opium, if necessary, to prevent diarrhea. Useful in the treatment of primary and secondary syphilis. 75. R I'il- hydrarg. biniodidi, gr. jV-s- Sig. I pill may be taken after each meal. Useful in the treatment of the later stages of syphilis. 76. IjL Hydrarg. bichlor., gr. iij ; Aqute deslil., l^j. — M. Sig. Corrosive sublimate solution for hypodermic use. m>^ = g'-- T6- mx"j = gj^- T2- m^v = gr. j^. i^xx = i Useful in syphilitic affections of the nose and throat where it is advisable to get the patient under the influence of mercury as speedily as possible. The injections may be made as often as once a day, deep into the cellular tissue of the back. The injec- tion causes a moderate amount of pain, which continues for about an hour, and the place where the injection was made remains a little sensitive to the touch for twenty to forty-eight hours ; ab- scess does not occur when the proportion of corrosive sublimate is not greater than in this formula. In a small proportion of cases mercury or iodid of potassium produce a violent reaction, the syphilitic lesions, for the time at least, being rendered worse instead of better by the exhi- bition of these drugs. Other cases, because of the disturbance of the gastro-intestinal tract, cannot tolerate either the iodids or mercury. Such cases generally do well on the following pre- scription : 77. R Ext. berberis aquifolii, f^iv- Sig. 15 to 120 drops in water every three hours. The initial dose is 15 drops every three hours, increased 5 drops per week until the patient is taking 2 fluiddrams every three hours. The dose is then reduced each week until the initial dose of 15 drops is reached. This is continued for a week or two and again increased. 78. R Tr. guaiac. ammoniati, f^j. Sig. \ teaspoonful in milk every three or four hours, gargle and swallow. See Formula 138. Useful in acute pharyngitis or tonsillitis of rheumatic origin. HYPNOTICS 8o. K Trional, 8i. li Sulphonal, 82. R Paraldehyd., Olei gaultherioe, Pulveris acacioe, Elixir simplicis, HYPNOTICS 517 79" R Potassii bromidi, ?ss ; Potassii iodidi, Tiss; Ext. glycyrrhizK, ^^iss ; Aquoe, q. s. ad. V^iv.— M. Sig. I teaspoonful three or four times a day. Useful in pharyngitis sicca, to increase the pharyngeal secre- tions arid relieve the feeling of dryness in the throat. gr. x-xxx. gr. x-xxx. f^ss; q. s. ad. f^iv. — M. Sig. \ to I tablespoonful in water every hour or two in the restlessness and insomnia following mastoid operations. 83. JJ Chloral hydratis, gr. x; Codein sulpbatis, gr. \\ StrychnicE sulpbatis, gr. ^^. — M. Ft. cbartDe No. i. Sig. To relieve restlessness and insomnia after mastoid operations. Dis- solve in half-tumblerful of water and repeat dose in three hours if necessary. 84. R Somnos, f^iij- Sig. 2 teaspoonfuls to I tablespoonful every hour or two, if necessary, to quiet restlessness and induce sleep after operations. After many severe operations on the nose, throat, or ear the patient for the first night or two will complain of pain, restless- ness, and inability to sleep. This is especially true in neglected mastoid cases that have been operated on only after weeks of needless suffering and consequent demoralization and debility. In some such instances a hypodermic of ] gr. of morphin will be required in order to soothe the patient's sufferings. In other cases a reliable hypnotic produces the desired results. Under such circumstances the choice of an hypnotic in the patient's de- bilitated condition is by no means a matter of indifference, as all hypnotics are to a greater or less degree depressants. Sodium bromid (10 gr.) combined with chloral (5 gr.), repeated every hour if necessary, yielded good results in the practise of the writer for several years. More recently, however, he has relied either on Formula %'^ or 84. It should be observed that in Formula Zt^ any possible depressant effect of chloral on the heart is guarded 5l8 niSEASES OF THE NOSE, THROAT, AND EAR against by the addition of a small proportion of strychnin. Both Formula '^t^ and the succeeding Formula 84 usually produce sleep after one or two doses are taken, and are apparently free from any depressant after-effects. TONICS 85. U Hydrarg. bichlor., gr. i ; ' * Acidi arseniosi, gr. \ ; Ferri pyrophos., gr. vj ; Quinise sulph., gr. xv. — M. Ft. pil. No. xxiv. Sig. I after meals. Useful as a tonic pill in catarrh of the nose and throat, with a debilitated condition of the system. 86. R Tincturae gentianse comp., i%\} ; Elixir cinchonas, f5J ; Syrupi limonis, fo^s; Spiritis frumenti, q. s. ad. f^viij. — M. Sig. I or 2 tablespoonfuls in water before meals. A useful formula where it is desired to administer an alcoholic stimulant, but where it is undesirable from any cause to advise the use of whisky pure and simple. Z-]. H Ext. bellad. fol. ale, gr. iv ; Quin. sulph., gr. xxij ; Ferri sulph. exsic, gr. vij ; Strych. sulph., gr. i; Acidi arsenosi, gr. \ ; Oleoresince piperis, TTLviiss. — M. Ft. pil. No. XV. Sig. I pill three times a day. Jour, of the Avier. Med. Assoc. In the treatment of neuralgia of the ear, which is often a sign of defective nutrition and associated with anemia, the above combination is sometimes useful. MISCELLANEOUS 88. R Contractile collodion. Contractile collodion is sometimes applied to a cicatrix or atrophic drum-head to hold it in a more favorable position for hearing. For this purpose, after inflation by Politzer's method, only a small amount of the collodion should Idc painted upon the drum-head at one time, as there is some danger of producing myringitis if too large an amount of the remedy is painted on the drum-head at one sitting. MISCELLANEOUS 519 89. li Phospliotated oil. Forinerlv many ointments and solutions were a})plied to the membrana tymj)ani for the reliet" of tinnitus and deafness caused by catarrh of tlie middle ear. Although this form of medication has largely been abandoned, i)hosj)horus dissolved in olive oil, if applied to the drum-head, will sometimes bring about im- provement of the hearing in deafness due to senility. 90. li Clilorofurnii. 91. R lodini. 92. U TincUinu iodini, f:^] ; .luher, f5J-— ^I- 93. R Menthol. The vapor of these substances is sometimes used as an appli- cation to the mucous membrane of the middle ear. They should be preserved ready for use in wide-mouthed, glass-stoppered bottles, so that the Politzer air-bag can be filled with their vapor by placing the nozzle of the bag within the neck of the bottle while the bag is expanding. Ether and chloroform vapor will sometimes penetrate into the middle ear through the Eustachian tube when it is impossible to inflate the middle ear with simple air by Politzer' s method or the use of the catheter. 94. R Tincture of gelsemium, Tincture of lobelin, da ^] ; Potassium bromid, ,'^ss. — M. Sig. 20 drops in water every three hours. pjurnett. The above is said to be almost a specific as regards relief in asthma. 95. li Ac. carbol., gr. xxx ; Amnion, carb., ^] ; Pul. carbo. lig., ^j ; 01. lavend., WLxx ; Tr. benzoin CO., ^^^'■< Gum camphor, ^V]. — M. Sig. — .Smelling salts for acute nasal catarrh. 96. R Paraffin, ^iv ; Albolene, ^v. — M. Melt together in container surrounded by boiling water. Sig. For use as a subcutaneous injection for the correction of nasal deformities, etc. 520 DISEASES OF THE NOSE, THROAT, AND EAR For subcutaneous injections sterile paraffin, with a melting- point of 112° F,, is usually employed. When the melting-point is much higher than this, it is not readily forced through a long needle and does not as readily penetrate the spaces of the cellular tissue. When the melting-point is much lower than 112° F., paraffin behaves more like ordinary oil, permeates the tissues more readily, and may enter a vessel and cause embolus. Ordinary commercial paraffin, whose melting-point is usually 128° F., may be reduced to a melting-point of 112° F. by adding 5 parts of albolene to 4 parts of paraffin, the mixture sterilized by boiling it and its container in water, and preserved for future use. Thus prepared the melted paraffin should be drawn into a suit- able syringe (Fig. 93), the nozzle of which is then closed with its screw cap. The syringe with the paraffin it contains and the necessary needle are then sterilized by boiling in water. The syringe and paraffin contained in it are then cooled in sterile water, the screw cap removed, the needle screwed in its place, and the instrument is then ready for use. 97. R Acidi nitromuriatici (concentrated, freshly prepared), f^j, Sig. 5 to 10 drops in a tumbler of water after meals and at bedtime. In a large proportion of cases of hay-fever the above formula will eliminate all symptoms of the disease within forty-eight hours. If after two or three days' use of the remedy there is no improvement in the symptoms, it is probable that nitromuriatic acid will prove useless no matter how long continued. Mineral acids in the treatment of hay-fever are said to owe their efficiency to the fact that they diminish the alkalinity of the blood to an extent that it is no longer capable of holding in solu- tion uric acid, and hence the mucous membranes are no longer irritated by the secretion of this substance. However, in this connection it should be borne in mind that nitromuriatic acid has been employed for several generations as an alterative and tonic in gastro-intestinal diseases and in diseases of the liver, where it is said to increase the biliary secretions. It is probable, there- fore, that when exhibited in the treatment of hay-fever that it not only frees the blood from uric acid but also, by improving metabolism, limits the formation of uric acid and perhaps other products of defective metabolism. It should be borne in mind also in this connection that mineral acids were formerly used more frequently than at present in the treatment of diseases of the upper respiratory tract, 10 drops of dilute nitric acid every two M ISC EL LANEOUS 521 hours in water being an old but usually effective remedy in the treatment of the aphonia of singers and orators. The use of nitromuriatic acid may be commenced at any time before or during the hay-fever season. It is important that the acid be freshly prepared. At first a colorless liquid, it becomes within a iQ.\\ days yellow. The yellow color deepens almost to brown, but finally again becomes lighter, until at length the mixture is colorless. During this period of change in color fumes are given off and the remedy is then thought to be most active in its effects upon the gastro-intestinal tract. When lo drops are diluted with a tumbler of water the water is only slightly sour to the taste, but it is well enough as a precaution against possible injury to the teeth to rinse out the mouth either with pure water or water to which a pinch or two of baking soda has been added. If the use of nitromuriatic acid is successful in eliminating the symptoms of hay-fever, it is probable that they will cease to recur as long as the patient continues to take the remedy regularly. However, should he neglect to take a single dose, more especially the evening dose, it is probable that some symptoms of the dis- ease will be quickly manifested. For example, if the evening dose be omitted, it is probable that the patient will wake up the next morning with his nose occluded and irritable and very likely will have several attacks of sneezing. Prolonged use of nitromuriatic acid is apparently harmless. Some of the writer's earlier cases have used the acid for months at a time year after year during the hay-fever season, and occasion- ally some of them during the winter season as well, without noticing any deleterious effects. In cases where the remedy is effective, it is curative to the extent that it almost completely con- trols the symptoms during the hay-fever season, and there seems a tendency for the attacks to become less and less severe from year to year. In neurotics suffering from hay-fever much benefit sometimes results from large doses (20 to 30 gr.) of bromid of sodium three times a day, which is ordinarily sufficient to control the violent attacks of sneezing. In such cases the following formula is often useful : 98. R Acidi hydrobromici diluti, f^ij. Sig. 15 to 30 drops in a tumbler of water one hour after meals. Hydrobromic acid also yields in the majority of cases some- what better results in the treatment of tinnitus than bromid of sodium or the mixed bromids. 522 DISEASES OF THE NOSE, THROAT, AND EAR 99. K Ext. cimicifugae racemosse, fjij. Sig. 15 to 20 drops after meals and at bedtime. The above is sometimes useful in tinnitus. When effective its beneficial results are manifested within a few days. However, a rather large proportion of cases of tinnitus from chronic middle- ear catarrh are not benefited in the least by the use of cimicifuga. 100. Ijt Atropinae sulphatis, g^"- 4 ; Acidi sulphurici aromatici, f^ij ; Aquae rosae, q. s. ad. f^j. — M. Sig. 20 to 30 drops at bedtime, repeated if necessary. Useful in the night-sweats of phthisis. 101. li Acidi carbolici, gr. iij ; Pulveris camphorae, Resorcin, da gr. xx ; Acidi borici, gr. xxx ; Unguenti zinci oxidi, Jj. — M. Fiat unguentum. Sig. Use twice a day as an external application in acne rosacea of the nose. 102. R Pilocarpinae hydrochloras, gr. -y-^-\- Pilocarpin may be given hypodermically once a day in con- junction with potassium iodid three times a day by the mouth in effusion or hemorrhage into the labyrinth, tertiary syphilis, and traumatism involving the internal ear. The average dose of pilocarpin is about yL gr. hypodermically, but much larger amounts have been used with impunity. When administered for its action on the internal ear a sufficient amount should be taken to produce profuse sweating or salivation. The remedy should be continued a sufficient number of days to produce the desired result, unless the patient becomes greatly prostrated by its con- tinued use or it is manifestly unavailing in the treatment of the internal ear disease. When no improvement is manifest after two weeks' use of the drug it should be abandoned. It rarely is of use except in acute cases. Pilocarpin is a drug whose action should be carefully watched, because serious and even fatal consequences have resulted from the injection of medicinal doses. Shoemaker cites a case where the patient suddenly expired after an injection of pilocarpin. In another case the same author states that the employment of \ gr. was followed by profuse diaphoresis, salivation^ lacrimation, a discharge from the nose, sickness of the stomach, difficulty in breathing, and a sense of cardiac oppression. Internal and external stimulation caused the symptoms to disappear. A tropin is a phys- iologic antidote to pilocarpin. FORMULAS FOR USE WITH NEBULIZERS 523 Pilocarpi!"! may be given l)y the i!iouth instead of h)'])oder- mically, but its effects aie longer in !nanifesting themselves (fif- teen to twenty minutes) and moi^e uncertain. Politzer advises the injection of 6 to 8 drops of a warm 2 per cent, solution through the Eustachian catheter into the Eustachian tube in sclerosis of the !iiiddle ear. Mendosa, in 3 cases, relieved urgent dyspnea fro!n edema of the larynx by hypodermic injections of pilocarpin. FORMULAS FOR USE WITH NEBULIZERS In order to be successfully nebulized a fluid !nust have sufficient viscidity. Glycei-in nebulizes fairly well, but its nebulizing qualities are greatly improved by the addition of a s!nall propor- tion of tincture of benzoin. 1 he benzoin should be added drop by d!"op with constant stirring of the glycerin or shaking of the bottle which contains the glycerin in order to evenly diffuse the benzoin through the glycerin, which beco!nes white and opaque f!-0!n minute particles of benzoin suspended in the liquid. The !nixture is co!nparatively stable and the benzoin contained in about I dram of the tincture can thus be suspended in i ounce of glycerin. Ordinary bleached /^'/r^/^/^/w oil or albolene, with or without the proportion of benzoin it can be made to dissolve, nebulizes fairly well. Alcohol made viscid by the solution of one of the balsams, preferably benzoin, nebulizes fairly well. However, alcohol is somewhat irritating to the bronchial mucous me!nbranes, and in use the product of a nebulizer containing an alcoholic solution is best diluted by the product of one containing a bland oily solu- tion. The alcohol evaporates so!i-iewhat rapidly during the process of nebulization, so that the fluid in the nebulizer becomes more and more concentrated until, finally, the dissolved balsams are deposited within the nebulizer tubes and clog them up to an ex- tent to prevent the instrument working unless more alcohol is added from time to time to replenish that which has evaporated. Any substance can be nebulized successfully if reduced to a fluid state by solution in one of the above three liquids. Essen- tial oils and caiiiphors are best dissolved in albolene for nebuliza- tion ; substances insoluble in oil, either in the glycerin mixture or in alcohol. 11ie following fomiulas may pi'ove useful when used with a nebulizer. They should not be used with an atomizer, because 524 DISEASES OE THE NOSE, THROAT, AND EAR the amount of fluid deposited on mucous membranes by an atomizer is many times greater than that derived from a nebulizer, and some of the following solutions are sufficiently concentrated to produce deleterious results if applied to the nose or pharynx by means of an atomizer. The fact that only a minute amount of nebulized fluid is deposited on the mucous membrane of the upper respiratory tract during the short time available for the treatment of a patient during an ordinary office visit, probably accounts for the lack of enthusiasm manifested by many special- ists for this method of treatment. The atomizer will probably always be the favorite instrument for applying remedies to the nose, pharynx, and larynx of office patients. However, for the patient's use at home, especially when the circumstances are such as to allow the patient to devote con- siderable time to the treatment of his condition, the nebulizer possesses advantages that should not be overlooked. Also in children sufficiently nervous to be terrified by an atomizer spray, the nebulizer can be used to advantage. If necessary the nebulized fluid can be conveyed by a long rubber tube underneath a tent improvised by throwing a sheet over the shoulders of a nurse while the child is seated in her lap. By this method the air sur- rounding the little patient can be saturated with the nebulized vapor, thus securing a prolonged and thorough application of the remedies without producing the struggle and fright so frequent when an atomizer is employed in young children. 103. Ijt Ex. ipecacuanha, f^j ; Glycerini, f^ij ; Tr. benzoin comp., f^j. — M. For use in nebulizer to relieve dryness in throat. Increases fluidity of secretions. 104. R Olei cinnamomi, TTtxx ; Olei eucalypti, 'nix>; ; Menthol, gr. xl ; Camphor, " gr. Ixxx ; Albolene, fjviij. — M. Porch. Antiseptic, emollient. 105. R lodin, gr. xvj ; Camphor, ^^j ; Menthol, ,^j ; Oil pine-needles, ,^ij ; Albolene, fjviij. — M. FORMULAS FOR USE WITH NEBULIZERS 525 For acute and subacute coryza, catarrh in the head passages, dry catarrh, ozena, and rhinitis. May be used regularly by pub- lic speakers, singers, actors, etc. A pleasant stimulant and pro- tective. 106. li Liq. adrenalin chlorid (l : 5000), f3J; Menthol, gr. xl ; Oiei gaultheriae, TTlxx; Cilyceriiii, Aqiuie dcstil., f^viij. — M. fjiv .— M. gm. I ; gm. 2.5; gm. 2-5; gm. gm. ■5; 93-5.- McCli -M. intock. For severe or chronic cases of hay-fever. Constringent, hemo- static, local anesthetic, antiseptic. 107. li Terebeni, Oiei eucalypti, Glycerini, For catarrhal conditions and as an antisepti 108. K Chloietone, Camj^hor, Menthol, Oil cinnamon, Albolene, Anodyne, antiseptic, emollient. Useful in acute and subacute catarrh and bronchitis. According to the manufacturers balsamol is a combination of balsam of Tolu, benzoin, balm of Gilead, and myrrh, with oil of Scotch pine dissolved in alcohol. Respiral is a combination of albolene and cocoanut oil. NabuUn is a glycerin compound. These compounds are used to dissolve the other ingredients in the following ''Globe" formulas and render them capable of nebulization : 109. R Oil eucalyptus, '7^]\ Oil cassia, Tllxxx ; Menthol, gr. xx ; Balsamol,! q. s. ^iv.— M. Use with nebulizer for simple catarrh of the nose, throat, and bronchial tubes, and after the first stage in all acute affections ; ^ If the vapor from balsamol and other alcoholic solutions should seem uncomfortably pungent when applied directly to the nasal mucous membrane, it should at first be diffused or diluted either by using a mask or by holding the nasal tip near, instead of placing it in, the nostril, gradually increasing to full strength. Where a multinebulizer is used, the vapor may be diluted with that from a mild oil solution like Formula 114. 526 DISEASES OF THE NOSE, THROAT, AND EAR also as a preventive during epidemics of the contagious diseases, and in any case where an antiseptic and healing action is desired. Alcohol should be added occasionally as the fluid becomes too thick from evaporation. no. B Menthol, gr. XXX ; Camphor, gr. xxx ; Cocain muriate, gr. xv ; Balsamol,^ q. s. ^iv. — M. Use with nebulizer for acute bronchitis, pneumonia, and all acute inflammatory affections of the air-passages. Alcohol should be added occasionally as the fluid becomes too thick from evapo- ration. III. K Oil cloves, Tllxxx; Creosote (beechwood), 3J ; Oil tar, 5J ; lodin, gr. xxx ; Balsamol,^ q. s. 5iv. — M. Use with nebulizer for pulmonary and laryngeal tuberculosis, and in any condition requiring an active antiseptic. Alcohol should be added occasionally as the fluid becomes too thick from evaporation. ;. K Chloretone, 3iv; Resorcin, gr. XX ; Quinin hydrobromate, •^^j' .. Balsamol,^ q. s. ,^iv. — M, Use in nebulizer for hay-fever, asthma, whooping-cough, etc. Alcohol should be added occasionally as the fluid becomes too thick from evaporation. 113. R Chloretone, ^ij ; Todin, gi-;. xl ; Creosote, .^ij ; Balsamol,! q. s. ,^iv. — M. Use in nebulizer for tuberculosis with irritable cough, and in any condition requiring an alterative, antiseptic, and sedative action. Alcohol should be added occasionally as the fluid becomes too thick from evaporation. 114. H Oil cassia, TnL>^xx ; Camphor-menthol, ^ij ; Cocain alkaloid, gr. viij ; Respirol, q- s. ^iv.— M. 1 See note under Formula 109. FORMULAS FOR USF WITH NEBULIZERS 527 Use with nebulizer for acute colds, sore throat, and in all cases of acute inflammation or congestion of the upper air-passages and middle ear. 115. H Oil cloves, TTlxl ; Oil gaultheria, 3J ; Cocain alkaloid, gr. xv ; Menthol, gr. xl ; Respirol, q. s. ^^iv. — M. Use with nebulizer for acute bronchial and pulmonary con- gestion and inflammation, also in irritable cough of tuberculosis. It is both sedative and antiseptic. 116. H Chloretone, gr. xl Camphor monobromate. 3J; Camphor-menthol,' 3J; Oil sassafras, HJ; Respirol, q. s. |iv.- -M. Use with nebulizer for irritable and ulcerated conditions of throat. 117. Chloretone, gr. 3 Camphor-menthol, 3J; Oil pinus pumilionis, 5J' q. s. 51V Respirol, gr. XXX M. Use in nebulizer for nasopharyngeal and bronchial catarrh with a tendency to hay-fever or asthma. 118. li Chloretone, gr. xl ; Camphor monobromate, "7^} ; Camphor-menthol, ^j ; Cocain alkaloid, Oil anise, ^^^j ; Oil bitter almonds, _:^j ; Respirol, q. s. ^iv. — M. Use in nebulizer for relief of acute paroxysms of asthma, croup, hay-fever, whooping-cough, etc. 119. H Oil terebinth, (rectified), !^iv ; Cocain alkaloid, gr. xv ; Respirol, q. s. ^iv. — M. Use with nebulizer for pulmonary hemorrhage. 120. R Formaldehyd (40 per cent. ), :^iss ; Ext. sarsaparilla cap. fl., ^^iv ; Nebulin, *^j ; Water, q. s. 5iv.— M. 528 DISEASES OF THE NOSE, THROAT, AND EAR Use in nebulizer for diphtheria, tonsillitis, hay-fever, and all diseases of a zymotic origin, and in all conditions requiring an active germ destroyer. 121. Ijt Tannic acid, ^j ; Nebulin, ^j ; Cinnamon -water, q. s. ^iv. — M. Use with nebulizer in relaxed conditions of mucous membrane and in passive congestion. It is a simple astringent. FORMULA FOR THE BOTTLE INHALER, CROUP KETTLE, ETC, The steam from a kettle containing unslaked lime has been used for many years in the treatment of croup and diphtheria. A croup kettle consists usually of a vessel with a long spout, to which a rubber hose is attached, by means of which steam is conveyed to the vicinity of a patient or under a croup tent erected over a bed. As the quantity of unslaked lime that will dissolve in water is not great, a piece of lime the size of a walnut is more than sufficient for several quarts of boiling water. The following formula may be used with the bottle inhaler or added to the water in a teapot containing boiling water. 122. R Tr. benzoin comp. Sig. Add \ teaspoonful to a bottle inhaler half-full of hot water. Use the inhaler four or five times a day. Useful in most forms of laryngeal inflammation. To the above formula, when requisite, an expectorant — ammonia muriat., fluid extract of senega, or ipecac — may be added. When it is desired to diminish expectoration and at the same time produce a sedative effect upon the laryngeal mucous mem- brane, fluidextract of belladonna or hyoscyamus in combination with the compound tincture of benzoin will yield satisfactory results. COUGH MIXTURES Although remedies designed to affect the respiratory tract are best administered by means of an atomizer or nebulizer, and when that is impossible or inconvenient in the form of a lozenge, yet the cough mixture still retains at least a measure of its former popularity. The following formulas are effective and sometimes convenient to prescribe : COUGH MIXTURES 529 123. IJ Syrup ipecac, (5ss; Syrup scilhv, f^vj ; Liq. potass, citrat., f?j ; Mucil, acacia;, q. s. ad. f^iij. — M. Sig. I tcaspoonful in water every three liours. Ilaehnlen. Useful for controlling the coughs of children. 124. H Potassii bromidi, ^ss ; Potassii cyanidi, gr. iss ; Ext. prunus virginiani, f^^ss ; Ext. grindelia robustce, fjiij ; Muc. acaciac, Aquae dest., dd q. s. ad. fjiv. — M. Sig. 1 teaspoonful in water four times a day. Useful in the so-called " useless or dry cough " of nervous individuals due to pharyngeal irritation. 125. U Morph. sulph., gr- j 5 Syr. limonis, • ^ij ; Syr. scillce, Syr. pruni virg., dd ^]. — M. Sig. I teaspoonful every four hours. 126. ifc Morphin?e sulphatis, gr. ss-ij ; Potassii cyanidi, gr. iij ; Acidi sulphurici aromatici, %'-iJ 5 Syrupi pruni virginianre, q. s. ad. f^iij- — M. Sig. I teaspoonful every two or three hours if required to prevent coughing. Useful as an anodyne, but somewhat stimulating cough mixture. 127. U Amnion, carb., ^ij ; Syr. seneg?e, ^] ; Aq. fontan., ^iij. — M. Sig. I teaspoonful every two or four hours. Useful as an expectorant. 12S. R Codeinje sulph., gr. iv; Syr. glycyrrhizae, Syr. tolutani, dd 3J.— M. Sig. I teaspoonful every two or four hours. 129. R Codeinae, gr. iv ; Acidi hydrocyanic! diluti, tttxxxij ; Syrupi tolutani, q. s. ad. f^^ij. — M. Sig I teaspoonful three or four times a day. Da Costa. Both the above are most useful as sedative cough mixtures. 34 530 DISEASES OF THE NOSE, THROAT, AND EAR 130. K: Heroin, g'- J ; Creosoti, m^vj ; Eucalyptoli, gr. viij ; Strycbnioe sulphatis, gr. i; Terpin hydratis, 3ss; Syrupi aurant. cort., Mucilag. acacice, aa 5J. — M. Sig. I teaspoonful every three or four hours. 131- li Terpin hydratis, gr. xxxvj Heroin hydroch., g»"- J ; , Ext. sumbiil, gr. xij ; Ytxxx valerianaiis, gr. xij.— Fiat capsul. No. xii. Sg- I every four hours. M. GARGLES Gargles are of little value unless employed with more than the usual care. Pope, by means of experiments with methylene- blue and other substances, demonstrated that as ordinarily per- formed gargling does not bring a medicament in contact with the fauces further back than the anterior pillars. When neces- sary to prescribe a gargle the patient should be instructed to close the nose tightly, throw the head far back, and gargle. By this method the probability of the fluid reaching the posterior wall of the pharynx is increased. Children cannot use a gargle, and rarely is it practical to teach a patient to gargle properly during an ordinary ofhce visit. Gargles as ordinarily employed rarely reach the posterior wall of the pharynx and never the larynx. However, the following are cheap astringent gargles, and they may at some time be convenient to prescribe. The small amount of the gargle swallowed is, of course, effective. 132. R Glycerol tannici, ^j. Sig. I teaspoonful in a half-tumbler of vv'ater. Use as a gargle. Astringent gargle. 133. R Alcoholis, 95 percent. Sig. Use as a gargle. Antiseptic and astringent. 134. R Listerin. Sig. Use as a gargle. Sedative and antiseptic. 135. R Acidi tannici, Acidi gallici, aa gr. xx. — M. Sig. Add to a tumblerful of water. Gargle and swallow a portion. As a styptic after tonsillotomy to control oozing of blood. LOZENGES 53 136. li Hydrogen (lioxid, 15 voIuiiil'S (3 per cenl. ). Sig. Use as a gargle lo control oo/.iiig ol' blood after loiisilloloiny. U7- li Tincturx ferri chloridi, £31]; Potassii bromidi, 3U » Potassii chloratis, ^iij ; Ext. glycyrrhiza, 3J ; AqiKV, q. s. ad. I'^vj.— M. vSig. I teaspoonful in water every two hours, gargle and swallow. Useful in acute pharyngitis and tonsillitis. LOZENGES Lozenges, when well made, are superior to cough syrups or gargles for the treatment of throat affections. The excipient for each formula should be selected for its harmony with the active drug and its solubility. They should be so made as to dissolve sknoly and evenly in the mouth, thereby giving a more prolonged local effect than is possible with gargles or a spray, and a c|uicker and more pronounced result than can be obtained by a greater quantity of the medicant introduced into the stomach. The favorite excipients seem to be black-currant paste and gel- atin. Because of the length of time required for the drying of lozenges, druggists cannot quickly make them from the prescrip- tion of a physician, and it is therefore better in most instances to rely on the manufactured product of lozenge-makers, some of whom have national or international reputations. A business man can carry a bottle of lozenges in his vest pocket and take one as required from time to time, when he would be embarrassed by the use of an atomizer. However, it should be remembered that lozenges produce both a local and a coiistitutional effect and are only especially useful Avhen this effect is desired. Where the constitutional effects of a drug is not desired its use in the form of a lozenge is less desir- able than that of a spray, although the spray may be much more inconvenient for the patient. Lozenges have in common with cough mixtures a notorious reputation for disordering the stomach. This is largely due to the character of the excipient and the method of manufacture. Most of the following formulas have been selected from the stock lozenges of manufacturers. Among those the writer has found most useful are — 532 DISEASES OF THE NOSE, THROAT, AND EAR GUAIACUM AND ITS COMBINATIONS "In cases of deep tonsillitis there is, fortunately, a remedy which, if administered at the outset of the attack, will almost always cut short the crescent inflammation. This is guaiacum. I prescribe it as a lozenge. Taken in this way it seems to have a local as well as a constitutional effect." — Morell Mackenzie. 138. IJ Troch. guaiac,. gr. ij. The lozenges are stimulant and alterative, and are capable of arresting recent inflammation of the tonsils. These lozenges should contain 2 gr. of the resin of guaiacum and made in accordance with Mackenzie's formula, so as to be efitirely soluble in the mouth. They are useful in the treatment of acute and subacute inflammation of the pharynx and acute follicular disease of the tonsils. Mackenzie claims that guaiacum is a specific in acute tonsillitis, and Sajous is equally emphatic in praise of the remedy. 139. Troch. guaiac. comp. R Resin guaiac, gr. ij ; Potassii iodid, gr. j. — M. Wm. Pepper. Stimulant and alterative. Efficient in throat disorders with syphilitic taint. Is especially useful when in acute inflammations of the tonsils there is a sensation of dryness, as the iodid increases secretion. 140. Troch. guaiac. et acidi tannici. H Resin guaiac, gr. iss ; Acidi tannici, gi". \. — M. Sig. I lozenge to be dissolved slowly on the tongue every one or two hours. Stimulant and astringent, probably the most useful of the guaiacum lozenges in acute and subacute inflammation of the tonsils, pharynx, and larynx. Useful in the so-called "relaxed throats " of public speakers. They are especially useful inhyper- emic throat disorders caused by cold and damp atmospheric con- ditions. The astringent action of the tannic acid is greatly assisted by the alterative effect of the guaiacum upon the con- gested mucosa, and they effectively reduce the capillary tension and quickly relieve the inflammation. They are pleasant to ad- minister and do not constipate. 141. Troch. guaiac. and benzoic acid. R Resin guaiac, gr. ij ; Acidi benzoici, gr. j. — M. J. F. Martenet. LOZENGES 533 Stimulant in nervomuscular weakness of the throat. It is somewhat useful in tlie treatment and the loss of control of the laryngeal muscles experienced by nervous actors, singers, and orators, and those of these professsons who have lost confidence in their ])owers as the result of subacute inflammation of the pharynx and larynx. In addition to the lozenge, J„ gr. of strychnin or i dram of fluidextract of cocoa in i ounce of sherry wine may be prescribed, to be taken a few moments before going upon the stage or platform. Any one of the above guaiacum lozenges may be used every one, two, or three houns, according to the acuteness of the inflammation. CAMPHOMENTHOL AND ITS COMBINATIONS 142. R Troch, camphomenthol, gr. J^. Sig. I lozenge dissolved on the tongue every hour or two, as required. These lozenges exert a more soothing and corrective effect upon the nerves and blood-vessels of the mucosa than do the usual preparations of menthol. They check excessive discharges, liquefy tenacious mucus, correct perverted secretions, and are an excel- lent voice stimulant. 143, Troch. camphomenthol et eucalypti. R Eucalyptus rostratce (red gum), gr. j ; Camphomenthol, gr. yL. — M. Sig. I lozenge dissolved on the tongue every hour or two, as required. A pleasant antiseptic astringent, with sedative effect upon irri- tations of the mucosa. When greater anodyne effect is desired, in acute or chronic bronchitis, the following is an efficient and reliable sedative : 144. Troch. codein comp, R Codeinae, gr. JL . 10 ' Camphomenthol, gr. J^. — M. Sig. I lozenge to be dissolved slowly on the tongue every one or two hours if required to prevent coughing. 145. Troch. heroin. K Heroin, gr. J^ ; Camphomenthol, gr. J^. — M. Sig. I lozenge every two hours if required to relieve cough. 146. Troch. orthoform comp. R Orthoform, gr. j ; Camphomenthol, gr. -^-^. — M. Fiat troch. No. i. Sig. I ten minutes before meals or as required, as a safe analgesic after throat operations and other pamful conditions of the pharynx and larynx. McConachie. 534 DISEASES OF THE NOSE, THROAT, AND EAR COCAIN AND ITS COMBINATIONS Instead of the above orthoform lozenge, either of the two fol- lowing may be employed in the dysphagia of tuberculous laryn- gitis, where greater analgesia is required : 147. Troch. cocain comp. R Cocain hydroch., g^'- To 5 Extract, hyoscyami, gr. J^ ; Extract, opii, gr. J^ ; Tincturae aconiti, TTLt- — ^I- Sig. I lozenge a few muments before eating and every two or three hours J. J. Chisholm. This combination is of considerable value as an anesthetic and anodyne in the laryngeal lesions of phthisis and to control the paroxysms of asthma. 148. H; Cocain hydrochloridi, gm. 0.002 ; Acetanilid, gm. 0.02. — M. Fiat troch. No. i. Sig. I four to six times a day. Winslow. These lozenges have a pungent taste and leave an agreeable tingling sensation in the throat. They are useful in chronic pharyngitis associated with painful deglutition, paresthesia, and various neurotic sensations. 149. H Cocain hydrochloridi, gr. i-1. Fiat troch. No. i. Sig. I before meals to relieve painful deglutition in tuberculosis, cancer, etc., of the larynx. AMMONIUM SALTS AND THEIR COMBINATIONS Am.monium salts have long been used in the treatment of pharyngitis and bronchitis. They may be given in the form of a lozenge for the local effect on the pharynx, but the lozenge should be so made that the ammonium salts do not dissolve more rapidly than the other ingredients of the lozenge. 150. R Troch. glycyrrhiza comp. Sig. I lozenge every two or three hours. Brown mixture lozenges should be so made that each lozenge corresponds to a teaspoonful of the well-known *' brown mixture. ' ' LOZENGES 535 151. B Trocli. ammonia.' comp Sig. I every two or three hours. Pennsylvania Hospital formula. 152. li Ammoniix: chloridi, gr. ij. Fiat troch. No. i. Sig. I every two or three hours as a stimulating expectorant. Morell Mackenzie, 153- Troch. amnionirc iodidi comp. li Amnionire iodidi, gr. j; Ammoni.x chloridi, i;r. ij ; Codeincc, gr- i ; Morphince acetatis, ^"^i. Ext. prunis virginiance, q. s.— M. Fiat troch. No. i. Sig. I every three hours as an alterative, sedative. ex|)ectc)rant. MISCELLANEOUS Some of the prescriptions under this heading are old favorites and have been popular with many physicians for years. The three next lozenges may be given to children and adults who strenuously refuse any remedy having an unpleasant taste, as they are as pleasant as a confection. 154. Troch. mucilag. ulmi (mucilage of slippery elm). B Mucilag. ulmi, q. s. Facio troch. No. i. These lozenges are probably the best demulcent in painful con- ditions of the pharynx. They are vastly different from the ordinary ''slippery elm lozenges," made by grinding up the bark of the elm tree and mixing it with gum and sugar. 1 55- R Ipt-'cacuanhce. (Allen & Hanbury's, Ltd., London.) These are large gum arable pastils of the same strength as the lozenges of the British Pharmacopoeia. They are readily taken by children and exert the expectorant effects of ipecacuanha with the demulcent characteristics of the lozenge. 156. Troch. acidi borici compositas, R Acidi benzoici. gr. ss ; Acidi borici. gr- j ; Ext. erythrox. cocce. gr. iss. — M. Faulkner 536 DISEASES OF THE NOSE, THROAT, AND EAR This lozenge is sedative, demulcent, and of a pleasant taste. It is a valuable voice lozenge in cases of orators and singers of the neurotic temperament, who dread that their voice will fail them in the presence of an audience because of nervous muscular weakness. One should be slowly dissolved in the mouth every four hours. When used as a ''voice lozenge " one should be taken one-quarter of an hour before using the voice and fluids should be avoided. 157. Troch. acidi cavbolici. R Acidi carbolici, gi"- j- Fiat troch. No. i. Morell Mackenzie. This formula has long been a favorite as an analgesic, anti- septic lozenge. 158. Troch. potassse chloratis et acidi tannici. R Potassae chloratis, gr. iij ; Acidi tannici, gr. ss. — M. Antiseptic and astringent. Is especially valuable in severe acute pharyngitis, where the mucous membrane is dusky red, much swollen, and ''glazed " from scanty secretions. 159. Trochisci kramerise (rhalany). R Ext. kramerise, gr- j. Sig. 1 every hour. Astringent. 160. R Potassii chloratis, Potassii bromidi, Ext. glycyrrhizae, aa gr. iij ; Tr. ferri chloridi, TTLiss.— M. Sig. I every two or three hours. Seiler. Useful in acute pharyngitis, tonsillitis, and laryngitis. INDEX AiJDUCTOR paralysis of larynx, 270 Abraham's tonsil knives, 220 Abscess, extradural, from otic disease, 475 in mastoid, perforation of, 468 of cerebellmn from otic disease, 478 of cerebrum from otic disease, 478 of membrana tympani, 366 of nasal septum, 152 retropharyngeal, 208 subdural, in otic disease, 475 Accessory sinuses of nose, diseases of, differentiation, 159 inflation of, by Politzer's air- bag, 165 by Valsalva's method, 166 Acetanilid, 514 Acoustics, 308 Actinomycosis of pharynx, 207 Adam's apple, 229 Adams' septum forceps, 154 Adductor muscle, spasm of, 266 paralysis of larynx, 269 Adenoids of middle ear, 380 of pharyngeal tonsil, 189 Aditus ad antrum, 298 Adnephrin, 502 Adrenalin, 497, 502 effects of, on heart, 503 for epistaxis, 503, 504 in hay-fever, 503 internally, 503 secondary hemorrhage after, 502 Air-bag, Politzer's, 321 Air-compressors, cut-off for, 52, 53 for atomizers, 50 Aire of nose, 65 Albolene as nebulizer, 523 fluid, 498 Albuminuria in croupous tonsilliiis, 216 Alcohol, 509 as nebulizer, 523 flaming, for sterilization, 59 Alkalol, 496 Allen's nasal applicator, 46 with Gottstein's cotton plug, 102 speculum, 35, 36 probe, 46, 85, 86 as applicator in Eustachian tube, 328 for removing cerumen, 353 Alligator nasal cutting forceps, Myles', 182 AUport's dilator, 466 middle-ear forceps, 437 Alpha-eucain, 502 Alphasol, 495 Alteratives, 515 Alypin, 501 Ammonium salts lozenges, 534 Amygdalitis, 214 Analgesics, 499 Anemia of labyrinth, 490 of larynx, 239 Anesthesia of larynx, 264, 500 of nasal mucous membrane, 1 1 1 of nose, 499, 500 of i^harynx, 210 Anesthetics in hypertrophy f)f tonsil, 192 local, 499 Aneurism of aorta, laryngeal paral- ysis of, 236 Angina catarrhalis, 194 chronic, 195 faucium, 214 tonsillaris, 214 Angioma of nose, 124 Ankylosis of stapes, 426 537 53B INDEX Annulus tympanicus, 297, 448 Anosmia, no Antipyrin, 505 Antitoxin, diphtheria, 2S0 hay-fever, 115 Antrum of Highmore, illumination of, 163, 164 inflammation of, 161 Caldwell -Luc operation for, 169 cleansing opening, 168 diagnosis, 161 drainage in, 166 Jansen's operation for, 169 Kuster's operation for, 169 symptoms, 163 treatment, 1 64-1 71 size of, 168 Anvil bone of ear, 299 Applicator, Allen's, with Gottstein's cotton plug, 102 cotton, 45 nasal, Allen's, 46 Argyrol, 510 Aristol, 514 Aryepiglottic fold, 29 Arytenoid cartilages, 29, 231 pyriform, 253 Arytenoideus muscle, 233 Asch's compressing forceps, 141 operation for deviated septum, 141 scissors, 141, 142 separators, 142 Asthma, in miller's, in Astringents, 508 Atomizer, 46 air-compressors for, 50 at home, 46, 50 DeVilbiss, 48, 51 Atrium of tympanum, 296 Atrophic catarrh, 70 Attic of tympanum, 296 wall, removal of, 437 Auditory canal, external, 293. See also External auditory canal. nerve, 306 Aural auscultation-tube, 319 cholesteatoma, 358 masseur, 44, 45 polypi, 405 removal of, anesthesia for, 501 stethoscope, 319 Auricle of ear, 292 absence of, 329 arteries of, 293 burns of, 335 chancre of, 337 congenital defects of, 329 cutaneous diseases of, 333 dermatitis of, 334 eczema of, 339 erysipelas of, 337 phlegmonous, 338 frost-bite of, 334 gangrene of, 339 gumma of, 337 herpes of, 335 hyperemia of, m impetigo contagiosa of, 336 keloid of, zy^ lobule of, cleft, 333 lupus vulgaris of, 336 multiple, 329 muscles of, 293 nerves of, 293 new growths on, 341 othematoma of, 330 perichondritis of, 330 chronic, 332 syphilis of, 337 veins of, 293 wounds of, 332 Auscultation of ear, 325 Auscultation- tube, aural, 319 Toynbee's, 320 Autolaryngoscopy, 27 Autophony, 385 Autoscope, 30 Autoscopy, advantages of, 33 instruments for, 32 of larynx, 30 of trachea, 30 Autumnal catarrh. III Axial ligament of malleus, 299 Bali^knger's operation for deviated septum, 145 septum knife, 146 swivel knife, 147 Balsamol, 525 Bell's palsy from otic disease, 483 diagnosis, 486 prognosis, 487 symptoms, 485 treatment, 488 INDEX 539 iJenzoinol, 499 lieta-cocain, 502 IJing'.s test for liearinorolyptol, 496 IJosworth's nasal saw, 93 operation for deviatctl septum, 133 tongue-depressor, 28 Boucheron's specula, 41 Bougies, Eustachian, 328 in exploring Eustachian tubes, 323 Brain complications of mastoiditis, 456 of otic disease, 475 Bii Cynanche tonsillaris, 214 Cyst of auricle, 341 of nose, 124, 125 of tonsils, 220 Cystocele of frontal sinus, 178 Davidson's pow^der-blower, 56 Deafness, causes of, 489 from otitis media catarrhalis chron- ica, operation for, 417 suppurativa chronica, opera- tion for, 427 hysteric, 491 miti die-ear and internal-ear, differ- entiation, 489 operations for, history, 428 Delaborde's tracheal dilator, 287 Delstanche's masseur, 44 Dench"s ear instruments, 416 Dermatitis of auricle, 334 Detergent washes, 494 DeVilbiss atomizer, 48, 5 1 Diabetes, otitis media from, 415 Dilator, Allport's, 466 laryngeal, Browne's, 251 tracheal, Delaborde's, 287 Diphtheria, 273 antitoxin, 280 complications, 278 classification, 274 croupous tonsillitis and, differenti- ation, 215, 216 diagnosis, 278 epistaxis in, 278 etiology, 274 extubation in, 284 faucial, 274 intubation in, 281 accident following, 283 extubation after, 284 feeding in, 285 inability to breathe after, 284 treatment of patient, 284 laryngeal, 274, 276 malignant, 274 membrane in, 274 mild, 274 nasal, 274, 276 otitis media from, 412 otorrhea in, 278 paralysis in, 277 pathology, 274 JNDKX 541 Diphtheria, prognosis, 279 propliylaxis, 279 serum treatment, 280 severe, 274 symptoms, 274 systemic infection, 277 toxemia in, 277 tracheotomy in, 285. See also I'racheotoniy treatment, 279 constitutional, 280 local, 279 operative, 281 prophylactic, 279 serum, 280 well-marked, 274 Diphtheritic inflammation of Schnei- dcrian membrane, 71 Diploetic mastoid, 452 Dilhymol diiodid, 514 Douche, nasal, anterior, 100 postnasal, loi Drills, bone, 94 electric-motor, 95 for exostosis of septum, 95 Drum-head, 294. See also Membrana tyuipani. Dry catarrh, 70 Ductus cochlearis, 303, 304 Dusting-powders, 5 1 1 Dysacousma, 385 Dysesthesia acoustica, 385 Ear, 292 anatomy of, 292 auricle of, 292. See also Auricle of ear. auscultation of, 325 bones of, 298 diseases of, intracranial complica- tions, 475 pathologic conditions of nose causing, 318 of pharynx causing, 318 examination of, 62 external, 292. See also External ear. forceps for foreign bodies, 360 Politzer's, 361 instruments, Dench' 5,416 internal, 303. See also Labyrinth. lobule of, 293 middle, 294. See also Middle ear. Ear, ]X)lypi in, 405 sectional study of, 444 speculum, 40, 41 syringe, soft-rubber, 57, 58 Ear-spout, 357 lOcchondroma of nose, 124 Ecchondroscs of septum, 90 treatment, 91-97 Eczema of auricle, 339 Edema of glottis, 248 of larynx, acute, 248 Electric-motor drills, 95 Electrolysis for Eustachian stricture, 329 Empyema of sphenoidal cells, 183 Encephaloscope, Whiting's, 480 Endolymph, 303 Entotic use of speaking trumpet in testing hearing, 316 Enzymol, 497 Epiglottis, 29, 229, 232 muscles of, 235 turbine-shaped, 253 Epilepsy, laryngeal, 268 Epistaxis, 1 17, 504 adrenalin for, 503, 504 in diphtheria, 278 Epithelial plug in auditory canal, 357 Epithelioma of auricle, 341 Equinia of pharynx, 206 Ergotin, 504 Ermold's tonsillotome, 222 Erysipelas of auricle, 337 phlegmonous, 338 of pharynx, 201 Ethmoidal sinus, inflammation of, 179 treatment, 181 purulent disease of, 179 Ethmoiditis, necrosing, 179 Eucain, 501 Eustachian bougies, 328 catheter, 321 Hartmann's, 322 inflation of middle ear through, 326 introduction of, into tubes, 323 medication through, 326 spraying through, 326 salpingitis, acute, 373 tubes, 302 Allen's probe as applicator in, 328 arteries of, 302 54- INDEX Eustachian tubes, catheterization of, 321 introduction of catheter, 323 obstacles to, 324 dilation of, 328 direct medication of, 326, 327 examination of, 63 introduction of catheter into, 323 muscles that dilate, 302 nerves of, 302, 303 patency of, 319 bougies in testing, 323 catheter test, 321 in chronic otitis media, 388 Politzer's test, 320 probes in testing, 323 Valsalva's test, 319 pharyngeal mouths of, 319 stricture of, 391 electrolysis for, 329 head noises in, 394 inflation in, 392 massage in, 392 phonomassage in, 393 pneumomassage in, 393 treatment, 392 Euzone, 496 Examination of patients, 61 Exostoses of external auditory canal, 349 of nose, 124 of septum, 90 treatment, 91-97 External auditory canal, 293 cholesteatoma in, 358 circumscribed inflammation of, acute, 341 diseases of, 341 epithelial plug in, 357 exostosis of, 349 foreign bodies in, 350 removal, 352 furunculosis of, 341 hyperostosis of, 349, 350 inflammation of, 341 . See also Otitis. mycosis of, 346 of fetus, frontal section through, 447 osteomata of, 349 washing out of, 356 ear, anatomy of, 292 congenital defects, 329 External ear, diseases of, 329 of newborn, 446 meatus, frontal section through, 438 horizontal section through, 446 Extradural abscess from otic disease, 475 Extubation in diphtheria, 284 Eye syringe, soft-rubber, 57, 58 Facial nerve, situation of, in new- born, 450 wounding of, in mastoid opera- tion, 474 paralysis from otic disease, 483 diagnosis, 486 prognosis, 487 symptoms, 485 treatment, 488 False croup, 266 hearing, 386 vocal cords, 235 Falsetto voice, 237 Farcy of pharynx, 206 Faucial tonsils, 186 Fenestra ovalis of tympanum, 298 Ferguson's antrum illuminator, 164 Fetterolf's triangular files, 145 Fibroid of auricle, 341 Fibroma, nasopharyngeal, 124, 126 of nose, 124 Files, Fetterolf's triangular, 145 Foramen of Rivini, 360, 369 Forceps, Adams' septum, 154 Asch's compressing, 141 ear, for foreign bodies, 360 Politzer's, 361 Gleason's bone-cutting, 155 Griinwald's cutting, 182 laryngeal, Cusco's, 262 Mackenzie's, 262 middle ear, Allport's, 437 Myles' alligator cutting, 182 polyp, 360 postnasal, Lowenburg's, 190 rongeur, Hopkins', 462 vSchroeter's, 212 Sexton's, 406 Foreign bodies in external auditory canal, 350 removal of, 352 in larynx, 262 in nose, 109 INDEX 543 Foreign bodies in pharynx, 212 Foreign-lxKly forceps, 360 Formal in as sterilizer, 60 Formulas, 494 aUeralives, 515 animoniiim salts lozenges, 534 analgesics, 499 anesthetics, local, 499 astringents, 508 camphomenlhol lozenges, 533 caustics, 508 cocain lozenges, 534 cough mixtures, 528 detergent washes, 494 dusting-powders, 511 for cleansing mucous membranes, 494 for croup kettle, 528 for epistaxis, 504 for hemoptysis, 504 for inhalers, 528 for net)ulizers, 523 gargles, 530 guaiacum lozenges, 532 hemostatics, 502 hypnotics, 517 local anesthetics, 499 lozenges, 531 miscellaneous, 518 ointments, 507 pigments, 506 protectives, 498 sedatives, 505 slippery elni lozenges, 535 tonics, 518 washes, 494 Fossa of nose, arteries of, 68 nerves of, 68 supratonsillaris, 187 Fox's head-band, 18 Frog face, 125 Frontal disease, inflammation of, pur- ulent, Killian's operation for, 178 section through external auditory canal of fetus, 447 through external meatus, 438 through skull, 442, 443 through spina of child, 450 sinus cannula, Hartmann's, 176 chiseling into, 177 cystocele of, 178 illuminator, 170 inflammation of, 171 Frontal sinus, inflammation of, })uru- lent chronic, 175 mucocele of, 178 purulent disease of, chnjnic, 175 Killian's operation for, 178 P'rost-bite of auricle, 334 Furunculosis of external auditcjiy canal, 341 G Alton's whistle, 310 Galvanocautery for removing hyper- trophies, 83 handle, 87 in chronic follicular pharyngitis, 198 knives, 87 tonsillotomy by, 224 Gangrene of auricle, 339 Gargles, 494, 530 Gelles' test for hearnig, 316 Glanders of pharynx, 206 Glaserian fissure, 298 Gleason's bone-curet, 464 electric light, 418 motor drill, 95 head-band, 19 nasal bone-cutting forceps, 155 speculum, 34 tubes, 150 operation for deviated septum, 135 polypus snare, 407 Globe multinebulizer, 54, 55 Globus hysteriee, 211 Glosso-epiglottic fold, 30 fossae, 30 Glossopharyngeal nerve, tympanic branch, 301 Glottis, 29, 235 chink of, 235 edema of, 248 Glycerin as nebulizer, 523 Glycothymolin, 495 Goodwillie's tonsil-compressor, 221 Gottstein's nasal curat, 191 treatment of atrOy)hic rhinitis, 102 Gouges, mastoid, Whiting's, 465 Granulations on membrana tympani, 366 Greasy paste, 446 Gruber's instrument for introducing artificial drum-head, 372 specula, 40, 41 Giiinwald's cutting forceps, 182 Guaiacum lozenges, 532 544 INDEX Gumma, nasal, 104 of auricle, 337 of phai-ynx, 204, 209 Habitus lymphaiicus, 192 Hair-cells, 305 Hajek's elevators, 146 Halle's cannula, 167 trocar, 167 Hammer bone of ear, 298 Hand-gouge, Randall's, 463 Hard tonsil, 221 Harland's laryngeal caret, 256 Harmony, 311 Hartmann's Eustachian catheter, 322 frontal sinus cannula, 176 tuning-forks, 312 Hassler's site of predilection, 410 Hay-asthma, III Hay-fever, ill adrenalin in, 503 antitoxins for, 115 hypersensitiveness, 113 mineral acids in, 520 pollantin for, 115 prognosis, II 5 treatment, 1 1 2-1 1 5 Head noises in stricture of Eusta- chian tube, 394 Head-band, Fox's, 18 Gleason's, 19 Hearing, Bing's test for, 316 cells, 306 entotic use of trumpet as test, 316 false, 3 86 Gelle's test for, 316 Rinne's test for, 314 Schwabach's test for, 316 tests for, 62, 308, 310 Bing's, 316 entotic use of trumpet for, 316 Gelle's, 316 pressions centripetes, 316 Rinne's, 314 Schwabach's, 316 voice as, 317 watch as, 316 Weber's, 313 voice as test for, 317 watch in testing, 316 Weber's test for, 313 Heart, effects of adrenalin on, 503 Hematoma of nasal septum, 152 Hemophilia, 124 Hemoptysis, 504 Hemorrhage into labyrinth, 490 nasal, 117 pressure-cone for, 121 recurrent, 123 treatment, 1 1 9-1 24 secondary, from use of adrenalin, 502 Hemorrhagia narium, 117 Hemostatics, 502 hydrogen peroxid as, 497 Herpes of auricle, 335 tfopkins' rongeur forceps, 462 Horizontal section through external meatus, 446 semicircular canal, opening of, in mastoid operation, 474 Horse cold, iii Hot-air apparatus, 57 Van Sant's, 57 Hydrobromic acid, 521 Hydrochlorate of cocain, 499 Hydrogen peroxid, 496 Hydrorrhea, nasal, 115 Hyperemia of auricle, 2>ZZ of labyrinth, 490 of larynx, 239 Hyperesthesia of larynx, 264 of nasal mucous membrane, ill of pharynx, 210 Hyperosmia, 1 1 1 Hyperostosis in mastoiditis, 454 of external auditory canal, 349, 350 Hypertrophied angle of septum, 128 Hypertrophies, anterior nasal, re- moval of, 82 posterior nasal, removal of, 88 Hypertrophy of lingual tonsil, 225 of pharyngeal tonsil, 189 of tonsils, chronic, 221 soft, 221 of uvula, 227 Hypnotics, 517 Hysteric deafness, 491 ICHTHYOL, 507 Illumination for laiyngoscopy, 20 Illuminator, Ferguson's antrum, 164 frontal sinus, 170 Impacted cerumen, 354 Impetigo contagiosa of auricle, 336 INDEX 545 Incudo.stapedial articulation, severing of, 422 Incus, 299 malleus, and iiienibrana tympani, removal of, 417 in suppurative ca>cs, 434 Infants, mastoid antrum of, 450 membrana tympani of, 450 Inferior meatus of nose, 66 washing out of, 47 turbinated bone, 66 Intiltration of nasal septum, submu- cous, 153 Inflammation of mucous membranes of nose, 70. See also Schiteidcriaii nuDibranc, inJiaiii7)iatio)i of. Inlluenza, otitis media from, 412 Infraglottic laryngoscopy, 28 Ingal's operation for deviated septum, 134 Inhalers, 55 formulas for, 528 Insects in ear, 350 Instruments for examination, steiiliza- tion of, 58 for treatment, sterilization of, 58 sterilization of, 58 Intensity of tone, 309 Interarytenoid space, 29 Internal ear, 303. See also Laby- rinth. massage, 393 Intracranial complications of otic dis- ease, 475 Intratympanic operations, history, 428 Intubation in diphtheria, 281 accident following, 283 extubation after, 284 feeding in, 285 inability to breathe after, 284 treatment of patient after, 284 lodin, 519 lodomnth, 515 Ipecacuanha, 535 Iter chordae anterius, 297 posterius, 297 Jacobson's nerve, 301 Jan sen's operation for disease of an- trum of Highmore, 169 Jarvis' snare, 83 transfixing needles, 82 Jugular vein, position of, 437 35 Keloid of auricle, t^t^t^ Keratosis obturans, 357 Killian's operation for deviated sep- tum, 145 for jmrulent disease of frontal sinus, 178 Kirkpatrick's lingual tonsil scissors, ^225 Knives, IJallenger's septum, 146 swivel, 147 cautery, 87 Seller's septum, 151 tonsil, Abraham's, 220 Konig's rods, 310 Kiister's oj^eration, 169, 440, 441 Kyle's malleable nasal tube, 149 operation for deviated septum, 144 Labyrinth, anatomy of, 303 and middle-ear deafness, differen- tiation, 489 anemia of, 490 bloody discharge from, 491 concussion of, 491 hemorrhage into, 490 hyperemia of, 490 osseous, boundaries of, 303 contents of, 303 saccule of, 303 syphilis of, 49I utricle of, 303 vestibule of, 303 functions, 307 Labyrinthitis, primary acute, 493 La grippe, otitis media from, 412 Lamina reticularis, 306 spiralis ossea, 303 Lancet, laryngeal, Tobcld's, 250 Lanolin, cocain in, 501 Laryngeal chorea, 265 cough, spasmodic, 265 curet, Harland's, 256 dilator, Browne's, 251 diphtheria, 274, 276 electrode, Mackenzie's, 273 epilepsy, 268 forceps, Cusco's, 262 Mackenzie's, 262 image, 29 bringing into view, 26 normal, 29 lancet, Tobold's, 250 mirror, 17 546 INDEX Laryngeal mirror, introduction of, 24 temperature of, 26 sound, 45 vertigo, 268 Laryngismus stridulus, 266 Laryngitis, acute, 239 catarrhal, acute, 239 chronic, 244 treatment, 246 edematous, 248 mucous, acute, 239 phlegmonous, 248 phthisica, 252 sicca, 246 specific, 250 subacute, 242 syphilitica, 250 tubercular, 252 differential diagnosis, 254 treatment, 255-258 Laryngology, 22 Laryngopharynx, 184 Laryngoscope, 17 laryngeal mirror of, 17 reflector of, 17, 18 method of wearing, 19 Laryngoscopy, 22 illumination for, 20 infraglottic, 28 light for, 20 concentrators in, 20 obstacles to, 26 source of light in, 21 tongue in, controlling of, 24 Laryngotomy, 288 Laryngotraclieoscopy, tongue-depres- sor for, 30 Laryngotracheotomy, 287, 288 Larynx, 229 anatomy of, 229 anemia of, 239 anesthesia of, 264, 500 arteries of, 236 autoscopy of, 30 carcinoma of, 260 treatment, 260 cartilages of, 229 diseases of, 239 edema of, acute, 248 foreign bodies in, 262 hyperemia of, 239 hyperesthesia of, 264 in voice production, 237 Larynx, inflammation of. See Laryn- gitis. ligaments of, 233 lupus of, 254 mucous membrane of, 235 muscles of, 233 nerves of, 236 neuroses of, 264 motor, 264 sensory, 264 papilloma of, 259 treatment, 260 paralysis of, 268 abductor, 270 adductor, 269 from aneurism of aorta, 236 treatment, 272 paresthesia of, 264 size of, 237 spasm of, 265 submucous tissue of, inflammation of, 248 tuberculosis of, 252 differential diagnosis, 254 treatment, 255-258 tumors of, 258 ihyrotomy for, 263 treatment, 260 veins of, 236 ventricles of, 235 ventricular bands of, 29 ■ Lateral sinus, wounding of, in mastoid operation, 473 Laxator tympani muscles, 300 Leeches in otitis media catarrhalis acuta, 377 ^ ^ Leptomeningitis from otic disease, 476 purulent, from otic disease, 477 Leptothrix buccalis, 199 Levator palati muscle, 302 Light concentrators in laryngoscopy, 20 for laryngoscopy, 20 source of, in laryngoscopy, 21 Lignol, 506 Lingual tonsil, hypertro])hy of, 225 scissors, Kirkpatrick's, 225 Listerin, 495 Little Wonder pnmp, 52 Lobule of auricle, cleft, 333 of ear, 293 Lowenburg's method of catheteriza- tion of Eustachian tubes, 323 INDEX 547 Lowenburg's postnasal forcei)s, 190 Loudness of musical notes, 238 Lozenges, 531 annnoniuni salts, 534 caniphomenthol, 533 cocain, 534 guaiacuni, 532 miscellaneous, 535 slippery elm, 535 voice, 535, 536 Lucca's pressure jtrobe, 393 Lumbar puncture, 476 Lupus, 108 of larynx, 254 vulgaris, 108 of auricle, 336 of pharynx, 206 Lythol, 495 MacEwen's triangle, 469 Mackenzie's laryngeal forceps, 262 Malleo-incudal joint, 300 Malleus, 298 incus, and membrana tympani, re- moval of, 417 in suppurative cases, 434 Massage, internal, 393 of middle ear, 392 Masseur, aural, 44, 45 of Delstanche, 44 Mastoid antrum, 303 of infants, 450 chisels, Whiting's, 465 curet, McKernon's, 462 gouges, Whiting's, 465 operation, 458 accidents, 472 after- technic, 470 history, 458 instruments for, 461 opening horizontal semicircular canal, 474 posterior cranial fossa in, 473 preparation of patient, 461, 462 technic, 461 wounding facial nerve in, 474 lateral sinus in, 473 process, abscess in, perforation of, 468 diploetic, 452 hyperostosis of, 454 in adult, 451 of temporal bone, 303 Mastoid process, pathologic impor- tance of types, 452 pneumatic, 45 I l)neumodii)loelic, 452 sclerosed, 452 structure of, 4-^1 tip of, removal, 468 Mastoiditis, 446 brain complications in, 456 caries in, 454 complications, 454 etiology, 452 hyperostosis in, 454 necrosis in, 454 operation for, 458. See also Mas-, ioid operation. operative cases, 455 otorrhea in, sudden cessation of, 455 pathology, 453 prognosis, 457 sudden cessation of discharge in, 455 symptoms, 452, 455 tenderness in, 456 treatment, 457 Mayer's tube, 143 McKernon's mastoid curet, 462 Measles, otitis media from, 412 Meati of nose, 66 Membrana basilaris, 303 flaccida, 294 propria, 295 tectoria, 306 tensor, 295 tympani, 294 abscess of, 366 artificial, contrivance for introduc- ing, 372 Toynbee's, 372 chalk deposits on, 367 curvature of, changes in, 361 discharge from, 366 diseases of, 360 granular spots on, 366 in chronic otitis media, 386 in newborn, 446 incision of, 415 inflammation of, 362 chronic, 365 malleus, and incus, removal of, 417 in suppurative cases, 434 nerves of, 295 548 INDEX Membrana tympani of children, ex- amination, 449 perforation of, 369 in otitis media, 396, 397 treatment, 369 polypi on, 366 puncturing of, in otitis media, 378 rupture of, 367 secundaria, 298 ulcer of, 369 vessels of, 295 vibrans, 295 Meniere's disease, 386, 492 Meningitis, external, from otic dis- ease, 475 otic, 456 Menthol, 498, 511, 519 Menzel-Hajek operation for deviated septum, 145 Metal ear-spout, 357 Metastasis, ear conditicms from, 492 Methyl- violet, 513 Middle ear, adenoids of, 380 anatomy of, 294 and internal-ear deafness, differ- entiation, 489 catarrh of. See Otitis jnedia. cleansing of, 404 hydrogen peroxid for, 497 diseases of, 360 forceps, Allport's, 437 inflammation of, 373. See also Otitis media. inflation of, by Eustachian cath- eter, 326 massage of, 392 of newborn, 446 operations upon, 415 meatus of nose, 67 turbinated bone, 66 Miller's asthma, ill Mineral acids, 520 Mixture, 1-2-3, 5^5 Mixtures, cough, 528 Motor neuroses of larynx, 264 of nose, 1 10 Mouth-breather, 80 Mouth-washes, 494 Mucocele of frontal sinus, 1 78 Mucous membrane of nose, 267. See also Schneiderian niC7nbra7je. remedies for cleansing, 494 Mucus, 71 Multinebulizer, 54, 55 Music, 308 Musical notes, 237, 238 qualities of, 238 Mycosis of external auditory canal, 346 of pharynx, 199 Myles' alligator nasal cutting forceps, 182 nasal speculum, 34 tonsil punches, 224 Myringitis, 362 chronic, 365 Myringotomy, 415 for permanent opening, 417 multiple openings, 417 Myxoma of nose, 124 Nabulin, 525 Nares, 'i^'h occlusion of, congenital, 150 posterior, plugging of, 123 Nasal applicator, Allen's, 46 with Gottstein's cotton plug, 102 catarrh, acute, 74 atrophic, 98 hypertrophic, 80 chancre, 104 curet, Gottstein's, I91 diphtheria, 274, 276 douche, anterior, 100 gumma, 104 hemorrhage, 1 17 pressure-cone for, 121 recuiTent, 123 treatment, 11 9- 124 hydrorrhea, 1 15 mucous membrane, anesthesia of, III hyperesthesia of, ill paresthesia of, ill saws, 93 Bosworth's, 93 Bucklin's reversible, 93 Sajous', 93 scissors, 94 septum, 64, 65 abscess of, 152 deflection of, ear disease from, deformities of, 153 INDEX 549 Nasal septum, deviation of, 128 Asch's operation for, 141 Jiallenger's operation for, 145 IJoswortli's operation for, 133 Gleason's operation for, 135 Ingal's operation for, 134 Killian's operation for, 145 Kyle's operation for, 144 Menzel-Hajek operation for, 145 operations for, 133 factors interfering with, 132 patliology, 130 Roberts' operation for, 140 Roe's operation for, 145 Sajous' operation for, 134 Seiler's operation for, 134 symptoms, 130 Watson's operation for, 135 window resection for, 145 diseases of, 128 dislocation of, 153 ecchondroses of, 90 treatment, 91-97 exostoses of, 90 treatment, 91-97 hematoma of, 152 hypertrophied angle of, 128 infiltration of, submucous, 153 osteoma of, hyperplastic, 90 provisional callus of, 128 redundancy of, 132 resiliency of, 132 speculum, 34 Allen's, 35, 36 Gleason's, 34 Myles', 34 syphilis, 104 tubes, Gleason's, 150 Kyle's, 149 Nasophaiyngeal fibroma, 124, 126 Nasopharynx, TiZ^ 184 diseases of. 188 Nebulizers, 53 formulas for use in, 523 Necrosing ethmoiditis, 179 Necrosis in mastoiditis, 454 of temporal bone, 408 Needles, Jarvis' transfixing, 82 Neuroses of larynx, 264 motor, 264 sensory, 264 of nose, 1 10 \ Neuroses of nose, reflex, 1 1 1 sensory, 1 10 of pharynx, 210 Nevus of auricle, 341 Newborn, external ear of, 446 facial nerve in, 450 middle ear of, 446 osseous canal in, 448 Schrapnell's membrane in, 449 temporal bone of, 449 Nitrate of silver, 509 Nitromuriatic acid, 520, 521 Normal laryngeal image, 29 Nose, 64 accessory sinuses of, diseases of, 159 differentiation, 159 inflation of, by Politzer's air- bag, 165 by Valsalva's method, 166 alse of, 65 anatomy of, 64 anesthesia of, 499, 500 angioma of, 124 arteries of, 66 bony arch of, 64- framework of, deformities of, 153 injuries of, 153 bridge of, 64 flattening of, 154 carcinoma of, 124, 127 cartilaginous arch of, 64 cavities of, 66 cyst of, 124, 125 deformities of, congenital, 158 diseases of, 73 causing disease of ear, 318 effect on other parts of body, 73 extension of, 73 ecchondroma of, 124 erectile tissue of, 67 examination of, 61 exostosis of, 124 external, 64 fibroma of, 124 foreign bodies in, 109 fossae of, arteries of, 68 nerves of, 68 functions of, 69 interior, washing out of, 47, 50 lymphatics of, 69 meati of, 66 motor neuroses of, 1 10 550 INDEX Nose, mucous membrane of, 67. See also Schtieiderian 7?ie?7ibrane. muscles of, 66 myxoma of, 124 nerves of, 66 neuroses of, no reflex, in sensory, no olfactory region of, 67 osteoma of, 124 packing, 96 papilloma of, 124, 126 paralysis of, no polypus of, 124 treatment, 126 pug, 66 regions of, 67 respiratory region of, 67 saddle-back, 154 sarcoma of, 124, 127 Schneiderian membrane of, 67. See also Schneiderimi jfiembi-ane. septum of, 64, 65. See also Nasal septum. sesamoid cartilages of, 64 skin covering, 66 •* stenosis of, no sterilization of, 60 triangular cartilage of, 65 tumors of, 124 turbinated bones of, 66 vestibular region of, 67 Nosebleed, 117. '$)^t 2X^0 Epistaxis. Nose-washes, 494 Nosophen, 514 Octave, definition, 312 O' Dv^^yer's intubation set, 282 Oil, phosphorated, 519 Ointments, 507 Operator, preparation of, 60 Organ of Corti, 304 Oropharynx, 184 diseases of, 194 Orthoform, 512 Ossicles, 298 Osteoma, hyperplastic, of septum, 90 of external auditory canal, 349 of nose, 124 Otalgia, pain in, relief of, 501 Othematoma of auricle, 330 Otitis externa, circumscribed, 341 crouposa, 348 Otitis externa diffusa acuta, 344 chronica, 345 diphtheritica, 347 media, atrophic, 382 catarrhalis acuta, 373 bacteriology, 375 dry heat in, 377 leeches in, 377 pathology, 375 Politzer air-douche in, 378 prognosis, 375 puncturing drum-head in, 378 symptoms, 375 treatment, 376-379 chronica, 382 deafness in, operation for, 417 etiology, 384 hearing in, 384, 385 membrana tympani in, 386 operation for, 417 patency of Eustachian tube in, 388 prognosis, 389 symptoms, 334 objective, 386 subjective, 384 tinnitus in, 386 treatment, 389-391 vertigo in, 386 cum ostitide mastoidae, 373 ex tubce, 373 subacuta, 379 inflammation of mucous glands in, 38 1 diy, 382 from Bright' s disease, 415 from diabetes, 415 from diphtheria, 412 from influenza, 412 from la grippe, 412 from measles, 412 from pneumonia, 414 from scarlatina, 4n from syphilis, 414 from tuberculosis, 413 from typhoid fever, 412 hyperplastic, 382 moist, 382 mucosa acuta, y^T, non-purulenta, 373 proliferous, 382 INDEX 55 Otitis media serosa acuta, 373 simple acute, 380 suppurativa acuta, 396 treatment, 398 chronica, 400 cleansing ear in, 404 otorrhea in, 402 tinnitus from, operation for, 427 treatment, 402-405 removal of drum-head, mal- leus, and incus in, 434 systemic diseases causing, 410 Otoliths, 306 Otomycosis, 346 Otorrhea, bloody, 491 chronic, causes, 431 conditions preventing cessation, 431. operations for, 432 relapses, 433 dusting-powders for, 513 in diphtheria, 278 in otitis media suppurativa chron- ica, 402 sudden cessation of, in mastoiditis, 455 Otoscope, 39 Brunton's. 40 reflector of, 40 Otoscopy, 39 accessory instruments, 45 introduction of speculum in, 42 obstacles to, 42 relative position of patient and ob- server, 41 specula for, 40 Oval window of tympanum, 298 Ozena, 97 syphilitic, 104 Pachymeningitis from otic disease, 475 Packing nose, 96 Palate retractor. White's, 38 Panotitis, 493 Papilloma of larynx, 259 treatment, 260 of nose, 124, 126 Paracusis diplocusis, 385 duplicata, 385 Willisii, 385 Paraffin injections, 519, 520 Paraffin prothesis, 156 syringe for, 156 syringe, Smith's (Harmon), 156 Paraklehyd, 517 Paralysis, diphtheritic, 277 facial, from otic disease, 483 diagnosis, 4S6 prognosis, 487 symptoms, 485 treatment, 488 of arytenoideus muscle, 269 of crico-arytenoid muscle, 270 of cricothyroid muscle, 271 of larynx, 268 abductor, 270 adductor, 269 from aneurism of aorta, 236 treatment, 272 of lateral crico-arytenoid muscles, 269 of nose, no of pharj'nx, 2 II of soft palate after croupous tonsil- litis, 216 of tensors of vocal cords, 271 of thyro-arytenoid muscles, 271 Paresthesia of larynx, 264 of nasal mucous membrane, 1 1 1 of pharynx, 21 1 Parosmia, III Patients, examination of, 61 Peach cold, ill Pendulum vibration, 308 Perforation whistle, 369 Perichondritis of auricle, 330 chronic, 332 Perilymph, 303 Perimeningitis from otic disease, 475 Peroxid of hydrogen, 496 Petrolatum as nebulizer, 523 Pharyngeal mouths of Eustachian tubes, 319 tonsils, 186 adenoid vegetations of, 189 hypertrophy of, 189 inflammation of bursa of, 193 Pharyngitis, acute, 1 94 atrophic, 198 dry, 198 follicular, 195 chronic, 196 granular, 195 phlegmonous, 202 55: INDEX Phar}-ngitis sicca, 198 simple chronic, 195 syphilitic, 204 Pharyngoscopy, tongue -depressor for, 30 Pharynx, 184 actinomycosis of, 207 anatomy of, 184 anesthesia of, 210 arteries of, 186 attachments of, 184 diseases of, causing disease of ear, 318 divisions of, 184 equinia of, 206 erysipelas of, 201 farcy of, 2o5 foreign bodies in, 212 glanders of, 206 gumma of, 204, 209 hyperesthesia of, 210 int^ammation of. See Pharyngitis. lupus vulgaris of, 206 lymphatics of, 186 mucous membrane of, 186 muscles of, 184 mycosis of, 199 nerves of, 186 neuroses of, 210 paralysis of, 21 1 paresthesia of, 21 1 posterior wall of, abscess of, 208 ray fungus of, 207 relations of, 184 syphilis of, 204 tuberculosis of, 205 tumors of, 209 ulcer of, simple, 202 Phonomassage, 393 Phosphorated oil, 519 Pigments, 506 Pilocarpin, 522 Pinna, 292 Piston-syringe, 44 Pitch, 237, 238, 309 Pituitary membrane, 67 Pneumatic mastoid, 451 speculum, Siegle's, 43 Pneumodiploetic mastoid, 452 Pneumomassage, 393 Pneumonia, otitis media from, 414 Politzer's air-bag, 321 filling of, 165 Politzer's air-bag in otitis media catar- rhalis acuta, 378 inflation of accessory sinuses with, 165 ear forceps, 361 test of patency of Eustachian tubes, 320 Pollantui for hay-fever, 115 Polypi, aural, 405 removal of, anesthesia for, 501 forceps, 360 nasal, 124 treatment, 126 on membrana tympani, 366 snare, 406 Blake's, 399 Gleason's, 407 Posterior cranial fossa, opening of, in mastoid operation, 473 nares, plugging of, 123 Postnasal catarrh, 188 douche, loi space, zz, 184 diseases of, 188 washing out of, 48 Powder-blower, 56 Davidson's 56 Pressions centripetes, 316 Pressure probe, Lucca's, 393 Pressure-cone for nasal hemorrhage, 121 Probe, Allen's, 46, 85, 86 as applicator in Eustachian tube, 328 for removing cerumen, 353 in exploring Eustachian tubes, 323 pressure, Lucca's, 393 Processus auditorius, 448 cochleariformis, 298 Protargol, 510 Protectives, 498 Provisional callus of septum, 128 Prussak's space, 294 Pseudacousma, 386 Pug nose, 66 Puncture, lumbar, 476 Pynchon's cabinet, 53, 54 Pyoktanin, 513 Pyramid of light, 362 Pyriform arytenoids, 253 Quality of tone, 309 Quinsy, 214 INDEX 553 Ragged tonsil, 221 Randall's hand -gouge, 463 Range of voice, 238 Ray fungus of pharynx, 207 Recessus epitynipanicus, 296 Reflector of laryngosc<)|K', 1 7, 18 method of wearing, 19 otoscopic, 40 Reflex, the term, 73 Reissner's membrane, 304 Respiral, 525 Retropharyngeal abscess, 208 Rhinitis, 74 acute, 74 atrophic, 97 average case, 103 prognosis, 103 treatment, 100-103 cheniic, 70 chronic, simple, 75 hypertrophic, 79 obstructive, 80 pseudomembranous, 79 purulent, 77 scrofulous, 97, 98 specific, 104 subacute, 75 syphilitic, 104 tubercular, 107 Rhinoliths, 109 Rhinorrhagia, 1 17 Rhinorrhea,75 Rhinoscleroma, 108 Rhinoscopic image, posterior, ^Z Rhinoscopy, 33 anterior, 36 posterior, 36 image in, 38 obstacles to, 38 technic, 33 Rima glottidis, 29, 235 Rinne's test forbearing, 314 Rivini's foramen, 360, 369 Roberts' operation for deviated septum, 140 Roe's operation for deviated septum, 145 Rohrer's diagnostic table, 62 Rongeur forceps, 462 Hopkins', 462 Rose cold, III Round window of tympanum, 298 Rupture of membrana tympani, 367 SACCtJLK of labyrinth, 303 Sacculus laryngis, 235 Saddle-back nose, 154 Sagittal section through temporal bone, 432 through tympanum, 444 S.ijous' nasal .^aw, 93 operation for deviated septum, 134 Salpingitis, Kustachian, acute, 373 Santorini's cartilages, 30, 232 Sarcoma of auricle, 341 of nose, 124, 127 Saws, nasal, 93 Bosworth"s, 93 Rucklin's reversible, 93 Sajous', 93 Scala media, 304 tympani, 304 vestibuli, 304 Scarlatina, otitis media from, 41 1 Schneideriau membrane, 67 inflammation of, 70 catarrhal acute, 70 chronic, 70 croupous, 71 diphtheritic, 7 1 pathology, 71 physiology, 69 Schrapnell's membrane, 294 in newborn, 449 perforation of, 369 Schroeter's forceps, 212 Schwabach's test for hearing, 316 Scirrhous tonsil, 221 Scissors, Asch's, 141, 142 lingual tonsil, Kirkpatrick's, 225 nasal, 94 Sclerosed mastoid, 452 Secondary hemorrhage from use of adrenalin, 502 Sedatives, local, 505 Seiler's operation for deviated septum, 134 septum knife, 151 Semicircular canal, horizontal opening of, in mastoid operation, 474 membranous, 306 functions, 307 osseous, 303 Sense of smell, derangements of, no Sensory neuroses, no Separators, Asch's, 142 Septum forceps, Adams', 154 554 INDEX Septum knife, Ballenger's, 146 Seller's, 151 nasal. See iVasal sepiiun. Sesamoid cartilages, 64 Sessile exostoses of auditory canal, 349 Sexton's forceps, 406 Shute of tympanum, 296 Siegle's pneumatic speculum, 43 Silver nitrate, 509 Singing voice, 238 Sinks, 53 Sinus thrombosis from otic disease, 481 Skin covering nose, 66 Skull, frontal section through, 442, 443 Slippery elm lozenges, 535 Smell, derangements of, no Smith's (Harmon) screw-syringe for paraffin injection, 156 Snare, Jarvis', 83 polypus, 406 Blake's, 399 Gleason's, 407 tonsillotomy by, 224 Sneezing, III definition, 74 Snow cold. III Snuffles, 74 Soft-rubber ulcer syringe, 57, 58 Somnos, 517 Sore throat, acute, 194 chronic, 195 clergyman's, 196 Sound, 30S laryngeal, 45 sources of, 308 Spasm of adductor muscles, 266 of larynx, 265 of tensors of vocal cords, 265 Spasmodic laryngeal cougli, 265 Speculum, Boucheron's, 41 ear, 40, 41 for otoscopy, 40 Gruber's, 40, 41 nasal, 34 Siegle's pneumatic, 43 Sphenoidal sinus, empyema of, 183 Spittoon, swinging, 53 Stacke's operation, 432, 438 indications, 438 technic, 439 Stapedectomy, 422 Stapedius muscle, 300 Stapes, 300 bony ankylosis of, 426 extraction of, 422 mobilizing of, 422 Stenosis of nose, no Sterilization of mstruments, 58 of nose, 60 of operator, 60 Stethoscope, aural, 319 Stirrup bene of ear, 300 Stovain, 501 Stricture of Eustachian tube, 391. See Eustachian tubes, stricture of. Subdural abscess in otic disease, 475 Sulphonal, 517 Superior meatus of nose, 67 turbinated bone, 66 Suprameatal space, 469 Suprarenal gland, powdered, 503 Suprarenalin, 502 Swinging spittoon, 53 Syphilis, nasal, 104 of auricle, 337 of internal ear, 491 of larynx, 250 of phar}'nx, 204 otitis media from, 414 Syringes, 49 ear, soft-rubber, 57, 58 eye, soft-rubber, 57, 58 ulcer, soft-rubber, 57, 58 Tegmen tympani, 296 Temporal bone, caries of, 408 mastoid process of, 303 necrosis of, 408 of newborn, 449 sagittal section through, 432 Tenotomy of tensor tympani, 417 Tensor palati muscle, 302 tympani, 300 tenotomy of, 417 Tertiary syphilitic rhinitis, 104, 106 Therapeutic test for lupus, 108 Thornwaldt's disease, 193 Throat, catarrh of, chronic, 195 relaxed, 195 sore, acute, 194 chronic, I95 clergyman's, 196 Thrombosis, sinus, from otic disease, 481 INDEX 555 Tliymozonc, 496 'I'liyro-arytcnouicus muscle, 234 Thyruitl cartilage, 229 Thyrotoniy, 263 Timbre, 238, 309 Tinnitus, 394 from otitis media suppurativa chronica, operation fur, 427 in otitis media, 386 operation for, 417 history, 428 Tobold's laryngeal lancet, 250 Tone, 309 Tongue, controlling of, in laryngos- coi)y, 24 examination of, 61 Tongue-depressor, Bosworths, 28 folding, 27 for laryngotracheoscopy, 30 for pharyngoscopy, 30 Torek's, 27 Tonics, 518 Tonsil knives, Abraham's, 220 punches, Myles', 224 Tonsil-compressor, Goodwillie's, 221 Tonsillitis, acute, 214 abortion of, 218 treatment, 217-219 chronic, with hypertrophy, 221 without hypertrophy, 219 croupous, 214, 215 diphtheria and, differentiation, 215, 216 treatment, 217-219 erythematous, 215 follicular, 214 parenchymatous, 215 phlegmonous, 214 treatment, 217-219 Tonsillotome, Ermold's, 222 removal of tonsils by, 222 Tonsillotomy by galvanocautery, 224 by snare, 224 by tonsillotome, 222 piecemeal, 225 Tonsils, 214 cysts of, 220 diseases of, 214 faucial, 186 functions, 187 hard, 221 hypertrophy of, chronic, 221 soft, 221 Tonsils, innanimation of. See Tun- sill it is. lingual, hypertrophy of, 225 pharyngeal, 186 adenoid vegetations of, 189 hypertrophy of, 189 r.igged, 221 removing of, by tonsillotome, 222 scirrhous, 221 Toynbee's artificial drum-head, 372 auscultation-tube, 320 Trachea, autoscopy of, 30 Tracheal dilator, Delaborde's, 287 Tracheotomy, 285 after-treatment, 291 anesthetic in, 286 high operation, 285, 287 instruments for, 286 low operation, 285, 288 preparation of patient, 286 Tracheotomy-tube, 290 Transfixing needles, Jarvis', 82 Trephining, 479 Triangle of MacEwen, 469 Triangular cartilage of nose, 65 Trichloracetic acid for removing hypertrophies, 86 Trional, 517 Trocar, Halle's, 167 True vocal cords, 235 Tuberculosis of larynx, 252 differential diagnosis, 254 treatment, 255-258 of pharynx, 205 otitis media from, 413 Tumors of auricle, 341 of larynx, 258 thyrotomy for, 263 treatment, 260 of pharynx, 209 Tuning-forks, 310, 312 Hartmann's, 312 Turbinated bones, 66 removal of, 96 Turbinectomy, 96 Turbine-shaped epiglottis, 253 Turbinotomy, 96 Turck's tongue-depressor, 27 Tympanum, arteries of, 301 atrium of, 296 attic of, 296 cavity of, 296 diseases of, 373 556 INDEX Tympanum, fenestra ovalis of, 298 floor of, 296 inner wall of, 298 muscles of, 300 nerves of, 301 outer wall of, 297 oval windoM' of, 298 plexus of, 301 roof of, 296 round window^ of, 298 sagittal section through, 444 shute of, 296 Typhoid fever, otitis media from, 412 Ulcer of membrana tympani, 369 of pharynx, simple, 202 of uvula, 226 syringe, soft-rubber, 57, 58 Useless cough, 197 Utricle of labyrinth, 303 Uvula, bifid, 226 deformities of, 226 diseases of, 225 elongation of, 227 hypertrophy of, 227 inflammation of, 225 removal of, 228 ulceration of, 226 Uvulitis, 225 pseudomembranous, 226 Valsalva's method of inflating ac- cessory sinuses, 166 test of patency of Eustachian tubes, 319 Van Sant's hot-air apparatus, 57 Vaselin, 498 Ventricles of larynx, 235 Ventricular bands, 235 of larynx, 29 Vernix caseosa, 446 Vertigo in otitis media, 386 laryngeal, 268 Vestibule of labyrinth, 303 functions, 307 Vibration, aerial, 308 pendulum, 308 Vibrissae, 36, 66 Vocal cords, 29, 235 cadaveric position of, 271 spasm of tensors of, 265 tensors of, paralysis of, 271 process of arytenoid cartilage, 232 Voice, 237 falsetto, 237 in testing hearing, 317 lozenges, 535, 536 production, 237 qualities of, 238 singing, 238 Washes, detergent, 494 Watch in testing hearing, 316 Water-pump for compressed air, 50 Watson's operation for deviated sep- tum, 135 Weber's test for hearing, 313 White's palate retractor, 38 Whiting's encephaloscope, 480 mastoid chisels, 465 gouges, 465 Window resection for deviated sep- tum, 145 Wounds of auricle of ear, 332 Wrisberg's cartilages, 30, 232 i Xeroform, 515 SAUNDERS* BOOKS Skin, Genito-Urinary Diseases, Chemistry, and Eye, Ear, Nose, and Throat W. B. SAUNDERS COMPANY 925 Walnut Street Philadelphia 9, Henrietta Street Covent Garden, London MECHANICAL EXCELLENCE l^OT alone for their literary excellence have the Sa jnders pub- • lications become a standard on both sides of the Atlantic : their mechanical perfection is as universally commended as is their scientific superiority. The most painstaking attention is bestowed upon all the details that enter into the mechanical production of a book, and medical journals, both at home and abroad, in reviewing the Saunders publications, seldom fail to speak of this distinguishing feature. The attainment of this perfection is due to the fact that the firm has its own Art De- partment, in which photographs and drawings of a very high order of merit are produced. This department is of decided value to authors, in enabling them to procure the services of artists specially skilled in the various methods of illustrating medical publications. A Complete Catalo|>ue of our Publications will be Sent upon Request SAUNDERS' BOOKS ON Stelwa^on*s Diseases of the Skin A Treatise on Diseases of the Skin. For Advanced Stu- dents and Practitioners. By Henry W. Stelwagon, M. D., Ph. D., Professor of Dermatology in the Jefferson Medical College; and Clinical Professor of Dermatology in the Woman's Medical College, Philadelphia. Handsome octavo volume of 1 136 pages, with 258 text-cuts and 32 full-page colored litho- graphic and half-tone plates. Cloth, ^6.00 net; Sheep or Half Morocco, ^7.50 net. RECENTLY ISSUED— NEW (4th) EDITION, REVISED FOUR LARGE EDITIONS IN THREE YEARS The demand for four editions of this work in a period of three years and the many gratifying review notices indicate beyond a doubt the practical character of the book. In preparing the work the predominant aim kept in view was to supply the physician with a treatise written on plain and practical lines, giving abundant hel|-)ful case illustrations. In this edition, although some fifty new illustrations have been added, the size of the work has not been increased, many old illustrations having been eliminated and the text, wher- ever possible, made more concise. PERSONAL AND PRESS OPINIONS John T. Bo wen, M. D., Assistant Professor of Dermatology, Harvard University Medical School, Boston. " It gives me great pleasure to endorse Dr. Stelwagon's book. The clearness of descrip tion is a marked feature. It is also very carefully compiled. It is one of the best text-books yet published." George T. Elliot, M. D. Professor of Dermatology, Cornell University. " It is a book that I recommend to my class at Cornell, because for conservative judg- ment, for accurate observation, and for a thorough appreciation of the essential position of dermatology, I think it holds first place." Boston Medical and Surgical Journal " We can cordially recommend Dr. Stelwagon's book to the profession as the best text- book on dermatology for the advanced student and general practitioner that has been brought strictly up to date. . . . The photographic illustrations are numerous, and many of them are of great excellence." DISEASES OF THE EYE. DeSchweinitzV Diseases of the Eye Just Issued— New (5th) Edition Diseases of the Eye : A Handbook of Ophthalmic Prac- tice. By G. E. deSchweinitz, M. D., Professor of Ophthalmol- ogy in the University of Pennsylvania, Philadelphia, etc. Handsome octavo of 894 pages, 313 text-illustrations, and 6 chromo-lithographic plates. Cloth, $5.00 net ; Half Morocco, $6.c^o net. WITH 313 TEXT-ILLUSTRATIONS AND 6 COLORED PLATES In this new edition the text has been very thoroughly revised, and practically reset. Many new chapters have been added, among which may be mentioned the X-ray treatment of Epithelioma ; Jequiritol and Jequiritol Serum; X-ray treatment of Trachoma ; Infected Marginal Ulcers; Uveitis and its Varieties ; Eyeground Lesions of Heriditary Syphilis ; Worth's Amblyoscope ; Stovain, Alypin ; Motais' Operation for Ptosis; Haab's Elec- tromagnet ; and Sweet's X-ray method of Localizing Foreign Bodies. The illustrative feature of the work has been greatly enhanced in value by the addition of many new cuts and six full-page chromo-lithographic plates, all most accurately portraying the pathologic conditions which they represent. PERSONAL AND PRESS OPINIONS Samuel Theobald, M.D., Clinical Professor of Ophthalmology, Johns Hopkins University, Baltimore. " It is a work that I have held in high esteem, and is one of the two or three books upon the eye which I have been in the habit of recommending to my students in the Johns Hop- kins Medical School." W. Franklin Coleman, M. D. Professor of Diseases of the Eye, Postgraduate Medical School, Chicago. " I am very much pleased with deSchweinitz's work and will recommend it to the members of my class as a most reliable, complete, and up-to-date text-book." British Medical Journal "A clearly written, comprehensive manual. One which we can commend to students as a reliable text-book, written with an evident knowledge of the wants of those entering upon the study of this special branch of medical science." SAUNDERS' BOOKS ON Theobald's Prevalent Diseases of the Eye Prevalent Diseases of the Eye. By Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology, Johns Hopkins University. Octavo of 550 pages, with 219 text-illustra- tions and 10 plates. Cloth, $4.50 net ; Half Morocco, $6.00 net. JUST READY With few exceptions all works on diseases of the eye, although written ostensibly for the general practitioner, are in reality adapted only to the specialist ; but Dr. Theobald in his book has described very clearly and in detail only those conditions the diagnosis and treatment of which come within the province of the general practitioner. The therapeutic suggestions are concise, unequivocal, and specific, in every case only one course of definite treatment being given. It is the one work on the Y.\Q: written particiilai-ly for the physician engaged in ge^ieral practice. Saxe's Urinalysis Examination of the Urine. By G. A. De Santos Saxe, M. D., Pathologist to Columbus Hospital, New York. i2mo of 391 pages, illustrated. Flexible leather, $1.50 net- RECENTLY ISSUED This work is intended as an aid in diagnosis, by interpreting the clinical significance of the chemic and microscopic urinary findings. Francis Carter Wood, M. D., Adjunct Professor of Clinical Pathology , Columbia University. " It seems to me to be one of the best of the smaller works on this subject ; it is indeed, better than a good many of the larger ones." CHEMISTRY AND EYE, EAR, NOSE, AND THROAT. 5 Wells* Chemical Pathology Chemical Pathology. Being a Discussion of General Path- ology from the Standpoint of the Chemical Processes Involved. l>y H. Gideon Wells, Ph.D., M.D., Assistant Professor of Pathology in the University of Chicago. Octavo of 549 pages. Cloth, $3.25 net; Half Morocco, $4.75 net. JUST ISSUED Dr. Wells' work is written for the physician, for those engaged in research in pathology and physiologic chemistry, and for the medical student. In the introductory chapter are discussed the chemistry and physics of the animal cell, giving the essential facts of the composition of proteids, and of ioniza- tion, diffusion, osmotic pressure, etc., and the relation of these facts to cellular activities. Special chapters are devoted to Diabetes and to Uric-Acid Metab- olism and Gout. American Text-Book of Eye, Ear, Nose, and Throat American Text=Book of Diseases of the Eye, Ear, Nose, and Throat. Edited by G. E. de Schweinitz, M. D., Pro- fessor of Ophthalmology in the University of Pennsylvania ; and B. Alexander Randall, M. D., Clinical Professor of Diseases of the Ear in the University of Pennsylvania. Imperial octavo, 125 1 pages, with 766 illustrations, 59 of them in colors. Cloth, ;^7.oo net; Sheep or Half Morocco, ^8.50 net. This work is essentially a text-book on the one hand, and, on the other, a volume of reference to which the practitioner may turn and find a series of articles written by representative authorities on the subjects portrayed by them. American Journal of the Medical Sciences " The different articles are complete, forceful, and, if one may be permitted to use the term, ' snappy,' in decided contrast to some of the labored but not more learned descrip- tions which have appeared in the larger systems of ophthalmology." SAUNDERS' BOOKS ON Brtihl, Politzer» and Smith's Otology Atlas and Epitome of Otology. ByGusTAv Bruhl, M. D., of Berlin, with the collaboration of Professor Dr. A. Politzer, of Vienna. Edited, with additions, by S. MacCuen Smith, M.D., Professor of Otology in the Jefferson Medical College, Philadelphia. With 244 colored figures on 39 lithographic plates, 99 text-illustrations, and 292 pages of text. Cloth, ^3.00 net. I?i Saunders'' Hand-Atlas Series. The work is both didactic and clinical in its teaching. A special feature is the very complete exposition of the minute anatomy of the ear, a working knowledge of which is so essential to an intelligent conception of the science of otology. Clarence J. Blake, M.D., Professor of Otology' in Harvard University Medical School, Boston. " The most complete work of its kind as yet published, and one commending itself to both the student and the teacher in the character and scope of its illustrations." Haab and DeSchweinitz's Operative Ophthalmology Atlas and Epitome of Operative Ophthalmology. By Dr. O. Haab, of Zurich. Edited, with additions, by G. E. deSchweinitz, M.D., Professor of Ophthalmology, University of Pennsylvania. With 30 colored lithographic plates, 154 text- cuts, and 375 pages of text. Cloth, ^3.50 net. In Saunders' Hand-Atlas Series. RECENTLY ISSUED This work represents the author's thirty years" experience in eye work. The various operative interventions are described with all the precision and clearness that such an experience brings. Recognizing the fact that mere verbal descriptions are frequently insufficient, Dr. Haab has taken particular care to illustrate plainly the different parts of the operation. Johns Hopkins Hospit&l Bulletin " The descriptions of the various operations are so clear and full that the volume can well hold place with more pretentious text-books." DISEASES OF THE E YE. H&ab and DeSchweinitz*s External Diseases cf the Eye Atlas and Epitome of External Diseases of the Eye. By Dr O. Haab, of Zurich. Edited, with additions, by G. E. deSchweinitz, M. D., Professor of Ophthalmology, University of Pennsylvania. 98 colored illustrations on 48 lithographic plates and 232 pages of text. Cloth, $3.00 net, Saimders Atlases. SECOND REVISED EDITION The conditions attending diseases of the external eye, which are often so complicated, have probably never been more clearly and comprehensively expounded than in the forelying work. The Medical Record, New York " The work is excellently suited to the student of ophthalmology and to the practising physician. It cannot fail to attain a well-deserved popularity." Haab and DeSchweinitz's Ophthalmoscopy Atlas and Epitome of Ophthalmoscopy and Ophthal= moscopic Diagnosis. By Dr. O. Haab, of Zurich. From the Third Revised and Enlarged German Edition. Edited, with additions, by G. E. deSchweinitz, M. D., Professor of Ophthal- mology, University of Pennsylvania. With 152 colored litho- graphic illustrations and 85 pages of text. Cloth, $3.00 net. Ifi Saunders' Hand- Atlas Series. In this work not only is the student made acquainted with carefully pre- pared ophthalmoscopic drawings done into well-executed lithographs of the most important fundus changes, but, in many instances, plates of the micro- scopic lesions are added. The whole furnishes a manual 01 the greatest possible service. The Lemcet, London " We recommend it as a work that should be in the ophthalmic wards or in the library of every hospital into which ophthalmic cases are received." SAUNDERS' BOOKS ON THE BEST nnierican standard Illustrated Dictionary Just Issued— New (4th) Edition The American Illustrated Medical Dictionary. A new and complete dictionary of the terms used in Medicine, Surgery, Dentistry, Pharmacy, Chemistry, and kindred branches; with over I oo new and elaborate tables and many handsome illustra- tions. By W. A. Newman Borland, M. D, Large octavo, 850 pages. Full flexible leather, ^4.50 net; with thumb index, ^5.00 net. WITH 2000 NEW TERMS In this edition the book has been subjected to a thorough revision. The author has also added upward of two thousand important new terms that have appeared in medical literature during the past few months. Howard A. Kelly, M.D., Professor of Gynecology , Johns Hopkins University, Baltimore. " Dr. Dorland's Dictionary is admirable. It is so well gotten up and of such convenient size. No errors have been found in my use of it." Grunwald and Grayson's Diseases of the Larynx Atlas and Epitome of Diseases of the Larynx. By DRo L. Grunwald, of Munich. Edited, with additions, by Charles P. Grayson, M.D., Clinical .Professor of Laryngology and Rhi- nology, University of Pennsylvania. With 107 colored figures on 44 plates, 25 text-cuts, and 103 pages of text. Cloth, ^2.50 net. In Samiders' Hand-Atlas Series. British Medical Journal "Excels everything we have hitherto seen in the way of colored illustrations of dis- eases of the larynx. . . . Not only valuable for the teaching of laryngolog-y, it will prove of the greatest help to those who are perfecting themselves by private study." NOSE, THROAT, AND F.AR^ GradleV Nose, Ph&.rynx, and Ear Diseases of the Nose, Pharynx, and Ear. By Henry Gradle, M. D., Professor of Ophthalmology and Otology, North- western University Medical School, Chicago. Handsome octavo of 547 pages, illustrated, including two full-page plates in colors. Cloth, $3.50 net; Half Morocco, ^5.00 net. This volume presents diseases of the Nose, Phar^'nx, and Ear as the author has seen them during an experience of nearly twenty-five years. Topographic anatomy has also been accorded liberal space. Pennsylvania Medical Journal " This is the most practical volume on the nose, pharynx, and ear that has appeared recently. ... It is exactly what the less experienced observer needs, as it avoids the con- fusion incident to a categorical statement of everybody's opinion." Kyle's Nose and Throat Diseases of the Nose and Throat. By D. Braden Kyle, M.D., Professor of Laryngology in the Jefferson Medical Col- lege, Philadelphia ; Consulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital. Octavo, 669 pages; over 184 illustrations, and 26 lithographic plates in colors. Cloth, ^4.00 net ; Half Morocco, $5.50 net. RECENTLY ISSUED— THIRD REVISED EDITION This work has now reached its third edition. With the practical purpose of the book in mind, extended consideration has been given to treatment, each disease being considered in full, and definite courses being laid down to meet special conditions and symptoms, Dudley S. Reynolds. M.D., Formerly Professor of Ophthalmology and Otology, Hospital College of Medichie, Louisz'ille. " It is an important addition to the text-books now in use. and is better adapted to the uses of the student than any other work with which I am familiar. I shall be pleased -io commend Dr. Kyle's work as the best text-book." SAUuDERS' BOOKS ON Greene and Brooks' Genito-Urinary Diseases A Text=Book of Genito=Urinary Diseases. By Robert H. Greene, M.D., Professor of Genito-Urinary Surgery at Fordham University; and Harlow Brooks, M.D., Assistant Professor of Pathology, University and Bellevue Hospital Medi- cal School. Octavo of 550 pages, profusely illustrated. JUST READY This new work covers completely the subject of genito-urinary diseases, presenting both the medical and surgical sides. It has been designed as a work of quick reference, and has therefore been written in a clear, condensed style, so that the information can be readily grasped and retained. Kidney diseases are very elaborately detailed, and especially well presented is surgery of the kidney. The text is profusely illustrated with original line-drawings. Gleason on Nose, Throat, and Ear A Manual of Diseases of the Nose, Throat, and Ear. By E. Baldwin Gleason, M.D., LL.D., Clinical Professor of Otology, Medico-Chirurgical College, Philadelphia. i2mo of 556 pages, profusely illustrated. JUST ISSUED Anatomy, physiology, and pathology of the upper respiratory tract and ear have been carefully presented, the author rightly believing such knowledge essential to the efficacious treatment of diseases of these organs. Methods of treatment have been simplified as much as possible, so that in most instan- ces only those methods, drugs, and operations have been advised which have proved essential. A valuable feature consists of the collection of formulas. American Text=Book of Qenito=Urinary Diseases, Syphilis, and Diseases of the Skin. Edited by L. Bolton Bangs, M.D., late Professor of Genito-Urinary Surgery, Bellevue University, New York; and W. A. Hardaway, M.D., Professor of Diseases of the Skin, Missouri Medical College. Two octavos, 1229 pages, 300 engravings, 20 colored plates. Cloth, 30s. net. DISEASES OE THE SKIiV. Mracek and Stelwa^on's Diseases of the Skin Atlas and Epitome of Diseases of the Skin. By Prof. Dr. Franz Mracek, of Vienna. Edited, with additions, by Henry W. Stelwagon, M. D., Professor of Dermatology in the Jefferson Medical College, Philadelphia. With 77 colored plates, 50 half-tone illustrations, and 280 pages of text. I?i Saunders' Hand- Atlas Series. Cloth, $4.00 net. RECENTLY ISSUED-NEW (2nd) EDITION American Journal of the Medical Sciences " The advantages which we see in this book and which recommend it to our minds are: First, its handiness ; secondly, the plates, which are excellent as regards drawing, color, and the diagnostic points which they bring out Mracek and Bancs' Syphilis ^ Venereal Diseases Atlas and Epitome of Syphilis and the Venereal Dis= eases. By Prof. Dr. Franz Mracek, of Vienna. Edited, with additions, by L. Bolton Bangs, M. D., late Prof, of Genito- urinary Surgery, University and Bellevue Hospital Medical Col- lege, New York. With 71 colored plates and 122 pages of text. Cloth, $3.50 net. In Saunders' Hand-Atlas Series. According to the unanimous opinion of numerous authorities, the illus- trations in this work surpass in beauty anything of the kind that has been pro- duced, not only in Germany, but throughout the literature of the world. Robert L. Dickinson, M. D., Art Editor of" The American Text-Book of Obstetrics." '"The book that appeals instantly to me for the strikingly successful, valuable, and graphic character of its illustrations is the ' Atlas of Syphilis and the Venereal Diseases.' I know of nothing in this country that can compare with it." 12 SAUNDERS' BOOKS ON Holland's Chemistry and Toxicolog'y A Text=Book of Medical Chemistry and Toxicology. By James W. Holland, M.D., Professor of Medical Chemistry and Toxicology, and Dean, Jefferson Medical College, Philadel- phia. Octavo of 592 pages, illustrated. Cloth, ^3.00 net. RECENTLY ISSUED Dr. Holland's work is an entirely new one, and is based on his thirfy-five years' practical experience in teaching chemistry and medicine. Recognizing that to understand physiologic chemistry students must first be informed upon points not referred to in most medical text-books, the author has included in his work the latest views of equilibrium of equations, mass-action, cryoscopy, os- motic pressure, etc. Much space is given to toxicology. American Medicine " Its statements are clear and terse; its illustrations well chosen; its development logi- cal, systematic, and comparatively easy to follow. . . . We heartily commend the work." Griinwald and Newcomb's Mouth, Pharynx, and Nose Atlas and Epitome of Diseases of the Mouth, Pharynx, and Nose. By Dr. L. Grunwald, of Munich. F7^07n the Second Revised and Enlarged German Edition. Edited, with additions, by James E. Newcomb, M. D., Instructor in Laryn- gology, Cornell University Medical School. With 102 illustrations on 42 colored lithographic plates, 41 text-cuts, and 219 pages of text. Cloth, $3.00 net. In Saundei's' Hand-Atlas Se7'ies. In designing this atlas the needs of both student and practitioner were kept constantly in mind, and as far as possible typical cases of the various diseases were selected. The illustrations are described in the text in exactly the same way as a practised examiner would demonstrate the objective findings to his class, the book thus serving as a substitute for actual clinical work. The illustrat ons themselves are numerous and exceedingly well executed. American Medicine " Its conciseness without sacrifice of clearness and thoroughness, as well as the excel- lence of text and illustrations^ are commendable." EYE, EAR, NOSE, AND TI/ROAT. Jackson on the Eye A Manual of the Diagnosis and Treatment of Diseases of the Eye. By Edward Jackson, A.M., M.D., Professor of Ophthalmology, University of Colorado. i2mo of 615 pages, with 184 illustrations. Cloth, $2.50 ret. JUST ISSUED— NEW (2d) EDITION The Medical Record, New York " It is truly an admirable work. . . . Written in a clear, concise manner, it bears evi- dence of the author's comprehensive g^rasp of the subject. The term ' multuin in parvo ' is an appropriate one to apply to this work. It will prove of value to all who are interested in this branch of medicine." Friedrich and Curtis on Nose, Larynx, and Ear Rhinology, Laryngology, and Otology, and Their Sig= nificance in General Medicine. By Dr. E. P. Friedrich, of Leipzig. Edited, with additions, by H. Holbrook Curtis, M.D., Consulting Surgeon to the New York Nose and Throat Hospital. Octavo volume of 350 pages. Cloth, $2.50 net. Grant on the Face, Mouth, and Jaws A Text=Book of the Surgical Principles and Surgical Diseases of the Face, Mouth, and Jaws. For Dental Students. By H. Horace Grant, A.M., M.D., Professor of Surgery and of Clinical Surgery, Hospital College of Medicine, Louisville. Octavo of 231 pages, with 68 illustrations. Cloth, ^2.50 net. »4 SAUNDERS' BOOKS ON Ogden on the Urine Clinical Examination of Urine and Urinary Diagnosis. A Clinical Guide for the Use of Practitioners and Students of Medicine and Surgery. By J. Bergen Ogden, M. D., Late Instructor in Chemistry, Harvard University Medical School ; Formerly Assistant in Clinical Pathology, Boston City Hospital. Octavo, 418 pages, fully illustrated, including a number of colored plates. Cloth, $3.00 net. SECOND REVISED EDITION— RECENTLY ISSUED In this edition important changes have been made in connection with the tletermination of Urea, Uric Acid, and Total Nitrogen ; and the subjects of Cryoscopy and Beta-Oxybutyric Acid have been given a place. Special at- tention has been paid to diagnosis by the character of the mine and the diag- nosis of diseases of the kidneys and urinary passages. The Lancet, London " We consider this manual to have been well compiled ; and the author's own experience, so clearly stated, renders the volume a useful one both for study and reference." Vecki's Sexual Impotence The Pathology and Treatment of Sexual Impotence. By Victor G. Vecki, M. D. From the Second Revised and Enlarged German Edition. i2mo volume of 329 pages. Cloth, ^2.00 net. THIRD EDITION. REVISED AND ENLARGED This volume will come to many as a revelation of the possibilities of thera- peutics in this important field. The whole subject of sexual impotence and its treatment is discussed by the author in an exhaustive and thoroughly sci- entific manner. In this edition the book has been thoroughly revised, and new matter has been added, especially to the portion dealing with treatment. Johns Hopkins Hospital Bulletin "A scientific treatise upon an important and much neglected subject. . . . The treatment of impotence in general and of sexual neurasthenia is discriminating and judicious." CHEMISTRY, SKIN, AND VENEREAL DISEASES. 15 American Pocket Dictionary just issued, stn Ed. The American Pocket Medical Dictionary. Edited by W. A. Newman Borland, M. D., Assistant Obstetrician to the Hospital of the University of Pennsylvania. Containing the pronunciation and defi- nition of the principal words used in medicine and kindred sciences. Flexible leather, with gold edges, ^i. 00 net ; with thumb index, ^1.25 net. " I am struck at once with admiration at *the compact size and attractive exterior. I can recommend it to our students without reserve." — James W. Holland, M. D., Professor 0/ Me Jical Chemistry and Toxicology, at the Jefferson Medical Col- lege, Philadelphia. Stelwagon's Essentials of Skin New*^(6th^ Edition Essentials ok Diseases of the Skin. By Henry \V. Stelwagon, M. D., Ph.D., Professor of Dermatology in the Jefferson Medical College and Woman's Medical College, Philadelphia. Po.st-octavo of 276 pages, with 72 text-illustrations and 8 plates. Cloth, ^i.oo net. In Saunders' Question-Compend Series. " In line with our present knowledge of diseases of the skin. . . . Continues to main- tain the high standard of excellence for which these question compends have been noted." — The Medical News. Wolffs Medical Chemistry sixth^Edmon. Revised Essentials of Medical Chemistry, Organic and Inorganic. Containing also Questions on Medical Physics, Chemical Physiology, Analytical Processes, Urinalysis, and Toxicology. By Lawrence Wolff, M. D., Late Demonstrator of Chemistrj^, Jefferson Medical College. Revised by Smith Ely Jelliffe, M. D., Ph. D., Professor of Phamacognosy, College of Pharmacy of the City of New York. Post-octavo of 222 pages. Cloth, $1.00 net. In Saunders^ Question- Compend Series. " The author's careful and well-studied selection of the necessary requirements of the student has enabled him to furnish a valuable aid to the student." — New York Medical Jonrttal. Martin's Minor Surgery, Bandaging, and the Venereal Diseases second Edition. Revised Essentials of Minor Surgery, Bandaging, and Venereal Dis- eases. By Edward Martin, A. M., M. D., Professor of Clinical Sur- gery, University of Pennsylvania, etc. Post-octavo, 166 pages, with 78 illustrations. Cloth, ^i.oo net. In Saunders'' Question Cot?ipends. " The best condensation of the subjects of which it treats yet placed before the pro' fession." — The Medical News. Stevenson's Photoscopy just Ready Photoscopy (Skiascopy or Retinoscopy). By Mark D. Steven- son, M. D., Ophthalmic Surgeon to the Akron City Hospital. I2moof 200 pages ; illustrated. Cloth, $1.2^ net. Dr. Stevenson's work fully and clearly explains the use of this objective test and elucidates the reasons of the various phenomena observed. The illustrations have been drawn with special attention to their practical usefulness. 1 6 URINE, EYE, EAR, NOSE, AND THROAT. Wolfs Examination of Urine A Laboratory Handbook of Physiologic Chemistry and Urine- examination. By Charles G. L. Wolf, M. D., Instructor in Physi- ologic Chemistry, Cornell University Medical College, New York i2mo volume of 204 pages, fully illustrated. Cloth, ^1.25 net. " The methods of examining the urine are very fully described, and there are at the end of the book some extensive tables drawn up to assist in urinary diagnosis." — British Medicul Journal. Jackson's Essentials of Eye Third Revised Edition Essentials of Refraction and of Diseases of the Eye. By Edward Jackson, A. M., M. D., Emeritus Professor of Diseases of the Eye, Philadelphia Polyclinic. Post-octavo of 261 pages, 82 illustrations. Cloth, ^l.oo net. /« Saunders' Question- Coinpend Series. " The entire ground is covered, and the points that most need careful elucidation are made clear and easy." — Johns Hopkins Hospital Bulletin. Gleason's Nose and Throat Third Edition, Revised Essentials of Diseases of the Nose and Throat. By E. B. Gleason, S. B., M. D., Clinical Professor of Otology, Medico-Chirurgical College, Philadelphia, etc. Post-octavo, 241 pages, 112 illustrations. Cloth, ^ 1. 00 net. In Saunders'' Question- Covipend Series. " The careful description which is given of the various procedures would be sufficient to enable most people of average intelligence and of slight anatomical knowledge to make a very good attempt at laryngoscopy." — The Lancet, London. Gleason's Diseases of the Ear Revised °"' Essentials of Diseases of the Ear. By E. B. Gleason, S. B., M. D., Clinical Professor of Otology, Medico-Chirurgical College, Phila- delphia, etc. Post-octavo volume of 214 pages, with 114 illustrations. Cloth, ^ I. GO net. In Saunders' Question- Co??tpend Series. " We know of no other small work on ear diseases to compare with this, either in freshness of style or completeness of information." — Bristol Medico-Chirurgical Journal. Wilcox on Genito-Urinary and Venereal Dis- eases J"st Issued Essentials of Genito-Urinary and Venereal Diseases. By Starling S. Wilcox, M.D., Professor of Genito-Urinary Diseases and Syphilology, Starling Medical College, Columbus, Ohio. i2nio of 313 pages, illustrated. Cloth, ;g 1. 00 net. In Saunders' Question- Cornpends. Senn's Genito-Urinary Tuberculosis Tuberculosis of the Genito-Urinary Organs, Male and Female. By N. Senn, M.D., Ph.D., LL.D., Professor of Surgery in Rush Medical College. Octavo of 317 pages, illustrated. Cloth, $3.00 net. W-^'^ 33"^ % '♦••V^^ .,. ^-^^ -•• ^^ ,/»^" .^ o**"** ;• _J!> "'5^^ ^^^^)'/ .**• -^ ^.^^ : -. ^^d« ^ov^ :^ *.T.« ^0 .0 i'^'^ •!••• ^J^' :>f #f X • >f • \^ ^^-^^^ 0- ^O 'o.. N. MANCHESTER, INDIANA 46962 :d ^. A' .!^i:. '".^. ^^ .♦>4fe^<